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  • 1. This article was downloaded by: [HINARI Consortium (T&F)] On: 20 October 2009 Access details: Access Details: [subscription number 791527919] Publisher Taylor & Francis Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK European Journal of Surgery Publication details, including instructions for authors and subscription information: http://www.informaworld.com/smpp/title~content=t713798801 Mesh repair of incisional Hernia: Comparison of Laparoscopic and open repair M. van't Riet a; W. W. Vrijland a; J. F. Lange b; W. C. J. Hop c; J. Jeekel a; H. J. Bonjer a a Department of Surgery, Erasmus University Medical Center Rotterdam -Dijkzigt, Rotterdam, The Netherlands b Department of Surgery, Medical Center Rijnmond Zuid, Rotterdam, The Netherlands c Department of Epidemiology and Biostatistics, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands Online Publication Date: 01 January 2002 To cite this Article Riet, M. van't, Vrijland, W. W., Lange, J. F., Hop, W. C. J., Jeekel, J. and Bonjer, H. J.(2002)'Mesh repair of incisional Hernia: Comparison of Laparoscopic and open repair',European Journal of Surgery,168:12,684 — 689 To link to this Article: DOI: 10.1080/000000000000003 URL: http://dx.doi.org/10.1080/000000000000003 PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: http://www.informaworld.com/terms-and-conditions-of-access.pdf This article may be used for research, teaching and private study purposes. Any substantial or systematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.
  • 2. ORIGINAL ARTICLE Mesh Repair of Incisional Hernia: Comparison of Laparoscopic and Open Repair M. van ’t Riet1, W. W. Vrijland1, J. F. Lange2, W. C. J. Hop3, J. Jeekel1 and H. J. Bonjer1 From the 1Erasmus University Medical Center Rotterdam – Dijkzigt, Department of Surgery. 2Medical Center Rijnmond Zuid, Rotterdam, Department of Surgery, 3Erasmus University Medical Center Rotterdam, Department of Epidemiology and Biostatistics, Rotterdam, The Netherlands Eur J Surg 2002; 168: 684–689 ABSTRACT Objective: To compare our results of open and laparoscopic mesh repair of incisional hernias. Design: Retrospective cohort study. Setting: Teaching hospitals, The Netherlands. Subjects: All patients who had had a laparoscopic (n = 25) or an open (n = 76) mesh repair of incisional hernia between January 1996 and January 2000. Interventions: Physical examination at the time of the study. Downloaded By: [HINARI Consortium (T&F)] At: 17:48 20 October 2009 Main outcome measures: Morbidity and recurrence. Results: The groups were comparable. 11 patients (14%) developed postoperative infections after open repair and 1 (4%) after laparoscopic repair (p = 0.29). Median hospital stay was 5 days (range 1–19) in the open group and 4 (range 1–11) in the laparoscopic group (p = 0.28). The 2-year cumulative incidence of recurrence was 18% after open repair (median follow-up of 17 months (range 1–46) and 15% after laparoscopic repair (median follow-up of 15 months, range 1–44). Recurrences in the laparoscopic group were all among the first 7 cases in which the mesh was fixed with staples alone. Conclusion: There were fewer infections and hospital stay was shorter in the laparoscopic group, but not significantly so. Recurrence rates were comparable. Key words: incisional, hernia, mesh, laparoscopic. INTRODUCTION operative wound complications and recurrence rates than open repair. Incisional hernia is one of the most common long-term complications of abdominal surgery. In prospective studies, the incidence has been reported to range from PATIENTS AND METHODS 11 to 20% after a laparotomy (4, 13, 15, 18). Although many techniques have been described for their repair, All patients who had had open or laparoscopic results are often disappointing. After primary suture, incisional hernias repaired between January 1996 and recurrence rates of 24% to 54% have been reported January 2000 at the Erasmus University Medical (7, 9, 10, 16, 20). A tension-free repair using a pros- Center Rotterdam and the Medical Center Rijnmond thetic mesh seems to be associated with lower Zuid in Rotterdam were entered into the study. Criteria recurrence rates of 10% to 34% (8, 22). However, for inclusion were midline incisional hernia and mesh open mesh repair requires more tissue-dissection than repair. Patients had a physical examination at the primary suture, which predisposes to wound infection outpatient department at the time of the study (mid- and painful recovery (1, 6, 19, 23). 2000), to detect recurrent incisional hernias. Laparoscopic incisional hernia repair is an alter- All operations were done under general anaesthesia native to open incisional hernia repair. Because large and patients were given antibiotic prophylaxis with a abdominal incisions and extensive tissue dissection are first generation cephalosporin. There were no consis- avoided, less wound infection, and faster recovery with tent guidelines about how patients were selected for the shorter hospital stay are likely. This technique may also open or laparoscopic groups. reduce recurrence rates as a result of better visual In the open procedure, the dorsal side of the fascia peroperative detection of other subclinical fascial adjacent to the hernia was freed from the underlying defects. tissue by at least 4 cm. The hernial sac was reduced into The purpose of this study was to compare open and the abdominal cavity, without resection. A polypropy- laparoscopic mesh repairs, to find out if laparoscopic lene mesh (Marlex1 or Prolene1) was tailored to the incisional hernia repair is associated with fewer post- defect in a sublay position with a continuous suture of  2002 Taylor & Francis. ISSN 1102–4151 Eur J Surg 168
  • 3. Mesh repair of incisional hernia 685 Table I. Characteristics of patients Data given are number of patients or mean (range). Laparoscopic Open (n = 25) (n = 76) Age (years) 60 (33–79) 57 (29–85) Male: Female ratio 13:12 40:36 Body mass index (kg/m2) 28 (20–35) 29 (21–44) Number of previous abdominal operations: 1 12 34 2 7 18 = or >3 6 24 Fig. 1. Laparoscopic mesh fixation with staples and trans- Number of previous abdominal sutures. incisional hernia repairs: 0 16 56 1 6 16 0/0 or 1/0 Prolene, with an overlap of the fascial edges 2 1 4 = or >3 2 0 of at least 3 cm. The hernial defect was not sutured. Diameter of hernial defect 6 (2–10) 7 (1–30) In the laparoscopic procedure, a polypropylene mesh (cm) was fixed intraperitoneally. The laparoscopic technique started with the establishment of CO2 pneumoperito- Downloaded By: [HINARI Consortium (T&F)] At: 17:48 20 October 2009 neum. A 30° laparoscope and two or three additional 5 or 10 mm trocars were inserted, some way from body mass index, history of previous abdominal previous incisions, and as far as possible from the surgery, number of previous incisional hernia repairs, hernial defect. Adhesions at or around the defect were and size of the hernial defect (Table I). Median taken down carefully using blunt and sharp dissection operating time was 120 minutes in the laparoscopic to allow sufficient surface to place a mesh. The hernial group (range 90–160) and 110 minutes in the open sac was not resected. After lysis of adhesions, a group (range 45–203), which was not significantly polypropylene mesh was introduced into the abdominal different. cavity. It was fixed to the circumference of the defect Intraoperative complications occurred in five pa- with an overlap of at least 3 cm with staples (Origin tients (7%) in the open group (bowel perforation n = 2, Med-systems, Menlo Park, CA, USA). In some cases, serosal damage n = 2, superficial hepatic rupture n = 1) transfascial sutures that were positioned with an and in two patients (8%) in the laparoscopic group Endoclose-needle1 (United States Surgical Coopera- (intestinal perforation, n = 2). In the two patients with tion, Norwalk, CT, USA) were added for mesh fixation bowel perforations in the open group, the perforation (Fig. 1). was closed and a polypropylene mesh was placed Mild wound infection was defined as redness and subfascially. In the two patients with peroperative discharge of pus from the wound, while severe bowel perforation in the laparoscopic group, the infection was defined as fever with pathogens cultured procedure was converted to an open approach and the from the mesh. Seroma was defined as postoperative bowel injury was repaired. In one of these patients, the accumulation of fluid at the site of the former hernial defect of the abdominal wall was closed by a suture, sac. while the other patient had a mesh repair. Prophylactic Statistical analysis was based on the intention-to antibiotics were continued for 5 days in these patients. treat principle. Percentages were compared using Another laparoscopic procedure was converted be- Fisher’s exact test. The Mann-Whitney test was used cause of severe adhesions, a conversion rate of 12% (3/ to evaluate hospital stay. Cumulative incidence of 25). recurrence of incisional hernia was determined using In the laparoscopic procedures, the mesh was fixed Kaplan Meier curves and compared with the logrank- solely by staples in 16 patients and by a combination of test. Probabilities of less than 0.05 (two-tailed) were staples and transfascial sutures in six patients. accepted as significant. Median postoperative hospital stay was 4 days (range 1–11) after the laparoscopic procedure and 5 days (range 1–19) after an open repair. This difference RESULTS was not significant (P = 0.28) A total of 101 patients, 25 in the laparoscopic group Postoperative complications are shown in Table II. and 76 in the open group, were included in the study. Postoperative wound infection developed in 11 patients The two groups were comparable in terms of age, sex, in the open group, and in one patient in the Eur J Surg 168
  • 4. 686 M van ’t Riet et al. Table II. Postoperative complications and recurrences peration for enterocutaneous fistula (n = 1), and severe Data are number (%) of patients. wound infection (n = 2). At the time of the study, 94 patients (93%) had a Laparoscopic Open (n = 25) (n = 76) physical examination in the outpatient department. One patient from the laparoscopic group and 6 from the Early postoperative open group could not be traced or did not respond to the complications: Seroma/haematoma 9 (36%) 13 (17%) invitation. For these patients, the general practitioner Wound infection: 1 (4%) 11 (14%) was contacted and follow-up was defined as the last mild 1 (4%) 1 11 (14%) 7 physical examination that had been made. severe 0 4 During a median follow-up time of 17 months in the Ileus 1 3 open group (range 1–46) and 15 months in the Retention of urine 1 1 Pneumonia 0 2 laparoscopic group (range 1–44), there were 14 Pulmonary embolism 1 0 recurrences after open repair and four after laparo- Mean follow-up (months) 16 19 scopic repair. Six of these recurrences (two in the open Recurrence 4 (16%) 14 (18%) group and four in the laparoscopic group) had not been Readmission 1 (4%) 8 (11%) detected before and were only diagnosed at per- Re-operation indication: 1 (4%) 6 (8%) protocol physical examination. The time of occurrence recurrence 1 5 of these recurrences could be calculated retrospectively enterocutaneous fistula 0 1 when the patient was interviewed. Calculated with the Kaplan Meier method, the 2-year cumulative incidence Downloaded By: [HINARI Consortium (T&F)] At: 17:48 20 October 2009 There were no significant differences between the groups. of recurrence was 18% after open repair and 15% after laparoscopic repair, which was not significantly dif- ferent (p = 0.91). There was no significant relation laparoscopic group, in whom the procedure had been between initial diameter of the hernial defect and converted to an open repair (p = 0.29). Wound infec- recurrence. All four recurrences in the laparoscopic tion was considered mild in eight patients, but severe in group occurred during the first series of 7 laparoscopic four patients, including all three patients in whom a incisional hernia repairs that were done in each mesh was placed after intraoperative bowel injury. In hospital. In one of these cases the laparoscopic three of the patients with mesh infection, conservative procedure had been converted to an open procedure. treatment with drainage and antibiotics was successful. The other three recurrences after a laparoscopic The fourth patient however, in whom open incisional procedure developed in the group of 16 patients hernia repair had been complicated by two peropera- in whom the mesh was fixed with staples alone tive bowel perforations, developed two enterocuta- (3/16 = 19%). No recurrences were seen in the six neous fistulas. For this reason, the patient was patients in whom the mesh was fixed by a combination reoperated on 7 months postoperatively. During this of staples and transfascial sutures. reoperation, the mesh was removed and a segment of Only five of the patients with recurrences (all in the small bowel was resected, followed by primary suture open group) had the recurrent hernia repaired, all open of the fascia. After this the patient recovered well. procedures with mesh. One patient in the laparoscopic Seroma was the most common complication in both group had a reoperation because of suspicion of a groups, with an incidence of 13/76 (17%) in the open, recurrent incisional hernia, but at reoperation no and 9/25 (36%) in the laparoscopic group (not recurrence could be detected and a blind hernial sac significantly different, p = 0.09). In most of the that was filled with fluid was resected. patients, the seroma resolved spontaneously, or after one or two aspirations. However, one patient in the laparoscopic group developed a persisting seroma that DISCUSSION resolved only after 12 aspirations. Other postoperative complications consisted of Laparoscopic repair of incisional hernia has been urinary retention (n = 1), pneumonia (n = 2), and studied by several authors, and the results of all pulmonary embolism (n = 1). All were treated success- published comparative studies on open and laparo- fully. Three patients died during follow-up. Their scopic incisional hernia repair to our knowledge are causes of death were related to malignancy and not to shown in Table III (1, 5, 14, 17, 19, 23). the incisional hernia repair. In these studies, operating time of laparoscopic Nine patients (eight in the open group and one in the repair varied, which seemed to be related to the laparoscopic group) were readmitted to hospital: for laparoscopic experience of the operating team. In the symptomatic recurrent incisional hernia (n = 6), reo- present study, operating time was comparable in both Eur J Surg 168
  • 5. Downloaded By: [HINARI Consortium (T&F)] At: 17:48 20 October 2009 Table III. Overview of published comparative studies between laparoscopic and open ventral incisional hernia repair Data are number (%) of patients. DeMaria et al. (4) Ramshaw et al. (18) Carbajo et al. (2) Holzman et al. (6) Park et al. (16) Chari et al. (3) Prospective not Prospective Prospective not Matched case- randomised Retrospective randomised Retrospective randomised control Laparoscopic Open Laparoscopic Open Laparoscopic Open Laparoscopic Open Laparoscopic Open Laparoscopic Open No. of patients 21 18 79 174 30 30 22 16 56 49 14 14 Material ePTFE PP ePTFE Suture ePTFE 8 ePTFE PP 10 PP 1 44 PTFE 12 3 ePTFE ePTFE PP or 22 PP ePTFE 5 PP 42 PP 4 mesh suture Vicryl Operating time (min) 58 82 87* 112* 129 98 96* 79* 124 78 Blood loss (ml) 17 70 68 168 Peroperative bowel injury 3 2 2 1 0 1 2 1 Hospital stay (days) 0.8* 4.4* 1.7 2.8 2* 9* 1.5 3.9 3.4* 6.5* 5 5.5 Postoperative complications: Wound infection 2 (10) 6 (33) 2 (3) 11 (6) 0 5 (17) 0 1 (7) 2 (4) 3 (6) 1 (7) 0 Iinfected mesh removed 1 0 0 5 0 3 0 0 0 0 1 0 Haematoma/Seroma 9 (43) 4 (22) 2 (3) 12 (7) 4 (13) 26 (87) 1 (5) 0 2 (4) 6 (12) Other complications 2 3 5 15 1 1 3 3 4 6 1 Total 62% 72% 20% 27% 17%* 90%* 23% 31% 18%* 37%* 14% 7% Mean follow-up (months) 12–24 12–24 21 21 27 27 20 19 24 54 Recurrence (%) 5 0 3 20 0 6 9 13 11 35 ePTFE = polytetrafluoroethylene, PP = polypropylene, Vicryl = polyglactin. * Significant difference between open and laparoscopic group. Mesh repair of incisional hernia Eur J Surg 168 687
  • 6. 688 M van ’t Riet et al. groups, although surgeons had limited experience with is contaminated, the risk of developing an enterocuta- laparoscopic incisional hernia repair. nous fistula is probably increased. We recommend that During both open and laparoscopic incisional hernia the mesh is not placed intraperitoneally and that repair the most delicate part of the procedure is the lysis prophylactic antibiotics are continued for several of adhesions, during which the bowel may be injured. days in these patients. In our series, bowel injury was encountered in 8% in Hospital stay is an important variable used to assess both groups. In other series, comparable percentages postoperative recovery, and was reduced after laparo- were reported after both open incisional hernia repair scopic repair in three comparative studies (1, 5, 19). (0–7%) and laparoscopic repair (0–14%) (1, 5, 14, 17, However, although hospital stay was slightly reduced 19, 23). Probably, the incidence of peroperative bowel after laparoscopic repair in the present study, this injury will decrease with the increasing experience of difference was not significant. the surgeon. The recurrence rate after laparoscopic repair in the Most published comparative studies have reported present study was higher than the recurrence rate that fewer wound infections after laparoscopic repair than was found by other authors (1, 5, 14, 17, 19, 23). The after open repair. (1, 5, 14, 19, 23) We saw the same explanation for this is not clear, although it is trend in the present study, with 4% postoperative remarkable that all the recurrences developed in the wound infection in the laparoscopic group and 15% in first series of 7 repairs. For this reason, a learning curve the open group. This difference was, however, not may have played a part in the higher incidence of significant, which may be because there were so few recurrence after laparoscopic repair. Another factor is patients in the laparoscopic group. Possibly the the method of fixing the mesh. As all recurrences in the Downloaded By: [HINARI Consortium (T&F)] At: 17:48 20 October 2009 combination of a smaller port of entry for micro- laparoscopic group occurred in the patients in whom organisms and the lack of large tissue dissection in the mesh was fixed with staples alone, the addition of laparoscopic repair may contribute to a lower risk for transfascial sutures to fix the mesh may reduce infection. recurrence rates. Unfortunately, the group in which it In both the present study and other comparative was fixed with both staples and transfascial sutures in studies, the most common complication after incisional the present study was too small from which to draw any hernia repair was the formation of a seroma or a conclusions. haematoma, with reported incidences between 2% and Another factor, which may have played a part in the 36% for the laparoscopic group and between 4% and higher recurrence rate in the present study, is the fact 87% for the open group (1, 5, 14, 17, 19, 23). The wide that in most other studies follow-up was not by physical spread of incidence of this complication is remarkable, examination (1, 14, 17, 19, 23). Six of the 18 recur- and probably results from differences in definition. The rences that had developed were only diagnosed at most plausible explanation for the occurrence of physical examination in the outpatient department at seroma is the collection of fluid in a persisting hernial the time of the study. A physical examination is sac or in the cavity that remains after removal of the therefore essential for adequate follow-up. hernial sac. Seromas can be drained by aspiration, but We found no significant difference between recur- resolve spontaneously in most cases, so resection of the rence rates after laparoscopic or open incisional hernia hernial sac does not seem indicated in laparoscopic repair, which has been confirmed by other authors (1, incisional hernia repair. To differentiate seroma from 14, 17, 19). However, two comparative studies found recurrent incisional hernia, which can be clinically fewer recurrences after laparoscopic repair than after difficult in obese patients, an ultrasound or computed open repair (5, 23). In contrast to the present study, in tomogram can be obtained. both of these studies mesh material varied between the Seven patients were reoperated on (six in the open open and laparoscopic group, and both studies also group and one in the laparoscopic group). One of these included patients in the open group in whom open patients had developed an enterocutaneous fistula after repair was by primary suture without a mesh (5, 23). As an open procedure. Although this complication has has been shown by various authors, incisional hernia been previously reported after intraperitoneal mesh repair without the use of a mesh is associated with placement, it is a rare complication with a long-term higher recurrence rates (2, 18, 20, 21). In addition, both incidence of about 1% (3, 9, 11, 12). Its occurrence is these studies included a variety of incisional hernias, mostly restricted to cases in which the mesh was placed while the present study included only incisional hernias in an infected abdomen (11). In the patient in the that had developed after midline laparotomy. present study who developed the enterocutaneous In conclusion, laparoscopic incisional hernia repair fistula, the mesh was also placed in a contaminated seems to be an effective technique, and as safe as the abdomen, as the incisional hernia repair had been open procedure. Although the differences were not complicated by two bowel perforations. If the abdomen significant, there were fewer postoperative wound Eur J Surg 168
  • 7. Mesh repair of incisional hernia 689 infections and shorter hospital stay after laparoscopic or vertical Mayo repair of primary hernias of the midline. incisional hernia repair, compared with open mesh World J Surg 1997; 21: 62–66. 13. Miller K, Junger W. Ileocutaneous fistula formation repair. Recurrence rates were comparable. following laparoscopic polypropylene mesh repair. Surg To establish if laparoscopic incisional hernia repair Endosc 1997; 11: 772–773. is associated with less postoperative pain and faster 14. Morris-Stiff GJ, Hughes LE. The outcomes of non- return to normal activity and work (compared with absorbable mesh placed within the abdominal cavity: open incisional hernia repair with mesh), we are literature review and clinical experience. J Am Coll Surg 1998; 186: 352–367. currently doing a prospective randomised multicentre 15. Mudge M, Hughes LE, Incisional hernia: a 10 year trial in the Netherlands that is co-ordinated by the prospective study of incidence and attitudes. Br J Surg Erasmus University Medical Centre Rotterdam. 1985; 72: 70–71. 16. Park A, Birch DW, Lovrics P. Laparoscopic and open incisional hernia repair: a comparison study. Surgery REFERENCES 1998; 124: 816–21. 17. Paul A, Korenkov M, Peters S, Kohler L, Fischer S, 1. Cahalane MJ, Shapiro ME, Silen W. Abdominal Troidl H. Unacceptable results of the Mayo procedure for incision: decision or indecision? Lancet 1989; i: 146– repair of abdominal incisional hernias. Eur J Surg 1998; 148. 164: 361–367 2. Carbajo MA, Marin del Olmo JC, Blanco JI, et al. 18. Ramshaw BJ, Esartia P, Schwab J, et al. Comparison of Laparoscopic treatment versus open surgery in the laparoscopic and open ventral herniorrhaphy. Am Surg solution of major incisional and abdominal wall hernias 1999; 65: 827–832. with mesh. Surg Endosc 1999; 13: 250–252. 19. Sugerman HJ, Kellum JM Jr, Reines HD, DeMaria EJ, 3. Chari R, Chari V, Eisenstat M, Chung R. A case Newsome HH, Lowry JW. Greater risk of incisional Downloaded By: [HINARI Consortium (T&F)] At: 17:48 20 October 2009 controlled study of laparoscopic incisional hernia repair. hernia with morbidly obese than steroid dependent Surg Endosc 2000; 14: 117–119. patients and low recurrence with prefascial polypropy- 4. De Maria EJ, Moss JM, Sugerman HJ. Laparoscopic lene mesh. Am J Surg 1996; 171: 80–84. intraperitoneal polytetrafluoroethylene (PTFE) pros- 20. Turkcapar AG, Yerdel MA, Aydinuraz K, Bayar S, thetic patch repair of ventral hernia. Surg Endosc 2000; Kuterdem E. Repair of midline incisional hernias using 14: 326–329. polypropylene grafts. Surg Today 1998; 28: 59–63. 5. Hesselink VJ, Luijendijk RW, De Wilt, JHW, Heide R, 21. Van der Linden FT, Van Vroonhoven TJ. Long-term Jeekel J. Incisional hernia recurrence; an evaluation of results after correction of incisional hernia. Neth J Surg risk factors. Surg Gynecol Obstet 1993; 176: 228–234. 1988; 40: 127–129. 6. Holzman MD, Purut CM, Reintgen K, Eubanks S, 22. Vrijland WW, Jeekel J, Steyerberg EW, Den Hoed PT, Pappas TN. Laparoscopic ventral and incisional hernia- Bonjer HJ. Intraperitoneal polypropylene mesh repair of plasty. Surg Endosc 1997; 11: 32–35. incisional hernia is not associated with enterocutaneous 7. Houck JP, Rypins EB, Sarfeh IJ, Juler GL, Shimoda KJ. fistula. Br J Surg 2000; 87: 348–352. Repair of incisional hernia. Surg Gynecol Obstet 1989; 23. Wissing JC, Van Vroonhoven TJMV, Eeftinck Schat- 169: 397–399. tenkerk M, Veen HF, Ponsen RJ, Jeekel J. Fascia closure 8. Kaufman Z, Engelberg M, Zager M. Fecal fistula: a late after midline laparotomy—results of a randomized trial. complication of Marlex mesh repair. Dis Col Rectum Br J Surg 1987; 74: 738–741. 1981; 24: 53–54. 9. Leber GE, Garb JL, Alexander AL, Reed WP. Long-term complications associated with prosthetic repair of Submitted May 17, 2002 accepted November 26, 2002 incisional hernias. Arch Surg 1998; 133: 378–382. 10. Liakakos T, Karanikas I, Panagitidis H, Dendrinos S. Use Address for correspondence: of Marlex mesh in the repair of recurrent incisional H. J. Bonjer, M.D. hernia. Br J Surg 1994; 81: 248–249. Erasmus University Medical Center Rotterdam – Dijkzigt 11. Luijendijk RW, Hop WC, van den Tol MP, et al. A Dr. Molewaterplein 40 comparison of suture repair with mesh repair for NL-3015 GD Rotterdam incisional hernia. N Engl J Med 2000; 10: 392–398. The Netherlands 12. Luijendijk RW, Lemmen MH, Hop WC, Wereldsma JC. Fax: ‡31 10 4635307. Incisional hernia recurrence following “vest over pants” E-mail: bonjer@hlkd.azr.nl Eur J Surg 168