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32921 Incisional Hernia: The “Open” Techniques (Excluding Parastomal Hernia)
technique favored a continuous suture rather than interrupted
stitches [
27 ] . More recently a further meta-analysis indicated
that there was no difference in rate of incisional hernia with
midline laparotomy closure between a nonabsorbable suture
and a slowly absorbable suture material. This analysis also
revealed similar outcomes with continuous and interrupted
suture techniques [ 53 ] . The continuous suture method may
be more effective since it requires half as much time and less
suture material [ 54 ] . The meta-analysis by these authors also
con fi rmed previous fi ndings that braided suture materials
increased the incidence of infection, suture sinus formation,
and postoperative abdominal wall pain. More recently two
groups have challenged the dogma of big-bite closure. Using
small stitches with small suture differences (a 0.5-cm bite
with a 0.5-cm stitch interval), the suture length/wound length
ratio can be maintained at 4:1, but at the same time in an
experimental animal model increasing the tensile strength
across the wound from 534 to 787 N. The small sutures are
placed 4–6 mm from the wound edge and cut through the
aponeurosis and not through the rectus abdominis muscle
[ 55 ] . In the clinical scenario this short stitch length resulted
in a greatly reduced incidence in incisional hernia from 18 to
5.6% and reduction of wound infection by half from 10.2 to
5.2% [ 56 ] .
In epigastric incisional hernia repair it should be remembered that the linea alba is broad in the epigastrium—at least as
broad as the xiphoid cartilage is wide—therefore, efforts to
draw the rectus muscles close together are unanatomic and
doomed to disruption. Most of the side-to-side tension in the
linea alba in the epigastrium is generated in the anterior rectus
sheath which consists of two laminae, the anterior lamina being
the external oblique arising from the lower ribs. The short span
of this muscle makes this layer relatively inelastic and unstretchable to the midline for repair [ 57 ] . For this reason, on occasion
the epigastric midline cannot be closed even with an external
oblique release, and an inlay prosthetic graft is required.
Incisional Hernia Following Appendectomy
Incisional hernias related to open appendectomy are reported
in all series. Etiological factors include severe postoperative
wound sepsis and the placement of a drain through a gridiron
appendectomy wound. These hernias occurring through the
red muscle in the fl ank are dif fi cult to repair adequately. If
there is a well-developed fi brous margin to the defect, this
can be used as the basis of a Mayo-type overlap repair, prior
to supplementary prosthetic mesh. Direct suture of these hernias, suturing red muscle, often fails, and if an adequate overlap cannot be constructed, extraperitoneal mesh (page 337) or
mesh reinforcement of the external oblique aponeurosis is
advised.
Table 21.1 A grading system for abdominal wall injury that can be
helpful in predicting the potential for future abdominal wall herniation
at the site of injury [
Clinical presentation Type
Subcutaneous tissue contusion I
Abdominal wall muscle hematoma II
Single abdominal wall muscle disruption III
Complete abdominal wall muscle disruption IV
Complete abdominal wall muscle disruption with
herniation of abdominal contents
Complete abdominal wall muscle disruption with evisceration VI
60 ]
V
Traumatic Abdominal Wall Hernia
Abdominal wall injury may result in hernia that is not be
immediately recognized at the time of injury [ 58 ] . Clinically
apparent anterior traumatic abdominal wall hernias have a
high rate of associated intra-abdominal injuries requiring
laparotomy. Occult traumatic abdominal wall hernias are
diagnosed only with CT scan and usually do not require
urgent laparotomy or hernia repair. The mechanism of
injury should be considered when deciding if urgent laparotomy is required. Diaphragmatic lumbar and extrathoracic hernias are also well-described complications of
blunt trauma [ 59 ] . Early recognition of these hernias can be
a diagnostic challenge and delayed presentation is common. The surgical treatment for these hernias is evolving
and a variety of options are available to the surgeon. On the
basis of a review of all available abdominal and pelvic CT
scans of 1,549 patients presenting to a trauma unit over an
18-month period, 9% of patients were shown to have an
abdominal wall injury and a grading system was devised
(Table 21.1 ).
The incidence of these was found to be as follows: I
(53%), II (28%), III (9%), IV (8%), V (2%), and VI (0.2%).
There was no association between abdominal wall injury and
seat belt use or injury severity score. This large study concluded that abdominal wall injury occurs in 9% of blunt
trauma patients having CT scan, the incidence of herniation
at presentation was only 0.2%, and the incidence of future
herniation was 1.5% [ 60 ] .
Pneumoperitoneum as an Aid in Surgical Treatment of Giant Hernias
Management of giant incisional hernia is often compromised
by obesity, intrahernial adhesions, and contraction in the volume of the abdominal cavity—the hernial contents have lost
their “right of domain.” Long operations to free the adhesions and brutal reduction of the contents can lead to ileus,
pulmonary restriction, and cardiac compromise. After these
330 A.N. Kingsnorth
operations, if the patient does not succumb to the cardiorespiratory complications, the persistent ileus will lead to
disruption of the repair.
The use of pneumoperitoneum before attempting de fi nitive
repair of giant hernias was originally suggested by Moreno
in 1940 [ 61 ] . The advantages of the technique are:
Stretching of the abdominal wall, creating a larger cavity •
into which the hernial contents can be replaced
Reduction of edema in the mesentery, omentum, and vis-•
cera in the hernial sac, creating less mass to be reduced
Stretching of the hernial sac leading to elongation of •
adhesions, making dissection and reduction easier [
Increased tone of the diaphragm, allowing preoperative •
respiratory and circulatory adaptation to the elevation of
the diaphragm [ 63 ]
The technique of pneumoperitoneum is simple: under local
anesthetic an epidural catheter, an intracath or a ureteric pigtail
catheter, is introduced into the peritoneal cavity. The site of
puncture should be kept well away from the hernia or its margins to avoid damaging viscera fi xed by adhesions. The optimum site is probably through the linea alba. Successful
abdominal puncture is marked by a lessening of the pressure
required to advance the needle. The catheter can then be easily
threaded into the peritoneal cavity and its position checked
radiologically after injection of a small quantity of contrast
medium [ 64 ] . The catheter is fi xed into position and about
500 mL of gas or air is injected via a micropore fi lter [ 65 ] .
Graduated amounts of gas or air are injected on successive
days, 500 mL at a time once, twice or thrice a day, until a daily
volume of about 2.5 L is obtained. Caldironi and colleagues
used nitrous oxide in 41 patients with giant incisional hernias.
A laparoscopic insuf fl ator was used to top up the pneumoperitoneum every other day for a mean of 5.5 days, a total volume
of 23.2 L of nitrous oxide being injected. The volume introduced at each session was 1,000/1,500 mL greater than the
previous session and the procedure was well tolerated in all
but one patient. The good results of the subsequent repairs
(only two recurrences in 40 repairs at a mean 25 months follow-up) attest to the success of this technique [ 66 ] . The abdo-
men will inevitably be blown up like a balloon and much
patient reassurance may be needed. If the patient develops discomfort, shoulder tip pain, tachycardia, or dyspnea, the rate of
insuf fl ation can be reduced; indeed, if severe symptoms occur,
gas or air can be withdrawn. No attempt is made to prevent the
hernial sac distending; distension of the hernial sac is helpful,
stretching adhesions and allowing contents to reduce spontaneously prior to operation. Unfettered distension of the peritoneal sac may reveal subsidiary hernial protrusions, enabling a
more adequate surgical repair to be planned and undertaken.
There is a need for this technique in the surgical armamentarium, but while this has been found to be of signi fi cant bene fi t
in South America and some parts of Europe, the experience
with this technique in the United States is limited.
62 ]
Due to the failure of most clinicians to adopt pneumoperitoneum, few advances have been made in its application
[
67 ] . However, recently a simpler technique using a double
lumen intra-abdominal catheter inserted through a Veress
needle in the left hypochondrium has utilized the daily
insuf fl ations of ambient air [
of 9.3 days between 1,000 and 4,000 cc were insuf fl ated
depending on patient comfort to reach a maximum intraabdominal pressure of 15 mm of mercury (measured by
sphygmomanometer). Subsequent successful hernia repair
was carried out in all patients.
In practice, the patient is ready for operation at about a 2
weeks after induction of the pneumoperitoneum, the end
point being judged by the tension of the abdominal wall,
which should feel as tight as a drum, especially in the fl anks
[
69 ] . The patient should be operated on at this stage—if pos-
sible most of the dissection should be performed with the
hernial sac unpunctured and distended. Puncture of the sac at
operation will allow easy reduction of contents and the slack
parietes will facilitate repair. Air is only slowly absorbed
from the peritoneal cavity, and often after the fi rst 2 or 3 days
absorption is so reduced as to become inconsequential.
Contraindications to pneumoperitoneum include abdominal wall sepsis, prior cardiorespiratory decompensation, and
strangulation of hernial contents. Complications, which are
very rare, include visceral puncture, hematoma, and the risk
of an embolism into a solid organ if the liver or spleen is
needled prior to insuf fl ation. Mediastinal and retroperitoneal
surgical emphysema are rare complications.
68 ] . Over a period or an average
Indications for Operation
Incisional hernias produce symptoms of dis fi gurement, discomfort, and pain, and often recurrent colic if subacute
obstructive episodes occur. Such symptoms are reason
enough for operative intervention. Irreducibility and a narrow neck are further indications for surgery. Obstruction and
strangulation are absolute indications.
Contraindications to Elective Operation
Extreme obesity can be a contraindication to surgery. Obese
patients frequently have cardiorespiratory decompensation
and diabetes, making weight reduction essential prior to surgery [ 70 ] . Subcutaneous and intra-abdominal obesity make
the open repair more dif fi cult and postoperative complications more likely. In the particularly high-risk patients, the
use of invasive monitoring such as a Swan-Ganz catheter
and the monitoring that the intensive care units provide will
allow such patients to undergo these operations without
undue risk.
33121 Incisional Hernia: The “Open” Techniques (Excluding Parastomal Hernia)
Continuing deep sepsis in the wound is also a contraindication to repair surgery. Such cases frequently have a history
of more than one repair attempt, and the wound may be
indurated with many sinuses in it. If the sepsis is long standing, calci fi cation may be present. Usually wounds with continuing infection contain buried and heavily infected
nonabsorbable material; it is best to open these wounds,
remove all the foreign material, and drain all the pockets of
pus. The wound is then left to granulate over. Only when the
wound has been without deep sepsis for 6–9 months should
repair surgery be undertaken.
Skin infections and intertrigo beneath a vast incisional
hernia are common and require vigorous preoperative treatment. Operation should be delayed until the skin is sound.
Biological meshes can be used in infected situations if
surgery cannot be delayed until the infected areas have been
fully treated. The long-term results of such usage of biologic
products are still under investigation.
Choice of Operative Technique
It is usually preferable to make an accurate assessment of
the anatomy of the hernia prior to surgery. How big is the
defect? Does the size of the defect increase or decrease on
movement? Are the contents easily reducible? If the hernia
contents are incarcerated, this may not be possible. If the
hernia is reducible, the sac and fi brous margins of the sac
are examined with the patient supine and at ease and then
standing erect.
Finally the patient is laid fl at again, and as much of the
sac as possible is reduced and held reduced by the examining surgeon. The patient is then asked to sit up while the
surgeon continues to hold the hernia reduced. In some hernias, particularly upper midline ones, the margins of the
defect close together on movement and the contraction of
the abdominal wall will then hold the sac reduced (Fig. 21.1 ).
These maneuvers may provide the surgeon with the information necessary to decide upon the operation that should
be used and if there is a possibility that the laparoscopic
method (smaller defects of up to 10–15 cm) should be performed rather than the open repair.
Prosthetic Mesh Operation
Due to the poor results of tissue repairs, it is mandatory that
a prosthesis is used in all incisional hernia repairs. Even if
the fascial defect is less than 4 cm, a prosthesis is recommended. The prosthetic materials that are available are
described in Chap. 7.
The tissue repair or Mayo procedure for repair of abdominal
incisional hernia gives unacceptable results with recurrence
rates of up to 84% with 5.7 years of follow-up [
suture repair for incisional hernia is compared with mesh
repair, the incidence in incisional hernia at 36 months is
reduced from 43% (suture) to 24% (mesh) in patients with a
vertical midline incision of less than 6 cm in length [
However, in this study patients only received 2-cm overlap of
mesh which currently would be considered inadequate, and
the 10-year cumulative rate for recurrence was 32% for the
mesh repair, a fi gure that would now be highly unacceptable
[ 72 ] . Further insight into the bene fi t of mesh came from a
comparative retrospective study of 421 incisional hernias on
348 patients undergoing 241 Mayo repairs and 180 mesh
repairs over a 25-year period [ 73 ] . The total recurrence rate
following Mayo repair was 37% in contrast to 15% after
mesh implantation. In the mesh repair group the only
signi fi cant prognostic factor concerning quality of life and
recurrence was the size of the mesh implanted. There were
more wound-related complications in the mesh repair group
and recurrences occurred at the upper and lower edges of the
mesh where there had been insuf fi cient overlap.
The choice of mesh material today is generally between a
prosthesis of polypropylene and polyester. There are many
designs and con fi guration of weave, thickness of weave, and
strand and size of pore [ 74 ] . The effect that these differences
between the various weaves and knits, organic polymers,
spinning an extrusion of yarns, and conversion to mesh and
the properties of the fi nal product is complex. Some materials shrink, but additionally some mesh studies reveal that no
shrinkage takes place. Polyester was developed in 1939 and
introduced in the USA in 1946 then marketed by Ethicon in
1950 under the trade name of Mersilene and is still used and
is widely popular in France. Polypropylene products resulted
from further advances in polymerization techniques and
introduced into hernia surgery in the 1950s. Explantation of
meshes shows that they remain intact but that minor fl aking
and fi ssuring occurs. In experimental studies the reduction in
area due to shrinkage is shown to be at a maximum of
between 3 and 6 months of approximately 30–45%. In reality this would result in the reduction in area of a 10 cm × 10 cm
mesh (100 cm 2 ) to an area of 8 cm × 8 cm (64 cm 2 ) or a 36%
reduction in area and a reduction in width from 10 to 8 cm
leaving suf fi cient overlap to prevent recurrence, if the mandatory 5 cm (each side of the repaired defect) is adhered to.
It is therefore not necessary to have an overlap of more than
5 cm as long as peripheral fi xation is secure [ 75, 76 ] . This
rate of shrinkage has been con fi rmed in humans with ventral
hernias by Vega-Ruiz [ 77 ] . In 23 patients radiological fol-
low-up was undertaken in patients who underwent surgery
for midline ventral hernias with diameter of at least 5 cm.
The polypropylene mesh was marked with titanium clips at
the ends of the longest transverse and longitudinal axes.
X-rays performed at 1, 3, 6, and 12 months measured the
distance between the clips and the area of the mesh was
71 ] . When
46 ] .
332 A.N. Kingsnorth
calculated. In patients receiving both onlay and sublay mesh
repairs, the maximum reduction in calculated area occurred
between 6 and 12 months and was between 29 and 34%.
Several attempts have been made to classify synthetic
meshes that are used in abdominal wall hernia surgery [
However, these are not of particular practical use to the surgeon. Four types of mesh have been identi fi ed depending on
pore size (greater or less than 75 m m), the larger pore meshes
tending to admit macrophages and fi broblasts to a greater
degree allowing new blood vessel formation and collagen
synthesis, and pore size of less than 10 m m delivers a
microporous mesh with greater anti-adhesive properties and
suitable for intraperitoneal implantation. Although it was
originally intended that lightweight meshes may improve
abdominal wall compliance after incisional hernia repair, a
randomized controlled trial comparing lightweight composite meshes with polyester or polypropylene [
difference in abdominal wall compliance between the two
groups of patients. The lightweight mesh also had a more
than two times increased incidence of recurrence of the incisional hernia occurring at the edges of the mesh [
79 ] showed no
78 ] .
80 ] .
Classi fi cation
Incisional hernias are a diverse and heterogeneous problem because of the multiplicity of incisions used to gain
access to the abdominal cavity. Therefore it is not easy to
produce a classi fi cation system that covers all eventualities. Nevertheless classi fi cations are useful for comparison of results of new methods of repair to enable
comparisons to be made. Important factors, which should
be taken into account for a classi fi cation system, include
localization of the previous incision (vertical, transverse,
oblique, or combined), the size of the defect (horizontal
and transverse strati fi ed into less than 5 cm, 5–10 cm,
greater than 10 cm), number of times the hernia has
recurred, reducibility, and symptoms [
vertical midline incisional hernias can be closed primarily
(with or without separation of components) the most
important dimension of the abdominal wall defect is vertical length, when the fascia has been completely closed,
prior to mesh placement.
81 ] . Since 98% of
Anesthesia
Unless there is a strong contraindication to general anesthesia, even small incisional hernias without a tissue defect
should be repaired using a general anesthetic because of the
unexpected fi nding of an occult hernia that may escalate the
complexity of the operation. Muscle relaxants will assist in
reducing the contents of the sac, and drawing together the
Fig. 21.2 Elliptical incisions are made on either side of the hernial
cicatrix
margins of the defect during the repair and full cooperation
of an anesthetist is required at this critical stage of the operation. In some circumstances, the use of spinal or epidural
anesthesia may be considered, but this would depend upon
the location of the hernia site and the surgeon’s familiarity
with the choice of that anesthesia method.
The Open Operation
Position of Patient
If the hernia is located in the midline or lateral aspects of the
anterior abdominal wall, the patient is placed in the supine
position on the operating table.
The Incision
A wide elliptical incision is made to enclose the cutaneous
scar. The incision must generally be extended at either end
to give adequate access to all the margins of the defect.
The direction of this initial incision will depend on the
shape of the original scar through which the hernia has
come. Care should be taken not to excise too much skin: at
this stage the minimum excision of cutaneous scar tissue is
done (Fig. 21.2 ).
Removal of Overlying Redundant Tissue
The redundant skin and scar are separated from the underlying hernial sac, which is often just subcutaneous especially
33321 Incisional Hernia: The “Open” Techniques (Excluding Parastomal Hernia)
Fig. 21.3 Removal of the redundant scar
Fig. 21.5 Skin fl aps are raised in order to fully dissect out the sac and
allow placement of the mesh, with or without “components separation.”
A 4–5-cm exposure of the anterior rectus sheath is required on each side
for an onlay (prefascial) repair; less exposure is required for a sublay
(retrorectus) repair
near the fundus of the hernia. Redundant skin and scar tissue
are removed (Fig. 21.3 ). This is a signi fi cant advantage of the
open approach compared with the laparoscopic method
because a better cosmetic result is achieved.
If the hernia is very large, the skin and underlying peritoneal sac may be virtually fused into one layer near the fundus
of the hernial protrusion. When removing the redundant skin,
care is necessary to avoid damage to the hernia contents
which may be adherent over wide areas inside the sac
(Fig. 21.4 ).
Fig. 21.4 Care must be taken not to remove too much skin and not to
damage the hernial sac. The cutaneous cicatrix is often closely adherent
to the sac
Exposure
The hernia is dissected from the surrounding subcutaneous
fat by raising skin fl aps (Fig.
to use the scalpel blade, scissors, electrocautery pencil and/
or the ultrasonic dissection device for this dissection. The
coverings of the hernia are stretched scar tissue merging into
the stretched abdominal wall aponeurosis at the circumference of the protrusion and a variable amount of extraperitoneal fatty tissue.
The hernia sac is now dissected out completely following
the contours carefully until the neck of the sac is reached
circumferentially, which in a large hernia will require the
elevation of large skin fl aps (Fig. 21.6 ). These large areas of
pannus should be removed later by horizontal panniculectomy (see later) to lessen the incidence of seroma formation
collecting in loose folds of skin.
21.5 ). The surgeon may choose
334 A.N. Kingsnorth
Fig. 21.6 Circumferential exposure of the neck of the sac is achieved
Fig. 21.8 Adhesions between the bowel and sac are divided, and
bowel is returned to the peritoneal cavity
abdominal cavity. The advent of laparoscopic techniques for
incisional hernia repair has revealed that at least one-third of
hernia sacs contain visceral contents which are adherent to
the sac itself. After opening the sac, adhesions of the contents are divided (Fig. 21.8 ), the viscera returned to the peri-
toneal cavity, and then the sac is completely excised to the
edge of the rectus fascia on each side (Fig. 21.9 ). Since the
peritoneal layer will not be sutured separately (it is too weak
to retain sutures), complete excision of the sac allows the
medial fascial edges of the rectus sheath to be seen clearly
for accurate suture placement when closing the abdomen.
Fig. 21.7 The sac is opened at a point where it is judged that bowel is
not adherent beneath it, usually at the fundus
Managing the Peritoneal Sac
The hernia sac is now opened carefully avoiding damage to
the visceral contents of the sac, either at the fundus or by an
elliptical incision around the hernia neck, where it merges
with the stretched aponeurosis (Fig. 21.7 ).
It is recommended that the hernia sac is completely
resected in all cases because intra-sac adhesions and sac
compartmentalization can be a potent cause of intestinal
obstruction if the sac is merely inverted and pushed into the
Contents of the Sac
The sac may contain almost any intraperitoneal viscus, but
usually omentum, small bowel, and transverse colon are
found.
Unless the hernia is strangulated and the small bowel nonviable, any adhesions are divided and the small bowel is
returned to the abdominal cavity. Strangulated small bowel
or omentum can be resected at this stage. The diagnostic
decision is now made as to what should be done about very
adherent and frequently partially ischemic omentum. If there
is any doubt about omentum, it is best excised; to return
omentum of doubtful viability to the peritoneal cavity invites
the formation of adhesions.
Particular care must be taken in manipulating and dissecting any colon in the sac. Any densely adherent hernial sac
should be trimmed and left adherent to the bowel and returned
to the peritoneal sac rather than risk perforating the bowel in
33521 Incisional Hernia: The “Open” Techniques (Excluding Parastomal Hernia)
Fig. 21.9 Completion of excision of the sac, laying bare the medial
margins (linea alba) of the rectus sheath in preparation for midline
fascial closure
a tedious dissection. The greatest care must be taken to avoid
puncturing the colon. If the colon is punctured, a minor
injury could generally be closed with sutures. A substantial
injury must be treated by creation of a colostomy, the reanastomosis of the colon and repair of the hernia can be performed at a later operation after full patient evaluation and
colon antibacterial preparation.
Closure of Aponeurotic Layer
For the onlay (prefascial, Chevrel) method fascial closure is
achieved by placing a running suture of a strong nonabsorbable or slowly absorbable suture into the anterior rectus
sheath (without taking a bite of the rectus muscle) taking
bites of 5–10 mm, with a stitch interval of 5 mm, to achieve
a suture length/wound length of 4:1 (Fig. 21.10 ). The author
uses a nonabsorbable suture that is started at each end of the
defect, and the two ends are tied together at the midpoint of
the closure. The repair of large defects of the abdominal wall
in this manner will result in a signi fi cant amount of tension
on the fascia in the midline and also the risk of abdominal
compartment syndrome. If this situation is likely to occur, a
Ramirez “components separation” technique is recommended (see below), and surgeons operating on such large
hernias should have this technique in their armamentarium.
For the sublay (retrorectus, Rives) method fascial closure
of the posterior rectus sheath is achieved after bilateral,
medial opening of the rectus fascia which exposes the medial
edges of the rectus muscles and the bloodless plane behind
the muscles (see later). After mesh placement, the anterior
Fig. 21.10 Construction of a neo-linea alba by approximation of the
medial edges of the rectus sheaths. This should be achieved with negligible
tension utilizing a nonabsorbable or slowly absorbable continuous suture of
1 gauge suture material to achieve 4:1 suture length/wound length (<10 mm
bites at <10 mm intervals). Suture bites do not include muscle
rectus sheath is closed in a similar fashion to that described
for the onlay method.
Panniculectomy if required is carried out after complete
fascial closure at this stage. Depending upon local custom,
the subcutaneous fat is either left unclosed or is closed in
layers with absorbable sutures. The skin margins are now
approximated. Skin closure must be effected without any
tension. This may be accomplished with sutures and/or
skin staples.
Postoperative Care
Immediate active mobilization is the key to rapid convalescence. In the absence of extensive handling of the intestines
there is no postoperative adynamic ileus and no need for
encumbrances such as nasogastric suction or intravenous
drips. The patient is made to take deep breaths; breathing
exercises and, where necessary, chest percussion are given.
As soon as possible the patient gets up and walks. Fluids are
given for the fi rst day, and then a light diet is started. These
patients may experience a signi fi cant amount of pain, which
will require parenteral analgesia. If this can be controlled
with oral analgesics and the patient does not experience a
signi fi cant ileus, a minimal hospital stay can be expected.
Generally, the length of stay will be 3–5 days depending
upon the size of the hernia, the amount of dissection required,
and the number of comorbid conditions of the patient.
336 A.N. Kingsnorth
An onlay vs. intraperitoneal mesh trial showed no differences
The Choices of Technique in Open Prosthetic Repair
The choice is between the onlay (prefascial, Chevrel) technique and the sublay (retrorectus, Rives) technique. The use
of unprotected intraperitoneal mesh in open surgery is not
considered appropriate because it leads to adhesion formation between the mesh and bowel and the risk of fi stulation.
A survey in Sweden revealed that when using mesh for incisional hernia repair 54% of surgeons employed the onlay,
prefascial technique and 44% the sublay, retrorectus technique. Recurrence rates did not differ signi fi cantly [ 82 ] . The
onlay technique is technically simpler to perform, it is applicable to all quadrants of the abdominal wall, and there is no
risk of contact between the bowel and mesh, which can
occur with the sublay technique, particularly when the mesh
is placed in the lower midline where a tear in the peritoneum
below the arcuate line risks contact between mesh and
bowel. Moreover, the posterior rectus sheath is frequently a
thin and fragile layer, which tears easily when under minimal tension.
For very complex abdominal wall reconstruction techniques of tissue expansion, vacuum-assisted closure devices,
abdominal component separation, local and distant muscle
fl aps, and free tissue transfer can be adopted [ 83 ] . However,
for the general surgeon performing incisional hernia repair
such advanced surgical techniques should only be attempted
in collaboration with a plastic surgeon unless he or she is
familiar with these techniques. In general small hernias
below 10 cm in size are amenable to laparoscopic repair (see
Chap. 16) although they are satisfactorily repaired by the
open technique with the additional bene fi t of achieving cosmesis of the anterior abdominal wall skin. Hernias between
10 and 15 cm in size are best repaired by open techniques
although advanced laparoscopic surgeons can achieve good
results. Hernias over 15 cm in size usually require a Ramirez
“component separation” of parts repair because of signi fi cant
loss of domain [ 84 ] .
A Cochrane database of systematic reviews in 2008 concerning open surgical procedures for incisional hernia
included eligible studies if they were randomized controlled
trials comparing different techniques for open incisional
repair. Eight trials were identi fi ed of which one was excluded
and 1,141 patients had been enrolled into the studies. Three
trials concerned suture vs. mesh repair (onlay or sublay),
which revealed that the recurrence and wound complications
were more frequent after sutured repair. Two trials compared
the onlay (prefascial) vs. the sublay (retrorectus) technique
and found no difference in outcome except for a shorter operative time for the onlay method indicating its ease of use.
Finally comparison between lightweight and standard mesh
showed a trend for more recurrence in the lightweight group.
in outcomes except for increased pain in the intraperitoneal
group [
85 ] . The review concluded that open mesh was supe-
rior to suture techniques for recurrence and reduction in
wound infection, but there was insuf fi cient evidence as to
which type of mesh or which mesh position (onlay or sublay)
should be used. In addition the study also found insuf fi cient
evidence to advocate the use of components separation
technique and clearly this requires further study. A quasirandomized study allocating patients alternately to either a
sublay or an onlay arm for meshplasty in ventral hernias,
excluding patients with defects greater than 10 cm found a
more favorable outcome for the onlay technique with complications recurring in 22.5% (sublay) vs. 15% (onlay) with
similar wound complications [ 86 ] . Hospital stay was similar
and there were no recurrences.
The Onlay (Prefascial, Chevrel) Technique for Open Prosthetic Repair
Chevrel popularized the onlay, prefascial technique more
than 30 years ago [ 87 ] . Reporting 257 prosthetic repairs,
Chevrel reported a morbidity of 10.5% including 6.3%
seroma, two wound infection, and 4.9% recurrence and
favoring the use of polypropylene mesh. In addition Chevrel
advocated the use of fi brin glue and relaxing incisions in
approximately half of his patients. Relaxing incisions were
placed in the anterior rectus sheath, which was a favored
technique prior to the introduction of the component separation, which places the relaxing incisions in the external
oblique aponeurosis. Similar results have been reported in
smaller series which advocate a signi fi cant overlap of mesh
after the midline fascial closure and extensive suturing of the
mesh to the anterior abdominal wall in order to prevent shifting, curling, or movement of the mesh allowing recurrence
[ 88– 90 ] . Recurrence rates in the series ranged from 3 to 16%,
which is a satisfactory outcome for large incisional hernias.
Panniculectomy is an important adjunct to surgery of the
anterior abdominal wall to allow removement of large fl aps
of skin, which are redundant, once the large underlying hernia sac has been removed and reduced [ 91 ] . Failure to remove
a large pannus or skin fl ap can result in a troublesome chronic
seroma requiring multiple aspirations or surgery if it forms a
pseudocyst on the abdominal wall.
The onlay technique is the ideal operation to combine
with components separation in patients with very large incisional hernias with loss of domain [ 92 ] . In a series of 116
large hernias treated in a 2-year period, 21 patients required
component separation in order to achieve fascial closure
avoiding abdominal compartment syndrome. Only 9.5% of
patients experienced seroma and 1.7% deep wound infections with no requirement for mesh removal, and four patients
33721 Incisional Hernia: The “Open” Techniques (Excluding Parastomal Hernia)
Fig. 21.11 The onlay (prefascial) technique. After construction of the
neo-linea alba, a strip of prosthetic mesh 8–10 cm in width and 3–4 cm
longer than the abdominal wall closure is placed and secured with a
continuous peripheral suture of nonabsorbable suture material and a
continuous suture to attach the mesh to the midline closure
experienced recurrent hernias. In a telephone follow-up at 2
years 82% of patients were pain-free, 9% had occasional
pain, and 8% had pain limiting some daily activity indicating
not only a good anatomical outcome but an excellent physiological outcome with return of function of the abdominal
wall musculature.
The mesh should be approximately 10 cm in width in
order to get a 5 cm either side of the midline fascial closure.
If the midline fascial closure cannot be achieved without tension, then a components separation may be required. The
mesh is secured with a continuous suture with nonabsorbable or slowly resorbable material around the periphery of
the mesh with an additional reinforcing suture down the midline to fi x it to the fascial closure (Fig. 21.11 ).
Incision and Dissection
An elliptical incision removing the previous scar is used.
In order to perform the panniculectomy triangular wedges
of skin and subcutaneous fat are removed at the lower end
of the midline scar, which will eventually produce an
inverted T-shaped incision which requires closure with
care and accuracy. Beginning at the fundus of the sac, the
entire sac is carefully dissected down to its neck in order to
expose it completely without opening. At this stage the
skin fl ap should only be minimally dissected in order to
mobilize the sac and clearing an area of not more than
5 cm beyond the edge of the rectus muscle. The sac is now
opened, and any adhesions between the bowel, peritoneum,
and the sac are divided and abdominal contents returned to
the peritoneal cavity. In all cases the sac should now be
completely excised.
In all cases the surgeon should be able to completely
close the midline without tension. Where the width of the
gap between the rectus muscles is relatively small, the anterior rectus sheath on each side may be closed with a strong
running suture of nonabsorbable or slowly resorbable suture
material. Prior to doing this the anterior rectus sheath is
dissected from the subcutaneous fat for 5–7 cm to accommodate the onlay mesh. The mesh is now cut to size being
a width of 10 cm and allowing for 3–4-cm overlap superiorly and inferiorly. If the polypropylene or polyester mesh
is allowed to be in direct contact with intestine, there is a
risk of adhesion formation and fi stulation. There is also a
risk of mesh erosion into the bowel with these types of
meshes. In open prosthetic mesh repair there is no place for
the use of newer meshes with incorporated anti-adhesive
agents placed over the bowel as an inlay method without
midline fascial closure. These dual meshes are speci fi cally
for use by laparoscopic surgeons when placed over a defect
from inside the abdomen and in which contact with viscera
is inevitable. There are no long-term studies to verify
absence of complications seen many years after the insertion of such meshes. However, the use of such products has
been longer than 15 years.
The Sublay (Retrorectus, Rives) Repair
The sublay repair places the mesh in the retromuscular
space. Rives originally described this technique more than
30 years ago [ 93 ] . Placement of the prosthesis in the retro-
muscular plane requires opening of the rectus sheath near
the linea alba to gain access to this space on both sides.
After closure of the posterior rectus sheath the mesh is
placed on top of this behind the rectus muscles, and conclusion of the abdominal wall closure is achieved by suture of
the anterior rectus sheaths in the midline. Leaving a gap in
the anterior or posterior rectus sheath achieves poor results
and a high recurrence rate, and the relaxing incision in the
external oblique of “components separation” should be
applied in order to gain complete midline closure. The mesh
overlap achieved is similar to the onlay technique with
5–6 cm in all directions and gives good results [ 94, 95 ] . This
repair also gives good results in patients with large hernias
with signi fi cant loss of domain [ 96 ] .
Each rectus sheath is incised along its medial border and
opened in the midline to expose the anterior and posterior
aspects of the rectus muscle (Fig.
tion the entire width of the muscle is exposed on its undersurface super fi cial to the posterior rectus sheath (Fig.
The posterior rectus sheath is now closed with a continuous
21.12 ). With blunt dissec-
21.13 ).
338 A.N. Kingsnorth
Fig. 21.12 The medial border of the rectus sheath is incised along the
length of the fascial defect on both sides
Fig. 21.14 The posterior rectus sheath is closed with a nonabsorbable
suture. This should be achieved with negligible tension
Fig. 21.13 The bloodless plane behind the rectus muscle and anterior
to the posterior rectus sheath is dissected to the lateral limit of the rectus
muscle
running suture of nonabsorbable or slowly resorbable material and the mesh placed in the posterior retrorectus position
to occupy the width of the rectus muscles on both sides
(Fig. 21.14 ). A prosthetic mesh approximately 10 cm in
width and long enough to achieve a 3–4-cm overlap superiorly and inferiorly is now placed in the retrorectus space
(Fig. 21.15 ). To prevent migration or movement of the mesh,
a few absorbable sutures are placed between the mesh and
the posterior rectus sheath or peritoneum. It may be advisable to place a suction drain in the retrorectus position prior
to closure of the anterior rectus sheath, which is achieved by
a continuous suture of nonabsorbable or slowly absorbable
mono fi lament material (Fig. 21.16 ) .
Open Intraperitoneal Prosthetic Mesh Repair
This alternative technique has been popularized in one or
two French centers [ 97, 98 ] . The initial steps of the operation
are the same as for the onlay or sublay techniques with complete excision of the peritoneal sac to the medial edge of the
rectus muscles. The mesh is placed intraperitoneally with
5–6-cm overlap and secured by nonabsorbable through-andthrough sutures spaced 2 cm apart and 1 cm from the border
of the mesh. The sutures transverse the entire width of the
muscular fascial abdominal wall and also the subcutaneous
layers, and each is tied through a small incision in the skin.
Protagonists of this technique claim that the prosthesis acts
as a substitute for the abdominal wall avoiding suture of the
two opposite fascial edges of the defect with tension. The
muscular aponeurotic edges are closed in the midline as
much as possible to isolate the prosthesis from possible surgical skin contamination. The authors promoting this technique have not encountered problems with enterocutaneous
fi stula. If this method is used, the choice of a biologic mesh
will require the preservation of the hernia sac to be used as a
vascularized pedicle to allow for the proper resorption of the
collagen product.