Best Practice Management of

Incisional Hernia
Kevin Sexton
Bonus Conference February 2013

Disclosure:

None for this presentation.

A gentleman is someone who

owns land. -Tarp

Definitions:
Incisional hernia is any

gap in the abdominal wall

with or without a bulge in the
area of a postoperative scar
that can be seen or palpated
on clinical exam or imaging.
herniagigante.com
Sanders DL, Kingsnorth AN. The modern management of incisional hernias. BMJ 2012;344(may09 1):e28433.
3

Is timing important?
What separates incisional
hernia from dehiscence?

herniagigante.com
Sanders DL, Kingsnorth AN. The modern management of incisional hernias. BMJ 2012;344(may09 1):e28433.
4

Risk
??%

Incidence
3-60%

1. de Vries Reilingh TS, van Goor H, Rosman C, et al.

Components separation technique for the repair of large
abdominal wall hernias. J Am Coll Surg 2003;196:3237.
2. Dumanian GA, Denham W. Comparison of repair
techniques for major incisional hernias. Am J Surg
2003;185:6165.
3. Dunne JR, Malone DL, Tracy JK, et al. Abdominal wall
hernias: risk factors for infection and resource utilization. J
Surg Res 2003;111:7884.
4. Flum DR, Horvath K, Koepsell T. Have outcomes of
incisional hernia repair improved with time? A populationbased analysis. Ann Surg 2003;237:129135.

9. Luijendijk RW, Hop WC, van den Tol MP, et al. A

comparison of suture repair with mesh repair for incisional
hernia. N Engl J Med 2000;343:392398.
10. Manninen MJ, Lavonius M, Perhoniemi VJ. Results of
incisional hernia repair. A retrospective study of 172
unselected hernioplasties. Eur J Surg 1991;157:2931.
11. McGreevy JM, Goodney PP, Birkmeyer CM, et al. A
prospective study comparing the complication rates
between laparoscopic and open ventral hernia repairs. Surg
Endosc 2003;10:10.

12. Paul A, Korenkov M, Peters S, et al. Unacceptable

5. Gecim IE, Kocak S, Ersoz S, et al. Recurrence after
results of the Mayo procedure for repair of abdominal
incisional hernia repair: results and risk factors. Surg Today incisional hernias. Eur J Surg 1998;164:361367.
1996;26:607 609.
13. Raftopoulos I, Vanuno D, Khorsand J, et al. Comparison
6. George CD, Ellis H. The results of incisional hernia repair: of open and laparoscopic prosthetic repair of large ventral
a twelve year review. Ann R Coll Surg Engl 1986;68:185 hernias. JSLS 2003;7:227332.
187.
14. Vrijland WW, Jeekel J. Prosthetic mesh repair should be
7. Goodney PP, Birkmeyer CM, Birkmeyer JD. Short-term
used for any defect in the abdominal wall. Curr Med Res
outcomes of laparoscopic and open ventral hernia repair: a Opin 2003;19: 13.
metaanalysis. Arch Surg 2002;137:11611165.
8. Koehler RH, Voeller G. Recurrences in laparoscopic
incisional hernia repairs: a personal series and review of
the literature. JSLS 1999;3:293304.
7

Average
25%
Hawn MT, Snyder CW, Graham LA, Gray SH, Finan KR, Vick CC. Long-term follow-up
of technical outcomes for incisional hernia repair. Journal of the American College of
Surgeons 2010;210(5):648556557.

50% are detected within one year of

initial operation.
2% risk per year after.
Mudge M, Hughes LE. Incisional hernia: a 10 year prospective study of incidence and attitudes. Br J
Surg 1985;72(1):701.
Bucknall TE, Cox PJ, Ellis H. Burst abdomen and incisional hernia: a prospective study of 1129 major
laparotomies. Br Med J (Clin Res Ed) 1982;284(6320):9313.

348,000 repairs annually in US

154,000 inpatient ($15,900)
194,000 outpatient ($3,800)
$3.2 billion in annual cost

Poulose BK, Shelton J, Phillips S, et al. Epidemiology and cost of ventral hernia repair: making the
case for hernia research. Hernia 2012;16(2):17983.

10

Prevention

The only way not to spill water is

not to carry water. -Tarp

Continuous Closure with Running

Suture
Monofilament slowly absorbable
suture (PDS) #1 or 2
Suture:Wound Length < 4:1

van t Riet M, Steyerberg EW, Nellensteyn J, Bonjer HJ, Jeekel J. Meta-analysis of techniques for
closure of midline abdominal incisions. Br J Surg 2002;89:1350-6.
Hodgson NC, Malthaner RA, Ostbye T. The search for an ideal method of abdominal fascial closure:
a meta-analysis. Ann Surg 2000;231:436-42.
Ceydeli A, Rucinski J, Wise L. Finding the best abdominal closure: an evidence-based review of the
literature. Curr Surg 2005;62:220-5

11

Stitch Length

1 cm from edge 1 cm apart

Shorter may be better
5 mm bites 5 mm apart
730 patient RCT
Incisional hernia 6% vs 18%
SSI 5% vs 10%
Harlaar JJ, van Ramshorst GH, Nieuwenhuizen J, Ten Brinke JG, Hop WC, Kleinrensink
GJ, et al. Small stitches with small suture distances increase laparotomy closure strength.
Am J Surg 2009;198:392-5.
Millbourn D, Cengiz Y, Israelsson LA. Effect of stitch length on wound complications after
closure of midline incisions: a randomized controlled trial. Arch Surg 2009;144:1056-9.

12

Complication
Wound
Dehiscence
SSI
Incisional
Hernia

Long
1/381

Short
0/356

P
.99

35/343 (10.2)
49/272 (18)

17/326 (5.2) .02

14/250 (5.6) <.001

Liars figure and figures lie. -Tarp

Millbourn D, Cengiz Y, Israelsson LA. Effect of stitch length on wound complications after
closure of midline incisions: a randomized controlled trial. Arch Surg 2009;144:1056-9.

13

Prediction:

SSI double the risk

Increased intrabdominal pressure
post op
Ileus, urinary retention, coughing,
vomiting, mechanical vent >48hrs
BMI
Wound Epithelialization > 16 days
Veljkovic R, Protic M, Gluhovic A, Potic Z, Milosevic Z, Stojadinovic A. Prospective clinical
trial of factors predicting the early development of incisional hernia after midline laparotomy.
J Am Coll Surg 2010;210:210-9.
14

603 Patients

Hernia

15

When do we fix it?

Most frequent indication is
symptomatic hernia (20
50%)

Most common symptom is

pain

6 - 15% for strangulation or

obstruction

Sanders DL, Kingsnorth AN. The modern management of

incisional hernias. BMJ 2012;344(may09 1):e28433.

Mudge M, Hughes LE. Incisional hernia: a 10 year prospective

study of incidence and attitudes. Br J Surg 1985;72(1):701.
Kingsnorth A. The management of incisional hernia. Ann R Coll
Surg Engl 2006;88(3):25260.
16

A commonsense approach is advocated. If the patient

can safely have general anesthesia and the chance of
successful repair is reasonable, then surgery is indicated.
If the patient presents a high anesthetic risk or surgical
repair will be technically difficult, then the size of the
fascial defect relative to the hernia, the symptom
complex, the patients age, and the patients preferences
must be carefully considered. In such cases, conservative
management may be more appropriate. This decision
making process is patient specific and therefore we
recommend that all patients are referred for a specialist
opinion.
-David Sanders and Andrew Kingsnorth
17

You need to fit your suit to the cloth.

-Tarp

18

How do we maximize our chances for

a successful repair?

Study it like a racing card.

Get in the habit of having
good habits.
The pleural of anecdote isnt
data.
-Tarp
19

Use mesh in anything > 3 cm.

David R Flum KHTK. Have Outcomes of Incisional Hernia Repair Improved With Time?: A PopulationBased Analysis. Annals of Surgery 2003;237(1):129.
Luijendijk RW, Hop W, van den Tol MP. A comparison of suture repair with mesh repair for incisional
hernia. NEJM 2000;

20

But what if I cause an enterotomy?

Choi JJ, Palaniappa NC, Dallas KB, Rudich TB, Colon MJ, Divino CM. Use of Mesh
During Ventral Hernia Repair in Clean-Contaminated and Contaminated Cases.
Annals of Surgery 2012;255(1):17680.

21

Data on IHR and Small Bowel

Resection

Xourafas D, Lipsitz SR, Negro P, Ashley SW, Tavakkolizadeh A. Impact of mesh

use on morbidity following ventral hernia repair with a simultaneous bowel
resection. Arch Surg 2010;145(8):73944.

22

Mesh in an infected field

Living under Damocles sword.

-Tarp
23

Biologic Mesh
24

http://www.sageswiki.org/
25

Biologic Mesh Summary

Use in hernia repair in the non contaminated setting
not justified due to increased cost without benefit.
Ideal use as reinforcement of repair

Dont bridge the gap with biologic mesh

Only level one study comparing mesh to tissue repair

(PEH) showed no difference in recurrence at 5y.
Sageswiki
Oelschlager BK, Pellegrini CA, Hunter JG, et al. Biologic Prosthesis to Prevent Recurrence after Laparoscopic
Paraesophageal Hernia Repair: Long-term Follow-up from a Multicenter, Prospective, Randomized Trial. Journal of the
American College of Surgeons 2011;213(4):4618.
Oelschlager BK, Pellegrini CA, Hunter J, et al. Biologic prosthesis reduces recurrence after laparoscopic paraesophageal
hernia repair: a multicenter, prospective, randomized trial. Annals of Surgery 2006;244(4):48190.

26

More on Biologics:
Smart NJ, Marshall M, Daniels IR. Biological meshes: A
review of their use in abdominal wall hernia repairs. The
Surgeon 2012;10(3):15971.

27

Laparoscopic vs Open Repair

Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez M. Laparoscopic

versus open surgical techniques for ventral or incisional hernia repair. The
Cochrane Library 2011;

28

Laparoscopic vs Open Repair

Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez M. Laparoscopic

versus open surgical techniques for ventral or incisional hernia repair. The
Cochrane Library 2011;

29

Laparoscopic vs Open Repair

Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez M. Laparoscopic

versus open surgical techniques for ventral or incisional hernia repair. The
Cochrane Library 2011;

30

Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez M. Laparoscopic versus open surgical
techniques for ventral or incisional hernia repair. The Cochrane Library 2011;

31

Laparoscopic vs Open Repair

No clearly defined difference in long term outcomes.
Lower risk of wound infection
Increased enterotomies
Less pain and hospital stay

Sauerland S, Walgenbach M, Habermalz B, Seiler

CM, Miserez M. Laparoscopic versus open
surgical techniques for ventral or incisional hernia
repair. The Cochrane Library 2011;
32

Where do I put the

mesh?
Onlay
Inlay
Sublay
Oy Vey
Sanders DL, Kingsnorth AN. The modern management of
incisional hernias. BMJ 2012;344(may09 1):e28433.

33

Technique

Recurrence Notes

Inlay

44%

Adhesions
Erosions
Not
recommended

Onlay

5.5-14.8%

Have to close
abdominal wall

Sublay

1-23%

European Hernia
Society Standard

Rives Stoppa 1-8%

difficult

Sanders DL, Kingsnorth AN. The modern management of incisional hernias. BMJ 2012;344(may09 1):e28433.
Yaghoobi Notash A, Yaghoobi Notash A Jr, Seied Farshi J, Ahmadi Amoli H, Salimi J, Mamarabadi M. Outcomes of
the RivesStoppa technique in incisional hernia repair: ten years of experience. Hernia 2006;11(1):259.
34

Summary

Hernias are common, morbid, and costly.

Best chance of success is mesh repair in an
uncontaminated field.

Laparoscopic vs Open still debated

Sublay vs Onlay

Rives Stoppa = one shot

What cant be cured must be endured.

Swamp/Alligator argument Tarp
When you are up to your ass in alligators, its hard to
remember you came to drain the swamp.
35

American Hernia Society Quality Collaborative (AHSQC).

36

Discussion

37

1.
Beck WC, Holzman MD, Sharp KW, Nealon WH, Dupont WD, Poulose BK. Comparative Effectiveness of Dynamic Abdominal Sonography for Hernia vs Computed Tomography in the
Diagnosis of Incisional Hernia. Journal of the American College of Surgeons 2013;216(3):44753.

2.

Smart NJ, Marshall M, Daniels IR. Biological meshes: A review of their use in abdominal wall hernia repairs. The Surgeon 2012;10(3):15971.

3.

Sanders DL, Kingsnorth AN. The modern management of incisional hernias. BMJ 2012;344(may09 1):e28433.

4.
Altom LK, Graham LA, Gray SH, Snyder CW, Vick CC, Hawn MT. Outcomes for incisional hernia repair in patients undergoing concomitant surgical procedures. Am Surg
2012;78(2):2439.

5.
Choi JJ, Palaniappa NC, Dallas KB, Rudich TB, Colon MJ, Divino CM. Use of Mesh During Ventral Hernia Repair in Clean-Contaminated and Contaminated Cases. Annals of Surgery
2012;255(1):17680.

6.

7.
Oelschlager BK, Pellegrini CA, Hunter JG, et al. Biologic Prosthesis to Prevent Recurrence after Laparoscopic Paraesophageal Hernia Repair: Long-term Follow-up from a Multicenter,
Prospective, Randomized Trial. Journal of the American College of Surgeons 2011;213(4):4618.

8.
Kulacoglu H, Oztuna D. Growth and trends in publications about abdominal wall hernias and the impact of a specific journal on herniology: a bibliometric analysis. Hernia
2011;15(6):61528.

9.
Bansal VK, Misra MC, Kumar S, et al. A prospective randomized study comparing suture mesh fixation versus tacker mesh fixation for laparoscopic repair of incisional and ventral
hernias. Surg Endosc 2011;25(5):14318.

10. Snyder CW, Graham LA, Gray SH, Vick CC, Hawn MT. Effect of Mesh Type and Position on Subsequent Abdominal Operations after Incisional Hernia Repair. ACS 2011;212(4):496
502.

11.

Harth KC, Blatnik JA, Rosen MJ. Optimum repair for massive ventral hernias in the morbidly obese patientis panniculectomy helpful? AJS 2011;201(3):396400.

12.

Millbourn D, Cengiz Y, Israelsson LA. Risk factors for wound complications in midline abdominal incisions related to the size of stitches. Hernia 2011;15(3):2616.

13.

Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez M. Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. The Cochrane Library 2011;

14.

Hartog D den DATWKR. Open surgical procedures for incisional hernias. 2010;:136.

Gurusamy KS AVSK. Wound drains after incisional hernia repair. 2011;:121.

38

15.

Verma R NR. Prophylactic nasogastric decompression after abdominal surgery. 2010;:150.

16. Xourafas D, Lipsitz SR, Negro P, Ashley SW, Tavakkolizadeh A. Impact of mesh use on morbidity following ventral hernia repair with a simultaneous bowel resection. Arch Surg
2010;145(8):73944.

17.

18. Hawn MT, Snyder CW, Graham LA, Gray SH, Finan KR, Vick CC. Long-term follow-up of technical outcomes for incisional hernia repair. Journal of the American College of Surgeons
2010;210(5):648556557.

19. Veljkovic R, Protic M, Gluhovic A, Potic Z, Milosevic Z, Stojadinovic A. Prospective Clinical Trial of Factors Predicting the Early Development of Incisional Hernia after Midline
Laparotomy. ACS 2010;210(2):2109.

20. Millbourn D, Cengiz Y, Israelsson LA. Effect of Stitch Length on Wound Complications After Closure of Midline IncisionsA Randomized Controlled TrialStitch Length and Midline
Incision Complications. Archives of Surgery 2009;144(11):10569.

21.

Harlaar JJ, van Ramshorst GH, Nieuwenhuizen J, et al. Small stitches with small suture distances increase laparotomy closure strength. AJS 2009;198(3):3925.

22.

Muysoms FE, Miserez M, Berrevoet F, et al. Classification of primary and incisional abdominal wall hernias. Hernia 2009;13(4):40714.

23.

Nemeth NL, Butler CE. Complex torso reconstruction with human acellular dermal matrix: long-term clinical follow-up. Plastic and Reconstructive Surgery 2009;

24. Rauth TP, Poulose BK, Nanney LB, Holzman MD. A comparative analysis of expanded polytetrafluoroethylene and small intestinal submucosa--implications for patch repair in
ventral herniorrhaphy. Journal of Surgical Research 2007;143(1):439.

25.

Kurzer M, Kark A, Selouk S, Belsham P. Open Mesh Repair of Incisional Hernia Using a Sublay Technique: Long-Term Follow-up. World J Surg 2007;32(1):316.

26.

Bingener J, Buck L, Richards M, Michalek J, Schwesinger W, Sirinek K. Long-term Outcomes in Laparoscopic vs Open Ventral Hernia Repair. Archives of Surgery 2007;142(6):5627.

27. Weyhe D, Belyaev O, Mller C, Meurer K. Improving outcomes in hernia repair by the use of light meshesa comparison of different implant constructions based on a critical
appraisal of the literature. World journal of 2007;

28. Yaghoobi Notash A, Yaghoobi Notash A Jr, Seied Farshi J, Ahmadi Amoli H, Salimi J, Mamarabadi M. Outcomes of the RivesStoppa technique in incisional hernia repair: ten years
of experience. Hernia 2006;11(1):259.

29. Oelschlager BK, Pellegrini CA, Hunter J, et al. Biologic prosthesis reduces recurrence after laparoscopic paraesophageal hernia repair: a multicenter, prospective, randomized trial.
Annals of Surgery 2006;244(4):48190.

30.

Kingsnorth A. The management of incisional hernia. Ann R Coll Surg Engl 2006;88(3):25260.

31.

Rudmik LR, Schieman C, Dixon E, Debru E. Laparoscopic incisional hernia repair: a review of the literature. Hernia 2006;

32.

Klinge U, Conze J, Krones CJ, Schumpelick V. Incisional Hernia: Open Techniques. World J Surg 2005;29(8):106672.

DiCocco JM, Magnotti LJ, Emmett KP, et al. Long-Term Follow-Up of Abdominal Wall Reconstruction after Planned Ventral Hernia: A 15-Year Experience. ACS 2010;210(5):68695.

39

33. Conze J, Kingsnorth AN, Flament JB, et al. Randomized clinical trial comparing lightweight composite mesh with polyester or polypropylene mesh for incisional hernia repair. Br J
Surg 2005;92(12):148893.

34.

Millbourn D, Israelsson LA. Wound complications and stitch length. Hernia 2004;8(1):3941.

35.

Sanchez LJ, Bencini L, Moretti R. Recurrences after laparoscopic ventral hernia repair: results and critical review. Hernia 2004;

36.

Rutkow IM. Demographic and socioeconomic aspects of hernia repair in the United States in 2003. Surgical Clinics of NA 2003;83(5):104551vvi.

37.

David R Flum KHTK. Have Outcomes of Incisional Hernia Repair Improved With Time?: A Population-Based Analysis. Annals of Surgery 2003;237(1):129.

38.

Bencini L, Sanchez LJ, Boffi B, Farsi M, Scatizzi M. Incisional hernia repair. Surgical 2003;

39.

Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic repair of ventral hernias: nine years' experience with 850 consecutive hernias. Annals of Surgery 2003;

40.

Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic Repair of Ventral Hernias. Transactions of the Meeting of the American Surgical Association 2003;121:8594.

41.

van 't Riet M, Steyerberg EW, Nellensteyn J, Bonjer HJ, Jeekel J. Meta-analysis of techniques for closure of midline abdominal incisions. Br J Surg 2002;89(11):13506.

42.

Goodney PP, Birkmeyer CM, Birkmeyer JD. Short-term outcomes of laparoscopic and open ventral hernia repair: a meta-analysis. Archives of Surgery 2002;

43.

Korenkov M, Paul A, Sauerland S. Classification and surgical treatment of incisional hernia. Archives of Surgery 2001;

44.

Welty G, Klinge U, Klosterhalfen B, Kasperk R. Functional impairment and complaints following incisional hernia repair with different polypropylene meshes. Hernia 2001;

45.

Nicole C F Hodgson RAMT. The Search for an Ideal Method of Abdominal Fascial Closure: A Meta-Analysis. Annals of Surgery 2000;231(3):436.

46.

Luijendijk RW, Hop W, van den Tol MP. A comparison of suture repair with mesh repair for incisional hernia. England Journal of 2000;

47.

Mudge M, Hughes LE. Incisional hernia: a 10 year prospective study of incidence and attitudes. Br J Surg 1985;72(1):701.

48.

Bucknall TE, Cox PJ, Ellis H. Burst abdomen and incisional hernia: a prospective study of 1129 major laparotomies. Br Med J (Clin Res Ed) 1982;284(6320):9313.

40