E-ISSN:2349-3275
P-ISSN:2349-5502

Research Article

Incisional hernia

Biomedical Review-Journal of Basic and Applied Medical Science

2018 Volume 5 Number 1 Jan-Dec
Publisherwww.biomedicalreview.in

A comparative study of operative management of incisional hernia

Vipulbhai Shah J.1, M. Pukar M.2*, G. Mewada S.3, Aggrawal K.4
DOI:

1 Jigar Vipulbhai Shah, Associate Professor, Surgery, SBKSMI & RC, Piparia, Vadodara, India.

2* Mahesh M. Pukar, Professor, Surgery, SBKSMI & RC, Piparia, Vadodara, India.

3 Sohank G. Mewada, Resident, Surgery, SBKSMI & RC, Piparia, Vadodara, India.

4 Kuldeep Aggrawal, Assistant Professor, Surgery, SBKSMI & RC, Piparia, Vadodara, India.

Introduction: Incisional hernia is one of the common hernias in middle aged females. There are various studies conducted on risk factors, clinical presentation and different methods of surgical repair, whether these inferences hold good for our population is a pertinent question. In view of this, we need to study Incisional hernia in our setup. Material and method: This study aims at diagnosing, operatingand following up cases of Incisional hernia in the department of General Surgery of our Hospital from October 2010 onwards. The study is performed by analyzing various operative methods used to manage Incisional hernias. Result: This study include 50 cases of Incisional hernias which presented to our opd and were repaired at our hospital from our hospital 2010 to august 2012.

Keywords: Incisional hernia, Ventral hernia, Shoelace repair, Onlay mesh repair

Corresponding Author How to Cite this Article To Browse
Mahesh M. Pukar, Professor, Surgery, SBKSMI & RC, Piparia, Vadodara, India.
Email: 		Jigar Vipulbhai Shah, Mahesh M. Pukar, Sohank G. Mewada, Kuldeep Aggrawal, A comparative study of operative management of incisional hernia. Biomed Rev J Basic Appl Med Sci. 2018;5(1):14-22.
Available From
http://www.biomedicalreview.in/a-comparative-study-of-operative-management-of-incisional-hernia-research-article

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2018-12-08 2018-12-10 2018-12-17 2018-12-24 2018-12-31
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 18 IJB Archive

© 2018by Jigar Vipulbhai Shah, Mahesh M. Pukar, Sohank G. Mewada, Kuldeep Aggrawaland Published by Siddharth Health Research and Social Welfare Society. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

Biomedical Review-Journal of Basic and Applied Medical Science 2018;5(1)14
Shah J et al: A comparative study of operative management of incisional hernia

Introduction

“Hernia is a protrusion of a viscus or a part of viscus through normal or abnormal opening in the wall of its containing cavity” [1]. “Incisional hernia is abnormal protrusion of the viscus due to failure of line of closure of abdominal incisions” [2]. Incisional hernias, also often referred to as ventral hernias, may occur in the area of any prior surgical incision. No incision in the abdomen is immune to the development of Incisional hernias, as Incisional hernias of the perineum and coccyx have also been reported [2]. These hernias can vary in size from very small and uncomplicated, to very large and complex. Incisional hernias develop in up to 11 % of abdominal surgical wounds. Incisional hernias most commonly develop as the result of:

  • Disruption along or adjacent to the area of abdominal wall incision closure.
  • Tension, placed on the tissue as a result of suturing wound edges inadequately or under tension.
  • Other inhibitors to adequate healing (infection, poor nutrition, long smoking history, obesity, or metabolic diseases such as diabetes)

Incisional (or ventral) hernias present as a bulge, or protrusion, at or near the area of the prior surgical incision scar. Although most commonly occurring along midline incisions, virtually any prior abdominal operation can subsequently develop an Incisional hernia. These include those from large abdominal procedures (intestinal surgery, vascular surgery) to small incisions (Appendisectomy, or even laparoscopy) [2]. Again Incisional hernia can occur at any incision, but tends to be larger and more complex along prior mid-line incisions. Mid-line Incisional hernias also have a higher rate of recurrence if required using a simple tissue-to-tissue or suture-only technique under tension (up to 44 %) [2]. It is advised therefore, that these hernias be repaired initially using the far more effective. Tension free repair method using mesh so as to significantly reduce the risk of future recurrence of hernia. Incidence of Incisional hernia ranges from 2 – 11 % [22]. Incisional hernia is more common in female patient with midline incision and any postoperative complication like wound infection, burst abdomen, straining etc. Any of the above mentioned complication present at the time of previous operation predisposes

the condition. Various methods of repair of Incisional hernia have been tried starting from anatomical suturing to modern laparoscopic repair but every modality has their merits and demerits. Difficulties in finding out single superior technique are due to multifactorial nature of Incisional hernia [22]. So genuine effort is made in this study of 50 cases of Incisional hernia to learn incidence, precipitating factor and type of incision related to development of Incisional hernia and to learn various methodology for repair of Incisional hernia and its post-operative complication.

Aims and objectives

A study of 50 cases Incisional hernia is done with following aims and objectives.

1. To study etiology of Incisional hernia.

2. To study various modalities of treatment.

3. To study post-operative complications.

Review of literature

History: The term hernia is probably derived from the Greek Epvoo, “Hernios”- meaning a bud, a branch or an off shoot, and this is descriptive of the swelling that the lesion produces. The earliest recorded mention of hernia and its treatment is found in Egyptian Ebers Papyrus in 1500BC. Celsus in first century AD was the first to be aware of Incisional hernias. He advised to the study and art of herniology. Major abdominal surgery developed rapidly during the latter part of the 19th century and with it raised the incidence of post-operative hernias. For more than 100Yrs. attempts have been made to develop successful methods for repairing them. Gerdy (quoted by Ponka, 1980) has recorded as having successfully repaired an Incisional hernia in 1836. Maydl (Ponka) [7]. Is credited with an Incisional hernia repaie in 1886. He identified the musculo-aponeurotic layers and closed them in layers. W. mayo (Ponka) [7] in 1889, described his famous transverse overlapping technique for umbilical hernias, this was adopted for Incisional hernia repair by surgeons. Witzek in 1990, Goepel also in 1990, Bartlett in 1903, and McGavin in 1909 advocated the use of silver wire filigree (Jack Abrahamson) [8] (McArthur in 1901) [9]. Described the repair of Incisional hernia from contiguous facial sutures from the external oblique in autoplastic suture of hernia (Allen, 1957)


Biomedical Review-Journal of Basic and Applied Medical Science 2018;5(1)15
Shah J et al: A comparative study of operative management of incisional hernia

[8]. Judd in 1912 [38]. (Ponka) anf Gibson in 1916 both described repair techniques based on extensive anatomical dissection of the scar and adjacent tissues. Gibson again in 1920 [39]. reported having repaired successfully (quoted Ponka, 19800 [40]. Cases of large Incisional hernias using lateral relaxing incisions in the abterior rectus sheath, parallel to the midline. Burtoin described his fingered fascia lata graft repair in 1959. Hamilton used mattresses on lay graft of fascia lata in 1968 [15]. In 1937 [40] Nuttel from Liverpooi, (role and carless, 1952) detached the recti muscles from their insertions, crossed them over one another and reinserted them on the other side. In 1929, Dixon of the Mayo clinic (quoted Jack Abrahamson) [8]. described his operation, ehich was named Dixon’s repair. He reconstituted the strong new midline anchor for the flat muscles by reconstructing a new linea Alba by suturing together a strip of fascia from the medial edge of each anterior rectus sheath. Rodney Maingot from London described his famous operation for large Incisional hernias in 1940, which was named “keel repair” by his registrars. Allen and Wallace (Ponka) [7] in 1942, pointed out, drainage tubes brought out through the operation wound are a potent cause of Incisional hernias. In 1948 Ab el [9]. reported his initial experiences with closing abdominal incisions and repairing Incisional hernias with monofilament stainless steel wire. In Lahay’s practice of surgery 1950, R.B. Cattell [11]. Described the cattell’s repair in five layers for moderately large Incisional hernias. Well’s (11). described a method of repair using reflected flaps of anterior rectus sheath. Koontz and Throckmorton, each in 1948. [12] (quoted Allen g, 1957) used tantalum gauze. Kimberly [12]. Reported a large series of cases in which tantalum mesh was used. However tantalum mesh began to loose favour with reports of “work fracture” with fragmentation of the mesh resulting in a weakened repair and associated pain in some patients. Thomson in 1948 used pliable plastic sheets in the repair of large Incisional hernias. Schofield and his co-workers, in 1955, (quoted by J.J. Abrahams, 1957) [2]. In an experimental study, showed that, polyvinyl alcohol sponge meets all the requirements of a foreign material for use in the repair of abdominal wall defects. Abrahams J.J. and Jonassen [13] in 1957 successfully repaired recurrent Incisional hernias with polyvinyl alcohol sponge. The technique of introducing a pneumo-peritoneum preoperatively to regain abdominal domain was reported

in 1947. In more recent years, this technique has rarely been used because of the frequent use of tension free mesh repairs. Nonetheless, a number of authors still content that selected patients will benefit from progressive pneumo-peritoneum, regardless of the repair utilized [14]. The modern era of prosthetic hernia repair began in 1958, when F.C. Usher and Wallace, reported their experience with the use of a high density polyethylene (Marlex) mesh for repairing hernias and other body wall defects F.C. Usher again in 1963 [13] reported his experience with the use of knitted polypropylene version of marlex mesh, (prolene mesh) for repair of large Incisional hernias. Usher again in 1967, reported a recurrence rate of 10 % in 98 patients with Incisional hernias repaired with marlex mesh. Drainer and Reid in 1972 (quoted Ponka, 1980) [1] found marlex an effective implant but reported in infection rate of 22.2 %. In 1979 Usher, again described a technique of repair using marlex mesh in which the mesh was placed deep to the muscle and musculofascial sutures closed completely over it. In 1979, Norman Browse and Paul hurset [16] described a method of repair using Marlex mesh as an onlay fascial approximation. To prevent the development of a chronic seroma in the abdominal wall after Incisional hernioplasty with a prosthetic material, Usher, in 1971, recommended the routine use of large hemovac drains, and the post-operative application, in 1974 [17], also advocated into the wound. Abdul-Husn, [18] in 1974 first used a synthetic mesh of polyester fibres (mersilene, Dacron) Durden and Pemberton [17], also reported their experience with the use of Dacron mesh for Incisional hernia repair in 1974. New and more innovative ways of dealing with large, complex or recurrent Incisional hernias include the use of full thickness abdominal skin, (reported by Marchac and Kaddoura in 1983), muscle and myocutaneous flaps (reported by Ger and Duboy’sin 1983) [19]. Polymeric silicone (silastic) and polyglycolic acid mesh (reported by Jenkin’s et. Al, in 1983) [20] or combination of mesh and an aponeurotic graft, (reported by Adloff and Arnaud, in 1987) [21]. Stone and associates, namely, a lower incidence of post-operative wound sepsis and fewer bowel fistulae. Hamer Hodges D.W. and scott N.B. [22] in 1985 reported their successful use of PTFE mesh for repair of abdominal wall defects. Stanley D. Berliner [23] in 1989 found the expanded weave PTFE mesh satisfactory for groin hernias and currently he is studying the use of expanded PTFE


Biomedical Review-Journal of Basic and Applied Medical Science 2018;5(1)16
Shah J et al: A comparative study of operative management of incisional hernia

mesh for repair on Incisional hernias. Jayanth Sharma ET al [23], in their study have stated that Incisional hernia occurring through lower midline incision was the most common variety requiring prolene mesh repair (7.5 %), prolene mesh is an excellent synthetic material incorporating with the body tissue for the repair of the hernia. Repair of giant ventral hernia becomes technically easy with the use of mesh and given good results if asepsis is ensured. Polypropylene mesh has been used extensively because it has the greatest tissue ingrowth of all the mesh products available with least complication rate [25-28]. Retrorectus placement of mesh more commonly known as Stoppa technique became more popular during the 1990s 29]. This technique keeps the hernia sac as a buffer between the mesh and the intra-abdominal contents. Laparoscopic repair of Incisional hernia came into picture in 1990s. And the use of composite mesh has promoted the interest towards laproscopic repair.

Anatomy of abdominal incision:

“Technical skills and tons of antibiotics will not prevent complications, if the discipline to ensure safety is ignored’ The choice of incision and correct methods of making and closing such wounds are factors of great importance. Any mistake, such as badly placed incision, incorrect methods of suturing or ill-judged selection of suture materials, may result in serious complications such as hematoma formation, infection, such as abscess, an ugly scar, an Incisional hernias or worst of all, complete disruption of the wound.(22). Therefore to prevent such complications certain essentials should be achieved (Harold Ellis).

1. Accessibility: The incision must give ready and direct access to the anatomy to be investigated and must also provide sufficient room for the required procedure to be performed.

2. Extensibility: The incision should be extensible in a direction that will allow for any probable enlargement of the scope of the operation, but it should interfere as little as possible with the functions of the abdominal wall.

3. Security: The closure of the wound must be reliable and ideally should leave the abdominal wall as strong after the operation as before.

4. Incision placed against the lines of tension is

prone to post-operative complication of dehiscence or hypertrophic scars. Sutures hold best when and where they pull across tissue fibers. This can be accomplished only by making the incisions so that it runs parallel to the tissue fibers. The muscle must be split in the direction of their fibers rather than cut across.

5. The incision must traverse the muscle rather than fascia as the scar left in the peritoneum is best protected.

6. Incisions placed across the blood and nerve supply are prone to post-operative complications of dehiscence.

7. Parallel incisions are generally undesirable because of compromise in circulation and denervation of muscle.

8. The rectus muscle may be cut transversely without seriously weakening the abdominal wall as such a cut passes between two adjacent nerves without injuring them. The rectus has a segmental nerve supply so that there is no risk of a transverse incision cutting off the distal part of the muscle from its nerve supply.

9. The opening made by the cut through the different layers of the abdominal wall must as far as possible not to be superimposed.

10. Re entry into the abdomen should preferably be performed through previous incisions, as there is a distinct risk that a second incision placed alongside the previous wound, would cut off the blood supply of the skin between the two incisions, resulting in necrosis of the skin bridge. Also denervated muscle may not hold sutures wel.

11. In children, the skin incision should continue to Langer’s lines otherwise the scar becomes hypertrophic and unsightly with age.

Incidence of Incisional hernia:

  • The incidence of Incisional hernia varies. In 1987 John Himans of Boston (quoted by ponka) [6] reported in incidence of 10 % of Incisional hernias in 184 cases of laparotomies. In 1933, Cave (quoted by Zimmerman in 1967) found an incidence of 6 % of Incisional hernias in laparotomy wounds.
  • Rodney Maingot states that, Incisional hernia occur in 1 – 1.4% of patient

Biomedical Review-Journal of Basic and Applied Medical Science 2018;5(1)17
Shah J et al: A comparative study of operative management of incisional hernia
  • undergoing trans peritoneal abdominal operations. According to Acman, who studied hernias for 15 years, the incidence of Incisional hernia was 1.6%.
  • Goligher and colleagues in 1975, at the Leads General Infirmary, noted that not even a single patient out of 108 laprotomies developed incisiuonal hernia when they were closed by all coats interrupted wires.
  • Donaldson and colleagues in 1982, at Str.James’s Hospital, Leeds, using the lateral paramedian incision, found only a single Incisional hernia in 231 laparotomies. Buknall and colleagues in 1982, detected 84 cases of Incisional hernias (7.4%) in 1129 major laparotomy wounds,12 months after operation, Pollock in 1981, rewiewed 961 patients, 6 months after laprotomy and detected 96 cases of Incisional hernias(10 %).

Materials and Methods

This study aims at diagnosing, operating and following up cases of Incisional hernia in the department of General Surgery of our Hospital from October 2010 onwards. The study is performed by analyzing various operative methods used to manage Incisional hernias.

A detailed clinical study and management of 50 cases of Incisional hernia has been personally made. The cases have been selected at random. All patients of primary Incisional hernia with previous history of laprotomy are selected ar random.

Inclusion criteria

1. Only those patients who are willing to participate in study will be included.

2. Patient referred to the general surgery department for swelling per abdomen, and found to have positive finding, will be included in this study.

3. Already diagnosed cases of Incisional hernia which either need operative management or follow up and are referred to our general surgery department will be included in study.

Exclusion criteria

1. Patient presenting to general surgery department already being operated for Incisional hernia in past and are cured completely or partially will be excluded from the study.

2. Patients with strangulated or incarcerated hernias, and pts with severe co morbid conditions (severe cardio-pulmonary disease, uncontrolled ascites) and pregnant women with Incisional hernias are excluded from the study. No other criteria have been adopted in selection of cases.

Results and Analysis

This study include 50 cases of Incisional hernias which presented to our opd and were repaired at our hospital from our hospital 2010 to august 2012.

  • In present study maximum no of patients are in age group 31 – 40 and 41 – 50, each having 13 patients. Age (21 – 30) = 6, (31 – 40) = 13, (42 – 50) = 13, (51 – 60) = 9, (61 – 70) = 9.
  • In this study of 50 patients, 39(78 %) were female and rest 11(22 %) were male. Male to female ratio is near 1:4. Study conducted by Le and J.S. Bender also showed similar age distribution in their study of 150 cases.
  • In present study swelling was the most common presenting symptom and was present in 47((94 %) patients, followed by pain in 39(78 %), heaviness in 12(24 %), vomiting in 6(12 %) and abdominal distension in 4(8 %) patients.
  • The present study showed 16(32 %) patients presented early that is within one year of the primary operation and the rest presented late 34(68 %) that is more than one year of primary operation.
  • Out of 50 cases, 29(58 %) patients had undergone some obstetric and gynecological procedure of which L.S.C.S. comprised of 16(32 %), Hysterectomy 8(16 %) and T.L. 5(10 %) patients. Of the remaining, Exploratory laparotomy comprise of 11(22 %) patients and other includes open Appendisectomy in 3(6%), Gall bladder and CBD surgery 4(8 %), laparoscopy in 2(4 %) and anterior resection 1(2 %).
  • Out of 50 cases observed in our study 30(60 %) of patients had undergone elective surgery and only 20(40 %) patients required some emergency surgery.
  • Out of 50 cases midline vertical incision was present in 39(78 %) patients out of which 28(56 %) had low mid line incision. Other includes Kocher’s incisions in 3 (6 %),

Biomedical Review-Journal of Basic and Applied Medical Science 2018;5(1)18
Shah J et al: A comparative study of operative management of incisional hernia
  • Mcburney’s in 3(6 %), paramedian in 2(4 %) and Pfannenstiel in 1(2 %) patients.
  • Out of 50 cases, 9(18 %) patients had history of wound infection at the time of their previous surgery out of which 4(8 %) underwent resuturing for wound gaping. Other complications include post op straining in 5(10 %) and distension of abdomen in 4(8 %) patients.
  • Out of 50 cases, 15(30 %) patient had associated hypertension, 8(16 %) patients were diabetic. Other associated medical disease includes 5(10 %) patients.
  • Study shows out of 50 cases,20(40 %) patients had straining as a precipitating factor either due to constipation 12(24 %), chronic cough 6(12 %), or difficulty in maturation 4(8 %). Smoking was associated in 10(20 %) of patients and alcohol in 2(4 %).
  • In our study obesity is taken weight more than 70 kg in women and 80 kg in men. Out of 50 cases 20 (40 %) were obese and 6 (12 %) were anemic.
  • Out of 50 cases 41 (82 %) had reducible hernia and 9 (18 %) had irreducible.
  • Out of 50 cases 17 (34 %) had good abdominal tone and rest 33 (66 %) had poor abdominal muscle tone.
  • Out of 50 cases 19 (38 %) had intestine, 16 (32 %) had intestine and omentum, 11 (22 %) had only omentum and in 2 (4 %) patients sac was empty.
  • Method of repair done 5 (Anatomical), 4 (Shoe Lace repair), 16 (On Lay mesh), 21 (In Lay mesh), 3(Intraperitoneal), 1 (Laproscopic repair).
  • Post-operative complications, wound infection in 4, Seroma in 2, Pulmonary complication in 2, Recurrence in 4, Retention of urine in 1, Sub acute intestinal obstruction in 1, Mortality in 1.
  • Out of 9 patient suture repair 2 had recurrence, 1 patient by Shoe Lce repair and one with intraperitoneal mesh had recurrence.

Discussion

It is a common complication of abdominal surgery. Reported in upto 11 % patients in general and

up to 23.3 % of those who develop post-operative wound infection. Incisional hernia may present develop immediately after operation but presentation may be later on.

More than half of all Incisional hernia develop within first two years of primary operation. However Incisional hernia may present later and becomes symptomatic even after ten years of primary operation.

Risk factors for development of Incisional hernia include:

  • Age greater than 65 years.
  • Hypoproteinemia in malnourishment
  • Anaemia and co-morbid disease.
  • Obesity
  • Wound infection is the most significant independent risk factor for Incisional hernia. The risk increases up to 25 % after wound infection.
  • Increase post-operative intra-abdominal pressure in conditions like paralytic ileus, cough, vomiting, retention of urine can cause increase chances of Incisional hernia
  • Technical factor like type of incision, method of closure and type of suture used.
  • Smokers have a 4 fold increased risk of Incisional hernia. In this clinical study

In this clinical study, 50 patients with Incisional hernia were admitted and operated from December 2010 to april 2012.

The same group of patients was studied for various risk factors in causation of Incisional hernia and its clinical presentation.

Table 1: Comparison of previous operation

Preoperative Operation No. of patients in present study No. of patients in Bhat Mahabaleshwar G study
L.S.C.S. 16 78
Exploratory Laprotomy 11 15
Hystrectomy 8 22
T.L. 5 23
GB and CBD operation 4 12
Open appendisectomy 3 8
Laproscopy 2 7
Anterior resection 1 5

Biomedical Review-Journal of Basic and Applied Medical Science 2018;5(1)19
Shah J et al: A comparative study of operative management of incisional hernia

Out of 50 cases 29 (58 %) patients had undergone some obstetric and gynecological procedure pf which L.S.C.S. 16, Hystrectomy 8, and T.L. 5 patients.

Table 2: Comparison of post-operative complication

Complication No. of patients in present study (n=50) No. of patients In study conducted by Bhat Mahabaleshwar G et al (N=130) No. of patients in study conducted by Z.S. Matar (N=68)
Wound infection 4 18 7
Seroma 2 8 5
Haematoma 0 6 2
Pulmonary complication 2 6 3
Recurrence 4 20 3
Retention of urine 1 9 1
Sub-acute intestinal obstruction 1 0 0
Mortality 1 0 0

Most common complication includes wound infection in 4(8 %) patients and seroma in 2(4 %).Bhat and Mahabaleshwar study also showed a wound infection rate to be 10 %. Z.S.

Matar study also showed seroma rate of 7.35 % in their patients.

Table 3: Comparison of recurrence and mortality in various types of mesh repair

Author Type of repair No. of cases Recurrence Percentage Mortality
Rodney Keel 115 5 4.3 Zero
Abrahamson Shoe Lace 300 6 2.0 Zero
Adloff Intraperitoneal 130 6 4.5 1.5 %
Usher Two layer 96 10 10.4 Zero

In our study, recurrence was found in 4(8 %), out of which 2 (4 %) were repaired by anatomical closure, 1 (2 %) by shoe lace repair, and 1 (2 %) by open intraperitoneal mesh repair.

Recurrence rate after mesh plasty is 2 %, which coincides with the world literature.

In our study mortality rate was 2 % and the cause was pulmonary failure with septicemia.

Mortality rate was 0.6 % in Harry et al study and was 1.5 % in Adoff et al study.

Table 4: Comparison of recurrence in open mesh repair

Author Year No. of patients Type of mesh Technique Recurrence
Mc Carthy et al 1981 25 Polypropylene Intraperitoneal 8 %
Matapurkar et al 1991 60 Polypropylene Extraperitoneal 0 %
Temudon et al 1996 50 Polypropylene Extraperitoneal 4 %
Gillion et al 1997 158 PTFE Extraperitoneal 4 %
Mclanahan et al 1997 106 Polypropylene Extraperitoneal 4 %
Balen et al 1998 45 PTFE Extraperitoneal 2 %
Turkcapar et al 1998 45 Polypropylene Extraperitoneal 2 %
Arnauld et al 1999 250 Dacron Intraperitoneal 3 %
Bauer et al 1999 98 PTFE Extraperitoneal 10 %
Utera Gonazalez et al 1999 84 PTFE Intraperitoneal 2 %
Chrysos et al 2000 52 PTFE Intraperitoneal 8 %
Luijendijk et al 2000 84 Polypropylene Extraperitoneal 23 %
Burger et al 2004 84 Polypropylene Extraperitoneal 32 %
Martin – Duee et al 2001 152 Polypropylene Extraperitoneal 1 %

Most of the studies conducted on open mesh repair of Incisional hernias shows a recurrence rate ranging between 1 % to 4 %. Recurrence rate after open meshplasty in our study is 2 % which coincide coincides with the world literature.

Table 5: Comparison of suture repair Vs mesh repair

Type of repair No. of patients in present study Recurrence in present study No. of patients in study conducted by Kalpan And Meier Recurrence in study conducted by Kalpan And Meier
Suture repair 9 3 (6 %) 97 54 (29.8 %)
Mesh repair 41 1 (2 %) 84 27 (14.9 %)
Total 50 4 (8 %) 181 81 (44.7 %)
  • Overall recurrence rate in our study was 8 %.
  • Whereas recurrence rate in study conducted by Kalpan and meier was 44.7 %.
  • Kalpan observed a recurrence rate of 29.8 % when Incisional hernia was repaired using sutures and 14.9 % when repaired using mesh.
  • Low recurrence rate in our study might be because of the reason that a lot more patients were operated using mesh.

Conclusion

In this study of 50 cases of Incisional hernia we conclude that:-


Biomedical Review-Journal of Basic and Applied Medical Science 2018;5(1)20
Shah J et al: A comparative study of operative management of incisional hernia
  • Incisional hernia is more common in females of reproductive age group.
  • Most of the females undergoing obstetric or a gynec operation with low line incision.
  • Regarding etiology, previous wound complication and post-operative straining are the main important factors responsible for Incisional hernia.
  • Other associated medical conditions which predisposes to the condition are obesity, anaemia and diabetes.
  • Poor muscle tone and Smoking also predisposes and leads to Incisional hernia.
  • Recurrence rate for sutures repair is much higher than mesh repair.
  • Mesh repair is the ideal method of repair.
  • In our study most of the patients 40 (80 %) were repaired by open mesh plasty which showed very good results with a recurrence rate of only 2.5 % and complication rate being 20 %, most of which were minor complications like mild wound infections, seroma etc.
  • As far as mesh required is considered onlay technique is easier to perform but have more post-operative complications.
  • In lay repair has its limitations of higher rate of recurrence due to tension between the edge and the mesh.
  • Underlay repair is the preferred repair because of posterior protection of bowel by the posterior rectus sheath and anterior buffering by the rectus muscle and the anterior rectus sheath.
  • Preperitoneal and intraperitoneal technique is a technically easier procedure but carry a higher rate of complications because of contact of mesh with bowel.
  • Laparoscopic repair has all the advantages of minimally access surgery but cost factor limits its use in every paients.

Reference

1. Bailey and love: short practice of surgery, 25th edition.

2. Maingot: Abdominal operation, 11th editon.

3. Sabiston: textbook of surgery, volume 2, 18th edition.

4. S.k bhattacharya: short cases in surgery, 4th edition.

5. A.k dutta: human anatomy, 6th edition.

6. B. D chaurasia: human anatomy, volume 2, 5th edition.

7. Ponka, hernias of anterior abdominal wall sunders company, 1980.

8. Jack abrhamson , “Hernias” 14 th chapter ,rodeny maingot’s abdominal operation .10 th edition ,548-572.

9. Mc arther LL, autoplastic suture in hernia and other diseases, preliminary report, JAMA 1901; 37:1162.

10. Adolf m, and arnaud J.P, surgical management of large Incisional hernia by intraperitoneal mersilene mesh and an aponeurotic graft. Surg Gaynec Obst. 165(3) 204 -206, 1987.

11. Bhat mahabaleshwar G et al: preperitoneal mesh repair of incisional hernia: 7yr. Study. IJS; 69 (3), 95 -98, 2007.

12. Antonine hamy et al: surgical treatment of large incisionL hernia by intraperitoneal dacrone mesh and apponeurotic graft.

13. Azurin D et al: trocar site hernia following lap cholecysctectomy , Am. Surg :61:718 _20,1995.

14. Burger JU et al: suture verses mesh repair of Incisional hernia, annals of surg, 240 (4) :578 -83,2004 oct.

15. Hamilton le et al: retro fascial mesh repair of ventral Incisional hernia, AM .journal of Surg: 189,373 -375, 2005.

16. Hong lau et al: laproscopic Incisional hernia Repair, annals of the college of surgery, Hong kong: 9 (1):13 -17, 2005 September.

17. H. Lau et al: laproscopic Incisional hernioplasty using e –PTFE dual mesh: Hong Kong Med. J: Vol: 8(6): 413-417, 2002 dec.

18. H. Lau et al: laproscopic repair Incisional hernia. HKMJ: volume 7 (3): 319 -21, 2001 sept.

19. H. S. Kharia: repair of IH, J. R. Coll. Surg, 46; 39-43; 2001.

20. Israelsson L. A.: Incisional hernia after midline laprotomy: a prospective study: Eur. J. surg, 162: 125 -129, 1996.


Biomedical Review-Journal of Basic and Applied Medical Science 2018;5(1)21
Shah J et al: A comparative study of operative management of incisional hernia

21. Jacobes W .A burges : suture vs ,mesh repair of IH, annals of surg, 240 (4),578 -587,2004

22. JB shah: Incisional herni, study of 50 cases: Ind, J Surg: 335 -356:1977 july.

23. Johana S et al; laroscopic incisonal hernia repair in obese patient, jour. soc. lap surg: 9(1); 47-50, 2005.

24. Vrijland WW et al: intraperitoneal polypropylene mesh repair of incisional hernia is not associated with enterocutaneous fistula, BJS: 87 (3): 348-52, 2000 march.

25. Bose SM, Lal Roshan, Kalra Manju , Wig JD , Khanna SK . Ventral hernia - A review of 175 cases. Indian journal of surgery 1999 ; 61 (3) : 180 -84

26. TC Goel and P.C. dubey : abdominal Incisional hernia , anatomical technique of repair ,Ind .J surg : 324 -327 ,1981,april

27. Donaldson DR, Hegarty JH et al. The lateral paramedian incision –experience with 850 cases. Br J Surg 1982 ;69 :630 -32

28. Molbey et al : BJS : 78 ,242 244 : 1991

29. P.M Lamat and H ellis: Incisional hernia or reopened abdominal insicion: an overlooked risk factor. BJS: Vol .75: 374- 376, April 1998.

30. Le blank RA: incisional hernia repair: laproscopic technique: world journal of surg: 29 (8): 1073 – 9 .2005 aug.

31. K. Cassor and A. Munro: surgical treatment of incisional hernia, Br. Jour. of Surg : 89,534 – 545 : 2002

32. Ellis H, Gajraj H, Geroge CD. Insicional hernias-when do they occur? Br J Surg 1983 ; 70 : 290

33. Goel TC, Dubey PC. Abdominal Incisional hernia- anatomical technique of repair. Indian journal of surgery 1981 ;43:324 -27

34. K.M.F Itani et al: repair of ventral Incisional hernia, Am. J. of Surg: 188, 22 -29, 2004 Dec.

35. Shah JB. Incisional hernia – A study of 50 cases. Indian journal of surgery 1977 ; 39 :353 -56

36. Koontz A .R and Kimberly R.C further experimental works on prostheses for hernia repair, Surg Gynaec Obst. 109,321;1959


37. Usher F.C, hernia repair with knitted polypropylene mesh, surg Gynaec Obst. 117; 239, 1963.

38. Judd E.S prevention and treatment of ventral hernias. Surg Gy .Obst. 14; 175. 1972

39. Gibson C. Operation for cure of large ventral hernias. Ann surgery 72; 214-217. Aug , 1920

40. Nuttal HCW/ rectus transplantation for midline Incisional hernia. BJS, 25, 344,-1937.

41. Abdul Husn. S.Biomaterials and herniology , JAMA , 251 ; 1431, 1984

42. Adolf M, and Arnaud J.P, surgical management of large incisional hernia by intraperitoneal mersilene mesh and an aponeurotic graft. Surg Gynaec Obst . 165 (3), 204-206, 1987.

43. Abrahamson J, Eldar S. Anew method of repair of large post-operative ventral hernias. Dig surg 1884; 1: 117.

44. Teixeira F et al: Incisional hernia at trocar site: Rev. Hosp. Clin. Med. S. Parto : 58 (4): 219-222,2003.


Biomedical Review-Journal of Basic and Applied Medical Science 2018;5(1)22