COMPARISON BETWEEN ON LAY AND IN LAY MESH IN REPAIR OF INCISIONAL HERNIA

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1 COMPARISON BETWEEN ON LAY AND IN LAY MESH IN REPAIR OF INCISIONAL HERNIA Department of General Surgery, Mataria Teaching Hospital, Cairo, Egypt. ABSTRACT Background: Incisional hernia is a common complication of abdominal surgery with a reported incidence of (2-11%) following all laparotomies and an important source of morbidity. A wide spectrum of surgical techniques has been developed ranging from suturing techniques to the use of various types of prosthetic mesh repair. Aim of the work: The aim of the present study is to evaluate the technique of preperitoneal mesh repair for incisional hernias and study the postoperative complications of this procedure. Patients and Methods: Our study consisting of 60 patients with incisional hernia, managed by preperitoneal mesh implantation and postoperative complications were estimated during the period from January 2008 to may Follow up for 12 months for any complications or recurrences. Results: The results of our study: sixty patients, 75% of females (n 45) and 25% males (n=15). The female to male ratio was 3:land the highest incidence was in the 4th decade of life. The main presenting feature was abdominal swelling in all patients (100%) in the near of the previous operative scar. In 70% of patients (n=42), the most common incision leading to incisional hernia was the midline incision (upper 5 and lower 37) of abdomen followed by fanensteil sincision in (13.3) percent (n=8) and paramedian incision in (11.7) percent (n=7). Two patients (3.3%) post subcostal incision and one patient (1.7%) post Mc Burney s incision. Major wound infection occurred in two patients (3.3%) only but without the removal of mesh. Comparing with other preperitoneal mesh repair studies, minimal postoperative complications with no recurrence were noted in the present 362

2 study.conclusion:preperitoneal mesh repair had excellent results, with minimal morbidity (few postoperative complications with no recurrence). So it is a gold standard treatment for incisional hernia repair. Keywords: Incisional hernia; Mesh repair; preperitoneal mesh repair; postoperative complications; Recurrence. INTRODUCTION Fail to heal; it is one of the most common conditions requiring major surgery.despite Incisional hernia is defined as diffuse advances in surgical techniques and suture extrusion of peritoneurn and abdomina material. The incidence of incisional contents through a weak scar after hernia is (2-11%) following all lap-operation or accidental wound. It is the tomies (Santor and Roslyn, 1993) and it is only hernia considered to be truly a source of morbidity that requires high iatrogenic. It occurs due to the failure of health care costs. Recent studies however the lines of closure of abdominal wall show that about 2/3 appear within the first following laparotomy(manohar andramadev, 2010). An incisional hernia appears 5-10 years after the operation. It occurs in all the layers except the skin, seen more in females, obese, older age group. Jack Abrahrnson a pioneer in hernia surgery in the modern era said, many factors singly or in various combinations may cause failure of the wound to heal satisfactorily and lead to development of incisional hernia, main causes in its causation are poor surgical technique and sepsis. Hernias were considered large, when the width measured more than 10 cm at its greatest diameter. Medium hernias measured between 6 and 10 cms in diameter. Small hernias were those diameter6 cm. Complications of hernia include irreducibility is frequent and partial obstruction, strangulation, spontaneous ulceration, rupture. Considering the significant recurrence rate noted after various techniques for incisional hernia repair, the task of repairing this defect can challenge the scientific and artistic talents of the most experienced surgeon. Various types of repair have 363

3 been described, both anatomical and prosthetic. But the results have been disappointing with a high incidence of recurrence between (30-50%) after an anatomical repair (Cassar and Munro, 2002) and in between (1.5%-1O%) following prosthetic mesh repairs (Bauer et al., 2002). In general the postoperative complications of incisional hernia include pulmonary atleciactasis, bronchitis, pulmonary embolism, postoperative ileus, thrombophlebitis and deep venous thrombosis or local complications like wound seroma, haematoma, infection, sinuses and complications of mesh. The introduction of prosthetics has revolutionized hernia surgery with the concept of tension free repair. Although a wide variety of surgical procedures have been adopted for the repair of incisional hernia, but the implantation of prosthetic mesh remains the most efficient method of dealing with incisional hernia patients with large defects of the anterior abdominal wall, especially preferred more than 4 cm, size defect (Ahmed et al., 1995). The prosthetic mesh can be placed between the subcutaneous tissues of the abdominal wall and the anterior rectus sheath (onlay mesh repair) as well as in the preperitoneal plane created between the rectus muscle and posterior rectus sheath (sublay mesh repair or Rive sstoppa technique ). The main advantage of pre -peritoneal mesh repair are, Less chance of mesh infection or erosion through skin because the graft lies deep in preperitoneal plane between posterior rectus sheath and peritoneum, avoids adhesions bowel obstruction, enterocutaneous fistula and erosion of mesh, minimal morbidity and duration of hospital stay is less compared to other techniques(bhat and Santosh, 2007). Moreover the mesh implanted in the preperitoneal space unites and consolidates the anterior abdominal wall. The mesh also adheres to the posterior rectus sheath and renders it inextensible allowing no further herniation. The preperitoneal (sublay) mesh hernia repair was first described by Rives (1987), Stoppa (1989) and Wantz (1991). This technique is considered by many surgeons to be the gold standard for the open repair of abdominal incisional hernia (Martin et al., 2001, Langer et al., 2005, 364

4 Berry et al., 2007, Iqbal et al., 2007, and Lasheen, 2009). The main disadvantage is more time consuming, extensive preparation of preperitoneal plane and surgical experience. The present study was undertaken to evaluate the technique of preperitoneal (sublay) mesh repair of incisional hernias with regards to post operative complications, hospital stay and recurrences. PATIENTS AND METHODS This study consisting of 60 patients with incisional hernia managed by preperitoneal mesh repair during the period from January 20!Jto may The patients, who were admitted to Surgery Department, diagnosed to have incisional hernia and these patients managed by preperitoneal mesh repair are included in this study. Inclusion Criteria: 1. All the patients with incisional hernia between 15 and 60 years without sex discrimination. 2. Incisional hernias located in the midline (upper and lower), paramedian and subcostal incisions of the abdomen. 3. Incisional hernias after the PfannensteWs and McBurney s incision. Exclusion Criteria: 1.All the patients with chronic obstructive pulmonary Disease (COPD). 2.Patients with abdominal malignancy and cirrhosis with end stage liver disease. 3.Patients with previous loss of the abdominal wall and large scarred area of the abdominal skin. 4.Patients with age less than 15 years and more than 60 years. 5.Patientswith size of hernia larger than 15 cm in its largest dimension. 6.Incisional hernia in pregnant patients. The age of the patients included in the study varies from 15 years to 62 years. Regarding the sex distribution, seventy five percent of patients were females (n= 45 and twenty five percent were males (n15). All patients were admitted to our 365

5 surgery unit. The epidemiological data i.e. the name, age, sex, address and phone number was recorded at the time of admission. The clinical features and their duration, time of initial operation and the interval between the first surgery and appearance of incisional hernia were asked from patients and recorded. The known suspected risk factors like obesity, diabetes and history of wound infection, type of incision made were noted and recorded. All the details were entered in the database and results were statistically analyzed by Statistical Package for Social Sciences (SPSS). All patients underwent thorough clinical examination and a detailed history and details of previous operation were asked for. All patients were evaluated for systemic disease or precipitating cause. Patients who had hypertension, diabetes mellitus or cough were controlled preoperatively. Routine investigations were done for all patients including chest x-ray and ultrasonography of the abdomen. A day prior to surgery, shaving of the abdomen and genitalia was done. Overnight fasting, enema once in night and once in morning in the day of surgery were advised. A nasogastric tube and Foley s catheter was passed and broad- spectrum antibiotics was given to all patients before the procedure. Patient was informed about the effects and complications of the procedure. The procedure was done under general anaesthesia, spinal or epidural anaesthesia in supine position. In all cases, old operative sear was excised, generous skin incision was used to permit adequate exposure of hernial sac and defect. The sac was onened and contents were reduced after lysis of the adhesions. The excess sac was excised; peritoneum was closed with absorbable synthetic suture. 366

6 Operative Technique: The principles of the prepcritonealorsublay mesh repair include Adequate preperitoneal plane was prepared between the posterior rectus sheath and peritoneum (fig 1). Mesh placement deep to the recti muscles, peripheral suture fixation, mesh extension well beyond the hernia defect (fig 2) and closure of the fascia over the mesh. Fibrous tissue growth in the pours mesh consolidates the abdominal wall and widely disperses intra-abdominal spreure to prevent recurrence. Our technique involves the placement of prosthetic mesh Figure (1): prepared plane between posterior rectus sheath and peritoneum. In the postoperative period, nasogastric aspiration two hourly in first 24 hours was done. The nasogastric tube was removed once the patient passed flatus. Foley s catheter was removed on 1 postoperative day. Suction drain was removed once the drainage falls to 20 to 30 cc in 24 hours. Antibiotics were continued for six days. Postoperatively, deep breathing exercises, movement of limbs in bed was advised as (Polypropylene) in a preperitoneal plane. A plane is created between the posterior rectus sheath and the peritoneum for placement of the mesh. A prolene mesh tailored to the size is placed in the plane created in front of the peritoneum. The mesh is secured with few interrupted 2/0 or 3/0 sutures polypropylene sutures. A suction drain is placed over the mesh and brought out through separate stab wound. The posterior rectus sheath is closed 367

7 with 2/0 prolene suture. The anterior rectus sheath is closed with continuous 1/0 polypropylene sutures as soon as patient recovered from anesthesia. Early limited ambulation was done once the patient was able to bear the pain. Skin sutures removed on 10th day and in few cases after that. At discharge, patients were advised to avoid carrying heavy weights and advised to wear abdominal belt. Patients were reviewed after one month, 3 months, 6 months and 12 months in all cases. At follow up visits, symptoms were asked for and operative site examined for any recurrence. These cases were then analyzed and results were compared with existing literature. Statistical Methods Chi-square and Fisher exact test have been used to test the significance of proportions of postoperative complications between PPMR of present study and other studies. Two tailed Student t test has been used to find the significance of difference of hospital stay between the patients presented with risk factors. Excel has been used to generate graphs and tables. 368

8 RESULTS A prospective clinical study consisting of 60 patients with incisional hernia who undergone preperitoneal mesh repair is undertaken to investigate the role of preperitoneal mesh repair and its postoperative complications. The age distribution of these 60 cases ranged from 15 years to 62 years (male, n 15/ female, n= 45) with peak incidence age group, with female preponderance seen (Table 1). Table (1): Age and Sex distribution of Patients with incisional Hernia. Age in year Male Female Total % Obstructive pulmonary disease in 1.7% (n=1). All patients presented with history of swelling of which 20 cases also presented with history of dragging pain. On examination, swelling was reducible in 50 cases (83.3%) and irreducible in 10 cases (16.7%) (Table2). We had approximately, 33.3% (n=20) of cases with early onset of incisional hernia (within one year), 66.7 %( n=40) of cases had late onset of incisional hernia >1 year. Seven patients) 11.7 %had undergone more than one surgery and 4 patients (6.7%) had already been operated for incisional hernia by anatomical repair. In present study, 58.3% (n=35) of cases following obstetric and gynaecological operations. Thirty seven patients (61.7%) had lower midline incision. The percentages of other incisions causing hernias are shown in (Table 3). In present study, there were no postoperative complications in 88.3% of cases. Only 2 patients (3.3%) had wound infection, 4 patients (6.7%) had seroma and one patient (1.7%) had deep vein thrombosis (Table 4). 369

9 370 Obesity was found in diabetes mellitus in 16.7% multipara 10% (n=6), 20% (n=12), (n10), grand and chronic Table (2): Clinical presentation of patients with incisional hernia. Sr.No. Clinical features No. of Patients % 1 Swelling of abdomen Dragging pain Irreducibility Table (3) : Types of Incisions causing hernia. Incision type Number % Lower Midline Upper Midline Pfanncnsteiul,s incision Paramedian incision Subcostal incision McBurney s Total % Table (4) : Postoperative complications of preperitoneal mesh repair. Postoperative complications Number % Nil Major wound infection Hernia recurrence - - Seroma DVT Table (5): Comparison of postoperative complications in preperitoneal mesh repair (Present study and other mesh repairs (Other Studies). Operative Complications Repair Post PPMR (Present Study) (mi=60) Other Mesh Repairs Onlay, inlay and underlay (Leber et al, 1998) (n=200) Underlay Mesh repair (Antoine et al 2003)(n=350) Onlay Mesh repair (Machiras et al 2004)(n=43) PPMR (Manohar and Rarnadev 2010) (n=50) Cellulites - 14 (7.0%) Wound Infection 2 (3.3%) 8 (4.0%) 14 (4.0%) 3 (7.0%) 1(2.0%) Seroma 4 (6.7%) 6 (3.0%) - 6 (14.0)% 5 (10.0%) Wound Gapping I Postoperative Ileus - 16 (8.0%) Pneumonia - 2 (1.0%) Pulmonary Embolism - 2 (1.0%) DVT 1 (1.7%) 1 (0.5%) (2.0%) Chronic Infection/Sinus tract - 12 (6.0%) - I - Small Bowel Obstruction - 11(5.5%) Enterocutaneous Fistula - 7 (3.5%) Chronic Pain (0.6%) 3 (7.0%) - Death - - 2(0.6%) - Recurrence - 34 (17.0%) 11(3.1%) 4 (9.0%) -

10 DISCUSSION Incisional hernia is produced by deficient wound healing from the beginning or by gradual yielding of an apparently soundly healed wound. It is estimated that 2-11% of all abdominal operations result in an incisional hernia (Piece et al., 2007). Small hernias less than 2.5cm in diameter are often successfully closed with primary tissue repairs. However larger ones have a recurrence rate up to 30-40% when tissue repair is performed alone (Fakhar et al., 2009). Hernia recurrence is distressing to the patient and embarrassing to surgeon. Nowadays tension free repair using prosthetic mesh has decreased the recurrence to negligible. Despite excellent results, increased risk of infection with implantation of a foreign body and cost factor still exist (Iqbal and Anjurn, 2009). In the present study, the ages of patients were ranged from 15 years to 62 years with peak incidence in age group from 31 to 50 years (41.7%). In this study, there is a female preponderance, the mean age was around 45 years (75%), and this coincides with the study of Manohar and Ramadev (2010) in which the percentage was 88%. In the present study, all patients presented with history of swelling; 20 of them (33.3%) presented with pain and 10 patients had irreducible hernia (16.7%). We had approximately 33.3% of cases with early onset of incisional hernia (within one year of previous surgery) whereas 66.7% of cases had late onset of incisional hernia (> 1 year of previous surgery). In present study 58.3% occurred following obstetrics and gynaecological operation, in comparison to the study of Manohar and Rarnadev (2010) it was 78% of cases. In the present study, seven patients (11.7%) had undergone more than one surgery and 4 patients (6.7%) had already been operated for incisional hernia by anatomical repair. Repeated wounds in the same region or just parallel to each other will often lead to development of herniation as shown by (Hope, 2011). In 371

11 this study, 61.7% of cases developed incisional hernia through lower midline incision, 13.3% through Pfannensteil,s incision, 8.3% through upper midline incision, 11.7% through paramedian incision, 3.3% through subcostal incision and 1.7% through McBurney s incision. In present study, associated risk factors like diabetes mellitus (16.7%), obesity (20%), and grand multi-para (10%) were seen. Obesity was found in 20% (n12), diabetes mellitus in 16.7% (n10), grand multipara 10% (n=6). In the present study, we encountered 11.7% of eases with postoperative complications of which, postoperative wound infection occurred in 2 cases (3.3%), which healed by secondary intention, seroma in 6.7% of cases and deep vein thrombosis in lower limb 1.7% of cases. There were no postoperative complications in 88.3% of cases. Comparison of postoperative complications in the present study (preperitoneal mesh repair) and previous studies (other mesh repairs) are shown in table 5. Postoperative complications were less in present study (11.7%) when compared with other mesh repair techniques (Leber et al., 1998, Antoine et al., 2003, Machiras et al., 2004 and Manohar&Ramadev, 2010). In present study, we had followed up all the patients after discharge for two weeks, 1 month, 3 months, 6 months and 12 months. There was no recurrence of incisional hernia noticed in the present study, this agrees with the results of studies of Elsesy et a!. (2008) and Manohar and Ramadev (2010). While Luidendi et al. (2000) reported a recurrence rate of 46% with suture repair technique and 23% with mesh repair technique. De VriesRelingh et al., (2004) reported a recurrence rate of incisional hernia following different techniques of mesh repair as follows: In onlay technique it was 28.3%, inlay technique 44%, and underlay technique 12%. Macharias et al. (2004) reported a recurrence rate of incisional hernia following onlay mesh repair with 9% of cases. Antonie et al. (2003) reported a recurrence rate of incisional hernia following underlay mesh repair with 3.1% of cases. In a recent study, excellent results in terms of low 372

12 recurrence rate (only 1 case on 207 patients, 0.48%) was obtained (Forte et al., 2011) The preperitoneal mesh repair procedure is, among all those practiced, the treatment of choice in incisional hernioplasty. We advocate this method of incisional hernia repair as it is applicable to all sites of incisional hernia, the mesh is mostly bidden and anchored in front the peritoneurn, as the postoperative complications are low and there is no recurrence. CONCLUSION Preperitoneal mesh repair had excellent results, with minimal morbidity (few postoperative complications with no recurrence). So it is a gold standard treatment for incisional hernia repair. 373

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15 19. Manohar C and Rarnadev K (2010): Springer Paris, Management of incisional hernia by 23.Santor T and Roslyn J (1993): Incisional preperitoneal mesh repair. IJBMS, 1: hernia. SurgClin North Am., 73: Martin DA, Noguerales F, Villet AR and 24. Stoppa RE (1989): The treatment of Langer C (2001): Modifications to Rives complicated groin and incisional hernias. technique for midline incisional hernia repair. World J Surg., 13: Hernia, 5: Wantz GE (1991): Incisional hernioplasty with 22. Piece RA, Spitter JA and Frisella M (2007): Mersilene. SurgGynaecol Obstet., 172: 129- Pooled data analysis of laparoscopic versus الطرق الملخص العربى المختلفة فى عالج الفتك الجرحى بالشبكة مختلفة االوضاع دخل وخارج عامر نصر عمر استشار الجزاحت العاهت بوستشف الوطزيت التعليوي البريتون ذ الذراست ال ذف ه ا همار ت عالج الفتك الجزاح بالشبكت هزة د البزيت ى ذا البحث شول هجو عت هي الوزض يتزا ح اعوار ن هي 15 س ت اخل البزيت ى هزة خارج 62 س ت هي حيث ضع الشبكت داخل البزيت ى ا خارج ف هختلف االعوار همار ت ال تائج هي حيث الوضاعفاث بعذ العوليت الوذة الت يستغزل ا الوزيض حت يتعاف تواها سب رج ع الفتك ارتجاع هز تا ي لذ جذ ا اى افضل ال تائج الت استخذام في ا الشبكت داخل البزيت ى عل ذا فمذ استفذ ا هي البحث اى افضل الطزق ف العالج الفتك الجزح ضع الشبكت داخل البزيت ى. 376