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| ORIGINAL ARTICLE |
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| Year : 2018 | Volume
: 1
| Issue : 1 | Page : 32-36 |
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Fundamentals of incisional hernia prevention
Samuel A Heathcote, Zachary F Williams, W Borden Hooks, William W Hope
Department of Surgery, New Hanover Regional Medical Center, Wilmington, North Carolina, USA
| Date of Submission | 02-May-2018 |
| Date of Acceptance | 02-May-2018 |
| Date of Web Publication | 16-May-2018 |
Correspondence Address:
William W Hope
Department of Surgery, New Hanover Regional Medical Center, 2131 South 17th Street, Post Box 9025, Wilmington, North Carolina 28401
USA
 Source of Support: None, Conflict of Interest: None  | 3 |
DOI: 10.4103/ijawhs.ijawhs_3_18
BACKGROUND: The incidence of incisional hernia following surgery is a major economical and clinical burden for healthcare.
METHODS: This report reviews and consolidates pertinent literature related to hernia prevention to give surgeons a solid framework on the current perspectives and emerging topics related to incisional hernia prevention.
RESULTS: Pertinent anatomy and fundamentals of laparotomy closures are reviewed. Recommended closures of laparotomy incisions include the use of monofilament, slowly absorbing suture in a running fashion with a 4:1 suture to wound length ratio using a short stitch technique. The use of prophylactic mesh reduces the rate of incisional and parastomal hernias in high-risk patients.
CONCLUSION: The current fundamentals of hernia prevention including pertinent anatomy and surgical techniques for appropriate laparotomy closures should be known to surgeons operating on the abdominal wall. The use of prophylactic mesh to reduce incisional and parastomal hernias has shown promise, and further research is needed to evaluate long-term efficacy.
Keywords: Closure, hernia, incisional laparotomy, prevention
How to cite this article:
Heathcote SA, Williams ZF, Hooks W B, Hope WW. Fundamentals of incisional hernia prevention. Int J Abdom Wall Hernia Surg 2018;1:32-6 |
| Introduction | |  |
Despite significant advances in surgical techniques and understanding of abdominal wall anatomy and function, the rate of incisional hernias following laparotomy incision remains high. Due to this and the realization that long-term outcomes of repair of incisional hernias are suboptimal, there has been an increased emphasis on hernia prevention. The two main focuses related to hernia prevention have been suture techniques for laparotomy closures and the concept of prophylactic mesh augmentation (PMA) in patients at high risk for incisional hernias.
| Methods | | |
This literature review focuses on hernia prevention including laparotomy closure and PMA. The review is restricted to major topics related to hernia prevention including types of incisions, laparotomy closure techniques, suture to wound length ratio, short stitch techniques, and the use of prophylactic mesh for incisional and parastomal hernia prevention.
| Results | | |
Pertinent anatomy and function of the abdominal wall
While it is not imperative to be experts in abdominal wall anatomy and function, surgeons operating in the abdominal cavity should have a general knowledge of wound healing and abdominal wall anatomy. The general principles of wound healing, including the phases of inflammatory, proliferative, and maturation, apply to the fascia, and laparotomy incisions.
The abdominal wall includes layers of skin, subcutaneous tissue, superficial fascia, deep fascia, muscle, extraperitoneal fascia, and peritoneum. The linea alba is a key structure in the abdominal wall anatomy, and surgeons undertaking laparotomy incisions should have a thorough understand of the linea alba and surrounding anatomic structures. The linea alba runs from the xiphoid process to the symphysis pubis in the midline and is formed by the fusion of the anterior and posterior rectus sheath. Lateral to the linea alba on both sides run the rectus muscles. If laparotomy incisions are not done with caution and veer off midline, the rectus muscle can be exposed making closure more difficult. The lateral boundary of the rectus muscle is comprised of the fusion of the external and internal oblique and the transversus abdominis and is called the linea semilunares.
The blood supply to the abdominal wall can be confusing and is simplified by dividing the abdomen into three zones. The blood supply to Zone I (upper and mid-central part of the abdominal wall bordered by xiphoid process, medial costal margins, linea semilunares, and inferior edge of umbilicus) consists of the deep superior and deep inferior epigastric arteries. The blood supply of Zone II (inferior abdominal wall bordered by the inferior edge of the umbilicus to the inferior edge of the abdominal wall with the lateral border being the midaxillary line) consists of the epigastric arcade, superficial inferior epigastric, superficial external pudendal, and superficial circumflex iliac arteries. The blood supply to Zone III (lateral abdominal wall bordered by the costal margin, linea semilunares, and midaxillary line) consists of musculophrenic, lumbar, and lower intercostal arteries.
Types of incision
Surgeons should have a keen knowledge of the advantages and disadvantages of different incision types used for abdominal surgery. While many factors should be considered when choosing the incision type, formation of an incisional hernia should be part of the decision-making process. The 2015 guideline on closure of abdominal wall incisions by the European Hernia Society (EHS) recommended using nonmidline incisions when possible due to the decreased incisional hernia rate associated with these.[1] Although this was a strong recommendation based on available evidence, this recommendation has been met with some controversy and has not yet been adopted by many surgeons for a variety of reasons.
Laparotomy closure techniques
When surgeons choose a midline laparotomy incision, several key technical points should be followed to help reduce the incidence of incisional hernias. Incisions should only be made as long as needed to provide adequate exposure and should be made in the midline without veering into adjacent structures (muscle) which can cause bleeding and disrupt abdominal wall layers that can make closure more difficult. Conventionally, a mass closure technique of suturing fascia and muscle was recommended; however, experimental and clinical studies have led to the recent guideline recommendation to close only the aponeurosis.[1],[2] It is important to use good surgical technique when closing fascia including placing the needle at a 90° angle to the desired tissue and gently following the curve of the needle through the tissue to minimize tissue trauma [Figure 1]. | Figure 1: Laparotomy closure using a slowly absorbing monofilament suture in a running fashion. It is important to have meticulous surgical technique when closing fascia and to place the needle at 90° angles to the tissue/fascia
Click here to view |
There has been much debate on the best suture type and technique to use for laparotomy closure, with multiple randomized trials and meta-analyses undertaken to help determine this. The 2015 EHS guidelines recommend a continuous closure technique with avoidance of rapidly absorbing sutures.[1] There remains debate regarding slowly absorbing and permanent sutures; however, many surgeons favor slowly absorbing sutures due to the higher rate of suture sinus formation with permanent sutures.[1]
Recommendations vary regarding which structures should be included in abdominal closure. Conventionally, a mass closure technique of suturing fascia and muscle was recommended; however, some experimental and clinical studies recommend closure of the aponeurosis only,[2] and this is the recommendation from the recent guidelines.
Suture to wound length ratio
The suture to wound length ratio is a key principle in laparotomy closure and refers to the amount of suture used to close an incision. The ratio is simply calculated by measuring the length of the incision measured after closure and the amount of suture used. A large body of literature has supported the notion of achieving a >4:1 suture to wound length ratio, and there is general consensus that this provides a strong closure and helps reduce incisional hernia formation [3],[4] with a three-fold higher risk of herniation reported when this ratio is not achieved.[5],[6] It is recommended that suture to wound length ratio initially be calculated and surgical practices audited to ensure achievement of a 4:1 ratio, since surgeons often think they are meeting the 4:1 ratio requirement but are not.[7]
Short stitch technique
The short stitch technique which was first popularized by Cengiz et al.[8] has recently gained attention due to a 2015 randomized controlled trial (RCT).[9] The traditional teaching for laparotomy closure was that the fascial bites should be at least 1 cm from the fascial edges with 1 cm advances, and this has been passed on to surgeons in many training programs. This practice, however, has been challenged by many well-done studies, including those from Israelsson et al. showing that smaller bites in the aponeurosis (<1 cm) result in less hernia formation and is the recommended technique for closure.[6],[8],[10],[11],[12],[13] This finding was replicated in a Dutch multicenter trial reporting the small bite technique was more effective than the large bite technique for incisional hernia prevention without an increase in adverse events [9] and has led to a weak recommendation in the EHS guidelines that this technique should be used.[1]
Prophylactic mesh for laparotomy incisions
Although incisional hernia rates can be decreased using meticulous suturing techniques and following evidence-based recommendations, the rate of incisional hernias (especially in high-risk patients) remains high. To try and reduce the rate further, the concept of closing a laparotomy incision with a PMA [Figure 2] to prevent future hernia formation has gathered support. | Figure 2: Prophylactic mesh augmentation using an onlay mesh following an open abdominal aortic aneurysm repair
Click here to view |
Multiple studies have evaluated the use of PMA in high-risk patients and have demonstrated clear reductions in the incisional hernia rates. The 2015 EHS guidelines have given a weak recommendation for the use of PMA in high-risk patients (pending more long-term data).[1] There are four groups of high-risk patients that require further discussion including patients undergoing open abdominal aortic aneurysm (AAA) repair, obese patients, patients undergoing colorectal procedures, and patients undergoing permanent ostomy formation.
Patients undergoing an open repair of AAA have increased risk for developing incisional hernias and therefore may be good candidates for PMA. Several studies have demonstrated a significant reduction in incisional hernia formation when PMA is used as an adjunct in closing the midline incision during open AAA repairs. A recent RCT of 120 patients demonstrated a 28% incisional hernia rate with primary suture repair compared with a 0% incisional hernia rate with PMA at 2 years' follow-up (P < 0.0001).[14] Although longer-term data are needed, PMA has clearly shown a reduction in incisional hernias following open AAA repair.
Obesity is also a risk factor for incisional hernia formation with several studies, mostly in patients undergoing bariatric surgery, evaluating the use of PMA. Strzelczyk et al. performed a RCT comparing patients undergoing open Roux-en-Y gastric bypass with conventional closure (n = 38) or retrorectus placement of polypropylene mesh (n = 36).[15] With a short-term follow-up of only 6 months, they reported 8 hernias in the conventional closure group while none developed in the PMA group (no statistical analysis reported).[15] Abo-Ryia also conducted an RCT comparing conventional closure (n = 50) with retrorectus polypropylene (n = 45) in patients undergoing open biliopancreatic diversion and reported the incidence of incisional hernia in the conventional group to be 30% compared with 4.4% in patients that underwent PMA (P < 0.05) at 2-year follow-up.[16] Although the majority of bariatric surgeries have converted to using minimally invasive approaches, the concept of PMA in the obese population is important and should be further studied.
Similar to other operations that employ midline laparotomies, the rate of incisional hernias following colorectal surgical operations remains high. There is, however, movement by some surgeons to place a prophylactic mesh at the time of colorectal surgery due to the clean contaminated nature of these cases and the concern for mesh-related infections. There are, however, some data evaluating the use of PMA in this group of patients. Garcia-Urena and colleagues studied PMA use in both elective and emergent colorectal operations. Although approximately 25% of patients in both groups (54 control vs. 53 PMA) did not complete follow-up at 24 months, there was a significant reduction in incisional hernias in the PMA group (11.3%) compared with the control group (31.5%).[17] Importantly, there was no significant difference in morbidity regarding surgical site infection, seroma, mesh rejection, or evisceration between the control and PMA groups.[17] This study highlights the potential use of PMA in high-risk patients while also demonstrating its feasibility in clean-contaminated cases.
The rationale for PMA use in patients undergoing permanent stomas relates to the high incidence of parastomal hernia formation in this patient group and the difficulty associated with their repair. There have been many reports on the use of PMA in patients having stomas with overall promising results [Figure 3]. | Figure 3: The use of prophylactic mesh in the retrorectus position during end ostomy formation (ileal conduit)
Click here to view |
Several RCTs and some meta-analyses have examined PMA use for stomas.[18],[19],[20] One meta-analysis of three RCTs showed a significant reduction in the parastomal hernia rate from 54.7% in the conventional group to 12.3% in the prophylactic mesh group.[18] A recent RCT from Norway also determined a significant reduction in hernias and indicated the number needed to treat to avoid one parastomal hernia is 2.5 patients.[19] One of the largest RCTs, with a sample size of 150 patients, evaluated the complications of mesh placement. Using a preperitoneal retromuscular mesh in elective open end-colostomy repairs as opposed to end-colostomy alone, the authors demonstrated no differences in chronic pain, postoperative infection rates, stoma-related complications, or quality of life.[20] They also noted no mesh-related complications in the 72 patients who underwent prophylactic mesh repair.[20]
Although the initial and short-term outcomes of using PMA for stomas in an attempt to reduce parastomal hernia rates appears promising, many unknowns remain such as ideal indications for use, ideal patient populations, techniques of surgery, and mesh choices. Further study with longer-term outcomes is needed.
| Conclusion | | |
Incisional and parastomal hernias remain a conundrum for surgeons performing abdominal surgery. There are several evidence-based approaches that can help significantly reduce the incisional hernia rates. Suturing techniques and the use of PMA will continue to evolve as more research is completed with the goal of eliminating incisional and parastomal hernias in the future.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 9. | Deerenberg EB, Harlaar JJ, Steyerberg EW, Lont HE, van Doorn HC, Heisterkamp J, et al. Small bites versus large bites for closure of abdominal midline incisions (STITCH): A double-blind, multicentre, randomised controlled trial. Lancet 2015;386:1254-60. |
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| 11. | Cengiz Y, Gislason H, Svanes K, Israelsson LA. Mass closure technique: An experimental study on separation of wound edge. Eur J Surg 2001;167:60-3. |
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| 14. | Muysoms FE, Detry O, Vierendeels T, Huyghe M, Miserez M, Ruppert M, et al. Prevention of incisional hernias by prophylactic mesh-augmented reinforcement of midline laparotomies for abdominal aortic aneurysm treatment: A randomized controlled trial. Ann Surg 2016;263:638-45. |
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| 17. | García-Ureña MÁ, López-Monclús J, Hernando LA, Montes DM, Valle de Lersundi AR, Pavón CC, et al. Randomized controlled trial of the use of a large-pore polypropylene mesh to prevent incisional hernia in colorectal surgery. Ann Surg 2015;261:876-81. |
| 18. | Wijeyekoon SP, Gurusamy K, El-Gendy K, Chan CL. Prevention of parastomal herniation with biologic/composite prosthetic mesh: A systematic review and meta-analysis of randomized controlled trials. J Am Coll Surg 2010;211:637-45. |
| 19. | Lambrecht JR, Larsen SG, Reiertsen O, Vaktskjold A, Julsrud L, Flatmark K, et al. Prophylactic mesh at end-colostomy construction reduces parastomal hernia rate: A randomized trial. Colorectal Dis 2015;17:O191-7. |
| 20. | Brandsma HT, Hansson BM, Aufenacker TJ, van Geldere D, van Lammeren FM, Mahabier C, et al. Prophylactic mesh placement to prevent parastomal hernia, early results of a prospective multicentre randomized trial. Hernia 2016;20:535-41. |
[Figure 1], [Figure 2], [Figure 3]
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