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COMPARISON BETWEEN ON LAY AND IN LAY MESH IN

REPAIR OF INCISIONAL HERNIA
Amer Nasr Omer
Department of General Surgery, Mataria Teaching Hospital, Cairo, Egypt.
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ABSTRACT
Background: Incisional hernia is a common complication of abdominal
surgery with a reported incidence of (2-11%) following all laparotomies and an
important source of morbidity. A wide spectrum of surgical techniques has been
developed ranging from suturing techniques to the use of various types of
prosthetic mesh repair. Aim of the work: The aim of the present study is to
evaluate the technique of preperitoneal mesh repair for incisional hernias and
study the postoperative complications of this procedure. Patients and Methods:
Our study consisting of 60 patients with incisional hernia, managed by
preperitoneal mesh implantation and postoperative complications were
estimated during the period from January 2008 to may 2010. Follow up for 12
months for any complications or recurrences. Results: The results of our study:
sixty patients, 75% of females (n 45) and 25% males (n=15). The female to male
ratio was 3:land the highest incidence was in the 4th decade of life. The main
presenting feature was abdominal swelling in all patients (100%) in the near of
the previous operative scar. In 70% of patients (n=42), the most common
incision leading to incisional hernia was the midline incision (upper 5 and
lower 37) of abdomen followed by fanensteil’sincision in (13.3) percent (n=8)
and paramedian incision in (11.7) percent (n=7). Two patients (3.3%) post
subcostal incision and one patient (1.7%) post Mc Burney’s incision. Major
wound infection occurred in two patients (3.3%) only but without the removal of
mesh. Comparing with other preperitoneal mesh repair studies, minimal
postoperative complications with no recurrence were noted in the present

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study.Conclusion:Preperitoneal mesh repair had excellent results, with minimal

morbidity (few postoperative complications with no recurrence). So it is a gold
standard treatment for incisional hernia repair.
Keywords: Incisional hernia; Mesh repair; preperitoneal mesh repair;
postoperative complications; Recurrence.
INTRODUCTION
Fail to heal; it is one of the most common conditions requiring major
surgery.Despite Incisional hernia is defined as diffuse advances in surgical
techniques and suture extrusion of peritoneurn and abdomina material. The
incidence of incisional contents through a weak scar after hernia is (2 - 11%)
following all lap-operation or accidental wound. It is the tomies (Santor and
Roslyn, 1993) and it is only hernia considered to be truly a source of morbidity
that requires high iatrogenic. It occurs due to the failure of health care costs.
Recent studies however the lines of closure of abdominal wall show that about
2/3 appear within the first following laparotomy(Manohar andRamadev, 2010).
An incisional hernia appears 5-10 years after the operation. It occurs in all the
layers except the skin, seen more in females, obese, older age group. Jack
Abrahrnson a pioneer in hernia surgery in the modern era said, many factors
singly or in various combinations may cause failure of the wound to heal
satisfactorily and lead to development of incisional hernia, main causes in its
causation are poor surgical technique and sepsis. Hernias were considered large,
when the width measured more than 10 cm at its greatest diameter. Medium
hernias measured between 6 and 10 cms in diameter. Small hernias were those
diameter6 cm. Complications of hernia include irreducibility is frequent and
partial obstruction, strangulation, spontaneous ulceration, rupture. Considering
the significant recurrence rate noted after various techniques for incisional
hernia repair, the task of repairing this defect can challenge the scientific and
artistic talents of the most experienced surgeon. Various types of repair have

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been described, both anatomical and prosthetic. But the results have been
disappointing with a high incidence of recurrence between (30-50%) after an
anatomical repair (Cassar and Munro, 2002) and in between (1.5%-1O%)
following prosthetic mesh repairs (Bauer et al., 2002). In general the
postoperative complications of incisional hernia include pulmonary
atleciactasis, bronchitis, pulmonary embolism, postoperative ileus,
thrombophlebitis and deep venous thrombosis or local complications like
wound seroma, haematoma, infection, sinuses and complications of mesh. The
introduction of prosthetics has revolutionized hernia surgery with the concept of
tension free repair. Although a wide variety of surgical procedures have been
adopted for the repair of incisional hernia, but the implantation of prosthetic
mesh remains the most efficient method of dealing with incisional hernia
patients with large defects of the anterior abdominal wall, especially preferred
more than 4 cm, size defect (Ahmed et al., 1995). The prosthetic mesh can be
placed between the subcutaneous tissues of the abdominal wall and the anterior
rectus sheath (onlay mesh repair) as well as in the preperitoneal plane created
between the rectus muscle and posterior rectus sheath (sublay mesh repair or
Rive’sStoppa technique ). The main advantage of pre -peritoneal mesh repair
are, Less chance of mesh infection or erosion through skin because the graft lies
deep in preperitoneal plane between posterior rectus sheath and peritoneum,
avoids adhesions’ bowel obstruction, enterocutaneous fistula and erosion of
mesh, minimal morbidity and duration of hospital stay is less compared to other
techniques(Bhat and Santosh, 2007). Moreover the mesh implanted in the
preperitoneal space unites and consolidates the anterior abdominal wall. The
mesh also adheres to the posterior rectus sheath and renders it inextensible
allowing no further herniation. The preperitoneal (sublay) mesh hernia repair
was first described by Rives (1987), Stoppa (1989) and Wantz (1991). This
technique is considered by many surgeons to be the gold standard for the open
repair of abdominal incisional hernia (Martin et al., 2001, Langer et al., 2005,
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Berry et al., 2007, Iqbal et al., 2007, and Lasheen, 2009). The main
disadvantage is more time consuming, extensive preparation of preperitoneal
plane and surgical experience. The present study was undertaken to evaluate the
technique of preperitoneal (sublay) mesh repair of incisional hernias with
regards to post operative complications, hospital stay and recurrences.
PATIENTS AND METHODS
This study consisting of 60 patients with incisional hernia managed by
preperitoneal mesh repair during the period from January 20!Jto may 2010. The
patients, who were admitted to Surgery Department, diagnosed to have
incisional hernia and these patients managed by preperitoneal mesh repair are
included in this study.
Inclusion Criteria:
1. All the patients with incisional hernia between 15 and 60 years without
sex discrimination.
2. Incisional hernias located in the midline (upper and lower), paramedian
and subcostal incisions of the abdomen.
3. Incisional hernias after the PfannensteWs and McBurney’s incision.
Exclusion Criteria:
1.All the patients with chronic obstructive pulmonary Disease (COPD).
2.Patients with abdominal malignancy and cirrhosis with end stage liver disease.
3.Patients with previous loss of the abdominal wall and large scarred area of the
abdominal skin.
4.Patients with age less than 15 years and more than 60 years.
5.Patientswith size of hernia larger than 15 cm in its largest dimension.
6.Incisional hernia in pregnant patients.
The age of the patients included in the study varies from 15 years to 62 years.
Regarding the sex distribution, seventy five percent of patients were females (n=
45’ and twenty five percent were males (n15). All patients were admitted to our

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surgery unit. The epidemiological data i.e. the name, age, sex, address and
phone number was recorded at the time of admission. The clinical features and
their duration, time of initial operation and the interval between the first surgery
and appearance of incisional hernia were asked from patients and recorded. The
known suspected risk factors like obesity, diabetes and history of wound
infection, type of incision made were noted and recorded. All the details were
entered in the database and results were statistically analyzed by Statistical
Package for Social Sciences (SPSS).
All patients underwent thorough clinical examination and a detailed history
and details of previous operation were asked for. All patients were evaluated for
systemic disease or precipitating cause. Patients who had hypertension, diabetes
mellitus or cough were controlled preoperatively. Routine investigations were
done for all patients including chest x-ray and ultrasonography of the abdomen.
A day prior to surgery, shaving of the abdomen and genitalia was done.
Overnight fasting, enema once in night and once in morning in the day of
surgery were advised. A nasogastric tube and Foley’s catheter was passed and
broad- spectrum antibiotics was given to all patients before the procedure.
Patient was informed about the effects and complications of the procedure. The
procedure was done under general anaesthesia, spinal or epidural anaesthesia in
supine position. In all cases, old operative sear was excised, generous skin
incision was used to permit adequate exposure of hernial sac and defect. The sac
was onened and contents were reduced after lysis of the adhesions. The excess
sac was excised; peritoneum was closed with absorbable synthetic suture.

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Operative Technique: The principles of the prepcritonealorsublay mesh

repair include Adequate preperitoneal plane was prepared between the posterior
rectus sheath and peritoneum (fig 1). Mesh placement deep to the recti muscles,

peripheral suture fixation, mesh extension well beyond the hernia defect (fig 2)
and closure of the fascia over the mesh. Fibrous tissue growth in the pours mesh
consolidates the abdominal wall and widely disperses intra-abdominal spreure
to prevent recurrence. Our technique involves the placement of prosthetic mesh
Figure (1): prepared plane between posterior rectus sheath and
peritoneum.
In the postoperative period, nasogastric aspiration two hourly in first 24
hours was done. The nasogastric tube was removed once the patient passed
flatus. Foley’s catheter was removed on 1 postoperative day. Suction drain was
removed once the drainage falls to 20 to 30 cc in 24 hours. Antibiotics were
continued for six days. Postoperatively, deep breathing exercises, movement of
limbs in bed was advised as (Polypropylene) in a preperitoneal plane. A plane is
created between the posterior rectus sheath and the peritoneum for placement of
the mesh. A prolene mesh tailored to the size is placed in the plane created in
front of the peritoneum. The mesh is secured with few interrupted 2/0 or 3/0
sutures polypropylene sutures. A suction drain is placed over the mesh and
brought out through separate stab wound. The posterior rectus sheath is closed
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with 2/0 prolene suture. The anterior rectus sheath is closed with continuous 1/0
polypropylene sutures as soon as patient recovered from anesthesia. Early
limited ambulation was done once the patient was able to bear the pain. Skin
sutures removed on 10th day and in few cases after that. At discharge, patients
were advised to avoid carrying heavy weights and advised to wear abdominal
belt. Patients were reviewed after one month, 3 months, 6 months and 12
months in all cases. At follow up visits, symptoms were asked for and operative
site examined for any recurrence. These cases were then analyzed and results
were compared with existing literature. Statistical Methods Chi-square and
Fisher exact test have been used to test the significance of proportions of

postoperative complications between PPMR of present study and other studies.

Two tailed Student t test has been used to find the significance of difference of
hospital stay between the patients presented with risk factors. Excel has been
used to generate graphs and tables.

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RESULTS
A prospective clinical study consisting of 60 patients with incisional hernia
who undergone preperitoneal mesh repair is undertaken to investigate the role of
preperitoneal mesh repair and its postoperative complications. The age
distribution of these 60 cases ranged from 15 years to 62 years (male, n 15/
female, n= 45) with peak incidence 3 1-50 age group, with female
preponderance seen (Table 1).
Table (1): Age and Sex distribution of Patients with incisional Hernia.
Age in year Male Female Total %
15—30 2 13 15 25
31-50 7 18 25 41.7
51-62 6 14 20 33.3
Obstructive pulmonary disease in 1.7% (n=1). All patients presented with
history of swelling of which 20 cases also presented with history of dragging
pain. On examination, swelling was reducible in 50 cases (83.3%) and
irreducible in 10 cases (16.7%) (Table2).
We had approximately, 33.3% (n=20) of cases with early onset of
incisional hernia (within one year), 66.7 %( n=40) of cases had late onset of
incisional hernia >1 year. Seven patients) 11.7 %had undergone more than one
surgery and 4 patients (6.7%) had already been operated for incisional hernia by
anatomical repair.
In present study, 58.3% (n=35) of cases following obstetric and
gynaecological operations. Thirty seven patients (61.7%) had lower midline
incision. The percentages of other incisions causing hernias are shown in (Table
3).
In present study, there were no postoperative complications in 88.3% of
cases. Only 2 patients (3.3%) had wound infection, 4 patients (6.7%) had
seroma and one patient (1.7%) had deep vein thrombosis (Table 4).

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Obesity was found in diabetes mellitus in 16.7% multipara 10% (n=6),

20% (n=12), (n10), grand and chronic
Table (2): Clinical presentation of patients with incisional hernia.
Sr.No. Clinical features No. of Patients %
1 Swelling of abdomen 60 100
2 Dragging pain 20 33.3
3 Irreducibility 10 16.7
Table (3) : Types of Incisions causing hernia.
Incision type Number %
Lower Midline 37 61.7
Upper Midline 5 8.3
Pfanncnsteiul,s incision 8 13.3
Paramedian incision 7 11.7
Subcostal incision 2 3.3
McBurney’s 1 1.7
Total 60 100%
Table (4) : Postoperative complications of preperitoneal mesh repair.
Postoperative complications Number %
Nil 53 88.3
Major wound infection 2 3.3
Hernia recurrence - -
Seroma 4 6.7
DVT 1 1.7
Table (5): Comparison of postoperative complications in preperitoneal
mesh repair (Present study and other mesh repairs (Other Studies).
Other Mesh
Repair Post
Repairs — Onlay PPMR
PPMR Onlay, inlay Underlay Mesh (Manohar
(Present and Mesh repair repair and
Study) underlay (Antoine et al (Machiras Rarnadev
(mi=60) (Leber et al, 2003)(n=350) et al 2010)
1998) 2004)(n=43) (n=50)
Operative Complications
(n=200)
Cellulites - 14 (7.0%) - - -
Wound Infection 2 (3.3%) 8 (4.0%) 14 (4.0%) 3 (7.0%) 1(2.0%)
Seroma 4 (6.7%) 6 (3.0%) - 6 (14.0)% 5 (10.0%)
Wound Gapping - - - - I
Postoperative Ileus - 16 (8.0%) - - -
Pneumonia - 2 (1.0%) - - 1
Pulmonary
- 2 (1.0%) - - -
Embolism
DVT 1 (1.7%) 1 (0.5%) - - 1 (2.0%)
Chronic
- 12 (6.0%) - I -
Infection/Sinus tract
Small Bowel Obstruction - 11(5.5%) - - -
Enterocutaneous Fistula - 7 (3.5%) - - -
Chronic Pain - - 2 (0.6%) 3 (7.0%) -
Death - - 2(0.6%) -
Recurrence - 34 (17.0%) 11(3.1%) 4 (9.0%) -

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DISCUSSION
Incisional hernia is produced by deficient wound healing from the
beginning or by gradual yielding of an apparently soundly healed wound. It is
estimated that 2- 11% of all abdominal operations result in an incisional hernia
(Piece et al., 2007). Small hernias less than 2.5cm in diameter are often
successfully closed with primary tissue repairs. However larger ones have a
recurrence rate up to 30-40% when tissue repair is performed alone (Fakhar et
al., 2009). Hernia recurrence is distressing to the patient and embarrassing to
surgeon. Nowadays tension free repair using prosthetic mesh has decreased the
recurrence to negligible. Despite excellent results, increased risk of infection
with implantation of a foreign body and cost factor still exist (Iqbal and Anjurn,
2009).
In the present study, the ages of patients were ranged from 15 years to 62
years with peak incidence in age group from 31 to 50 years (41.7%). In this
study, there is a female preponderance, the mean age was around 45 years
(75%), and this coincides with the study of Manohar and Ramadev (2010) in
which the percentage was 88%. In the present study, all patients presented with
history of swelling; 20 of them (33.3%) presented with pain and 10 patients had
irreducible hernia (16.7%).
We had approximately 33.3% of cases with early onset of incisional hernia
(within one year of previous surgery) whereas 66.7% of cases had late onset of
incisional hernia (> 1 year of previous surgery). In present study 58.3%
occurred following obstetrics and gynaecological operation, in comparison to
the study of Manohar and Rarnadev (2010) it was 78% of cases.
In the present study, seven patients (11.7%) had undergone more than one
surgery and 4 patients (6.7%) had already been operated for incisional hernia by
anatomical repair. Repeated wounds in the same region or just parallel to each
other will often lead to development of herniation as shown by (Hope, 2011). In

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this study, 61.7% of cases developed incisional hernia through lower midline
incision, 13.3% through Pfannensteil,s incision, 8.3% through upper midline
incision, 11.7% through paramedian incision, 3.3% through subcostal incision
and 1.7% through McBurney’s incision.
In present study, associated risk factors like diabetes mellitus (16.7%),
obesity (20%), and grand multi-para (10%) were seen. Obesity was found in
20% (n12), diabetes mellitus in 16.7% (n10), grand multipara 10% (n=6). In the
present study, we encountered 11.7% of eases with postoperative complications
of which, postoperative wound infection occurred in 2 cases (3.3%), which
healed by secondary intention, seroma in 6.7% of cases and deep vein
thrombosis in lower limb 1.7% of cases. There were no postoperative
complications in 88.3% of cases. Comparison of postoperative complications in
the present study (preperitoneal mesh repair) and previous studies (other mesh
repairs) are shown in table 5.
Postoperative complications were less in present study (11.7%) when
compared with other mesh repair techniques (Leber et al., 1998, Antoine et al.,
2003, Machiras et al., 2004 and Manohar&Ramadev, 2010).
In present study, we had followed up all the patients after discharge for two
weeks, 1 month, 3 months, 6 months and 12 months. There was no recurrence of
incisional hernia noticed in the present study, this agrees with the results of
studies of Elsesy et a!. (2008) and Manohar and Ramadev (2010). While
Luidendi et al. (2000) reported a recurrence rate of 46% with suture repair
technique and 23% with mesh repair technique. De VriesRelingh et al., (2004)
reported a recurrence rate of incisional hernia following different techniques of
mesh repair as follows: In onlay technique it was 28.3%, inlay technique 44%,
and underlay technique 12%. Macharias et al. (2004) reported a recurrence rate
of incisional hernia following onlay mesh repair with 9% of cases. Antonie et al.
(2003) reported a recurrence rate of incisional hernia following underlay mesh
repair with 3.1% of cases. In a recent study, excellent results in terms of low
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recurrence rate (only 1 case on 207 patients, 0.48%) was obtained (Forte et al.,
2011)
The preperitoneal mesh repair procedure is, among all those practiced, the
treatment of choice in incisional hernioplasty. We advocate this method of
incisional hernia repair as it is applicable to all sites of incisional hernia, the
mesh is mostly bidden and anchored in front the peritoneurn, as the
postoperative complications are low and there is no recurrence.
CONCLUSION
Preperitoneal mesh repair had excellent results, with minimal morbidity
(few postoperative complications with no recurrence). So it is a gold standard
treatment for incisional hernia repair.

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‫الملخص العربى‬
‫الطرق المختلفة فى عالج الفتك الجرحى بالشبكة مختلفة االوضاع دخل وخارج البريتون‬
‫عامر نصر عمر‬
‫استشارٓ الجزاحت العاهت بوستشفٔ الوطزيت التعليوي‬
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‫ُذٍ الذراست الِذف هٌِا همارًت عالج الفتك الجزاحٔ بالشبكت هزة د اخل البزيتْى ّهزة خارج‬
‫البزيتْى ُذا البحث شول هجوْعت هي الوزضٔ يتزاّح اعوارُن هي ‪ 15‬سٌت – ‪ 62‬سٌت هي حيث ّضع‬
‫الشبكت د اخل البزيتْى اّ خارجَ فٔ هختلف االعوار ّهمارًت الٌتائج هي حيث الوضاعفاث بعذ العوليت‬
‫ّالوذة التٔ يستغزلِا الوزيض حتٔ يتعافٔ تواها ًّسبَ رجْع الفتك ّارتجاعَ هزٍ تاًيَ ّلذ ّجذًا اى‬
‫افضل الٌتائج ُٔ التٔ استخذام فيِا الشبكت داخل البزيتْى ّعلٔ ُذا فمذ استفذًا هي البحث اى افضل‬
‫الطزق فٔ العالج الفتك الجزحٔ ُْ ّضع الشبكت داخل البزيتْى ‪.‬‬

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