The Effect of Operation Technique on Recurrence of Incisional Hernia Repair

Abstract

I ncisional hernia (IH) is a common complication after open abdominal surgery and its incidence varies between 2-20% depending on the patient's age, obesity, comorbidity and type of the surgery. [1, 2] Incision type, closure of the incision and the suture material are the important factors for preventing hernia development. Incisional hernias are usually asymptomatic but may cause serious complications, such as abdominal pain, skin deformity, intestinal obstruction, strangulation, incarceration and enterocutaneous fistula. [3] Surgical intervention is indicated to prevent these complications and the expansion of the defect. Surgical options include primary repair with suture and open or laparoscopic repair with mesh. In mesh repair, onlay, sublay and inlay repairs can be applied according to the area where the mesh will be laid. [4] All three techniques are widely used, and there is no definite consensus on which technique is superior. The aim should be to apply the best Objectives: The selection of incision type, closure type of incision and the suture material are some of the important factors to prevent hernia development. We should aim to perform the best procedure with the best technique to reduce the risk of recurrence. Surgical options include primary repair and open or laparoscopic repair with mesh. Mesh repairs can be performed as onlay, sublay or inlay according to the area where the mesh is to be laid. In this retrospective study, our main goal was to compare the recurrence rates in patients who underwent incisional hernia repair with onlay and inlay mesh techniques. Methods: This retrospective study included 185 patients who underwent surgery due to incisional hernia in our clinic between January 2012 and October 2017. Patients were divided into two groups according to the technique as Group 1 with onlay mesh repair and Group 2 with inlay mesh repair. The same type of mesh (prolen) was applied to all patients. Results: There were 121 patients in Group 1 and 64 patients in Group 2. According to data we obtained, 64.3% of the patients were women and the mean age of all patients was 58.4±16.4 years. Postoperative complications (such as seroma-hematoma, surgical site infection, mesh rejection, postoperative ileus) developed in 29.2% (n=54) of the patients. The length of hospital stay was 4.2±3 days in Group 1 and 5.6±5 days in Group 2. The mean follow-up period was 48.6 months (24-93 months), with the recurrence rates of 5.8% (n=7) in Group 1 and 10.9% (n=7) in Group 2, respectively. There was a statistically significant difference between the groups concerning comorbidity, postoperative complications, the length of hospitalization stay and recurrence. Conclusion: We believe that the onlay technique will be more appropriate than the inlay technique when only prolen mesh is preferred because the recurrence rates are higher in the inlay technique.

Comparison of "onlay" and "sublay" methods of mesh repair of incisional hernia in terms of early and late period wound complications

“…In some studies, the "onlay" method is stated to cause seroma and hematoma formation more frequently [13] . In the study conducted by Acar et al [1] , the development of seroma and hematoma after the "onlay" graft method was detected in 15.7% of the patients. This rate was found as 3.8% for seroma and 3.8% for hematoma for surgeries performed with the same method in our study.…”

“…Wound complications such as wound infection, seroma and hematoma can be seen at varying rates after incisional hernia repair. Such complications are evaluated in relation to the tissue dissection width and the graft material used [1] . In some studies, the "onlay" method is stated to cause seroma and hematoma formation more frequently [13] .…”

“…T he development of an incisional hernia after abdominal surgery is an important complication. Rates of up to 20% have been reported in previously published series [1][2][3] . Although this rate is related to clinical features such as the patient's age, obesity, co-morbidities and the type of surgery performed, the physical characteristics of the graft used in the repair and surgical techniques are also considered to be important factors for the development of hernia [1,2] .…”

“…In addition to incisional hernia repairs with laparoscopic and robotic approaches in recent years, hernia repair surgeries using composite and biological grafts are also per-formed [4][5][6][7] . However, the open method is still the most commonly used incisional hernia repair technique due to the need for advanced technology and high cost grafts and the difficulty of applying it to complex hernias with extensive tissue loss [1,8] .…”

“…During the repair of the incisional hernia with the open method, the graft is fixed to different anatomical layers of the abdominal wall. These different repair techniques can be grouped as "onlay", "inlay", "underlay" and "sublay" [1,2,9] . Open incisional hernia repair with graft using the "sublay" method is accepted as the gold standard method by some authors [4,5] .…”