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1.  Health Technology Assessment of laparoscopic compared to conventional surgery with and without mesh for incisional hernia repair regarding safety, efficacy and cost-effectiveness 
Incisional hernias are a common complication following abdominal surgery and they represent about 80% of all ventral hernia. In uncomplicated postoperative follow-up they can develop in about eleven percent of cases and up to 23% of cases with wound infections or other forms of wound complications. Localisation and size of the incisional hernia can vary according to the causal abdominal scar. Conservative treatment (e. g. weight reduction) is only available to relieve symptoms while operative treatments are the only therapeutic treatment option for incisional hernia. Traditionally, open suture repair was used for incisional hernia repair but was associated with recurrence rates as high as 46%. To strengthen the abdominal wall and prevent the development of recurrences the additional implantation of an alloplastic mesh is nowadays commonly used. Conventional hernia surgery as well as minimally invasive surgery, introduced in the early 90s, make use of this mesh-technique and thereby showed marked reductions in recurrence rates. However, there are possible side effects associated with mesh-implantation. Therefore recommendations remain uncertain on which technique to apply for incisional hernia repair and which technique might, under specific circumstances, be associated with advantages over others.
The goal of this HTA-Report is to compare laparoscopic incisional hernia repair (LIHR) and conventional incisional hernia repair with and without mesh-implantation in terms of their medical efficacy and safety, their cost-effectiveness as well as their ethical, social und legal implications. In addition, this report aims to compare different techniques of mesh-implantation and mesh-fixation as well as to identify factors, in which certain techniques might be associated with advantages over
Relevant publications were identified by means of a structured search of databases accessed through the German Institute of Medical Documentation and Information (DIMDI) as well as by a manual search. The former included the following electronic resources:
SOMED (SM78), Cochrane Library – Central (CCTR93), MEDLINE Alert (ME0A), MEDLINE (ME95), CATFILEplus (CATLINE) (CA66), ETHMED (ED93), GeroLit (GE79), HECLINET (HN69), AMED (CB85), CAB Abstracts (CV72), GLOBAL Health (AZ72), IPA (IA70), Elsevier BIOBASE (EB94), BIOSIS Previews (BA93), EMBASE (EM95), EMBASE Alert (EA08), SciSearch (IS90), Cochrane Library – CDSR (CDSR93), NHS-CRD-DARE (CDAR94), NHS-CRD-HTA (INAHTA) as well as NHSEED (NHSEED).
The present report includes German and English literature published until 31.08.2005. The search parameters can be found in the appendix. No limits were placed on the target population. The methodological quality of the included clinical studies was assessed using the criteria recommended by the “Scottish Intercollegiate Guidelines Network Grading Review Group“. Economic studies were evaluated by the criteria of the German Scientific Working Group Technology Assessment for Health Care.
The literature search identified 17 relevant medical publications. One of these studies compared laparoscopic and conventional surgery with and without mesh for incisional hernia repair, while 16 studies compared laparoscopic and conventional surgery with mesh for incisional hernia repair. Among these studies were 14 primary studies (one randomised controlled trial (RCT), two systematic reviews and one HTA-Report. The only study comparing laparoscopic and conventional surgery without mesh found substantial differences in terms of baseline characteristics between treatment groups. The outcome parameters showed decreased recurrence rates for the laparoscopic repair and similar safety of the procedures. Studies comparing laparoscopic and conventional surgery with mesh found similar outcome in terms of medical efficacy and safety. However, there was a trend towards lower recurrence rates, length of hospital stay, and postoperative pain as well as decreased complication rates for laparoscopic repair in the majority of studies. The impact of the technique of mesh-implantation and -fixation as well as the impact of certain factors on the choice of technique has not been systematically assessed in any of the studies.
All identified studies suffer from significant methodological weaknesses, such as differences between treatment groups, mainly due to the non-randomised study design, small treatment groups causing low case numbers and lack of statistical power as well as the neglect of important risk factors or adjustment for those. Therefore, no conclusive differences could be identified concerning compared operative techniques, mesh-implantation and -fixation techniques or certain risk factors. Only the comparison of laparoscopic and conventional technique with mesh provides some evidence for a trend towards similar or slightly improved outcome in terms of medical efficacy and safety for the laparoscopic technique. However, there is still a great need for further research to investigate these questions.
Basically, there is no full economic evaluation focussing on the relevant alternatives. Cost compareisons were available, even though only briefly attached to clinical research results. None of the studies primarily aimed to investigate costs or even cost-effectiveness.
When deciding on the choice of operative technique for incisional hernia repair, surgeons take various considerations into account, including patient characteristics, hernia characteristics and their own experience. The studies included in this HTA did not provide conclusive evidence to answer the research questions. Nonetheless, laparoscopic surgery demonstrated a trend towards similar or slightly improved outcome following incisional hernia repair. However, for more conclusive recommendations on the choice of operative technique, high quality trials are required
From the economic perspective, alternative methods are not yet assessed. Only five of the studies involve a cost analysis, though in an insufficient manner. None of the studies identified were laid out as a health economic evaluation. Hence, further research is strongly recommended.
PMCID: PMC3011306  PMID: 21289907
2.  The use of mesh in acute hernia: frequency and outcome in 99 cases 
Hernia  2011;15(3):297-300.
Incarceration of inguinal, umbilical and cicatricial hernias is a frequent problem. However, little is known about the relationship between the use of mesh and outcome after surgery. The goal of this study was to describe the relationship between the use of mesh in incarcerated hernia and the clinical outcome.
Patients and methods
Correspondence, operation reports and patient files between January 1995 and December 2005 of patients presented at one academic and one teaching hospital in Rotterdam were searched for the following keywords: incarceration, strangulation and hernia. The patient characteristics, clinical presentation, pre-operative findings and clinical course were scored and analysed.
A total of 203 patients could be identified: 76 inguinal, 52 umbilical, 39 incisional, 14 epigastric, 14 femoral, five trocar and three spigelian hernias. In the statistical analysis, epigastric, femoral, trocar and spigelian hernias were pooled, due to their small group sizes. One patient was excluded from the analysis because the hernia was not corrected during operation. In total, 99 hernias were repaired using mesh versus 103 primary suture repairs.
Twenty-five wound infections were registered (12.3%). One mesh was removed during a reintervention for anastomotic leakage, although no signs of wound infection were present. Nine patients died, none of them due to wound-related problems [one cardiovascular, one ruptured aneurysm, two anastomotic leakage, two sepsis e causa incognita (e.c.i.), three pulmonary complications]. Univariate analysis showed that female patients (P = 0.007), adipose patients (P = 0.016), patients with an umbilical hernia (P = 0.01) and patients who underwent a bowel resection (P = 0.015) had a significantly higher rate of wound infections. The type of repair (e.g. primary suture or mesh), use of antibiotic prophylaxis, gender, ASA class and age showed no significant relation with post-operative wound infection. After logistic regression analysis, only bowel resection (P = 0.020) showed a significant relation with post-operative wound infection.
Wound infection rates are high after the correction of acute hernia, but clinical consequences are relatively low. Mesh correction of an acute hernia seems to be safe and should be considered in every incarcerated hernia.
PMCID: PMC3114066  PMID: 21259032
Hernia; Abdominal; Acute
3.  Laparoscopic Incisional Hernia Repair in Obese Patients 
Background and Objectives:
Laparoscopic incisional hernia repair is coming to the forefront as a preferred method of repair due to the advantages offered by minimally invasive techniques. To evaluate safety and feasibility of this approach in obese patients when performed by a general surgeon trained in basic laparoscopy with no prior experience in this technique, we reviewed our early experience in the first 18 patients.
All patients with incisional hernias presenting to a single surgeon from 2000 to 2002 were offered laparoscopic repair. Patients were informed about the limited experience of the surgeon in this particular field. Those who consented were repaired laparoscopically using a standard 4-port technique, one 12-mm port and three 5-mm ports. All patients with body mass index ≥30 were included in this review. A retrospective review of the data included demographics, operative time, blood loss, hospital stay, postoperative complications, and patient satisfaction.
Nineteen laparoscopic repairs were completed in 18 patients. No conversions to open repair were necessary. All patients were females except for 2. All hernia sacs were left in place, some of which were empty while others required extensive lysis of adhesions to release sac contents. Mean fascial defect was 102.5 cm2. One defect was closed primarily without mesh, while the rest were closed using Composix mesh in 1 and Dual Plus Gore-Tex mesh in the rest. Three patients were discharged from the recovery room. Mean follow-up was 24 months. No wound or mesh infections occurred. Eight patients had no complications. Eight patients had asymptomatic seromas. Two patients had hematomas; none of them required drainage. One patient had nonspecific dizziness. One patient presented with bowel obstruction secondary to early recurrence (within a week). The repair was salvaged laparoscopically. Upon evaluation by telephone calls, all patients indicated extreme satisfaction with the results.
A general surgeon with training in basic laparoscopy can safely perform laparoscopic incisional hernia repair on obese patients with minimal complications. The procedure requires a short leaning curve of no more than 3 cases and few extra materials to be feasible at any hospital in the US. Patient satisfaction with this technique is certainly gratifying.
PMCID: PMC3015547  PMID: 15791970
Laparoscopy; Ventral hernia; Incisional hernia; Obesity
4.  Laparoscopic Hernia Repair: a Two-Port Technique 
Results of this study suggest that laparoscopic herniorrhaphy with a 2-port technique may allow a safe, efficient repair of ventral and incisional hernias.
Various ventral and incisional hernia repair techniques exist and have largely replaced the open ones. The purpose of this study was to document the 2-port technique and demonstrate that it is feasible, efficient, and safe. To our knowledge, this is the largest report on this topic to date in the English-language literature.
Forty patients with ventral hernias (VH) or incisional hernias (IH) underwent laparoscopic repair with a 2-port technique. The technique involves insertion of one 10-mm to 12-mm balloon port and one 5-mm port, usually on the left side as laterally as possible. A mesh is inserted through the balloon port site and secured to the abdominal wall by using either 4 peripheral or 1 central Prolene suture. Helical fasteners are used to attach the mesh to the abdominal wall.
Forty patients with 47 hernias underwent repair. Operating time ranged from 15 minutes to 70 minutes. Early complications were seen in 5 patients and included 1 small bowel enterotomy, 2 small bowel obstructions (SBO) with bowel adhering to the visceral side of the mesh, 1 wound infection, and 1 seroma. Late postoperative complications occurred in 8 patients (20%) who experienced persistent abdominal pain that resolved without any treatment. There was one recurrence during a mean follow-up of 23.5 months.
Laparoscopic herniorrhaphy with the 2-port technique offers an efficient, safe, and effective repair for ventral and incisional hernias.
PMCID: PMC3021302  PMID: 20529535
Laparoscopy; Ventral hernia; Two-port technique
5.  Modified onlay technique for the repair of the more complicated incisional hernias: single-centre evaluation of a large cohort 
Hernia  2010;14(4):369-374.
The repair of incisional hernias remains a challenge for the general surgeon. Indications for surgery are severe bowel obstruction, as well as aesthetic problems. There are various surgical methods to correct these hernias, with varying results. However, the gold standard has not yet been found. Both laparoscopic repair and the component separation technique (CTS) have proven to be acceptable techniques; however, they are not always suitable for resolving the more complicated abdominal wall defects, i.e. after open-abdomen treatment or fascial necrosis. In our hospital, we developed a new onlay technique which we have evaluated in the following research.
Patients and methods
During a period of 10 years (1996–2007), 101 patients with an incisional hernia were corrected with the new onlay technique. A Marlex mesh of dimensions at least 10 × 20 cm was used, overlapping the fascia by at least 5 cm on each side. This mesh was stapled onto the fascia with skin staples. Of the 101 patients, there were 45 men and 56 women, with a mean age of 55 years. Nine patients died and 13 were lost during follow-up. Of the remaining 79 patients, eight refused to participate. The mean follow-up time was 64 months (normal distribution, standard deviation [SD] 34 months). This cohort of 101 patients was studied retrospectively.
Seventy-one of the 101 patients were evaluated at our out-patient clinic. For 24 patients (25%), the operation was for a recurrence after an incisional hernia correction in the past. Twenty-one patients (20%) had an open-abdomen treatment in their medical history. The surgical procedure was technically possible in all patients and the mean operation time was 63 min. The median admission time was 4.5 days (quartiles 3–6.25). The mean follow-up time was 64 months (SD 35 months). A seroma was reported in 27 of 101 patients (27%) and a wound infection in 22 patients (21%), of which seven patients had to be re-operated. Only if a patient was evaluated at our out-patient clinic could reherniation have been scored; this occurred in 11 of 71 patients (16%).
This technique is an effective and simple procedure to correct incisional hernias with acceptable complication rates and is feasible even in the more complicated hernias.
PMCID: PMC2908454  PMID: 20229287
Incisional hernia; Abdominal wall defects; Mesh repair; Hernia
6.  Characterizing laparoscopic incisional hernia repair 
Canadian Journal of Surgery  2007;50(3):195-201.
Laparoscopic repair of ventral and incisional hernias (LVIHRs) is feasible; however, many facets of this procedure remain poorly defined. The indications, essential technical features and postoperative management should be standardized to optimize outcomes and facilitate training in this promising approach to incisional hernia repair.
All patients referred to one surgeon at a tertiary care centre for LVIHR from 1999 to 2004 were analyzed. Patient records were analyzed and perioperative outcomes were documented.
Of the 69 patients who were referred for management of incisional hernia, 64 underwent LVIHR. The mean age of patients selected for surgery was 61.4 years (28% of patients over age 70 years); their mean body mass index (BMI) was 32.8 kg/m2 and mean American Association of Anaesthetists (ASA) score was 2.5 (52% of patients had an ASA score equal to 3). The mean operating time was 130.7 minutes for a mean abdominal wall defect of 123.9 cm2 and a mean prosthetic mesh size of 344 cm2. Patients with recurrent incisional hernias and previous prosthetic mesh were the most challenging, with a mean BMI of 39 kg/m2, mean operating time of 191 minutes, mean defect of 224 cm2 and mean prosthetic mesh size of 508 cm2. One patient was converted to open surgery and, in 2 patients, small bowel injuries were repaired laparoscopically without adverse sequelae. The mean length of stay was 4.5 days (median 3.0 d). Postoperatively, 78% of patients developed seromas within the residual hernia sac. All seromas were managed nonoperatively; one-half resolved by 7 weeks, and larger seromas persisted for up to 24 weeks. There was an 18.7% rate of minor complications and a 3.1% rate of major complications (no deaths). After a mean follow-up of 7.7 months, 2 recurrent hernias (3.1%) were identified in patients with multiple previous open mesh repairs.
Although LVIHR may be challenging, it has the potential to be considered a primary approach for most ventral and incisional hernias, regardless of patient status or hernia complexity.
PMCID: PMC2384279  PMID: 17568491
7.  Laparoscopic incisional and ventral hernia repair 
It has been more than a decade, since the introduction of laparoscopic management of ventral and incisional hernia. The purpose of this article was to systematically review the literature, analyze the results of Laparoscopic repair of ventral and incisional hernia and to ascertain its role.
Materials and Methods:
Pubmed was used for identifying the original articles. Both incisional and ventral hernia repair were included. Out of 145 articles extracted from Pubmed, 34 original studies were considered for review. More than three thousand patients were included in the review. Variables analyzed in the review were inpatient stay, defect size, mesh size, hematoma, seroma, wound infection, bowel perforation, obstruction, ileus, recurrence and pain. Qualitative analysis of the variables was carried out.
Seromas (5.45%) and post operative pain (2.75%) are the two common complications associated with this procedure. Recurrence rate was found to be 3.67%. Overall complication rate was 19.24%, with two deaths reported.
The results suggest laparoscopic repair of ventral and incisional hernia as an effective procedure. Faster recovery and shorter in patient stay - makes it a feasible alternative to open repair.
PMCID: PMC2749189  PMID: 19789663
Incisional hernia; laparoscopy; mesh; repair; ventral hernia
8.  Short- and long-term outcomes of incarcerated inguinal hernias repaired by Lichtenstein technique 
The use of tension-free inguinal hernia repair techniques using commercially available implants is now rather common. However, it is widely accepted that the use of biomaterials should be limited to non-infected surgical fields. As such, most current studies pertain to the application of various implants during the surgical repair of uncomplicated hernias.
To compare the short- and long-term outcomes of incarcerated inguinal hernia repair using the Lichtenstein or Bassini technique.
Material and methods
Between 1997 and 2012, 107 patients were operated on an emergency basis due to the incarceration of inguinal hernias – 105 subjects were included for further analysis in our study.
Postoperative complications were observed in 13 out of the 84 (15.5%) patients subjected to Lichtenstein repair. In 9 of these patients (10.7%), morbidity was associated with the surgical wound. In 2 cases (2.4%), a small inflammatory infiltration was observed and resolved within a few days. Serous fluid accumulation within the wound was observed in 3 patients (3.6%), but the fluid was successfully drained by puncture. Finally, hematoma formed in 4 cases (4.8%). In total, 4 complications (19%) were recorded in the group of 21 patients who were operated on with the Bassini technique. In 3 of these cases (14.3%), the complications were related to suppuration of the surgical wound.
Polypropylene mesh may be safely implanted during the repair of incarcerated hernia and this approach is reflected by satisfactory long-term outcomes.
PMCID: PMC4105675  PMID: 25097686
incarcerated inguinal hernias; Lichtenstein technique
9.  Incisional Hernia in Women: Predisposing Factors and Management Where Mesh is not Readily Available 
Background / Aim: Incisional hernia is still relatively common in our practice. The aim of the study was to identify risk factors associated with incisional hernia in our region. The setting is the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria during a period when prosthetic mesh was not readily available. Patients and Methods: All the women who presented with incisional hernia between 1996 and 2005 were prospectively studied using a standard form to obtain information on pre-hernia (index) operations and possible predisposing factors. They all had open surgical repair and were followed up for 18–60 months. Results: Forty-four women were treated during study period. The index surgeries leading to the hernias were emergency caesarian section 26/44 (59.1%), emergency exploratory laparotomy 6/44 (13.6%), and elective surgeries 12/44 (27.3%). Major associated risk factors were the use of wrong suture materials for fascia repair, midline incisions, wound sepsis, and overweight. Conclusion: For elective surgeries, reduction of weight should be encouraged when appropriate, and transverse incisions are preferred. Absorbable sutures, especially chromic catgut, should be avoided in fascia closure. Antibiotics should be used for complicated obstetric cases.
PMCID: PMC3066721  PMID: 21483511
Incisional hernia; Women; Predisposing factors; Nigeria
10.  Analysis of Risk Factors for the Development of Incisional and Parastomal Hernias in Patients after Colorectal Surgery 
The purpose of this study was to evaluate the overall rate and risk factors for the development of an incisional hernia and a parastomal hernia after colorectal surgery.
The study cohort consisted of 795 consecutive patients who underwent open colorectal surgery between 2005 and 2007 by a single surgeon. A retrospective analysis of prospectively collected data was performed.
The overall incidence of incisional hernias was 2% (14/690). This study revealed that the cumulative incidences of incisional hernia were 1% at 12 months and 3% after 36 months. Eighty-six percent of all incisional hernias developed within 3 years after a colectomy. The overall rate of parastomal hernias in patients with a stoma was 6.7% (7/105). The incidence of parastomal hernias was significantly higher in the colostomy group than in the ileostomy group (11.9% vs. 0%; P = 0.007). Obesity, abdominal aortic aneurysm, American Society of Anesthesiologists score, serum albumin level, emergency surgery and postoperative ileus did not influence the incidence of incisional or parastomal hernias. However, the multivariate analysis revealed that female gender and wound infection were significant risk factors for the development of incisional hernias female: P = 0.009, wound infection: P = 0.041). There were no significant factors related to the development of parastomal hernias.
Our results indicate that most incisional hernias develop within 3 years after a colectomy. Female gender and wound infection were risk factors for the development of an incisional hernia after colorectal surgery. In contrast, no significant factors were found to be associated with the development of a parastomal hernia.
PMCID: PMC3548144  PMID: 23346508
Ventral hernia; Surgical stomas; Ileostomies; Colostomies
11.  Allograft AlloDerm® tissue for laparoscopic transabdominal preperitoneal groin hernia repair: A case report 
Synthetic mesh is the prosthetic material used for most inguinal hernioplasties. However, when left in contact with intra-abdominal viscera, it often becomes associated with infection and migration, particularly in irradiated tissues, contaminated fields, immunosuppressed individuals, and patients with intestinal obstruction or fistula. AlloDerm® Regenerative Tissue Matrix (LifeCell Corporation, Branchburg, NJ) is derived from human cadaver skin and may be associated with fewer visceral adhesions and more durability in infected fields than synthetic mesh.
We report the first case in which AlloDerm was used in a laparoscopic transabdominal preperitoneal repair of a multiple recurrent right inguinal hernia, a left femoral hernia, and an umbilical hernia in the same patient. Use of AlloDerm greatly enhanced the maneuverability during laparoscopic hernia repair due to its pliability and strength and eliminated the need to cover the prosthetic with peritoneum.
Previous pelvic radiation and multiple previous groin repairs can render the peritoneum friable, resulting in obstacles to successful closure. AlloDerm is a reasonable choice for groin hernia repairs when such factors are present.
The long-term durability of AlloDerm for laparoscopic groin hernia repairs is yet to be determined, but based on current data it seems prudent to use this technique in laparoscopic repair of complex groin hernias where infection is suspected or inadequate prosthetic coverage with peritoneum is anticipated.
PMCID: PMC4066573  PMID: 24780773
AlloDerm; Inguinal hernia; Femoral hernia; Recurrent hernia; Laparoscopic hernia repair
12.  Surgical management of inguinal hernias at Bugando Medical Centre in northwestern Tanzania: our experiences in a resource-limited setting 
BMC Research Notes  2012;5:585.
Inguinal hernia repair remains the commonest operation performed by general surgeons all over the world. There is paucity of published data on surgical management of inguinal hernias in our environment. This study is intended to describe our own experiences in the surgical management of inguinal hernias and compare our results with that reported in literature.
A descriptive prospective study was conducted at Bugando Medical Centre in northwestern Tanzania. Ethical approval to conduct the study was obtained from relevant authorities before the commencement of the study. Statistical data analysis was done using SPSS software version 17.0.
A total of 452 patients with inguinal hernias were enrolled in the study. The median age of patients was 36 years (range 3 months to 78 years). Males outnumbered females by a ratio of 36.7:1. This gender deference was statistically significant (P = 0.003). Most patients (44.7%) presented late (more than five years of onset of hernia). Inguinoscrotal hernia (66.8%) was the commonest presentation. At presentation, 208 (46.0%) patients had reducible hernia, 110 (24.3%) had irreducible hernia, 84 (18.6%) and 50(11.1%) patients had obstructed and strangulated hernias respectively. The majority of patients (53.1%) had right sided inguinal hernia with a right-to-left ratio of 2.1: 1. Ninety-two (20.4%) patients had bilateral inguinal hernias. 296 (65.5%) patients had indirect hernia, 102 (22.6%) had direct hernia and 54 (11.9%) had both indirect and direct types (pantaloon hernia). All patients in this study underwent open herniorrhaphy. The majority of patients (61.5%) underwent elective herniorrhaphy under spinal anaesthesia (69.2%). Local anaesthesia was used in only 1.1% of cases. Bowel resection was required in 15.9% of patients. Modified Bassini’s repair (79.9%) was the most common technique of posterior wall repair of the inguinal canal. Lichtenstein mesh repair was used in only one (0.2%) patient. Complication rate was 12.4% and it was significantly higher in emergency herniorrhaphy than in elective herniorrhaphy (P = 0.002). The median length of hospital stay was 8 days and it was significantly longer in patients with advanced age, delayed admission, concomitant medical illness, high ASA class, the need for bowel resection and in those with surgical repair performed under general anesthesia (P < 0.001). Mortality rate was 9.7%. Longer duration of symptoms, late hospitalization, coexisting disease, high ASA class, delayed operation, the need for bowel resection and presence of complications were found to be predictors of mortality (P < 0.001).
Inguinal hernias continue to be a source of morbidity and mortality in our centre. Early presentation and elective repair of inguinal hernias is pivotal in order to eliminate the morbidity and mortality associated with this very common problem.
PMCID: PMC3526506  PMID: 23098556
Inguinal hernias; Surgical management; Treatment outcome; Predictors of outcome; Tanzania
13.  The INCH-Trial: a multicentre randomized controlled trial comparing the efficacy of conventional open surgery and laparoscopic surgery for incisional hernia repair 
BMC Surgery  2013;13:18.
Annually approximately 100.000 patients undergo a laparotomy in the Netherlands. About 15,000 of these patients will develop an incisional hernia. Both open and laparoscopic surgical repair have been proven to be safe. However, the most effective treatment of incisional hernias remains unclear. This study, the ‘INCH-trial’, comparing cost-effectiveness of open and laparoscopic incisional hernia repair, is therefore needed.
A randomized multi-center clinical trial comparing cost-effectiveness of open and laparoscopic repair of incisional hernias. Patients with a symptomatic incisional hernia, eligible for laparoscopic and open incisional hernia repair. Only surgeons, experienced in both open and laparoscopic incisional hernia repair, will participate in the INCH trial. During incisional hernia repair, a mesh is placed under or on top of the fascia, with a minimal overlap of 5 cm. Primary endpoint is length of hospital stay after an incisional hernia repair. Secondary endpoints are time to full recovery within three months after index surgery, post-operative complications, recurrences, mortality and quality of life.
Our hypothesis is that laparoscopic incisional hernia repair comes with a significant shorter hospital stay compared to open incisional hernia repair. A difference of two days is considered significant. One-hunderd-and-thirty-five patients are enrolled in each treatment arm. The economic evaluation will be performed from a societal perspective. Primary outcomes are costs per patient related to time-to-recovery and quality of life.
The main goal of the trial is to establish whether laparoscopic incisional hernia repair is superior to conventional open incisional hernia repair in terms of cost-effectiveness. This is measured through length of hospital stay and quality of life. Secondary endpoints are re-operation rate due to post-operative complications or recurrences, mortality and quality of life.
The difference in time to full recovery between the two treatment strategies is thought to be in favor of laparoscopic incisional hernia repair. Laparoscopic incisional hernia repair is therefore expected to be a more cost-effective approach.
Trial registration
Netherlands Trial register: NTR2808
PMCID: PMC3680330  PMID: 24499061
14.  Early outcome of incisional hernia repair using polypropylene mesh: A preliminary report 
The use of prosthetics for open repair of incisional hernia is very recent in our practice. We highlight our experience repairing incisional hernias with polypropylene mesh.
Patients and Methods:
Patients presenting with incisional hernia >5 cm in length or width received open polypropylene mesh repair and were followed for two years. Data obtained included age, sex, primary surgery causing the hernia, the length of the fascial defect and previous attempts at repair. Post-operative wound complications were recorded. The integrity of the scar and patient satisfaction or concerns with the repair was assessed at each visit.
Nineteen females with a mean age of 35 years (range 30-54) underwent repair; most arising from obstetric or gynaecological procedures. Sixteen (82.2%) had midline, 2 (10.5) transverse and 1 (5.3) Pfannenstiel scars. One patient had no previous repair (R0), 7 had undergone one repair (R1), 9 had undergone two repairs (R2) and 1 had three previous repairs (R3). The length of fascial defects ranged from 8 to 18 cm and seroma collection and stitch sinus were the common problems encountered. Two (10.5%) recurrences were recorded in two years.
Open mesh repair of incisional hernia carries a low risk of infection and recurrence in two years.
PMCID: PMC4124548  PMID: 25114370
Incisional hernia; low recurrence; polypropylene mesh; seroma
15.  Low recurrence rate of a two-layered closure repair for primary and recurrent midline incisional hernia without mesh 
Hernia  2009;13(4):421-426.
Incisional hernia is a serious complication after abdominal surgery and occurs in 11–23% of laparotomies. Repair can be done, for instance, with a direct suture technique, but recurrence rates are high. Recent literature advises the use of mesh repair. In contrast to this development, we studied the use of a direct suture repair in a separate layer technique. The objective of this retrospective observational study is to assess the outcomes (recurrences and complications) of a two-layered open closure repair for primary and recurrent midline incisional hernia without the use of mesh.
In an observational retrospective cohort study, we analysed the hospital and outpatient records of 77 consecutive patients who underwent surgery for a primary or recurrent incisional hernia between 1st May 2002 and 8th November 2006. The repair consisted of separate continuous suturing of the anterior and posterior fascia, including the rectus muscle, after extensive intra-abdominal adhesiolysis.
Forty-one men (53.2%) and 36 women (46.8%) underwent surgery. Sixty-three operations (81.8%) were primary repairs and 14 (18.2%) were repairs for a recurrent incisional hernia. Of the 66 patients, on physical examination, three had a recurrence (4.5%) after an average follow-up of 2.6 years. The 30-day postoperative mortality was 1.1%. Wound infection was seen in five patients (6.5%).
A two-layered suture repair for primary and recurrent incisional hernia repair without mesh with extensive adhesiolysis was associated with a recurrence rate comparable to mesh repair and had an acceptable complication rate.
PMCID: PMC2719741  PMID: 19296196
Ventral hernia; Abdominal hernia; Suture repair; Direct repair; Recurrence
16.  Parastomal hernias successfully repaired using a modified components separation method: two case reports 
Parastomal hernia is a frequent complication after enterostomy formation. A repair using prosthetic mesh by way of a laparoscopic or open transabdominal approach is usually recommended, however, other procedures may be done if the repair is to be performed in a contaminated environment or when the abdominal cavity of the patient is difficult to enter due to postsurgical dense adhesion. The components separation method, which was introduced for non-transabdominal and non-prosthetic ventral hernia repair, solves such problems.
Case presentation
Case 1. A 79-year-old Japanese woman who underwent total cystectomy with ileal conduit for bladder cancer presented with a parastomal hernia, which was repaired using a keyhole technique. Simultaneously, an incisional hernia in the midline was repaired with a prosthetic mesh. One year after her hernia surgery, a recurrence occurred lateral to the stoma, but it was believed to be difficult to enter the peritoneal cavity because of the wide placement of mesh. Therefore, surgery using the components separation method was performed.
Case 2. A 72-year-old Japanese man underwent an abdominoperineal resection for rectal cancer. At 5 and 12 months after his operation, a perineal hernia and an incisional hernia in the midline were repaired with prosthesis using a transabdominal approach, respectively. Three years after his rectal surgery, a parastomal hernia developed lateral to the stoma. For the same reason as case 1, surgery using the components separation method was performed. No recurrence was observed in either case as of 40 and 8 months after the last repair, respectively.
The components separation method is a novel and effective technique for parastomal hernia repair, especially in cases following abdominal polysurgery or midline incisional hernia repairs using large pieces of mesh. To the best of our knowledge, this is the first report in English on the application of the components separation method for parastomal hernia repair.
PMCID: PMC3711726  PMID: 23830070
Parastomal hernia; Components separation method; Incisional hernia; Repair
17.  Non-crosslinked porcine-derived acellular dermal matrix for the management of complex ventral abdominal wall hernias: a report of 45 cases 
Hernia  2013;18(1):71-79.
Ventral abdominal wall hernias are common and repair is frequently associated with complications and recurrence. Although non-crosslinked intact porcine-derived acellular dermal matrix (PADM) has been used successfully in the repair of complex ventral hernias, there is currently no consensus regarding the type of mesh and surgical techniques to use in these patients. This report provides added support for PADM use in complex ventral hernias.
In a consecutive series of adult patients (2008–2011), complex ventral abdominal wall hernias (primary and incisional) were repaired with PADM by a single surgeon. Patient comorbidities, repair procedures, and postoperative recovery, recurrence, and complications were noted.
Forty-four patients (mean age, 57.5 years) underwent 45 single-stage ventral abdominal wall hernia repairs (3 primary; 42 incisional). Previously placed synthetic mesh was removed in 17 cases. In 40 cases, primary fascial closure was achieved; in 5 cases, PADM was used as a bridge. Vacuum-assisted closure (VAC) was used for 38/45 cases: 19 closed incisions, 16 cases using the “French fry” technique, and 3 cases with open incisions. Mean hospital stay was 8.2 days (range, 3–32) and mean follow-up was 17 months (range, 1–48). There were 4 (8.9 %) hernia recurrences, 3 requiring additional repair and 1 requiring PADM explantation. There were 3 (6.7 %) skin dehiscences, 4 (8.9 %) deep wound infections requiring drainage, and 5 (11.1 %) seromas (4 self-limited, 1 requiring drainage).
Non-crosslinked intact PADM yielded favorable early outcomes when used to repair complex ventral abdominal wall hernias in high-risk patients.
Electronic supplementary material
The online version of this article (doi:10.1007/s10029-013-1148-x) contains supplementary material, which is available to authorized users.
PMCID: PMC3902083  PMID: 23934355
Ventral abdominal wall hernias; Non-crosslinked intact porcine-derived acellular dermal matrix; Vacuum-assisted closure; Synthetic mesh; Biologic acellular dermal matrix; Strattice
18.  Incisional hernia appendicitis: A report of two unique cases and literature review 
Acute appendicitis is a common surgical emergency. The presence of an inflamed appendix in an incisional hernia is rare. Incisional hernias complicate both open and laparoscopic surgery.
We describe two unique cases of acute appendicitis within incisional hernias following an open cholecystectomy and a diagnostic laparoscopy. Acute appendicitis was diagnosed intraoperatively and a formal appendicectomy was performed with subsequent primary repair of the hernial defect in each case.
The method chosen for primary repair of an incisional hernia containing an acutely inflamed appendix depends on a number of factors including size of hernial defect and degree of contamination. Closure of 5 mm port sites is not routine in current surgical practice. Herniation of intra-abdominal contents through such defects can occur rarely. The repair of an incisional hernia using mesh in a contaminated surgical field is controversial. There may be advantages in the use of biological meshes.
Surgical awareness of potential complications relating to the management of incisional hernia appendicitis is of primary importance in determining intraoperative strategy.
PMCID: PMC3604693  PMID: 23333806
Acute appendicitis; Incisional hernia; Port site hernia
19.  A rare approach to entero-atmospheric fistula 
Patient: Female, 60
Final Diagnosis: Recurrent incisional hernia
Symptoms: —
Medication: —
Clinical Procedure: Limited ileo-cecal resection
Specialty: Surgery
Diagnostic/therapeutic accidents
Iatrogenic entero-atmospheric fistula is devastating and its management is extremely difficult because it is often associated with fluid and electrolyte disturbances, nutritional problems, and life-threatening sepsis.
Case Report:
A 60-year-old woman underwent laparoscopic repair of a recurrent incisional hernia that was complicated by iatrogenic cecal injury necessitating a limited ileocecal resection and onlay prosthetic mesh repair of the hernia. Postoperatively, sloughing of the overlying skin led to mesh exposure. An attempted rotational flap coverage was complicated by small bowel injury, which was recognized and repaired. However, an entero-atmospheric fistula developed after the removal of contaminated mesh. The fistula was initially treated by vacuum-assisted closure dressing and later was converted to a ‘stoma’. Six months later, the small bowel segment bearing the fistula was excised and bowel continuity was restored.
In selected cases, the conversion of entero-atmospheric fistula to a ‘stoma’ allows the patient to be discharged home early and maintain good nutritional status while awaiting the definitive surgical intervention.
PMCID: PMC3835275  PMID: 24265846
laparoscopy; incisional hernia repair; colon injury; entero-atmospheric fistula; stoma
20.  Components Separation Technique Combined with a Double-Mesh Repair for Large Midline Incisional Hernia Repair 
World Journal of Surgery  2011;35(11):2399-2402.
The surgical treatment of large midline incisional hernias remains a challenge. The aim of this report is to present the results of a new technique for large midline incisional hernia repair which combines the components-separation technique with a double-prosthetic-mesh repair.
The records of all consecutive patients who received a double-mesh combined with the components-separation technique for ventral hernia repair were reviewed. The clinical, surgical, and follow-up data were analyzed.
Nine patients [3 women, 6 men; median age = 62 years (range = 26–77)] were included in the study. Median transverse defect size was 20 cm (range = 15–25). The median duration of hospital stay was 8 days (range = 5–17). Postoperative complications occurred in 66% (6/9). Follow-up [median = 13 months (range = 3–49)] showed no recurrent hernias, but one patient had a small hernia after a relaparotomy for colon carcinoma recurrence. The overall occurrence of wound infections was 44% (4/9). There was no mortality.
The components-separation technique in combination with a double-mesh has shown a low recurrence rate in the short-term follow-up. However, there is a considerable occurrence of postoperative wound infections. Long-term results of the hernia recurrence rate have to be awaited.
PMCID: PMC3191289  PMID: 21882019
21.  The laparoscopic modified Sugarbaker technique is safe and has a low recurrence rate: a multicenter cohort study 
Surgical Endoscopy  2012;27(2):494-500.
Parastomal hernia is a frequent complication of intestinal stomata. Mesh repair gives the best results, with the mesh inserted via laparotomy or laparoscopically. It was the aim of this retrospective multicenter study to determine the early and late results of the laparoscopically performed, modified Sugarbaker technique with ePTFE mesh.
From 2005 to 2010, a total of 61 consecutive patients (mean age = 61 years), with a symptomatic parastomal hernia, underwent laparoscopic repair using the modified Sugarbaker technique with ePTFE mesh. Fifty-five patients had a colostomy, 4 patients an ileostomy, and 2 a urostomy according to Bricker. The records of the patients were reviewed with respect to patient characteristics, postoperative morbidity, and mortality. All patients underwent physical examination after a follow-up of at least 1 year to detect a recurrent hernia. Morbidity rate was 19 % and included wound infection (n = 1), ileus (n = 2), trocar site bleeding (n = 2), reintervention (n = 2), and pneumonia (n = 1). One patient died in the postoperative period due to metastasis of lung carcinoma that caused bowel obstruction. Concomitant incisional hernias were detected in 25 of 61 patients (41 %) and could be repaired at the same time in all cases. A recurrent hernia was found in three patients at physical examination, and in one patient an asymptomatic recurrence was found on a CT scan. The overall recurrence rate was 6.6 % after a mean follow-up of 26 months.
The laparoscopic Sugarbaker technique is a safe procedure for repairing parastomal hernias. In our study, the overall morbidity was 19 % and the recurrence rate was 6.6 % after a mean follow-up of 26 months. Moreover, the laparoscopic approach revealed concomitant hernias in 41 % of the patients, which could be repaired successfully at the same time.
PMCID: PMC3580038  PMID: 23052490
Parastomal; Hernia; Sugarbaker; ePTFE; GoreTex; Mesh repair
22.  Laparoscopic repair of incisional and ventral hernias with the new type of meshes: randomized control trial 
Laparoscopic incisional and ventral hernia repair (LIVHR) was first reported by Le Blanc and Booth in 1993. Many studies are available in the literature that have shown that laparoscopic repair of incisional and ventral hernia is preferred over open repair because of lower recurrence rates (less than 10%), less wound morbidity, less pain, and early return to work.
To identify the long-term outcomes between the different types of meshes and two techniques of mesh fixation, i.e., tacks (method Double crown) and transfascial polypropylene sutures.
Material and methods
A total of 92 patients underwent LIVHR at our department between January 2009 and August 2012. The hernias were umbilical in 26 patients, paraumbilical in 15 patients and incisional in 51 patients. All patients admitted for LIVHR were randomized to either group I (tacker fixation of ePTFE meshes) or group II (suture fixation of meshes with nitinol frame) using computer-generated random numbers with block randomization and sealed envelopes for concealed allocation.
The mean mesh fixation time was significantly higher in the tacker fixation group (117 ±15 min vs. 72 ±6 min, p < 0.01). There were no conversions in either group. The median postoperative hospital stay was 3.5 ±1.5 days. All patients were followed up at 1, 3, 6, 12 and every 6 months thereafter postoperatively. There were 5 recurrences in the study population. In group I there were 4 patients with recurrence, and only 1 patient in the group with meshes with a nitinol frame.
Meshes of the new generation with a nitinol framework can significantly improve laparoscopic ventral hernia repair. The fixation of these meshes is very simple using 3–4 transfascial sutures. The absence of shrinkage of these meshes makes the probability of recurrence minimal. Absence of tackers allows postoperative pain to be minimized. We consider that these new meshes can significantly improve laparoscopic ventral hernia repair.
PMCID: PMC4105668  PMID: 25097679
laparoscopic hernia repair; meshes; ventral hernia
23.  Polyester Composite Versus PTFE in Laparoscopic Ventral Hernia Repair 
This study demonstrated no significant association between polyester composite and PTFE mesh and postoperative complications.
Both polyester composite (POC) and polytetrafluoroethylene (PTFE) mesh are commonly used for laparoscopic ventral hernia repair. However, sparse information exists comparing perioperative and long-term outcome by mesh repair.
A prospective database was utilized to identify 116 consecutive patients who underwent laparoscopic ventral hernia repair at The Mount Sinai Hospital from 2004-2009. Patients were grouped by type of mesh used, PTFE versus POC, and retrospectively compared. Follow-up at a mean of 12 months was achieved by telephone interview and office visit.
Of the 116 patients, 66 underwent ventral hernia repair with PTFE and 50 with POC mesh. Patients were well matched by patient demographics. No difference in mean body mass index (BMI) was demonstrated between the PTFE and POC group (31.8 vs. 32.5, respectively; P=NS). Operative time was significantly longer in the PTFE group (136 vs.106 minutes, P<.002). Two perioperative wound infections occurred in the PTFE group and none in the POC group (P=NS). No other major complications occurred in the immediate postoperative period (30 days). At a mean follow-up of 12 months, no significant difference was demonstrated between the PTFE and POC groups in hernia recurrence (3% vs. 2%), wound complications (1% vs. 0%), mesh infection, requiring removal (3% vs. 0%), bowel obstruction (3% vs. 2%), or persistent pain or discomfort (28% vs. 32%), respectively (P=NS).
Our study demonstrated no significant association between types of mesh used and postoperative complications. In the 12-month follow-up, no differences were noted in hernia recurrence.
PMCID: PMC3183558  PMID: 21985714
Laparoscopic ventral hernia repair; Mesh repair; PTFE; Polyester; Ventral hernia
24.  A Comparative Analysis on Various Techniques of Incisional Hernia Repair–Experience from a Tertiary Care Teaching Hospital in South India 
The Indian Journal of Surgery  2012;75(4):271-273.
This prospective study was conducted at a tertiary care teaching hospital in South India over a period of 7 years and included 90 patients with incisional hernia (n = 90; 76 females and 14 males), operated over 2 years (January 2004 to December 2005), and followed-up for 5 years postoperatively (2005–2009). As per the surgical unit preference, patients underwent different methods of hernia repair—onlay mesh repair (n = 45, 50 %), underlay mesh repair (n = 18, 20 %), and anatomical repair (i.e., without mesh) (n = 27, 30 %). Parameters studied included seroma formation, wound infection, postoperative pain, and hernia recurrence. Although the first two parameters were statistically not significant, postoperative pain was found to be more in patients who underwent an underlay repair. A significant difference in the hernia recurrence rate was observed between mesh repair and anatomical repair groups. Hence, we conclude that all incisional hernias should be repaired with a mesh (meshplasty).
PMCID: PMC3726823  PMID: 24426451
Incisional hernia; Mesh repair; Recurrence
25.  A double blind randomized controlled trial comparing primary suture closure with mesh augmented closure to reduce incisional hernia incidence 
BMC Surgery  2013;13:48.
Incisional hernia is the most frequently seen long term complication after laparotomy causing much morbidity and even mortality. The overall incidence remains 11-20%, despite studies attempting to optimize closing techniques. Two patient groups, patients with abdominal aortic aneurysm and obese patients, have a risk for incisional hernia after laparotomy of more than 30%. These patients might benefit from mesh augmented midline closure as a means to reduce incisional hernia incidence.
The PRImary Mesh Closure of Abdominal Midline Wound (PRIMA) trial is a double-blinded international multicenter randomized controlled trial comparing running slowly absorbable suture closure with the same closure augmented with a sublay or onlay mesh. Primary endpoint will be incisional hernia incidence 2 years postoperatively. Secondary outcomes will be postoperative complications, pain, quality of life and cost effectiveness.
A total of 460 patients will be included in three arms of the study and randomized between running suture closure, onlay mesh closure or sublay mesh closure. Follow-up will be at 1, 3, 12 and 24 months with ultrasound imaging performed at 6 and 24 months to objectify the presence of incisional hernia. Patients, investigators and radiologists will be blinded throughout the whole follow up.
The use of prosthetic mesh has proven effective and safe in incisional hernia surgery however its use in a prophylactic manner has yet to be properly investigated. The PRIMA trial will provide level 1b evidence whether mesh augmented midline abdominal closure reduces incisional hernia incidence in high risk groups.
Trial registration
Clinical NCT00761475.
PMCID: PMC3840708  PMID: 24499111

Results 1-25 (1157199)