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181
VI
Anatomical Limitations – Where Are the Layers?
the diaphragm with limited options for mesh fixation.
It should be kept in mind that mesh-related compli-
cations threaten if meshes are in direct contact with
intra-abdominal structures.
The standard procedure for incisional hernias of the
midline is the sublay technique. The mesh is covered by
tissue of the abdominal wall on both sides, the rectus
muscle externally and the posterior rectus sheath in-
ternally, thus preventing a direct contact with the intes-
tines. A sufficient mesh subduction cranial and caudal
of the defect can be achieved by incision of the posterior
rectus sheath on both sides of the linea alba, opening
the preperitoneal space that appears like a fatty triangle
[4]. In the case of neighbouring osseous structures, the
preparation can be extended into the retroxiphoidal or
retropubic area (
⊡
Fig. 21.4) [5].
This is different when the defect neighbours or
crosses the lateral margin of the rectus sheath, as oc-
curs in transverse or pararectal incisional hernias.
Due to the different muscular and fascial composition
of the lateral and medial compartment, the prepara-
tion of a mesh layer is more challenging. In the lateral
compartment the ideal anatomical layer is between the
external and internal oblique muscle. This avascular
connective tissue plane is known from the abdominal
wall separation technique of Ramirez [6]. In the case
below L. arcuata
above L. arcuata
⊡
Fig. 21.3. Anatomical-topographical
view of the components of the rectus
sheath above and below the arcuate line
⊡
Fig. 21.4. Mesh position and neigh-
bouring osseous structures in different
techniques
182 Incisional Hernia
21
of incisional hernia defects crossing the compartments,
a mesh extension from the medial-retromuscular to
the lateral-intermuscular layer (between external and
internal oblique muscle) is a possibility to fulfil the pos-
tulates of mesh repair.
References
1. Prescher A, Lierse W (2000) Anatomie der ventralen
Leibeswand. In: Schumpelick V (Hrsg) Hernien. Thieme,
Stuttgart, pp 1–27
2. Prescher A (1999) Surgical anatomy of the abdominal wall.
In: Incisional Hernia. Springer, Berlin Heidelberg New York,
pp 45–60
3. Klinge U, Prescher A, Klosterhalfen B, Schumpelick V (1997)
Development and pathophysiology of abdominal wall de-
fects. Chirurg 68: 293–303
4. Conze J, Prescher A, Klinge U, Saklak M, Schumpelick V (2004)
Pitfalls in retromuscular mesh repair for incisional hernia: the
importance of the “fatty triangle”. Hernia 8: 255–259
5. Conze J, Prescher A, Kisielinski K, Klinge U, Schumpelick V
(2004) Technical consideration for subxiphoidal incisional
hernia repair. Hernia 9(1):84-7
6. Ramirez OM, Ruas E, Dellon AL (1990) “Components separa-
tion” method for closure of abdominal-wall defects: an ana-
tomic and clinical study. Plast Reconstr Surg 86:519–526
Discussion
Frantzides: I don’t advocate an overlap of 2 cm, but what
I use personally is at least 3cm overlap. The data show,
however, based on the 53 papers that I have reviewed,
that it doesn’t matter, there is no statistical significant
difference if the overlap is 2 or 5cm.
Conze:
If we talk about evidence and prospective stud-
ies, there are only two studies, that is the study from
Luijendyk/The Netherlands and the Vypro I study. The
Luijendyk study had an overlap of 2cm and didn’t close
the fascia in front of the mesh in all cases. This study,
with the follow-up by Burger, has a high recurrence rate
and is always mentioned to show the limitations of this
technique; but we should also look at the limitations of
this study protocol, where augmentation and bridging
techniques are mixed together. In the Vypro I study there
was an overlap of 5cm, with a result of 12% recurrences
after 24 months compared to 23% in the Luijendyk study.
So I believe there is considerable importance concerning
the overlaps and again, the mesh polymer and structure
has also a great impact.
Deysine:
You have presented us with a challenge that
will demand another conference. Basically, if you ap-
proach a flank hernia, e.g. postnephrectomy, it is easy
to anchor the mesh in the front, but then at the top you
have to anchor it to the rib and in the lower abdomen
you have nothing to anchor to. There is no answer to
this. Most of the talks on abdominal ventral hernia
repair don’t face this problem. It will require a lot of
imagination, so I congratulate you on opening this prob-
lem.
Conze:
It’s not only in the talks that you don’t find this
topic, its also missing in all the hernia books.
Bendavid: I have seen at least six cases of iliac crest her-
nias that were quite generous, and I have never had any
problem, because all I have done was drill holes, up to
nine of them, and anchor a Marlex or polypropylene mesh
of any kind.
Conze:
How is the mobilization of the patient afterwards?
I am afraid that might cause some limitations, most cer-
tainly if you take heavy-weight meshes.
Bendavid: None whatsoever.
Flament:
The only point where I disagree totally with you
is when you write “no mesh fixation to body structures”.
At the end of the 19th century, anatomists showed that
with three stitches through the Cooper ligament you can
lift the cadaver. Why not use these thick structures, e.g.
the iliac crest, to put stitches in?
Conze:
I personally believe that the abdominal wall is
something dynamic and I want to keep it like this. Mesh
fixation to osseous structures will have an influence on
the mobility and dynamic.
Schumpelick:
We have learned from Rene Stoppa that
a large overlap is better than fixation, and there is no
fixation in the Stoppa procedure!
VI
22 Biomechanical Data – “ Hernia Mechanics”:
Hernia Size, Overlap and Mesh Fixation
Introduction
Mesh repair has not been able to eliminate hernia recur-
rence. Therefore several possible biomechanical causes
have been accused: the size of the prosthesis, the extent of
surgical dissection, the overlap of the mesh and whether
it is properly secured, all have been shown to affect the
risk of recurrence after hernia repair.
Secure mesh fixation is intended to prevent the risk of
recurrence due to implant dislocation caused by abdomi-
nal shear forces. The fixation of biomaterials is required
until sufficient ingrowth has made collagen impregnation
sufficiently strong to ensure repair of the fascial defect.
Whereas there is controversy about the need for fixation
in preperitoneal inguinal hernia repair ( sublay position),
there is consent that an additional mesh fixation in an-
terior inguinal ( onlay position) and all types of incisional
hernia repairs seems to be essential.
In preperitoneal repairs, the fixation of the prosthe-
sis is postulated to be strong enough based only on the
physiological intra-abdominal pressure and no additional
suturing or fixing is mandatory in the case of a sufficient
overlap. On reviewing the literature, a lack of biomechani-
cal data regarding this problem becomes apparent. There-
fore we developed a standardized hernia simulation model
to investigate possible correlations between hernia size,
overlap and mesh fixation.
Design of the Hernia Test Stand
and Methods
⊡
Fig. 22.1
▬
▬ The standardized abdominal wall is patterned by a
▬
▬ The measurement device to determine the protru-
184 Incisional Hernia
22
Overlap and Mesh Fixation: Sublay Setup
⊡
Figs.22.1 and 22.2
⊡
Fig. 22.1. Standardized model for abdominal wall hernia simulation, the hernia test stand. Monitoring of the mesh dislocation
(left) and protrusion of the mesh and abdominal wall (right) during pressure enhancement
⊡
Fig. 22. 2. Circular defect in a simulated
sublay repair
peritoneum
mesh
muscular tissue
fascia
adominal pressure
Sublay
185
VI
Biomechanical Data – „Hernia Mechanics“: Hernia Size, Overlap and Mesh Fixation
⊡
Fig. 22.3
⊡
Fig. 22.3).
⊡
Fig. 22.4). None of the ten meshes was
⊡
Fig. 22.3. Simulation of a
sublay repair without mesh
fixation (initial overlap 2 cm)
and movement of the mesh
on the muscle during pressure
enhancement
⊡
Fig. 22.4. Post trial: sublay simula-
tion (1.5 cm overlap) following non-fixa-
tion (dislocation through the defect at
150 mmHg) and fibrin sealant (no move-
ment or dislocation after pressures up to
200 mmHg)
⊡
Fig. 22. 5. Face of contact between mesh
(Ultrapro®) and abdominal wall following
different fixation techniques (non-fixation
vs. eight single sutures vs. fibrin glue. Mesh
in a sublay position bridging a 3-cm defect
by a 1.5-cm overlap
0 mmHg 100 mmHg 150 mmHg post trial
brin
sutures
non-
xation
186 Incisional Hernia
22
⊡
Fig. 22.5
Fixation of Meshes: Onlay Setup
⊡
Fig. 22.6
Conclusions
Discussion
Miserez:
Firstly, there was a paper published 2 or 3 years
ago with a similar high-pressure chamber where Vypro
did not perform very well; with a collapse of the mesh
in the different experimental setups. Secondly, I am still
struggling with the tensile strength of the abdominal wall,
hernia orice open
mesh dislocation
4 SS
0
100
200
50
150
250
6 SS 4 SS and RS Fibrin Fibrin and RS
⊡
Fig. 22.6 . Onlay simulation and fixation
of the mesh by single sutures (SS) or fibrin
sealant (fibrin) and additional closure of
the defect by running sutures (RS)
187
VI
Biomechanical Data – „Hernia Mechanics“: Hernia Size, Overlap and Mesh Fixation
16 or 32 N, is this in both the transversal and longitudinal
direction the same or is it different?
Schwab:
They explanted, we have standardized. These
are the calculated forces, we don’t know the forces.
Kukletta:
It is very impressive how fibrin glue, which is
not a glue, improved your results. Did you think of using
a glue that really is a glue, because fibrin doesn’t have any
adhesive strength?
Schwab:
Although fibrin is not glue it has adhesive
strength; you can take some fibrin and lift a Swiss
chocolate of 200 g without any problem. It is not a
question of taking a glue at each edge point. The fu-
ture could be to coat the mesh with a glue so that the
mesh doesn’t move at all. The peaks at square millime-
tres are smaller than if you have three or four fixation
points.
Carlson:
My summary of how to perform a suture repair:
in general don’t do it except in very limited indications
like small defects (fingertip size) or infected wounds.
Flament: In open incisional hernia repair we favour the
open sublay technique, for most but not all types of in-
cisional hernia, with a low rate of septic complications,
and good functional and cosmetic results. When this is
not possible, we need a very dedicated mesh for intra-
abdominal placement. We must not forget that these
hernias are a general disease, and we must have a very
long follow-up, since 8–10% of the recurrences occur after
10 years. So retromuscular seems better, though I still do
not understand why not fix the mesh also to the bone as
you stitch the mesh all around the abdominal wall? For
a small number of patients we need a good prosthesis for
intra-abdominal placement.
Concluding Remarks
VII
How to Treat the Recurrent
Incisional Hernia
23 Open Repair 191
24 Laparoscopical Repair 223
VII
23 Open Repair
Introduction
Even with the routine use of mesh, repair of an incisional
hernia is a challenge. Increasing evidence of impaired
wound healing in these highly selected patients supports
routine use of an open prefascial, retromuscular mesh repair
(
⊡
Fig. 23.1
). Basic pathophysiological principles dictate
that a wide overlap underneath healthy tissue is required
for a successful long-term outcome and prevention of re-
currence. The extent of overlap should be 5 cm in all direc-
tions: surrounding the fascial wound closure, subxiphoidal,
underneath the ribs, below the arcuate line and retropubic.
Generally, it is not the preparation of the hernia sac or the
dissection of the mesh area that generates difficulty during
the management of recurrent incisional hernias, but it is the
patients and their comorbid conditions which may cause
some troubles and delay the reconvalescence.
Pathophysiological Concept
For decades incisional hernia was hypothesized to be
caused mainly by technical problems with suture tech-
nique. Consequently, correction of this problem was
undertaken by a repeat, but more meticulous, suture
repair with a variety of configurations to prevent re-
recurrence. Additional doubling of the fascia to rein-
force the abdominal wall was performed in some cases.
Whereas the intra-operative aspects were ostensibly
satisfying, the long-term results were disappointing.
Recurrence rates of 50% after suture repair of an in-
cisional hernia were reproduced in several studies [2,
19]. It was the introduction of mesh by Usher et al. in
1958 that opened a new era [20]. Reinforcement of the
abdominal wall with strong polyester or polypropylene
nets produced a resilient scar–mesh compound that
23.1 How to Treat the Recurrent Incisional Hernia: Open Repair in the Midline
V. S, U. K, R. R, J. C, K. J
⊡
Fig. 23.1. Mesh position in retromuscular,
prefascial (sublay) position
192 How to Treat the Recurrent Incisional Hernia
23
prevented recurrences through the mesh. Indeed, re-
currences through mesh are still a rarity. In accordance
with the widespread use of mesh, several personal series
reported excellent results, with recurrence rates of far
less than 10%. Examination of the literature shows that
the results are independent of mesh type and opera-
tive technique [11, 18]. This early euphoria has been
recently clouded by the results of the only randomized,
controlled trial that has compared mesh and suture re-
pair [1, 16]. In this Dutch trial, a mesh was applied in a
prefascial, retromuscular position with an overlap of 2
to 4 cm. After 3 years there were 43% recurrences in the
suture group, as expected. However, the authors found
24% recurrence in the mesh group as well. Interestingly,
the results were not affected by the size of the hernia.
Furthermore, in 2003 a retrospective population-based
cohort study by Flum et al. analyzed data from 10,822
patients operated on for incisional hernia by either su-
ture or unspecified mesh repair [5]. Within 5 years,
14% of the patients after suture repair underwent at
least one subsequent re-repair compared to 11% after
mesh repair (log-rank differences, p < 0.001). First,
both studies clearly reveal a reduced recurrence rate
after mesh implantation at any time point. The lower
rate seen by Flum et al. might be due to the fact that
several patients with a relapse have not undergone re-
operation. Nevertheless, the most striking fact is that
both studies unexpectedly found a constantly rising
incidence of hernia recurrence over the years of fol-
low-up, not only in the suture group but in the mesh
group as well. Over a decade, this recurrence rate shows
an almost linear curve. Comparing suture to mesh, the
implants seem only to delay the recurrence for 2 to 4
years and the time course never reaches a plateau. These
data substantiate that the development of a recurrence
in an incisional hernia repair is not primarily a techni-
cal one. Recently, molecular biological investigations
have proven the theory of disturbed composition of
the extracellular matrix in patients with recurrent her-
nia. In particular, there is a decreased ratio of collagen
types I and III [7, 9, 10, 12, 13]. Furthermore, in situ
dysfunction in fibroblasts has been found, indicating a
primary malfunction of the cells independent of their
local environment.
Reinforcement of the closed hernial gap by mesh
is based on the concept of ingrowth of fibrous tissue
into prosthetic material, forming a scar–mesh com-
pound. Although the intensity of the scar formation
is influenced by the amount of material, its quality is
not improved [8]. As a consequence, mesh fixation
by fibrosis cannot prevent recurrence unless a wide
overlap underneath healthy tissue can be achieved.
Although such data are not yet published, it may be
hypothesized that the width of the overlap correlates
with the duration of the delay. However, clinical experi-
ence with all techniques developed in recent years has
uniformly shown a trend towards utilizing larger pros-
theses.
In conclusion, a defective process of wound heal-
ing should be assumed in patients suffering from in-
cisional hernia. Rare exceptions refer to patients with
a traumatic defect or an obvious technical fault (e.g.
unclosed trocar incisions or broken suture material).
Consequently, every connection end-to-end has to be
regarded as a weak point and should be avoided.
In accordance, every surgical technique has to
consider this biological cause for the incisional hernia.
Taking into account an insufficient scar formation, this
lead to the requirement of an extended overlap, and it
is the frontal coverage with a large area of healthy tis-
sue which hinders the hernia recurrence at the mesh
border.
This principle must be carefully considered regard-
ing technique and performance, and the surgeon has
to decide where to place the mesh, and how to achieve
the demanded overlap.
From our experience, the placement of a mesh
behind the rectus muscles, above the linea arcuata in
front of the posterior rectus sheath is advantageous. In
contrast to a mesh in front of the fascia in onlay posi-
tion, the sublay mesh position facilitates a sufficient
subduction of intact linea alba, even behind the xiphoid
or pubic bone. It is the retromuscular mesh with a fascia
closure in front, which is kept in position just by tissue
ingrowth and intra-abdominal pressure, whereas the
onlay mesh has to be fixed additionally by permanent
sutures. The mesh in the space behind the rectus muscle
can be easily dissected, whereas the extended prepara-
tion of the subcutaneous space in the case of the onlay
position frequently is accompanied by haematoma or
seroma, in the case of infection sometimes even lead-
ing to a disaster.
Incisional Hernia Repair in the Midline
Using a Retromuscular, Prefascial Mesh
Prosthesis ( Sublay Repair)
Apart from surgical repair, there is no alternative treat-
ment for incisional hernia. Hernia repair should be
considered early because of the tendency for the de-
fect to increase in size and impair quality of life. Apart
from previous technical faults or traumatic defects
of the abdominal wall, the surgical technique should
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