Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1498_Библиотеки_им_академика_М_И_Перельмана.pdf
239
20. Polyester, Polypropylene, ePTFE for Inguinal Hernias
5. Di Vita G, Milano S, Frazzetta M, et al. Tension-free hernia repair is associated with
an increase in in fl ammatory response markers against the mesh. Am J Surg.
2000;180(3):203–7.
6. Calne RY. Repair of bilateral hernia. A technique using mersilene mesh behind the
rectus abdominus. Br J Surg. 1967;54(11):917–20.
7. Copello AJ. Technique and results of te fl on mesh repair of complicated re-recurrent
groin hernias. Rev Surg. 1968;25(2):95–100.
8. Earle DB, Mark LA. Prosthetic material in inguinal hernia repair: how do I choose?
Surg Clin North Am. 2008;88(1):179–201. x.
9. Shah BC, Goede MR, Bayer R, et al. Does type of mesh used have an impact on
outcomes in laparoscopic inguinal hernia? Am J Surg. 2009;198(6):759–64.
10. Gilbert AI, Felton LL. Infection in inguinal hernia repair considering biomaterials and
antibiotics. Surg Gynecol Obstet. 1993;177(2):126–30.
11. Agarwal BB, Agarwal KA, Mahajan KC. Prospective double-blind randomized
controlled study comparing heavy- and lightweight polypropylene mesh in totally
extraperitoneal repair of inguinal hernia: early results. Surg Endosc.
2009;23(2):242–7.
12. Deeken CR, Abdo MS, Frisella MM, Matthews BD. Physicomechanical evaluation of
polypropylene, polyester, and polytetra fl uoroethylene meshes for inguinal hernia
repair. J Am Coll Surg. 2011;212(1):68–79.
13. Yang J, Papandria D, Rhee D, Perry H, Abdullah F. Low-cost mesh for inguinal hernia
repair in resource-limited settings. Hernia. 2011;15:485–9.
14. Champault G, Bernard C, Rizk N, Polliand C. Inguinal hernia repair: the choice of
prosthesis outweighs that of technique. Hernia. 2007;11(2):125–8.
Part V
Essentials of Ventral and Incisional
Hernia Repair
243
B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair,
DOI 10.1007/978-1-4614-4824-2_21,
© Springer Science+Business Media New York 2013
21. Evolution of Incisional and Ventral
Hernia Repair
Malini D. Sur and L. Brian Katz
The dif fi culties of obtaining a “radical cure” in the
large ventral hernia are well known, and from time
to time various new principles have been
suggested.
H.C. Wardleworth Nuttall, FRCS, 1926
Despite numerous advances in surgical techniques over the last
century, successful long-term treatment of ventral hernias remains a
challenge for general surgeons. With a reported incidence between 9 and
20% after laparotomy, incisional hernias occur when there is a protrusion
of intra-abdominal contents through a postoperative abdominal wall
defect. They range from small, isolated fascial defects to large, complex
recurrent hernias with visceral involvement. Laparoscopy has helped
limit the need for laparotomy, but incisional hernias from prior midline
and transverse incisions as well as trocar and extraction sites continue to
pose a risk of life-threatening bowel obstruction and ischemia. Some
100,000–200,000 incisional hernia repairs are performed annually in the
United States with estimated rates of reoperation within 5 years of 12%
following the fi rst repair and 23% following the second repair [ 1 ] .
Methods of repair have changed over time and continue to vary across
institutions. In the last three decades, several randomized controlled
trials (RCTs) helped to compare surgical techniques and support
standardized approaches to treating patients with incisional hernias. The
aim of this chapter is to review the evolving management of ventral and
incisional hernias over the last 100 years with an emphasis on evidence-
based literature.
244
M.D. Sur and L.B. Katz
Prevention
A number of patient risk factors have been implicated in incisional
hernia formation, including obesity, chronic obstructive pulmonary
disease, immunosuppression, and steroid use. The development of
postoperative wound infection is also a particularly important predictor
of subsequent hernia formation. While many of these patient factors are
unavoidable, technical aspects of wound closure are important to consider
in hernia prevention. Surgical residents of past and present have been
lectured on the value of meticulous fascial closure technique in the
prevention of subsequent dehiscence. Taking wide tissue bites,
maintaining short intervals between stitches, and placing nonstrangulating
tension on sutures while knot-tying are thought to keep sutures from
tearing through fascial edges [
2 ] . Early descriptions of midline laparotomy
closure included continuous and interrupted suturing with either rapidly
or slowly absorbable suture material. In 2010, a meta-analysis of 14
RCTs evaluating techniques of elective midline laparotomy closure in
6,752 aggregated patients de fi nitively concluded that an elective primary
or secondary midline laparotomy has the lowest chance of progressing to
an incisional hernia when the fascia is closed in a continuous technique
using slowly absorbable suture [ 3 ] .
In addition to closure technique, incisional direction has been
suggested as a risk factor for hernia formation. Some surgeons argue that
the closure of a transverse incision allows sutures to be placed
perpendicular to the dominant fascial collagen bundles, thus theoretically
reducing the risk of sutures tearing through fascia. Transverse incisions
are also more often closed in two layers, offering greater wound strength.
The latest Cochrane review examining pooled data from 7 RCTs
comparing transverse and midline incisions for various abdominal
operations suggested a lower incidence of incisional hernia following
transverse laparotomy. However, the length and location of the incisions
varied across studies and follow-up ranged from 4 months to 4 years.
Long-term data on these patients would help support the notion that risk
of hernia formation should be considered when planning the direction of
a laparotomy incision [ 4 ] .
Finally, the concept of prophylactic use of mesh during laparotomy
closure in clean cases has become popularized over the last decade. Data
from a RCT comparing primary versus mesh closure in 85 patients
undergoing open abdominal aortic aneurysm repair between 2003 and
2007 found a signi fi cantly lower rate of incisional hernia formation over
3 years without mesh infections when a prophylactic mesh was used [ 5 ] .
245
21. Evolution of Incisional and Ventral Hernia Repair
Manual Reduction
The emergency department often requests surgical consultation for
suspected incarcerated ventral hernias. Patients typically present with
pain centered over a new and persistent bulge in the abdominal wall.
Obstructive symptoms are often present. Rarely, patients with a delayed
presentation may be fl oridly septic from strangulated bowel. Fever,
tachycardia, and leukocytosis with neutrophil predominance must be
noted. Abdominal scars should correspond to the given surgical history.
A tender, irreducible mass associated with a surgical scar suggests an
incarcerated incisional hernia. In the patient with a known chronically
incarcerated hernia, signi fi cant tenderness in other areas of the abdomen
should raise suspicion for other diagnoses.
For centuries, manual reduction or “taxis” was the only treatment for
incarcerated ventral hernias. In the late 1800s and early 1900s, surgeons
began to warn against the risk of returning compromised bowel to the
abdomen. Today, the question of when reduction is safe persists.
Erythema and crepitus over the hernia with associated peritonitis indicate
bowel ischemia, and immediate operative repair is usually indicated
without attempts at reduction. However, a delayed surgical approach
without reduction of herniated contents, when the patient is severely
dehydrated, has severe obesity and/or loss of abdominal domain, and
other extenuating circumstances may be appropriate if there is no
suspicion of strangulation. When overt stigmata of strangulation are
absent, successful reduction with delayed repair may avoid the increased
risks of emergent surgery in a patient with multiple comorbidities.
Harissis et al. followed 101 patients with incarcerated anterior abdominal
wall hernias after attempted reduction. In 60% of cases, the hernia was
successfully reduced, and the patient showed no signs of occult bowel
ischemia during 24-h observation. Although most underwent elective
repair within 30 days, some patients were lost to follow-up. In patients
with anticipated noncompliance with follow-up instructions, strong
consideration should be given to inpatient repair after hernia reduction
and medical optimization [ 6 ] .
246
M.D. Sur and L.B. Katz
Primary Suture Repair
For much of the twentieth century, ventral and incisional hernia repairs
were repaired primarily using suture alone. Primary incisional hernia
repair involves incising the skin through the prior scar and dissecting
down to the defect. The hernia sac is isolated and excised. Healthy fascial
edges are identi fi ed and joined together using nonabsorbable or slowly
absorbable sutures. It is now believed that more than half of all primary
ventral hernia repairs eventually fail, but the technique remains an option
in grossly contaminated cases where nonabsorbable mesh is contraindicated
or regions where mesh is unavailable. Many surgeons believe that small
defects less than 2 cm may be amenable to primary suture repair without
a long-term increase in recurrence risk compared to a mesh repair, but
data supporting this conclusion is lacking.
Component Separation
By the early 1900s, surgeons had recognized the challenges in
obtaining a lasting ventral hernia repair. The introduction of relaxing
aponeurotic incisions was an important step toward reducing tension in
primary suture repairs. In 1926, Nuttall described a method of “rectus
transplantation” in which the inferior edge of the rectus muscle was
detached from the pubic symphysis and transposed to the contralateral
side as an adjunct to a primary suture repair. The method of component
separation used today, however, is adapted from the technique described
by Ramirez et al. in 1990. This method initially requires dissection of
skin and subcutaneous fat away from the anterior rectus sheath and the
external oblique aponeurosis. The latter is then incised longitudinally
about 2 cm lateral to the rectus sheath and extended in either direction as
needed. Taking advantage of a relatively avascular plane, the external
oblique is then separated from the internal oblique muscle. For further
tension release, the posterior rectus sheath can be divided from the rectal
muscle. Recent descriptions of endoscopic and laparoscopic approaches
to component separation remain to be tested in high numbers. Despite
these advances in surgical technique, primary ventral hernia repairs
continue to be associated with high recurrence rates [ 7, 8 ] .
247
21. Evolution of Incisional and Ventral Hernia Repair
Mesh-Based Repair
In the late 1800s, Billroth foresaw the development of prosthetic
mesh when he wrote, “If we could arti fi cially produce tissues of the
density and toughness of fascia and tendon the secret of the radical cure
of hernia would be discovered.” Over the next century, surgeons came to
envision an “ideal” mesh that would have several additional qualities. In
a concise summary, Shankaran et al. described this ideal prosthesis as
noncarcinogenic; capable of being sterilized; chemically inert; unlikely
to produce a signi fi cant host immune response; resistant to mechanical
forces, infection, and visceral adhesions; and amenable to mass
fabrication in an affordable manner [ 10, 11 ] .
The fi rst prosthetic mesh was developed in 1900 when Witzel and
Goepel made silver fi ligrees by hand in Germany. Silver was thought to be
bacteriocidal, but its rigidity, slow disintegration, and propensity toward
sinus tract formation were problematic. Tantalum and stainless steel
meshes were introduced in the 1940s and 1950s, respectively, but their
stiffness caused patient discomfort. The development of fl exible plastic-
based prostheses in the mid-1900s was a major advance in hernia repair.
Nylon mesh was used in inguinal hernia repairs during World War II, but
its susceptibility to weakening from denaturation and hydrolysis was a
disadvantage. In the late 1950s, Usher fi rst described the use of a knitted,
polypropylene mesh for incisional hernia based on animal studies.
Polypropylene would go on to become the most widely utilized mesh for
ventral hernia repair today. Flexible and relatively affordable, polypropylene
mesh could be easily placed as an “overlay” to buttress a primary fascial
repair anteriorly. With their description of mesh placement in the
“preperitoneal” plane immediately posterior to the rectus muscle, Rives
and Stoppa, using a polyester mesh, independently helped to popularize
mesh repair. The creation of composite prostheses combining polypropylene
with adhesion-resistant coatings further expanded its versatility as an
“underlay” beneath the fascia within the peritoneum or as an “inlay” to
bridge a fascial defect. Polyester and expanded polytetra fl uoroethylene
prostheses have become increasingly popular in recent years [ 9, 10, 11 ] .
During the 1990s, Luijendkil et al. conducted the fi rst multicenter
RCT comparing outcomes of suture versus underlay polypropylene mesh
repair of primary and fi rst-time recurrent incisional hernia in 181 elective
surgical patients. The 3-year recurrence rate was 46% for suture repair
and 23% for mesh repair. In a follow-up study, the authors found a 10-year
recurrence rate of 63% for suture repair and 32% for mesh repair with no
signi fi cant difference in complications. Aside from suture repair, wound
248
M.D. Sur and L.B. Katz
infection and history of abdominal aortic aneurysm were independent risk
factors for recurrence. Hernia size did not affect the recurrence rate. Based
on this data, surgeons were encouraged to “abandon” primary suture
repair of incisional hernias, even for small defects [ 12, 13 ] .
In a retrospective analysis of incisional hernia repairs at 16 Veterans
Affairs Medical Centers (VAMC) between 1997 and 2002, Hawn et al.
found that the underlay mesh position, whether laparoscopic or open, was
speci fi cally associated with a signi fi cantly reduced risk of recurrence
compared to suture repairs. On the other hand, onlay or inlay mesh placement,
which comprised 30% of the repairs, did not appear to reduce the recurrence
risk when compared to suture repairs. There was no data suggesting that
mesh placement affected rates of enterocutaneous fi stula development [ 14 ] .
Interestingly, despite strong evidence supporting the utilization of
mesh in incisional hernia repairs, signi fi cant variability in the practice
still existed across the United States at the turn of the century. Using the
same VAMC data, Gray et al. showed that mesh was used in only 70% of
cases. The strongest predictor of mesh use was the hospital where the
operation was performed, with rates varying from 40% at one facility to
90% at another. Long-term facility-level analysis of this data showed that
the rate of mesh use at the hospital level was signi fi cantly associated with
the 5-year hospital recurrence rate for all cases. Speci fi cally, a 3%
decrease in the recurrence rate was associated with every 10% increase
in the rate of mesh use. Other complications and patient satisfaction was
not correlated with the hospital rate of mesh placement [ 15, 16 ] .
Advent of Laparoscopy
After the fi rst laparoscopic cholecystectomy by Muhe in 1985,
minimally invasive surgery was rapidly expanded to other common
operations in general surgery with the hopes of reducing postoperative
pain and length of stay. Leblanc is credited for having described the fi rst
laparoscopic ventral hernia repair in 1992. After pneumoperitoneum is
achieved and trocars are inserted, the fascial defect is visualized. Any
omental and intestinal adhesions are lysed to clear an approximately
4-cm circumferential margin of healthy fascia. The mesh is tailored to
the size and shape of the defect, and sutures may be placed for transfascial
fi xation. The mesh is inserted into the abdomen, and sutures are passed
through fascia using a suture passer. Circumferential fi xation is achieved
using tacks or additional transfascial sutures. A speci fi c advantage of the
249
21. Evolution of Incisional and Ventral Hernia Repair
laparoscopic approach is the ability to view the fascial defect and identify
visceral involvement while avoiding the pitfalls of a tedious anterior
dissection. Additionally, contact between the mesh and skin fl ora is
theoretically substantially reduced as the mesh is inserted into the
abdomen through a trocar. On the other hand, achieving laparoscopic
access involves inherent risks of inadvertent vascular or visceral injury.
An extensive lysis of adhesions, which is often required in complex
incisional hernias, is also considerably more challenging with the
physical constraints of laparoscopy.
Although some early voices called for widespread adoption of
laparoscopic ventral hernia repair, it was not until recently that randomized
studies demonstrated its ef fi cacy. Between 2004 and 2007, Itani et al.
performed an RCT across 4 VAMCs, assigning 146 patients with ventral
hernias to an open or laparoscopic repair. The laparoscopic group had
signi fi cantly lower pain scores, a shorter return to work activities, and
fewer complications such as wound infections and seroma formation at
8 weeks. The authors noted, however, serious complications such as
bowel injury, sepsis, and anesthesia-related problems only occurred in
the laparoscopic group. Overall rates of recurrence were similar in the 2
groups at 2-year follow-up [ 17 ] .
Questions remain regarding technical aspects of laparoscopic ventral
hernia repair, particularly with respect to the method of mesh fi xation to
the abdominal wall. In a recent study by Bansal et al., 68 patients with
ventral hernias were randomized to laparoscopic repair with tacker fi xation
after placement of four transfacial sutures or laparoscopic repair with
suture fi xation alone. Use of sutures alone was associated with signi fi cantly
longer operative time but less postoperative pain. No recurrences were
found in the short 3-month follow-up period. In an observational study
comparing 27 patients who underwent suture repairs to 21 patients who
had tack repairs, the recurrence rate was 14% at 18-month follow-up, but
no association with repair method was identi fi ed [ 18, 19 ] .
Evidence suggests that as experience with laparoscopic abdominal
wall hernia repair grows, long-term outcomes will improve. LeBlanc et al.
compared their fi rst 100 and second 100 laparoscopic ventral hernia
repairs and found that the later group had a lower recurrence rate, despite
older mean age and higher number of comorbidities. Traditional support
for an open approach to incarcerated hernias has also been challenged as
some studies suggest acceptable outcomes when emergent laparoscopic
repair is performed in experienced hands. Further studies are needed to
evaluate the long-term outcomes of laparoscopic repair methods [ 20, 21 ] .
250
M.D. Sur and L.B. Katz
Strategies for Contaminated Cases
Ventral hernia repair in a contaminated setting is a uniquely
challenging problem for the general surgeon. Mesh infection is a feared
postoperative complication often requiring emergency mesh removal.
The usual culprit is Staphylococcus aureus , often methicillin resistant.
Mesh infection is of special concern in contaminated cases. Contamination
may be present at the outset from a coexisting ostomy, an enterocutaneous
fi stula, a chronically infected wound, an infected mesh from a previous
repair, or strangulated bowel. Additionally, any clean case may become
contaminated after inadvertent bowel injury or concomitant bowel
resection. The traditional approach to ventral hernia repair in the presence
of contamination was limited to primary repair with or without component
separation. Over the last decade, however, surgeons have increasingly
utilized biologic mesh derived from bovine or human acellular dermal
matrix (HADM) in these repairs. The use of biologic mesh for ventral
hernia repair is discussed in detail elsewhere in this manual. One ongoing
concern is the signi fi cant cost of biologic mesh products, and this remains
a potential barrier to widespread use [ 22 ] .
Conclusion
Ventral hernia repair has considerably evolved over the last 100 years.
Use of synthetic mesh has become widespread and is associated with a
lower long-term recurrence rate. Familiarity with laparoscopic repair
methods is growing across academic and community settings. Continuous
advances in mesh technology may help to achieve improved mesh
prostheses. Many challenges remain, however. Standardized descriptions
of hernias and repair methods are needed so that prospective data analysis
is more accurate. Additional well-designed studies are needed to
understand long-term outcomes of various repair methods. Finally, as
improved mesh prostheses are developed, the overall value to the patient
and system must be taken into consideration to allow general utilization.
It will become increasingly important to understand the value of the mesh
and the entire treatment regimen, rather than focusing on costs alone.