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193
VII
Open Repair
routinely include the use of mesh. The only exception
may be small defects of less than 3 cm, which can be
closed by a continuous nonabsorbable suture repair (a
suture length/wound length ratio of 4:1). In the case of
a giant hernia or obesity, pre-operative improvement
of respiratory function and reasonable weight reduc-
tion [3] should be encouraged. Additionally, the skin
should be in optimal condition to minimize the risk of
infection. Pre-operative bowel preparation and peri-
operative antibiotics are advisable. In principle, flat
mesh is placed in a prefascial, retromuscular position
to reinforce the fascia closure and form an extended
mesh–scar compound. After excising the entire skin
scar, the hernia sac is prepared down to the margins of
the fascia. The sac then is opened, and local adhesiolysis
eases the complete opening of the previous incision.
For midline incisions, the retromuscular space behind
the rectus muscles and in front of the posterior rectus
sheath (prefascial) is bluntly dissected. The neuro-vas-
cular bundles at the lateral part should be preserved as
carefully as possible. At the cranial margin, the posterior
sheath is incised on both sides parallel to the linea alba.
A triangle of preperitoneal fat with separating fascial
margins them becomes apparent (
⊡
Fig. 23.2a) [4]. To
realize a sufficient overlap (at least 5 cm), preparation
continues far behind the xiphoid. Similar preparation
is needed at the caudal margin of the fascial incision,
where below the arcuate line the disappearing poste-
rior rectus sheath demands dissection in the fatty pre-
peritoneal space. Finally, the mesh is placed behind
the pubic bone in front of the bladder (
⊡
Fig. 23.2b
).
It is advisable to complete the circular preparation of
the preperitoneal mesh placement before closing the
peritoneum to avoid damage during the dissection to
closely attached bowel or organs.
A major task is the prevention of direct contact be-
tween the bowel and the mesh prosthesis to avoid dense
adhesions or late fistulas. Thus, the peritoneum or, if
necessary, hernia sac tissue must be carefully closed by
continuous absorbable suture. A further interposition
of omentum might be helpful, especially in cases of
peritoneal defects. After careful control for bleeding, the
mesh is trimmed to fit the specific dimensions of the
defect to be treated. Usually, implants have a width of 12
to 14 cm and a length of 20 to 35 cm (
⊡
Fig. 23.3).
Respecting the physiological elasticity of the abdom-
inal muscle fibres, the mesh should feature its main
elasticity in a vertical direction. This ensures adapta-
tion to the physiological stretchability of the abdomi-
nal wall and reduces craniocaudal shrinkage by mesh
deformation. An overall overlap of at least 5 cm in all
directions is mandatory (
⊡
Fig. 23.4). To prevent early
dislocation, the unfolded mesh is fixed circularly to the
⊡
Fig. 23.2a,b. Preparation of the (a) cranial and (b) caudal border
⊡
Fig. 23.3. Mesh placed in retromuscular, prefascial position
a b
194 How to Treat the Recurrent Incisional Hernia
23
posterior rectus sheath and the peritoneal sac below
the arcuate line, respectively. It remains controversial
as to whether the use of non-absorbable sutures is ab-
solutely indicated. During fascia closure, wrinkling of
the mesh should be avoided. After placing drains in
the retromuscular space, the anterior fascia is closed
by non-absorbable continuous suture respecting a 4:1
ratio for suture/wound length. Working as thrust-bear-
ing and preventing early strain to the mesh, closure
of the fascia is imperative. If closure of the anterior
fascia occurs with undue tension, relaxing incisions
in the anterior rectus sheath or an additional Ramirez
component separation is added. Skin closure follows as
usual. Postoperative care is mainly directed to the con-
trol of wound problems. Because the mesh is assumed
to be integrated, mobility restriction is required for no
longer than 1 week. Only the repair of giant hernias
sometimes demands prolongation of postoperative arti-
ficial respiration until respiratory function has fully rec-
overed.
⊡
Fig. 23.4a–d. Technical pitfalls: a pseudo-
recurrence due to insufficient excision of
the entire fascial scar. b Recurrence at the
borders due to insufficient overlap at the
margins (fatty triangle, retropubic space).
c Cranial border recurrence due to insuf-
ficient preparation behind the xiphoid
(subxiphoidal space). d Central mesh re-
currence due to insufficient closure of the
anterior rectus sheath
a
b
c
d
195
VII
Open Repair
Technical Pitfalls
Lateral to the rectus sheath and crossing the linea semi-
lunaris, a sufficient overlap of healthy tissue is more
difficult to achieve. In such cases, the posterior rectus
sheath must be cut in proportions similar to the prepa-
ration lateral of the linea semilunaris. Further laterally,
the dissection has to create a new preperitoneal space. If
this is not feasible, the transverse and internal oblique
muscles must be separated. Preservation of the nerves
innervating the rectus muscles and running at the dor-
sal side of the internal oblique is mandatory.
However, sufficient overlap of the ribs sometimes
cannot be achieved owing to the insertion of the dia-
phragm. In cases of extended abdominal wall defects
and failure to achieve closure of the fascia in front of
the mesh, materials with a tensile strength of > 32
N/cm are recommended to avoid central mesh rup-
ture.
Results from our institution have shown that large-
pore meshes with a tensile strength of 16 N/cm are in-
sufficient in such cases if used as a single layer.
Results
Postoperative results are frequently complicated by se-
roma formation, wound infections, wound discomfort
and recurrence. Whereas a sizable seroma is seen in
about 30% of the patients, it rarely requires re-inter-
vention apart from intermittent aspiration. However,
there are always some few patients with excessive fluid
accumulation around the wound who require surgical
intervention and removal of the seroma capsule, which
may have persisted for months. Infections may be ex-
pected in about 10% of the patients. Usually restricted
to the subcutaneous space, they should be treated con-
servatively as common wound infections. Even if the
infection encroaches into the mesh itself, a conserva-
tive attempt is justifiable, provided the mesh is porous.
Late infections appearing after months or even years
are more challenging. They are often combined with
complex fistulas including bowel [14]. In these cases,
preservation of the mesh is likely to fail, and sooner
or later most of the mesh has to be removed. After a
temporary mesh-free closure, any subsequent mesh
repair should be performed no sooner than 6 months
later. Moderate complaints after incisional hernia repair
are quite common, especially in patients with a long
history of previous incisions.Fortunately, the develop-
ment of a stiff abdomen is rare, although it sometimes
requires a mesh exchange [15]. Whether modern large-
pore meshes with preserved elasticity can prevent this
unpleasant complication is not yet clear.
Summary
Despite recurrences after mesh implantation, the re-
cently published data are encouraging. These series
prove the superiority of mesh compared to simple su-
ture repair. In summary, the use of mesh can reduce
the recurrence rate from 40 to 50% to about 10% [17].
Even if this effect represents only a delay in the appear-
ance of a recurrence, it reduces morbidity and the rate
of re-operation required for re-recurrence. Perhaps an
extensive overlap can prolong this delay for the rest of
the patient’s life. Lacking valid data, mesh should be
positioned behind the abdominal wall muscles (sublay
technique) using physiological abdominal wall pres-
sure for further fixation of the implant. If (and only
if) retromuscular placement cannot be achieved, an
onlay implant is justified. In the absence of results from
randomized trials, closure of the covering fascia is pre-
ferred with non-absorbable suture material. Extended
defects of the abdominal wall where the fascia cannot
be closed and the mesh is used to bridge the defect
must be reinforced by materials with a tensile strength
of > 32 N/cm.
Further technical pitfalls mainly refer to anatomy but
usually can be answered successfully. Mesh explantation
is strictly limited to patients with complex infections
or a stiff abdomen.
References
1. Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG,
Jeekel J. Long-term follow-up of a randomized controlled
trial of suture versus mesh repair of incisional hernia. Ann
Surg 2004; 240(4): 578–583
2. Cassar K, Munro A. Surgical treatment of incisional hernia.
Br J Surg 2002; 89(5): 534–545
3. Chan G, Chan CK. A review of incisional hernia repairs: pre-
operative weight loss and selective use of the mesh repair.
Hernia 2005; 9(1): 37–41
4. Conze J, Prescher A, Klinge U, Saklak M, Schumpelick V.
Pitfalls in retromuscular mesh repair for incisional hernia:
the importance of the “fatty triangle”. Hernia 2004; 8(3):
255–259
5. Flum DR, Horvath K, Koepsell T. Have outcomes of incisional
hernia repair improved with time? A population-based anal-
ysis. Ann Surg 2003; 237(1): 129–135
6. Israelsson LA. The surgeon as a risk factor for complications
of midline incisions. Eur J Surg 1998; 164(5): 353–359
7. Jansen PL, Mertens PP, Klinge U, Schumpelick V. The biology
of hernia formation. Surgery 2004; 136(1): 1–4
196 How to Treat the Recurrent Incisional Hernia
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8. Junge K, Klinge U, Klosterhalfen B, Mertens PR, Rosch R,
Schachtrupp A et al. Influence of mesh materials on col-
lagen deposition in a rat model. J Invest Surg 2002; 15(6):
319–328
9. Junge K, Klinge U, Klosterhalfen B, Rosch R, Stumpf M,
Schumpelick V. Review of wound healing with reference to
an unrepairable abdominal hernia. Eur J Surg 2002; 168(2):
67–73
10. Junge K, Klinge U, Rosch R, Mertens PR, Kirch J, Klosterhal-
fen B et al. Decreased collagen type I/III ratio in patients with
recurring hernia after implantation of alloplastic prostheses.
Langenbecks Arch Surg 2004; 389(1): 17–22
11. Kingsnorth A, LeBlanc K. Hernias: inguinal and incisional.
Lancet 2003; 362: 1561–1571
12. Klinge U, Si ZY, Zheng H, Schumpelick V, Bhardwaj RS,
Klosterhalfen B. Abnormal collagen I to III distribution in
the skin of patients with incisional hernia. Eur Surg Res 2000;
32(1): 43–48
13. Klinge U, Si ZY, Zheng H, Schumpelick V, Bhardwaj RS,
Klosterhalfen B. Collagen I/III and matrix metalloprotein-
ases (MMP) 1 and 13 in the fascia of patients with incisional
hernias. J Invest Surg 2001; 14(1): 47–54
14. Leber GE, Garb JL, Alexander AI, Reed WP. Long-term com-
plications associated with prosthetic repair of incisional
hernias. Arch Surg 1998; 133(4): 378–382
15. LeBlanc KA, Whitaker JM. Management of chronic postopera-
tive pain following incisional hernia repair with Composix
mesh: a report of two cases. Hernia 2002; 6(4): 194–197
16. Luijendijk RW, Hop WC, van den Tol MP, de Lange DC,
Braaksma MM, IJzermans JN et al. A comparison of suture
repair with mesh repair for incisional hernia. N Engl J Med
2000; 343(6): 392–398
17. Millikan KW. Incisional hernia repair. Surg Clin North Am
2003; 83: 1223–1234
18. Morris-Stiff GJ, Hughes LE. The outcomes of nonabsorb-
able mesh placed within the abdominal cavity: literature
review and clinical experience. J Am Coll Surg 1998; 186(3):
352–367
19. Paul A, Korenkov M, Peters S, Kohler L, Fischer S, Troidl H.
Unacceptable results of the Mayo procedure for repair of
abdominal incisional hernias. Eur J Surg 1998; 164(5): 361–
367
20. Usher F, JL O, Tuttle LJ. Use of Marlex mesh in the repair of
incisional hernias. Am Surg 1958; 24: 969–974
21. van ‘t RM, Steyerberg EW, Nellensteyn J, Bonjer HJ, Jeekel J.
Meta-analysis of techniques for closure of midline abdominal
incisions. Br J Surg 2002; 89(11): 1350–1356
Discussion
Jeekel:
You talk about bridging. Why don’t you put the
mesh in and leave it with 6-cm overlap and why do you
take so much effort to close the fascia?
Schumpelick:
I think that bridging is only necessary if
you have no other chance of making a sublay or onlay.
If you have a big defect and can’t close the defect, we call
that bridging when you replace the abdominal wall by
mesh. We put the mesh behind or in front of the fascia.
But this in only necessary in very rare cases with gigantic
defects. Usually we try to close this defect.
Jeekel:
We never close the defect, because you get tension
on the muscles again.
Schumpelick:
We are afraid of blowing the mesh through
the defect, when there is no thrust bearing in front of it.
Jeekel:
In our trial we did not see that in any case. Should
we still do a randomized controlled trial on the kind of
mesh? Because I do not think we have real problems
with heavy polypropylene meshes. Should we also try to
do a randomized controlled trial to prove, for example,
whether to put it retromuscular or to put the retrorectus
sheath on top of the peritoneum or to put it intraperitone-
ally on top of the omentum?
Schumpelick: I think it is not proven which mesh is the
best. We should do randomized controlled trials. We need
good criteria to describe the effects, not only elasticity of
the abdomen, infection morbidity etc.
Jeekel: Maybe also in the intraperitoneal position?
Schumpelick:
In the beginning we tried to put it between
rectus sheath and peritoneum, this space is really difficult
to get at. Untill now we are reluctant to place meshes within
the abdominal cavity, because we do not know how it works.
The new meshes may work well in the abdomen.
Kingsnorth:
First, no one has yet made any mention of the
material analysis done by Korenkov, presented at the ex-
perts’ meeting that took place in 1999, seven studies with
sublay and 11 with onlay, and no differences between the
results of the two techniques. You have been telling us,
that it is the best. But the best compared between what?
Because there really are no data to compare, to look at
individual series, and one meta-analysis by Korenkov in
fact shows a similar quality between the two. The next
thing is, the laparoscopic versus open trial in Europe using
the sublay as the open method. In America they use the
onlay as the open method, because I think that is the best
practice for incisional hernia repair. So, we have a differ-
ence here between Europe and America, they are using
different techniques. My final point is about the mesh; you
didn’t mention a lot about the data from the trial that
was published in December 2005, which was the primary
outcome looking at the quality of life and the abdominal
wall compliance. There is no difference between the two
groups. This scar-plate impression of the polypropylene
versus light-weight mesh does not exist, because all the
symptoms were the same in both groups. The recurrence
rate was three times higher with light-weight mesh. I don’t
think the case is proven yet. Light-weight mesh is a good
concept, but I think it is one thing we need to pursue, and
at the moment there is no proof and no comparative data
that suggest that it is better.
197
VII
Open Repair
Schumpelick:
Yes, you are right. Our randomized multi-
center trial did not show the expected results. Recurrences
were seen only in 3 of 8 centres, making a technical reason
very likely. You are right, so far there is no proven study
to show that light-weight meshes are better, but also no
proven study shows the opposite.
Kingsnorth:
Well, is there a randomized study? Light-
weight versus heavy-weight? Is there any study existing
on the abdominal wall compliance and the quality of life
measures? In the Vypro II group, which is a very light
mesh against polypropylene mesh there was no difference:
this was a randomized trial.
Schumpelick: Make some more studies, with a standard-
ized surgical technique and you will see that it works.
There is no recurrence by mesh, but by technique. From
theoretical point of view, it will be better, but it is only an
opinion. I think the onlay technique is simple and feasible,
but we fear the problems of subcutaneous infection. We
have seen skin necrosis, even in your study. That is a real
problem of onlay meshes.
Itani:
I’d like to make a quick comment about the Ameri-
can trial. When the investigators met to decide which
technique to use in the open repair, they were very much
aware of the European consensus and about the sublay re-
pair. They decided concisely that, in order not to replicate
the laparoscopic repair with the open one, an onlay repair
using the Chevrel technique would be very appropriate. So
far, we have had very good results. Of course, this study is
randomized, so we don’t know which one is better, but the
investigators have now adopted this repair in their general
practice, because they were so happy with it on trial.
Schumpelick: We will see the results.
Introduction
The treatment of incisional hernias outside the rectus
sheath is still a challenging procedure, when done as retro-
muscular sublay repair. There are an amazingly small num-
ber of publications about this field of hernia surgery and
therefore any evidence-based data are lacking. It is also
impossible to find any guidelines helping to perform such
an operation.
All these facts lead to the hypothesis that the repair
of incisional hernia outside the midline is a kind of free-
style surgery.
To test this hypothesis and to reject it, we performed
some anatomical studies using fresh-frozen corpses
to find rules of treatment. We also present some cases
of treated patient with different kinds of lateral her-
nias.
The main problem of sublay repair is to maintain the
principle of adequate overlap of the mesh underneath
healthy tissue. The challenge regarding lateral hernias is
the question, of which anatomical layer has to be used
to create the maximal overlap with the minimal side-ef-
fects?
In our view, we have to distinguish between two main
types of lateral hernias: hernias partly outside the rectus
sheath and lumbar hernias.
Hernias Partly Outside Rectus Sheath
If the preparation has to be done below the arcuate line,
the lateral extension of the preparation can be done eas-
ily on the layer of the preperitoneal space. A mainly
blunt dissection is able to create an adequate overlap
to both lateral sides. More challenging seems to be the
preparation above the arcuate line, e.g. repair of an in-
cisional hernia after subcostal incision. Theoretically,
there are two possible layers of preparation. It is pos-
sible to dissect between the external and the internal
oblique muscle or between the internal oblique and the
transverses muscle.
⊡
Figure 23.5
illustrates why the
anatomical circumstances lead to a preparation between
internal oblique and transversal muscle when leaving
the rectus sheath laterally. This is, in fact, a useful layer
to place the mesh with adequate overlap, if you do not
have to extend the preparation into the lumbar region.
If an extended preparation to the lateral side is nec-
essary, a dissection between the two oblique muscles is
recommended, because the segmental nerves and blood
vessels are lying on the transversal muscle laterally. To
reach the layer between external and internal oblique
muscle, e.g. repair a hernia after subcostal incision, the
dissection should begin at the lateral side and then go
further to the lateral border of the rectus sheath.
23.2 Sublay: Incision Crossing the Linea Semilunaris
M. S, J. C, A. P, U. K
198 How to Treat the Recurrent Incisional Hernia
23
Lumbar Hernia
Repair of a lumbar incisional hernia has to respect the
same principles as described above. Because of the seg-
mental nerves positioned on the transversus abdominis
muscle laterally, this layer of dissection is not recom-
mended for this hernia type. If there is enough lateral
abdominal wall left, a dissection between external and
internal oblique muscle can be done easily. After this
preparation it is possible to create an adequate medial
overlap with incision of the lateral rectus sheath and
preparation of the posterior layer to place the mesh
(
⊡
Fig. 23.6). If the hernia has a relevant lateral defect,
without adequate muscle and fascia inserting at the
crista iliaca, the preperitoneal space has to be used for
dissection, to create an adequate lateral overlap under-
neath healthy tissue. If an extended lateral preparation
is done in the preperitoneal space, it has to be certain,
that a correct positioning of the mesh, without folding,
is guaranteed.
In summary, the repair of lateral hernias has to
follow the same principles as the median sublay re-
pair. An adequate mesh overlap has to be assured.
With adequate knowledge of the anatomical layers of
the abdominal wall this can be achieved for any kind
of lateral hernia. Therefore, the hypothesis that repair
of incisional hernia outside the midline is “free-style”
surgery has to be rejected.
Discussion
Miserez:
If you have a very giant hernia, which is extend-
ing outside the semilunar line, then you put your mesh
in the lower part of the abdomen, in the preperitoneal
space. Now we hear from you, in the upper part, that you
should put it between the external and internal oblique.
How do you make the connection between both, because
the meshes were on two different planes? It is impossible.
What is your solution?
Young:
An option in these situations is to do two lay-
ers of mesh with a partial sandwich technique, and go
through the muscle, catching the lower edge of the outer
layer and the upper edge of the lower layer, which can
overlap. They can be on opposite sites of the muscle; but
light-weight mesh is better.
Bendavid:
Why would you bother, when extraperitonally
you have a full thickness and have never had difficulties
with it? Being in the extraperitoneally space, at any level,
it is easy, you have the full thickness of the abdominall
wall, when even try to find an intramuscular plane?
Conze:
The extraperitoneal space is easy to dissect be-
neath the linea arcuata down behind the pubic bone, but
above the linea arcuata the preperitoneal space behind
the posterior rectus sheath is very challenging to dissect,
and should not be promoted.
⊡
Fig. 23.5. Dissected layers of the lateral abdominal wall
⊡
Fig. 23.6. Repair of lateral incisional hernia with Ultrapro
mesh placed in retromuscular position between external and
internal oblique muscle and posterior rectus sheath
199
VII
Open Repair
Introduction
Closure of a laparostomy is the most challenging opera-
tion a hernia surgeon can undertake. Because the ab-
dominal compartments syndrome is a relatively recently
recognized phenomenon, the operation of laparostomy
to manage this condition is increasing in incidence and
the management strategies for closing a laparostomy are
evolving [1, 2].
The hernia surgeon should not manage these wounds
alone but should work in partnership with intensivists,
respiratory physicians, trauma surgeons and plastic sur-
geons. The surgical skills required for closure of laparosto-
mies are wide-ranging and include a detailed understand-
ing of the anatomy of the anterior abdominal wall, function
of its constituent parts, knowledge of the abdominal com-
partments syndrome and methods of reconstruction of
the abdominal wall, including vacuum-assisted closure,
free flaps, tissue expansion, and components separa-
tion.
Staged Management
Once the decision has been made to omit fascial clos-
ure of the abdomen because of the potential risk of
abdominal compartments syndrome, phased man-
agement should begin at that time, in the operating
room [3]. The most important prognostic factor for
the success of management of the laparostomy is the
surgeon’s experience [4]. Other important factors sig-
nificantly influencing the outcome are patient obe-
sity and size of the hernia. Although staged manage-
ment is possible, no technique is the “best” solution;
knowledge of a wide variety of surgical options will
be of benefit [5]. Although laparoscopy is an involv-
ing technique for the repair of an incisional hernia, it
has no role to play in the management of laparostomy
[6, 7].
The aims of the operation should be adequate
soft tissue coverage to achieve prevention of visceral
eventration, and restoration of abdominal wall func-
tion [8]. In the vast majority of cases, laparostomy has
been performed through a vertical midline incision,
therefore limiting the techniques required to close the
defect.
Acute Phase
Shock resuscitation leads to visceral oedema precluding
abdominal wall closure. This may be compounded by
a retroperitoneal haematoma and packing to prevent
haemorrhage. The ideal temporary abdominal wound
closure should provide containment of intra-abdominal
viscera, protection of the viscera from mechanical injury,
prevention of bowel desiccation, minimize abdominal
wall tissue damage, prevention of contamination of the
peritoneal cavity, control of the egress of peritoneal fluid,
rapid application lend itself to multiple applications and
be relatively inexpensive [9]. Open packing is generally
unsatisfactory because it fails to contain the viscera and
results in large quantities of fluid loss. An inexpensive
option is the use of a sterilized soft three-litre plastic
cystoscopy fluid irrigation bag cut to an oval shape and
sutured to the skin or fascial edges of the wound [10].
This method was originally used in Columbia and has
acquired the name of the Bogotá bag [11]. The plastic
bag holds sutures well, helps retain body heat, mini-
mizes fluid loss, is quick and easy to apply and non-ir-
ritant to the viscera. A similar alternative is the use of
a temporary abdominal closure with silicone sheeting
which also allows acute management of visceral oe-
dema before planned surgery to close the laparostomy
defect [12].
Recently, a vacuum-assisted closure method has been
successfully used for temporary management of the
open abdomen [13]. The original technique described
the placement of a perforated polyethylene sheet over
the viscera, which was covered with moist sterile surgi-
cal towels, and two suction drains were positioned over
these followed by the application of a plastic polyester
adhesive drape to the wound and skin edges. Follow-
ing this procedure, suction was applied, which assisted
resolution of the visceral oedema and wound repair
with minimal tissue damage. In this report Barker and
colleagues managed 112 trauma patients and applied
216 vacuum-assisted devices (VAD). Fifty five percent
of these patients went on to primary fascial closure dur-
ing the same hospital admission, with the development
of fistulas in 5% of patients and intra-abdominal ab-
scesses in a further 5%. This was a significant advance-
ment on previous strategies, in two respects: first, the
number of patients that left the hospital with primary
23.3 Closure of a Laparostomy
A. K
200 How to Treat the Recurrent Incisional Hernia
23
fascial closure was greatly increased and second, the
size and complexity of the residual incisional hernias
requiring surgical treatment several months later was
reduced. Other reports have confirmed the success of
the VAD in shortening hospital stay and preventing
re-admission for hernia repair [14, 15]. In a relatively
small series, Stonerock and colleagues reported that
67% of patients had successful fascial closure of the
abdominal wall within 11 days of initiating use of the
VAD. Predictors of successful primary closure included
duration of VAD placement (less than 12 days), the
total amount of VAD output (less than 3 l), the patient’s
cumulative fluid balance within the first 2 weeks (less
than 2 l) and the presence of systemic infection at the
time of attempted closure.
VAD is therefore the temporary abdominal wall clo-
sure of choice in the acute phase for patients undergoing
open abdominal management.
Intermediate Phase
If fascial closure cannot be completed within 1 to 3
weeks of creating an open abdomen, then various strate-
gies exist to manage this intermediate phase before the
final stage of definitive reconstruction. In the inter-
mediate phase, granulation tissue covers the exposed
viscera (
⊡
Fig. 23.7
) and two options exist: placement
of temporary absorbable mesh or skin grafting. The
absorbable mesh placed over the abdominal viscera at
this stage may later be pleated to assist in fascial closure
[16]. After 2 or 3 weeks, when healthy granulation tissue
covers the exposed viscera, the temporary absorbable
mesh can be removed and split skin grafts applied to
bridge the defect between the skin edges [17]. This ef-
fectively results in a planned ventral hernia for which
definitive reconstruction could be planned at a later
stage. During this intermediate phase there is further
resolution of soft tissue oedema affecting the bowel,
and other complications such as intra-abdominal sep-
sis or fistulas can be managed and treated definitively.
This intermediate phase was generally of a duration
of approximately 6 to 12 months, but in some centres
the timing to fascial closure has been reduced to 3 or
4 months [18].
Definitive Closure
The aetiology of the open abdomen correlates with the
likelihood of fascial closure [19]. If the laparostomy
followed an operation for trauma, the likelihood of
fascial closure is greatest. If the operation was for GI
sepsis, closure is more likely to be achieved with the
utilization of supplementary mesh; and if the original
operation was for pancreatitis, definitive closure is less
likely. Reconstruction is complicated because the open
abdomen has resulted in lateral migration of the rectus
muscles, decreased compliance of the oblique muscles,
suboptimal skin quality and availability, and the need
for enterolysis, possible ostomy reversal and poor pul-
monary function [20]. In addition, the reconstructive
surgeon may be faced with the difficult removal of skin
grafts which are densely adherent to underlying bowel
loops (
⊡
Fig. 23.8).
By far the most useful adjunct for definitive closure
of a midline laparostomy is the components separa-
tion technique (see below) and success rates are greatly
enhanced if plastic and other specialty surgeons are
involved in the definitive abdominal wall reconstruc-
⊡
Fig. 23.7. Open laparostomy wound showing mature granula-
tion tissue covering exposed bowel loops
⊡
Fig. 23.8. Mature split skin grafts covering bowel loops with
widely separated rectus abdominis muscles
201
VII
Open Repair
tion. For instance, between 5 and 10% of patients will
have developed fistulas through the temporarily closed
laparostomy wound which will require management by
a GI surgeon [16].
Components Separation Method
With this technique, an innervated rectus abdominus
– internal oblique – transversus abdominis muscle com-
plex is mobilized bilaterally into the midline [21, 22].
At the waist line a 10-cm advancement on each side
can be achieved allowing for closure of 20-cm defects.
The external oblique is released 1 to 2 cm from its at-
tachment to the rectus abdominis muscle and separated
from the underlying internal oblique in an avascular
plane. In addition, the rectus muscle and the under-
lying anterior rectus sheath can be elevated from the
underlying posterior rectus sheath by incision in the
midline of its fascia, thus allowing further migration
into the midline of the rectus muscles. The skin flaps
must be raised to the anterior axillary line. A modifica-
tion of the technique has been devised for closure of
abdominal wall defects in the presence of an enteros-
tomy [23, 24].
In a series of 43 patients deVries Reilingh reported
a complicated postoperative course in 17 patients with
fascial dehiscence occurring in one, haematoma in five,
seroma in two, wound infection in six, skin necrosis
in one and respiratory insufficiency in two patients.
At 15 months follow-up the recurrent hernia rate was
32% [25]. This high recurrence rate calls into question
whether the components separation operation should
be supplemented with prosthetic mesh. It is now our
practice to supplement this operation with an onlay
mesh attached to the two lateral cut edges of the exter-
nal oblique aponeurosis (
⊡
Fig. 23.9).
Tissue Flaps
For large defects of the lower abdomen where fas-
cial closure is not possible, a tensor fascia lata (TFL)
flap is a useful adjunct [26]. This should be consid-
ered where, in addition to a large tissue defect, there
is absence of stable skin coverage, recurrence after
prior closure attempts, infected or exposed prior mesh
or compromised tissues and fistulas. The TFL flap is
suitable for reconstructive procedures in the lower ab-
domen because it has a reliable vascular pedicle and
a safe arc of rotation to this zone of the abdominal
wall.
Tissue Expansion
Rarely, a subcutaneous or subfascial tissue expander
placed between the external and internal oblique
muscles may be required before fascial closure can
be achieved [27]. The expander is usually required to
be in place for at least 3 months and the final volume
achieved is usually between 500 to 2000 ml. These pa-
tients often require supplementary prosthetic mesh for
the definitive procedure.
Mental and Functional Outcomes
Most patients who have undergone life-saving ab-
dominal surgery followed by open abdominal wound
management and staged abdominal wall reconstruc-
tion experience a stress reaction [18]. However, al-
though these patients experience a decrease in physical,
social and emotional health while they are awaiting de-
finitive surgery, their mental health is not affected and
after completion of fascial closure, their health status is
equivalent to that of the general population. Following
surgery, the majority of patients are then able to return
to their pre-injury employment.
Conclusion
Closure of a laparostomy requires a multidisciplinary
approach which in the intermediate and late phase
should be co-ordinated by the hernia surgeon assisted
by a team of other specialists. Outcomes are optimized
by this team approach.
⊡
Fig. 23.9. Onlay mesh sutured to cut lateral edges of the
external oblique aponeurosis, supplementing components
separation closure of a laparostomy wound
202 How to Treat the Recurrent Incisional Hernia
23
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Discussion
Franz:
Can you tell us what mesh do you use for this
procedure in addition to the components operation tech-
nique, and when and why you started to do that? You
have shown some pretty white skin flaps. Do you have any
problems concerning overlapping that mesh?
Kingsnorth:
The data that were shown this morning,
about my series of onlay, was my very early experience.
When I first came to this meeting, and was learning about
the Rives technique, I decided that a good incisional her-
nia surgeon should do sublay, because it was the best
operation, and then as I gained experience, people sent
me the very challenging hernias. The only way I could
do them was with an onlay repair. Sublay was not an
option, because of the destruction of the lower abdominal
wall. With these really big ones I started doing an onlay
and got excellent results. So practically my practice has
shifted. I still do sublay for the upper midline incisional
hernias, because there you have got a very good posterior
rectus sheath.
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