2/9/2018 Postoperative complications of mesh hernioplasty for incisional hernia repair and factors affecting the occurrence of complications

:Karan Vir…

ORIGINAL ARTICLE
Year : 2013 | Volume : 6 | Issue : 1 | Page : 25--31

Postoperative complications of mesh hernioplasty for incisional hernia repair

and factors affecting the occurrence of complications
Karan Vir Singh Rana, Gurjit Singh, Niteen A Deshpande, Viju K Bharathan, Srihari Sridharan
Department of Surgery, Padmashree Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri,
Pune, India

Correspondence Address:
Karan Vir Singh Rana
Department of Surgery, Padmashree Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune
India

Abstract
Context: Incisional hernia is one of the common postoperative complications of abdominal surgery. Mesh hernioplasty
represents the standard of care for incisional hernia repair. Aims: We report our experience with the use of mesh for hernia
repair, with respect to the postoperative complications and factors affecting the occurrence of complications. Settings and
Design: Fifty four cases of incisional hernia presenting to the institute between April 2008 and September 2010 were included
in the study. Materials and Methods: The predisposing risk factors were identified. Mesh hernioplasty was done by the onlay
technique and the patients followed up for at least 6 months. Statistical Analysis Used: An association of complications with
various risk factors was explored with chi-square test and odds ratio with 95% confidence interval. Results: Twenty four
patients developed at least one complication, the most common being seroma (12 cases) and surgical site infection (9 cases).
The factors that showed a significant relationship with the occurrence of complications were diabetes mellitus, obesity,
smoking, hypoproteinemia, advanced age, size of fascial defects, and number of defects. The recurrence rate was 3.7%
(mean follow up: 13.05 months). Conclusions: Mesh hernioplasty gives acceptable results for incisional hernia repair. A
sound understanding of the factors affecting the occurrence of complications and recurrence is required to improve the results
of the procedure.

How to cite this article:

Rana KV, Singh G, Deshpande NA, Bharathan VK, Sridharan S. Postoperative complications of mesh hernioplasty for
incisional hernia repair and factors affecting the occurrence of complications.Med J DY Patil Univ 2013;6:25-31

How to cite this URL:

Rana KV, Singh G, Deshpande NA, Bharathan VK, Sridharan S. Postoperative complications of mesh hernioplasty for
incisional hernia repair and factors affecting the occurrence of complications. Med J DY Patil Univ [serial online] 2013
[cited 2018 Feb 8 ];6:25-31
Available from: http://www.mjdrdypu.org/text.asp?2013/6/1/25/108634

Full Text

Introduction

Incisional hernia is one of the common postoperative complications of abdominal surgery. [1] Despite the advances in the
understanding of the anatomy and physiology of the abdominal wall, the choice of suture materials and the knowledge of
closure techniques, the incidence of incisional hernias continues to be 2-11% after laparotomy. [2] An incidence of 0.5-1.5%
has been reported in laparoscopic surgery as well. [3] These are serious surgical problems owing to their propensity to enlarge
and cause complications, association with common systemic disorders and the technical difficulties associated with their

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2/9/2018 Postoperative complications of mesh hernioplasty for incisional hernia repair and factors affecting the occurrence of complications :Karan Vir…

successful repair.

The phrase "if there are multiple ways of fixing a problem then there is not one good way" holds very true in incisional hernia
repairs. [4] Several methods of repair of incisional hernias have been proposed, each with its own merits and de-merits. Mesh
hernioplasty is the standard of care at present for repair of incisional hernias. [5] However, this technique has also been
associated with recurrence rates of up to 32% on 10 year follow up. [6]

Although prosthetic repair of incisional hernia is tension free and gives acceptable recurrence rates, despite this significant
benefit, it is a foreign material and susceptible to infection, sinus formation, enteric fistulization and possible extrusion. [7] In
this article, we report our experience with the use of onlay mesh hernioplasty for incisional hernia repair.

The article studies the postoperative complications and recurrence rates of mesh hernioplasty for incisional hernias by the
onlay technique. The various factors that could predict the occurrence of postoperative complications have also been studied.

Materials and Methods

A total of 54 cases of incisional hernia presenting to the institute during a period of two and a half years (April 2008 to
September 2010) were included in the study. The patients were subjected to detailed clinical examination and relevant
investigations. Data regarding the previous surgery and its associated complications was recorded. The co-existing co-morbid
conditions and predisposing risk factors were identified and the entire data was tabulated. Obesity was defined as a Body
Mass Index greater than 29.99 kg/m 2 . Operative repair was performed at least 1 year after the index surgery, as this time
was required for scar maturation.

The surgery was performed under general or spinal anesthesia, in view of the adequate muscle relaxation required. A single
dose of intravenous third generation cephalosporin (Intravenous Cefotaxime 1 gm) was administered at the time of skin
incision. Intraoperatively, the sac was identified and delineated. The sac was opened. The contents of the sac were reduced
[Figure 1]. If omentum was adherent to the sac and could not be reduced, it was ligated and excised. The fascial defect was
identified all around. The maximum dimension of the fascial defect was measured in centimeters. The edges of the defect
were approximated with simple sutures with non-absorbable suture material (Polypropylene, size: No. 1). The sutures were
passed at a distance of 1.5 cm from the edge of the defect, and the distance between adjacent sutures was 1 cm. The sutures
were tied just tight enough to approximate the edges. After approximation of the edges, a polypropylene mesh of suitable size
was placed over the rectus sheath (Onlay technique) so as to overlap the healthy fascia by at least 5 cm all around [Figure 2].
The mesh was anchored in place by suturing it to the rectus sheath with Polypropylene suture of size 1.0. Hemostasis was
attained. A suction drain was placed superficial to the mesh, and the wound was closed.{Figure 1}{Figure 2}

Postoperatively the patient was administered intravenous antibiotics. The antibiotics routinely used were intravenous
Cefotaxime (1 gram Q12h) and intravenous Gentamicin (80 mg Q12h) for a period of 5 days and intravenous Metronidazole
(500 mg Q8h) for a period of 2 days. Postoperative analgesia was provided by administering tramadol (50 mg intravenous
Q8h) in the immediate postoperative period (first 24 hours), followed by oral analgesics thereafter when the patient had pain.
The drain was removed after the drain output was less than 20 ml per day for at least 2 days. Sutures were removed on the
eighth postoperative day.

The patients were followed up for a minimum of 6 months. The postoperative complications and recurrence rate were
recorded.

An association of complications with various risk factors was explored with the chi-square test and odds ratio with 95%
confidence interval.

Results

Of the 54 patients included in the study, 25 were males and 29 were females. The average age of the patients was 55.03
years. The average age of males was 61.5 years and the average age of females was 47.5 years. There was no case of
complicated hernia in the study. The most common predisposing risk factors were advanced age, diabetes mellitus, and
postoperative wound infection [Table 1]. The incidence of incisional hernia was higher after emergency surgery. The most
common emergency surgery leading to incisional hernia was emergency laparotomy (40.7%) and the most common elective
surgery was total abdominal hysterectomy (14.8%). The most common incision was infraumbilical midline incision [Chart 1]
[SUPPORTING:1].{Table 1}

Intraoperatively the mean defect size in largest dimension was 7.92 cm. A single defect was noted in 44% cases, and multiple
defects were noted in 56% cases. The content of the hernia sac was omentum in 54% cases.
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The mean follow up period was 13.05 months. The standard deviation was 5.6 months. The patients were followed up for a
period ranging from 6 to 27 months with a median of 18 months. The postoperative complications include seroma and
superficial surgical site infection [Table 2]. There were two cases of recurrence [Table 3]. The risk factors associated with
recurrence were diabetes mellitus, obesity, smoking, postoperative straining, and advanced age [Table 4].{Table 2}{Table 3}
{Table 4}

Discussion

Incisional hernia occurs due to a biomechanical failure of the acute fascial wound early in the healing period, when the wound
tensile strength is low or absent. [8] It is the most common complication by a 2:1 ratio over bowel obstruction, and is the most
common indication for reoperation by a 3:1 ratio over adhesive small bowel obstruction. [4] The incidence of incisional hernias
was 13% at 5 years, occurring during the first 24 months in 80% of cases. A majority of these hernias occur within the first
year of the abdominal surgery. [9]

Even though simple suture repair was considered the gold standard for incisional hernia repair in the 1990s, the high
recurrence rate with this technique was always a concern for the surgeon. Burger et al. had reported that the 10 year
cumulative recurrence rate with suture repair was 63%. [6] This has led to the widespread acceptance of mesh repair. Even
though several prosthetic materials had already been used for incisional hernia repair, the modern era of hernia repair with
prosthetic material started in 1959, when Usher FC introduced the polyamide mesh as a prosthetic graft. He tried it as "onlay"
and "inlay" methods. [10] He later introduced the knitted polypropylene meshes in 1963, these have some advantages such as
less tissue reaction, excellent tensile strength, easy sterilization, and easy use. [7] The use of mesh has increased from 34.2%
in 1987 to 65.5% in 1999. [4]

Apart from the polypropylene mesh which has stood the test of time, Polyester meshes and Polytetrafluoroethylene meshes
are also used. Laparoscopic repair of incisional hernia needs intraperitoneal placement of a material which has both high
tissue ingrowth toward the abdominal wall and nonadhesiveness on the other side to prevent bowel adhesions, which are
satisfied by composite/Dual meshes.

Composite meshes [11] used are:

Light weight composite meshes without barrier that are partially absorbable. Induces a better tissue ingrowth of a strong three-
dimensional collagen fiber network and allow optimum mobility to the abdominal wall.Absorbable barrier composite meshes -
These are dual meshes, one side of which gets absorbed. Lightweight and leaves behind less residual foreign body
reaction.Nonabsorbable barrier composite meshes -It is designed to be implanted with the smooth surface against the visceral
organs-tissue to which no or minimal adhesion is desired-and the other surface against which tissue incorporation is desired.

The most common method of mesh hernioplasty used by most surgeons today is the onlay technique. [4] In this technique, the
placement of the mesh is anterior to the anterior sheath, with an overlap of 5 cm. This method avoids contact with the bowel,
hence there is no chance of enterocutaneous fistula. It is also a tension free method. Multiple defects are highly likely to be
detected because of the wide undermining done. [4] This however, can lead to increased seroma formation. Critics of this
method also propose that the mesh placed in this method has very little support from the rest of the abdominal wall, hence can
be displaced easily. [4] The weakest point of the repair that is most prone to recurrence is the mesh-tissue interface. [4]

Laparoscopic ventral hernia repair [LVHR] is a recent effective way of treating incisional hernia. It involves using a large mesh,
adequate overlap of the defect without tension. In this, the mesh is placed intraperitoneally and extensive soft tissue dissection
is eliminated and thus wound complication rate, patient discomfort, length of hospital stay, and recurrence rates are all
reduced. [12] The success of this technique lies on smaller incisions, wide overlap of defects, correction of unpalpable defects
and use of large non-absorbable sutures for stronger patch fixation.

In the present series, wound complications were noted in 44.4% of patients. White et al. noticed wound complications in 44%
patients of mesh repair in their study. [13] The most common complication noticed was seroma formation. Seroma formation is
one of the most commonest complications associated with onlay mesh hernioplasty because of the wide undermining
involved. [4] The cases of seroma in our study were noticed between 3 rd and 7 th postoperative day, needed aspiration and
resolved within a week with pressure dressing. No case of wound hematoma was noticed.

The next most common complication was surgical site infection. All the infections were superficial, and responded well to
dressings and antibiotics. There was no case with deep infection or extrusion of the mesh. Chew et al., reported that if mesh
was infected, incorporation rather than rejection usually can be expected; the prosthesis is not floating free in the wound but is
in firm contact with healthy tissue. [14]

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2/9/2018 Postoperative complications of mesh hernioplasty for incisional hernia repair and factors affecting the occurrence of complications :Karan Vir…

The incidence of tissue necrosis at the wound edge was 9.3%. The occurrence of wound edge necrosis is due to disturbance
of the blood supply of the tissue at the wound margins due to the large size of skin and subcutaneous flap raised during the
repair. This can be prevented by placing moist laparotomy pads over the edge of the wound and meticulous dissection of flaps.
[15]

The most important complication of incisional hernia repair is recurrence of the hernia. [15] The recurrence rate in the study
was 3.7%. While this is partly due to the shorter followup periods, it may also be due to the sound surgical technique used in
the repair. This indirectly establishes that in spite of the introduction of newer methods of repair, onlay mesh hernioplasty is still
an acceptable method for incisional hernia repair.

The rate of postoperative complications and recurrence are comparable to that of other studies that have used onlay method
for mesh hernioplasty [Table 5] and [Table 6].{Table 5}{Table 6}

There is no real agreement on the factors that predict the occurrence of postoperative complications or recurrence after mesh
repair of incisional hernia. [16],[17] Out of the two cases of recurrence in our study, one was associated with SSI and the other
had post-operative straining [Table 3]. Diabetes mellitus is well known to increase the incidence of postoperative complications
of all types of surgery including mesh repair. Hawaz Al-Hawaz reported that among the patients who developed postoperative
complications, about 60% were diabetics. [15] In the present series, diabetes was associated with increased incidence of
wound complications and recurrence (P=0.000).

Obesity is also a factor that can increase the occurrence of postoperative complications and recurrence of incisional hernia.
[18] The association was found to be statistically significant in the present study (P = 0.001). Turkcapar et al. also reported that
obesity and wound sepsis are the two most important risk factors for recurrence in incisional hernia repair. [17] Vidovic et al.
also proved that obesity was associated with higher risk for complication in incisional hernia repair. [19] In a study on factors
affecting recurrence of incisional hernias, Murariu et al. reported that the most important factor was obesity. [20]

The detrimental effect of smoking on the healing of the acute fascial wound has been well documented. Smoking and
peripheral tissue hypoxia, which may be caused by smoking, increase the risk of wound infection and dehiscence presumably
through reduction of the oxidative killing mechanism of neutrophils, which constitute a critical defense against surgical
pathogens. In addition, decreased collagen deposition and the reduced collagen I-collagen III ratio may also be attributed to
smoking. Degradation of connective tissue caused by an imbalance between proteases and their inhibitors has also been
postulated. [18] In the present study, smoking was significantly associated with the occurrence of postoperative complications.

Poor nutritional status has been implicated in the occurrence of incisional hernias, [4],[21] but not much data exists, that
correlates this factor with the incidence of postoperative complications after surgery. Veljkovic et al. have highlighted
hypoproteinemia as a risk factor for ventral herniation. [22] In our series, hypoproteinemia contributed to complications in
incisional hernia repair in a significant way. Murariu et al. also proposed that hypoproteinemia contributes to recurrence of
incisional hernias. [20] The association is most likely to be due to the impairment of wound healing that occurs due to
hypoproteinemia.

Corticosteroids are known to impair wound healing through several mechanisms. In our series, there was a significant
correlation between corticosteroid use and the occurrence of postoperative complications. Hawaz Al-Hawaz et al. noted that
50% of all patients who developed postoperative complications were steroid users. [15] Similar findings were also published by
Murariu and coworkers. [20]

Advanced age has been highlighted as a significant factor for the occurrence of incisional hernia in almost all reviews. [4],[21],
[22] However, the relation between advanced age and the occurrence of complications in incisional hernia repair has not been
well highlighted. Murariu et al. also reported old age as one of the factors that can increase the risk of complications and
recurrence. [20] In our series also, there was a significant association between old age and postoperative complications.
However, no association could be established between gender and the occurrence of complications.

Of all the factors implicated in the occurrence of complications such as seroma and wound edge necrosis, the most
extensively studied factors are the size of the defect and number of defects. Several studies have reported that the larger the
defect, the more likely are the complications of the repair procedure. [13],[19] The larger the defect and the higher the number
of defects, the larger is the size of mesh required and the greater is the degree of undermining required. This explains the
greater incidence of seroma, hematoma, and wound infections. Al-Hawaz also reported that among the patients who
developed wound complications, a large size of the mesh had been used. [15] This further justifies our findings.

Thus, although the type and technique of repair have been the most emphasized factors that decide the outcome of incisional
hernia repair, it has to be emphasized that patient related factors and comorbidities do play a very important role in
determining the success of repair. Adequate control of these factors can go a long way in improving the overall results of the
repair procedures.

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Conclusions

The postoperative complications associated with mesh hernioplasty were seroma and surgical site infection. The technique of
onlay repair was associated with acceptably low recurrence rates, thus establishing its efficacy as an optimal method for
incisional hernia repair. The important factors affecting the occurrence of complications were diabetes mellitus, obesity,
smoking, hypoproteinemia, size of fascial defect, and number of defects. A sound understanding of the factors affecting the
occurrence of complications and recurrence is required to improve the results of the procedure.

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