[Incisional hernia - how do I do it? Standard surgical approach]

J Conze, M Binnebösel, K Junge, V Schumpelick
Der Chirurg; Zeitschrift Für Alle Gebiete der Operativen Medizen 2010, 81 (3): 192-200
Various techniques for repair of an incisional hernia are available for the surgeon. Conventional suture techniques are quick and easy to perform but they are associated with an unacceptable rate of recurrence and therefore should only be used in exceptional cases. An underlying systemic disturbance of collagen metabolism is assumed to exist in patients with an incisional hernia. In such patients the mechanisms of wound healing and remodeling of the abdominal wall following laparotomy are insufficient, which necessitates reinforcement of the abdominal wall with a non-resorbable alloplastic mesh prosthesis to enable a long-term cure. The implantation of such meshes can be carried out laparoscopically or by an open approach. The gold standard of open repair techniques is the retromuscular placement of a mesh prosthesis. The retromuscular mesh placement as a reinforcement of the abdominal wall (augmentation) must be categorically differentiated into the abdominal wall replacement by mesh bridging. In this technique the mesh is likewise placed in the retromuscular space, however a complete closure of the ventral fascia is not necessary. Retromuscular augmentation enables an extra-peritoneal placement of the prosthesis, an optimization of tissue integration by plane coverage of the prosthesis by well vascularized muscular tissue and a sufficient overlap in cranio-caudal and lateral directions. Mesh fixation is best made with absorbable suture material but is better suited for technical simplification. The use of a prophylactic drainage should be decided depending on the individual patient's risk factors, because sufficient evidence-based data are currently not available. If augmentation is not possible bridging is necessary and then the mesh has to be fixed without underlying support. Current data reveal that the recurrence rate following incisional hernia repair by retromuscular mesh augmentation has decreased promisingly in comparison to simple suture techniques. In total the recurrence rate following retromuscular mesh placement ranges between 2 and 12%. Current results of prospective randomized multicentre trials are not available. However, it is to be expected that further development of mesh materials as well as improvement of surgical techniques with avoidance of typical pitfalls will lead to further reduction of the recurrence rate with an improvement in patient satisfaction.

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