Open incisional hernia repair with retromuscular mesh augmentation - general and visceral surgery

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date of publication: 25.04.2009

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  • Exzision der Hautnarbe

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    70-4

    The present skin scar is excised completely

  • Exposing the fascial defect

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    Dissect down to the fascia and fully expose the entire fascial scar.

  • Opening the abdominal cavity

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    When opening the abdominal cavity, the fascial scar is transected completely.

    It is not enough to repair the fascial defect because frequently there are small multiple incisional hernia orifices.

  • Local adhesiolysis

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    Local adhesiolysis of abdominal organs in the hernia sac allows better overview and helps avoid iatrogenic bowel lesions when dissecting the tissue for the mesh bed.

    Follow this by covering the abdominal cavity with a warm wet laparotomy pad.

    Note: Interenteric adhesiolysis should only be performed in case of pertinent complaints

  • Dissecting the anterior fascia

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    Dissect the anterior fascia epifascially and sparingly. This facilitates the subsequent dissection of the tissue for the mesh bed and later fascial closure.

  • Incising the rectus sheath

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    Starting at the margin of the fascia, incise the rectus sheath on both sides of the linea alba, thereby opening up the retromuscular space, and mobilize the tissue up to the lateral margin of the rectus sheath. Open up the rectus sheath as far mediad as possible because this will preserve sufficient anterior fascia for the planned fascial closure. During subsequent dissection in the lateral direction carefully preserve the segmental vascular branches of the epigastric vessels as much as possible.

    On both sides the goal is to prepare an area large enough for a sufficient mesh bed.

  • Dissecting the mesh support

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    The goal is to prepare an area large enough for a sufficient mesh bed, requiring a mesh overlap of at least 5 cm in all directions. In case of some initial incisions this may require sharp dissection to free the posterior lamina of the rectus sheath from the xiphoid process, thereby opening up the retroxiphoid space.

    This requires a 5 cm long incision of the posterior lamina of the rectus sheath on both sides of the linea alba (see “LA” in figure), which opens up the preperitoneal space. The preperitoneal fatty tissue thus exposed is better known as the “fatty triangle” (see “FT” in figure).

    In the inferior direction, free the umbilical arch first. If the inferior margin of the defect is inferior to the arcuate line, you can dissect the preperitoneal/retrosymphysial space in blunt fashion.

  • Closing the abdominal cavity

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    Close the abdominal cavity with an absorbable running suture size 1/0 of the peritoneum and hernia sac including the posterior rectus sheath, if possible. The primary reason is to prevent any direct contact of the mesh with the intraabdominal organs.

  • Measuring the mesh bed

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    After painstaking hemostasis, measure the mesh bed and establish the dimensions of the prosthetic mesh.

    Ensure that the mesh will overlap the closed defect by at least 5-6 cm in all directions.

  • Placing and fixating the mesh

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    Depending on the type of mesh implanted, the largest elasticity of the mesh should be aligned with the pull of the muscle fibers.

    During placement ensure that the mesh is spread out in planar fashion and without any folds.

    In retromuscular mesh augmentation the mesh buttresses the abdominal wall but does not replace it by any means. Augmentation calls for non-absorbable prosthetic meshes with large pores and reduced surface area.

    Fixate the mesh to the posterior lamina of the rectus sheath with a few interrupted sutures (vicryl 3/0), keeping a distance of at least 1 cm from the edge of the mesh.

    Insertion of a Redon drain in the retromuscular space is not mandatory and should be considered on a case by case basis.

  • Closing the anterior rectus sheath

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  • Fixating the umbilicus and closing the wound in layers

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