Langenbecks Arch Surg (2007) 392:453457 DOI 10.

1007/s00423-006-0065-1

ORIGINAL ARTICLE

Incisional hernia: challenge of re-operations after mesh repair

Joachim Conze & Carsten J. Krones & Volker Schumpelick & Uwe Klinge

Received: 14 June 2005 / Accepted: 31 March 2006 / Published online: 2 September 2006 # Springer-Verlag 2006

Abstract Background and aims The widespread use of meshes for the repair of incisional hernia is currently followed by an increasing number of re-operations. The incidence of incisional hernia recurrence after mesh repair varies between 3 and 32%. The problem of mesh failure and options for another surgical intervention seem rather unattended. Methods We present our experience of 77 re-operations after previous mesh repair that were performed between 1995 and 2004 out of a total of 1,070 operations for incisional hernia. The retrospective analysis focused on recurrence in relation to location, material of the previous mesh repair and the surgical procedure to resolve the problem. Results The locations of the preceding meshes were epifascial as onlays (n=23), retromuscular as sublays (n=46), within the defect as inlays (n=6) or intraperitoneally (n=2). The direction of the incision was vertical medial (n=41) or horizontal crossing the linea semilunaris (n=36). Recurrences after median incisional hernia mesh repair mainly occurred at the cranial border of the mesh subxiphoidal. Except for two patients, all recurrences manifested at the margin of the enclosed mesh. Conclusions Re-operation after previous mesh repair is a surgical challenge. The type of revision procedure has to consider the position and material of the previous mesh. In our clinic recurrences, heavyweight polypropylene meshes were mostly treated with mesh exchange and lightweight
J. Conze (*) : C. J. Krones : V. Schumpelick : U. Klinge Surgical Department of the Rhenish Westfalian Technical University, RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany e-mail: jconze@ukaachen.de

polypropylene meshes could be treated by extension with a second mesh. In contrast to suture techniques, deficient mesh repairs are more evidently related to technical problems. Keywords Incisional hernia . Surgical mesh . Recurrence . Overlap . Adhesion . Shrinkage

Introduction Due to a cumulative incidence of about 20% [1], the repair of incisional hernias following laparotomy remains a perpetual task for general surgeons. For decades, mainly technical faults have been accused: bites that are too small, distances that are too far and tensions that are too high. However, despite multiple efforts, still no technique can reliably prevent incisional hernias. Regarding recurrence rates of about 50%, today any repeating of a suture technique seems to be insufficient and even obsolete [2]. For the short term, the introduction of meshes reduced the number of relapses to less than 10% [3]. However, current long-term results could not maintain this initial success. In an epidemiological study, Flum et al. compared the number of re-operations after treatment of incisional hernias by mesh or suture repair [4]. In both groups, an almost linear rise of the cumulative recurrence rate up to 20% after 10 years was reported. Lacking any initial peak, the time course additionally misses any plateau. Thus, the curve progression could reveal neither a typical technical fault (with an initial peak to be expected) nor a reliable, longlasting reduction of recurrence. Instead, the mesh implantation just induced a recurrence delay of about 2 years. This strongly supports an underlying dysfunction related to the patients biology. Recently confirmed by molecularbio-

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logical studies [5], these data are encouraged by a longterm prospective multicentre trial [6]. Here, a similar linear rise of recurrence in the mesh-group led to a delay of 4 years and an overall recurrence rate of 32%. In contrast to the crucial importance of a proper wound healing for a successful suture repair, the long-term success of a reinforcing implantation of non-absorbable meshes mainly depends on technical aspects. In an adequate position, the mesh prosthesis should prevent a recurrence even for life if specific challenges to the technique of mesh implantation have been considered. To illustrate the range of problems resulting from the widespread use of meshes, we analysed our patients that were re-operated on for recurrences after previous mesh repair in the years 19952004. Reasons for mesh failure were evaluated and the surgical options highlighted.

first 2 years. Forty-one patients developed a recurrent hernia subsequent to a previous median laparotomy with a repair not leaving the rectus sheets, whereas 36 showed a horizontal or lateral incision crossing the linea semilunaris (n=36). In 31 patients the previous mesh repairs was performed with a small-pore, heavyweight polypropylene (PP) mesh (pore size<1 mm=PP-small). Thirty-eight patients had received large-pore, lightweight PPpolyglactin composite meshes (pore size>2.5 mm=PP-large). In seven patients the abdominal walls had been repaired with an expanded polytetrafluoroethylene (ePTFE)-prosthesis, and only one patient received a polyester mesh at the previous operation. In the medial hernia group, primary mesh repair was performed in 24 sublay, 12 onlay and 4 inlay procedures. In the horizontal hernia group, previous incisional hernia repair was achieved by 22 sublay, 10 onlay, 2 inlay and 2 open intraperitoneal onlay mesh (IPOM) procedures (Table 1). Location of hernia recurrence

Materials and methods Between 1995 and 2004, we performed 1,070 repairs of incisional hernias. During this period, 77 patients underwent revision operations for recurrences after previous mesh repairs. The 52 men and 25 women were 45 to 81 years old (mean 5811). Forty-four of the patients had their primary mesh repairs in other surgical departments, 33 of the patients were our own recurrences. The records were analysed with regard to the previously applied technique, the type of prosthesis and the interval to the index operation. The incision was classified as median within the linea alba with a mesh not leaving the rectus sheath or as horizontal crossing the linea semilunaris and leaving the rectus sheath. The anatomical reconstruction of the prior operation was sometimes difficult to identify, particularly in case of mesh dislocation. Then, the data reflected the surgeons main impression or surgical notes if available. The location of mesh and fascia defect was registered intra-operatively. The extent of adhesions was classified as little if it was not or little mentioned, as moderate if it was mentioned without bowel resection and as severe in the case of bowel resection. The problem of shrinkage of the mesh area was also recorded, though it was not measured in figures but described in the operation record and documented by photography of the mesh explants. Statistical analysis was done with Statistical Package for the Social Sciences for Windows 12.0. Significant difference was assumed if p<0.05 using the Pearson Chi-square test.

After median incision within the rectus sheath, hernia recurrences mostly occurred subxiphoidally (n=19) and medially (n=16), rarely suprapubicly (n=3) and laterally (n=1). Hernia recurrence after lateral horizontal incision were almost similarly distributed to the following locations: suprapubic (n=9), subxiphoidal (n=7), lateral (n=7), medial (n=6) and subcostal (n=7) (Table 2). The location of recurrence was independent of the previous mesh position, whether it had been placed in a sublay or onlay position. After PP-small mesh repair we found an equal distribution of fascia defects to all sides but never a recurrence through a mesh. After PP-large mesh repair most fascia defects were found at the cranial mesh-border, particularly after midline incision. In this group there were two recurrences through a mesh, all in between the rectus sheaths. In the PP-large group significantly more recurrences were found at the upper border of the mesh compared to the PP-small group (63 vs 29%). Instead, patients of the PP-small group showed more recurrent hernias at the lateral side of the mesh (48%), usually combined with extensive shrinkage (Table 2). Eighteen of 31 PP-small meshes, two of 37 PP-large meshes and four of seven ePTFE materials were noted to be heavily shrunken (Table 3). The intraabdominal adhesions were assessed in four cases as severe, all of them forced a partial bowel resection and all of these patients had PP-small meshes (Table 3).
Table 1 Allocation of techniques to the direction of incision (n=77) Mesh position at index surgery Sublay 24 22 Onlay 13 10 Inlay 4 2 IPOM 2

Results The time interval from the first operation to the revision ranged from 1 to 128 months (mean 2222). Half of the patients were re-operated on within the first 14 months and 75% within the

Median-vertical incision Lateral-horizontal incision

Langenbecks Arch Surg (2007) 392:453457 Table 2 Location of the recurrence in dependency of the mesh and incision Position Recurrence location Cranial Med PP-small n=31 PP-large n=38 ePTFE n=7 POL n=1 POL polyester mesh 6 16 1 Lat 3 8 2 Total 9 24 3 Central Med 2 Lat Total 2 Lateral Med 11 1 Lat 4 7 2 1 Total 15 7 3 1 Caudal Med 2 1 Lat 5 3 1

455

Total 7 4 1

Type of revision operation Independent of the type of incision, a mesh exchange was performed in most cases preceding a PP heavy mesh repair, including explantation of the previous mesh and implantation of a PP light mesh (23/31). In five cases an extension with a second mesh was done, in another three patients a mesh explantation was followed by a simple suture repair. After previous implantation of a PP light mesh, the standard procedure was an extension with a second mesh (28/38). Mesh exchange was performed in four cases for recurrent lateral hernias. Mainly because of contaminated wounds, suture repairs were done in 12 cases, with an additional onlay mesh in two cases (Table 4). The seven recurrences after ePTFE meshes were repaired twice by mesh exchange replaced with a PP light mesh, twice by mesh extension after sublay position and three times by suture repairs. The recurrence after a sublay polyester mesh was repaired by a mesh extension.

reflect the history of current changes in mesh surgery. Different types of meshes were found in various positions. Without doubt, meshes have markedly improved the results of incisional hernia repair. Thus, they have largely replaced former suture techniques. However, despite convincing results of personal series, controlled studies and epidemiological data indicate that meshes per se do not always eradicate all difficulties. In general, there are two major aspects: recurrences and local mesh-related problems, e.g. infection, complaints and adhesions. Successful mesh-repair demands appropriate overlap Recurrences after mesh repair mainly appear at the border of the implant. This is in accordance with the known high strength of current meshes and the consecutively rare rate of mesh ruptures. Until now, there have been only few reports about central mesh rupture; interestingly, two of them occurred after implantation of a highly resistant, small-pore, heavyweight PP mesh (Marlex) [7]. Nevertheless, we observed two cases of mesh rupture in our own patient collective. Both of them occurred after the implantation of material reduced large-PP meshes that were placed in the sublay position. Noticeably, in both patients it was impossible to close the fascia in front of the mesh. Thus, a sufficient thrust bearing to counter the intra-abdominal pressure was missed. With the tensile strength reduced to 16 N/cm and designed only for abdominal wall reinforcement, the meshes were obviously under-dimensioned for the purpose of wall replacement. Consequently, either stronger or doubled large pore meshes with tensile strengths of 32 N/cm should be preferred in case of abdominal wall defect-bridging [8]. However, most of the recurrences occurred at the border of the meshes through their fixation by surrounding scar tissue. The increasing evidence of a basic defect in wound healing mainly forming collagen of poor quality [5] may lead to an insufficient incorporation of the layers, so far as meshes can still not improve the quality of collagen. Correspondingly, a too-small subduction underneath healthy tissue will accelerate the process of relapse. In

Discussion Hernia recurrence after mesh repair has become a new surgical entity and remains challenging. The reported operations were performed between 1995 and 2004 and

Table 3 Mesh material and described extent of shrinkage and adhesion formation Shrinkage mentioned Mesh PPsmall PPlarge ePTFE No 42% 95% 43% Yes 58% 5% 57% Adhesions

No/ little 74% 89% 71%

Remarkable 13% 11% 29%

Severe with bowel resection 13% 0% 0%

456 Table 4 Revision operation in dependency of mesh material and incision used Position Re-operation performed Exchange Med PP-small n=31 PP-large n=38 ePTFE n=7 POL n=1
a

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Extension Lat 8 4 1 Total 23 4 3 Med 2 16 Lat 3 12 1 1 Total 5 28 1 1

Explantation and suture Med 2 2a 2 Lat 1 4a 1 Total 3 6 3

15 2

POL polyester mesh One suture & onlay mesh

contrast, an extended overlap might prevent the recurrence for life. According to the current literature, an overlap of 5 cm in all directions should be sufficient, though until now there are no clinical studies addressing this problem. Small-pore PP meshes with high tendencies of shrinkage seem to encourage this relapse. Our recent insights in the pathogenesis of incisional hernias confirm that even an extended scar formation cannot prevent the recurrence if the tissue is of poor quality [9]. Whereas the rectus muscle can be easily subducted, this is more challenging in the midline, where the linea alba constrains the mesh placement. Early technical problems are most probably responsible for most of our own recurrences. Beyond the end of the former incision, underneath the intact linea alba, the posterior rectus sheath has to be incised on both sides close to the linea alba, opening the preperitoneal space that appears as a triangle of fatty tissue. Afterwards, the mesh can be placed behind the intact linea alba [10]. When the fascia defect reaches close to the xiphoid, the posterior rectus sheath needs to be dissected from the xiphoid in a similar way. The open retroxiphoidal space serves as a mesh layer, providing an extension from the retromuscular to the retroosseous space [11]. Further problems appear if the fascia defect leaves the rectus sheath crossing the linea semilunaris (about 47% of our patients with a recurrence after mesh repair). Then, the dissection has to continue either in the preperitoneal space or in-between the muscles of the lateral abdominal wall. In particular, close to the costal arch or to the iliac crest, this can be difficult. Sometimes, compromises with regard to the aspired subduction are inevitable. Mesh-related local problems depend on the material used Besides hernia recurrence, pain or persisting infection must be recognised as mesh-related problems. An extensive shrinkage might present as rolled lumps. In four patients, severe adhesions to the mesh made bowel resection

necessary. As a principle, needless mesh material should be removed, considering the amount of mesh-related problems that may appear even after years. Though the individual response varies, both human and animal studies give evidence that the inflammatory activity of the meshes mainly depends on the amount of material and its textile structure [1214]. In accordance, the majority of these problems are associated with small-pore PP meshes. In some patients, excessive shrinkage induced considerable complaints and even demanded a mesh exchange. Our experiences in this field can be shared with other authors [15]. With its reduced amount of polymer, large-pore PP meshes only rarely cause severe mesh-related problems. Due to decreased scar formation and maintained elasticity, it is more difficult to identify these meshes during a revision operation. Whereas the heavyweight PP meshes usually appear as stiff plates, the thin scarmesh compound of large pore meshes is mainly not identified until the scissor cuts the filaments.

Fig. 1 Small-pore PP-mesh coated with collagen with severe adhesions to the small bowel

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Whether new mesh modifications (e.g. coating with collagen) will reliably reduce intestinal adhesions has to be shown by future experiences. At least experiences with two collagen-coated PP meshes (Fig. 1) that were implanted by laparoscopy (IPOM) reveal that coating does not always protect against severe adhesions. Mesh enlargement or mesh removal Whether the revision operation can be restricted to a local mesh augmentation or to a removal of the preceding mesh depends on the indication for the re-operation, the location of the incorporated mesh and the mesh material itself. In the case of proper mesh position but insufficient overlap, an additional mesh can be fixed with non-absorbable sutures to the original prosthesis. To avoid re-recurrence, an extended overlap beneath scar-free tissue structures is essential. Instead, recurrences following an improper onlay repair, usually close to bony structures, demand a change in technique towards a retromuscular mesh repair. However, every re-operation after previous mesh repair remains a demanding procedure, and individual solutions are not unusual.

effects. The widespread use of meshes for the repair of abdominal wall hernias will confront the surgical community with an increasing number of re-operations after previous mesh-implantation.

References
1. Hoer J, Lawong G, Klinge U, Schumpelick V (2002) Factors influencing the development of incisional hernia. A retrospective study of 2,983 laparotomy patients over a period of 10 years. Chirurg 73(5):474480 2. Schumpelick V, Conze J, Klinge U (1996) Preperitoneal meshplasty in incisional hernia repair. A comparative retrospective study of 272 operated incisional hernias. Chirurg 67(10): 10281035 3. Schumpelick V, Klinge U, Junge K, Stumpf M (2004) Incisional abdominal hernia: the open mesh repair. Langenbecks Arch Surg 389(1):15 4. Flum DR, Horvath K, Koepsell T (2003) Have outcomes of incisional hernia repair improved with time? A population-based analysis. Ann Surg 237(1):129135 5. Jansen PL, Mertens PR, Klinge U, Schumpelick V (2004) The biology of hernia formation. Surgery 136(1):14 6. Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel J (2004) Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 240(4):578583 (discussion 583585) 7. Langer C, Neufang T, Kley C, Liersch T, Becker H (2001) Central mesh recurrence after incisional hernia repair with Marlexare the meshes strong enough? Hernia 5(3):164167 8. Schumpelick V, Nyhus L (2003) Meshes: benefits and risks. Springer, Berlin Heidelberg New York 9. Junge K, Klinge U, Rosch R, Mertens PR, Kirch J, Klosterhalfen B et al (2004) Decreased collagen type I/III ratio in patients with recurring hernia after implantation of alloplastic prostheses. Langenbecks Arch Surg 389(1):1722 10. Conze J, Prescher A, Klinge U, Saklak M, Schumpelick V (2004) Pitfalls in retromuscular mesh repair for incisional hernia: the importance of the fatty triangle. Hernia 8 (3):255259 11. Conze J, Prescher A, Kisielinski K, Klinge U, Schumpelick V (2005) Technical consideration for subxiphoidal incisional hernia repair. Hernia 9(1):8487 12. Klosterhalfen B, Junge K, Hermanns B, Klinge U (2002) Influence of implantation interval on the long-term biocompatibility of surgical mesh. Br J Surg 89(8):10431048 13. Klosterhalfen B, Klinge U, Hermanns B, Schumpelick V (2000) Pathology of traditional surgical nets for hernia repair after longterm implantation in humans. Chirurg 71(1):4351 14. Klosterhalfen B, Klinge U, Schumpelick V (1998) Functional and morphological evaluation of different polypropylene-mesh modifications for abdominal wall repair. Biomaterials 19: 22352246 15. LeBlanc KA, Whitaker JM (2002) Management of chronic postoperative pain following incisional hernia repair with Composix mesh: a report of two cases. Hernia 6(4):194197

Conclusion Confirmed by our increasing knowledge in pathophysiology, the use of meshes is almost indispensable for a successful treatment of incisional hernias. The acceptance of biological reasons for hernia recurrence even underlines the importance of an adequate technique with wide subduction of the entire incision to achieve low recurrence rates. At the least, the delay of hernia recurrence seems to be extended, ideally for the rest of the patients life. In addition, particularly in horizontal hernias beyond the rectus sheath, further technical improvements are desirable to optimise the implants position. The number of local complications due to the inflammatory stimulants of the foreign body might be diminished with the progressive reduction of material amount and the increasing pore size. Noticeably, the corresponding renunciation of inducing a stiff scar plate may stress the importance of an adequate overlap, which is sometimes a challenge to realise. Nevertheless, the ideal size and material of our mesh prosthesis are not yet defined. Anyhow, though the introduction of meshes means a marked improvement of our technical abilities, we are still far from offering a technique without any side