Recurrent incisional hernia sublay repair with
fully reabsorbable monofilament mesh – a case
report
RUNNING TITLE KEYWORDS WORD COUNT CONFLICT OF INTERESTSIncisional hernia sublay repair
incisional hernia, recurrent hernia, hernia repair, sublay method, sublay hernioplasty, reabsorbable mesh, phasix 1 963
no conflicts of interest
Incisional hernia is a common postope-rative complication of abdominal surge-ry, with the incidence ranging from 11% up to 20% of all laparotomy incisions.
ABSTRACT
Incisional hernia is the most common indication for reoperation after abdominal surgery. Mesh hernioplasty is almost a gold standard of treatment, associated with the low recurrence rate. Study presents a case of usage of a fully reabsorbable mesh for successful sublay hernioplasty in recurrent incisional hernia with a past history of many wound complications. Magdalena Kwapisz 1, Michał Wszoła1#, Piotr Domagała1, Piotr Góralski 1, Agnieszka Nalewajek 1, Anna Zuchowska2, Andrzej Chmura1, Artur Kwiatkowski1
1. Department of General and Transplantation Surgery, Warsaw Medical University, Warsaw, Poland 2. Department of Clinical Radiology, Warsaw Medical University, Warsaw, Poland
# Corresponding author: Michał Wszoła MD, PhD, ul. Nowogrodzka 59 , 02-006 Warsaw, Poland. Phone:+48225021470, e-mail: michal. wszola@wp.pl
INTRODUCTION
I
ncisional hernia is a common postoperative com-plication of abdominal surgery, with the incidence ranging from 11% up to 20% of all laparotomy incisions [1, 2] and the most common indication for reoperation after laparotomy [3]. It is defined as a defect occurring through the operative scar, caused by a failure of the lines of closure of abdominall wall.Thereby, it is the only hernia considered to be truly iatrogenic. The most common incision of previous surgery leading to incisional hernia is the infraumbi-lical or supraumbiinfraumbi-lical midline incision, followed by Pfannenstiel’s incision, paramedial, lumbar and right subcostal [4, 5]. Not only a closure technique and suture materials have an effect on hernias incidence. Postoperative wound infection and patient factors, such as advanced age, obesity, diabetes mellitus,
tobacco abuse, hypoproteinemia, corticosteroid use and immunosupresion are esthablished risk factors of hernia formation likewise [4, 6, 7].
Most of incisional hernia require elective surgical re-pair, because of becoming larger and causing morbi-dity complications if left untreated. A great variety of surgical techniques have been adopted for the repair of abdominal incisional hernias. Nowaday, the best results are believed to be achieved by the implanta-tion of prosthetic mesh [8] and the use of prosthetic material is almost a standard practise. Fibrous tissue, while growing in the porous mesh, consolidates the abdominal wall and disperses intraabdominal pressu-re, to prevent a recurrence of hernia. Anatomical repair is associated with recurrence rates about 23-50% [9, 10, 11] in comparison to 1,5-10% following prostetic mesh repair [12]. As in general, diabetes mellitus, obesity, smoking, postoperative straining and advanced age are also established risk factors of recurrence [4]. Despite of its significant benefits, a mesh should be treated as a foreign material and susceptible to infection, sinus formation or enteric fistulization [13]. The foreign body implantation may lead to chronic inflammation or excessive fibrosis and may result in increased stiffness and loss of plia-bility at the site of sewing [10, 14].
There is no general agreement as to the best choice of one of many prosthetic mesh repair techniques that have been proposed. The material can be placed between the subcutaneus tissues of the abdominal wall and the anterior rectus sheath (named onlay method) as well as in the preperitoneal plane cre-ated between the rectus muscle and posterior rectus sheath (named sublay method). This study reports a case of usage of a fully reabsorbable Phasix Mesh for sublay hernioplasty of recurrent incisional midli-ne hernia after a primary surgery by Pfanmidli-nenstiel’s incision and hernioplasty with polypropylene mesh complicated by surgical site infection.
CASE REPORT
In July 2014, 62 y.o. female admitted to the surgical department with a complaint of the recurrent ventral hernia and the symptoms of pain and movement limitations while performing activities of her daily life. She testified, that she underwent ginecological pro-cedure by Pfannenstiel’s incision few years ago. Her comorbidities were hypertension, diabetes mellitus and obesity (BMI = 35).
Her past medical history revealed an incisional hernia repaired with polypropylene mesh in January 2014, complicated with a large hematoma (sized 200 x 120 x 90 mm). Transdermal puncture and drainage with a subsequent antibiotic prophylaxis (ciprofloxacin) were succesfully performed then. In March 2014, control ultrasound examination showed giant multi-chamber seroma (sized 130 x 70 x 140 mm) in the lower part of anterior abdominal wall tissues. Those
abnormal fluid collections remained under medical careful control. In June 2014, another antibioticotera-py (metronidazol and cefuroxime) was administered, but pathological conditions still maintained unhealed. As a result of her first consultation in our department, computer tomography of the abdomen was admini-stered. It revealed a midline gap of hypogastric linea alba, sized 130 x 110 mm, with concomitant inflam-matory infiltration of the surrounding adipose tissue. Any pathologic fluid collection within the abdominal cavity wasn’t found. Therapy with cefuroxime was continued with sufficient result. Patient was qualified for operative treatment. In May 2015, direct preope-rative examination revealed palpable midline gap sized about 13 x 8 cm [Fig. 1, 2]. Computer tomo-graphy showed midline ventral hernia (137 x 112 x 56 mm trans x cc x ap) containing mesenteric adipose tissue and distended loops of small intestine within numerous adhesions. The hernia gate was measured on 104 x 75 mm [Fig. 3].
Under general anesthesia, open sublay hernioplasty (with the mesh placed in the retromuscular space) was performed [Video 1]. Patient was prepared and an antimicrobial-impregnated adhesive drape was placed over the skin of the anterior abdominal wall. The abdomen was accessed through a midline inci-sion, mostly through the previous scar. A single dose of cefazolin (2,0 g intravenously) was administered at the time of skin incision. In a first step, an inflam-matory tumor around previous polypropylene mesh was ressected and residual prosthetic material was explanted [Fig. 4]. Peritoneal adhesions were rele-ased [Fig. 5]. Then, the sac was delineated [Fig. 6]. Its contents was reduced and discharged into the in-terior of the abdominal cavity. The fascial defect was identified all around. The preperitoneal dissection of the anterior abdominal wall, allowing for mesh to be extended, began. When the posterior fascia has been released, the edges of the defect were reapproxima-ted with running non-absorbable polydioxanone (size: 1.0) sutures [Fig. 7]. After that, Phasix Mesh sized 4” x 6” (10 x 15 cm) was placed into retromuscular space and anchored by suturing it to the rectus she-ath [Fig. 8]. Additional simple sutures were placed on either side laterally to ensure its flat position [Fig. 9]. In the next step, anterior fascia was finally recon-structed over the mesh with a running polydioxano-ne suture (size: 1.0) [Fig. 10, 11]. Then, hemostasis was attained and two suction drains were placed in subcutaneous plane superficial to the mesh. Next, the excessive skin and subcutaneous tissue were re-duced through additional incision needed in Pfannen-stiel’s line. Endmost, the wound was closed [Fig.12]. In the postoperative period, patient required anal-gesic treatment only for 24 hours. The drains were removed in second postoperative day and she was discharged at the third day of hospital stay with no direct postoperative complications.
Two weeks later, she attended a clinic as an outpatient with delayed wound healing caused by
hernias remains wound complications. The dissec-tion required to proper mesh placement and reap-proximate the midline can lead to significant wound and mesh infections. In 2010, Venclauskas and colleagues published their results of 1-year follow-up after incisional hernia treatment. That prospective randomized study demonstrated wound complica-tions in 49.1% of onlay patients vs 24% of sublay repairs. Also the incidence of seroma was signi-ficantly higher in the onlay technique (45%) when compared with the sublay (24%) [27]. It must be noted, that the rate of wound morbidity after incisio-nal hernia repair depends on not only mesh material or the technique selection, but it is connected with patient comorbidities as well. Prior wound infection, obesity, diabetes mellitus, heart failure, presence of a stoma or malnutrition are well known independent risk factors of surgical site infections [28]. It leads to some difficulties in interpreting and comparing the findings published in the literature.
It is believed, that placing the mesh deep in the retrorectus plane prevents the transmittion of infec-tion from subcutaneous tissues down to the mesh [29]. Otherwise, there is a necessity to perform mesh reinforcement in contaminated area in some cases. It significantly affects the success of the operation. When repairing a contaminated abdominal wall de-fect, the sublay method provides The opportunity of rapid revascularize that prevents a material failure, improve bacterial clearance and long-term success of the repair [30]. Placing a mesh in a poorly vascula-rized area increases the risk of its early degradation by bacterial collagenase prior to achieving neovascu-larization and utilization of the native host immune system. Using a bioabsorbable or even biologic grafts in the retrorectus compartment is hypothesized to improve the outcomes related to recurrence rates when contamination is present [28]. Those products significantly raise the cost of the procedure.Howe-ver, if infectious complications can be avoided, cost would be offset by offering value to the patient. In presented case of recurrent incisional hernia with a previous history of many wound complications, a procedure of sublay reinforcement with fully resor-bable mesh implant (Phasix Mesh) was performed. The used material degradates through the processes of hydrolysis and a hydrolytic enzymatic digestive process within 12 to 18 months. There was no recu-rrence in 4 month follow-up observation. An episode of surgical site infection has been effectively healed with no futher complications.
The role of bioabsorbable implants in contaminated cases has not been determined yet, and ongoing prospective studies are indispensable to provide guidance for these difficult patients. The concern for mesh infection must be weighted against the concern of reccurence.
seroma in the operated side. She had no fever and microbiological test results were negative. The pro-phylactic therapy with Sorbact method was carried out to prevent the wound from being infected. Patient remained under ambulatory care with persistent wound exudate and without its adequate healing. After three weeks, Proteus mirabilis was identi-fied in another microbiological tests. Then, woman was hospitalized with diagnosis of wound infection. Intravenous amikacine was administered. Simulta-neously, negative pressure therapy was succesfully performed. She was fully recovered at the begining of August 2015 and with no complaints of pain or mesh sensitivity in follow-up 2 months later [Fig. 13, 14].
DISCUSSION
The predominance of mesh reinforcement over suture-based repair in incisional hernia surgery has been well established in the literature. Although its in-cidence rate remains low, the risk of recurrence after meshplasty is not completely eliminated. The best technique to provide a durable correction has not been determined. Moreover, recurrences of abdomi-nal wall hernia as shown by the literature are rarely induced because of failure of the mesh. In most of cases, they occur at the mesh-tissue interface – typi-cally at the cranial edge of the wound in the midline, or at the lateral border of nonmidline hernias [15, 16]. It allows to suggest, that the recurrence arise either due to technical problems with sufficient mesh coverage or next to inadequate coverage of the de-fect, rather than because of the mesh material itself [17]. The numerous approaches, types of prosthetic materials for repair, and possible locations of mesh placement testify to the lack of unequivocal evidence to promote any of repair technique that have been proposed so far.
The sublay method, popularized by Rives [18] and Stoppa [19] in the late 1980s, uses the potential space dissected posterior to the rectus sheath for the mesh placement. It is considered by many surgeons as a gold standard for open abdominal incisional hernia repair [20, 21, 22, 23]. The recurrence rate of preperitoneal (sublay) mesh repair mentioned in different series varies from 2% to less than 10% [24]. Its main advantages in the reconstruction of complex abdominal wall defects are associated with a release of rectus abdominis muscle that provides a 2-lay-ered closure of midline anterior fascia [25]. More importantly, the posterior rectus sheath dissection from the overlying muscle, provides a well-vascu-larized pocket for mesh placement. In contrast, the anterior sheath is tightly adherent to the tendinous inscriptions of the rectus muscle. It was proved by Binnebosel at collegues on their rabbit model of open incisional hernia repair, that mesh placed in the rec-torectus space demostrates more of both type I and type III collagen deposition in a porcine model, when compared with its onlay position [26].
FIG. 1. PALPABLE MIDLINE GAP
FIG. 2. PALPABLE MIDLINE GAP
FIG. 3. MIDLINE VENTRAL HERNIA IN PREOPERATIVE CT SCAN
CONCLUSIONS
Retrorectus (sublay) method of mesh reinforcement is preferable in incisional hernia repair, that provides 2-layered closure of the midline fascia to recre-ate native abdominal wall anatomy. A surgical site infection, as well as implanted foreign body contami-nation, significantly increases the risk of recurrence. Using the bioabsorbable implants, that completely hydrolyze after providing a support throughout the period of soft tissue healing, is suggested in contami-nated area. Despite its encouraging outcomes, a cost factor still existst and futher prospective studies are necessary to establish its position in incisional hernia surgery.
CITE THIS AS
MEDtube Science 2015, Sep 3(3), 14-20.
VIDEO 1. RECURRENT INCISIONAL HERNIA SUBLAY REPAIR WITH FULLY REABSORBABLE MESH
Click here to play the video.
LIST OF THE FIGURES
Fig.1: Palpable midline gap. Fig.2: Palpable midline gap.
Fig.3: Midline ventral hernia in preoperative CT scan.
Fig.4: Ressection of inflammatory tumour around previous polypropylene mesh.
Fig.5: Release of peritoneal adhesions. Fig.6: Hernia sac delineation.
Fig.7: Reapproximation of the posterior fascia. Fig.8: Retrorectus mesh placement.
Fig.9: Additional suturing to ensure mesh flat position.
Fig.10: Reconstruction of anterior fascia over the mesh.
Fig.11: Anterior abdominal wall reconstruction visu alised in postoperative CT scan.
Fig.12: Excessive skin and subcutaneous tissue reduction through additional Pfannestiel’s incision.
Fig.13: Wound appearance in 2 – month follow-up after full recovery.
Fig.14: The appearance of anterior abdominal wall in 4 months after procedure.
FIG. 7. REAPPROXIMATION OF THE POSTERIOR FASCIA
FIG. 8. RETRORECTUS MESH PLACEMENT
FIG. 9. ADDITIONAL SUTURING TO ENSURE MESH FLAT POSITION
FIG. 4. RESSECTION OF INFLAMMATORY TUMOUR AROUND PREVIOUS POLYPROPYLENE MESH
FIG. 5. RELEASE OF PERITONEAL ADHESIONS
FIG. 12. EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE REDUCTION THROUGH ADDITIONAL
PFANNESTIEL’S INCISION
FIG. 13. WOUND APPEARANCE IN 2 – MONTH FOLLOW-UP AFTER FULL RECOVERY
FIG. 14. THE APPEARANCE OF ANTERIOR ABDOMINAL WALL IN 4 MONTHS AFTER PROCEDURE FIG. 10. RECONSTRUCTION OF ANTERIOR FASCIA OVER
THE MESH
FIG. 11. ANTERIOR ABDOMINAL WALL RECONSTRUCTION VISUALISED IN POSTOPERATIVE CT SCAN
randomized study. Hernia 2010;14:575-582.
28. Rosen MJ, Denoto G, Itani KM, et al. Evaluation of surgical outcomes of retro-rectus versus intraperitoneal reinforcement with bio-prosthetic mesh in the repair of contaminated ventral hernias. Hernia 2013;17:31-35.
29. Bhat Mahabhaleshwar G, Somasundaram Santosh K. Pre-peritoneal Mesh Repair of incisional Hernia: A seven year retrospective study. Ind J Surg. 2007;69: 95-8.
30. Harth KC, Broome AM, Jacobs MR et al (2011) Bacterial clearance of biologic grafts used in hernia repair: an experi-mental study. Surg Endosc 25:2224.
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