Hernia

, Volume 10, Issue 3, pp 253–257

Preliminary results of a two-layered prosthetic repair for recurrent inguinal and ventral hernias combining open and laparoscopic techniques

Authors

  • J. M. Treviño
    • Texas Endosurgery Institute
    • Texas Endosurgery Institute
  • K. R. Berghoff
    • Texas Endosurgery Institute
  • J. L. Glass
    • Texas Endosurgery Institute
  • E. J. Jaramillo
    • Texas Endosurgery Institute
Original Article

DOI: 10.1007/s10029-006-0085-3

Cite this article as:
Treviño, J.M., Franklin, M.E., Berghoff, K.R. et al. Hernia (2006) 10: 253. doi:10.1007/s10029-006-0085-3

Abstract

The use of prosthetic mesh has become the standard of care in the management of hernias because of its association with a low rate of recurrence. However, despite its use, recurrence rates of 1% have been reported in primary inguinal repair and rates as high as 15% with ventral hernia repair. When dealing with difficult recurrent hernias, the two-layer prosthetic repair technique is a good option. In the event of incarcerated or strangulated hernias, however; placement of prosthetic material is controversial due to the increased risk of infection. The same is true when hernia repairs are performed concurrently with potentially contaminated procedures such as cholecystectomy, appendectomy, or colectomy. The purpose of this study is to report our preliminary results on the treatment of recurrent hernias by combining laparoscopic and open techniques to construct a two-layered prosthetic repair using a four ply mesh of porcine small intestine submucosa (Surgisis®, Cook Surgical, Bloomington, IN, USA) in a potentially infected field and a combination of polypropylene and ePTFE (Gore-Tex®, W.L. Gore and Associates, Flagstaff, AZ, USA) in a clean field. From September 2002 to January 2004, nine patients (three males and six females) underwent laparoscopic and open placement of surgisis mesh in a two layered fashion for either recurrent incisional or inguinal hernias in a contaminated field. A total of eight recurrent hernia repairs were performed (five incisional, three inguinal) and one abdominal wall repair after resection of a metastatic tumor following open colectomy for colon carcinoma. Six procedures were performed in a potentially contaminated field (incarcerated or strangulated bowel within the hernia), two procedures were performed in a contaminated field because of infected polypropylene mesh, and one was in a clean field. Mean patient age was 56.4 years. The average operating time was 156.8 min. Operative findings included seven incarcerated hernias (four incisional and three inguinal), one strangulated inguinal hernia, and one ventral defect after resection of an abdominal wall metastasis for a previous colon cancer resection. In two of the cases, there was an abscess of a previously placed polypropylene mesh. All procedures were completed with two layers of mesh (eight cases with surgisis and one with combination of polypropylene/ePTFE). Median follow up was 10 months. Complications included two seromas, one urinary tract infection, two cases of atelectasis and one prolonged ileus. There were no wound infections. The average postoperative length of stay was 7.8 days. There have been no mesh-related complications or recurrent hernias in our early postoperative follow-up period. The use of a new prosthetic device in infected or potentially infected fields, and the two-layered approach shows promising results. This is encouraging and provides an alternative approach for the management of difficult, recurrent hernias.

Keywords

RecurrentHerniaTwo-layeredSandwichRepairSurgisis

Introduction

Since the treatment of hernias by the Egyptians using external manipulation and bandage, recurrences have been a problem faced by many surgeons. Usher et al. [1] in 1958 introduced the use of prosthetic material in the primary repair with good results. The use of prostheses have reduced recurrence rates, but have not eliminated them altogether. Recurrence rates as high as 10–20% have been reported with suture repair of inguinal hernias, with the use of mesh this rate is below 5% and frequently is less than 1%. Ventral hernias have a 25–52% recurrence rate with repair without mesh and a 12–24% recurrence rate despite the use of prosthetic mesh [25, 7, 1012]. The two-layered prosthetic repair has been described previously by Condon [8]. As he described, when the margins of the hernia cannot be re-approximated without tension, the subcutaneous plane superficial to the musculoaponeurotic abdominal wall and the extraperitoneal plane immediately below the abdominal wall is dissected at least 6 cm circumferentially from the hernia margin. A piece of prosthetic material is placed in each dissected layer and transabdominal mattress sutures are placed along the mesh margins to include both meshes in each tie. The skin is closed over a suction drain placed in the subcutaneous space.

We used the two-layered prosthetic repair for treatment of difficult, recurrent hernias (Fig. 1); however, we combined both laparoscopic and open techniques to accomplish this task. Laparoscopy was used to reduce the hernia and place the bottom layer of mesh. This was done in the intraperitoneal layer in an onlay fashion, but as opposed to the extraperitoneal mesh placement described by Condon [8]. The superficial layer was placed by performing open surgery through an abdominal incision. In the repairs performed in either a contaminated or potentially contaminated field, Surgisis® (Cook Surgical, Bloomington, IN, USA) mesh was used. This is a prosthetic, biomaterial derived from porcine small intestinal submucosa. It is a naturally occurring extracellular matrix that is easily absorbed, supports early abundant tissue growth, and serves as a template for constructive remodeling. It allows for permanent repair despite early absorption. As such, we believe that Surgisis® mesh is a good option for use in contaminated or potentially contaminated fields in which mesh use is necessary [9].
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Fig. 1

Female patient with a giant recurrent strangulated inguinal hernia

The purpose of this study is to report our preliminary results on the treatment of recurrent hernias by combining laparoscopic and open techniques to construct a two-layered prosthetic repair.

Materials and methods

From September 2002 to January 2004, nine patients (three males and six females) underwent simultaneous open and laparoscopic placement of mesh (surgisis in eight cases and polypropylene/ePTFE in one case) for either recurrent incisional or recurrent inguinal hernias. A total of eight recurrent hernia repairs were performed (five incisional, three inguinal) and one abdominal wall repair after resection of a metastatic tumor following open colectomy for colon carcinoma. Six procedures were performed in a potentially contaminated field (either incarcerated or strangulated bowel within the hernia), two procedures was performed in a contaminated field because of an infected, previously placed polypropylene mesh and one more in a clean field due to a wound metastasis from colon cancer.

All patients received perioperative antibiotics, a first generation cephalosporin for clean, elective cases, and a broad-spectrum antibiotic for infected cases. A cleansing only bowel prep was used in each case. In all the cases, pneumoperitoneum was achieved with CO2 up to 14 mmHg. This was done in the right upper quadrant by way of a Veress needle. A 5 mm trocar and laparoscope was subsequently placed. After a laparoscopic look of the cavity, the specific number and location of trocars was dependant on the size and location of the hernia. Once in the abdomen, an adhesiolysis was performed, the hernia was reduced, and the previous mesh removed when necessary (Fig. 4). An abdominal incision was then made, the myoaponeurosis was reapproximated and a large piece of mesh was sewn to the abdominal wall anteriorly (Figs. 2, 3). Then the abdomen was reinsufflated and a piece of mesh was fixed to the posterior aspect of the abdominal wall using an Autosuture laparoscopic stapler (TYCO Healthcare, Norwalk, CT, USA). In the case of the incisional metastasis, the tumor was resected with a portion of full thickness abdominal wall to completely remove the tumor. The abdominal wall was re-approximated, pneumoperitoneum was achieved and the “sandwich repair” was performed as described above. In the recurrent inguinal hernia cases, an intraperitoneal placement of mesh was used to cover the hernia defect laparoscopically after its reduction. The mesh was fixed to the posterior aspect of the anterior abdominal wall and Cooper’s ligament using the laparoscopic stapler (Fig. 2). Next, a traditional open inguinal hernia incision was made and a piece of mesh was used to cover the hernia defect anteriorly by sewing it to Poupart’s ligament and the conjoin tendon. All 10 mm. trocar fascial defects were closed with 1-vicryl using a suture passer.
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Fig. 2

External view of the surgisis mesh, you can see in the half portion of the picture how we attached two meshes due the big size of the hernia

Results

Six women and three men were enrolled in the study. Ages ranged from 32 to 84 years (mean 56.4). Operating time ranged from 51 to 300 min (average 156.8 min). All patients received general endotracheal anesthesia along with local infiltration of all port sites using 0.5% bupivacaine. Operative findings included seven incarcerated hernias (four incisional, three inguinal); two of these recurrent incisional hernias required removal of a previously placed infected, polypropylene mesh. There was one strangulated incisional hernia in which an infarcted portion of small bowel was resected and repaired primarily using a stapled technique during the open portion of the repair. The other case involved abdominal wall resection to remove a metastasic colon cancer. All procedures were completed successfully with a two-layered mesh repair. In eight cases u Surgisis® mesh was used and in the clean case polypropylene was used in the external layer and ePTFE (Gore-Tex®, W.L. Gore and Associates, Flagstaff, AZ, USA) in the internal layer. Median follow up was 10 months with a range of 3–12 months. There was one intraoperative complication of a cecal injury during the open repair portion of a giant incarcerated inguinal hernia (Fig. 3). This was repaired with 3–0 vicryl in a running fashion. The postoperative complications included two seromas, one urinary tract infection, two cases of atelectasis, and one 12 day ileus. There were no wound infections. The average length of hospital stay was 7.8 days (range 1–13). There have been no mesh-related complications or recurrent hernias in our early postoperative follow-up period.
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Fig. 3

Close up where we show the lateral attachment of the mesh using regular skin staples in the external side

Discussion

Since its beginning, hernia surgery probably has produced the largest variety of repair techniques. Recurrence rates as high as 10–20% have been reported for simple suture repair of inguinal hernias. With the use of mesh, this rate frequently is less than 1%. Ventral hernias have a 25–52% recurrence rate with simple suture repair and a 12–24% recurrence rate despite the use of prosthetic mesh [25, 7, 1013]. Thorough knowledge of the anatomy and adequate training for the surgeon’s chosen procedure is essential to help decrease the rates of complication and recurrence. The use of the Kugel method described by Kugel [14] is no relevant in this cases, because the presence of infected fields. The two layered “sandwich repair” used in this study utilizes the benefits of both laparoscopic and open surgery. Laparoscopy allows for complete visualization of the hernia defect and adequate mesh overlap and the addition of open mesh placement allows for additional tissue in-growth for a strong repair [6] (Fig. 5).
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Fig. 4

Laparoscopic view of the previous infected mesh

We found the two-layered hernia repair to be safe with a 0% rate of wound infection, compared with infection rates of 12–45% in a series of open repairs and 2% in the laparoscopic approach [5, 15, 1720]. All patients were examined by the lead author postoperatively.

The 0% early recurrence rate may have been at least partly due to the short-term follow- up, but the two-layered method by itself may be responsible for the low recurrence rate. This technique, which is based on Condon’s method for repair of ventral hernias [8], involves posterior and anterior covering of the defect with large pieces of surgisis mesh (Figs. 4, 5). The large surface area of the mesh allows for substantial ingrowth of tissue for permanent mesh fixation, and the intraabdominal pressure tends to hold the lower mesh in place against the posterior surface of the anterior abdominal wall [21] (Fig. 6). To our knowledge, this is the first reported series with this type of mesh and operation in human patients.
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Fig. 5

Internal view of the surgisis mesh, attached to the posterior layer of the anterior abdominal wall with staples, after completing the external procedure and closing the defect

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Fig. 6

Diagram where we show the position of both layers of mesh after closing the defect

Conclusion

Successful treatment of recurrent hernias is a difficult problem. As shown by our early postoperative follow-up, combining open and laparoscopic techniques for placement of a two-layered prosthetic repair is a valid alternative for treatment of these difficult, recurrent hernias.

Copyright information

© Springer-Verlag 2006