Meshed ventral hernias

meshed ventral herniaI have read the recent discussion on hernia, especially ventral hernia. The last time I used a mesh repair was in a refugee from some unfortunate country, from Iraque I believe, 7-8 years ago. He had been shot in the abdomen during the war and had had about 20 operations and was eventually referred to us with a large segment of his abdominal muscle wall gone and much of what remained was a fibrous scar. The defect was repaired with 2 or 3 Goretex patches and healed remarkably well; I say so because I was surprised.

This week I repaired an unfortunate woman who was striken by the flesh eating killer bacteria a year and a half ago. The beta-strepts ate a large segment of the lower right abdomen which had to be excised and eventually grafted. She made it and it was now time to repair the large defect. She had part of the rectus abdominis left with muscle fibres fanned out and there was a 2-3 cm segment of the oblique muscles remaining along their insertion on the pelvis. It was possible to dissect out the bowel loops. The abdominal skin and fat was raised from the left rectus abdominis and the anterior rectus sheet was incised along the lateral margin about 25 cm long from above the umbilicus. The relaxing incision widenend broadly and it was possible to transpose and suture to the remains of the oblique muscle closing the gap. I used a running Maxon loop which is my preferred suture.

Having said that I also admit that ventral hernias are not a big thing in our practice. Most of them are intensive care patients who have been treated with open abdomens and need a secondary hernia repair. It always seems possible to approximate the rectus abdominis to the midline. I suture muscle to muscle, never use fascia or any other substitue to bridge the gap. I sometimes use relaxing incisions into the anterior rectus sheet, placing them rather laterally. The midline is closed with a running suture exactly the way I close other midline incisions. The trick may be the proper lateral dissection of bowel and skin and subcutaneous tissue, and to excise most of the scar. The suture is single running wide bites through the rectus sheets and muscle, and minimal tension. Restoring bowel continuity at the same time is another reason not to use mesh.

I do the same when colonic or other cancer infiltrate through the abdominal wall. Or I just leave it open to secondary healing because such wounds of the size of the palm of the hand will shrink in healing usually without a hernia. One must leave the skin wound open as well or closure will not happen. I do not see many trauma wounds with abdominal defects but assume many US surgeons have the same experience.

I got worried by statement that most studies report 50% recurrence for simple tissue repair. I do not know the precise recurrence rate of such repairs here but the patients will come back to us because there is no other place they can go to have a second repair.

I got even more worried to learn that mesh repairs are so common in the US. I did a Medline search and found almost nothing but mesh repairs. That seems crazy to me and I certainly support Eric4s vivid description of this folly and his statement to the effect that virtually every case can be closed primarily with no problem. (Which is the reason why the spread of mesh repairs had escaped me).

Are all these mesh repairs only an excuse to write yet another paper about it. Or is it an industry driven practice? There is time for reappraisal.

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