Surgical Treatment by alloplastic reconstruction of

postoperative eventrations of the anterolateral

abdominal wall
Doicescu Dragos
Department: Pharmaceutical Sciences II
Facultatea de Farmacie University Ovidius
Constanta, Romania
dragosdoicescu@yahoo.com
Bratu Iulian Catalin
Department: Pharmaceutical Sciences II
Facultatea de Farmacie University Ovidius
Constanta, Romania
dr_bratuiulian@yahoo.com

Abstract-Incisional hernia is a frequent complication in
open abdominal surgery. Repair procedures for incisional
hernias, classic sutures or mesh, is an important problem,
but there is no consensus which type of procedure is better.
We have performed a retrospective analysis on 241
patients operated in Clinic Harbour Hospital Constanta
between 2006 and 2012, for simple or recurrent incision
hernias. The mesh has been used in a number of 101
patients. There were followed only the patients with
postoperative eventrations of the anterolateral abdominal
wall. The authors wanted to comparatively evaluate the
methods of classical surgical treatment and the techniques
of alloplastic reconstruction. The study aims to
retrospectively evaluate the results of the surgical
treatment depending on the place where the alloplastic
material was inserted.
KEY WORDS-I ncisional hernia, suture repair, mesh
repair, sutureless sublay mesh repair, onlay mesh mesh
rejection and recurrence
I. METHODS
We did a retrospective study mainly assessing the
precocious and late post operative evolution, depending
only on the operating technique used and not on the type
of mesh. We are taking into consideration the post
operative precociously and late complications.
Regarding the patients operated during 2006-2008, the
assessment of results was done on a period of 5 years. If
analyze the cases, we find that at the beginning of the
period we have used primary suture without mesh, but
later the most used procedure was the use of the mesh
mostly for the recidivated incisional hernias.
RESULTS: The studied group was made up of 169
women with an average age of 58, 29 years old and 72
men with an average age of 55,16 years old. We
identified a contributing factor for recidivated incisional
hernias, namely obesity, present in 148 cases. Among
systemic contributing factors, it stands out the increased
incidence of the disease at patients aged over 50 years
194 cases out of 241. At 124 patients, with incisional
hernia after previous surgery we identified in their
history certain local contributing factors: postoperative
suppurations 70 patients, emergency surgery
accompanied by multiple drains on a long period -54
patients, repeated surgical interventions 48 patients,
post operative physical effort 20 patients. At 53 cases
we did not identify any prominent contributing factors.
Out of 241 patients, 12 were operated in the emergency,
the rest of the group being operated in elective
conditions. Some of the patients needed to be delayed for
the treatment of related pathology. From the point of
view of localization, the studied group was made up of
patients with post operative eventrations of the
anterolateral abdominal wall. Depending on the size of
the parietal flaw, we encountered 24 giant eventrations
with dimensions over 15 cm, 101 cases with eventrations
over 5 cm, out of which 52 with multiple flaws and 140
eventrations with small unique parietal flaws of 2-3 cm.
Having in view the specificity of our clinic which is not
a unit specialized in receiving emergency cases, only a
number of 25 patients were hospitalized by the service of
emergency, most of them for association with other acute
illnesses: acute cholecystitis 6 cases, acute appendicitis
12 cases. The surgical treatment was a classical one
with a simple suture in 140 cases and 101 alloplastic
interventions for the cure of eventration. 42 alloplastic
interventions were practiced for parietal substitution and
59 alloplastic procedures for consolidation. The
evaluation of results have been done depending on the
adopted surgical technique, namely the site of placing
the prosthesis at the level of the parietal structure and not
depending the material of the mesh. The mesh for
parietal substitution have been placed intraperitoneal or
extraperitoneal, subfascial. Concerning extraperitoneal
subfascial mesh there were precocious postoperational
complications such as: seromas and hematomas 40;
postoperative suppurations 15; severe parietal
persistently suppurative sites 2.
The most frequent meshes used in our operations
were Marlex, Mersilene or Plastex, but we can not
specify which is the most used or which of this is
associated with less complications. [4,6]
II. DISCUSSION & CONCLUSIONS
Incisional hernia is described as a protrusion of an
organ through an abdominal incision, produced by poor
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wound healing and inadequate surgical techniques. In
addition, favored factors which can potentiate the
weakening of such an incision are: poor nutritional
status, malnutrition, smoking, infection or hematoma
(bleeding under the skin) after a prior surgery, excess
fluid retention,
cough, pulmonary disease, steroid usage, malignancy
advanced age and morbid obesity. [2, 5] Tension created
after sutures used to close a surgical incision may also be
responsible for developing an incisional hernia. The
incisional hernia is an important complication of open
surgery of anterolateral wall. This complication appears
in 11% of the cases with an abdominal operation. In the
cases with infected wound the rate of incisional hernia
increase to 23%.[1] The incidence of recurrence is
higher, about 30-50% after anatomical repair [7,9] and
1.5-10% following prosthetic mesh repairs [8].
The favorite treatment not much ago was the repair
of incisional hernias with primary suture. The procedure
is limitated by the tension of suture. The recidive is high
up to 49%. [1] The absence of tension in procedures
using mesh is a benefit, the recurrence rate descending to
10%, but the infection of the mesh appears often. [1] In
spite of the multitude of old or new surgical procedures,
the results are almost the same and the consensus is not
reached.
For the repair of incisional hernia, the abdominal
wall should be free of signs of inflammation or infection.
There is no clearly defined defect size at which incision
hernia surgery becomes necessary. The surgeon can
choose from a number of treatment options, which fall
into two principal categories: the conventional suture
technique and the open or laparoscopic mesh
technique.The last time has brought technical
developments to incisional hernia repair. The tension-
free hernia repair using prostheses reduces recurrence
rates significantly. The prosthetic mesh is possible to be
placed in the onlay type, between the subcutaneous
tissues and the anterior rectus sheath, as well as in the
sublay mesh repair type, that mince in the preperitoneal
plane created between the rectus muscle and posterior
rectus sheath. The later technique has the advantage of
not transmitting the infection from subcutaneous tissues
to the mesh wich lies in the preperitoneal plane.
Under the reserve that it is possible that some
patients could have gone to different clinics to solve their
complications, the study revealed: the simple suture of
the abdominal wall after treating the eventration bag was
followed by a relapse in proportion of 20%, a fact which
determined us to resort more frequently to the alloplastic
procedure which decreased the rate of relapses to 7%. [3]
Even if the chemical compatibility looks to be perfect,
the association of the mesh with some complications -
infection of the wound, intestinal obstruction, sero-
hematomas, fistulas - enhance the distrust in this method.
We remarked that when we are placing the mesh
onlay, although is more facile technical, this increase
incidence of complications: sero-hematomas, late
suppurative postoperative complications, relapses and
rejections, which occasionally led to partial or total
extraction of the alloplastic material. Today the sublay
technique has moved to the front. The sublay prosthesis
had a low incidence of sero-hematomas, implicitly less
late suppurative operative sites and reduced risk of
relapses. The intraperitoneal substitution was followed
by a reduced incidence of precocious complications.[2]
This technique is a safe, quick, convenient method and
may be considered the most successful method to place a
mesh, with minimum morbidity and mortality. The
postoperative time was shorter and evolution was
simpler compared to other laborious alloplastic
techniques. The complications associated with
intraperitoneal placement of the mesh were not seen in
our cas, as in other studies.[10]
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