British Journal of Plastic Surgery (1999), 52, 399 403 1999 The British Association of Plastic Surgeons TECHNICAL INNOVATION A technique for repairing massive ventral incisional hernias without the use of a mesh D. Johnson and D. H. Harrison Department of Plastic and Reconstructive Surgery, Mount Vernon Hospital, Northwood, Middlesex, UK SUMMARY. Incisional hernias are common. Those involving large fascial defects are usually repaired using a synthetic mesh. Complications of such repairs involving mesh pose particular problems in management. This paper describes a new technique for repairing large ventral incisional hernias which does not involve the use of a mesh. Our repair is anatomical in first reconstructing the posterior rectus sheath and then using a darn to approximate the recti. We have used this technique successfully in three cases of massive incisional hernias measuring 20 cm or more in diameter and have not experienced any complications. In particular, no recurrences of the hernias have occurred. The technique described can be used to repair primary incisional hernias as well as salvage cases when previous repairs have failed. Keywords: hernia, ventral, incisional, repair, mesh, darn. Incisional hernias are common, occurring in approximately 12% of patients undergoing transparietal abdominal operations. 1,2 The fascial defect varies in size and may actually be small despite there being a large hernial sac. In other instances, however, the fascial defect itself may be as large as 15 cm or more. 3,4 Many operations have been described to repair incisional hernias. In the case of small fascial defects, the abdominal wall can be repaired as in primary laparotomy with anatomical layer-by-layer or direct mass closure. Overlapping techniques can be employed when the edges of the fascial defect can be easily approximated. These techniques share their fundamental principles with that of Mayo s Imbrication Operation, 5 and may involve either transverse or vertical overlapping of the anterior rectus sheath. For larger incisional hernias in which the fascial defect cannot be easily opposed, a different approach needs to be adopted. A variety of techniques have been described in an attempt to facilitate the apposition of the fascial edges of the defect. For example, Nuttall described a repair for large subumbilical hernias in which the inferior tendinous portion of each rectus muscle was detached from the pubic origin, and transposed to the opposite side in order to facilitate closure of the defect. 6 Others have advocated laterally placed vertical relaxing incisions in the rectus sheath to allow approximation of the edges of the defect and so facilitate closure. 7,8 More recently, DiBello and Moore described a technique using a rectus abdominis myofascial flap to close ventral hernias. 4 Amongst the most elegant methods of anatomical repair for large incisional hernias are those described by Dixon, 9 Young, 7 Hunter 10 and Loh et al, 11 whose repairs all involve first the reconstitution of the peritoneum/posterior rectus sheath by longitudinally incising, turning in and then suturing the medial part of both anterior rectus sheaths. These repairs then vary in their method of reconstituting the anterior rectus sheath by the use of either relaxing incisions, 7 or a nylon darn. 10,11 Many of the older techniques for repairing large incisional hernias have now been superseded by the use of synthetic mesh to bridge the fascial defect rather than attempting to primarily close it. This can be performed either by an open procedure or by laparoscope. 12,13 Mesh repair has been particularly useful for long-standing ventral hernias with considerable divarication of the abdominal wall musculature resulting in an enormous fascial defect. The use of synthetic mesh, however, carries with it the complication of infection (estimated to occur in about 8% of cases 14 ) and sinus formation, both of which persist until it is removed. Other complications include adhesions and migration of the mesh into the intestinal lumen. Recurrence rates using mesh repairs are reported to be between 5 and 10%. 3,15 17 We describe here a new technique to repair the very large ventral incisional hernia without using a mesh. It shares its fundamental principles with some of the older style repairs in first reconstituting the posterior rectus sheath 7,9 11 and then using a darn. 10,11 It can be used for large primary repairs as well as salvage repairs when other methods have failed. We have experience in treating three such patients with massive incisional hernias measuring 20 cm or more. Two of these had been referred following a complication of a previous mesh repair involving postoperative wound breakdown and subsequent exposure of the mesh with recurrence of the hernia. In the remaining patient, no attempts had been made at repair and so no mesh was involved. 399
400 British Journal of Plastic Surgery Figure 1 Schematic illustration of the anatomical hernia repair. (A, B) Anterior and cross-sectional views of a ventral incisional hernia. (C) Dotted lines show the position of incisions 1.5 cm lateral to the medial edge of the anterior rectus sheath. (D) Cross-section to show how the peritoneum/posterior rectus sheath is reconstituted by suturing the turned-in medial flaps of the anterior rectus sheath. (E) Anterior view of the reconstituted posterior rectus sheath. (F) Cross-section showing the position of the nylon darn attached at the junction of the rectus and external oblique aponeurosis. (G) Anterior view demonstrating the running horizontal mattress nylon darn. (H) A demonstration of how the darn can be tightened in the same manner as a shoe lace. (I) In the completed repair, note how the darn is hidden within the anterior and posterior rectus sheaths, with only the lateral loops visible. (J) Cross-section demonstrating the final three-layer repair.
Ventral hernia repair 401 Surgical technique An elliptical incision is made around the old abdominal scar. Deepening the incision through fat, the anterior rectus sheath is identified and its medial border, which forms the edge of the hernial defect itself, is dissected free. The dissection is then carried laterally to at least 2.5 cm lateral to the lateral edge of the rectus sheath so that the external oblique can be clearly seen. Focus can then be turned to the hernia itself, and if marlex mesh has been previously used it is carefully removed whilst avoiding damage to the intestines. The medial edge of the rectus should be clearly visualised at this stage (Fig. 1A, B). In order to reconstitute the peritoneum and retain the bowel within the abdominal cavity, the anterior rectus sheath is incised approximately 1.5 cm lateral to the medial edge of the muscle. The incisions are carried out on both recti, from the superior to the inferior edge of the hernia (Fig. 1C). The two edges are then turned over and sutured to each other with no. 1 vicryl (Figs 1D, E). A formal repair of the abdominal wall may now be carried out. A long length of 1 nylon is threaded through a Colts needle and then knotted at the end making a double thickness of nylon. At the upper end of the wound, the Colts needle is passed through the muscle picking up the lateral edge of the rectus where it fuses with the external oblique. The Colts needle is then brought back into the rectus where the needle is passed through the loop of nylon thus obtaining a firm grip of the lateral edge of the rectus. The Colts needle is then passed through the rectus on the opposite side, again picking up the extreme lateral edge of the rectus into the external oblique aponeurosis (Fig. 1F). The needle and doubled nylon is then woven through the rectus muscle picking up the external oblique aponeurosis down the length of the hernia (Fig. 1G). At the beginning there appears to be quite a gap between the two medial edges of the rectus, but, much as one might tighten a boot lace, so the nylon darn can be tightened thus producing creep of the external and internal oblique which permits the medial edges of the rectus to easily appose (Fig. 1H). Once this has been achieved, the nylon darn can be locked by ending with the knot within the rectus sheath. All of the nylon except for the lateral loop should therefore be enclosed within the anterior and posterior rectus sheaths. The free edge of the anterior rectus sheath is then closed without excessive tension using vicryl (Fig. 1I, J). The skin is then closed and the wound drained with closed suction drains. Postoperatively, a corset is applied to provide extra support for 6 weeks. Results Table 1 shows the dimensions of the hernial defect in the three patients with massive incisional hernias in which we have performed this repair. There were no immediate or late complications and no recurrences of the hernias. The follow-up ranges from 1 year (in our most recent case) to 15 years. Figures 2 4 show the preoperative, and peroperative photographs of case no. 2 in Table 1. Discussion Crucial to the success of any incisional hernia repair is the need for adequate preoperative work-up. A significant proportion of patients with large incisional hernias are obese, which increases the anaesthetic complication rate as well as having a compromising effect on wound healing. We have therefore encouraged all patients to lose a significant amount of weight prior to surgery. Attention should also be paid to optimising the nutritional status of the patient and correcting any co-existing anaemia. We have been particularly strict in enforcing a non-smoking policy for at least a month prior to surgery and extending well into the ensuing postoperative months. The operation takes on average 3 h to perform as there is often marked fibrosis and scarring. Extensive undermining of the skin flaps is required in order to clearly visualise the lateral margin of the rectus abdominis muscles and their junction with the external oblique aponeurosis (Fig. 3). As the margins of the hernial defect are dissected free, great care is taken to prevent inadvertent perforations of the bowel wall, which in the case of a previous mesh repair is inevitably adherent to the undersurface of the mesh. For this reason we have performed all our repairs in conjunction with a general surgeon. Once the contents of the hernia are returned to the abdominal cavity the repair can begin. The strength of the rectus sheath lies in the anterior lamina and so part of the reason for the strength of this repair is the reconstitution of the posterior rectus sheath/ peritoneum by using the turned-in medial portion of the anterior sheath. To the first-time observer, it is difficult to appreciate how the darn can be used to approximate the rectus muscles. However, in a similar way in which a boot lace or a corset is tightened, the sequential pulling on each loop of the darn causes creep from the external/internal oblique. With successive tightening of each loop of the darn, eventually the recti are opposed so that the Table 1 The dimensions of the three massive incisional hernias Age Sex Cause of hernia Size Repair date Comments 43 M Following laparotomy for gun-shot wound 20 15 cm 1982 No complications 55 M Recurrence post mesh repair following laparotomy 22 10 cm 1990 No complications 45 M Recurrence post mesh repair following gastropexy 20 15 cm 1997 No complications
402 British Journal of Plastic Surgery Figure 2 Preoperative photograph of one of the cases.the site of the incision to be made around the old scar is marked. Note the exposed mesh in the centre of the scar. free edges of the anterior sheath of the recti can be sutured without tension and without the need for any relaxing incisions (Figs 1, 4). The final repair is thus a strong three-layer closure of the hernia. Postoperatively, our patients were maintained on bed rest for 48 h. All efforts are made to prevent sudden rises in intra-abdominal pressure and include generous analgesia, daily physiotherapy and stoolsoftening agents to prevent constipation. Abdominal support strapping is worn continuously for a period of 6 weeks to protect the repair. The suction drains are left in place for at least 1 week to drain any haematoma and also to promote adherence between the extensively undermined skin flaps and the underlying abdominal wall musculature. Clearly, easily installable inelastic non-absorbable mesh such as marlex has an important role in the surgical repair of incisional hernias.the circumstances in which a mesh repair is appropriate are when there is an absence of muscle bulk available for repair,as in a hernia positioned lateral to the recti,or in the case of ventral midline hernias when the recti have been destroyed by,for example,trauma. In these situations there is no alternative but to use a mesh repair. However,in a midline incisional hernia where there is an otherwise normal healthy rectus muscle,the use of a mesh repair has several disadvantages compared with an anatomical repair such as the one described here. A plastic surgical unit only occasionally sees large ventral incisional hernias. The majority of these are salvage cases where previous attempts at repair have failed. We have, therefore, experience of treating a small number of cases (Table 1). However, all the hernias we have repaired using this technique have been closed successfully with no immediate or delayed complications. In particular, no recurrences of the hernias have developed. Figure 3 This photograph shows the extent of undermining of the skin flaps in order to visualise the junction of the external oblique aponeurosis and the recti. Meticulous haemostasis is essential in preventing haematoma formation.
Ventral hernia repair 403 Figure 4 Here the posterior rectus sheath has been restored and the darn is in place. The recti are now opposed and further sequential tightening of the loops of the darn will produce creep from the external oblique aponeurosis and so approximate the anterior laminae of the rectus sheath. We conclude that the repair described here provides a safe alternative to mesh repairs for the massive ventral incisional hernias without recourse to division of the muscle laterally or inferiorly. It can be used in both primary and salvage cases. Experience with a larger number of cases will be useful in confirming the reliability of this repair. References 1. Mudge M, Hughes LE. Incisional hernia: a 10 year prospective study of incidence and attitudes. Br J Surg 1985; 72: 70 1. 2. Santora TA, Roslyn JJ. Incisional hernia. Surg Clin North Am 1993; 73: 557 70. 3. Usher FC. The repair of incisional and inguinal hernias. Surg Gynae Obstet 1970; 131: 525 30. 4. DiBello JN Jr, Moore JH Jr. Sliding myofascial flap of the rectus abdominus muscles for the closure of recurrent ventral hernias. Plast Reconstr Surg 1996; 98: 464 9. 5. Mayo WJ. An operation for the radical cure of umbilical hernia. Ann Surg 1899; 34: 276. 6. Nuttall HCW. Rectus transplantation for midline incisional herniae. Br J Surg 1937; 25: 344. 7. Young D. Repair of epigastric incisional hernia. Br J Surg 1961; 48: 514 16. 8. Maingot R. Umbilical and incisional hernia. In: Maingot R (ed.), Abdominal Operations, 7th edition. New York: Appleton-Century-Crofts, 1980; 1618. 9. Dixon CF. Repair of incisional hernia. Surg Gynecol Obstet 1929; 48: 700 1. 10. Hunter RR. Anatomical repair of midline incisional hernia. Br J Surg 1971; 58: 888 91. 11. Loh A, Rajkumar JS, South LM. Anatomical repair of large incisional hernias. Ann R Coll Surg Engl 1992; 74: 100 5. 12. Park A, Gagner M, Pomp A. Laparoscopic repair of large incisional hernias. Surg Laparosc Endosc 1996; 6: 123 8. 13. LeBlanc KA, Booth WV. Laparoscopic repair of incisional abdominal hernias using expanded polytetrafluoroethylene: preliminary findings. Surg Laparosc Endosc 1993; 3: 39 41. 14. DeBond JR. Expanded polytetrafluoroethylene prosthetic patches in repair of large ventral hernia: incisional hernia. In: Nyhus LM, Condon RE (eds), Hernia, 4th edition. Philadelphia: JB Lippincott, 1995; 328 36. 15. Schumpelick V, Conze J, Klinge V. Preperitoneal mesh-plasty in incisional hernia repair. A comparative retrospective study of 272 operated incisional hernias. Chirurg 1996; 67: 1028 35. 16. Liakakos T, Karanikas I, Panagiotidis H, Dendrinos S. Use of Marlex mesh in the repair of recurrent incisional hernia. Br J Surg 1994; 81: 248 9. 17. Becouran G, Szmil E, Leroux C, Arnaud JP. Surgical care of postoperative eventrations with intraperitoneal implantation of dacron mesh. Apropos of 160 operated cases. J Chir Paris 1996; 133: 229 32. The Authors D. Johnson MA, BM BCh, FRCS, SHO in Plastic Surgery, Mount Vernon Hospital, Rickmansworth Road, Northwood, Middlesex HA6 2RN, UK. Currently Wellcome Clinical Training Fellow in Plastic Surgery, The Institute of Molecular Medicine, John Radcliffe Hospital, Oxford, UK. D. H. Harrison FRCS, Consultant Plastic Surgeon, Mount Vernon Hospital, Rickmansworth Road, Northwood, Middlesex HA6 2RN, UK. Correspondence to Mr D. Johnson, 4 Park Way, Old Marston, Oxford OX3 0QH, UK. Paper received 29 July 1998. Accepted 12 January 1999.