Preliminary results of a two-layered prosthetic repair for recurrent inguinal and ventral hernias combining open and laparoscopic techniques
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- Treviño, J.M., Franklin, M.E., Berghoff, K.R. et al. Hernia (2006) 10: 253. doi:10.1007/s10029-006-0085-3
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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.
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.  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 [2–5, 7, 10–12]. The two-layered prosthetic repair has been described previously by Condon . 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.
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.
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, 17–20]. All patients were examined by the lead author postoperatively.
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.