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_1601_Библиотеки_им_академика_М_И_Перельмана
.pdf
203
VII
Open Repair
I work quite a lot with plastic surgeons, and I noticed that
they have particular techniques to use skin flaps. They are
not frightened of closing with a small amount of tension.
So you never leave a skin flap loose. You should pull the
skin flap in the midline where the overlap is and take
that skin away. And then you close it quite carefully into
two layers. You have a danger of necrosis if, for example,
you don’t treat the skin around stoma properly, or you
don’t take regard of where previous incisions have been
made. And you don’t get a lot of serum formation if you
treat with skin flaps, properly. We follow the full Chevrel
package, which is relaxing incisions if necessary, usually
no incisions in the anterior rectus sheath but Ramirez,
and we use tissue glue, fibrin glue. That is the Chevrel
package that we use.
Jeckel:
What I learned from a plastic surgeon is to use
the tensia fascia lata, which is fantastic, maybe not strong
enough in all cases, and you cannot reach far above the
umbilicus. But it is sometimes a good technique to use.
Do you use Gore-Tex and in that same line more or less
Vicryl? Do you use both or was it either/or, because Vicryl
gives always a hernia and not Gore-Tex.
Kingsnorth:
Personally, we actually use a dual mesh now,
and we don’t use it very often. If we do, we just do a tem-
porary bridging of the mesh. We will actually use a dual
mesh and stick it to the fascia. There are options, some
stick it to the skin, some stick it to the fascia.
Schumpelick:
It is very expensive for temporary closure.
Kingsnorth: It is, but these are expensive patients.
Schumpelick: Why don’t you use a Vypro mesh? It works.
Did you fix the mesh with glue as Chevrel did, if you
make an onlay? Or did you fix it with suture?
Kingsnorth: This mesh thing is a question of belief. The
glue itself, some people believe, is a wallpaper effect. You
glue the wall, and then you put the mesh over it, which is
the way they sold it to me. But actually I believe, though
I have no evidence for this, I believe that it seals the lym-
phatics in the skin flaps. I use most of the glue to spray the
undersurface of the skin flaps, and the remainder I spray
over the mesh itself. Again, I have no evidence.
Schumpelick:
Is there any contra-indication for you to
closing a laparostomy, for example, in a fistula case? And
when you have fistulas, do you always close the abdomen
or are there any contra-indications?
Kingsnorth: Yes, we will close a stoma at the same time
as we close laparostoma. We cover patients for 5 days
with intravenous antibiotics, and have no major septic
problems.
Sarr: I have been sitting here and we are talking about
hernias. I have not heard anybody talk about infection
and chronic mesh infection. I look at your laparostomy
closure with these wide flaps in a patient who is com-
promised. I can’t imagine that there is not a high rate
of infection.
Kingsnorth: Absolutely. When I see these patient it is the
first thing I tell them. Their wound will almost certainly
not heal primarily. They will get at least a small area of
dehiscence, they may have a small area of infection, and
I make it quite clear to them. There is a high instance,
but considering what we are dealing with, I mean we
don’t have meshes swimming around and we don’t have
complete dehiscence of the abdominal wall. But one of
the major issues is actually getting a perfect skin closure,
which you never get.
Introduction
The treatment of choice for a large incisional hernia us-
ing open techniques is the tension-free repair with mesh,
placing it in the retromuscular-preperitoneal space (sub-
lay technique) or subcutaneously in the prefascial space
( onlay technique) [1–4]. Weight loss and optimization of
pulmonary and cardiac function are important. Calculation
of lung functional volumes and muscle strength, pre-op-
eratively, with the hernia intact and after hernia reduc-
tion are very important [1,5,6]. These calculations under
protocol can be done intra-operatively at the closure of
peritoneum, determining the postoperative respiratory
mechanical workload [6].
Open-Onlay Technique
The important steps of the onlay technique are the fol-
lowing [1, 7]:
1. Administration i.v. of antibiotics upon anesthesia
induction or 2 h earlier and one more dose 12 h later
23.4 Onlay
A. M
204 How to Treat the Recurrent Incisional Hernia
23
(Ampicillin plus Sulbactam/second generation
Chephalosporin/ Vancomycin).
2. Skin cleansing and draping.
3. Excision of the skin scar.
4. Identification and preparation of the hernial sac.
The skin-cutaneous flaps, rectus abdominis fascia
and fascial margins are all prepared.
5. Opening of the hernial sac permits the thorough
exploration of the abdominal cavity, checking for sac
crypts and safe lysis of intestinal or omental adhe-
sions and subsequent reduction.
6. Excision of the protruding peritoneum ( hernial
sac).
7. Closure of the hernial gap with complete or partial
re-approximation of the rectus abdominis muscles
to the midline by peritoneum-fascia adaptation with
non-absorbable sutures. This is important depend-
ing on the intra-operative assessment of respiratory
mechanics.
8. Onlay, tension-free mesh fixation on the anterior
rectus fascia, extending 6–8 cm beyond the gap bor-
ders in all directions.
9. Tension-free mesh fixation on the aponeurosis by the
means of two rows of interrupted non-absorbable
sutures, in a 1- to 2-cm distance from each other.
10. Suction drains and trauma closure.
Some reasonable questions are raised about the open-
onlay technique/method:
▬ Is it an easy or a difficult technique? Are there any
technical problems concerning the application of
this method?
▬ What about morbidity and mortality?
▬
What is the incidence of trauma-mesh infection
(early complication) and hernia recurrence (late
complication)?
▬
Is this methods comparable to the sublay tech-
nique?
There is no doubt that the open-onlay technique is eas-
ily performed by a low-experienced surgeon or a senior
resident with no need for extensive dissection in the
preperitoneal space and blood preparation [1, 7]. In
a midline subxiphoidal hernia, mesh fixation with an
overlap 6–8 cm in all directions is difficult or impos-
sible because this theoretically will restrict chest mobil-
ity. Failed stitch or stitches of the first suture row near
the rectus fascia gap may lead to the development of
buttonhole hernia (recurrent hernia between the fascia
and the mesh). It should be remembered that the main
difference between the open-sublay and open-onlay
methods is that in the first case the mesh is held in
place by the positive intra-abdominal pressure against
the closed fascia of the abdominal wall, but in the lat-
ter by the stay-anchoring sutures [2, 7]. The incidence
of morbidity in open-onlay technique ranges between
4 and 28% and mortality between 0 and 2.7% [2, 7, 8,
9]. The incidence of wound infection ranges between
5 and 16% and the recurrence rate between 2.5 and
11% [3, 7, 8, 10].
Comparisons between the open-sublay and open-
onlay techniques are difficult in a high level of evidence-
based data for many reasons:
▬
There are no prospective randomized or controlled
studies that have tested the onlay technique versus
the sublay technique.
▬
A small number of operations for incisional her-
nias are performed, even in large surgical clinics,
per year.
▬ The type of technique, sublay or onlay, is mainly
dependent on the surgeon’s experience and choice.
▬
The type of mesh that is used in hernia repair de-
pends on the surgeon’s preference, the financial
background of the hospital and it may change even
within the period of this study [1, 3, 7, 11, 12]. In
conclusion, the open-onlay technique is an easily
performed and safe method, with an acceptable
complication rate (especially wound infection and
recurrence). For real comparison, with the open-
sublay technique, however, randomized trials or
control studies are needed.
References
1. Kingsnorth A, LeBlanc K: Hernias: Inguinal and Incisional.
The Lancet 2003, 362: 1561–1570
2. Stumpf M, Conze J, Klinge U, Rosch R, Schumpelick V: Open
mesh repair. Eur J Surg 2003, 35: 21–24
3. Korenkov M, Raul A, Sauerland S, et al: Classification and
surgical treatment of incisional hernia. Langenbeck’s Arch
Surg 2001, 386: 65–73
4. Israelsson L: The surgeon as a risk factor for complication of
midline incisions. Eur J Surg 1998, 164: 353–59
5. Kavvadia V, Greenough A, Laubscher B, et al: Perioperative
assessment of respiratory compliance and lung volume in
infants with congenital diaphragmatic hernia: prediction of
outcome. J Pediatr Surg 1997, 32: 1665–1669
6. Munegato G, Brandolese R: Respiratory physiology in surgi-
cal repair for large incisional hernias of the abdominal wall.
J Am Coll Surg 2001, 192: 298–304
7. Machairas A, Misiakos E, Liakakos T, et al: Incisional hernio-
plasty with extraperitoneal onlay polyester mesh. Am Surg
2004, 70: 726–729
8.
Petersen S, Henke G, Freitag M, et al: Erfahrungen mit der
reconstruction bauchwadnarbenhernien mittels praperito-
nealer nach Stopa-Rives. Zentralbl Chir 2000, 125: 152–156
205
VII
Open Repair
9. Cobb W, Harris J, Lokey J, et al: Incisional herniorrhaphy with
intraperitoneal composite mesh: a report of 95 cases. Am
Surg 2003, 69: 784–787
10. Luijenndijk R, Hop W, van den Tol P, et al: Comparison of
suture repair with mesh repair for incisional hernia. N Engl
J Med 2000, 343: 392–398
11. Chevrel J: Hernias and surgery of the abdominal wall.
Springer, Berlin Heidelberg New York, 1998
12. Chrysos E, Athanasakis E, Saridaki Z, et al: Surgical repair
of incisional ventral hernias: tension-free technique using
prosthetic materials (ePTFE Goretex dual mesh). Am Surg
2000, 66: 679–682
Discussion
Simons: It is better not to go into the abdominal cavity,
if it is not necessary, not to do an adhesiolysis, because
the adhesions will come back. What is the reason why
you do an adhesiolysis when you don’t really have to be
in the abdominal cavity anyway? Do you agree with me
that cutting adhesions means that you will have a recur-
rence of adhesions?
Machairas:
Sometimes there is no need to open this up. It
is understandable in small hernia defects, smaller than 6
cm in length. The advantage of opening the abdominal
cavity is the opportunity to explore the abdominal cavity
and to free the borders. Also we can free loops and see, if
there are any other defects that cannot be recognized by
examining the patient from the outside.
Deysine:
I observe that your infection rate is about 10%.
I know that you inject the patient an antibiotic. What
other measures do you take to prevent bacteria from fall-
ing from the air into your wound, from your hands and
everywhere? Not to create this famous film that would
allow them to survive? And would you use any antibiotic
locally? And if you don’t, why not? Actually the orthopae-
dic literature is very clear on this, their prosthesis surfaces
are smaller than ours. They use irrigational antibiotics,
they use intravenous antibiotics to prevent bacterial infec-
tion. They have lamina air flow in the operating rooms,
and they have a drop in their infection rate from initially
about 60% to below 1%.
Machairas:
No. In the past we used to use antibiotics
locally, or hypertonic solutions, like natrium chloride.
The committee against infections in the hospital doesn’t
permit local antibiotics.
Sarr:
I am going to ask again about wound infections.
If there is a 10 or 12% incidence of wound infections,
how many of these patients are left with a chronic mesh
infection? We are including these mesh infections in our
calculation of recurrences.
Machairas: In 43 patients we had three wound infections.
There was need to remove the mesh in the first 3 weeks
in only one patient. The other two patients developed
wound infection and we had to remove the mesh 4 and
6 months later.
Schumpelick: I have some concern about the skin necro-
sis, especially these cases with big flaps. I have seen some
skin necrosis here; how do you handle that?
Machairas:
No, we had no skin necrosis. Because we take
care to preserve the vessels of the skin.
Introduction
Despite better understanding of possible predisposing
factors and preventional measures, 10 to 15% of all pa-
tients, having had a midline laparotomy, still develop an
abdominal wall defect (AWD). Introduction of prosthetic
mesh in the repair of these defects has reduced recur-
rence rates during recent years, but long-term results of
reconstruction of large abdominal wall defects remain
poor with recurrence rates still up to 44%. Among others,
incorrect application of the mesh might be an important
factor for this number. Moreover, surgical repair of recur-
rences is demanding and entails considerable concomitant
morbidity in major surgery.
In theory, the goal of any reconstruction of an AWD
should be full restoration of abdominal wall function
with an intact muscular coverage, prevention of visceral
eventration and adequate soft tissue conditions. Various
techniques to achieve this have been advocated, but up
to now there is still no gold standard for surgical repair
of AWDs. Important factors for the choice of technique
are the size and site of the defect, availability of viable
tissue and degree of contamination. One possible solu-
tion for closure of large median AWDs is the use of local
23.5 Long-Term Results of Reconstructing Large Abdominal Wall Defects
With the Components Separation Method
H.J.A.A. V G, D. K, R.K.J. S, J. O, C. V W
206 How to Treat the Recurrent Incisional Hernia
23
tissue after a tension-relaxing procedure, i.e. components
separation method (CSM), first described by Ramirez [1]
in 1990. With this technique, the abdominal midline can
often be reconstructed in a one-stage procedure without
the need of a musculofascial transfer (distant flaps) or the
use of prosthetic material.
The purpose of this study is to evaluate our long-term
results of large abdominal wall reconstruction by means of
the CSM with special regard to recurrences, the influence
of contamination and additional use of prosthetic mesh.
Patients and Method
In a 6-year period, we treated 95 patients with large
mid-line abdominal AWDs at the University Medical
Centre in Utrecht and at the Jeroen Bosch Hospital in
‘s-Hertogenbosch. Defects exceeding 5 cm in width
and 50 cm2 were considered as large. All patients had
debilitating symptoms or local conditions which urged
surgical intervention (e.g. an AWD with atrophic skin
coverage and subsequent imminent enterocutaneous
fistulation). Population characteristics are shown in
⊡
Table 23.1. All operations were planned procedures
(no emergencies) and performed by an experienced
surgeon under peri-operative antibiotic prophylaxis us-
ing amoxicilline/clavulan acid 1200 mg i.v. 30 min prior
to incision (repeated after 3 h if necessary). In cases of
bacterial peritonitis or drained abscesses antibiotics
were continued for 3 days. Bowel preparation was not
routinely performed. Contamination was classified ac-
cording to the National Research Council (NRC) [2].
Previously implanted mesh was removed if possible and
the component separation method was performed, as
illustrated in
⊡
Fig. 23.10. After bilateral mobilization
of skin and subcutaneous tissues, the aponeurosis of the
external oblique muscle was incised pararectally, about
1 cm lateral to the rectus muscle. Then the external
and internal oblique muscles were separated by blunt
dissection, which is rather easy due to loose connective
tissue and the avascularity in this plane (
⊡
Fig. 23.11
).
This mobilization was carried out as far as the poste-
rior axillary line in order to facilitate medialization of
the rectus abdominus muscle to achieve tension-free
closure of the abdominal wall defect.
Due to this extensive dissection, large wound
surfaces are created, essentially including the entire
ventral abdominal wall. To diminish the risk of skin
necrosis and seroma formation we used an alternative
approach in three cases: instead of bilateral subcutane-
ous mobilization starting at the midline, bilateral skin
incisions were made directly at the level of the rectus
⊡
Table 23.1. Patient characteristics (n = 95)
Age [years] 52
Male/female 48/47
Median body mass index (BMI) 28
Chronic obstructive pulmonary
disease (COPD)
13
Previous laparotomies (mean no.) 13
Ostomy 22
Fistulae 19
Skin defect 30
Size of defect (mean size in cm
2
) 230 (60–800)
Failed mesh repair 26
⊡
Fig. 23.10. Skin and subcutaneous tissue are mobilized and
the aponeurosis of the external oblique muscle incised para-
rectally, about 1 cm lateral to the rectus muscle
⊡
Figure 23.11. The external and internal oblique muscles can
be separated by blunt dissection
207
VII
Open Repair
abdominis/external oblique junction. The separation
of the external and internal oblique muscle could then
be made directly through this approach. After closure
of the linea alba, the consequent lateral skin defects
were covered by split-skin grafts. This method was not
routinely performed for cosmetic reasons.
In addition, the rectus muscles were separated
from the posterior rectus sheath which increases its
medialization by several centimetres (
⊡
Fig. 23.12
).
This procedure was normally performed bilaterally,
but in cases with an ostomy this was only done contra-
laterally in order to prevent skin necrosis around the
ostomy. After excision of the fibrotic fascial edges, the
midline was closed with looped PDS ( polydioxanone-S,
no. 1) in one layer. In 26 randomly chosen defects a non-
resorbable prosthetic mesh (18 Mersilene, 6 Prolene and
2 Marlex) was used as augmentation, being fixed with a
running PDS suture in the retromuscular space between
the rectus muscle and the posterior rectus sheath, with
at least 5-cm overlap at all sides (
⊡
Fig. 23.13
). The deci-
sion as to whether mesh augmentation was used was
strictly at random because these patients participated in
different randomized trials. Bilateral suction drainage
was used in the subcutaneous space.
The skin was closed with staples in cases with NRC-
III contamination. When NRC-IV was encountered, the
skin was just covered with a dressing. An abdominal
binder was used for 7 days, in order to limit seroma
and haematoma formation. We defined postoperative
wound infections according to the criteria for surgical
site infections of the US Centers for Disease Control
[3].
Information was obtained from the patient’s general
practitioner whether he or she was still alive and had
not moved. All patients were invited to visit the out-
patient clinic for an interview and physical examina-
tion with special attention to recurrences. Patients who
were unable or unwilling to travel were visited at their
private address by the authors, hereby accomplishing
100% follow-up.
Short-Term Results
Patients were operated in a median operating time
of 120 min (30–240) and with a median blood loss
of 500 ml (100–2500 ml). In 88% of the operations a
bilateral procedure was performed (n = 84) of which
more than half without mobilization of the posterior
rectus sheath (n = 46). We encountered contamina-
tion in 34 operations (36%) of which 4 were NRC-IV
contaminated. Patients were hospitalized for a median
stay of 11 days (3–201) during which 58% developed
one or more complications. Most complications were
grade-I and required no intervention. Seven patients
(7%) needed a re-operation during hospitalization: four
⊡
Fig. 23.12. Additionally, the rectus muscle can be separated
from the posterior rectus sheath
⊡
Fig. 23.13. Retromuscular mesh position on the posterior
rectus sheath
⊡
Table 23.2. Complications of the components sepa-
ration method
Complications n
Minor complications
Superficial wound infection 24
Seroma/haematoma 23
Pneumonia 13
Enterocutaneous fistulae 16
Major complication
Death 12 (2.1%)
208 How to Treat the Recurrent Incisional Hernia
23
cases because of progressive seroma formation, two pa-
tients due to postoperative hemorrhage. One patient
suffered an anastomotic disruption and died after 60
days due to severe peritonitis and multiple organ fail-
ure. Another patient died after 4 days due to massive
pulmonary embolism.
The most frequent complications are listed in
⊡
Table 23.2
. All wound infections were superficial
and could be treated by local drainage and secondary
healing of the wound. Most seromas could be aspirated
at the surgical ward or in the office.
Long-Term Results
Five patients died during the follow-up period, all by
unrelated causes (malignancies four of five). These
patients were not excluded from follow-up, but
we decided to use their last visit as date of follow-
up which ranged from 2 to 5 years. After a median
follow-up period of 48 months (1–95) we found 15
patients with a recurrence (15.7%). Thirteen of these
patients were asymptomatic and fully satisfied with
their situation. Two patients with a recurrence needed
a re-operation during which the CSM was performed
on the contralateral side (they had had a unilateral
CSM initially) in combination with a retrofascial, pre-
peritoneal non-absorbable mesh. We found only one
small asymptomatic recurrence (3.8%) in the group
with initial mesh augmentation versus 14 (20%) in
patients without augmentation (
⊡
Table 23.3
). The
only recurrence found in the mesh group concerned
a 60-year-old male (BMI = 30), who had a recurrent
fascial defect measuring 400 cm2 which was treated
with the CSM, augmented by Mersilene mesh. In his
postoperative period he developed a wound infection
and had prolonged seroma formation. After 40 months
we discovered an asymptomatic recurrence of 3 cm in
diameter in the most cranial part of the scar, about
2 cm below the xiphoid, possibly due to a technical
error.
In six patients we found postoperative entero-cu-
taneous fistulae. Three of those patients had fistulae
pre-operatively and in all three, previously implanted
Marlex mesh could initially only be partially removed
and all three required re-operation. Three other patients
had low-volume fistulae which healed spontaneously,
so eventually all patients recovered from fistulae. In
seven patients a non-infected skin defect was present
but no signs of entero-cutaneous fistulae were observed.
Thirteen patients had complaints about the cosmetic
result of the operation and 12 patients had used psy-
chological counselling for more than 6 months in the
postoperative period.
All patients had completed the questionnaire con-
cerning daily life activities. Twenty-nine patients (30%)
reported having one or more serious restriction in daily
life activities. In most cases this concerned restrictions
in heavy weight bearing (n = 22) and/or tying their shoe
laces (n = 12).
Discussion
Long-term results of patients treated for massive and
often recurrent abdominal wall defects in large series
are lacking in the literature. Due to the great variations
in aetiology, abdominal wall history and present pathol-
ogy, treatment has to be tailored individually and often
customized in detail, as we stated before [4]. Different
⊡
Table 23.3. Patient characteristics (mesh vs. non-
mesh)
n = 95 Component
separation
method + mesh
augmentation
CSM
Patients
[n]
126 169
Male/female 113/13 136/33
Age [years] 158 152
Body mass index
(BMI)
129 127
Defect size [cm
2
] 225 251
Median opera-
tion time [min]
115 120
Median total
blood loss (TBL)
[ml]
500 650
Contamination 115 (19%) 1
29 (42%)
Wound infection 117 117
Seroma 114 119
Recurrence 111 (3.8%) 114 (20%)
209
VII
Open Repair
treatment strategies for these patients are therefore dif-
ficult to investigate in randomized controlled trials and
the optimal treatment for an individual patient cannot
be derived from an algorithm.
Although minimal invasive approaches are being
used more often for incisional hernia repair in gen-
eral, most patients with massive and multiple recur-
rent ventral hernias will need an open reconstruction.
Laparoscopic series report recurrence rates up to 17%.
Recently, Perrone et al. [5] reported a recurrence per-
centage of 9.3% in his short-term follow-up of laparo-
scopic incisional hernia repair in 116 patients. Only
21% of his patients were operated for a recurrent hernia
and the mean fascial defect measured 115 cm2. These
patients were operated in 157 min, with a conversion
rate of 17% and a recurrence rate after 22 months of
8%. One of the specific risks of laparoscopic repair is
accidental enterotomy, which may remain undetected
during surgery. In this study 11.4% of patients with
recurrent ventral hernia suffered from this hazardous
complication. All were treated by laparotomy, bowel
resection and primary closure of the fascial defect be-
cause contamination apparently ruled out an additional
procedure. One patient developed multiple organ failure
and died.
Because of the alleged high risk of infection in the
case of encountered contamination, traditional one-
stage reconstruction, with or without mesh, is aban-
doned and a multistage procedure is chosen [6, 7]. The
latter procedure is time-consuming, often not finalized
and accompanied by considerable morbidity. However,
recent reports suggest that definitive closure despite
contamination is successful and does not necessarily
exclude the use of synthetic mesh [8–10].
For open reconstruction, abdominal wall defects can
be treated either by bridging (with synthetic material
or the patient’s own tissue) or closure of the abdominal
wall after tissue expansion or relaxing incisions [4]. The
latter will restore circumferential functional muscu-
lar support and (by avoiding the use of mesh) prevent
complications of direct contact between non-resorbable
mesh and the bowel. The ultimate goal of reconstruction
of the abdominal wall is preventing visceral eventration
by dynamic, muscular support and adequate soft-tissue
coverage. We therefore prefer closure of large, recurrent
abdominal wall defects in a one-stage manner by using
the components separation method.
Oscar Ramirez [1] first described the possible me-
dial mobilization of the rectus muscle by using his
tension-reducing technique. Nahas [11] documented
that these relaxing incisions and undermining of the
external oblique muscles resulted in a reduction of the
necessary force for medial mobilization. In a cadaver
study, we additionally found that release of the external
oblique muscle produces more benefit to abdominal
wall closure than release of the posterior rectus sheath
[12].
Few reports have been published about the results
of the CSM during the past decade with recurrence
rate varying from 5 to 32% [1, 13–18]. Most studies
are hampered by either study size or time of follow-up
(
⊡
Table 23.4).
⊡
Table 23.4. Results of the components separation method
Author Year Study size (
no. of patients)
Contamination
(no. of contami-
nated procedures)
Recurrences
[%]
Follow-up
[months]
Ramirez [1] 1989 11 13 10 1?
DiBello [14] 1996 35 15 18.6 22
Girotto [15] 1999 33 13 16.1 21
Shestak [16] 2000 22 1? 1552
Lowe [17] 2000 30 1?1012
De Vries [18] 2003 43 15 32 15.6
Van Geffen [?] 2006 95 34 15.7 48
210 How to Treat the Recurrent Incisional Hernia
23
These results are in accordance with a recent popu-
lation-based study of more than 10,000 patients. Flum
[19] reported a 12.3% re-operation rate within the first
5 years after initial incisional hernia repair (irrespective
of the technique). He also found a 5-year re-operative
rate of 23.8% after the first and 35.3% after the second
incisional hernia repair.
In this study we analyzed a large series of patients
with massive abdominal wall defects treated with the
CSM, during a follow-up period of 4 years. At this long-
term follow-up we found 15, mostly asymptomatic, pa-
tients with a recurrence (15.7%). Most patients could
perform daily life activities without limitations, with
the exception of heavy weight bearing in 22 patients
and tying their shoe-laces in 12 patients (
⊡
Table 23.5
).
Theoretically, the abdominal wall can become less flex-
ible after synthetic mesh augmentation and can there-
fore cause more restrictions in daily life, as opposed
to non-mesh repair. However, it was striking to see
that patients with postoperative limitations in heavy
weight bearing or tying shoe-laces were equally divided
between treatment with and without mesh augmenta-
tion. In this series, the application of synthetic mesh
for augmentation of abdominal wall reconstruction by
means of the CSM did not create more limitations in
daily life activities.
A large number of patients admitted to have had
psychological problems during hospitalization and 12
patients needed psychological counselling for more
than 6 months after discharge. All 12 patients held
the longevity of their illness, characterized by multiple
operations and intensive care admissions, accountable
for this.
At the present time, there are no reports on the ad-
ditional benefit of mesh augmentation during the CSM
regarding recurrence. Dibello [14] could not achieve a
tensionless repair with the CSM in 15 of his 35 patients.
In these cases, reconstruction was augmented by using a
resorbable mesh ( Vicryl) as an overlay and anchored be-
yond the semilunar line, but the specific results of these
augmented repairs are unknown. Lowe [17] reported
the additional use of mesh in 10 of the 30 patients who
underwent an open CSM but the indication, position
and type of synthetic mesh is unclear as well as the fol-
low-up of this group of patients.
The coincidental (random) use of non-absorbable
mesh in a preperitoneal position in our study, for aug-
mentation of the CSM, provided remarkable results.
Both groups of patients (with and without mesh aug-
mentation) are comparable, as shown in
⊡
Table 23.3 ,
with the exception of the amount of contaminated
procedures. We found only one small asymptomatic
recurrence in the group with initial mesh augmenta-
tion (3.8%), versus 14 in patients without augmentation
(20%). Analysis with a Fisher’s exact test proved this
difference to be statistically significant (p = 0.036). The
latter 14 patients were equally divided between contam-
inated and non-contaminated procedures. The higher
recurrence rate in patients without mesh augmentation,
therefore, does not seem to be correlated to the pres-
ence of contamination. Although we could not derive it
from the operative report, we suspect technical failure
to account for the single recurrence in the mesh-aug-
mented group. Careful dissection of the “ fatty triangle”
and sufficient mesh overlap are essential in this area to
prevent a subxiphoidal recurrence, as Conze et al. [20,
21] reported recently.
We conclude that massive and recurrent abdominal
wall defects can be safely treated by using the compo-
nents separation method, given the grotesque pathol-
ogy. The combination of the CSM with non-absorbable
mesh augmentation in the prefascial retromuscular
space clearly shows favourable results over mesh-less
reconstruction with the CSM. Future investigation in a
large prospective randomized trial is needed to validate
this finding.
References
1. 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
2. National Research Council. Postoperative wound infections.
Ann Surg 1964; 160: S1–192.
⊡
Table 23.5. Limitations in daily life activities
Patients Tying
shoe-
laces
Heavy
weight
bearing
Total no.
a
CSM +
mesh
(n = 26)
13 16 18 (30.7%)
CSM
(n = 69)
19 16 21 (30.4%)
Total
(n = 95)
12 22 29 (30.5%)
a
total number of patients with one or more serious
limitations.
211
VII
Open Repair
3. Horan TC, Gaynes RP, Martona WJ, et al. CDC definitions of
nosocomial surgical site infections, 1992: A modification of
CDC definitions of surgical wound infections. Infect Control
Hosp Epidemiol 1992; 13: 606–608
4. Van Geffen HJAA, Simmermacher RKJ. Incisional hernia re-
pair: abdominoplasty, tissue expansion, and methods of
augmentation World J Surg 2005 29(8): 1080–1085
5. Perrone JM, Soper NJ, Eagon Chr, Klingensmith ME, Aft RL,
Frisella MM, Brunt M. Perioperative outcomes and compli-
cations of laparoscopic ventral hernia repair. Surgery 2005,
138(4): 708–716
6. Fabian TC, Croce MA, Pritchard FE, et al. Planned ventral her-
nia. Staged management for acute abdominal wall defects.
Ann Surg 1994; 219: 643–650
7. Jernigan TW, Fabian TC, Croce MA, et al. Staged management
of giant abdominal wall defects; acute and long-term results.
Ann Surg 2003; 238: 349–355; discussion 355–357
8. Vix J, Meyer CH, Rohr S et al. The treatment of incisional and
abdominal hernia with a prosthesis in potentially infected
tissues. Hernia 1997; 1: 157–161
9. Campanelli G, Nicolosi FM, Pettinari D, Contessini Avesani E.
Prosthetic repair, intestinal resection and potentially contam-
inated areas: safe and feasible? Hernia 2004; 8: 190–192
10.
Van Geffen HJAA, Simmermacher RKJ, van Vroonhoven TJ, van
der Werken Chr. Surgical treatment of large contaminated ab-
dominal wall defects J Am Coll Surg 2005, 201(2): 206–212
11. Nahas FX, Ishida J, Gemperli R, Ferreira MC. Abdominal wall
closure after selective aponeurotic incision and undermin-
ing. Ann Plast Surg 1998; 41: 606–617
12. Van Geffen HJAA, Simmermacher RKJ, Bosscha K, van der
Werken C, Hillen B. Anatomical considerations for surgery
of the anterolateral abdominal wall Hernia 2004; 8: 93–97
13. Thomas WO, Parry SW, Rodning CB. Ventral/incisional ab-
dominal herniorhaphy by fascial partition/release. Plast
Reconstr Surg 1993; 91: 1080–1086
14. Dibello JN, Moore JH. Sliding myofascial flap of the rectus
abdominus muscles for the closure of recurrent ventral her-
nias. Plast Reconstr Surg 1996; 98: 464–469.
15. Girotto J, Ko M, Redett R, et al. Closure of chronic abdomi-
nal wall defects: a long-term evaluation of the components
separation method. Ann Plast Surg 1999; 42: 385–395
16. Shestak K, Edington H, Johnson R. The separation of ana-
tomic components technique for the reconstruction of mas-
sive midline abdominal wall defects. Plast Reconstr Surg
2000; 105: 731–738
17. Lowe JB, Jaime RG, Bowman JL, Rohrich RJ, Strodel WE. En-
doscopically assisted “Components Separation Method” for
closure of abdominal wall defects. Plast Reconstr Surg 2000;
105: 720–727
18.
De Vries Reilingh TS, van Goor H, Rosman C, Bemelmans MH,
de Jong D, van Nieuwenhoven EJ, van Engeland MI, Bleichrodt
RP. “Components separation technique” for the repair of large
abdominal wall hernias. J Am Coll Surg 2003; 196: 825–826
19. Flum DR, Horvath K, Koepsell Th. Have outcomes of incisional
hernia repair improved with time? Ann Surg 2003, 237 (1):
129–135
20. 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
21. Conze J, Prescher A, Kisielinski K, Klinge U, Schumpelick
V. Technical consideration for subxiphoidal incisional hernia
repair. Hernia 2005; 9(1): 84–87
Discussion
Jeekel:
You had a high incidence of pneumonia. What was
the reason, just the sick patients? Or was it that you made
it too tight? The other question is that the group with the
mesh is significantly better in recurrence. Couldn’t you
just use the mesh instead of the combination, because as
I said earlier, you don’t need to bridge the gap, you can
just use the mesh as the abdominal wall.
van Geffen:
I honestly do not know what is the best way to
do this, because Prof. Schumpelick told us that he puts in
a retromuscular mesh and then maybe a relaxing incision.
So maybe we do your components separation method,
the other way round. We do the components separation
method and maybe with a mesh. But I do not know which
is the best technique, because an advantage for the retro-
muscular mesh, at least we think, is the approximation of
the rectus muscle and the muscular coverage.
Jeekel:
This is just what we never do. That is the strange
thing.
van Geffen:
It is, but to me it produces more tension,
and probably more pulmonary problems. We have seen
a lot of infections with pneumonia, but there is no ratio
about that, because there was no tension. They were all
tension-less repairs. I do not think that this is the reason
for pneumonia.
Kingsnorth:
Can I ask you where you are getting the
recurrences? We have had two, and they both occurred
in the area that had been left bare after the component
separation. The sublay may not be sufficient in those
areas, which is why in that area I use mesh that goes
right to the full limits, where you cut the external oblique
aponeurosis.
van Geffen:
With the recurrences I agree with you. There
are a lot of recurrences in the lateral side and there where
some recurrences in the epigastric area. Of course, theo-
retically an onlay mesh is covering that, or an inlay mesh
is covering these sides to the flanks. I don’t know, it could
be.
de Vries:
We had our recurrences in the epigastric re-
gion and the cause is probably the fatty triangle. I want
to react to Prof. Jeekel. Before we started with our trial
we did a trial for large hernias with the Ramirez plastic
for prosthetic bridging. We have had to stop this trial,
because we had high mesh failure, probably because we
did not use the right mesh, we used Gore-Tex mesh and
everything became infected.
212 How to Treat the Recurrent Incisional Hernia
23
Introduction
With a cumulative incidence of about 20%, the repair of
incisional hernia following laparotomy remains a perpetual
task for general surgeons [5]. Regarding recurrence rates
of about 50% after conventional suture repair, a repeat of
this technique seems to be insufficient and even obsolete.
The introduction of meshes reduced the number of recur-
rences significantly. In a multicentre, prospective trial with
a follow-up of 24 months a recurrence rate of 12.1% was
found [2]. In contrast to the crucial importance of a proper
wound healing for a successful suture repair, the long-term
success of a reinforcing implantation of non-absorbable
meshes seems mainly dependent on technical aspects.
Though there are several well-described surgical op-
tions for primary mesh repair of incisional hernias,
whether open or laparoscopically, there is no litera-
ture that addresses the problem of re-operation of
failed mesh repair. Mesh failure can mean recurrence
but also mesh infection or persisting postoperative
pain.
For this reason we analyzed the re-operations after
mesh failures that were performed in our surgical de-
partment between 1995 and 2004. In this period of time
we performed 88 operations following mesh repair. The
investigation was complicated due to the different tech-
niques of mesh repair and different type of meshes. Since
almost 50% of the primary mesh repairs were performed
in other hospitals, the surgical notes were not available
in all cases.
In our series, the main reason for a mesh failure was
a hernia recurrence (77/88). The different procedures of
primary mesh repair mirror the historical advancements of
mesh techniques. Different meshes were found in various
positions: 46 sublay, 23 onlay, 6 inlay and 2 open IPOM
procedures. The primary mesh repair was performed with
a heavy-weight, small-pore polypropylene mesh (PPHW) in
31 patients, with a light-weight, large-pore polypropylene
mesh (PPLW) in 38 patients, a mesh made from ePTFE in
seven patients and polyester mesh (Pol) in one patient.
Type of Mesh Material and Location
of the Recurrence
Depending on the mesh size, extent of overlap and mesh
position within the abdominal wall, the recurrent fascia
defect most often occurred at the mesh border, and only
in very rare cases through the mesh (
⊡
Table 23.6
). In
patients with PPHW meshes, the allocation of hernia
recurrences was located equally on all sides of the mesh.
This stands in contrast to the recurrences after PPLW
implantation, where the fascia defect occurred almost
exclusively at the cranial edge, where the intact linea alba
23.6 Redo Following Mesh Repair
J. C, M. B, U. K
⊡
Table 23.6. Allocation of recurrence position in dependence on the implanted mesh
Loca-
tion
Cranial Central Lateral Caudal
Position Med Lat Total Med Lat Total Med Lat Total Med Lat Total
PPHW
n = 31
163 19– – – 114 1525 7
PPLW
n = 38
16 8 24 2 – 2 – 7 171 3 4
ePTFE
n = 7
112 13– – – 112 13–1 1
POL
n = 1
––– ––– –111–––
Соседние файлы в папке Библиотека им академика М.И. Перельмана