Implementation of Modern Incisional Hernia Repair Techniques

University dissertation from Lund University, Faculty of Medicine

Abstract: Incisional hernia is one of the most common complications (5–20%) after abdominal surgery. Surgery is the only option to cure a hernia. Symptoms of an incisional hernia depend on the size of the abdominal wall defect and the protruding tissue. About 30% of the patients with an incisional hernia will have an operation performed. Traditional surgical sutured techniques have very high recurrence rate, whereas recurrence rates can be substantially reduced using modern mesh techniques. Mesh placement in a retromuscular position have excellent results in curing the hernia, but often involves large incisions and demands dissection of the retromuscular space of the rectus abdominis muscles. The mesh reinforces the repair of the abdominal wall. Alternatively, a mesh can be placed in the abdominal cavity on the posterior surface of the abdominal wall, fixed with sutures or tackers. To prepare the abdominal wall all adhesions must be dissected with a risk of bowel injury. A Swedish multicenter randomized controlled trial (RCT) PROLOVE has been performed on midline incisional hernia repair, comparing open (OHR) retromuscular mesh to laparoscopic (LHR) intraabdominal mesh techniques, focusing on pain and quality of life and a retrospective long term follow up for recurrence and QoL after the implementation of the retromuscular hernia repair at two specialist centers. Paper I covers the RCT with 133 included patients in a short term perspective. Elsewhere laparoscopic techniques had proved to cause less postoperative pain, have fewer complications and shorten recovery. LHR had fewer surgical site infections (SSI) (p<001). The operative techniques did not differ in pain and time to recovery. The preoperative quality of life (QoL) was low but restored to norm level at 3 weeks, with physical function being better after LHR. Paper II covers 124 patients remaining at 1 year follow up for complications, QoL, and predictors for an uneventful recovery. The reoperation rates were similar; wound complications were more common in OHR, contrary to recurrence in LHR. Recurrence rate did not differ. QoL was restored after 8 weeks and maintained at 1 year at norm level. The LHR technique was a predictor for an uneventful recovery. Paper III investigates the contraction behavior of a cohort of 36 meshes included in the PROLOVE trial. Patients with metal clip-marked meshes had x-ray exams within 2 days and 1 year after surgery. Mesh area change was in LHR –6% and in OHR +10%, probably within the limits of the technique used for measuring, and not regarded as clinically significant. No correlation was found between mesh area change and recorded pain levels. Paper IV covers a long-term follow up of 11 years on 301 patients with midline incisional retromuscular hernia repair performed 1998–2006. Over all recurrence rate was 8%, with no difference between primary or secondary hernia repairs. Long term QoL was lower than the norm, similar to patients with 2 chronic conditions. Satisfaction with surgery high was high. Conclusions Incisional hernia patients have low QoL which is restored by both LHR and OHR, but OHR has more SSIs. OHR has excellent long-term outcome. Mesh contraction at LHR and OHR is not a clinical problem.