Narbenhernie – Wie ist zu verfahren?

Abstract

Various techniques for repair of an incisional hernia are available for the surgeon. Conventional suture techniques are quick and easy to perform but they are associated with an unacceptable rate of recurrence and therefore should only be used in exceptional cases. An underlying systemic disturbance of collagen metabolism is assumed to exist in patients with an incisional hernia. In such patients the mechanisms of wound healing and remodeling of the abdominal wall following laparotomy are insufficient, which necessitates reinforcement of the abdominal wall with a non-resorbable alloplastic mesh prosthesis to enable a long-term cure. The implantation of such meshes can be carried out laparoscopically or by an open approach. The gold standard of open repair techniques is the retromuscular placement of a mesh prosthesis. The retromuscular mesh placement as a reinforcement of the abdominal wall (augmentation) must be categorically differentiated into the abdominal wall replacement by mesh bridging. In this technique the mesh is likewise placed in the retromuscular space, however a complete closure of the ventral fascia is not necessary. Retromuscular augmentation enables an extra-peritoneal placement of the prosthesis, an optimization of tissue integration by plane coverage of the prosthesis by well vascularized muscular tissue and a sufficient overlap in cranio-caudal and lateral directions. Mesh fixation is best made with absorbable suture material but is better suited for technical simplification. The use of a prophylactic drainage should be decided depending on the individual patient's risk factors, because sufficient evidence-based data are currently not available. If augmentation is not possible bridging is necessary and then the mesh has to be fixed without underlying support. Current data reveal that the recurrence rate following incisional hernia repair by retromuscular mesh augmentation has decreased promisingly in comparison to simple suture techniques. In total the recurrence rate following retromuscular mesh placement ranges between 2 and 12%. Current results of prospective randomized multicentre trials are not available. However, it is to be expected that further development of mesh materials as well as improvement of surgical techniques with avoidance of typical pitfalls will lead to further reduction of the recurrence rate with an improvement in patient satisfaction.

Two cases about mesh adhesion to intra-abdominal cavity tissue after using mesh to repair incisional hernia

“…3,[8][9][10][11][12][13] Mesh repair helps to reduce the high hernia recurrence rate from over 50% to 20%. 16 Use of a mesh to reinforce the abdominal wall is considered the gold standard in OVHR, 16 since the mesh strengthens the abdominal wall defect without tension. LVHR is now widely accepted for the repair of ventral hernia defects.…”

Two cases about mesh adhesion to intra-abdominal cavity tissue after using mesh to repair an incisional hernia

“…3 , 8 - 13 Mesh repair helps to reduce the high hernia recurrence rate from over 50% to 20%. 16 Use of a mesh to reinforce the abdominal wall is considered the gold standard in OVHR, 16 since the mesh strengthens the abdominal wall defect without tension.…”

Prevention of Subcutaneous Seroma Formation in Open Ventral Hernia Repair Using a New Low‐Thrombin Fibrin Sealant

“…After excision of the scar, preparation of the hernia sac with reduction of its content, and adhesiolysis, the posterior rectus sheath was incised as medially as possible and detached from the muscles up to the lateral rectus border. On the cranial side, the preparation had to be expanded to the 'fatty triangle' behind the xiphoid and caudal into the retropubic 'Retzius space' [6]. If tensionfree closure of the posterior and anterior rectus sheath seemed possible, a polylactide self-gripping adhesive polyester mesh was placed in a sublay position (Parietex progripÒ, Covidien, Austria, Brunn am Gebirge TM ).…”

“…We aimed to evaluate whether this novel fibrin sealant is effective in preventing subcutaneous seroma formation by adhering the subcutaneous tissue to the underlying fascia in open ventral hernia repair (OVHR) with sublay mesh placement [6, 7] and wide subcutaneous dissection (WSD) of at least 100 cm 2 .…”