Open access peer-reviewed chapter
Abstract
Among the most frequent pathologies of the abdominal wall are hernias, which are defined as a protrusion of the abdominal organs through any of the weak points of the abdominal wall. They can be spontaneous appearing in weak points of the abdominal wall or along the site of surgical incisions. Even though hernias have been acknowledged since ancient times, the topic of incisional hernias was rarely discussed until the advent of modern surgery. After the introduction of anesthesia and antisepsis, abdominal interventions became common, and with this, the incidence of incisional hernias significantly increased. Until after the second world war, the correction of incisional hernias was done using simple sutures, continuous fascial sutures, etc. The large variety of prosthetic materials that are in use today, both dual and biological, helps in the successful correction of incisional hernias. A new era in the treatment of hernias began with the introduction of laparoscopic techniques in 1993 by Le Blanc. However, the correction of incisional hernias continues to remain a real challenge that requires a personalized approach for each patient with the aim of achieving good results and avoiding postoperative complications, of which hernia recurrence remains one of the most serious.
Keywords
- hernia
- incisional
- correction
- recurrence
- meshes
1. Introduction
Hernias are a common pathology of the abdominal wall, affecting a large number of people worldwide. They are defined as the protrusion of abdominal organs through any weak point in the abdominal wall. Although there are different types of hernias, including spontaneous hernias that develop in weak points of the abdominal wall, there is another group of hernias that can occur along the site of a previous surgical incision in the abdominal cavity. These are called incisional hernias and can occur after any surgical intervention that involves a cut in the abdominal wall, such as a laparotomy or a cesarean section.
Incisional hernias can be a challenging problem to manage, and their treatment often requires a multidisciplinary approach. In recent years, several advances have been made in the diagnosis and treatment of incisional hernias, leading to better outcomes for patients.
2. History
Hernias have been a concern since ancient times, but the concept of hernias was initially focused only on inguinal and umbilical hernias until the second half of the nineteenth century, when the era of modern surgery began [1].
The Edwin Smith papyrus, one of the oldest medical documents and a surgical treatise, does not mention any of the hernias of the abdominal wall [2]. Similarly, the papyrus of Ebers, which dates back to approximately 1500 years before Christ, describes swellings and tumors of the abdominal wall, including the first recorded instance of epigastric hernias [3].
Abdominal hernias were briefly mentioned in the Corpus Hippocraticum, the most famous medical work of ancient Greece, while incisional hernias were not mentioned at all [3]. However, the writings of Celsus in ancient Rome (first century AD) highlighted the importance of correcting abdominal hernias and described the method of closing the abdominal wall with layers to prevent incisional hernias [4]. Galen of Pergamon, another prominent Roman physician nearly a century later, described the mass closure technique for the closure of the abdominal wall and suggested the paramedian incision as the optimal technique for preventing incisional hernias [5].
During the Renaissance period, there were remarkable advances not only in art, literature, and science but also in the field of human anatomy, which led to the age of the anatomist surgeon. In 1721, La Chausse described in his dissertation “de Hernia Ventralis” a case of abdominal trauma that resulted in an incisional hernia, along with the different types of abdominal hernias. These findings represented a significant contribution to the understanding of abdominal wall hernias [6].
The development of surgery also saw remarkable advancements in France, where in 1768, during the reign of King Louis XV, surgeons were separated from barbers, and all surgeons had to attend the College of Surgeons [7]. The first documented correction of incisional hernias was performed by the French surgeon Pierre Nichollas Gerdy in 1836. Gerdy’s work in correcting incisional hernias represented a significant breakthrough in the field of surgery [8].
In 1896, the French surgeon Quenu made a significant contribution to the field of hernia repair by differentiating postoperative eventration from other types of eventration in his work “Traitement opertoire de l’éventration.” This is regarded as the first detailed description of incisional hernias [9].
After the advent of anesthesia and antisepsis, the incidence of incisional hernias increased substantially with the growing number of abdominal interventions [10, 11, 12]. Consequently, various techniques for correcting these hernias were developed, including simple sutures by Quenu, transverse overlapping technique by Mayo, and continuous fascial sutures from the external oblique by Witzel, Goepel, and Bartlet, among others [13, 14, 15, 16]. In 1954, the Keel technique was introduced by the renowned surgeon Maingot as a new technique for correcting large incisional hernias [17].
At the start of the twentieth century, homologous and autologous materials were introduced for the successful closure of large defects in the abdominal wall. During this time, well-known surgeons such as Kirschner, Loewe, Nuttall, and Judd described hernia repair using various structures of the abdominal wall, including fascia, peritoneum, muscles, and even skin. The results they reported in their papers were satisfactory [11, 18, 19, 20, 21].
The first hernia repair with metallic prosthetic materials was reported by Goepel and Witzel in 1900. The material used for these purposes was silver mesh. Other surgeons of this period such as Douglas, Koontz, and Throckmorton also referred to hernia repair through metal meshes, either silver or steel [22, 23, 24, 25, 26].
After the second world war, different plastic materials were synthesized, some of which began to be used for the correction of abdominal hernias. The first synthetic materials that were used for these purposes were nylon and perlon, which due to their poor characteristics were quickly withdrawn from use. Soon after that, other synthetic meshes with very good characteristics were synthesized and began to be widely used for the correction of hernias. Some of these materials that remain preferred for hernia repair are polypropylene, mersilene, polytetrafluoroethylene (ePTFE), etc. [27, 28, 29].
In 1993, for the first time, the correction of ventral hernias with laparoscopic techniques was reported by Le Blanc. The correction is done using synthetic meshes from prolene. Laparoscopic techniques are gaining more and more space in the correction of abdominal hernias, including incisional ones [30].
Great advances in the correction of hernias have been noted after the synthesis of dual and biological meshes, which enable their intraperitoneal placement without risking the appearance of adhesions or enterocutaneous fistulas [7, 31, 32, 33].
3. Anatomy of the anterior abdominal wall
The abdomen is the part of the body between the thorax and the pelvis. For hernias and their correction, the anterior abdominal wall is more important, because most of them are located in this part. The anterior abdominal wall is made up of different structures such as the skin, the oblique, transverse, and rectus muscles as well as their fascias and the parietal peritoneum.
The blood supply of the superficial layers of the abdominal wall is done through the arteries that originate from the femoral artery. The other three arteries that supply blood to the abdominal wall are two branches from the external iliac artery and one branch from the internal thoracic artery.
The sensory and motor innervation of the abdominal wall is done through several nerves such as the anterior and lateral cutaneous branches of the ventral rami of the 7th to 12th intercostal nerves and the ventral rami of the first and second lumbar nerves. The musculature of the abdominal wall consists of four paired muscles and their respective aponeuroses.
The external oblique muscle makes up the superficial layer of the abdominal wall. This muscle takes its origin from the lower eight ribs posteriorly to interdigitate with both the serratus and latissimus muscles. The fascia of this muscle takes part in the creation of the anterior portion of the rectus abdominis sheath, while together with the medial termination of all the aponeuroses of the three muscles, form the linea alba. External and internal oblique muscles support the abdominal organs as well as take part in the flexion and rotation of the body.
The internal oblique muscle takes its origin from the thoracolumbar fascia, iliac crest, and the lateral two-thirds of the inguinal ligament and inserts on the 10th and 12th ribs inferiorly. Studies show that incisional hernias in most cases are the result of disinsertion of these lateral muscles in the midline, thus resulting in retraction and subsequent atrophy.
The transversus abdominis muscle takes its origin from the 7th to 12th costal cartilages, iliac crest, and the lateral third of the inguinal ligament.
The rectus abdominis muscle originates from two different points. Its lateral head originates from the crest of the pubis, between the pubic symphysis and the pubic tubercle, while its median head originates from the pubic symphysis, being crossed with the fibers of the muscle on the contralateral side. The rectus sheath is formed from the aponeuroses and fasciae of the external oblique, internal oblique, and transversus abdominis. The anterior sheath of the rectus muscle superior to the umbilicus is composed only of aponeuroses from the internal and external oblique muscles, while the aponeurosis of the transverse muscle does not take part in this. The anterior sheath consists of all three aponeurotic layers only below the umbilicus. Even the posterior sheath of the rectus muscle is described in relation to the umbilicus. Above the umbilicus, it is built from the aponeuroses of the internal oblique and the transversus abdominis muscles, while below the umbilicus the internal abdominal aponeurosis does not participate in the construction of the posterior rectus sheath.
4. Incisions in the abdominal wall
The midline incision is the most commonly used incision in abdominal surgery due to its ease of performance and minimal blood loss, as the linea alba is poorly vascularized. This incision provides excellent exposure to the abdominal organs and can be easily extended superiorly or inferiorly as needed. However, the paramedian incision may be used in special cases, either as a conventional paramedian incision near the linea alba or a lateral paramedian incision made on the anterior side of the rectus muscle sheath’s lateral edge. The rectus muscle fibers are displaced to avoid damage to the epigastric vessels, and a longitudinal incision is made above the arcuate line to open the abdominal cavity. The paramedian incision has limitations and difficulties and takes longer to perform than the midline incision.
The transverse supraumbilical incision is often used in conventional interventions in the right upper quadrant, but it is associated with greater blood loss and takes longer to complete due to the need to cut the external and internal oblique muscles, the transverse muscle, and part of the rectus muscle. Pfannenstiel incision is a transverse incision in the lower abdomen widely used in gynecology and some urological procedures, where the muscles can be cut either transversely parallel to the skin or along the linea alba.
Kocher’s incision is an oblique subcostal incision widely used in surgical interventions of the biliary tract or bariatric surgery. It can be extended from both sides if necessary, and during this incision, the oblique, transverse, and rectus muscle fibers are cut, and many nerve fibers and segmental blood vessels are dissected.
McBurney’s incision is another mid-caudal incision used in the lower right quadrant during appendectomies. The muscle fibers of the three abdominal wall muscles are separated to avoid damage to them, as well as to the nerve fibers and blood vessels.
5. Etiology of incisional hernias
Incisional hernias are a common complication of surgical procedures and can result from inadequate closure of operative wounds or traumatic injury. Despite advancements in wound closure materials and surgical techniques, incisional hernias continue to pose a challenge in open abdominal surgery and are also observed in laparoscopic surgery albeit at a lower frequency.
Etiological factors for incisional hernias can be grouped into patient-related factors, factors related to the disease treated with surgical intervention, and those related to the surgical technique used for incision closure.
Certain health disorders, particularly chronic ones, have a direct impact on the closure of operative wounds, thereby affecting the strength of the newly formed scar tissue, which is crucial for resisting high abdominal pressure. Chronic diseases such as diabetes mellitus, autoimmune disorders, and malignant diseases, as well as long-term use of corticosteroids, immunosuppressors, or cytostatics, can impair wound healing [34, 35]. Additionally, morbid obesity is a major risk factor for the development of incisional hernias [34, 36]. Advanced age, which weakens the abdominal wall muscles and can result in changes in connective tissue, is another significant risk factor for incisional hernia development.
Malnutrition, smoking, radiotherapy, and frequent surgical interventions in the abdomen are major factors that can hinder good wound healing and promote the development of incisional hernias [34, 37, 38]. Infection of the operative wound is one of the most critical factors that can cause dehiscence of the wound and increase the likelihood of incisional hernias [39]. Several preventive measures can help reduce the risk of infection, such as atraumatic surgical techniques, careful handling of the gastrointestinal organs, good hemostasis, and removal of all necrotic tissue.
The second group of factors that can increase the risk of developing incisional hernias is that related to the disease treated through surgical intervention. This group of factors includes the site and size of the incision, the nature of the disease (malignant or benign), the duration of the intervention, the opening of any part of the digestive system, the amount of blood loss, and the presence of any complications during the surgery. Acute abdominal diseases and emergencies have a higher risk of causing incisional hernias.
Multiple studies have shown that certain surgical interventions, such as those for aortic aneurysms, liver pathologies, and colorectal cancer, are associated with a higher incidence of incisional hernias [40, 41]. The type of incision used during the surgical procedure is also a significant factor in the development of incisional hernias. Studies have demonstrated that incisions such as the lateral paramedian and transverse incisions pose a lower risk for the development of incisional hernias, owing to the fact that well-vascularized structures heal faster. Therefore, during the opening of the abdominal cavity, maximum care must be taken not to injure the large arteries supplying abdominal muscles [36, 42].
The direction of the pulling force of the abdominal muscles is another factor that affects the appearance of incisional wounds, mainly transverse. This leads to the edges of vertical incisions moving away from each other during exercises and pulling forces, while transverse incisions come closer to each other. If the lips of the muscle fascia are not properly sewn together using strong sutures with the appropriate length in relation to the incision (at least four times longer than the wound), there is a high risk of incisional hernias [43, 44].
Surgical wounds require time to restore their tensile strength. It is estimated that at least 4 weeks are needed for the wound to return around 50% of its strength, while after 12 months, the wound returns 80% of its tensile strength [43]. Therefore, suture materials must be strong and durable for at least 6 weeks until the damaged tissues regain sufficient tensile strength [44, 45].
6. Clinical presentation
The causes of incisional hernias vary and depend on factors such as the size, positioning, and contents of the hernial sac. Patients with incisional hernias are more prone to complications than those with primary hernias. Incisional hernias occur at the incision site and are clinically manifested by swelling due to the protrusion of abdominal organs through the abdominal wall defect. In the case of small hernias, patients may experience discomfort or moderate pain, although even small hernias can become incarcerated. In the case of large hernias, there is a risk of intestinal incarceration or, in severe cases, strangulation, which requires immediate surgical intervention.
Incarceration as a complication occurs in about 1.24 to 2.59% of patients with incisional hernia, while strangulation is the most serious complication and is recorded in about 2% of all patients with incarcerated incisional hernia [46].
Generally, early postoperative hernias are a consequence of wound infection or problems with suturing, while the causes of late postoperative hernias are not entirely known, although some are related to connective and fibrotic tissue disorders [42].
7. Diagnosis
Diagnosing incisional hernias is typically straightforward, as there is often a visible swelling above or near the site of the operative wound that can be reduced with manual pressure. The edges of the hernia can often be felt, allowing for determination of the size of the abdominal wall defect. Coughing or straining can also help to provoke the displacement of abdominal organs into the hernial sac and facilitate diagnosis.
In some cases, however, such as extreme obesity or complex cases, a CT scan of the abdomen may be necessary to confirm the diagnosis. This examination can also aid in planning the surgical intervention, identifying potential challenges for the surgeon during the repair of the defect and determining the appropriate incision size for correction.
Ultrasonography examinations can also provide important information about the size of the hernia, the contents of the hernial sac, and the condition of the abdominal wall muscles.
8. Treatment
Except in special cases when incisional hernias must be treated conservatively, such as in elderly patients or those with chronic diseases that may worsen their condition in the postoperative period or even threaten their life, surgical intervention is required to correct incisional hernias. This is especially true for large hernias, as correcting them eliminates the patient’s discomfort and avoids the risks of incarceration or strangulation, thus significantly improving their quality of life.
At the beginning of modern surgery, for a long time, the correction of incisional hernias was conventional, which involved closing the abdominal defect by approaching and suturing the edges of the wound. Later, with a better understanding of the nature and mechanisms of the development of incisional hernias, other correction techniques began to be used, such as the Mayo technique, which involves overlapping a part of the hernial sac on the incisional wound [47, 48]. Another successful technique for correcting incisional hernias is the separative technique, also known as the Ramirez technique [49].
However, great progress has been made in the correction of incisional hernias after the introduction of prosthetic materials, specifically the use of meshes for correcting abdominal wall defects.
These materials not only make it possible to close abdominal wall defects without tension but they also strengthen the abdominal wall. Among the first meshes used to correct incisional hernias were those made of prolene, which Usher introduced in 1963. The correction of hernias with simple meshes, while showing good results in terms of reducing recurrence rates, was often accompanied by complications resulting from contact with visceral organs and the development of intestinal adhesions and enterocutaneous fistulas. However, the introduction of dual meshes, which have one side covered with an absorbable layer that prevents the mesh from adhering to abdominal organs and another side made of a nonabsorbable layer that maintains proper abdominal wall strength after closing the defect, significantly reduced the incidence of these severe complications, such as adherent ileus and enterocutaneous fistulae.
The most commonly used meshes for incisional hernia correction are those made of prolene. There are two types of prolene meshes in use: lightweight with a weight < 50 g/m2, which are superior to heavy-weight ones (with a weight > 50 g/m2), in terms of reducing postoperative pain and enabling a faster return to daily activity. In recent years, coated or barrier meshes have become increasingly popular for incisional hernia correction. In these meshes, the surface that contacts the abdominal organs should prevent their adhesion to the mesh, while the other surface should integrate as best as possible with the abdominal wall. The first meshes with these characteristics to be put into use were those made of ePTFE [48].
Currently, there are many types of meshes available that have better antiadherence properties than ePTFE. Biological meshes have also been developed, which are made of collagen obtained from living tissues such as skin, submucosa of small intestines, and pericardium. These meshes can be left in their natural state or chemically reinforced. Unreinforced meshes were destroyed within 3 months and strengthened ones remained unchanged for over a year. They are useful in infected wounds and prevent intestinal adhesions to the mesh [50].
When it comes to using prosthetic materials to correct incisional hernias, there is no one-size-fits-all approach. It depends on various factors, such as the size and location of the hernia, the patient’s constitution and clinical condition, the surgeon’s experience, and the available types of meshes.
Laparoscopic correction of hernias, which involves inserting a dual mesh over the hernial defect and fixing it to the abdominal wall, has become increasingly popular since Le Blanc reported the first case in 1993. Studies indicate that the incidence of postoperative complications, such as pain, wound infection, and seromas, is significantly lower when using laparoscopic techniques for incisional hernia repair [40, 41, 49, 51].
9. Post operative complications
Postoperative complications following the correction of incisional hernias may include various issues, such as postoperative pain, wound bleeding, wound infection, seroma formation, dehiscence, and hernia recurrence.
Regarding the incidence and intensity of pain in the postoperative period, several randomized studies have shown that patients with incisional hernias along the linea alba experience a lower intensity of pain compared to those with transverse incisional hernias [52]. Furthermore, numerous studies have shown a higher incidence of postoperative pain after hernia correction with prosthetic materials [53]. However, the precise factors that cause pain after incisional hernia correction are still not known [53].
Postoperative pain, especially if it is of greater intensity and lasts longer, can increase the level of morbidity and patients’ need for analgesics, including potent ones such as opioids [54].
Moreover, there is a difference in the intensity of pain between open hernia correction techniques and laparoscopic procedures. Several studies show that the intensity of postoperative pain is higher in patients who underwent hernia correction with laparoscopic procedures compared to those who underwent hernioplasty with an open method [55]. The reason for the greater intensity of the pain in laparoscopic procedures is thought to be due to the way the mesh is fixed. The fixation of the mesh with transfascial sutures, which penetrate the abdominal muscles, can capture nerve fibers and blood vessels, inducing muscle ischemia and intense pain [56].
However, there are also studies that do not show any difference in pain intensity between open and laparoscopic techniques in the correction of incisional hernias [57].
One of the most serious problems in the early postoperative period after correction of incisional hernias, especially in cases where prosthetic materials are used, is the infection of the operative wound. This complication is not only difficult to eradicate because the mesh represents a foreign body, but it also makes it difficult for the wound to heal quickly, thereby significantly increasing the risk of hernia recurrence.
While pain is more frequent in patients with incisional hernias along the linea alba, numerous retrospective studies show that the risk of surgical wound infection after incisional hernia repair does not depend on its location.
The most serious complication after incisional hernia repair is hernia recurrence, and one of the main reasons for its appearance is considered to be infection of the operative wound. According to numerous studies, this complication shows a slightly higher incidence in midline hernias compared to hernias in other locations, while transverse hernias show a lower incidence compared to paramedian or medial ones.
The highest incidence of incisional hernias along the linea alba has several reasons, the most important of which seem to be the poor blood supply of this part of the abdominal wall, as well as the fact that the contraction of abdominal wall muscles during coughing, vomiting, or erecting retracts wound edges laterally and thereby facilitating wound dehiscence.
The type of incision with the lowest incidence for the development of hernias is transverse one, but this applies only if the defect is located in one quadrant of the abdominal wall. However, if these apertures extend beyond the midline, then this incidence does not differ from those along the linea alba.
While transverse incisions have the advantage of producing less scarring, they offer limited exposure to the abdominal cavity, which restricts their use in many surgeries. In addition, these incisions can damage the nerve fibers that innervate the abdominal muscles, leading to muscle weakness and numbness.
On the other hand, premedian incisions provide excellent exposure of the abdominal cavity similar to median incisions and can be expanded in both directions if necessary. During this type of incision, the rectus muscles can be displaced laterally, preserving not only the muscles but also the neurovascular structures of the abdomen. The low incidence of hernias in paramedian incisions is attributed to well-vascularized wound beds, as well as to other features such as wound reinforcement by the rectus muscle and the so-called shutter mechanism.
10. Factors affecting wound healing in incisional hernias
In the appearance of incisional hernias, many factors have an impact, some of which cannot be influenced by the surgeon, such as the age of the patients, obesity, the degree of urgency, the degree of contamination of the operative field, and the type of surgical intervention [58]. However, there are some factors on which the surgeon has a great impact, such as the type of incision, suture material, careful tissue handling, the type of meshes that will be used if it is necessary, and the surgical technique with which the intervention will be performed, i.e., conventional or laparoscopic.
Numerous studies have demonstrated that transverse and paramedian incisions, along with the Pfannenstiel incision, exhibit superiority in decreasing the likelihood of incisional hernias [59, 60, 61].
Furthermore, the speed and quality of wound healing play a critical role in mitigating the risk of incisional hernias. The more vascularized the tissues are, the faster the wound healing will be [62].
Conversely, the presence of bacteria and their toxins within the wound may trigger a pro-inflammatory cytokine response, hindering timely and effective healing [63].
Advancing age may also impede wound healing, given the observed delay in epithelialization, collagen synthesis, and angiogenesis in elderly individuals [64, 65].
Additionally, stress has recently emerged as a noteworthy factor in wound healing [66].
The latest estimates suggest that due to the hormonal action of estrogens, wound healing in women is slightly faster compared to men. This is because estrogens regulate a variety of genes associated with regeneration [67].
Diabetes has a great impact on wound healing through several complex mechanisms such as hypoxia and venous stasis [68, 69]. Other factors that prevent wound healing in diabetics are defects in leukocyte chemotaxis, phagocytosis, and bactericidal destructive capacity [70]. Diabetic neuropathy, a severe problem in diabetic people, also affects the timely healing of wounds [71].
Obese individuals, due to accompanying conditions such as diabetes, hypertension, dyslipidemia, and respiratory problems, have a higher risk of wound infection, hematomas, seromas development, and pressure and venous ulcer formation, thereby negatively affecting wound healing [72, 73].
The prolonged use of certain medications, particularly glucocorticoids, can affect fibroblast proliferation and collagen synthesis, resulting in difficult wound healing [74].
Additionally, cytostatic drugs inhibit DNA, RNA, or protein synthesis, which leads to decreased fibroplasia and neovascularization of wounds [75].
Finally, malnutrition and inadequate daily protein intake can also impede wound healing since proteins play a crucial role in capillary formation, fibroblast proliferation, collagen synthesis, and wound remodeling [76].
11. Discussion
Currently, incisional hernias not only represent a health problem but also an economic one. Their treatment remains a real challenge for surgeons, requiring good knowledge of the surgical techniques used for their correction, as well as sufficient experience and skills. According to many studies, the incidence of incisional hernias after abdominal surgical interventions ranges from 2 to 20%. This great difference in incidences is not only due to the experience that surgeons have in the treatment of these complications but also to many other factors, such as the different techniques used to correct them, the materials used to close the defect, the patient’s condition, and the incidence of nosocomial infections.
The etiological factors that affect the appearance of incisional hernias are different. Among those that have to do with surgical intervention, the most important is the type of incision, the infection of the operative wound, the technique used to repair the defect, and the type of sutures used for hernia correction, as well as the use or non-use of prosthetic materials for closing the operative wound.
Regarding incision and localization, the experience referred to by many researchers shows an advantage of transversal incisions compared to median ones in terms of the risk of developing incisional hernias. However, this remains correct only as long as they are located only in one quadrant of the abdominal wall and do not cross the linea alba. The incidence of hernias after transverse incisions is about 5% if they are unilateral and up to 10% if they cross the linea alba. Other incisions that show a low degree of risk for the appearance of incisional hernias are the paramedian one and that of Pfannenstiel.
Pfannenstiel transversal incisions, which are mainly used by gynecologists and obstetricians, also show a low incidence of hernia development. However, the negative side of all these incisions is that they do not allow for a good exposure of the abdominal cavity. The medial incision enables better exposure of the abdominal cavity in general and is particularly preferred in emergency abdominal interventions where quick exploration of the abdominal cavity is necessary for the treatment of the patient and a fast and safe diagnosis of abdominal organ damage should be made.
In addition to localization, the size of the operative wound also has a significant impact on the occurrence of incisional hernias. Large wounds are more prone to the development of this complication, as shown in almost every study on incisional hernias.
The incidence of incisional hernias is affected by suture materials and the technique used to close the operative wound, which is confirmed by many meta-analytical studies and researchers. Nonabsorbable materials such as prolene and continuous suturing have advantages in minimizing the incidence of incisional hernias compared to other materials and techniques used for closing wounds after laparotomy. Of the absorbable sutures, only polydioxanone (PDS) gives similar results to prolene regarding the risk of incisional hernias, although there are no convincing studies for this yet. The ratio between the length of the wound and the length of the suture used to close it also seems to be important in the risk of developing incisional hernias, which is related to the distance between the two stitches and should preferably be approximately 5 mm.
In recent decades, laparoscopic surgery is increasingly used for the treatment of incisional hernias, especially after the manufacturing of the so-called dual meshes, which have one side made of materials that do not adhere to the organs of the abdominal cavity. The incidence of recurrence of hernias treated with laparoscopic techniques is low, estimated to be somewhere between 0.2–2%, which is also due to the small wounds created during these interventions.
The incidence of recurrence after the correction of incisional hernias with prosthetic materials is also significantly lower compared to the classical closure by suturing the wound using any of the referred conventional techniques.
Regarding the positioning of the mesh during the correction of incisional hernias, specifically the onlay, inlay, and intraperitoneal technique, most studies show an advantage of the intraperitoneal technique over the other two, not only in terms of the rate of recurrence but also in terms of other complications such as the incidence of seromas, surgical wound infections, and postoperative pain.
Studies show that there is no difference in the recurrence rate of incisional hernias between laparoscopic and conventional techniques, as long as prosthetic materials are used for their correction. On the other hand, the laparoscopic technique has clear advantages in minimizing some postoperative complications, such as wound infections, seromas, recurrence, morbidity, hospitalization, and postoperative pain, according to various studies.
However, there are some disadvantages to laparoscopic techniques for treating incisional hernias, including the longer operative time required for correction and a slightly greater risk of intestinal damage that can be complicated by peritonitis, which can be life-threatening. Despite these potential risks, laparoscopic techniques remain effective and safe for treating not only incisional hernias but also other types of hernias.
The type of sutures used to close the defect or fix the mesh in the abdominal wall also has a significant impact on the incidence of postoperative complications after mesh hernia correction. The critical period for fixing the mesh to the abdominal wall is around 1 year, which is why the sutures used to fix the mesh should not be absorbed before this time. As a result, most authors prefer to use nonabsorbable sutures or a combination of absorbable and nonabsorbable sutures to ensure sufficient tensile strength during this critical period until the mesh is well integrated into the host’s tissues.
In recent years, biological meshes have also been used in the treatment of incisional hernias. Studies on the results of the correction of incisional hernias with these meshes are different and sometimes controversial. Some authors argue that biological meshes are superior to synthetic meshes in terms of recurrence rate and other complications, while others suggest a higher incidence of complications in cases corrected with biological meshes.
12. Conclusion
In conclusion, the treatment of incisional hernias requires careful consideration of various factors, such as the choice of suture material and technique for closing the operative wound, as well as the type and positioning of the mesh used for correction. Laparoscopic techniques have advantages in terms of minimizing certain postoperative complications but also carry some risks, such as longer intraoperative time and the potential for intestinal damage. Prosthetic materials for mesh hernia correction generally have a lower recurrence rate compared to traditional suturing techniques, and the type of suture used to fix the mesh also plays an important role in the prevention of postoperative complications. Furthermore, the use of biological meshes in incisional hernia correction remains controversial, with some studies reporting superior results compared to synthetic meshes, while others indicate a higher incidence of complications. Ultimately, the selection of the most appropriate technique and materials for the treatment of incisional hernias should be tailored to the individual patient’s needs and preferences and based on a thorough evaluation of available evidence and clinical experience.
Acknowledgments
The authors thank their surgeon colleagues from Albania and Macedonia for the valuable advice and suggestions for the successful completion of this work.
References
- 1.
Mulvany NJ. History of abdominal wall hernia repair. Surgical Clinics. 2018; 98 (2):153-163 - 2.
Bendavid R. Abdominal Wall Hernias: Principles and Management. New York: Springer; 2001 - 3.
Bryan CP. Ancient Egyptian Medicine: The Papyrus Ebers. Ares, Chicago; 1930 (1974 [printing]) - 4.
Breasted JH. The Edwin Smith Surgical Papyrus. Chicago: University of Chicago Press; 1980 - 5.
Nahai F. The Craft of Surgery. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013 - 6.
Zimmerman LM. A brief history of hernias and their repairs. Hernia. 2015; 19 (2):153-159 - 7.
Badylak SF. The extracellular matrix as a scaffold for tissue reconstruction. Seminars in Cell & Developmental Biology. 2002; 13 (2):377-383 - 8.
Leven K-H. The Invention of Hippocrates: Oath, Letters and Hippocratic Corpus. Aldershot: Ashgate; 1998 - 9.
Reiffel AJ. The pioneers of hernia repair: Bassini and Halsted. Journal of the American College of Surgeons. 2009; 209 (6):831-833 - 10.
Papavramidou N, Christopoulou-Aletra H. The ancient technique of “gastrorrhaphy”. Journal of Gastrointestinal Surgery. 2009; 13 (7):1345-1341 - 11.
Dunn KA. A glimpse into the past: Two millennia of inguinal hernia repair. Hernia. 2017; 21 (1):1-10 - 12.
Toledo-Pereyra LH. Galen’s contribution to surgery. Journal of the History of Medicine and Allied Sciences. 1973; 28 (4):357-375 - 13.
Rutkow IM. A selective history of groin hernia repair from ancient Egypt to the end of the 18th century. Hernia. 2013; 17 (3):305-312 - 14.
La Chausse BI. Dissertatio chirurgica de hérnia ventrali [Dissertation of surgical ventral hernia]. Naples: Gessare; 1756. Italian - 15.
Tintinalli JE. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 9th ed. New York, NY: McGraw-Hill Education; 2020 - 16.
Gerdy P. Nouvelles operations pour guerir radicalement les hernies du ventre. Gaz Hop. 1836; 1 :10-14 - 17.
Rutkow IM. A selective history of groin hernia repair from ancient Egypt to the end of the 18th century. Surgical Clinics. 2003; 83 (6):1165-1172 - 18.
Quenu E. Traitement opertoire de l’é ventration. Mémoires. Académie de Chirurgie. 1896; 22 :2 - 19.
Witzel O. Uber den Verschluss van Bauchwunden und Bruchpforten durch versenkte Silberdrahtnetze. Centralblatt für Chirurgie. 1900; 27 (3):36 - 20.
Goepel R. Uber die Verschliessung von Bruchpforten durch Einheilung geflochtener fertiger Silberdrahtnetze. Zentralblatt für Chirurgie. 1900; 17 :3 - 21.
Shulman AG, Amid PK, Lichtenstein IL. Maingot's Abdominal Operations. Vol. 1. London: Prentice-Hall International; 1994 - 22.
Maingot R. Abdominal Operations. 3rd ed. London: Lewis; 1955 - 23.
Judd E. The prevention and treatment of ventral hernia. Surgery, Gynecology & Obstetrics. 1912; 14 :7 - 24.
Zimmerman LM, Anand KJ. History of hernia mesh. Surgical Technology International. 2007; 16 :131-137 - 25.
Loewe O. Uber Hautimplantation an Stelle der freien Fascienplastik. Muncher Med Wochenschr. 1913; 60 :1320-1321 - 26.
Throckmorton TD. Tantalum gauze in the repair of hernias complicated by tissue deficiency; a preliminary report. Surgery. 1948; 23 (1):32-46 - 27.
Smith DR. Hernia surgery on coins from antiquity to the renaissance. Hernia. 2014; 18 (4):617-622 - 28.
Koontz AR, Kimberly RC. Tantalum and marlex mesh (with a note on marlex thread): An experimental and clinical comparison—Preliminary report. Annals of Surgery. 1960; 151 :796-804 - 29.
McBride ED. Synthetic mesh in hernia repair. Annals of Surgery. 1953; 137 (4):482-487 - 30.
Usher FC, Wallace SA. Tissue reaction to plastics; a comparison of nylon, orlon, dacron, teflon, and marlex. A.M.A. Archives of Surgery. 1958; 76 (6):997-999 - 31.
Grannell JP, Leonard JN. Hernia repair with Mersilene mesh. Surgery, Gynecology & Obstetrics. 1956; 103 (1):97-100 - 32.
LeBlanc KA, Booth WV. Laparoscopic Repair of Incisional Abdominal Hernias Using Expanded Polytetrafluoroethylene: Preliminary Findings. Surg Laparoscopy; 1993 - 33.
Davies SW, Turza KC, Sawyer RG, et al. A comparative analysis between laparoscopic and open ventral hernia repair at a tertiary care center. The American Surgeon. 2012; 78 :888-892 - 34.
Sorensen LT, Hemmingsen UB, Kirkeby LT, et al. Smoking is a risk factor for incisional hernia. Archives of Surgery. 2005; 140 (2):119-123 - 35.
Sugerman HJ, Kellum JM Jr, Reines HD, et al. Greater risk of incisional hernia with morbidly obese than steroid-dependent patients and low recurrence with prefascial polypropylene mesh. American Journal of Surgery. 1996; 171 (1):80-84 - 36.
Hoer J, Lawong G, Klinge U, et al. Factors influencing the development of incisional hernia. A retrospective study of 2,983 laparotomy patients over a period of 10 years. Der Chirurg. 2002; 73 :474-480 - 37.
Israelsson LA. Wound failure and incisional hernia: Mechanism and prevention. In: Fitzgibbons RJ Jr, Greenburg AG, editors. Nyhus and Condon’s Hernia. Philadelphia: Lippincott Williams & Wilkins; 2002. pp. 3-8 - 38.
Klinge U, Prescher A, Klosterhalfen B, et al. Development and pathophysiology of abdominal wall defects. Chirurg. 1997; 68 (4):293-303 - 39.
Walming S, Angenete E, Block M, Bock D, Gessler B, Haglind E. Retrospective review of risk factors for surgical wound dehiscence and incisional hernia. BMC Surgery. 2017; 17 :19 - 40.
Ahonen-Siirtola M, Rautio T, Ward J, Kössi J, Ohtonen P, Mäkelä J. Complications in laparoscopic versus open incisional ventral hernia repair. A retrospective comparative study. World Journal of Surgery. 2015; 39 :2872-2877 - 41.
Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic ventral and incisional hernia repair in 407 patients. Journal of the American College of Surgeons. 2000; 190 :645-650 - 42.
Höer J, Junge K, Schachtrupp A, Klinge U, Schumpelick V. Influence of laparotomy closure technique on collagen synthesis in the incisional region. Hernia. 2002; 6 (3):93-98 Epub 2002 Jul 20 - 43.
Editorial: Ten commandments of safe and optimum Abdominal Wall closure. Indian Journal of Surgery. 2018; 80 (2):105-108 - 44.
Patel SV, Paskar DD, Nelson RL, Vedula SS, Steele SR. Closure methods for laparotomy incisions for preventing incisional hernias and other wound complications. Cochrane Database of Systematic Reviews. 2017; 11 (11):CD005661. DOI: 10.1002/14651858.CD005661.pub2 - 45.
Henriksen NA, Deerenberg EB, Venclauskas L, Fortelny RH, Miserez M, Muysoms FE. Meta-analysis on materials and techniques for laparotomy closure: The MATCH review. World Journal of Surgery. 2018; 42 (6):1666-1678. DOI: 10.1007/s00268-017-4393-9 - 46.
Dadashzadeh ER, Huckaby LV, Handzel R, Hossain MS, Sanin GD, Anto VP, et al. The risk of incarceration during nonoperative Management of Incisional Hernias. Annals of Surgery. 2022; 275 (2):e488-e495 - 47.
Welty G, Klinge U, Klosterhalfen B, et al. Functional impairment and complaints following incisional hernia repair with different polypropylene meshes. Hernia. 2001; 5 (3):142-147 - 48.
Bauer JJ, Salky BA, Gelernt IM, et al. Repair of large abdominal wall defects with expanded polytetrafluoroethylene (PTFE). Annals of Surgery. 1987; 206 (6):765-769 - 49.
Eker HH, Hansson BME, Buunen M, Janssen IM, Pierik RE, Hop WC, et al. Laparoscopic vs. open incisional hernia repair: A randomized clinical trial. JAMA Surgery. 2013; 148 :259-263 - 50.
Franklin ME Jr, Gonzalez JJ Jr, Michaelson RP, et al. Preliminary experience with new bioactive prosthetic material for repair of hernias in infected fields. Hernia. 2002; 6 (4):171-174 - 51.
Lavanchy JL, Buff SE, Kohler A, Candinas D, Beldi G. Long-term results of laparoscopic versus open intraperitoneal onlay mesh incisional hernia repair: A propensity score-matched analysis. Surgical Endoscopy. 2019; 33 :225-233 - 52.
Erritzøe-Jervild L, Christoffersen MW, Helgstrand F, et al. Long-term complaints after elective repair for small umbilical or epigastric hernias. Hernia. 2013; 17 :211-215 - 53.
Gronnier C, Wattier JM, Favre H, et al. Risk factors for chronic pain after open ventral hernia repair by underlay mesh placement. World Journal of Surgery. 2012; 36 :1548-1554 - 54.
DeLong CG, Doble JA, Schilling AL, Pauli EM, Soybel DI. Delineating the burden of chronic post-operative pain in patients undergoing open repair of complex ventral hernias. American Journal of Surgery. 2018; 215 (4):610-617. DOI: 10.1016/j.amjsurg.2018.01.030 - 55.
Muysoms F, Vander Mijnsbrugge G, Pletinckx P, et al. Randomized clinical trial of mesh fixation with “double crown” versus “sutures and tackers” in laparoscopic ventral hernia repair. Hernia. 2013; 17 (5):603-612 - 56.
Gillian GK, Geis WP, Grover G. Laparoscopic incisional and ventral hernia repair (LIVH): An evolving outpatient technique. JSLS : Journal of the Society of Laparoendoscopic Surgeons. 2002; 6 :315-322 - 57.
McGreevy JM, Goodney PP, Birkmeyer CM, Finlayson SRG, Laycock WS, Birkmeyer JD. A prospective study comparing the complication rates between laparoscopic and open ventral hernia repairs. Surgical Endoscopy. 2003; 17 :1778-1780 - 58.
Rutkow IM. Demographic and socioeconomic aspects of hernia repair in the United States in 2003. The Surgical Clinics of North America. 2003; 83 (5):1045-1051 v–vi - 59.
Grantcharov TP, Rosenberg J. Vertical compared with transverse incisions in abdominal surgery. The European Journal of Surgery. 2001; 167 :260-267 - 60.
Burger JWA, van't Reit M, Jeekel J. Abdominal incisions: Techniques and postoperative complications. Scandinavian Journal of Surgery. 2002; 91 :315-321 - 61.
Orcutt ST, Balentine CJ, Marshall CL, Robinson CN, Anaya DA, Artinyan A, et al. Use of a Pfannenstiel incision in minimally invasive colorectal cancer surgery is associated with a lower risk of wound complications. Techniques in Coloproctology. 2012; 16 :127-132 - 62.
Edwards R, Harding KG. Bacteria and wound healing. Current Opinion in Infectious Diseases. 2004; 17 :91-96 - 63.
Davis SC, Ricotti C, Cazzaniga A, Welsh E, Eaglstein WH, Mertz PM. Microscopic and physiologic evidence for biofilm-associated wound colonization in vivo. Wound Repair and Regeneration. 2008; 16 :23-29 - 64.
Swift ME, Burns AL, Gray KL, DiPietro LA. Age-related alterations in the inflammatory response to dermal injury. The Journal of Investigative Dermatology. 2001; 117 :1027-1035 - 65.
Swift ME, Kleinman HK, DiPietro LA. Impaired wound repair and delayed angiogenesis in aged mice. Laboratory Investigation. 1999; 79 :1479-1487 - 66.
Boyapati L, Wang HL. The role of stress in periodontal disease and wound healing. Periodontology 2000. 2007; 2000 (44):195-210 - 67.
Hardman MJ, Ashcroft GS. Estrogen, not intrinsic aging, is the major regulator of delayed human wound healing in the elderly. Genome Biology. 2008; 9 :R80 - 68.
Vincent AM, Russell JW, Low P, Feldman EL. Oxidative stress in the pathogenesis of diabetic neuropathy. Endocrine Reviews. 2004; 25 :612-628 - 69.
Woo K, Ayello EA, Sibbald RG. The edge effect: Current therapeutic options to advance the wound edge. Advances in Skin & Wound Care. 2007; 20 :99-117 - 70.
Loots MA, Lamme EN, Zeegelaar J, Mekkes JR, Bos JD, Middelkoop E. Differences in cellular infiltrate and extracellular matrix of chronic diabetic and venous ulcers versus acute wounds. The Journal of Investigative Dermatology. 1998; 111 :850-857 - 71.
Galkowska H, Olszewski WL, Wojewodzka U, Rosinski G, Karnafel W. Neurogenic factors in the impaired healing of diabetic foot ulcers. The Journal of Surgical Research. 2006; 134 :252-258 - 72.
Greco JA 3rd, Castaldo ET, Nanney LB, Wendel JJ, Summitt JB, Kelly KJ, et al. The effect of weight loss surgery and body mass index on wound complications after abdominal contouring operations. Annals of Plastic Surgery. 2008; 61 :235-242 - 73.
Wilson JA, Clark JJ. Obesity: Impediment to postsurgical wound healing. Advances in Skin & Wound Care. 2004; 17 :426-435 - 74.
Wagner AE, Huck G, Stiehl DP, Jelkmann W, Hellwig-Bürgel T. Dexamethasone impairs hypoxia-inducible factor-1 function. Biochemical and Biophysical Research Communications. 2008; 372 :336-340 - 75.
Franz MG, Steed DL, Robson MC. Optimizing healing of the acute wound by minimizing complications. Current Problems in Surgery. 2007; 44 :691-763 - 76.
Campos AC, Groth AK, Branco AB. Assessment and nutritional aspects of wound healing. Current Opinion in Clinical Nutrition and Metabolic Care. 2008; 11 :281-288