Federal Scientific Clinical Center of Miners’ Health Protection,

Leninsk-Kuznetsky, Russia

 

During the last years one can observe wide spreading of prosthetic techniques for anterior abdominal hernia plastics [2, 7, 12]. The approaches to treatment of ventral hernias were discussed and revised many times [1, 8, 10]. However, there is no uniform opinion about choosing method of prosthetic surgery. As result, all researchers accepted necessity of carrying out hernioplasty with modern high tech and qualitative synthetic prostheses [2, 5, 8, 14] that allowed reducing recurrence rates in patients with ventral hernias up to 5-10 % [6, 7, 11].

Correct choice of an optimal way is a recipe for surgery success for each patient with hernia. However, there is no uniform view point for this problem, as well as no uniform opinion in choice of a method of prosthetic surgery [3, 4, 9, 13].

Objective – to analyze the results of herniotomies with mesh implants in patients with ventral hernias.

MATERIALS AND METHODS

 The results of treatment of 271 patients with ventral hernias after standard hernioalloplasty for 2005-2012 were analyzed and generalized. All patients gave written consent for participation.

The patients had planned surgery in the surgery department #2 of Federal Scientific Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky. Hernioplasty was performed with prosthesis installation according to the standard techniques: onlay, sublay, inlay. Abdominal wall hernioplasty was performed with Esfil polypropylene mesh endoprosthesis with polypropylene level from 65 g/m² to 95 g/m² and the pore size 100-200 mc (Linthex SP-b).

The mean age of the patients was 53.6 ± 10.224. There were 98 (36 %) men, mean age of 48.5 ± 8.36, and 173 (64 %) women, mean age of 54.2 ± 11.63.

The size of hernia protrusion is one of the determinant factors of choice of surgical treatment tactics. The classification by K.D. Toskin and V.V. Zhebrovsky (1990) was used for description of hernia protrusion. The number of the patients with small hernias – 51 (19 %), with middle ones – 114 (42 %), with large ones – 83 (31 %), with gigantic ones – 23 (8 %). 112 (41 %) patients had primary hernias (umbilical and midline hernia), 159 (59 %) – incision hernias (postsurgical, recurrent).

Chronic somatic pathology was identified in 128 (80.5 %) of the patients in that period.

In the study group the hernioalloplasty technique depended on type of hernia, its localization, size of hernial defect and presence of concomitant disease. For analysis of surgery time, early postsurgical complications and recurrence time the patients were divided into 3 groups depending on the position of prosthesis in relation to aponeurosis (onlay, sublay, inlay). The table 1 includes distribution of the patients according to alloplasty technique. 

Table 1
Type of alloplastics and its amount

In postsurgical period 147 patients had draining of surgical site with active aspiration according to Redon. Statistica 6.1 and Microsoft Office Excel 2010 software were used for statistical analysis. Quantitative variables were described as mean (M) and standard error of the mean (δ). Student’s t-test was used for estimation of reliability of differences in the groups. For analysis of qualitative values χ² test was used. The critical level of significance during hypothesis testing was 0.05. In the case of p < 0.05 the null hypothesis was rejected.

RESULTS

During the analysis the causes of development of postsurgical ventral hernias and recurrence were reviewed. There was an estimation of the standard techniques of hernioalloplasty used in that period. The positive and negative moments of these techniques for different stages of treatment were reviewed.

The analysis of causes of development of incisional hernias

The analysis of the results of 159 patients with incisional hernias showed prevailing proportion of women – 102 (64 %) persons, mean age of 52.8 ± 6.41. The postsurgical and recurrent hernias were identified in 57 (36 %) male patients, mean age of 49.5 ± 7.23.

During precise review of the causes of incisional hernia development their conditional distribution into local and general ones was performed.

For 23.7 % of the patients the immediate causes of postsurgical hernia development included postsurgical wound purulence in 23.7 %, recurrent relaparotomy in 4.3 % of the patients; in 2.6 % of the patients hernia developed after omentobursostoma for pancreonecrosis; 3.5 % of the patients had previous packings and drainings in the region of hernial protrusion; 4.8 % of the patients had intestinal eventration.

During the analysis of the factors favoring rapid increasing the abdominal pressure 19 patients noted the following causes of herniation: cough, vomit, chronic constipation, inappropriate urination and early physical load. 78 patients could not indicate precise causes of herniation.

During detailed review the accompanying pathology was as single or in combination with other somatic diseases in 80.5 % among all patients with incisional hernias. The number of cases of identified cardiovascular pathology (CVP) was 79 (62 %), obesity of degrees 2-3 - 57 (44 %), diabetes mellitus (DM) – 34 (27 %), chronic obstructive pulmonary disease (COPD) – 16 (13 %). The results are presented in the figure 1.

Figure 1

Concomitant diseases in patients with incisional hernias 

 

The most frequent combination of chronic diseases was presence of cardiovascular disease, obesity of degrees 2-3 and diabetes mellitus – 29 patients.

The analysis of the clinical materials showed that out of 73 patients with recurrent hernia 52 patients had previous administration of autoplastic hernioplasty techniques, 21 patients had procedures with using mesh implant.

 

Estimation of efficiency of standard techniques of hernioplasty

For estimation of standard techniques of hernioplasty with use of mesh implant in clinical groups, the surgery time was observed, as well as types of early postsurgical complications and recurrence rates.

The mean time for a surgical operation was 80.1 ± 36.42 minutes in the group I (onlay). The mean surgery time for the patients of the group II (sublay) was 104.7 ± 35.83 minutes. Considering the characteristics of this technique, prosthesis is placed into the preperitoneal space or into the posterior wall of sheath of rectus abdominis muscle. Such deep location of an implant requires long-term and painstaking work. In the group III (inlay) the surgery time was 93.3 ± 38.32 minutes. The statistically significant difference in the surgery time between the first group and the second group was found (p = 0.014). There were no statistically significant differences in the surgery time between the second and the third groups (p = 0.072).

In postsurgical period we oriented to duration of discharge in drains, presence of signs of seroma accumulation in the region of surgical intervention, amount and type of complications.

Long-term draining of the wound was required for the patients of the group I (onlay). The mean time of draining was 6.8 ± 2.2 days. Draining was 14 days for 27 patients. In the group II (sublay) the mean time of postsurgical wound draining was 4.1 ± 1.8 days, in the group III (inlay) – 3.9 ± 1.2 days. There were statistically significant differences in duration of draining between the groups I and II (p = 0.043). There were no statistically significant differences in draining duration between the groups II (sublay) and III (inlay) (p = 0.146).

In early postsurgical period the local complications were identified in 32 (11.8 %) patients. In 27 (15.3 %) patients of onlay group the wound complications were found in early postsurgical period. Minimal rate of wound complications was noted in the patients of sublay (10.9 %) and inlay (9.1 %) groups. It can be explained by close contact of prosthesis with peritoneum, location of mesh implant in conditions of good circulation, absent contact of endoprosthesis with subcutaneous fat. The analysis of early wound complications in the examined groups is presented in the table 2.

Table 2
Types and number of local complications in patients of examined groups during postsurgical period.

In early postsurgical period in 5 patients in the group of subgaleal location of prosthesis (sublay) the signs of intestinal paresis were found (table 3). Such complication was identified in 4 patients of inlay group. These complications were treated with conservative techniques.

Table 3
Types and number of complications in patients of examined groups during postsurgical period

Early adhesive enteric obstruction was identified in 2 patients of sublay and inlay groups.

The analysis of the long term results of treatment of the patients of the examined groups was performed.  The results of treatment were studied in 247 patients of all groups by means of direct examination in the in-hospital clinic. The terms of observation were 3-6 years. In assessment of long term results we oriented to absence of recurrent hernia.

In the group of superaponeurotic fixation of prosthesis (onlay) recurrence was in 7 (6.6 %) patients. In the group of subgaleal location of prosthesis (sublay) recurrence was in 2 (5.4 %). The patients after surgery by means of inlay technique had the greatest recurrence of the disease in percentage terms – 3 (21 %) individuals (Table 4). 

Table 4
Recurrence rate after standard techniques of alloplastics

DISCUSSION  

During examination of the data of the analysis of postsurgical and recurrent hernias it was found that in 38.9 % of the patients the direct causes of incisional hernias included the factors associated with disorders in wound healing processes. The presence of accompanying diseases as vascular ones, obesity and diabetes mellitus aggravated reparative processes in the wound in 24.5 % of the patients with incisional hernias. In such conditions wound healing unexceptionally results in formation of rough, nonelastic scar, which is not able to resist the intraabdominal pressure. The high rate of recurrence (19.1 %) after autoplastic techniques of hernioplasty, presence of hernia in the region of degenerative changes of the anterior abdominal wall after surgical interventions rationalize necessity of obligatory implantation (Fig. 2).

Figure 2

The picture of the patient I., age of 55, anterior (a) and lateral views (b), postsurgical gigantic ventral hernia, the state after laparotomy in regard to pancreatonecrosis   

 a   b

During evaluation of different hernioalloplasty techniques we used not only literature data, but also own clinical experience. In the process of using different techniques we assured ourselves that an ideal way of alloplasty did not exist. One ways of prosthesis implantation (onlay) are simple in technical realization, but are accompanied by high frequency of local complications (15.9 %); other ways of mesh positioning (sublay) have lower frequency of wound complications (9.5 %), but are technically difficult, traumatic, with significant lengthening surgery time (Fig. 3). Inlay technique is used mainly in situations when closing rims of hernial orifice is impossible or dangerous because of possibility of cardiopulmonary complications associated with decreasing abdominal cavity volume. However, high rate of recurrence (18.1 %) allows restrained administration of these techniques (18.1 %).

Figure 3

The picture of the patient I., age of 55, anterior (a) and lateral views (b), the state after hernioplasty with mesh implant, 14^th day   

a   b                         

Wound complications of hemorrhagic and infectious character required different tactical and surgical approaches. In the patients with superaponeurotic location of prosthesis (onlay) hematomas (1.7 %), seromas (6.3 %) and purulence (3.4 %) of the wound were in the higher layers of the anterior abdominal wall and were removed in conditions of dressing and subsequent conservative therapy (14 patients) or it required wound revision under phlebonarcosis (6 patients). In 5 patients with subaponeurotic fixation of prosthesis (sublay) the wound complications were localized in the deep layers of the anterior abdominal wall that required more aggressive surgical tactics in view of wound revision under endotracheal narcosis. The aim of these operations was identification of bleeding source or pus accumulation, and prevention of flowing into the abdominal cavity. Later these patients needed for repeated wound debridement under phlebonarcosis. There was no purulence in the group of patients who received surgery with inlay technique.

In the patients of sublay and inlay groups close positioning of prosthesis in relation to the abdominal organs provoked specific general complications, such as intestinal paresis and early adhesive obstruction. Intestinal paresis ended during conservative therapy. Two patients with adhesive obstruction needed for laparotomy, abdominal revision and adhesiolysis under endotracheal narcosis.

CONCLUSION:

1. The development of incisional hernias is influenced by purulent inflammatory complications after surgical interventions for the anterior abdominal wall (25.5 %), unfavorable conditions of wound healing (15.2 %), associated somatic pathology (14.3 %) and recurrent autoplastic methods of hernia treatment (19.1 %).

2. Hernioalloplasty with installation of prosthesis into superaponeurotic space (onlay) is considered by us as the most actual and rational, because it was performed in 65 % of the cases of all alloplasty procedures, and the mean consumed surgical time was 80.1 ± 36.42 minutes.

3. Installation of prosthesis into the layers of the anterior abdominal wall is directly related to characteristics of complications and influences on tactics of their treatment. In case of superaponeurotic fixation of prosthesis (onlay) wound complications were registered in 15.3 %, but their location and characteristics did not require time-consuming treatment. After subaponeurotic fixation (sublay) wound complications, despite their little amount (10.9 %), resulted in more aggressive repetitive surgical interventions.