UNIVERSITY OF MEDICINE AND FARMACY CRAIOVA

PhD School

PhD Thesis Abstract

SURGICAL TREATMENT OF INCISIONAL

HERNIAS

Scientific coordinator:

PROF.UNIV.DR. DAN MOGOȘ

PhD Student:

SFECLAN MARIA CRISTINA

CRAIOVA

2013

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Contents of PhD thesis

INTRODUCTION

IMPORTANCE OF SURGICAL TREATMENT IN INCISIONAL HERNIAS ........................... 1

CHAPTER I

Incisional hernia. Hystory, definition. ................................................................................. 3

CHAPTER II

Surgical, functional and pathological anatomy of abdominal wall .................................. 7

2.1. Surgical anatomy ............................................................................................................ 7

2.2. Functional anatomy ....................................................................................................... 14

2.3. Pathological and physiopathological anatomy of the abdominal wall ............................. 17

2.3.1. Local changes ........................................................................................................ 18

2.3.2. Systemic changes .................................................................................................. 19

CHAPTER III

INCISIONAL HERNIAS CLASIFICATIONS......................................................................... 20

3.1. Anatomical and clinical classification of the incisional hernias ....................................... 20

3.2. Etiopathogenic classification ......................................................................................... 22

CHAPTER IV

Etiopathogeny and incidence of the abdominal incisional hernias ............................... 24

4.1.General Factors ............................................................................................................. 24

4.2.Local Factors ................................................................................................................. 26

4.3. Incisional hernias incidence .......................................................................................... 28

CHAPTER V

Diagnosis, evolution and complications in incisional hernias ...................................... 30

5.1. Physical examination .................................................................................................... 30

5.2.Imagistic diagnosis ......................................................................................................... 31

5.3.Evolution and complications of postoperative incisional hernias ..................................... 33

CHAPTER VI

Surgical treatment of incisional hernias .......................................................................... 34

6.1. Steps of open surgical treatment .................................................................................. 35

6.2. Primary suture............................................................................................................... 36

6.3. Plasty with tension-free incisions................................................................................... 36

6.4. Procedures using local material .................................................................................... 37

6.5. Procedures using prosthetic material ............................................................................ 37

6.6. Intraperitoneal mesh ..................................................................................................... 38

6.7. Retromuscular mesh implantation ................................................................................. 40

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CHAPTER VII

Material and methods ........................................................................................................ 41

7.1. Numerical parameters comparation .............................................................................. 43

7.2. Preoperative preparation of patients with incisional hernias .......................................... 46

7.3. Anesthetics methods used for patients in the two studied groups.................................. 47

7.4. Surgical techniques used in incisional hernias .............................................................. 48

7.5. Prostheses used in surgical techniques ....................................................................... 53

7.6. Materials used to fix the prosthesis ............................................................................. 55

7.7. Postoperative care for patients with incisional hernias .................................................. 56

CHAPTER VIII

Results................................................................................................................................ 58

8.1. The results obtained by tracking the group of patients from IV Surgery Clinic

Craiova ............................................................................................................................... 58

8.1.2 Size classification of parietal defect in incisional hernias .......................................... 63

8.1.3. Clinical simptomatology............................................................................................ 63

8.1.4 Etiopathogeny of incisional hernias ........................................................................... 64

8.1.5. Correlation between the parietal defect size and patients old interventions .............. 66

8.1.6. Incisional hernias complications ............................................................................... 67

8.1.7. Incisionla hernias recurrences .................................................................................. 67

8.1.8. Incisional hernias treatment ..................................................................................... 69

8.1.9. Incisional hernias intraoperative aspects .................................................................. 72

8.1.10. Average hospitalization for patients ........................................................................ 74

8.1.11. Postoperative complication .................................................................................... 75

8.2. The results obtained by tracking the group of patients from Santa Maria

Multimedica Suregery Department Castellanza ............................................................... 76

8.2.1 Incisional hernias classifications according with European Hernia Society(EHS) ..... 76

8.2.2 Classification according to size defect of incisional hernias ....................................... 77

8.2.3. Gender incidence of patients with incisional hernias ................................................ 77

8.2.4. Age distribution for patients with incisional hernias ................................................... 78

8.2.5. Distribution of patients' hospitalization according to years of study ........................... 78

8.2.6 Clinical aspects presented by patients with incisional hernias ................................... 79

8.2.7 Etiopathogeny of incisional hernias ........................................................................... 79

8.2.8 Incisional hernias analysis on the number of defects found intraoperatively .............. 83

8.2.9. Correlation between size defect and old interventions .............................................. 84

8.2.10. Recurrent incisional hernias ................................................................................... 85

8.2.11. Types of anesthesia ............................................................................................... 88

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8.2.12 Surgical treatment of postoperative incisional hernias ............................................. 88

8.2.13. The relationship between the prosthesis and the used fixing methods ................... 96

8.2.14. The significance according to the used surgical method......................................... 97

8.2.15. Intraoperative aspects of the incisional hernias ...................................................... 97

8.2.16. Average hospitalization of patients with incisional hernias .................................... 101

8.2.17. Postoperative complications after incisional hernias surgical treatment ................ 102

CHAPTER IX

9.1. Etiopathogenic study of postoperative incisional hernias ............................................. 108

9.2. Discussions on prostheses used in the surgical treatment of incisional hernias .......... 114

9.3. Discussions about fixing methods and corellation between fixation, complications and

meshes .............................................................................................................................. 120

9.4. Discussions related to the surgical treatment of incisional hernias .............................. 124

9.4.1. Problems of breach ................................................................................................ 125

9.4.2. Problems of the sack and its content ...................................................................... 126

9.4.3.Problems of incisional hernias topography .............................................................. 127

9.5. Surgical techniques ..................................................................................................... 128

9.5.1. Tisular procedure ................................................................................................... 128

9.5.2 Preperitoneal procedure .......................................................................................... 129

9.5.3. Intraperitoneal procedure ....................................................................................... 130

9.6. Comparative analysis of the two studied groups ......................................................... 134

CHAPTER X

Conclusions ..................................................................................................................... 135

Key words: incisional hernias, risk factors, surgical treatment, retro-

muscular technique, fibrin glue, complications

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INTRODUCTION

The surgical treatment of incisional hernias represents one of the most

frequent intervention in general surgery together with the other abdominal wall

defects. Their occurrence rate is of 0.5-12% for the patients with laparotomy in their

historical record and 0.2 to 1.8% at patients with laparoscopic interventions .

Among time have appeared multiple procedures for repairing parietal defects

which have created a series of discussions on postoperative complications of

incisional hernias. One of the most feared is postoperative recurrence. We have

observed an increased rate after tissular procedures between 31-58% and after

prosthetic procedures is much lower rate reaching 8-10%.

We are currently witnessing at a development both prosthetic materials and

methods that we are using and to the research for a more efficient method of fixation

of the prosthesis during surgery which will help us to reduce postoperative

complications.

CHAPTER I

Incisional hernias. History, definition.

Hernia is defined in literature as representing the visceral protrusion belonging

to abdominal cavity through an anatomical zone, preformed, natural, while the

incisional hernia represents the under tegument protrusion of viscera from the

abdominal wall cavity at a thin zone level occurred after a laparotomical surgery or at

the entering level of the trocars used in laparoscopic surgery or following trauma harp

stick.

In the first chapter we presented the historical evolution of surgical treatment

of incisional hernias. Anatomy of the abdominal wall was described almost 6000

years ago, when civilization has begun. The first mention and description of the

abdominal wall was made by Professor George Ebers in 1862 , and surgery has

developed over three principles: simple laparoplasty, auto and organic heteroplasty

and alloplasty.

Laparoscopy, as treatment for parietal abdominal defects, is recently occurred,

in 1990 being described by LeBlanc. This technique has as improvements the

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hospitalization rate and the decreasing of the rate complications, while the

recurrence rate remains at least similar to the one of open surgery.

Currently, the best approach is the one proposed by Stoppa by implanting the

mesh outside the abdominal cavity .

CHAPTER II

Surgical, functional and pathological anatomy of abdominal wall

This paper aims to evaluate the influence of topographic anatomy on the

functioning mechanisms of protection against incisional hernia and their importance

in the choice of surgical technique to provide maximum efficiency in terms of

recurrence rate and postoperative pain.

From functional point of view, the abdominal wall needs to be considered a

unitary system: „this wall is composed of eight muscle, through which attract, keep,

prepare, removes and performs many other functions” Andres de Laguna wrote in

1953.

Mio-aponeurotic layer is involved in actions such as flexion, extension and

rotation of the trunk and pelvis, and also participates in the process of defecation,

micturition, childbirth and breathing by increasing intra-abdominal pressure. In the

presence of a large parietal gap, resulting from a total or partial disinsertion

abdominal muscles and the presence of a hernia bag occurs intra-abdominal

pressure drop and create a new cavitiy, affecting respiration, viscera, vascularization

and the vertebraes.

Ideal for repairing parietal defect, is the reconstruction of each structural

component of the abdominal wall using mio-fascial elements with their nervous and

vascular pedicles.

From the anatomo-pathological point of view, incisional hernias present: a

hole, a pocket and its content.

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CHAPTER III

Incisional hernias clasifications

In the present thesis we used the classification made by the European Hernia

Society for surface and localization, and in etiopathogenic terms, incisional hernias

can be classified into congenital or acquired for children and to adults in traumatic or

atraumatic.

CHAPTER IV

Etiopathogeny and incidence of abdominal incisional hernia

Among the factors of incisional hernias with a high importance are: obesity,

impaired collagen metabolism and numerous factors both local and general triggering

a vicious scarring. Any factor occurred during the process of wound healing may

appereance of incisional hernias and defects in collagen production.

CHAPTER V

Diagnosis, evolution and complications of incisional hernias

The incisional hernias wall diagnosis is based on patient historical record and

physical examination.

Laboratory diagnosis of incisional hernia is represented of the usual imaging

tests to confirm pathologies, especially in patients with specific clinical conditions,

such as obesity.

Evolution of incisional hernias consists in increasing the size of both the bag

and parietal defect with the development of local and systemic complications.

Complications are represented by strangulation, incarceration or trauma bag

incisional hernia.

CHAPTER VI

The surgical treatment of incisional hernias

The incisional hernias treatment is exclusively surgical and can be

distingushed in three steps: the isolation of the incisional hernia pocket, its reduction

and abdominal wall reconstruction.

To restore the abdominal wall current we use various surgical techniques.

Some provide primary suture using the abdominal wall structures, others use

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prosthetic materials that support the abdominal wall function after direct suture

(plastic hardening) or substitution plasty where edges cannot be closed.

Today, in most cases of incisional hernia treatment are used plastic

procedures. If incisional hernias are large or recurrent with loss of substance is

indicated only to use meshes.

CHAPTER VII

Materials and methods

Aim of the study was to determine the most effective method of repairing

incisional hernias in order to obtain results which states the presence of a low

complications rate on a long term.

The study includes patients with abdominal wall defects, incisional hernias

operated in the IVth Surgery Clinic from CF Hospital Craiova and in "Day and Week

Surgery Clinic" at the Institute Santa Maria Multimedia Castellanza, Italy on a period

of 6 years, January 1, 2007 -December 2012.

The retrospective aim is to analyze postoperative the incisional hernias in

terms of etiopathogeny, clinical aspects, topography, the type of treatment applied to

the reconstruction of the abdominal wall and the results , the attachment of prosthetic

materials, the hospital stay and complications after surgical procedures.

Descriptive analysis according to different parameters, graphical

representation and calculation of Pearson correlation coefficient r - was performed

with Excel, Pivot Tables using the controls, Functions, statistics, Chart and Data

Analysis module. To achieve complex statistical tests (Student's t test for comparing

two means, Chi square test and Fisher's exact test to compare differences in

distribution) were used XLSTAT or commands were performed using SPSS.

CHAPTER VII

The results obtained after analyzing the patients form IV Surgery Department

Craiova

The analysis of 298 patients included in the study showed an increased

incidence of median topography of the incisional hernias in females in the fifth age

decade. In most cases the bags were unique and were involved etiopathogenic

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triggers or contributing factors. We came across some of these, such as parietal

suppuration, obesity, chronic diseases such as diabetes, cardiovascular disease or

broncho-pulmonary discovered by the clinical and laboratory examination or in

patients’ history.

In the study group, 56 patients, which represents 18.79% of the total incisional

hernias in the IVth Surgery Department, had recurrent postoperative incisional

hernias resulting from association of etiopathogenic factors with inadequate surgical

technique used for wound closure.

Primary closure of incisional hernias was used in 43 cases, 14.42% and 255

were prosthetic procedures, representing 85.58%. Depending on the place where it

was placed, in the study group with prosthetic procedures, synthetic meshes were

present in 197 cases sublay fixed with transfixiant wires through aponeurosis and the

rectus abdominis muscle, in 42 cases the mesh was placed inlay and in 16 cases

onlay. Large incisional hernias with loss of substance were present in 75 patients

where was used for repair a substitution process. Patients with sublay fitted

prosthesis had a mean hospital stay of 10 days, those with inlay or onlay prosthesis

had a mean duration of hospitalization between 4 and 5 days.

Immediate complications were most common in surgery of incisional hernias:

hematoma, seroma, parietal suppuration. Parietal suppuration was found in 20 cases

and recurrences were present in 12 cases with tissular proceduresand and in 5

cases after prosthetic procedures which corresponds to 4.02% and respectively

1.67% of the total incisional hernias.

The results obtained by tracking the group of patients from Clinical Hospital

Santa Maria Multimedia Castellanza

The group was made up of 99 clinical patients. Their number was small

because of the confidentiality rules between the hospital, doctors and patient. The

study group had 56 women and 43 men, with a maximum incidencein the 6th age

decade. As etiopathogenic factors, were found obesity associated with obstructive

pulmonary disease, diabetes, vascular disorders.

89 of the 99 studied cases had a unique defect and 10 patients had a multiple

defect. Depending on the history intervention record, we can observe an increased

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number of cases after laparotomic surgery, while the smallest size was found in

patients with laparoscopic interventions. The recurrent incisional hernias had an

average size varied between 25 and 125 cm2.

Of the 99 patients operated for incisional hernias at various sites in the

abdominal wall for the majority 67 (67.68%) was performed a retromuscular

intervention.

For 10 of the patients (10.10%) associated with abdominal obesity was

associated abdominoplasty performed by plastic surgeon or dermolipectomy

performed by general surgeon.

The tissular method was used for 7 (7.07%) patients, laparoscopic procedure

only for 5 (5.05%) patients and for other 10 patients from the study group were used

other surgical methods to repair the parietal defect and to realise the abdominal wall

reconstruction.

The retromuscular - preperitoneal procedure used many types of protheses:

the polypropylene composite Physiomesh, vycril mesh and 2 biological meshes . In

37 of the cases the mesh was fixed only with fibrin glue, adhesive that has the ability

to attach the mesh to the surrounding tissue without any further stitches between the

mesh and the abdominal wall components , in 48 ( 48.48 % ) of the cases was used

the polypropylene mesh fixed with Prolene stitches .

It was observed that the hospitalization time for patients who used fibrin glue

had an average of 5 days, but it depends on the fixation method, the location, size of

the defect and surgical technique. In patients with prosthetic fixed by sutures the

length of stay was more than 6 days.

Immediate postoperative complications were observed in only 6 from the 99

patients including postoperative hematoma, ileal perforation, infection, wound

necrosis . Late complications were the postoperative pain with a lower rate where the

fixation was "sutureless" and recurrences were encountered after a follw-up realised

at a month, 3 months, 6 months and then annually. It was observed in two patients

with tissular procedure, one patient with polypropylene stitches and the other with

vycril absorbable wires and in one patient with retromuscular mesh, which has been

attached with threads of polypropylene.

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CHAPTER IX

Discutions

In this chapter we tried a comparation of etiopathogenic factors, intraoperative

encountered problems and the high resolution of the abdominal wall defect and

restoration. The study conducted at the level of the two groups of patients is

supported by the literature on the influence of etiopathogenic factors involved in the

occurrence of incisional hernias. The research revealed that the preperitoneal

retromuscular technique hass more satisfactory postoperatively results than other

studied techniques.

Patients with incisional hernias were more common in the Romanian group,

following the annual parietal repairs, and in terms of sizes defect, they revealed a

higher proportion of large incisional hernias. These dimensions are owed to the fact

that celiotomy is still a medical act more frequently here than in civilized countries

where laparoscopy precedence and the patients do not show for regular medical

checks.

Length of stay is a major economic factor for hospitals. If other countries are

trying minimally invasive surgical approach with an installation of closed drainage

with no risk of contamination of the operative wound, in Romania this is not yet

possible.

CHAPTER X

Conclusions

1. Median postoperative incisional hernias were the most common location in the

two studied groups 89.9% and 84.85%, depending on surgical interventions

present in the historical record, the most frequent being the laparomic one.

2. There was a decrease in the rate of relapses in using plastic procedures in both

groups of patients, compared with tissular procedures.

3. Following this study, we declare in favor of using retromuscular-preperitoneal

meshfor the cure of median incisional hernias, as well as the recurrent ones, due

to low rates of recurrence and late complications.

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4. Qualities that a prosthesis must meet are: to be mechanically adequate for the

tissue, to cause enough inflammatory or foreign body reaction,not to lead or

maintain the infection and not to be expensive.

5. In case of infectious history of patients wound, the prosthesis was used at an

interval of at least 6 months after infection draining.

6. The study was conducted to determine the influence of prosthetic fixation

methods on postoperative complications as recurrence and chronic pain. It was

found that application of a retromuscular mesh without suture and attached only

with fibrin glue causes a lower complications rate. Thus, the group of patients who

have undergone a procedure without suture, chronic pain occurred in only one

case, while in the group in which the prosthesis was sutured circumferentially

postoperative pain occurred in 9 cases.