How I do it

The use of the Kugel mesh in ventral hernia repairs

Rebecca Knight, M.D., Michael E. Fenoglio, M.D.*Department of Surgery Education, Saint Joseph Hospital, 1601 East 19th Ave., Ste. 4500, Denver, CO 80218, USA

Manuscript received May 29, 2001; revised manuscript December 18, 2001

Abstract

Background: The management of ventral hernias is a common problem. Goals of hernia repair include reduction of the contents,reperitonealization of the abdomen, repair of the fascial defect, and restoration of the normal abdominal wall contour. Repairs frequentlyrequire the use of mesh to reduce the incidence of recurrence. A variety of repair techniques have been described, often associated withsignificant pain, prolonged recovery, and complications.Methods: We describe a technique using a partial component separation, reperitonealization of the abdominal cavity with the hernia sack,and insertion of the Kugel mesh for bridging the gap.Results: We have used this technique on 65 ventral hernias. Fifty-two patients went home from the recovery room and 11 stayed less than23 hours. One patient had a wound infection and 2 had seromas. There have been no recurrences to date.Conclusions: Repair of ventral hernias with the Kugel mesh using a partial component separation is safe, effective and durable. © 2002Excerpta Medica, Inc. All rights reserved.

Keywords: Ventral hernia repair; Kugel mesh; Component separation

Ventral incisional hernia is a common complication follow-ing any type of abdominal surgery. As many as 20% ofpatients who undergo laparotomy develop an incisional her-nia [1]. The morbidity, including incarceration and strangu-lation, is as high as 15% [2]. The goals of ventral herniarepair include reduction of the hernia contents, reperitone-alizeation of the abdominal cavity, repair of the fascialdefect, and restoration of the normal abdominal wall con-tour. There are many operative options for repair of suchhernias, including primary suture repair, open mesh repair,and laparoscopic mesh repair. The primary suture repair isoften not free of tension and therefore is associated with arecurrence rate of greater than 50% [1]. Open mesh repairsare accomplished with a variety of prosthetic materialspositioned either dorsal or ventral to the fascial defect, withor without reperitonealization of the abdominal cavity [3].British and French surgeons have published many descrip-tive articles as well as reviews on the success of overlappingtechniques and retrorectus repairs [4,5]. These repairs maybe associated with considerable pain or ileus, often requir-ing a prolonged hospitalization and recovery period [1].

Traditional mesh repairs generally require multiple laterallyplaced sutures, the placement of which may lead to a bowelinjury. Although recurrence is less common when usingmesh, the recurrence rate still approaches one third of re-pairs [6]. Laparoscopic mesh repairs have become morepopular of late, but have a considerable learning curve whilethe surgeon acquires the advanced laparoscopic skills re-quired to perform the procedure, and are generally morecostly and time consuming than traditional open repairs [7].We present here a technique of ventral hernia repair thatallows an anatomical repair with mesh reinforcement in asimplified fashion.

Material and methods

The patient is in the supine position. General anesthesiais commonly used, although local anesthetics with moni-tored anesthesia care can be used as well. The abdomen isprepared and draped in the standard fashion. The previousskin incision and edges of the hernia defect are marked onthe abdominal wall. A skin incision is made directly overthe hernia. Sharp dissection is performed in the subcutane-ous tissues until the hernia sack is identified. The herniasack is opened along its full length (Figs. 1 and 2). The

* Corresponding author. Tel.: �1-303-831-6100; fax: �1-303-831-8200.

E-mail address: fenogliomd@cs.com

The American Journal of Surgery 183 (2002) 642–645

0002-9610/02/$ – see front matter © 2002 Excerpta Medica, Inc. All rights reserved.PII: S0002-9610(02)00859-0

contents of the sack are dissected free and reduced into theabdomen. Dissection is then performed superficial to thesack, circumferentially separating it from the subcutaneoustissue. An incision is then made in the posterior rectus fasciaon one side of the hernia defect, leaving the sack attached tothe anterior rectus fascia. On the contralateral side, an in-cision is made in the anterior rectus fascia, leaving the sackattached to the posterior rectus fascia (Fig. 2). This dissec-tion is carried laterally until one reaches the edge of therectus muscle. This creates a pocket just large enough toaccept the mesh, as indicated by the Xs in Fig. 2. Theabdominal cavity is reperitonealized by suturing the portionof the hernia sack attached to the posterior rectus fascia tothe contralateral posterior rectus fascia using an absorbablemonofilament suture (Fig. 3, “B to D”). The defect is thenmeasured and an appropriately sized Kugel mesh (Bard,Cranston, RI) is placed in the space created deep to therectus muscles. The slit side of the mesh is positionedanteriorly. The reinforced ring allows the mesh to remainexpanded to fill the bridge without requiring lateral sutures(Fig. 4). The edges of the anterior rectus fascia are circum-ferentially sutured to the anterior layer of the mesh using anonabsorbable monofilament suture. The fascial edges arereapproximated as close to the midline as possible withoutcreating tension. The remaining leaf of the incised herniasack is then trimmed and sutured to the contralateral ante-rior rectus fascia (Fig. 3, “A to C”). This completes theclosure over the anterior surface of the mesh. A closedsuction drain is placed in the subcutaneous space and

brought out through a separate inferior stab wound (Fig. 4).The skin is closed in a standard fashion. The drain remainsin place until it evacuates less than 30 cc of fluid in a24-hour period.

Results

To date we have performed the Kugel mesh repair on 65unselected patients with a ventral, umbilical, or incisionalhernia. Forty-four (68%) are men and 21 (32%) are women.Twelve patients (18.5%) were being treated for recurrenthernias. The average age is 55.3 years (range 23 to 86). Theaverage height is 67.9 inches (range 58 to 74), and theaverage weight is 206.3 pounds (range 107 to 316).

Forty-nine patients (75.4%) were repaired under generalanesthetic and 16 (24.6%) have been repaired under localanesthetic with sedation. The average length of time in theoperating room was 56.2 minutes (range 30 to 115). Theaverage operating time (from incision to closure) was 33.8minutes (range 14 to 88). There were no intraoperativecomplications. Of the 65 patients, 11 (16.9%) were repairedwith a small circle of mesh (8 cm), 1 (1.5%) required a largecircle (12 � 12 cm), 39 (60%) required a small oval (8 �12 cm), 8 (12.3%) required a medium oval (11 � 14 cm),and 6 patients (9.2%) were repaired with a large oval ofmesh (14 � 18 cm). One patient required two large ovals toclose the defect.

Fig. 2. Component separation: A and D represent the fascial edges; B andC represent the divided edges of the hernia sac. The Xs represent thepocket created to accept the Kugel mesh.

Fig. 3. Reperitonealization of the abdominal cavity by suturing B to D, andplacement of the Kugel mesh deep into the rectus muscle.

Fig. 4. Completion of the closure anterior to the mesh, drain placement, andskin closure.

Fig. 1. A schematic diagram of a typical ventral incisional hernia.

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Fifty-two patients (80%) were discharged to home fromthe recovery room after the procedure and 11 patients(16.9%) required an overnight stay. The patient who re-quired two large ovals of mesh for the repair stayed 2 days.One patient with severe asthma stayed in the hospital for 3days.

The average number of narcotic tablets used postopera-tively was 4.6, and ranged from 0 to 20. Fifty patients(76.9%) used 0 to 5 tablets, 11 patients (16.9%) used 6 to 10tablets, and only 4 patients (6.15%) required more than 10narcotic tablets. Hydrocodone-acetaminophin 5/500 is ournarcotic of choice.

Postoperative complications included 1 wound infection(1.5%), which was treated by opening the wound and ad-ministration of intravenous antibiotics. The infection re-solved without removal of the mesh. Two patients (3.1%)had wound seromas, which were managed by needleaspiration. To date no patient has had a recurrence of hisor her hernia. The mean duration of follow-up is 14months and ranges from 1 to 42 months. Fifty-one pa-tients (78.5%) have been followed up for at least 6months and 29 patients (44.6%) have been followed upfor more than 1 year.

Comments

Many techniques have been described for the repair ofventral hernias. Primary suture repair often leads to exces-sive tension on the fascial edges, which causes tissue isch-emia and subsequent damage, resulting in recurrence of thehernia. With the advent of the mesh repair hernia defects ofany size can be closed without tension, thus reducing therate of recurrence. However, mesh is often placed such thatthe abdominal cavity is not reperitonealized. The bowelmay adhere to the mesh with subsequent obstruction orenterocutaneous fistula formation [3]. Polytetrafluoroethyl-ene mesh, which does not allow tissue in-growth, has beenreported to avoid this complication [8]. Creating a simpleperitoneal flap closure as described in our procedure andby Validire et al [5], significantly reduces the risk of afistula while completely protecting the underlying peri-toneal cavity and bowel from the mesh. The procedurefor securing traditional types of mesh may require blindlyplacing sutures laterally and also requires that the entireperiphery of the mesh be sutured to the tissue. This canbe time consuming and treacherous if a bowel injurywere to occur. The Kugel mesh has a ring, which preventsrolling of the mesh and allows it to hold its shape andposition with a minimal number of sutures to secure it inplace (Fig. 5).

The vast majority of our patients were discharged within23 hours of their repair, with most of them going home fromthe recovery room. Postoperative narcotic pain medicationuse was also remarkably low after this procedure. Althoughwe do not have specific data on the duration of the recovery

period and the time it took to return to usual preoperativeactivities, the shorter hospital stay and limited use of nar-cotics suggest that this procedure is well tolerated andassociated with minimal disability.

Our overall complication rate is 4.6%. One patient hadtheir wound opened owing to infection, but the mesh wasnot removed. The patient was successfully treated withintravenous antibiotics. Seromas developed in 2 other pa-tients after their closed-suction drains were removed. Bothpatients required a single needle aspiration of their seroma.To date, no patient has experienced a recurrence of his orher hernia after this type of repair. Clearly a recurrence canpresent even years after a mesh repair so we view these datawith caution.

Conclusions

The above-described technique easily accomplishes thefour primary goals of ventral incisional hernia repair. Open-ing the hernia sack allows for adequate reduction of itscontents under direct vision. One leaf of the sack can thenbe used to reperitonealize the abdominal cavity and preventcomplications associated with bowel adhering to themesh. Performing a partial component separation tech-nique and using Kugel mesh creates a tension-free repairwith simplification of the mesh placement. Finally, thecontour of the abdominal wall is restored with the ante-rior closure. In our experience, the operative time isrelatively short and postoperative pain and disability arekept to a minimum. The recurrence rate for this techniqueis lower than that described for other techniques. We feelthat this technique is a safe, effective, and durable alter-native to both laparoscopic and traditional open mesh andprimary repairs.

Fig. 5. Kugel mesh.

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Acknowledgments

The authors have no financial interest in Kugel mesh.

References

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[2] Read RC, Yoder G. Recent trends in the management of incisionalherniation. Arch Surg 1989;124:485–8.

[3] Leber GE, Garb JL, Alexander AI, Reed WP. Long-term complications

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[4] Khaira HS, Lall P, Hunter B, Brown JH. Repair of incisional hernias.J R Coll Surg Edinb 2001;46:39–43.

[5] Validire J, Imbaud P, Dutet D, Duron JJ. Large abdominal incisionalhernias: repair by fascial approximation reinforced with a stainlesssteel mesh. Br J Surg 1986;73:8–10.

[6] Anthony T, Bergen PC, Keim LT, et al. Factors affecting recurrencefollowing incisional herniorrhaphy. World J Surg 2000;24:95–101.

[7] Heniford BT, Ramshaw BJ. Laparoscopic ventral hernia repair. SurgEndosc 2000;14:419–23.

[8] Chrysos E, Athanasakis E, Saridaki Z, et al. Surgical repair of inci-sional ventral hernias: tension-free technique using prosthetic material(expanded polytetrafluoroethylene Gore-Tex Dual Mesh). Am Surg2000;66:679–82.

645R. Knight and M.E. Fenoglio / The American Journal of Surgery 183 (2002) 642–645