, Volume 11, Issue 6, pp 473–479 | Cite as

Subxiphoid incisional hernias after median sternotomy

  • J. E. Losanoff
  • M. D. Basson
  • S. Laker
  • M. Weiner
  • J. D. Webber
  • S. A. Gruber



Subxiphoid incisional hernias are notoriously difficult to repair and are prone to recurrence. The few reports on subxiphoid hernia published over the last two decades have not fully addressed the etiology, pathology, treatment, and outcome of this problem. This review was performed to analyze the published experience and increase the understanding of these difficult hernias.


We reviewed the extensive literature, including the Medline and Current Contents computerized database searches, and searched the available bibliographies.


Seven retrospective studies of a total of 113 patients who had clinical subxiphoid hernias after median sternotomy were found. An additional surgical technique describing a modified median sternotomy preventing the hernia, and a single review article on selected technical considerations of subxiphoid ventral repair were also found.


The incidence of subxiphoid hernia after median sternotomy can be possibly reduced by paraxiphoid extension of the sternotomy, reinforcement near the xiphoid end of the incision, or by optimizing closure of the distal sternotomy and the linea alba. Abdominal wall reinforcement by open-mesh closure or laparoscopic transperitoneal prosthetic repair can effectively deal with the defect. Long-term outcome analyses are not yet available.


Subxiphoid hernia Median sternotomy Hernia Mesh repair Tissue repair Laparoscopic surgery 



This material is the result of work supported with the resources and by the use of the facilities at the John D. Dingell VA Medical Center, Detroit, MI, USA.


  1. 1.
    Cohen MJ, Starling JR (1985) Repair of subxiphoid incisional hernias with marlex mesh after median sternotomy. Arch Surg 120:1270–1271PubMedGoogle Scholar
  2. 2.
    Davidson BR, Bailey JS (1986) Incisional herniae following median sternotomy incisions: their incidence and aetiology. Br J Surg 73:995–996PubMedCrossRefGoogle Scholar
  3. 3.
    Davidson BR, Bailey JS (1987) Repair of incisional hernia after median sternotomy. Thorax 42:549–550PubMedCrossRefGoogle Scholar
  4. 4.
    Barner HB (1987) A technical modification of median sternotomy to eliminate subxiphoid incisional hernias. Arch Surg 122:843PubMedGoogle Scholar
  5. 5.
    Bouillot JL, Badawy A, Alexandre JH (1997) Incisional abdominal hernia after median sternotomy. Repair with the use of Dacron mesh. Hernia 1:129–130CrossRefGoogle Scholar
  6. 6.
    Muscarella P, Needleman BJ, Goldstein AH, Steinberg SM (2000) Laparoscopic repair of a subxiphoid incisional hernia following median sternotomy. Surg Rounds 23:605–611Google Scholar
  7. 7.
    Landau O, Raziel A, Matz A, Kyzer S, Haruzi I (2001) Laparoscopic repair of poststernotomy subxiphoid epigastric hernia. Surg Endosc 15:1313–1314PubMedCrossRefGoogle Scholar
  8. 8.
    Conze J, Prescher A, Kisielinski K, Klinge U, Schumpelick V (2005) Technical consideration for subxiphoidal incisional hernia repair. Hernia 9:84–87PubMedCrossRefGoogle Scholar
  9. 9.
    Mackey RA, Brody FJ, Berber E, Chand B, Henderson JM (2005) Subxiphoid incisional hernias after median sternotomy. J Am Coll Surg 201:71–76PubMedCrossRefGoogle Scholar
  10. 10.
    Milton H (1897) Mediastinal surgery. Lancet 1:872–875CrossRefGoogle Scholar
  11. 11.
    Julian OC, Lopez-Belio M, Dye WS, Javid H, Grove WJ (1957) The median sternal incision in intracardiac surgery with extracorporeal circulation: a general evaluation of its use in heart surgery. Surgery 42:753–761PubMedGoogle Scholar
  12. 12.
    Lachman N, Satyapal KS (1999) Origin and incidence of xiphoid branch of the internal thoracic artery. Surg Radiol Anat 21:351–354PubMedCrossRefGoogle Scholar
  13. 13.
    Yahchouchy-Chouillard E, Aura T, Picone O, Etienne JC, Fingerhut A (2003) Incisional hernias. I. Related risk factors. Dig Surg 20:3–9PubMedCrossRefGoogle Scholar
  14. 14.
    Dasika UK, Trumble DR, Magovern JA (2003) Lower sternal reinforcement improves the stability of sternal closure. Ann Thorac Surg 75:1618–1621PubMedCrossRefGoogle Scholar
  15. 15.
    Losanoff JE, Collier AD, Wagner-Mann CC, Richman BW, Huff H, Hsieh F-H, Diaz-Arias A, Jones JW (2004) Biomechanical comparison of median sternotomy closures. Ann Thorac Surg 77:203–209PubMedCrossRefGoogle Scholar
  16. 16.
    Askar OM (1977) Surgical anatomy of the aponeurotic expansions of the anterior abdominal wall. Ann R Coll Surg Engl 59:313–321PubMedGoogle Scholar
  17. 17.
    Bendavid R (2004) The unified theory of hernia formation. Hernia 8:171–176PubMedGoogle Scholar
  18. 18.
    Merrell RC, Than-Trong T (1985) Osseous and chondral fixation of polypropylene mesh. Am J Surg 149:816–818PubMedCrossRefGoogle Scholar
  19. 19.
    Amid PK (2003) The Lichtenstein repair in 2002: an overview of causes of recurrence after Lichtenstein tension-free hernioplasty. Hernia 7:13–16PubMedCrossRefGoogle Scholar
  20. 20.
    Freund HR, Charuzi I (2003) Laparoscopic and open repair of post-sternotomy incisional hernia of the subxiphoid region. In: Morales-Conde S (ed) Laparoscopic ventral hernia repair. Springer, Paris, France, pp 375–382Google Scholar
  21. 21.
    White TJ, Santos MC, Thompson JS (1998) Factors affecting wound complications in repair of ventral hernias. Am Surg 64:276–280PubMedGoogle Scholar
  22. 22.
    Ramshaw BJ, Esartia P, Schwab J, Mason EM, Wilson RA, Duncan TD, Miller J, Lucas GW, Promes J (1999) Comparison of laparoscopic and open ventral herniorrhaphy. Am Surg 65:827–831PubMedGoogle Scholar
  23. 23.
    Heniford BT, Park A, Ramshaw BJ, Voeller G (2003) Laparoscopic repair of ventral hernias: nine years’ experience with 850 consecutive hernias. Ann Surg 238:391–400PubMedGoogle Scholar
  24. 24.
    McKinlay RD, Park A (2004) Laparoscopic ventral incisional hernia repair: a more effective alternative to conventional repair of recurrent incisional hernia. J Gastrointest Surg 8:670–674PubMedCrossRefGoogle Scholar
  25. 25.
    Novitsky YW, Cobb WS, Kercher KW, Matthews BD, Sing RF, Heniford BT (2006) Laparoscopic ventral hernia repair in obese patients: a new standard of care. Arch Surg 141:57–61PubMedCrossRefGoogle Scholar
  26. 26.
    van’t Riet M, de Vos van Steenwijk PJ, Kleinrensink GJ, Steyerberg EW, Bonjer HJ (2002) Tensile strength of mesh fixation methods in laparoscopic incisional hernia repair. Surg Endosc 16:1713–1716PubMedCrossRefGoogle Scholar
  27. 27.
    Park A, Heniford BT, LeBlanc KA, Voeller GR (2001) Laparoscopic repair of incisional hernias. Part 2: surgical technique. Contemp Surg 57:225–238Google Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • J. E. Losanoff
    • 1
    • 2
    • 3
  • M. D. Basson
    • 1
    • 2
  • S. Laker
    • 2
  • M. Weiner
    • 2
  • J. D. Webber
    • 2
  • S. A. Gruber
    • 2
  1. 1.Surgical ServiceJohn D. Dingell VA Medical CenterDetroitUSA
  2. 2.Department of SurgeryWayne State UniversityDetroitUSA
  3. 3.Department of Surgery (11S)John D. Dingell VA Medical CenterDetroitUSA

Personalised recommendations