3. Evaluatation of the Sublay retromuscular technique
using light-weight "Vypro"mesh versus prolene mesh
THESIS
Submitted for partial fulfillment of the M.D degree in general
surgery
By
Dr.MOUSTAFA MOHAMED HEGAZY
4.
5. Incisional hernias remain one of the most
common surgical complications with a long-term
incidence of 10-20% (Schumpelick, et al., 2006).
Primary suture repair of incisional hernia results
in 31-58% recurrence (Clark et al., 2006).
With a move to the tension-free repair following
the introduction of the meshes, results improved,
with a dramatic decrease in the rate of recurrence
to approximately 10% (Millikan, 2003).
6. Several techniques have been advocated to
implant the mesh
or epifascial
underlay or retromuscular
within the defect
7. The onlay method may be complicated by:
seroma and wound infections, while
intraperitoneal mesh leaves the potential for
development of enteric fistula or small bowel
obstructions (Hamilton et al., 2005)
8. Within recent decades, the sublay prosthetic
herniorrhaphy, which was introduced in the 1970
by the French surgeons Stoppa and Rives, became
one of the widely accepted procedures for
incisional hernia repair. This technique is
basically characterized by mesh implantation in
the "sublay"position below the rectus muscle
and fixation of the mesh by transfascial sutures at
the edges of the mesh (Petresen et al., 2004 )
9. Increasing evidence of impaired wound healing
in incisional hernia patients supports routine use
of an open prefascial, retromuscular mesh repair.
Basic pathophysiologic principles dictate that for
a successful long-term outcome and prevention of
recurrence, a wide overlap underneath healthy
tissue is required ,only retromuscular placement
allows sufficient subduction of the mesh by
healthy tissue (schumpelick, et al; 2007).
10. Polypropylene is the material widely used for open
mesh repair. New developments have led to light-
weight meshe e.g`Vypro and Ultrapro``meshes,
which are adjusted to the physiological requirements
of the abdominal wall and permit proper tissue
integration. These meshes provide the possibility of
forming a scar net instead of a stiff scar plate ,
therefore help to avoid theformer known
complications (schumpelick, et al; 2009).
11.
12. In our study we try to evaluate the:
*challenge of the sublay retromuscular
technique of ventral incisional hernia repair, with
the advent of some new technical points in a trial
to reduce recurrence.
**compare results of using light-weight
``Vypro``mesh versus the standard heavy-weight
prolene mesh in respect of post-operative
complications, chronic pain and recurrence.
14. No disease of the human body, belonging
to the province of the surgeon, requires in its
treatment a better combination of accurate
anatomical knowledge with surgical skill than
hernia in all its varieties(Sir Astley Paston
copoer, 1804)
15. A hernia is a protrusion of a viscus or a part
a viscus through an abnormal opening in the
wallas of its containing cavity. The external
abdominal hernia is the most common form,
the most frequent varieties being the inguinal,
femoral and umbilical.
17. Anterior Abdominal Wall Hernia (Ventral
Hernias): represent defects in the parietal
abdominal wall fascia and muscle through which
intra-abdominal contents can protrude, it may be
congenital or acquired. Acquired hernias may
develop through slow architectural deterioration
of the muscular aponeuroses or they may develop
from failed healing of an anterior abdominal wall
incision (incisional hernia).
18.
19.
20.
21. Burst abdomen and incisional hernia
In 1-2% of cases, mostly between the sixth and
eighth day after operation, an abdominal wound
bursts open and viscera are extruded. The
disruption of the wound tends to occur a few days
beforehand when the sutures apposing the deep
layers (peritoneum, posterior rectyus sheath) tear
through or even become untied.
22. An incisional hernia usually starts as a symptomless
partial disruption of the deeper layers during the
immediate or early postoperative period , the event
passing unnoticed if the skin wound remains intact
after the skin sutures have been removed.
Causes of burst abdomen
*Poor closure technique *Deep wound infection
*Coughing or vomiting *Poor metabolic state
23. Incidence of Incisional Hernia:
An incisional hernia is represented by the escape of
organs from their physiologic position through an
area of weakness in the surgical scar. The frequency
for incisional hernias (IH) after laparotomy is 2-11%
Incisional hernias make up about 80% of the ventral
hernias that surgeons encounter (Voeller, 2007).
24. Factors affecting incisional hernia incidenc
A- Patient factors: Many patient-related risk
factors have been implicated in the development of
incisional hernias, including obesity, smoking,
aneurismal disease, chronic obstructive
pulmonary disease, male gender, malnourishment,
corticosteroid dependency, renal failure,
malignancy, and prostatism (Millikan, 2003).
25. B- Surgical factors: Like emergency surgery,
bowel surgery, suture type and technique,
chest infection, abdominal distension and
wound infection. There is evidence that in
many cases wound failure after abdominal
wall closure is dependent on the surgeon
(Yahchouchy-Chouillard et al., 2003).
26. Recently, molecular biologic investigations
have proven the theory of disturbed
composition of the extracellular matrix in
patients with recurrent hernia. In particular,
there is a decreased ratio of collagen types I
and III (Jansen et al., 2004 ).
….
27. Various studies have shown that 50% of
hernia recurrences are detected in the first
postoperative year, 75% are detected at 2 years,
and 90% are detected at 3 years, with continued
failure rates of 2% per year thereafter. These
findings implicate technical factors in early
wound failure and patient-related factors in late
wound failure (Millikan, 2003).
28. Prevention of incisional hernia :
The ability to prevent both abdominal wound
dehiscence and incisional hernia primarily lies
with the surgeon and the technique used to
close the laparotomy incision. Many of the risk
factors are unavoidable, but good surgical
techniques and avoidance of excessive tension
are important.
29. *The optimal technique for closing the a
midline incision is a mass closure with a non-
absorbable or slowly absorbable
monofilament suture (e.g. PDS) good bites
(>1cm), using a suture length : wound length
ratio of 4:1 (Jenkin's rule).
* Avoid the coagulation current of the cautery
when incising the aponeurosis
30. *Avoid excessively wide suture bites which
incorporate large masses of muscle and fat
*Avoid incisional closure in the presence of
excessive tissue tension
*Choose running suture over interrupted.
*Minimize the risk of surgical wound infection.
*Consider prophylactic mesh placement for the
patient at high risk for wound failure (Carlson
2007).
31. Treatment of Incisional Hernia
Once an IH occurs, the natural history of it is to
grow. Delay in repair complicates every single aspect
of the surgery and leads to increased morbidity; so
repair should be done as soon as possible. If the
patient is obese, weight loss should strongly be
advised prior to ventral hernia repair. The decrease
in intra-abdominal pressure that occurs with weight
loss leads to a lower recurrence rate.
32. Open Repair of IH
Different techniques that have been developed
for repair of IH. This is due to the fact that
IH repair has a high recurrence rate (up to
50%). There is a general agreament now that
tension-free mesh repair is the standard of
care for IH and fascia adaptation with suture
repair alone rarely has a place.
33. Suture Repair
Many suture techniques have been described,
but none has proven to be superior to the other
in well-performed clinical trials. However
(Jenkin's rule): mass closure with a non-
absorbable or slowly absorbable monofilament
suture (e.g. PDS) good bites (>1cm), using a
suture length : wound length ratio of 4:1,is good.
34. It is the opinion of many experts that suture
repair should not be first choice for treatment of
incisional hernia and non-mesh repairs are
indicated only when the operation is performed
under septic circumstances or when mesh is not
available.
The recurrence rate after open suture repair
may be as high as 54%, while for open mesh
repair, up to 32% (Burger et al., 2005).
35. Inlay Repair:
In this repair, the mesh is sutured to the fascial
edges without initially closing the defect. The
mesh lies in contact with the viscera. This
technique has a high recurrence rate and may
lead to bowel adhesions and development of
enterocutaneous fistulas, so it is not
recommended unless the substantial defect cannot
be closed with other technique .
36. Onlay Repair :
After dissection of the hernial sac, the fascial
edges are brought together and the mesh is
placed over the suture line making an overlap of
5 cm.and fixed with stiches to the anterior fascia
The skin is closed over the mesh.
There is no doubt that the onlay technique is
easily performed by a low-experienced surgeon or
a senior resident ,
37. but it should be remembered that the main
difference between the sublay and onlay methods
is that in the sublay repair the mesh is held in
place by the positive intra-abdominal pressure
against the closed fascia of the abdominal wall,
but in the onlay repair by the stay-anchoring
sutures (Machairas et al .,2004).
38. Sublay Repair (Rives-Stoppa-Retrorectus Repair)
The mesh is placed beneath the rectus muscle in
front of the closed posterior rectus sheath and
peritoneum. The anterior rectus sheath is closed.
The advantage of this technique is that if the mesh
is much larger in surface area than the hernia
defect, intra-abdominal forces hold the prosthesis
against the muscles. The forces that created the
hernia now are used to prevent its recurrence.
39. In contrast to a mesh in front of the fascia in
onlay position, the sublay mesh position facilitates
a sufficient subduction of intact linea alba, even
behind the xiphoid or pubic bone. It is the
retromuscular mesh with a fascia closure in front,
which is kept in position just by tissue ingrowth
and intra-abdominal pressure,
40. whereas the onlay mesh has to be fixed
additionally by permanent sutures. The mesh in
the space behind the rectus muscle can be
easily dissected, whereas the extended
preparation of the subcutaneous space in the
case of the onlay position frequently is
accompanied by hematoma, seroma, or wound
infection. (Schumpelick et al., 2007).
41. Comparisons between the sublay and onlay
techniques are difficult in a high level of
evidence based data for many reasons:
*There are no prospective randomized or
controlled studies that have tested the onlay
technique versus the sublay technique.
*A small number of operations for incisional
hernias are performed, even in large surgical
clinics, per year.
42. *The type of technique, sublay or onlay, is
mainly dependent on the surgeon’s experience
and choice.
*The type of mesh that is used in hernia repair
depends on the surgeon’s preference and the
financial background of the hospital (Machairas
2007).
43. Laparoscopic Repair of the Incisional Hernia
In 1991 LeBlanc reported the first successful
series of laparoscopic ventral hernia repair
(LeBlanc et al., 2001).
After creation of the pneumoperitoneum and
port placement, the hernial contents are reduced
intraperitoneally and the mesh is placed to
overlap the defect and fixed with clips and
sutures(Goodney et al., 2002).
44. The Ideal Mesh
There is no ‘‘best’’ mesh, so the decision of
which mesh to use is based on several factors:
the type of procedure being done, the clinical
situation, the desired handling characteristics,
and the products available to the surgeon based
upon hospital materials contracts and costs.
45. However there is general agreement on several
properties of this theoretically ideal mesh that it
should:
*Be strong enough to withstand physiologic
stresses over a long period of time
*Promote strong host tissue ingrowth, which
mimics normal tissue healing;
46. *Resist the formation of bowel adhesions and
erosions into visceral structures;
*Not induce allergic or adverse foreign body
reactions;
*Resist infection; and
*Noncarcinogenic (Schumpelick and Klinge,
2003).
48. Polypropylene: Prolene Marlex,, Atrium,
SurgiPro
Proceed Polypropylene/polydioxanone
Sepramesh IP Polypropylene/hyaluronate ge
C-Qur Polypropylene/omega-3 fatty acid
TiMESH Polypropylene/titanium
Composix Polypropylene/ePTFE
49. Material-reduced meshes: Polypropylene and polyglactin (Vypro
I/II), polypropylene and polyglecaprone (UltraPro):
Standard meshes made of polypropylene have a
tensile strength greater than that required
physiologically. In lightweight composite mesh an
absorbable component is incorporating into a
reduced polypropylene mass e.g Vypro and Ultrapro
Reducing the amount of polypropylene improve the
functional properties and reduces local
complications. (Conze et al .,2005).
51. Biological Meshes
Recently, a number of biological meshes
have become available. They are made of
human or animal tissue, their cellular
component is removed to avoid allergic
reactions, and then the protein structure is
stabilized, so that it can act as a scaffold of
collagen implant causing cellular ingrowth.
52. *Surgisis Gold Porcine small intestine submucosa
*AlloDerm Human dermis
*SurgiMend Fetal bovine dermis
*CollaMend Porcine dermis
*AlloMax Human dermis
l
These are Surgisis?, which is made from
porcine gut submucosa, Alloderm?, which is made
from cadaver dermis and Permacol? made from
porcine dermis. They are expensive and can be
used in contaminated situations. Long-term
evaluation is needed(Voeller 2007).
53. Postoperative complications
Postoperative complications of mesh repair are:
*seroma formation,
*wound haematoma,
*superficial and deep wound infection,
*mesh rejection and
*Abdominal discomfort,chronic pain and restriction
of abdominal wall mobility (stiff abdomen),
*recurrence.
54. To conclude:
•Mesh repair of ventral incisional hernia is
superior to suture repair and will reduce
recurrence by half.
•Repair of recurrent ventral incisional hernia is
associated with higher recurrence rates for each
subsequent repair.
55. •The type of open-mesh repair seems to favor
the sublay technique. Other types of repair in
the hands of experts can match the sublay
repair with similar recurrence rates.
•For proper assessment of recurrence after
ventral incisional hernia, long term follow-up
of at least 5 years is required (Itani, 2007).
56.
57.
58. Patients:
*30 patients complaining of moderate
sized ventral incisional hernia ,i.e size of
hernia ranging from 5-11cm.
*Larg and huge sized hernia are
excluded as it well need additional
methods of repair.
59. The patients classified into two
groups:
Group A: 15 patients treated by using
the Heavy-weight prolene mesh using
the sublay technique.
Group B: 15 patients treated by the
same sublay technique but using the
Light-weight`` vypro`` mesh in their
repair.
60. Follow up : of both group of patients
for at least one year post-operative ,at
intervals of 3;6;12 months. Stressing on
post-operative complications; Seroma
formation, post-operative pain, wound
infection, abdominal discomfort, Stiff
abdomen and recurrence.
61. “MMETHODES OF REPAIR
Sublay "mesh repair;
retromuscular technique i.e.
mesh implanted behind the
rectus abdominis muscle
infront of the closed
posterior rectus sheath and
peritoneum.
62. Operative detai
OPERATIVE DETAILS:
The steps of operation sublay retromuscular
mesh repair published by Schumpelick et al.,
(2007),stressing on the following technical points:
*The different layers of the abdominal wall were
reconstructed with mesh placed behind the rectus
muscle.
63. *The mesh was sized to give an overlap of at least
5 cm in all directions from the aponeurotic edges
i.e. wide overlap of the implanted mesh at least
5cm in all directions surrounding the hernia
defect.
*The posterior rectus sheath and the peritoneum
were closed to prevent direct contact between
mesh and intestine.
64. *The anterior fascia of the rectus sheath was then
closed to reconstruct the linea alba i.e.
reconstruction of the linea alba by closure of
anterior rectus sheath over the mesh is mandatory.
*Suction drain left in the retromuscular plane
before wound closure is essential .
78. The sublay technique of mesh repair in both
groups of patients was evaluated through
certain selected parameters which include;
Age Sex
Operative time
Duration and amount of suction
Hospital stay
Postoperative complications stressing on;
(1) Seroma (2) Wound
Infection
(3) Abdominal Discomfort (4) Recurrence
79. Group
Gender
Group A
(n= 15)
Group B
(n= 15)
Total (n= 30) P value
no % No % no % value comment
Male 8 53.3 % 9 60% 17 56.7% 0.318
Not
significant
female 7 46.7% 6 40% 13 43.3% 0.318
Not
significant
Total (30) 15 50% 15 50% 30 100% - -
GENDER DISTRIBUTION
Table 4: Distribution of cases in relation to gender
80. Table 5: Age difference
P valueAge (year)
Group
Gender CommentValueSDmean
Not
significant
0.715
6.3046.73Group (A)
8.3845.73Group (B)
81. P valueDuration (day)Duration of
suction
Group
CommentValueSDMean
Significant0.000
0.94
4 –7 days
(5.8)
Group (A)
0.73
3–5 days
(4.4 )
Group (B)
Table 7: Duration of suction
82. Table 6: Operative time
P valueTime (min.)Operative time
Group
CommentValueSDMean
Not
significant
0.527
12.2
80-120
(100.67)
Group (A)
13.4
85-125
(103.67)
Group (B)
83. Group
Group (A) Group (B)
Mean±SEdurationodsuction(day.)
0
1
2
3
4
5
6
7
Chart 1: Duration of Suction
84. Table 8: Amount of Suction
P valueAmount (mL)Amount of
suction
Group
CommentValueSDMean
Significant0.032
23.05
70 - 150 (102.0)
ml per day
Group (A)
16.85
50- 110 (85.3)
ml per day
Group (B)
85. Group
Group (A) Group (B)
Mean±SEamountodsuction(mL.)
0
20
40
60
80
100
120
Chart 2: Amount of Suction
86. Table 9: Hospital stay
P valueHospital stay (day)Hospital
stay
Group CommentValueSDMean
Not
Significant
0.565
2.58
10 -15 (12.33)
days
Group (A)
1.73
9 - 14
(11.87) days
Group (B)
87. Group
Group (A) Group (B)
Mean±SEhospitalstay(day.)
0
2
4
6
8
10
12
14
Chart 3: Hospital Stay
88. Table 14: Incidence of seroma
P value
Total
(n= 30)
Group (B)
(n= 15)
Group (A)
(n= 15)Group
Compli. CommentValue%no%no%no
Significant0.01320.0%613.3%226.7%4Seroma
Chart 6: Seroma
89. Table 16: Abdominal discomfort
P value
Total
(n= 30)
Group (B)
(n= 15)
Group (A)
(n= 15)
Group
Complications CommentValue%no%no%no
Signif.0.00336.7%1126.7%446.7%7
First
month
Abdominaldiscomfort
Signif.0.00713.3%46.7%120.0%3
Third
month
Signif.0.0073.3%10.0%06.7%1
Sixth
month
--0.0%00.0%00.0%0
Ninth
month
--0.0%00.0%00.0%0First year
91. Table 15: Incidence of Wound Infection
P value
Total
(n= 30)
Group (B)
(n= 15)
Group (A)
(n= 15)Group
Compli.
CommentValue%no%no%no
Significant0.00713.3%46.7%120.0%3
Wound
infection
Chart 7: Wound Infection
92. Table 17: Incidence of Recurrence (End of First Year)
P- value
Group (B)
(n=15)
Group (A)
(n=15)Group
Recurrence comme
nt
Value%no%no
Not
significa
nt
1.006.7%16.7%1Lost Patients
--0.0%00.0%0Recurrence
Chart 9: Incidence of
Recurrence (End of First Year)
93.
94. Between Aug. 2007 and March 2010, Patients
were randomized to receive lightweight composite
(Vypro) mesh, or standard polypropylene
(Prolene) mesh. The clinical course of all
patients was registered during the hospital stay as
well as 3 ,6,9, and 12 months after surgery. The
follow up of all patients was regular for at least
one year after surgery and we observed that :
95. *No significant differences concerning age,
gender,operative time,(hernia size were selected
from 5-11cm).
*Duratin and amount of suction, length of
hospital stay were lower in the low-weight
(Vypro)mesh.
*Minor complications; seroma and wound
infection appeared frequently more in the heavy-
weight (Prolene)mesh group
96. *Patients of the heavy-weight mesh complained
significantly and more frequently about chronic
pain and abdominal wall discomfort than those of
the low-weight (Vypro) mesh group,but non of
both groups complain of "stiff abdomen“.
* No hernia recurrences observed in both
groups ,this may be due to short follow up also the
hernias were selected of moderate size (5-11cm in
length).
97.
98. To conclude:
*Incisional hernia is a biologic problem due to
unstable scar formation with a defective collagen
metabolism.
*Due to the disappointing results of primary
suture repair, mesh repair is strongly suggested.
Prosthetic meshes are used for augmentation of
the abdominal wall, and thus require a wide
overlap of at least 5–6 cm.
99. *Mesh prosthesis should be developed ideally for
the physiologic parameters of the abdominal wall to
provide tensile strength, yet maintain elasticity.
*Retromuscular mesh repair offers the
advantage of an extraperitoneal mesh position
(avoiding the potential complications of an
intraperitoneal prosthesis) and a wide stable
fixation by its position within the abdominal wall.
100. *Important steps in repair of incisional
hernias include complete excision of the fascial
scar, use of a large enough mesh to provide a 5–
6 cm overlap in all directions, closure of the
posterior rectus sheath to prevent intraperitoneal
contact with the mesh, and closure of the
anterior fascia in front of the mesh (thrust
bearing resistance) whenever possible.
101. *Deficiencies in repair of incisional hernias
include insufficient scar excision, insufficient
preparation of the space for the mesh prosthesis,
too small a piece of mesh, and inadequate closure
of the anterior fascia.
*The introduction of retromuscular, sublay
technique using polypropylene meshes had
significantly decreased the recurrence rates after
open incisional hernia repair.This technique is
very simple can be easly done and learned.
102. Also the use of the lightweight composite
(Vypro,Ultrapro) mesh for incisional hernia
repair had similar outcomes to heavyweight
polypropylene mesh, but lightweight mesh
resulted in a better abdominal wall compliance
and less chronic pain, lower incidences of
postoperative seroma and infections with
accepted recurrence rate.
103. As compared to the heavyweight meshes, the
lighter-weight meshes show a decrease in
inflammatory response decreased stiffness, less
shrinkage, and fewer post operative complaints.
We thus now have evidence that if the surgeon
chooses a polypropylene mesh for ventral
incisional hernia repair, it should be a
lightweight mesh if possible.
