Preventing incisional ventral hernias: important for patients but ignored by surgical specialities? A critical review

Abstract

Purpose Incisional ventral hernias (IHs) are a common complication across all surgical specialities requiring access to the abdomen, pelvis, and retroperitoneum. This public health issue continues to be widely ignored, resulting in appreciable morbidity and expenses. In this critical review, the issue is explored by an interdisciplinary group. Methods A group of European surgeons encompassing representatives from abdominal wall, vascular, urological, gynecological, colorectal and hepato-pancreatico-biliarysurgery have reviewed the occurrence of His in these disciplines. Results Incisional hernias are a major public health issue with appreciable morbidity and cost implications. General surgeons are commonly called upon to repair IHs following an initial operation by others. Measures that may collectively reduce the frequency of IH across specialities include better planning and preparation (e.g. a fit patient, no time pressure, an experienced operator). A minimally invasive technique should be employed where appropriate. Our main recommendations in midline incisions include using the 'small bites' suture technique with a ≥ 4:1 suture-to-wound length, and adding prophylactic mesh augmentation in patients more likely to suffer herniation. For off-midline incisions, more research of this problem is essential. Conclusion Meticulous closure of the incision is significant for every patient. Raising awareness of the His is necessary in all surgical disciplines that work withing the abdomen or retroperitoneum. Across all specialties, surgeons should aim for a < 10% IH rate.

Introduction of Small Stitch Small Bite technique: a retrospective long-term follow-up

“…There is, as is pointed out by Garcia-Urea et al [ 26 ], a lack of intuitive understanding of the association between meticulous care when closing the abdomen and the risk for late incisional hernia. In the present study, SSSB was applied in 93% of the procedures.…”

Incisions in Hepatobiliopancreatic Surgery: Surgical Anatomy and its Influence to Open and Close the Abdomen

“…The consequence of a transverse incision is quite similar to a subcostal, although the incision only runs parallel to the TA muscle. This incision may preserve innervation to the segment of the rectus muscle above the scar but, laterally, can injure 11th and 12th branches that are considered the most important innervation contributors to the anterior abdominal wall (2,23). The vertical extension of a subcostal (Kocher) or transverse incision has been traditionally considered a "hernia-formation" incision.…”

“…There is no doubt that incisional hernias are an important public health issue, due to an estimated incidence of up to 37% ( 1 ), and also due to the implications they have on the patient’s quality of life. The patient’s symptoms may include pain, limitation of daily life activities, skin problems due to ulceration/infection, incarceration, and other complaints that may require an elective or even emergent surgical procedure ( 2 ).…”

Urinary diversions for benign and oncologic indications: what did we learn about short term complications in the last 24 months?

“…In population-based series, wound dehiscence occurs in one in 30 patients after cystectomy and UD [26]. For open RC and UD, the same principles as for closure of any midline incision with ‘small bites’ suture technique with a ≥ 4:1 suture-to-wound length has been recommended for several years based on randomized trials [27]. Still the cumulative incidence of midline incisional hernia at three years was 12% in the previously cited population-based study, and thus there is still a room for improvement.…”