VENTRAL INCISIONAL

HERNIA REPAIR

Evaluatation of the Sublay retromuscular technique using light-weight "Vypro"mesh versus prolene

mesh

THESISSubmitted for partial fulfillment of the M.D degree in general

surgery

By

Dr.MOUSTAFA MOHAMED HEGAZY

Supervised by PROF. Dr. AHMED MOHAMED LOTFY

Professor of General SurgeryFaculty of Medicine - Ain-Shams UniversityPROF. Dr. OSAMA FOUAD MOHAMED

ABD ELGAWADProfessor of General Surgery

Faculty of Medicine - Ain-Shams UniversityDr. MOHAMED ALI MOHAMED NADA

Lecture of General SurgeryFaculty of Medicine - Ain-Shams University

2010

Incisional hernias remain one of the most Incisional hernias remain one of the most

common surgical complications with a long-term common surgical complications with a long-term

incidence of 10-20% incidence of 10-20% (Schumpelick, et al., 2006).(Schumpelick, et al., 2006).

Primary suture repair of incisional hernia results Primary suture repair of incisional hernia results

in 31-58% recurrence in 31-58% recurrence (Clark et al., 2006).(Clark et al., 2006).

With a move to the tension-free repair following

the introduction of the meshes, results improved,

with a dramatic decrease in the rate of recurrence

to approximately 10% (Millikan, 2003).

Several techniques have been advocated to Several techniques have been advocated to implant the meshimplant the mesh

or epifascialor epifascial

underlay or retromuscularunderlay or retromuscular

within the defectwithin the defect

The onlay method may be complicated by: The onlay method may be complicated by:

seroma and wound infections, while seroma and wound infections, while

intraperitoneal mesh leaves the potential for intraperitoneal mesh leaves the potential for

development of enteric fistula or small development of enteric fistula or small

bowel obstructions bowel obstructions (Hamilton et al., (Hamilton et al.,

20052005)

Within recent decades, the sublay prosthetic Within recent decades, the sublay prosthetic

herniorrhaphy, which was introduced in the 1970 herniorrhaphy, which was introduced in the 1970

by the French surgeons Stoppa and Rives, became by the French surgeons Stoppa and Rives, became

one of the widely accepted procedures for one of the widely accepted procedures for

incisional hernia repair. This technique is incisional hernia repair. This technique is

basically characterized by mesh implantation in basically characterized by mesh implantation in

the "sublay"position below the rectus muscle the "sublay"position below the rectus muscle

and fixation of the mesh by transfascial sutures at and fixation of the mesh by transfascial sutures at

the edges of the mesh the edges of the mesh (Petresen et al., 2004 )(Petresen et al., 2004 )

Increasing evidence of impaired wound healing Increasing evidence of impaired wound healing

in incisional hernia patients supports routine use in incisional hernia patients supports routine use

of an open prefascial, retromuscular mesh repair. of an open prefascial, retromuscular mesh repair.

Basic pathophysiologic principles dictate that for Basic pathophysiologic principles dictate that for

a successful long-term outcome and prevention of a successful long-term outcome and prevention of

recurrence, a wide overlap underneath healthy recurrence, a wide overlap underneath healthy

tissue is required ,only retromuscular placement tissue is required ,only retromuscular placement

allows sufficient subduction of the mesh by allows sufficient subduction of the mesh by

healthy tissue healthy tissue (schumpelick, et al; 2007)(schumpelick, et al; 2007).

Polypropylene is the material widely used for Polypropylene is the material widely used for

open mesh repair. New developments have led to open mesh repair. New developments have led to

light-weight meshe e.g`Vypro and Ultrapro``meshes, light-weight meshe e.g`Vypro and Ultrapro``meshes,

which are adjusted to the physiological requirements which are adjusted to the physiological requirements

of the abdominal wall and permit proper tissue of the abdominal wall and permit proper tissue

integration. These meshes provide the possibility of integration. These meshes provide the possibility of

forming a scar net instead of a stiff scar plate , forming a scar net instead of a stiff scar plate ,

therefore help to avoid theformer known therefore help to avoid theformer known

complicationscomplications (schumpelick, et al; 2009).

In our study we try to evaluate the: In our study we try to evaluate the:

*challenge of the sublay retromuscular *challenge of the sublay retromuscular

technique of ventral incisional hernia repair, with technique of ventral incisional hernia repair, with

the advent of some new technical points in a trial the advent of some new technical points in a trial

to reduce recurrence. to reduce recurrence.

**compare results of using light-weight **compare results of using light-weight

``Vypro``mesh versus the standard heavy-weight ``Vypro``mesh versus the standard heavy-weight

prolene mesh in respect of post-operative prolene mesh in respect of post-operative

complications, chronic pain and recurrence.complications, chronic pain and recurrence.

REVIEW OF HERNIA

No disease of the human body, belonging No disease of the human body, belonging

to the province of the surgeon, requires in its to the province of the surgeon, requires in its

treatment a better combination of accurate treatment a better combination of accurate

anatomical knowledge with surgical skill anatomical knowledge with surgical skill

than hernia in all its varietiesthan hernia in all its varieties(Sir Astley (Sir Astley

Paston copoer, 1804) Paston copoer, 1804)

Incidence of Incisional Hernia:

An incisional hernia is represented by the escape of

organs from their physiologic position through an

area of weakness in the surgical scar. The frequency

for incisional hernias (IH) after laparotomy is 2-11%

Incisional hernias make up about 80% of the ventral

hernias that surgeons encounter (Voeller, 2007).

Factors affecting incisional hernia incidencFactors affecting incisional hernia incidenc

A- Patient factors: A- Patient factors: Many patient-related risk Many patient-related risk

factors have been implicated in the development of factors have been implicated in the development of

incisional hernias, including obesity, smoking, incisional hernias, including obesity, smoking,

aneurismal disease, chronic obstructive aneurismal disease, chronic obstructive

pulmonary disease, male gender, malnourishment, pulmonary disease, male gender, malnourishment,

corticosteroid dependency, renal failure, corticosteroid dependency, renal failure,

malignancy, and prostatismmalignancy, and prostatism (Millikan, 2003).

B- Surgical factors: B- Surgical factors: Like emergency surgery, Like emergency surgery,

bowel surgery, suture type and technique, bowel surgery, suture type and technique,

chest infection, abdominal distension and chest infection, abdominal distension and

wound infection. There is evidence that in wound infection. There is evidence that in

many cases wound failure after abdominal many cases wound failure after abdominal

wall closure is dependent on the surgeon wall closure is dependent on the surgeon

(Yahchouchy-Chouillard et al., 2003).(Yahchouchy-Chouillard et al., 2003).

Recently, molecular biologic investigations Recently, molecular biologic investigations

have proven the theory of disturbed have proven the theory of disturbed

composition of the extracellular matrix in composition of the extracellular matrix in

patients with recurrent hernia. In particular, patients with recurrent hernia. In particular,

there is a decreased ratio of collagen types I there is a decreased ratio of collagen types I

and III and III (Jansen et al., 2004 ). (Jansen et al., 2004 ). .…

Treatment of Incisional Hernia

Once an IH occurs, the natural history of Once an IH occurs, the natural history of

it is to grow. Delay in repair complicates it is to grow. Delay in repair complicates

every single aspect of the surgery and leads every single aspect of the surgery and leads

to increased morbidity; so repair should be to increased morbidity; so repair should be

done as soon as possibledone as soon as possible

Suture Repair

Many suture techniques have been described, Many suture techniques have been described,

but none has proven to be superior to the other in but none has proven to be superior to the other in

well-performed clinical trials. However well-performed clinical trials. However (Jenkin's (Jenkin's

rule):rule): mass closure with a non-absorbable or mass closure with a non-absorbable or

slowly absorbable monofilament suture (e.g. slowly absorbable monofilament suture (e.g.

PDS) good bites (>1cm), using a suture length : PDS) good bites (>1cm), using a suture length :

wound length ratio of 4:1,is good,insmall sized wound length ratio of 4:1,is good,insmall sized

hernia less than 4 cm.hernia less than 4 cm.

Inlay Repair:

In this repair, the mesh is sutured to the fascial In this repair, the mesh is sutured to the fascial

edges without initially closing the defect. The edges without initially closing the defect. The

mesh lies in contact with the viscera. This mesh lies in contact with the viscera. This

technique has a high recurrence rate and may technique has a high recurrence rate and may

lead to bowel adhesions and development of lead to bowel adhesions and development of

enterocutaneous fistulas, so it is not enterocutaneous fistulas, so it is not

recommended unless the substantial defect recommended unless the substantial defect

cannot be closed with other technique . cannot be closed with other technique .

Onlay Repair :

After dissection of the hernial sac, the fascial After dissection of the hernial sac, the fascial

edges are brought together and the mesh is edges are brought together and the mesh is

placed over the suture line making an overlap of placed over the suture line making an overlap of

5 cm.and fixed with stiches to the anterior fascia 5 cm.and fixed with stiches to the anterior fascia

The skin is closed over the mesh.The skin is closed over the mesh.

Sublay Repair (Rives-Stoppa-Retrorectus Repair)

The mesh is placed beneath the rectus muscle in The mesh is placed beneath the rectus muscle in

front of the closed posterior rectus sheath and front of the closed posterior rectus sheath and

peritoneum. The anterior rectus sheath is closed. peritoneum. The anterior rectus sheath is closed.

The advantage of this technique is that if the mesh The advantage of this technique is that if the mesh

is much larger in surface area than the hernia is much larger in surface area than the hernia

defect, intra-abdominal forces hold the prosthesis defect, intra-abdominal forces hold the prosthesis

against the muscles. The forces that created the against the muscles. The forces that created the

hernia now are used to prevent its recurrence. hernia now are used to prevent its recurrence.

In contrast to a mesh in front of the fascia in In contrast to a mesh in front of the fascia in

onlay position, the sublay mesh position onlay position, the sublay mesh position

facilitates a sufficient subduction of intact linea facilitates a sufficient subduction of intact linea

alba. It is the retromuscular mesh with a fascia alba. It is the retromuscular mesh with a fascia

closure in front, which is kept in position just by closure in front, which is kept in position just by

tissue ingrowth and intra-abdominal pressure, tissue ingrowth and intra-abdominal pressure,

whereas the onlay mesh has to be fixed whereas the onlay mesh has to be fixed

additionally by permanent sutures. The mesh in additionally by permanent sutures. The mesh in

the space behind the rectus muscle can be the space behind the rectus muscle can be

easily dissected, whereas the extended easily dissected, whereas the extended

preparation of the subcutaneous space in the preparation of the subcutaneous space in the

case of the onlay position frequently is case of the onlay position frequently is

accompanied by hematoma, seroma, or wound accompanied by hematoma, seroma, or wound

infection. infection. (Schumpelick et al., 2007).(Schumpelick et al., 2007).

Laparoscopic Repair of the Incisional Hernia

In 1991 LeBlanc reported the first successful In 1991 LeBlanc reported the first successful

series of laparoscopic ventral hernia repair series of laparoscopic ventral hernia repair

(LeBlanc et al., 2001). (LeBlanc et al., 2001).

After creation of the pneumoperitoneum and After creation of the pneumoperitoneum and

port placement, the hernial contents are reduced port placement, the hernial contents are reduced

intraperitoneally and the mesh is placed to intraperitoneally and the mesh is placed to

overlap the defect and fixed with clips and overlap the defect and fixed with clips and

suturessutures(Goodney et al., 2002).(Goodney et al., 2002).

The Ideal Mesh The Ideal Mesh

There is no ‘‘best’’ mesh, so the decision of There is no ‘‘best’’ mesh, so the decision of

which mesh to use is based on several factors: which mesh to use is based on several factors:

the type of procedure being done, the clinical the type of procedure being done, the clinical

situation, the desired handling characteristics, situation, the desired handling characteristics,

and the products available to the surgeon based and the products available to the surgeon based

upon hospital materials contracts and costs. upon hospital materials contracts and costs.

The most commonly used meshes

l

Biological Meshes Biological Meshes

Recently, a number of biological meshes have Recently, a number of biological meshes have

become available. These are Surgisis?, which is become available. These are Surgisis?, which is

made from porcine gut submucosa, Alloderm?, made from porcine gut submucosa, Alloderm?,

which is made from cadaver dermis and Permacol? which is made from cadaver dermis and Permacol?

made from porcine dermis. They are expensive and made from porcine dermis. They are expensive and

can be used in contaminated situations. Long-term can be used in contaminated situations. Long-term

evaluation is neededevaluation is needed(Voeller 2007).(Voeller 2007).

Postoperative complications

Postoperative complications of mesh repair are:Postoperative complications of mesh repair are:

**seroma formation,seroma formation,

**wound haematoma, wound haematoma,

**superficial and deep wound infection,superficial and deep wound infection,

**mesh rejection and mesh rejection and

**Abdominal discomfort,chronic pain and restriction Abdominal discomfort,chronic pain and restriction

of abdominal wall mobility (stiff abdomen), of abdominal wall mobility (stiff abdomen),

**recurrence.recurrence.

SUBLAY SUBLAY RETROMUSCULR RETROMUSCULR

MESH REPAIRMESH REPAIRPrinciple of Principle of

RepairRepair

SUBLAY RETROMUSCULR MESH REPAIR

PatientsPatients::

*30 patients complaining of moderate *30 patients complaining of moderate

sized ventral incisional hernia ,i.e size of sized ventral incisional hernia ,i.e size of

hernia ranging from 5-11cm.hernia ranging from 5-11cm.

*Larg and huge sized hernia are *Larg and huge sized hernia are

excluded as it well need additional excluded as it well need additional

methods of repair.methods of repair.

The patients classified into two groups:Group A: 15 patients treated by using the Heavy-weight prolene mesh using the sublay technique.

Group B: 15 patients treated by the same sublay technique but using the Light-weight`` vypro`` mesh in their repair.

“MMETHODES OF REPAIR

Sublay "mesh repair; Sublay "mesh repair; retromuscular technique retromuscular technique i.e. mesh implanted behind the rectus abdominis muscle infront of the closed posterior rectus sheath and peritoneum.

Operative detai

OPERATIVE DETAILS:OPERATIVE DETAILS:

The steps of operation sublay retromuscular

mesh repair published by Schumpelick et al.,

(2007),stressing on the following technical points:

*The different layers of the abdominal wall were

reconstructed with mesh placed behind the rectus

muscle.

*The mesh was sized to give an overlap of at least

5 cm in all directions from the aponeurotic edges

i.e. wide overlap of the implanted mesh at least

5cm in all directions surrounding the hernia

defect.

*The posterior rectus sheath and the peritoneum

were closed to prevent direct contact between

mesh and intestine.

*The anterior fascia of the rectus sheath was then

closed to reconstruct the linea alba i.e.

reconstruction of the linea alba by closure of

anterior rectus sheath over the mesh is

mandatory.

*Suction drain left in the retromuscular plane

before wound closure is essential .

pic.(1)moderate size incisional hernia pic.(2)moderate size incisional hernia

pic.(3)huge size incisional herni

pic.(4) skin incision

pic(5) scar excision

pic(6)opening of hernia sac

pic(7) adhenlysis

pic(8) peritoneal cavity

pic(9) the posterior rectus sheath

pic(10) incision of the posterior rectus sheath

pic(11) dissection of the posterior rectus sheath

pic(12)closure of the posterior rectus sheath

pic(13) Prolene mesh

pic(14) Vypro mesh

pic(15) mesh placement(Prolene mesh)

pic(16) mesh placement(Prolene mesh)

pic(17) mesh placement( Vypro mesh)

pic(18) mesh placement( Vypro mesh)

pic(19) mesh placement( Vypro mesh)

pic(20)Anterior fascia closure with submuscular suction drainage

pic(21) Anterior fascia closure( Prolene mesh)

pic(22) fascia closure( Vypro mesh)

pic(23) skin closure

Duration of suction

Group

Duration (day)P value

MeanSDValueComment

Group (A)4– 7 days

(5.8)0.94

0.000

Significant

Group (B)3–5 days

(4.4 )0.73

Table 7: Duration of suction

Group

Group (A) Group (B)

Mea

n±

SE

du

rati

on o

d s

uct

ion

(d

ay.)

0

1

2

3

4

5

6

7

Chart 1: Duration of Suction

Table 8: Amount of Suction

Amount of suction

Group

Amount (mL)P value

MeanSDValueComment

Group (A)70 - 150

(102.0 )ml per day

23.05

0.032Significant

Group (B)50 -110

(85.3 )ml per day

16.85

Group

Group (A) Group (B)

Mea

n±

SE

am

ou

nt

od

su

cti

on

(m

L.)

0

20

40

60

80

100

120

Chart 2: Amount of Suction

Table 14: Incidence of seroma

Group

Compli.

Group (A)(n= 15)

Group (B)(n= 15)

Total(n= 30)

P value

no%no%no%ValueComment

Seroma426.7%213.3%620.0%0.013Significant

Chart 6: Seroma

Table 16: Abdominal discomfort

Group

Complications

Group (A)(n= 15)

Group (B)(n= 15)

Total(n= 30)

P value

no%no%no%ValueComment

Ab

dom

inal d

iscomfort

First month

746.7%426.7%1136.7%0.003Signif.

Third month

320.0%16.7%413.3%0.007Signif.

Sixth month

16.7%00.0%13.3%0.007Signif.

Ninth month

00.0%00.0%00.0%--

First year00.0%00.0%00.0%--

Chart 8: Abdominal Discomfor

Table 15: Incidence of Wound Infection

GroupCompli.

Group (A)(n= 15)

Group (B)(n= 15)

Total(n= 30)

P value

no%no%no%ValueComment

Wound infection

320.0%16.7%413.3%0.007Significant

Chart 7: Wound Infection

Table 17: Incidence of Recurrence (End of First Year)

Group

Recurrence

Group (A) )n=15(

Group (B) (n=15)

P- value

no%no%Valuecommen

t

Lost Patients16.7%16.7%1.00Not

significant

Recurrence 00.0%00.0%--

Chart 9: Incidence of Recurrence (End of First Year)

Between Aug. 2007 and March 2010, Patients

were randomized to receive lightweight composite

(Vypro) mesh, or standard polypropylene

(Prolene) mesh. The clinical course of all

patients was registered during the hospital stay as

well as 3 ,6,9, and 12 months after surgery. The

follow up of all patients was regular for at least

one year after surgery and we observed that :

*No significant differences concerning age,

gender,operative time.

*Duratin and amount of suction, length of

hospital stay were lower in the low-weight

(Vypro)mesh.

*Minor complications; seroma and wound

infection appeared frequently more in the heavy-

weight (Prolene)mesh group

.

*Patients of the heavy-weight mesh

complained significantly and more frequently

about chronic pain and abdominal wall

discomfort than those of the low-weight (Vypro)

mesh group,but non of both groups complain of

"stiff abdomen“.

* No hernia recurrences observed in both

groups ,this may be due to short follow up also

the hernias were selected of moderate size (5-

11cm in length).

To conclude:

Incisional hernia is a biologic problem due to Incisional hernia is a biologic problem due to

unstable scar formation with a defective collagen unstable scar formation with a defective collagen

metabolism.metabolism.

*Due to the disappointing results of primary *Due to the disappointing results of primary

suture repair, mesh repair is strongly suggested. suture repair, mesh repair is strongly suggested.

Prosthetic meshes are used for augmentation of Prosthetic meshes are used for augmentation of

the abdominal wall, and thus require a wide the abdominal wall, and thus require a wide

overlap of at least 5–6 cm.overlap of at least 5–6 cm.

*Mesh prosthesis should be developed ideally for *Mesh prosthesis should be developed ideally for

the physiologic parameters of the abdominal wall to the physiologic parameters of the abdominal wall to

provide tensile strength, yet maintain elasticity. provide tensile strength, yet maintain elasticity.

**Retromuscular mesh repair offers the Retromuscular mesh repair offers the

advantage of an extraperitoneal mesh position advantage of an extraperitoneal mesh position

(avoiding the potential complications of an (avoiding the potential complications of an

intraperitoneal prosthesis) and a wide stable intraperitoneal prosthesis) and a wide stable

fixation by its position within the abdominal wall.fixation by its position within the abdominal wall.

*Important steps in repair of incisional *Important steps in repair of incisional

hernias include complete excision of the fascial hernias include complete excision of the fascial

scar, use of a large enough mesh to provide a 5–scar, use of a large enough mesh to provide a 5–

6 cm overlap in all directions, closure of the 6 cm overlap in all directions, closure of the

posterior rectus sheath to prevent intraperitoneal posterior rectus sheath to prevent intraperitoneal

contact with the mesh, and closure of the contact with the mesh, and closure of the

anterior fascia in front of the mesh (thrust anterior fascia in front of the mesh (thrust

bearing resistance) whenever possible.bearing resistance) whenever possible.

**DeficienciesDeficiencies in repair of incisional hernias in repair of incisional hernias

include insufficient scar excision, insufficient include insufficient scar excision, insufficient

preparation of the space for the mesh prosthesis, preparation of the space for the mesh prosthesis,

too small a piece of mesh, and inadequate closure too small a piece of mesh, and inadequate closure

of the anterior fascia. of the anterior fascia. **The introduction of retromuscular, sublay The introduction of retromuscular, sublay

technique using polypropylene meshes had technique using polypropylene meshes had significantly decreased the recurrence rates after significantly decreased the recurrence rates after open incisional hernia repair.This technique is open incisional hernia repair.This technique is very simple can be easly done and learned. very simple can be easly done and learned.

Also the use of the lightweight composite Also the use of the lightweight composite

(Vypro,Ultrapro) mesh for incisional hernia (Vypro,Ultrapro) mesh for incisional hernia

repair had similar outcomes to heavyweight repair had similar outcomes to heavyweight

polypropylene mesh, but lightweight mesh polypropylene mesh, but lightweight mesh

resulted in a better abdominal wall compliance resulted in a better abdominal wall compliance

and less chronic pain, lower incidences of and less chronic pain, lower incidences of

postoperative seroma and infections with postoperative seroma and infections with

accepted recurrence rate.accepted recurrence rate.

As compared to the heavyweight meshes, the As compared to the heavyweight meshes, the

lighter-weight meshes show a decrease in lighter-weight meshes show a decrease in

inflammatory response decreased stiffness, less inflammatory response decreased stiffness, less

shrinkage, and fewer post operative complaints. shrinkage, and fewer post operative complaints.

We thus now have evidence that if the surgeon We thus now have evidence that if the surgeon

chooses a polypropylene mesh for ventral chooses a polypropylene mesh for ventral

incisional hernia repair, it should be a incisional hernia repair, it should be a

lightweight mesh if possible.lightweight mesh if possible.

Thank you

الأمامي البطن لجدار الجراحي الفتق علاجالأماميةلجدارالبطن العضلات تحت برولين شبكه وضع طريق عن

من مقدم بحثحجازي/ محمد مصطفى الطبيب

العامة الجراحة ماجستيرالعامة الجراحة في الدكتوراه درجه على للحصول توطئه

إشراف تحت / لطفي محمد أحمد الدكتور الأستاذ

العامة الجراحة أستاذشمس – عين طب كليه

الجواد / عبد فؤادمحمد أسامه الدكتور الأستاذالعامة الجراحة أستاذ

- شمس عين طب كليهندا / محمد علي محمد الدكتور

العامة الجراحة مدرسشمس - عين طب كليه