Meshed ventral hernias
I 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.
Some people unfortuanely love in less civilised and less organised countries -their abdominal wall subjected to trauma inflicted by war, crime and wild surgeons.
In fact the papers which suggest that recurrent incisional hernias repaired without amesh are associated with a prohibitive recurrence rate come from “all over” the world.
I beleive, that in your hands a good tissue repair with relaxing incisions in the anterior sheath is adequate. Many patients, however, in this part of the world have their abdominal wall destroyed by multiple previous operations and repairs.
You must understand that in systems in which surgeon’s income depends on the number of operations they perform -more operations are performed. The estimate is that during his life an American has at least two-fold, if not more operations. He does not return to the same surgeon or hospital as in Sweden; he goes “all over the place”. Thus, you are dealing with different patients, different surgeons and different abdominal walls.
I really do not think that people use mesh in order to write papers. Not any more. They use it after having noticed that , at least in their hands, tissue repairs are failing.
Your argument to breaks down if another American surgeon claims his experience–even in an indigent urban Level I trauma center in the U.S. , where I work, my use of PTFE (that’s all I’ll use) for primary or recurrent ventral hernias is very uncommon. In fact, I tear out more of this junk that has failed with recurrence (and then close primarily!) than I ever use. And I do use it, but only when primary approximation is impossible–this only happens when there has been fascia loss due to such things as necrotizing fasciitis, since there is no earthly reason why fascial edges that were originally together can not come back to their original approximation! I doubt I am missing all these recurrences, because the bulk of our population has no where else to go, and they do come back when recurrence happens. Now let’s face it, my population is no different than anywhere else in this country, in fact is probably worse than average in terms of the horrendous problems we tend to see. Also, my technical prowess is certainly no better than anyone else’s on this list. I can assure you from our QA data that I have nowhere near a 50% recurrence rate, and I would question the technical mehtods of anyone who reports such rates–I haven’t seen these studies(maybe you can supply the references?), but let me guess–they recommend some form of prosthesis, right?
What is your approach with morbidly obese or even (moderatly obese) patients with LARGE incisional hernias?
It seems I see quite a few of these people because 1) they tend to have had previous operations 2) they tend to develop incisional hernias 3) they tend to be larger incisional hernias because they have been put off so the patient can “lose weight”. 4) I live in the midwest where obesity has a higher incidence. I have always generalized from some time spent in England that the US society is “heavier” than the rest of the world although I don’t know the data. Perhaps this is the reason we see more incisional hernias here (again generalizing).
These patients become even more difficult when they present with a large strangulated hernia. Now you have dead bowel, a high risk patient, and contamination.
I was taught that PTFE was an expensive prosthetic repair for incisional hernias. Articles I have read in the past have said 1) Marlex is poor because of the possible risk of fistulization or 2) PTFE is poor because of its cost and its poor incorporation into surrounding tissue.
I think in Europe mesh repair is not so common.
Could other surgeons from Europe share their experience?
Seeing the critics that have been carried out to the technique of placement of meshes over the aponeurosis, I have hesitated to respond, but the query of Dr gives me the opportunity to do it.
In my hospital we put on a mesh of Prolene over the aponeurosis in about 20 patients every year, with good results, having to retire very few of them. We open the aponeurosis of the rectus sheath on both sides and we stich the mesh to the external side of the wounds, allowing that most of the mesh rest over the rectus muscles. We make this thinking that the mesh will adhere to the muscle and will prevent their displacement.
On the subject of the muscular incisions of discharge I have observed that although they let closing the wound without tension, sometimes produce weakness in the lateral wall of the abdomen, giving a similar aspect to that of the abdomen of the patient with ascitis. For this reason I sometimes prefer to close the abdomen with somewhat tension with the added security of the mesh.
I expressed myself a bit ambiguous. I did not mean to say that I suture muscle fibres to muscle fibres without any fascial enclosure of the muscles in the bites. However, I take wide bites through the anterior rectus sheat, through the muscle, through the posterior rectus sheat. So, in a way I do suture through muscle and to my experience it works fine if the suture is loose enough not to strangulate the muscle cells. What I also mean is that I do not like to prepare the anterior, or posterior, rectus sheats and swing them across the midline to suture the two sides together. There are many such methods proposed, and I saw them executed as a trainee and also saw too many of them fail. My interpretation of the situation was that fascia when removed from the muscle it belongs to and used to repair a hernia it degenerates and a recurrence is likely. Since then I always try to transpose the entire muscle with its fascial enclosure.
You are probably right that patientes are different and medical systems are different. What works in one place may not be appropriate in another. I had a Tjeck surgeon visting and he remarked that *your patients look different* . I have also been to places where I would agree with that remark. Socio-economic status makes a difference, and the medical system is a part of that.
Now you describe a “mass closure” of the midline laparotomy which no doubt is the technique of choice. Thank you for correcting the misunderstanding.
Patients are different indeed. This I realised already as a medical student. My first surgical rotation was in Medical School where most postop patients moaned and groaned. Subsequently, I went for an elective in a surgical department in Switzerland and was astonished to find, on postop day 2, most Swiss men shaved, and in clean tracksuits. When asked “how are you”, instead of the usual groans the Swiss replied “Gute, Herr Doktor’ and smiled. There were many Italian patients in the Swiss hospital and they were not much different from the Middle Easterns.
I agree with your impression of an overall more obese society here in the U.S. – I have many relatives in Europe who are immediately struck by that observation when over here, and it’s not something confined to the midwest. Obesity does carry a higher risk of incisional hernia, and makes up a good proportion of the hernias I deal with.
This impression that the size of a hernia somehow corresponds with the need for a prosthetic patch is natural, but without any evidence to support it, something I must constantly remind our residents. They learn when they see for themselves what is virtually always true–that the fascia(which, after all WAS originally together!) comes together without a problem, except for those cases where fascia has actually been lost (uncommon). Now in morbidly obese patients we take greater care with the closure, altho the technique of closure is always important. In difficult cases I lay in interrupted sutures, tying them all down at the end by holding up the 2-3 sutures in front of the one being tied so each suture is tied down without tension, never using the tied suture to pull the edges together – this also assures an even distribution of tension along the wound, and the ties are not strangulating but only enough to approximate the edges. I’ve settled on this method after years of trial and error – I used to use running sutures on all wounds, and had a bothersomely high rate of dehiscence and hernias in the difficult incisions – since settling on this method(only in the difficult closures, such as morbidly obese) my rate has come down to about 5% in those I can follow. I use prolene for this, but I can’t dispute those who prefer absorbable. I rarely use retention sutures, and in the rare case I do it’s in recurrent cases. There is no demonstrable difference between running and interrupted in controlled studies, but in the difficult closure it is much easier to violate the tenets of no tension, avoid stretching or kinking the suture, and no strangulation with running method.
As usual, more ways than one of skinning a cat.
Spivak’s technique (1930’s or so, ether GA and straining patients) was to put several Moynihan or other heavy forceps on each edge, and cross the wound with them so their weight helped to close the wound while you were suturing.
I haven’t done a paramedian for years, but there you can run two continuous sutures, advancing the deeper one just a little ahead, so the second suture does the approximating.
Interrupted sutures are fine, but I think you can include their advantages in continuous suture if you put in a lock stitch every few bites using the Aberdeen knot – saves a lot of time, including use of fewer sutures, same mechanical [and biological, hopefully] result.
What I am impressed by but can’t measure and don’t know of studies about is tissue ‘creep’ or passive stretching over 5 – 60 minutes during an operation, different to micro-tears or small tears or elastic stretch, so that structures become easier to deal with during that time – comparable to a horrible big frail sapheno-femoral junction where the vein contracts down and becomes thicker and safer over about 10 minutes of gentle [very!] dissection from surrounding tissues.