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Incisional hernia

1) Incisional herniae may become apparent during the early months after
surgery when there has almost certainly been some deep wound
dehiscence in the postoperative period.
2)

3)

A poor-quality scar, as a result of a wound infection or faulty closure
technique may disrupt later however, and both morbid obesity and chronic
cough greatly increase the risk.
Easily reducible wide-necked defects may often be ignored.

4)

Some form of elasticated support for comfort is often all that a patient
wishes, but if repair is planned it is important to decide whether only part
of the wound, or the whole wound, needs to be explored.

5)

If there is more than one area of herniation it is usually advisable to repair
the whole wound.

6)

Accurate preoperative skin marking of the extent of the palpable sac and
the fascial defect is helpful.

7)

Access is via the original scar, and excision of the scarred skin gives a
better cosmetic result.

8)
9)

The sac is defined and the plane around it followed to identify the defect.
Before repair, the edges of the defect must be defined by incising the
junction of normal fascia with the attenuated fascial covering of the sac.

10) A shallow peritoneal protrusion from most of a scar need not be opened
and to do so unnecessarily merely increases the risk of small bowel injury,
and of ileus.
11) Therefore, if the peritoneum can be freed from the under-surface of the
abdominal wall it can be left intact, and the fascia repaired over it.
12) A peritoneal sac through a narrow defect should be excised, and the
peritoneum should also be opened if there is any concern that a widenecked sac could be loculated.
13) More often, the peritoneum has to be opened because it cannot be
separated from the abdominal wall, but this has the advantage that the
surgeon has the opportunity to palpate the under-surface of the adjacent
scar for weak areas which need to be repaired at the same operation.
14) If the peritoneum has been opened it may either be closed separately or
with the abdominal wall repair.
15) The edges of the abdominal wall defect are excised so that there is a
freshly cut edge of healthy tissue for closure.
16) The suture technique used is similar to that for any abdominal wall closure
as described above, but particular care must be taken to encompass
healthy fascia in the suture bites.
17) A non-absorbable continuous suture is suitable.

especially when there is extensive abdominal scarring. 19) There is also increasing evidence that some form of mesh repair may be the better option. Ultimately. 20) An on-lay mesh. although attractive in theory. 24) Several techniques which mobilize the abdominal wall fascia to close large defects have been described. Most surgeons. 22) Vacuum drainage of the subcutaneous fat to prevent postoperative haematoma collection and prophylactic antibiotics will reduce the incidence of this complication. 3) The mesh must be placed so that it is in contact with normal tissue for some distance on either side of the closure. folded medially and sutured in the midline. any superficial wound infection is likely to result in a chronic infection in the mesh. 21) However. even when the surgeon is confident that satisfactory tension-free apposition of the fascia can be achieved by using a simple suture technique. when faced with this problem would use mesh to bridge the defect in the abdominal fascia. however.18) If the abdominal wall has retracted laterally and there is any tension. 4) Alternatively. is disappointingly difficult to execute satisfactorily. and a few sutures are then used to prevent it becoming displaced in the immediate postoperative period. This is an operation which. 2) A mesh may be used over or under a simple repair to provide additional strength. or represent a portion of the abdominal wall lost through trauma. a congenital abnormality. has greatly simplified the treatment of most difficult herniae. 23) Frequently the fascial edges of an incisional hernia do not oppose without tension. This is only possible if the peritoneum can be separated from the overlying muscles and sufficient peritoneum from the sac can be saved to allow . placed over the closed fascia and secured to it with sutures. 5) The defect may be a large hernia. then a mesh or other technique should be used. A mesh overlay can be used in addition to ensure extra strength to this repair. For example. and the peritoneum separates it from the bowel. longitudinal incisions may be made through the lateral side of the anterior rectus sheath which is then elevated off the muscle. is the simplest technique. as described below. where intra-abdominal pressure pushes it against the muscles and fascia. or excised for malignancy. a mesh may be used to bridge a defect in the abdominal wall which cannot be closed without unacceptable tension. MESH IN ABDOMINAL WALL REPAIR 1) The development of inert meshes. 6) The ideal position for such a mesh is between the closed peritoneum and the abdominal wall. such as monofilament polypropylene. the mesh becomes incorporated into the tissues and adds greatly to the strength of the final scar.

as it is only in the areas of overlap that it can be incorporated into tissue and provide any inherent strength. 7) A mesh should be several centimetres larger than the defect it will replace. marketed as ‘Gore-Tex’. 8) An extraperitoneal or an intraperitoneal mesh first requires four sutures to prevent any rolling of the edges of the mesh. Although there are concerns that this might increase the risk of fistula formation and mesh infections. 16) Compound meshes with an inner layer of ePTFE and an outer layer of polypropylene may have a role. the results of recent studies have suggested that these fears may be unfounded. if omentum cannot be placed between. They can be of great value in bridging a fascial defect left when an infected mesh has had to be removed. 10) Any implanted mesh may become infected. 17) Inert collagen meshes are a recent advance. and in spaces too small to allow access to neutrophils. 9) The edges of the fascial defect are then sewn with a continuous nonabsorbable suture down onto the top surface of the mesh. 11) Recent advances in mesh material and pore size have improved this problem. with care being taken to prevent injury to any underlying viscus. Unfortunately.peritoneal closure. this situation is often unattainable and the mesh has to replace both the peritoneum and the fascia of the defect. its use is limited to situations where other techniques are inappropriate. 14) Smooth inert patches of expanded polytetrafluoroethylene (ePTFE). and antibiotic cover is always recommended. but the surgeon should still be very wary of using a mesh in any potentially infective situation. 12) A vacuum drain in the subcutaneous fat reduces the risk of a haematoma as a potential culture medium for infection. 15) The reduction in fibrosis may decrease bowel complications when the mesh has to be in direct contact with the bowel. 13) An infected non-absorbable mesh almost always has to be removed completely. The infection is difficult to eradicate as bacteria may be in a protected environment where there is poor antibiotic penetration. . which can be used in the presence of infection. are an alternative to polypropylene meshes. as this material is extremely expensive. In this position a mesh may be in direct contact with bowel. but the poor tissue ingrowth inevitably results in a weak attachment of the patch to the abdominal wall and a greater risk of recurrence. However.