The Treatment of Incisional Hernia

Abstract

Background: A meta-analysis of studies from multiple countries has shown that the incidence of incisional hernia varies from 4% to 10% depending on the type of operation. No epidemiological surveys have been conducted so far. The worst possible complication of an incisional hernia if it is not treated surgically is incarceration. In this article, we present the main surgical methods of treating this condition. We also evaluate the available randomized and controlled trials (RCTs) in which open and laparoscopic techniques were compared and analyze the patients' quality of life.

Methods: We selectively searched PubMed for relevant literature using the search terms "incisional hernia" and "randomized controlled trial." 9 RCTs were included in the analysis. The endpoints of the meta-analysis were the number of reoperations, complications, and recurrences. The observed events were studied statistically by correlation of two unpaired groups with a fixed-effects model and with a random-effects model. We analyzed the quality of life in our.

Results: Open surgery and laparoscopic surgery for the repair of incisional hernias have similar rates of reoperation (odds ratio [OR] 0.419 favoring laparoscopy, 95% confidence interval [0.159; 1.100]; p = 0.077). The rates of surgical complications are also similar (OR 0.706; 95% CI [0.278; 1.783]; p = 0.461), although the data are highly heterogeneous, and the recurrence rates are comparable as well (OR 1.301; 95% CI [0,761; 2,225]; p = 0.336). In our own patient cohort in Würzburg, the quality of life was better in multiple categories one year after surgery.

Conclusion: The operative treatment of incisional hernia markedly improves patients' quality of life. The currently available evidence regarding the complication rates of open and laparoscopic surgical repair is highly heterogeneous, and further RCTs on this subject would therefore be desirable. Moreover, new study models are needed so that well-founded individualized treatment algorithms can be developed.

Figure 1

Transverse section of the supraumbilical abdominal wall, showing relevant anatomical structures and mesh locations for incisional hernia repair. A) Releasing incision of the abdominal external oblique aponeurosis as part of the component separation technique described by Ramirez. B) Typical course of an intercostal nerve between the transversus abdominis muscle and the abdominal internal oblique muscle; the nerve enters at the lateral margin of the rectus sheath into the rectus abdominis muscle and gives off a cutaneous branch at its end. C) During transversus abdominis release (TAR) for positioning a mesh lateral to the rectus sheath, the course of this nerve has to be spared to prevent subsequent abdominal wall paralysis. D) With TAR, the mesh is placed between peritoneum and transversus abdominis muscle. E) Typical sublay mesh position (retromuscular). F) Underlay mesh position (preperitoneal). G) Intraperitoneal mesh position (IPOM = intraperitoneal onlay mesh). (Courtesy of Maren Hötten/Scientific Illustration)

Figure 2

With retromuscular mesh repair of midline incisional hernia, it is crucial to ensure a mesh overlap extending underneath the xiphoid to prevent recurrence. A) Xiphoid process; B) Posterior rectus sheath closed in the midline. Due to the midline xiphoid process insertion of the rectus sheath, a so-called fatty triangle (D) is created during the release of the posterior rectus sheath from the xiphoid. At the end of the mesh repair, this triangle is only secured by the synthetic mesh (D). With proper dissection, the mesh overlap underneath the xiphoid process extends several centimeters in cranial direction. C) Anterior rectus sheath. (Courtesy of Maren Hötten/Scientific Illustration)

Figure 3

Reoperation rate in the comparison of laparoscopic and open technique (p = 0.077). CI, confidence interval; OR, odds ratio; laparosc., laparoscopic

Figure 4

Complications in the comparison of laparoscopic and open technique (p = 0.461). CI, confidence interval; OR, odds ratio; laparosc., laparoscopic

Figure 5

Recurrence rate in the comparison of laparoscopic and open technique (p = 0.336). CI, confidence interval; OR, odds ratio; laparosc., laparoscopic

eFigure 1

PRISMA flow chart of literature search to identify publications comparing open versus laparoscopic incisional hernia repair (PRISMA, preferred reporting items for systematic review and meta-analyses)

eFigure 2

Consensus classification of incisional hernia of the European Hernia Society (EHS) (2009) a) Morphologically, it is distinguished between midline (M1–5) and lateral (L1–4, right or left) hernias. b) The location of midline hernias is allocated to the zones M1 to M5, based on the proximity of the hernia to the xiphoid process, umbilicus or symphysis pubis; a hernial orifice can extend over several areas, e.g. M1 to 3 or M3 to 5. c) Anatomically, lateral hernias are allocated to the zones L1 to L4 and labelled according their side. For the purpose of standardization, hernias are to be classified intraoperatively. The size of the hernial orifice is measured in “length” and “width“. Since width is of particular prognostic relevance, the size of the hernial orifice is categorized according to width (W) in W1 (<4 cm), W2 (4–10 cm) or W3 (>10 cm). (EuraHS, the Hernia Registry of the European Hernia Society uses this classification [www.eurahs.eu]; modified according to [12] and [e10]; courtesy of Springer-Verlag/the authors of the two articles [12] and [e10])