Journal of Visceral Surgery (2012) 149, e3e14

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www.sciencedirect.com

ORIGINAL ARTICLE

Incidence and prevention of ventral incisional hernia

R. Le Huu Nho a,b,c,1, D. Mege a,b,c,1, M. Ouassi a,b,c,, I. Sielezneff a,b,c, B. Sastre a,b,c
a

Aix-Marseille, UMR 911, Campus sant Timone, 13005 Marseille, France APHM, Hpital Timone, Service de chirurgie digestive et oncologique, Ple doncologie et spcialits mdico-chirurgicales, 13385 Marseille, France c Atelier dcriture mdicale provenc ale, 13005 Marseille, France
b

KEYWORDS
Incidence; Prevention; Incisional hernia

Summary Objective: Ventral incisional hernia is a common complication of abdominal surgery. The incidence ranges from 2% to 20% and varies greatly from one series to another. The goal of this study was to determine the incidence, risk factors, and preventive measures for ventral incisional hernia. Materials and methods: An analysis of the surgical literature was performed using the search engines EMBASE, Cochrane Library, and PubMed with the keywords: abdominal hernia, wound dehiscence, incisional hernia, incidence, trocar site hernia, and hernia prevention. Results: The overall incidence of incisional hernia after laparotomy was 9.9%. The incidence was signicantly higher for midline incisions compared with transverse incisions (11% vs. 4.7%; P = 0.006). In contrast, the incidence of ventral hernia was only 0.7% after laparoscopy. A compilation of all the studies comparing laparotomy to laparoscopy showed a signicantly higher incidence of incisional hernia after laparotomy (P = 0.001). Independent risk factors for incisional hernia included age and infectious complications. Only two meta-analyses were able to show a signicant decrease in risk-related to the use of non absorbable or slowly absorbable suture material. No difference in incisional hernia risk was shown with different suture techniques (11.1% for running suture, 9.8% for interrupted sutures: NS). Conclusion: A review of the literature shows that only the choice of incisional approach (transverse incision or laparotomy vs. midline laparotomy) allows a signicant decrease in the incidence of ventral incisional hernia. 2012 Published by Elsevier Masson SAS.

Introduction
Ventral incisional hernia is a common complication of gastrointestinal surgery. The incidence varies from 2 to 20% [1], with extreme values ranging from 0 to 91% [2,3]. Several factors may explain this wide variability, such as:

Corresponding author. Service de chirurgie digestive et viscrale, hpital Timone, 264, rue Saint-Pierre, 13385 Marseille cedex 05, France. Tel.: +04 91 38 58 52; fax: +04 91 38 53 55. E-mail address: Mehdi.ouaissi@mail.ap-hm.fr (M. Ouassi). 1 These two authors contributed equally to this study.

1878-7886/$ see front matter 2012 Published by Elsevier Masson SAS. doi:10.1016/j.jviscsurg.2012.05.004

e4 Table 1 Incidence of incisional hernia after laparotomy. Year Study type Surgery Mean length incision (cm) NR NR NR NR NR NR 6 18 NR 24.3 NR Follow-up (months)a 42 29 45 12 NR 36 25 6 NR 72 29

R. Le Huu Nho et al.

Authors (ref.)

Number of patientsb 465 623 310 53 959 118 80 603 626 92 149

Incidence of incisional hernia n (%) 54 (11.6) 31 (4.9) 81 (26) 25 (47.1) 44 (4.6) 18 (15) 6 (7.5) 81 (13.4) 11 (1.7) 50 (54.3) 63 (42)

Gomez et al. [13] Piazzese et al. [9] Sorensen et al. [6] Burger et al. [15] Vardanian et al. [11] Heisterkamp et al. [20] Engledow et al. [7] Veljkovic et al. [8] Gastaca et al. [10] Moussavian et al. [12] Al-Azzawi et al. [14] Total

2002 2004 2005 2005 2006 2008 2008 2010 2010 2010 2010

Retrospective Retrospective Cohort Retrospective Retrospective Cohort prospective Cohort prospective Cohort prospective Retrospective Retrospective Retrospective

LT LT Various gastrointestinal Various gastrointestinal LT LT Various gastrointestinal Various gastrointestinal LT Secondary peritonitis Acute pancreatitis

4078

464 (11.3)

NR: not recorded; LT: liver transplantation. a Mean or median follow-up. b Number of patients examined at the end of follow-up to allow diagnosis of incisional hernia.

failure of the operating surgeon to report incisional hernias or reparative surgery performed by a different surgeon; too short a period of follow-up: while most incisional hernias are diagnosed within the rst 3 years after initial laparotomy [4], some may not become evident for up to 10 years after the initial surgery [5]. This wide variation in the reported rates of incisional hernia is not unexpected, given the heterogeneity of the reported series with regard to the types of patients included, the types of surgery performed, and the duration of followup. Nonetheless, this complication necessitated 34,000 ventral hernia repairs in France, based on the ndings of the Programme de mdicalisation des systmes dinformation (PMSI) study of 2009, consisting of either direct suture herniorraphy or of mesh implantation. Numerous risk factors have been identied in the effort to limit the incidence of ventral incisional hernia, and numerous studies have been performed to determine surgical approaches and types of fascial closure with the best results and lowest incidence of incisional hernia. From this viewpoint, even the prophylactic placement of mesh has been proposed. The objective of this literature review was to determine the incidence and risk factors for ventral incisional hernia and to identify measures that might decrease the incidence of this complication.

the keyword descriptors: abdominal hernia, wound dehiscence, incidence, trocar site hernia, hernia prevention. The search engines of EMBASE, Cochrane Library, and PubMed were used. The search was limited to articles published in French or English and dealing with human populations. For research concerning preventive measures, the search was enlarged to include articles from 1981 to 2011 because of technical improvements of surgical suture during these last two decades and because there were very few randomized studies published during the last 8 years. Studies concerning the treatment of ventral incisional hernia and recurrence after repair as well as case reports were excluded. The studies included consisted of prospective, comparative and retrospective series dealing with gastrointestinal or urologic abdominal surgery in adults and children. This search identied 88 references that were sufcient to select the studies necessary for analysis of this problem.

Incidence and risk factors

The literature review identied 17 original articles concerning ventral incisional hernia after laparotomy [2,621], 17 original articles concerning ventral incisional hernia after laparoscopy [2237,39] and 17 comparative studies of laparotomy vs. laparoscopy [3,38,4054]. A total of 30,603 patients from the combined series, the incidence of ventral incisional hernia was 3,7%.

Review of the literature

A search of Evidence-based medicine articles published between 1998 and 2011 was carried out by cross-referencing

Incidence and prevention of ventral incisional hernia

Table 2 Authors

Prospective randomized studies of incisional hernia incidence as a function of surgical incision. Year Study type Type of surgery Incisional length (cm) Laparotomy Midline Transverse 23.3 NR 26.3 NR 14 > 12 53 NR 12 12 Follow-up (months) Number of patients included Laparotomy Midline 199 22 47 79 63 410 Transverse 196 15 47 69 60 387 Incidence of incisional hernia n (%) Laparotomy Midline 1 (0.5) 20 (91) 3 (6.4) 13 (16) 9 (14) 45 (11) Transverse 0 (0) 6 (40) 3 (6.4) 8 (12) 1 (2) 18 (4.7) NS 0.01 NS NS 0.017 0.006 P

Inaba et al. [16] Fassiadis et al. [2] Proske et al. [17] Seiler et al. [21] Halm et al. [18] Total

2004 2005 2005 2009 2009

PR PR PR PR PR

Upper abdominal Vascular Upper abdominal Various gastrointestinal Upper abdominal

20.4 NR 17.6 NR 16.4

PR: prospective randomized study; NR: not recorded; NS: not statistically signicant.

Table 3 Authors

Incidence of incisional hernia after laparoscopy. Year Study type Surgery Follow-up (months) Number of patients Incisional hernia incidence n(%) Global Trocar site 9 (3) 12 (4.8) 1 (0.2) 2 (0.33) 9 (1.2) 2 (4.1) 5 (0.37) NR 0 NR NR 7 (3.2) 2 (1) 1 (0.3) NR 12 (4.8) 62 (0.3) Extraction site 0 0 14 (3.3) 0 0 NR 0 NR 13 (7.8) NR NR 0 10 (6) 0 NR 0 37 (0.2) e5

Bowrey et al. [22] Duca et al. [23] Montgomery et al. [24] Chiu et al. [25] Johnson et al. [26] Neri et al. [27] Balakrishnan et al. [28] Sexton et al. [29] Singh et al. [30] Ferrari et al. [31] Hussain et al. [32] Cost et al. [33] Skipworth et al. [34] Lin et al. [35] Gangl et al. [36] Fuller et al. [37] Total
NR: not recorded.

2001 2003 2005 2006 2006 2008 2008 2008 2008 2009 2009 2010 2010 2011 2011 2011

Retrospective Prospective Retrospective Retrospective Retrospective Prospective Prospective Retrospective Prospective Prospective Retrospective Retrospective Prospective Retrospective Prospective Prospective

Gastric Biliary Urology Bariatric Bariatric Biliairy Biliary Gastric Colorectal Vascular All types Urology Colorectal Urology Biliary Urology

12 15 NR 29 20 NR NR 12 20.2 37.9 43 5.7 36 33.9 21.5 35

320 9542 424 752 747 48 1332 61 166 271 5541 218 167 308 134 250 20281

9 12 15 2 9 2 5 1 13 34 8 7 12 1 2 12

(3) (0.1) (3.5) (0.33) (1.2) (4.1) (0.37) (1.6) (7.8) (12.5) (0.14) (3.2) (7) (0.3) (1.5) (4.8)

144 (0.7)

e6

R. Le Huu Nho et al. (Table 2). The combination of patients from the ve series reported between 2004 and 2009 included a total of 410 midline incisions and 387 transverse incisions; the incidence of incisional hernia was higher for the midline incisions 11% vs. 4.7%; P = 0.006) [2,1618,21]. A recent study from the Cochrane Library conrms the statistically signicant increase in the incidence of incisional hernia after midline incision compared with transverse laparotomy [55]. A study by Fassiadis concerning surgery for abdominal aortic aneurysm showed a higher rate of incisional hernia for midline incision (91% vs. 40%; P = 0.01 [2]. However, the 91% rate of incisional hernia in this series is higher than any other reported series. Because of anatomical constraints, hepatic surgery requires unusual incisions (bilateral subcostal, J-shaped incisions, or stellate Mercedes incision). In hepatic transplantation series that used a Mercedes type incision [911,13], the reported incidence of incisional hernia ranged from 1.7% to 11.6%. In comparison with a J-shaped incision, the Mercedes incision for liver transplantation seemed to be more likely to result in incisional hernia as was shown in the prospective comparative study of Heisterkamp et al. (24% vs. 6%; P = 0.002) [20]. In their retrospective study, Piazzese et al. showed that three-quarters of incisional hernias were associated with a Mercedes incision while the other quarter occurred after a J-shaped incision [9]. Bilateral subcostal incision was associated with a 1.7% incidence of incisional hernia in the series of Gastaca et al., signicantly lower than that observed with J-shaped incision 96%; P = 0.03) and Mercedes incision (24%; P = 0.003) [10]. The advent of laparoscopy has made some of these surgical approaches obsolete such as the transverse subcostal incision for cholecystectomy.

SEX AGE
100 80

Previous surgery Corcosteroid therapy Size of incision Sepc complicaons

BMI Tobacco Diabetes

60 40 20 0

Risk factors

Figure 1. Percentage of each independent risk factor in the 18 studies evaluating risk factors for incisional hernia.

20 15 10 5 0 %

9,8%

11,1% Rapidly absorbable Slowly absorbable Non Absorbable

Interrupted sutures

Running suture

Figure 2. Overall incidence of incisional hernia by type of closure and suture material.

Ventral incisional hernia after laparotomy Ventral incisional hernia after laparoscopy
Despite the increasing acceptance of laparoscopic surgery, laparotomy still remains the most common surgical approach for abdominal surgery; in 2009 in the French Programme de mdicalisation des systmes d information (PMSI) database, 361,004 laparotomies were performed versus 288,224 laparoscopies. From the 17 original articles published between 2002 and 2008, 11 articles that included more than 50 patients and had a follow-up period longer than 6 months were selected for further analysis; (Table 1) evaluation showed an overall incidence of incisional hernia of 11.3% [615,20]. Sixty percent of these incisional hernias occurred within 1 year of the initial laparotomy [4,15]. The overall incidence of incisional hernia after laparotomy was about 9.9%. This result exceeds the global incidence of 3.7% is explained by a longer follow-up averaging 2.5 years with an extreme range of 72 months [12]. The cumulative incidence of incisional hernia increases with time [4]. While the rise in laparoscopic surgery has permitted a marked decrease in the rate of incisional hernia, even this approach is not immune to this complication. Incisional hernia can develop either at the incisional site through which the specimen is extracted, or even at trocar sites. In a compilation of 16 published reports (Table 3) over the last 10 years and including 20,281 patients, the reported rate of incisional hernia from all sites is 0.7%; 0.4% occur at trocar sites and 0.3% at the incision for specimen extraction [2237,39]. The risk seems to be less for upper abdominal surgery with a minimum rate of 0.1% reported by Duca et al. in a prospective study of 9542 cholecystectomies [23]. The highest rates of incisional hernia occur after colorectal or vascular surgery; the incidence of hernia after

Inuence of the type of laparotomy incision

The choice of incision depends largely on the anatomic region to be exposed, the type of surgery, and the surgeons customary practice. While the midline incision is adaptable to all surgical eventualities, but the incidence of incisional hernia is increased as was shown by the meta-analysis of Grantcharov et al. with an incisional hernia rate of 8.1% vs. a 5.1% rate for transverse incisions (P = 0.023) [19]. After this study, two out of ve randomized prospective trials [2,1618,21] showed a statistically signicant incidence of ventral incisional hernia for midline vs. transverse incision
%

25 20 15 10 5 0

*
Incisional Hernias Parietal Wound s

*
Control

(*) P=0,001

Figure 3. Overall rate of incisional hernia as a function of prosthetic mesh placement.

Incidence and prevention of ventral incisional hernia

Table 4 Authors

Comparison of incisional hernia rate after laparotomy vs. laparoscopy. Year Study type Surgery Follow-up (months) Number of patients Laparotomy Laparoscopy 55 123 37 53 59 155 27 58 32 65 109 25 29 50 210 190 370 1647 Incisional hernia incidence n (%) Laparotomy 1 (1.8) 5 (5.9) 9 (19.6) 10 (20) 22 (38.6) 53 (33) 4 (13.8) 21 (14.7) 10 (15.8) 6 (9.2) 18 (16.5) 3 (10.7) 2 (7.7) 10 (20) 4 (0.7) 18 (8.9) 28 (19.7) 224 (12) Laparoscopy 0 2 (1.6) 9 (24.3) 0 3 (5) 19 (13) 1 (3.7) 2 (3.4) 3 (9.4) 0 16 (14.7) 1 (4) 0 0 2 (1) 9 (4.7) 37 (10) 104 (6.3) NS NS < 0.05 < 0.01 < 0.001 NS 0.026 NS 0.011 NS NS NS NR NS NS NS 0.001 P

Milsom et al. [40] Sanz-Lopez et al. [41] Winslow et al. [42] Lujan et al. [3] Puzziferri et al. [43] Laurent et al. [44] Stocchi et al. [45] Holst Andersen et al. [46] Ihedioha et al. [47] Ito et al. [48] Llaguna et al. [49] Veenhof et al. [50] Eshuis et al. [51] Schouten et al. [52] Swank et al. [53] Braga et al. [54] De Souza et al. [38] Total

1998 1999 2002 2004 2006 2007 2008 2008 2008 2009 2010 2010 2010 2010 2011 2011 2011

Prospective randomised Retrospective Prospective randomised Prospective randomised Prospective randomised Retrospective Prospective randomised Retrospective Prospective Retrospective Retrospective Prospective Prospective randomised Prospective Retrospective Prospective randomised Retrospective

Colorectal Upper abdominal Colorectal Upper abdominal (b) Upper abdominal (b) Colorectal Colorectal Colorectal Colorectal Hepatic Colorectal Colorectal Colorectal Upper abdominal (b) Appendix Colorectal Colorectal

19 66 30.1 23 39 51 126 57 22 NR 26 20 80.4 84 106 96 17.5

54 84 46 51 57 165 29 143 63 65 109 28 26 50 545 201 142 1858

NR: not reported; (b): bariatric; NS: not statistically signicant.

e7

e8 Table 5 Type of suture material and absorption time. Absorption time (days) 6090 20 180 180

R. Le Huu Nho et al.

Risk factors for incisional hernia

Eighteen series published between 2002 and 2011 have analyzed risk factors for the development of postoperative incisional hernia [4,6,8,1215,18,24,33,38,39,42,49,53,5759] (Fig. 1). Anemia, the use of vasopressor agents [59], emergency surgery [57], coronary artery disease, postoperative peritonitis due to intestinal rupture [12], and preoperative uremia are all acknowledged risk factors. Thus, emergency surgery may increase the risk by 42 to 50% due to local and systemic effects of infection [1214]. The two factors that emerge from multivariate analysis in over half of the selected series are age and parietal surgical site infection. Obesity, gender, and the length of the incision are three other independent risk factors that have been found in 17 to 35% of the 18 series we studied. Preoperative medical factors such as chronic pulmonary disease, benign prostatic hypertrophy, constipation and ascites that result in increased abdominal pressure also increase the risk of incisional hernia, but have not been shown to be independent risk factors. Some authors have studied factors that can be determined by imaging; Berger et al. showed that the distance between the two bellies of the rectus muscle as measured by CT postoperatively are directly related to the risk of incisional hernia: 92% of patients with incisional hernia had a diastasis recti of more than 25 mm [1].

Suture material Rapidly absorbable (RA) Polygalactin 910 (Vicryl) Polyglycolic acid (Dexon) Slowly absorbable (SA) Polydioxane (PDS) Polyglyconate (Maxon) Non absorbable (NA) Nylon (Nurolon) Polypropylene (Prolene) Polyethylene (Ethibond) Polyanide (Ethilon)

surgery for repair of infra-renal aortic aneurysm is 12.5% [31]. The site of incision for extraction of the surgical specimen also inuenced the rate of incisional hernia. In the study by Singh et al., the rate of incisional hernia was signicantly higher with a vertical midline incision than with a Pfannenstiel incision (17.6% vs. 0%; P = 0.0002) [30]. These ndings were conrmed by Souza et al. in 2011; they found an incisional hernia rate of 16% for vertical midline incision vs. 0% for Pfannenstiel incision (P < 0.001) [38]. The incidence was not modied by a hand-assisted laparoscopic approach where the incisional hernia rate was 3.5% despite an 8 cm long Pfannenstiel incision [24]. In a comparative study, Sonoda conrmed this result with in incisional rate of 4.8% after standard laparoscopic surgery vs 6% for hand-assisted laparoscopy [39]. The risk of incisional hernia does not seem to be decreased in robotic laparoscopic surgery; a prospective cohort study of 250 laparoscopic prostatectomies found a 4.8% rate of incisional hernia [37]; this is comparable to results after classical laparoscopic prostatectomy. Other approaches such as single trocar laparoscopy have identical rates of incisional hernia (1.9%) compared to classical laparoscopy (2.1%) [36]. However, this is still a recent innovation and no long-term results are yet available. The development of herniation at trocar sites was rst described in 1968 by Fear et al. [56]. This type of incisional hernia is under-reported in the literature, mostly being described in individual case reports. However, in our compilation of 17 series in the literature, the rate of trocar-site hernia was 0.3%.

Inuence of the type of suture used for fascial closure

Sixteen articles published between 1982 and 2010 were selected that compared different techniques of fascial closure as a function of the type of suture material: non absorbable suture (NA), rapidly absorbable suture (RA), and slowly absorbable suture (SA) [21,6074]. The different absorption characteristics of the suture materials are detailed in Table 5. The majority of these articles were prospective randomized studies with a follow-up of 12 months (range: 0.53 years) (Table 6). Thirteen studies showed no difference in the rate of incisional hernia as a function of the type of suture material used [21,6062,6469,72,73]. Two of the 16 studies reported contradictory results: Wissing et al. reported a signicantly higher incisional hernia rate for rapidly absorbable suture (RA 20.6% vs. SA 10.4%; P < 0.009) [63], while Gislason reported a higher rate with slowly absorbable suture (SA 12% vs. RA 4.3%; P = 0.02) [70]. The combined total of patients in these series (Table 6) included 8516 randomized patients, but only 6914 (81%) could be evaluated for incidence of incisional hernia during their follow-up. The overall incidence of incisional hernia was 10.8%, and there was no signicant difference in incidence based on the suture material used for fascial closure: NA 11.2%, RA 10.2%, and SA 11%. However, two meta-analyses demonstrated a signicantly lower incisional hernia incidence when fascial closure was performed with NA or SA suture [75,76]. In contrast, a recent multicentric prospective randomized study of 625 cases did not detect any difference in hernia incidence based on the type of suture [21] RA 15.9%, SA 8.4% with PDS or 15.9% with MonoPlus . With regard to fascial wound infection, Van tRiets meta-analysis reported a signicantly increased rate of suture sinus and chronic pain with NA suture [76]. This is conrmed by Krukowskis study [64], which shows a lower infection rate with the use of SA suture (3.5% vs. 7%). In view of these results, it is

Incisional hernias after laparotomy and after laparoscopy

Seventeen series published between 1998 and 2011 compare the incidence of incisional hernia after laparotomy versus laparoscopy (Table 4). For a combined total of 1858 laparotomies and 1647 laparoscopies, the incidence of incisional hernia was 12% vs. 6.3%, a statistically signicant difference (P = 0.001) [3,38,4054]. Three prospective randomized studies and two retrospective comparative studies have reported a higher incidence of incisional hernia after laparotomy [3,4348]. Two of these series involved bariatric surgery [3,43] and two others involved colorectal surgery [44,46]. For hepatic surgery, the laparoscopic approach has also resulted in a signicant decrease in the incidence of incisional hernia [48].

Incidence and prevention of ventral incisional hernia

Table 6

Prospective randomized studies analyzing incisional hernia incidence as a function of fascial closure technique and type of suture material. Patients included Patientsa Suture technique Type of suture Incisional hernia N (%) P NS 1 yr Follow-up

Authors year (ref.)

Corman et al., 1981 [60]

161

161

IS IS IS IS RS IS RS IS RS RS RS RS RS RS RS IS RS RS IS RS RS RS RS RS RS IS RS IS

NA 49 NA 53c RA 59 (vicryl) RA 184 NA 201 NA 54 RA 51 RA 286 RA 290 SA 281 NA 299 SA 285 NA 295 SA 65 NA 64 RA 122 SA 118 SA 345 RA 339 NA 318 SA 325 NA 91 SA 80 SA 164 RA 163 RA 164 SA 120 NA 109

4 (8.9) 2 (4.4) 0 (0) 1 (0.5) 4 (2) 5 (9.2) 5 (10) 48 60 37 31 (16.7) (20.6)e (13.2) (10.4)e

Richards et al., 1983 [61]

473

385d

NS

1 yr

Mc Neil et al., 1986 [62]

105

105

NS

1.5 yrs

Wissing et al., 1987 [63]

1539

1156

P < 0.009e

1 yr

Kukowski et al., 1987 [64]

757

580

22 (7.7) 28 (9.5) 4 (6.2) 4 (6) 7 (5.7) 5 (4.2) 28 (8.1) 21 (6.2) 50 (15.7) 49 (15.1) 4 (4) 7 (8.8) 19 (12) 9 (5) 7 (4.3) 11 (10) 20 (18)

NS

1 yr

Gys et al., 1989 [65]

167

129

NS

1 yr

Trimbos et al., 1992 [66]

340

240

NS

1 yr

Sahlin et al., 1993 [67]

988

684

NS

1 yr

Israelsson et al., 1994 [68]

813

643

NS

1 yr

Carlson et al., 1995 [69]

225

171

NS

2 yrs

Gislason et al., 1995 [70]

599

491

P = 0.02

1 yr

Brolin 1996 [71]

229

229

P < 0.04

1.2 yrs e9

e10

Table 6 (Continued) Authors year (ref.) Patients included Patientsa Suture technique Type of suture Incisional hernia N (%) Colombo et al., 1997 [72] 632 614 IS RS RS RS RA 306 SA 308 RA 184 SA 156 45(14.7) 32 (10.4) 7 (3.8) 3 (1.9) P NS 0.53 yrs 2 yrs Follow-up

Hsiao et al., 2000 [73]

340

340

NS

Seiler et al., 2009 [21]

625

530

IS RS RS RS RS

RA 176 SA 178 SA 176 NA 223 SA 233

28 (15.9) 15 (8.4) 22 (12.5) 45 (20.2) 58 (24.9)d dehiscence excluded 747 (10.8)

NS

1 yr

Bloemen et al., 2011 [74]

523

456

NS

2 yrs

Total

8516

6914

RS: running suture; IS: interrupted suture; NA: non absorbable; SA: slowly absorbable; RA: rapidly absorbable; NS: non signicant a Number of patients with data concerning incisional hernia incidence. b Multilament braided. c Monolament. d Only midline closures are included in this table. e Signicative difference between rapidly absorbable with running suture and non absorbable with running suture.

R. Le Huu Nho et al.

Incidence and prevention of ventral incisional hernia

Table 7

Comparative studies of incisional rate after suture closure vs. prosthetic mesh abdominal wall closure. Type of study n Position of prosthesis placement Type of surgery Type of prosthesis n (%) Parietal infection P NS n (%) 0 5 (11.4) 0.02 Incisional hernia P NC NC Operative Follow-up time (min) (months) P NC NC NC NC P NC NC

Authors Year (ref.)

Gutierrez de la pena Prospective C. et al., 2003 [81] randomized

Prosthesis n = 44 Control (non absorbable running suture) n = 44

Pre-fascial

Gastrointestinal Polypropylene

1 (2.3) 1 (2.3)

Rogers M. et al., 2003 Prospective [82] non randomised El-Khadrawy et al., 2009[83] Herbert et al., 2009[84] Hidalgo M.P. et al., 2010 [85] Prospective randomised Prospective Prospective

Prosthesis n = 26

Pre-peritoneal space Sub-fascial

Abdominal aortic Polypropylene aneurysm All midline laparotomies Bariatric Colorectal Bariatric Polypropylene

4 (15.4)

147

NC

NC

Prosthesis n = 20 Control n = 20 Prosthesis n = 16 Prosthesis n = 72 Prosthesis n = 25 Control n = 25

2 (10) 4 (20)

NS

1 (5) 3 (15)

0.01

NC NC

37 36 6 46 12

NS

? Pre-peritoneal Retromuscular

Polypropylene or absorbable Polypropylene Polypropylene

3 (19) 0 1 (4) 1 (4)

NS

1 (6.2) 0 1 (4) 8 (32)

0.009

261 130 120

NS

Curro G. et al., 2010 Prospective [86] comparative Bevis P. et al., 2010[87] Prospective randomised

NS NS

12 31 20

Prosthesis n = 37 Control (non absorbable suture) n = 43

Pre-peritoneal

Abdominal aortic Polypropylene aneurysm

2 (5,4) 2 (4,6)

NS

5 (13.5) 16 (37.2)

0.022

150 140

Llaguna O et al., 2011 Prospective [88] comparative

Prosthesis n = 44 Control n = 62

Sub-fascial

Biologic

4 (9) 1 (1.6)

NS

1 (2.3) 11 (17) 0.01 NC

16 17

NS

NS: non signicant; NC: not communicated.

e11

e12 recommended that fascial closure be performed with SA suture such as PDS . But the fascial suture techniques vary widely and the denitions of parietal abnormalities are imprecise (dehiscence, incisional hernia) in these studies, which explain the heterogeneity of results.

R. Le Huu Nho et al. that noted in France in 2009 based on the PMSI database. This incidence varied from 0.7% after laparoscopy to 9.9% after laparotomy. Laparotomy clearly increases the risk of incisional hernia compared with laparoscopy. The patients general condition, advanced age, and parietal wound infection are the risk factors most commonly reported. Fascial closure using slowly absorbable suture, whether by running or IS, seems to be the technique that results in the lowest risk of incisional hernia. Systematic use of prosthetic material seems to be an interesting approach to minimizing the risk of postoperative ventral hernia, but its actual effectiveness must be conrmed in studies of larger numbers of patients, with a longer follow-up period before we can conclude the actual benet of this as a routine practice.

Inuence of suture technique on the development of incisional hernia

Studies have been done to evaluate the inuence on the incidence of incisional hernia of not only the type of suture but also the suture technique used for fascial closure, i.e., interrupted suture (IS) versus running suture (RS) (Table 6). Only one study showed a signicant decrease in the incidence of incisional hernia associated with RS closure but the type of suture differed between the two techniques (RS with SA suture [10%] vs. IS with NA suture 18%; P < 0.04) [71]. In this literature review, 5013 patients underwent RS closure and 1901 underwent IS closure. Of the patients with RS closure, 559 developed incisional hernia (11.1%), vs. 188 (9.8%) of those with IS closure (P = 0.13) (Fig. 2). The meta-analysis by Van tRiet shows no difference in the incidence of incisional hernia as a function of running or IS technique [76]. The recently published meta-analysis by Gupta reviewed 10,900 patients and showed no difference in incidence of incisional hernia related to RS or IS closure [77]. Some surgeons have suggested mass sutures of the full thickness of the abdominal wall including the skin. A prospective study published many years ago reported similar incisional hernia rates regardless of whether classical or full thickness abdominal wall closure was performed (4.2% vs. 5.2%) [78]. In a retrospective study, Ausobski et al. reported a signicantly lower rate of incisional hernia with classical closure than with full thickness mass sutures (3% vs. 10%; P = 0.01) [79], but the two types of closures were applied to different incisions (paramedian and midline, and their mass suture did not include the skin. The widely variable denition of full thickness abdominal wall suture and the small numbers included in these older series do not permit us to propose this closure technique for any particular type of surgery or degree of obesity. With regard to trocar site closure, a recent literature review of studies of trocar site herniation concluded that all trocar incisions larger than 10 mm should be closed under direct vision as well as all 5 mm trocar sites that were subjected to vigorous manipulation [80].

Disclosure of interest
The authors declare that they have no conicts of interest concerning this article.

Acknowledgements
We wish to thank Professeur Huber Johanet and Professeur Bertrand Millat for providing the PMSI data for the year 2009.

References
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Inuence of prosthetic material on the incidence of incisional hernia

We selected eight prospective studies published between 2003 and 2011, three of which were randomized, that compared conventional fascial closure with the use of prosthetic mesh [8186,88] (Table 7). Most commonly, polypropylene mesh was used. Operative duration was not statistically different between the control group and the prosthetic group in any of the comparative studies. For all the comparative studies (ve out of eight) there was a signicantly lower incidence of incisional hernia in the prosthetic group with no increase in septic complications and no need to explant the prosthesis (Fig. 3).

Conclusion
The overall incidence of postoperative incisional hernia was 3.7% in this literature review, essentially the same as

Incidence and prevention of ventral incisional hernia

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