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Background • 2 Million laparotomies/year in US • Incisional hernia rate between 2 - 15% • Approximately 100,000 repairs performed/year Presentation • First sign- Asymptomatic bulge around incision • 50% will present within 1 year from initial surgery • with time, become painful with straining, movement • vomiting/obstipation usually involved with incarceration/strangulation Risk Factors • Wound infection- # 1 abdominal distension pulmonary complications, male gender, obesity, age >65, emergency procedures, malnutrition, type of closure (continuous vs interrupted), suture material used for closure (absorbable vs. non-absorbable), mass closure vs layered closure • Hodgen et at. 2000 - midline laparotomy wounds closed with non-absorbable, continuous running stitch results in significantly less post-up incisional hernias (32% less) • Non-absorbable sutures nidus for infection/sinus tract formation, also may cut into fascia late ventral hernia, so trend is towards slowly absorbable monofilament • Continuous running sutures faster closure and spreads tension evenly on wound over entire length Tenants of repair • Anatomic reconstruction of abdominal wall • No tension Repairs 1 . Primary Repair • Using sutures to approximate the edges of the fascial defect • < 3-5cm detects • 4: 1 ratio of suture length to wound length • Up to 25-55% recurrence rates reported - no matter how small defect, tension always present on repair. • In effort to reduce tension, relaxing incisions or internal retention sutures 2. Mesh Repairs • Types of mesh -absorbable. permanent with incorporation into tissue, permanent without incorporation, composite • Polypropylene Marlex/prolene- permanent, nonabsorbable, highly inflammatory reaction, allows ingrowth of collagen/fibroblasts • Polyester Mersilene-permanent, nonabsorbable, significantly greater fistula, infection 289

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and hernia recurrence PTFE (Gore-Tex) - permanent microporous/nonabsorbable, fewest bowel complications Vicryl knitted polyglactin/Dexon knitted polyglycolic acid - absorbable-used only in cases where infection is significant risk and primary closure not option Composite polypropylene/PTFE Complications from mesh placement- infection fistula, nidus for adhesions intestinal obstruction Onlay mesh o used to reinforce the primary repair- usually sutured to anterior rectus sheath o 5 cm margins from aponeurotic defect o Advantage- keeps mesh separated from abdominal contents o Disadvantage- large subcutaneous dissection seromas infection Inlay mesh repair o Hernia sac excised and healthy fascial/muscular edge identified around defect o Mesh is circumferentially sewn to fascial edge o Recurrence rate 10 - 20% o significant tension at the attachment points of fascia and mesh Retrorectus sublay repair (Rieves-Stoppa) o dissection between rectus muscle and posterior rectus fascia/ preperitoneal space o posterior rectus fascia approximated o Mesh is placed in the space provided - extend at least 5 cm beyond aponeurotic defect o Anterior rectus sheath approximated o Recurrence rates < 10% o Pain is common - lateral fixation points, disappears after ingrowth Intraperitoneal underlay mesh repair o Possible because of bilayer prosthesis o Places mesh intraperitoneal with nonadhesive side down o Fixation to fascial edge, posterior abdominal wall laterally partial thickness, full thickness muscular facial abdominal wall fixation at least 5 cm lateral to hernia defect o Allowed for gastroscopic repair - mesh inserted thru trocar site, fixed to abdominal wall with partial thickness tacks or full thickness abdominal muscular/fascial wall sutures o Rate of recurrence 5% Laparoscopic technique o First described l 993 o Ensure adequate coverage by 3 cm overlap o Tacks are deployed along borders of prosthesis o Mean operative times 90 minutes 290

o Average hospital stay 2 days o Most serious complication - bowel injury o Recurrence rates 5% Sources • • •

Cameron's Current Surgical Therapy Hodgson et al. The search for an ideal method of abdominal fascial closure. Annals of Surgery, 2000 Millikan, Keith. Incisional hernia repair. Surg Clin N Am, 2003 Henry Lin, M.D.