Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Meta-Analysis
. 2008 Jul 16;2008(3):CD006438.
doi: 10.1002/14651858.CD006438.pub2.

Open surgical procedures for incisional hernias

Dennis den Hartog  1 , Alphons H M Dur, Wim E Tuinebreijer, Robert W Kreis
Affiliations
Meta-Analysis

Open surgical procedures for incisional hernias

Dennis den Hartog et al. Cochrane Database Syst Rev. .

Abstract

Background: Incisional hernias occur frequently after abdominal surgery and can cause serious complications. The choice of a type of open operative repair is controversial. Determining the type of open operative repair is controversial, as the recurrence rate may be as high as 54%.

Objectives: To identify the best available open operative techniques for incisional hernias.

Search strategy: Electronic databases MEDLINE, EMBASE, LILACS, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from 1990 to 2007 and trials were identified from the known trial reference lists.

Selection criteria: Studies were eligible for inclusion if they were randomized trials comparing different techniques for open operative techniques for incisional hernias.

Data collection and analysis: Statistical analyses were performed using the fixed effects model. Results were expressed as relative risk for dichotomous outcomes and weighted mean difference for continuous outcomes with 95% confidence intervals.

Main results: Eight trials comparing different open repairs for incisional hernias were identified; one trial was excluded. The included studies enrolled 1,141 patients. The results of three trials comparing suture repair versus mesh repair were pooled. Hernia recurrence was more frequent, wound infection less frequent in the direct suture group compared to the onlay or sublay mesh groups. The recurrence rates of two trials comparing onlay and sublay positions were pooled. This comparison yielded no difference in recurrences (two studies pooled), although operation time was shorter in the onlay group (one study). No difference was found in recurrence, satisfaction with cosmetics, or infection between the onlay standard mesh and skin autograft groups, following analysis pooling the two treatment arms. However, the analysis demonstrated less pain in the skin autograft group. Other trials comparing different mesh materials or different positions of the mesh, or comparing mesh with the components separation technique are described individually. The comparison between lightweight and standard mesh showed a trend for more recurrences in the lightweight group. The comparison between onlay and intraperitoneal mesh positions resulted in non significant fewer hernia recurrences, less seroma formation and more postoperative pain in the intraperitoneal group. No differences in the recurrence rates between the components separation and the intraperitoneal mesh technique.

Authors' conclusions: There is good evidence from three trials that open mesh repair is superior to suture repair in terms of recurrences, but inferior when considering wound infection. Six trials yielded insufficient evidence as to which type of mesh or which mesh position (on- or sublay) should be used. There was also insufficient evidence to advocate the use of the components separation technique.

PubMed Disclaimer

Conflict of interest statement

There are no known conflicts of interests.

Figures

1.1
1.1. Analysis
Comparison 1 Suture repair versus mesh repair, Outcome 1 Recurrence.
1.2
1.2. Analysis
Comparison 1 Suture repair versus mesh repair, Outcome 2 Pain.
1.3
1.3. Analysis
Comparison 1 Suture repair versus mesh repair, Outcome 3 Satisfied with cosmetic result.
1.4
1.4. Analysis
Comparison 1 Suture repair versus mesh repair, Outcome 4 Infection.
2.1
2.1. Analysis
Comparison 2 Lightweight mesh versus standard mesh in sublay position, Outcome 1 Recurrence.
2.2
2.2. Analysis
Comparison 2 Lightweight mesh versus standard mesh in sublay position, Outcome 2 Pain.
2.3
2.3. Analysis
Comparison 2 Lightweight mesh versus standard mesh in sublay position, Outcome 3 Deep infection.
2.4
2.4. Analysis
Comparison 2 Lightweight mesh versus standard mesh in sublay position, Outcome 4 Hospital stay in days.
2.5
2.5. Analysis
Comparison 2 Lightweight mesh versus standard mesh in sublay position, Outcome 5 Operation time in hours.
3.1
3.1. Analysis
Comparison 3 Onlay versus sublay mesh, Outcome 1 Recurrence.
3.2
3.2. Analysis
Comparison 3 Onlay versus sublay mesh, Outcome 2 Operation time in minutes.
3.3
3.3. Analysis
Comparison 3 Onlay versus sublay mesh, Outcome 3 Hospital stay in days.
3.4
3.4. Analysis
Comparison 3 Onlay versus sublay mesh, Outcome 4 Overall complication rate.
3.5
3.5. Analysis
Comparison 3 Onlay versus sublay mesh, Outcome 5 Postsurgical pain.
4.1
4.1. Analysis
Comparison 4 Mesh (polypropylene) versus skin autograft in onlay position, Outcome 1 Recurrence.
4.2
4.2. Analysis
Comparison 4 Mesh (polypropylene) versus skin autograft in onlay position, Outcome 2 Pain.
4.3
4.3. Analysis
Comparison 4 Mesh (polypropylene) versus skin autograft in onlay position, Outcome 3 Satisfied with cosmetic result.
4.4
4.4. Analysis
Comparison 4 Mesh (polypropylene) versus skin autograft in onlay position, Outcome 4 Deep infection.
5.1
5.1. Analysis
Comparison 5 Onlay mesh repair versus double mesh intraperitoneal repair, Outcome 1 Recurrence.
5.2
5.2. Analysis
Comparison 5 Onlay mesh repair versus double mesh intraperitoneal repair, Outcome 2 Seroma.
5.3
5.3. Analysis
Comparison 5 Onlay mesh repair versus double mesh intraperitoneal repair, Outcome 3 Superficial wound infection.
5.4
5.4. Analysis
Comparison 5 Onlay mesh repair versus double mesh intraperitoneal repair, Outcome 4 Wound hematoma.
5.5
5.5. Analysis
Comparison 5 Onlay mesh repair versus double mesh intraperitoneal repair, Outcome 5 Deep venous thrombosis.
5.6
5.6. Analysis
Comparison 5 Onlay mesh repair versus double mesh intraperitoneal repair, Outcome 6 Fatal pulmonary embolism.
5.7
5.7. Analysis
Comparison 5 Onlay mesh repair versus double mesh intraperitoneal repair, Outcome 7 Postoperative pain (> 6 mths).
5.8
5.8. Analysis
Comparison 5 Onlay mesh repair versus double mesh intraperitoneal repair, Outcome 8 Mesh removal.
6.1
6.1. Analysis
Comparison 6 Components separation technique versus intraperitoneal prosthetic repair (giant hernias), Outcome 1 Recurrence.
6.2
6.2. Analysis
Comparison 6 Components separation technique versus intraperitoneal prosthetic repair (giant hernias), Outcome 2 Reoperation for wound complications.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Afifi 2005 {published data only}
    1. Afifi RY. A prospective study between two different techniques for the repair of a large recurrent ventral hernia: a double mesh intraperitoneal repair versus onlay mesh repair. Hernia 2005;9:310‐5. - PubMed
Baracs 2007 {published data only}
    1. Baracs J, Weber G, Takacs I, Horvath OP. Results of open mesh versus suture repair in treatment of abdominal wall hernias (multicentric, prospective, randomised, internet‐based, clinical trial. Poster 29th International Congress of the European Hernia Society; 2007 May 6‐9; Athens (Greece). 2007.
    1. Weber G, Horvath OP. Results of ventral hernia repair: comparison of suture repair with mesh implantation (onlay vs sublay) using open and laparoscopic approach‐‐prospective, randomized, multicenter study. Magy Seb 2002;55(5):285‐9. - PubMed
Burger 2004 {published data only}
    1. Burger JWA, Luijendijk RW, Hop WCJ, Halm JA, Verdaasdonk EGG, Jeekel J. Long‐term follow‐up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Annals of Surgery 2004;240:578‐85. - PMC - PubMed
    1. Luijendijk RW, Hop WC, Tol MP, Lange DC, Braaksma MM, IJzermans JN, Boelhouwer RU, Vries BC, Salu MK, Wereldsma JC, Bruijninckx CM, Jeekel JJ. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med 2000;343(6):392‐8. - PubMed
Conze 2005 {published data only}
    1. Conze J, Kingsnorth AN, Flament JB, Simmermacher R, Arlt G, Langer C, Schippers E, Hartley M, Schumpelick V. Randomized clinical trial comparing lightweight composite mesh with polyester or polypropylene mesh for incisional hernia repair. British Journal of Surgery 2005;92(12):1488‐93. - PubMed
de Vries 2007a {published data only}
    1. Vries TS, Goor H, Charbon JA, Rosman C, Hesselink EJ, Wilt GJ, Bleichrodt RP. Repair of giant midline abdominal wall hernias: "components separation technique" versus prosthetic repair. World Journal of Surgery 2007;31:756‐63. - PMC - PubMed
Korenkov 2002a {published data only}
    1. Korenkov M, Sauerland S, Arndt M, Bograd L, Neugebauer EAM, Troidl H. Randomized clinical trial of suture repair, polypropylene mesh or autodermal hernioplasty for incisional hernia. British Journal of Surgery 2002;89:50‐6. - PubMed
Korenkov 2002b {published data only}
    1. Korenkov M, Sauerland S, Arndt M, Bograd L, Neugebauer EAM, Troidl H. Randomized clinical trial of suture repair, polypropylene mesh or autodermal hernioplasty for incisional hernia. British Journal of Surgery 2002;89:50‐6. - PubMed
Köhler 2004 {published data only}
    1. Köhler L, Sauerland S, Meyer A, Saad S, Schüller BK, Knaebel HP, Seiler CM. Mesh implantation in onlay‐ or sublay‐ technique for closure of median ventral hernias: first results of a randomized clinical trial [Netzimplantation in Onlay‐ oder Sublay‐ Technik zum Verschluss medianer Bauchwandhernien: erste Ergebnisse einer randomisierten klinishen Studie]. Poster presented at the Congress of the German Surgical Association. 2005.

References to studies excluded from this review

Schumpelick 1999 {published data only}
    1. Schumpelick V, Klosterhalfen B, Müller M, Klinge U. Minimized polypropylene mesh for preperitoneal net plasty (PNP) of incisional hernias [Minimierte Polypropylen‐Netze zur präperitonealen Netzplastik (PNP) der Narbenhernie]. Chirurg 1999;70:422‐30. - PubMed

Additional references

Amid 1997
    1. Amid PK. Classification of biomaterials and their related complications in abdominal wall hernia surgery. Hernia 1997;1:15‐21.
Brown 2005
    1. Brown SR, Goodfellow PB. Transverse verses midline incisions for abdominal surgery. Cochrane Database of Systematic Reviews 2005, Issue 4. [Art. No.: CD005199. DOI: 10.1002/14651858.CD005199.pub2.] - PMC - PubMed
Burger 2005
    1. Burger JWA, Lange JF, Halm JA, Kleinrensink GJ, Jeekel J. Incisional hernia: early complication of abdominal surgery. World Journal of Surgery 2005;29(12):1608‐13. - PubMed
Cassar 2005
    1. Cassar K, Munro A. Surgical treatment of incisional hernia. British Journal of Surgery 2002;89:534‐45. - PubMed
de Vries 2007b
    1. Vries Reilingh TS, Bodegom ME, Goor H, Hartman EH, Wilt GJ, Bleichrodt RP. Autologous tissue repair of large abdominal wall defects. Br J Surg 2007;94(7):791‐803. - PubMed
Deeks 2005
    1. Deeks JJ, Higgins JPT, Altman DG, editors. Analysing and presenting results. In Higgens JPT, Greeen S, editors. Cohrane Handbook for Systematic Reviews of Interventions 4.2.5 [updated May 2005]; Section 8. In: The Cochrane Library, Issue 3, 2005. Chichester, UK: John Wiley & Sons, Ltd, 2005.
Flum 2003
    1. Flum DR, Horvath K, Koepsell T. Have outcomes of incisional hernia repair improved with time? A population‐based analysis. Ann Surg 2003;237(1):129‐35. - PMC - PubMed
Hesselink 1993
    1. Hesselink VJ, Luijendijk RW, Wilt JH, Heide R, Jeekel J. An evaluation of risk factors in incisional hernia recurrence. Surg Gynecol Obstet 1993;176(3):228‐234. - PubMed
Higgins 2005
    1. Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions 4.2.5 [updated May 2005].. In: The Cochrane Library. Chichester, UK: John Wiley & Sons, Ltd, 2005.
Israelsson 2003
    1. Israelsson LA, Jönsson L, Wimo A. Cost analysis of incisional hernia repair by suture or mesh. Hernia 2003;7:114‐7. - PubMed
Klinge 2000
    1. Klinge U, Si ZY, Zheng H, et al. Abnormal collagen I to III distribution in the skin of patients with incisional hernia. European Surgical Research 2000;32(1):43‐8. - PubMed
Klinge 2001
    1. Klinge U, Si ZY, Zheng H, et al. Collagen I/III and matrix metalloproteinases (MMP) 1 and 13 in the fascia of patients with incisional hernias. Journal of Investigative Surgery 2001;14(1):47‐54. - PubMed
Korenkov 2001
    1. Korenkov M, Paul A, Sauerland S, Neugebauer E, Arndt M, Chevrel JP, Corcione F, Fingerhut A, Flament JB, Kux M, Matzinger A, Myrvold HE, Rath AM, Simmermacher RKJ. Classification and surgical treatment of incisional hernia. Results of an experts' meeting. Langenbeck's Archives of Surgery 2001;386:65‐73. - PubMed
Luijendijk 2000
    1. Luijendijk RW, Hop WC, Tol MP, Lange DC, Braaksma MM, IJzermans JN, Boelhouwer RU, Vries BC, Salu MK, Wereldsma JC, Bruijninckx CM, Jeekel JJ. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med 200;343(6):392‐8. - PubMed
Parmar 1998
    1. Parmar MKB, Torri V, Stewart L. Extracting summary statistics to perform meta‐analyses of the published literature for survival endpoints. Statistics in Medicine 1998;17:2815‐2834. - PubMed
Paul 1998
    1. Paul A, Korenkov M, Peters S, Köhler L, Fischer S, Troidl H. Unacceptable results of the Mayo procedure for repair of abdominal incisional hernias. European Journal of Surgery 1998;164:361‐7. - PubMed
Pollock 1989
    1. Pollock AV, Evans M. Early prediction of late incisional hernias. Br J Surg 1989;76(9):953‐4. - PubMed
Weber 2002
    1. Weber G, Horvath OP. Results of ventral hernia repair: comparison of suture repair with mesh implantation (onlay vs sublay) using open and laparoscopic approach‐‐prospective, randomized, multicenter study. Magy Seb 2002;55(5):285‐9. - PubMed

References to other published versions of this review

den Hartog 2008
    1. Hartog D, Dur AHM, Tuinebreijer WE, Kreis RW. Open surgical procedures for incisional hernias. Cochrane Database of Systematic Reviews 2008, Issue 3. [DOI: 10.1002/14651858.CD006438.pub2.] - DOI - PMC - PubMed