incorporated material and is responsible for the abdom- inal wall compliance [1,2]. In 20% of the cases heavy weight (HW) and small pore size PP meshes caused a reduction of the abdominal wall mobility ("stiff abdo- men”)[3,4]. This complication was associated with chronic abdominal pain. As a consequence macropore light weight (LW) PP meshes strong enough to resist maximal physiologic stress of the abdominal wall were developed . This development resulted in a reduction of the chronic pain [1,6,7]. Whether macropore LW-PP meshes have also a beneficial effect on the life quality of patients in the long term outcome after open incisionalherniarepair is still unclear. The objective of this study was therefore to assess the health related quality of life (HrQoL) and the long term outcome of patients with open incisionalherniarepair using HW- versus LW-PP meshes.
The incidence of seroma after incisionalherniarepair is high, reaching values of 3% . The reasons for this are not known, however, high BMI, lowered preoperative serum concentration of total protein and albumin and high serum concentration of IL-1-RA are related to an elevated risk for postoperative seroma formation . In this study, the small number of patients studied and the absence of seroma does not allow us to correlate the in- flammatory response and the amount of fluid drained with the development of seroma. A significant reduction of pH values was detected in DM fluid only on POD-4. The pH value within the wound-milieu indirectly and directly in- fluences all biochemical reactions which take place in the healing process. It could be proven that wound healing is correlated to wound pH changes, as they can lead to an inhibition of endogenous enzymes [25,26], such as an in- activation of fibroblast bindering its wound healing ac- tivity . For more than three decades the common assumption amongst physicians was that a low pH value, as found in normal skin, is favorable for wound healing. Recent investigation showed that the wound pH is indeed potent influential factor in the healing process . A significant reduction in pH is associated with the forma- tion of seroma  and the stabilization of the pH values can reduce the adverse tissue reaction .
Methods/Design: A randomized multi-center clinical trial comparing cost-effectiveness of open and laparoscopic repair of incisional hernias. Patients with a symptomatic incisionalhernia, eligible for laparoscopic and open incisionalherniarepair. Only surgeons, experienced in both open and laparoscopic incisionalherniarepair, will participate in the INCH trial. During incisionalherniarepair, a mesh is placed under or on top of the fascia, with a minimal overlap of 5 cm. Primary endpoint is length of hospital stay after an incisionalherniarepair. Secondary endpoints are time to full recovery within three months after index surgery, post-operative complications, recurrences, mortality and quality of life.
Initial Experience of Laparoscopic Incisional Hernia Repair ORIC3,INAL ARTICLE Initial Experience of Laparoscopic Incisional Hernia Repair J Razman, MS, S Shaharin, MS, M R Lukman, MS, N Sukumar, MS,[.]
Laparoscopic incisionalherniarepair is an intraabdominal, intraperitoneal herniarepair, that uses mesh prosthesis to repair and cover the hernia defect. After establishing pneumoperitoneum through a midline trocar, lateral trocars can be safely placed. After releasing the adhesions, the hernial defect is defined. The size of the defect is marked out on the skin and about three to five centimeter margin lateral to the fascial defect is given all around for the mesh, which is then inserted into the abdomen. The mesh is anchored to the abdominal wall by full thickness sutures at the corners. In-between the corners the mesh is tucked to the abdominal wall fascia, at one-centimeter intervals.
“STUDY OF INCISIONALHERNIA- EVALUATION OF RISK FACTORS AND OUTCOME OF VARIOUS SURGICAL TECHNIQUES USED IN THE INCISIONALHERNIAREPAIR” represents a genuine work of mine. The contributions of any supervisors to the research are consistent with normal supervisory practice and are acknowledged. I also affirm that this bonafide work or part of this work was not submitted by me or any others for any award, degree or diploma to any other university board, either in India or abroad. This is submitted to the Tamil Nadu Dr. M.G.R. Medical University, Chennai in partial fulfillment of the rules and regulations for the award of Master of Surgery degree Branch 1 (General Surgery).
The mean operative time recorded from incision to skin closure through dis- section of layers of abdomen and space behind muscle, placement of mesh, its fixation and placement of a vacuum drain was 221.7 minutes. Operative time tends to be shorter in defects of size 5 - 10 cm with operative time of 164.8 min- utes due to lesser adhesiolysis and dissection. The results almost overlapped with findings from the study done by Michael J. Rosen et al .  who reported a mean operating time of 244 minutes in open incisionalherniarepair. The mean hospital stay was similar 8 days Vs 7 days, mean time to removal of drain were also alike 10 days vs 12 days. The mean operative time however was less, 164 minutes as reported by Stefano Olmi et al .  which could be because less number of anchoring sutures utilised to hold the mesh in position 6 vs 24. Mean hospital stay and mean time to removal of drain were same.
. Post operatively 11 patients (9.5%) developed seroma and 2 patients (1.7%) had a deep wound infection. The study was a prospective audit including 116 patients. Our study included 56 consecutive patients in a single institution with a median follow-up period of 35 months (range 4–151). In accordance with previous studies we chose to combine a structured interview with a clinical examination [1,10-13]. This method proved to be effec- tive with a clinical examination of all eligible patients sus- pected of hernia. Our study group showed no significant differences with respect to distribution of known risk fac- tor between patients with or without recurrent hernia. The onlay technique is a simple and effective repair oper- ation with a short learning period for the surgeon. For open incisionalherniarepair the choice between inlay, onlay and sublay technique is often based on tradition and the individual surgeon's expertise rather than scien- tific evidence. It has been routine to perform all incisional hernias by the onlay technique at the institution involved in the present study, and we therefore don't have any patients who had been operated by other open tech- niques. Our study shows that the onlay technique seems to be safe in terms of complication and recurrence rates for the patient. In addition this technique requires little tissue dissection with an easy access to the herniarepair. These advantages should be taken into consideration when choosing between laparoscopic and open technique and when choosing between different open technique.
Range of the time for surgeries is around the same for both the cases in our study which is, minimum around 60 minutes and maximum around 300 minutes. Longer duration of laparoscopic surgeries in our study can be attributed to the learning curve of surgeons in our hospital and is due to difficulty in case due to dense adhesions and reducing the contents, all through laparoscopic approach. While some complex cases of open herniarepair were also time consuming in order to do repair by a pre-peritoneal approach. Most of the open cases were planned for pre-peritoneal repair unless otherwise complicated or if there was difficulty in creating the plane.
These inflammatory reactions are well documented complications of herniarepair with prostheses in both in vitro and in vivo models of herniarepair [2, 4–7]. Specifically, polypropylene mesh is known to cause a non-infective, host-initiated, foreign body granulomatous inflammatory response which may cause scar thickening [4, 8]. This is hypothesised to result from an interaction between native proteins such as fibrinogen and albumin and the mesh’s polymer, causing a denaturation of these proteins which stimulates the formation of a foreign body granuloma, characterised by the aggregration of macrophages and other inflammatory cells . This process can go on for an extended period of time [5, 6].
The overall reported occurrence of incisional hernias post laparotomy varies within a range between 11 and 23% in different studies [1–3]. However, an incisionalhernia in a case of antethoracic pedicled jejunal flap esophageal reconstruction is a very rare occurrence. Antethoracic je- junal esophageal reconstruction—an alimentary tract reconstructive method following esophagectomy—is con- ducted only in patients who have undergone gastric sur- gery previously. The distinctive feature of an incisionalhernia in such patients is that the pulled-up jejunum passes through the hernial orifice together with the her- niating intestine. Incisional hernias can be conventionally repaired by two methods: simple re-suturing or repair with mesh prosthesis; however, it is recommended that incisional hernias measuring more than 10 cm in diameter be repaired with mesh prosthesis because of the high re- currence rate with simple re-suturing [4, 5]. However, a mesh prosthesis cannot be conventionally used in an inci- sional hernia after antethoracic jejunal reconstruction, and consequently, the standard surgical treatment for this con- dition remains unclear.
Background: Incisional heia is a frequent complication of midline laparotomy. The use of mesh in herniarepair has been reported to lead to fewer recurrences compared to primary repair. However, in Ventral Hernia Working Group (VHWG) Grade 3 hernia patients, whose hernia is potentially contaminated, synthetic mesh is prone to infection. There is a strong preference for resorbable biological mesh in contaminated fields, since it is more able to resist infection, and because it is fully resorbed, the chance of a foreign body reaction is reduced. However, when not crosslinked, biological resorbable mesh products tend to degrade too quickly to facilitate native cellular ingrowth. Phasix ™ Mesh is a biosynthetic mesh with both the biocompatibility and resorbability of a biological mesh and the mechanical strength of a synthetic mesh. This multi-center single-arm study aims to collect data on safety and performance of Phasix ™ Mesh in Grade 3 hernia patients.
Our study shows that surgeon specialization in ab- dominal wall surgery is one main factor to reduce recur- rences in open elective incisionalherniarepair. This fact also has been described in the Shouldice technique for inguinal herniarepair, performed at the Shouldice Hos- pital, which has a four-fold decreased risk of recurrence compared with mesh repair performed in generalist hos- pitals in Canada . Low recurrence rates also have been related to specific techniques for ventral hernia re- pair, such as preperitoneal ventral herniarepair , achieving a 5.2% rate of recurrence; and, reoperation rates for recurrence, operative time, and costs were lower in high-volume surgeons (> 36 operations/year) .
From above study we come to know that incisionalherniarepair was most surgery done in ventral hernia category and hence contribute to higher proportion in mesh infection among the mesh repairs done (59%).Factors affecting the rate of mesh infection was included in this study except mesh related factor because we commonly used
Once the size of the hernial defect was defined, the proper size of mesh was determined. The prosthetic mesh was then inserted into the peritoneal cavity. These appears to be universal agreement that an overlap of atleast 3 cm between the mesh and the fascial edge is necessary. Fix the mesh in place by using staples or sutures. Most surgeons have not used drains, in contrast to the fashion with open mesh techniques where the use of drains is almost universal. The recurrence rates obtained with laproscopic incisionalherniarepair vary between 0 to 9%.53 Common complications of laproscopic repair includes seroma, wound infection, Ileus, hematoma and pain. 54
complications and a high rate of recurrence, while the inlay group got the highest rate of recurrence, sublay group had the least recurrence and least com plications also. During operations, there was less blood loss and less need for a wound drain in the laparoscopic repair. However, operative time was longer during laparoscopy. Perioperative complications were significantly higher in the laparoscopic group. Visual analog scores for pain and nausea did not differ between groups. The incidence of a recurrence was similar in both groups. The size of the defect was found to be an independent factor for recurrence of an incisionalhernia . Elective incisionalherniarepair were beset with high rates of readmission and reoperation for recurrence. Readmission and reoperation for recurrence were most pronounced after open repair and repair for hernia defects up to 20 cm. Additionally, sublay mesh position reduced the risk of reoperation for recurrence after open repairs  It is to be concluded that when a patient with recurrent incisionalhernia is in need for repair, it is better to avoid inlay technique, not to do the underlay and the onlay techniques, and recommended to do the sublay approach. CONSENTS
3. In a small, simple incision hernia, suture repair had similar outcomes in terms of recurrence rates. The incidence of other compbcations was less compared to onlay mesh repair in a small, simple hernia. Hence in a small, simple incisionalhernia, repair byconventionalsuture repair still has a role if proper technique is used and other factors for recurrences are taken care .These findings correlated with that of the randomized trial conducted by M.Korenkov, S.Saucrland et al (25). In both the simple and complex hernia, Sublay technique of Mesh repair, where the mesh is placed preperitoneally in a retro-rectus plane had virtually no complications and both the short term and long term results were excellent
Every surgical procedure that requires access through the abdominal wall carries a risk of development of incisionalhernia. Incisional hernias are mostly related to failure of the fascia to heal and involve technical and biological factors. They may cause pain, increase in size over time, and also result in severe complications such as bowel incarceration and strangulation. A vast majority of open surgical repair of incisional hernias are achieved using a prosthetic mesh which is still associated with early or late complications such as mesh complications and the recurrence rate of approximately 32% over a 10-year follow up period [Burger et al, 2004, Teserteli et al, 2008]. LeBlanc et al in 1993 [LeBlanc & Both 1993] reported the first case of laparoscopic incisionalherniarepair using a synthetic mesh to improve upon the open method. Since the introduction of this technique, a number of randomized control trials (RCTs) comparing laparoscopic and open methods have been published analyzing various aspects of these approaches. The objective of this meta-analysis was to determine the clinical outcomes, safety and effectiveness of laparoscopic repair compared with open repair for elective surgical treatment of incisionalhernia only.
Background: Minimally invasive incisionalherniarepair has been established as a safe and efficient surgical option in most centres worldwide. Laparoscopic technique includes the placement of an intraperitoneal onlay mesh with fixation achieved using spiral tacks or sutures. An additional step is the closure of the fascial defect depending upon its size. Key outcomes in the evaluation of ventral abdominal hernia surgery include postoperative pain, the presence of infection, seroma formation and hernia recurrence. TACKoMESH is a randomised controlled trial that will provide important information on the laparoscopic repair of an incisionalhernia; 1) with fascial closure, 2) with an IPOM mesh and 3) comparing the use of an articulating mesh-fixation device that deploys absorbable tacks with a straight-arm mesh-fixation device that deploys non-absorbable tacks.
This study was a prospective study and comprised of patients admitted for elective surgery for incisionalhernia in our ward of SMHS hospital, Srinagar between July 2008 to November 2010. 30 patients who underwent laparoscopic incisionalherniarepair were included in the study. The patients were selected unbiased from either sex, with age above 18 years and were evaluated on the basis of pre-determined proforma. High risk patients (ASA III or IV), patients with coagulation disorders, patients with massive hernial defects, complicated hernias and patients with intra-abdominal sepsis were excluded from the study.