Principles of open repair

The following principles should be followed:

1. Whenever possible the normal anatomy should be reconstituted. In midline hernias this means the linea alba must be firmly reconstructed; in more lateral hernias there should be layer-by-layer closure as far as possible. However, the use of sutures with the repair of these hernias is associated with a rate of recurrence. For this reason, the ability of the reconstitution of the linea alba may not be feasible or advisable. This is not always possible with the larger hernias and certainly not done with the laparoscopic repair.

2. Only tendinous/aponeurotic/fascial structures should be brought together. In situ darning over the defect without adequate mobilization and apposition of the aponeurotic defect gives a 100% recurrence rate.

3. The suture material must retain its strength for long enough to maintain tissue apposition and allow sound union of tissues to occur. A non-absorbable material must, therefore, be used.

4. The length of suture material is related to the geometry of the wound and to its healing. Using deep bites at not more than 0.5 cm intervals, the ratio of suture length to wound length must be 4 : 1 or more.

Figure 14.17. Incisional hernia repair using a mesh sublay with fixation by through-and-through sutures.

5. Repair of an incisional hernia inevitably involves returning viscera to the confines of the abdominal cavity with a resultant rise in intra-abdominal pressure. It is important to minimize this. Preoperative weight reduction is the first precaution. This, unfortunately, is generally not possible. Therefore the surgeon will usually be forced to repair these hernias with little consideration for the increase in the intra-abdominal pressure. In the majority of situations, this is not a clinical issue as few patients will not experience this increase in the intra-abdominal pressure that is clinically significant.

6. A tension-free repair with prosthetic reinforcement is recommended, for which there are several different approaches:

• The mesh is placed over the defect (onlay) and sutured in position (Fig. 14.16).

• The mesh is placed in the preperitoneal (and retro-muscular) space (Fig. 14.17) so that it does not contact the bowel (sublay). Each rectus sheath is incised along its medial border and opened in the midline to expose the anterior and posterior aspects of the rectus muscle, which by blunt dissection is mobilized to its entire width along the length of the defect. The mesh is then placed posterior (retro-) to the rectus muscles, after first closing the posterior leaf of the sheath/peritoneum with monofilament nylon. The mesh is secured with interrupted absorbable sutures between the edges of the mesh and the underlying posterior rectus sheath/peritoneum. The layered closure is completed by approximation of the anterior rectus sheath over the prosthesis.

• The mesh is placed between the unapproximated fascial edges (inlay). This exposes the bowel to the undersur-face of the mesh and should only be used in the exceptional circumstance of inability to close the fascial layers without hernioplasty techniques (less than 5% cases).

Whichever technique is employed, the mesh must overlap each margin of the aponeurotic defect by some 3-4 cm and must be well fixed to the aponeurosis.

Studies have shown a rate of recurrence that is consistently improved with the use of a synthetic biomaterial as an element to the open repair of incisional and ventral hernias. If there is any tissue loss, a defect greater than 4 cm or any risk factors prosthetic mesh reinforcement is mandatory.

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