INTRODUCTION

Incisional hernias complicate approximately 10% of all laparotomies. Repair of an incisional hernia is a challenging case and recurrence rates remain high. The first repair of an incisional hernia has the highest likelihood of success; therefore, considerable attention should be given to the surgical strategies that achieve optimal outcomes.¹ The key factor associated with decreased likelihood of recurrence is the use of mesh for the repair.² Long-term results of a randomized trial comparing suture with mesh repair demonstrated a 62% recurrence for suture repair and 32% for mesh repair.³ For small defects (<10 cm²), the efficacy of mesh was even greater, with a 67% recurrence in the suture arm and 17% in the mesh arm. This highlights the fact that even small hernias should have a mesh repair. However, mesh is associated with a twofold increase in the complication rate, some of which, such as mesh infection and fistula formation, can be devastating.³ Therefore, it is important to understand factors associated with increased risk of mesh complications.

Primary reapproximation of the fascial edges without a mesh overlay or component separation technique should be reserved for patients with a contraindication to mesh placement and, given the current literature, should not be considered a definitive hernia repair. Many different technical approaches to mesh placement are available, and they can essentially be divided into three categories: (1) intra-abdominal (underlay), (2) interfascial (interlay), and (3) suprafascial (overlay). We have an ongoing study of incisional hernia repairs performed in the Veterans healthcare system, and all three types of open repair are used equivalently. Without adequate outcomes data, we currently cannot advocate one approach over the other.

INDICATION

• Presence of an incisional hernia

PREOPERATIVE CONSIDERATIONS

1. Misdiagnosis. Eventration can be difficult to distinguish from herniation, especially in obese patients.

a. Diastasis recti. Upper midline attenuation of linea alba.

b. Lateral eventration. Most often seen after flank incisions for nephrectomy and results from denervation of the oblique musculature. A computed tomography (CT) scan can be useful in confirming the diagnosis of eventration.

3. Contraindications to mesh placement

a. Preexisting infection. Whenever possible, the preexisting infection should be definitely treated prior to hernia repair. Preexisting infection increases the risk for wound infection and subsequent failure of the repair (Fig. 53-1).

b. Concomitant bowel surgery. This is a relative contraindication. If the bowel surgery is elective and the bowel is prepared, mesh can be placed with relative safety.⁴

4. Modifiable factors that may improve outcome

a. Prostatism. A history of prostatism in men increases the risk for recurrence.² Although there are no studies to evaluate the efficacy of treating the symptoms, it seems logical to have men with symptoms of prostatism evaluated prior to elective surgery.

b. Smoking cessation. Smoking doubles the risk of surgical site infection.⁵ Surgical site infection is associated with a greater than 50% recurrence rate for incisional hernia repair.³ If the patient is at high risk, consideration should be given to smoking cessation prior to undertaking elective repair.

c. Obesity. Obesity is a risk factor for both surgical site infection and recurrence. If a patient has failed a prior repair without other explanation, consideration should be given to a weight loss intervention prior to undertaking repair of a recurrent hernia.

5. Nonmodifiable risk factors for recurrence

a. History of an abdominal aortic aneurysm (AAA). Patients with a history of an AAA are at fourfold risk for recurrence.²

b. Chronic steroid use is associated with a fourfold increase in postoperative wound infections.⁵