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COMMENTARY |
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Year : 2013 | Volume
: 6
| Issue : 1 | Page : 31-32 |
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Changing trends in the management of incisional hernias
Subhash Chawla
Department of Surgery, Command Hospital, Lucknow, Uttar Pradesh, India
Date of Web Publication | 14-Mar-2013 |
Correspondence Address: Subhash Chawla Department of Surgery, Command Hospital, Lucknow, Uttar Pradesh India
Source of Support: None, Conflict of Interest: None | Check |
How to cite this article: Chawla S. Changing trends in the management of incisional hernias. Med J DY Patil Univ 2013;6:31-2 |
"Hernia repair remains a challenge to surgeons"-Bilroth stated 150 years ago. Tremendous advances have taken place in the field of hernia surgery recently with the introduction of prosthetic meshes and minimal invasive techniques. Millions of patients are affected each year, presenting most commonly with primary ventral and incisional hernias. When symptomatic these patients present with pain but asymptomatic cases are aesthetically distressing. These concerns, coupled with the risk of complications such as incarceration and strangulation, are the most common reasons patients report to surgeon for repair of hernias. Based on Pascal's principle of hydrostatic forces and the law of Laplace, hernia will continue to enlarge if not repaired. Increased intra-abdominal pressure will exert its greatest force on the thinnest portion of the wall. As the hernia enlarges, the wall thins out at that point, and the diameter increases. This positive feedback loop virtually assures continued progression. Incisional hernias generally do not develop in the immediate postoperative period. Follow up for 3 to 5 years post laparotomy is necessary for the development of incisional hernias.
Incidence of incisional hernia varies between 2 to 20%. Large ventral abdominal hernias especially incisional still remain challenge to surgeons. Early reports of primary suture repair were discouraging, with failure rates ranging between 25% and 52%. [1] Some authors have called for the abandonment of the suture repair because of frequent recurrences. With the development and popularization of tension-free repairs using prosthetic meshes, the recurrence rates have decreased to less than 20%. Also, the mechanical superiority of mesh-placement in the pre-peritoneal or retro-muscular space (sublay or underlay) over mesh that is fixed anterior to abdominal wall musculature (onlay) is conceptually apparent. However, large abdominal incisions and wide tissue dissection with the creation of large flaps often lead to a high incidence of postoperative morbidity and wound complications.
Laparoscopy has revolutionized the practice of surgery by imparting the ability to avoid major abdominal-wall incisions. Thus, laparoscopic surgery is expected to reduce the burden of incisional hernias, but such morbidity in the era of conventional, open surgery is likely to remain a fairly frequent problem for the foreseeable future. Recently, open ventral herniorrhaphy has been challenged by reports of successful implementation of minimally invasive techniques. The benefits of laparoscopic ventral hernia repair (LVHR) include a faster convalescence, fewer complications, and most important a low recurrence rate. Obesity has long been considered a risk factor for the development of primary and incisional hernias. In addition, incisional hernia repair in the obese population has been marked by a recurrence rate of up to 50%. The use of minimally invasive techniques may minimize peri-operative complications and improve failure rates of hernia repair in the obese population. LeBlanc and Booth first described the laparoscopic repair of incisional hernia in 1993. Since then it has been gaining popularity as it avoids long incision and extensive dissection for mesh placement. Currently laparoscopic repair with prosthetic mesh is rapidly becoming the gold standard for treating ventral hernia, with 4.7% recurrence rate reported by Cobb et al. [2] Reports of the efficacy of laparoscopic repairs in obese patients have been mixed. Rosen et al. reported a 20% recurrence rate in 44 obese patients following LVHR with mesh. Birgisson et al. had 1 recurrence in 46 patients with BMI of 30 or higher but their follow-up was less than 1 year. Bower et al. reported a 4% recurrence in a short-term follow-up of 47 obese and morbidly obese patients. One recurrence was also observed in the small series by Raftopoulos et al. after removal of an infected mesh. Disadvantages of preperitoneal approach is longer operative duration required in dissection and the development of retromuscular plane for mesh placement. [3]
Laparoscopic ventral hernia repair is a safe and feasible option in expert hands and reduces perioperative morbidity, fewer wound complications, early return of bowel function, and faster resumption of normal activities and lower rates of recurrence. These benefits suggest that for many patients laparoscopy is an appropriate approach for the repair of incisional hernias in both straightforward and complex presentations. There is still a role for the traditional open approach, primarily in patients who have a specific contraindication to a minimally invasive approach or in whom additional procedures are planned. The laparoscopic approach may be especially advantageous in obese patients with recurrent hernia. This avoids multiple failures of open herniorrhaphies, which are prone to recurrences.
References | | |
1. | Robbins SB, Pofahl WE, Gonzalez RP. Laparoscopic ventral hernia repair reduces wound complications. Am Surg 2001;67:896-900. [PUBMED] |
2. | Cobb WS, Kercher KW, Matthews BD, Burns JM, Tinkham NH, Singh RF, et al. Laproscopic ventral hernia repair: A single centre experience. Hernia 2006;10:236-42. |
3. | Prasad P, Tantia O, Patle NM, Khanna S, Sen B. Laparoscopic transabdominal preperitoneal repair of ventral hernia: A step towards physiological repair. Indian J Surg 2011;73:403-8. [PUBMED] |
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