Very large and complex incisional hernias, especially those involving loss of abdominal wall, present a particular challenge to the surgeon. The open intraperitoneal technique was used prospectively for the repair of incisional hernias in a selected group of patients with large defects, often those with major loss of abdominal wall, overweight patients, and previous failures of incisional repair. Between 1 January 1999 and 31 December 2005, out of 275 patients operated on for incisional hernia repair, 61 of them, most of whom were obese with multiorificial recurrent or giant hernias and contraindicated for laparoscopy, were treated using an open intraperitoneal mesh technique. There were 50 females and 11 males, with a mean age of 61. The median ASA score of the group was 2.3, with a mean BMI of 34 kg/m2 and a mean hernia surface of 182 cm2. Sixty-four percent of the patients had undergone one or more previous incisional hernia repairs. Mean operating time was 130 min, with an average hospital stay of 13 days. None of the patients died. Postoperative complications occurred in 21% of the patients; most of which were minor, but two cases (3.3%) developed deep abscesses requiring surgery and removal of the mesh. A recurrence rate of 5% was found after a mean follow-up of 35 months (8–88). Open intraperitoneal mesh repair appears to be a good option for the treatment of complex incisional hernia (at least 10 cm in diameter or multiorificial) in obese patients contraindicated for laparoscopy.

Repair of giant incisional abdominal wall hernias using open intraperitoneal mesh

Few reports have dealt with incisional hernias originating at a McBurney incision after appendectomy. The purpose of the present study was to identify risk factors for development of incisional hernia at a McBurney incision, and to describe our experience with the treatment of this kind of hernia. We reviewed 4,862 files of patients older than 15 years of age operated on for acute appendicitis. Some 4,523 (93%) of that group were operated on through a McBurney incision, and 34 (0.7%) of them developed incisional hernia. To identify risk factors for development of incisional hernia we used binary logistic regression analysis. The following risk factors were identified: female gender (p = 0.011), diabetes (p < 0.0001), peritonitis, abscess or phlegmon as the cause of the first operation (p = 0.009), wound infection (p = 0.034), seroma (p = 0.023), the use of catgut to suture the aponeurosis (p < 0.0001), and interrupted suture to the aponeurotic layer (p = 0.046). Twenty-two hernias were repaired with Mayo-herniorrhaphy and 12 with a subaponeurotic polypropylene prosthesis. Recurrences developed in 3 patients, none in hernias repaired with prosthesis. The risk of incisional hernia after a McBurney incision for acute appendicitis was very low; we recommend the repair of this uncommon incisional hernia with current standard tension-free prosthetic techniques.

Incisional hernia after McBurney incision: retrospective case-control study of risk factors and surgical treatment.

Introduction
Repair of incisional hernias is complex in the setting of previous/current infection, loss of domain and bowel involvement, and is often on the background of significant co-morbidities. Reported repair techniques are associated with significant morbidity and led our unit to develop a novel technique for complex incisional hernia repair.

Improved Outcomes in the Management of High-Risk Incisional Hernias Utilizing Biological Mesh and Soft-Tissue Reconstruction: A Single Center Experience

Summary. Incisional hernia repair with conventional techniques (simple closure, Mayo-technique) is associated with unacceptable recurrence rates of 30–50 %. Therefore, surgical repair using different prosthetic biomaterials is becoming increasingly popular. Further to favourable results by French hernia surgeons, we studied the results of underlay prosthetic mesh repair using polypropylene mesh in complicated and recurrent incisional hernias. Method: After preparation and excision of the entire hernia sac, the posterior rectus sheath is freed from the muscle bellies on both sides. The peritoneum and posterior rectus sheaths are closed with a continuous looped polyglyconate suture. The prosthesis used for midline hernias is positioned on the posterior rectus sheath and extends far beyond the borders of the myoaponeurotic defect. The anterior rectus sheath is closed with a continuous suture. The prosthesis for lumbar and subcostal hernias is placed in a prepared space between the transverse and oblique muscles. Intraperitoneal placement of the mesh must be avoided. Results: Between January 1996 and August 1997 we performed a total of 33 incisional hernia repairs (14 primary hernias, 19 recurrent hernias) using this technique (16 women, 17 men, mean age 56.19 ± 12.92 years). Local complications occurred in four patients (12 %): superficial wound infection (n = 2), postoperative bleeding, requiring reoperation (n = 1), minor hemato-seroma (n = 1). One patient suddenly died on the 3rd post-operative day from severe pulmonary embolism (mortality 3 %). Twenty-two patients with a minimum follow up to 6 months were re-examined clinically. The average follow-up time for this group was 9 months (range 6–17 months). To date no recurrent hernias have been observed. There were only minor complaints like “a feeling of tension” in the abdominal wall (n = 3) and slight pain under physical stress (n = 6). Conclusions: The use of prosthetic mesh should be considered for repair of large or recurrent incisional hernias, especially in high-risk patients (obesity, obstructive lung disease) and complicated hernias. The aforementioned technique of underlay prosthetic repair using polypropylene mesh fixed onto the posterior rectus sheath allows for anatomical and consolidated reconstruction of the damaged abdominal wall with excellent results and low complication rates.Zusammenfassung.Problemstellung: Die Rezidivraten nach operativer Versorgung von Narbenhernien (NH) liegen für konventionelle Techniken (direkte Stoß-auf-Stoß-Naht, Fasciendoppelung nach Mayo) mit 30–50 % unakzeptabel hoch. Aus diesem Grund wird zunehmend der Einsatz von Verstärkungsplastiken mit diversen Kunststoffmaterialien propagiert. In Anlehnung an die herausragenden Ergebnisse französischer Hernienchirurgen versorgen wir seit 1996 im Rahmen einer prospektiven Studie alle komplizierten NH mit einem in Underlaytechnik implantierten Polypropylennetz. Methodik: Bruchsackpräparation und Abtragung erfolgen in üblicher Weise. Nach ausgedehnter intraabdomineller und subcutaner Mobilisation der Bauchdecke folgt die Präparation des hinteren Fascienblattes des M. rectus abdominis auf beiden Seiten bis in die lateralen Umschlagfalten. Nach fortlaufendem Verschluß von Peritoneum und hinterem Fascienblatt in der Medianen wird das Polypropylennetz spannungsfrei auf die hintere Rectusscheide aufgenäht und Muskulatur sowie vorderes Blatt der Fascienscheide fortlaufend verschlossen. Bei lateralen Hernien kann das Netz problemlos zwischen die einzelnen Muskelschichten eingebracht werden. Ergebnisse: Im Zeitraum vom 1. 1. 1996 bis 31. 8. 1997 wurden bei insgesamt 33 Patienten 14 primäre komplizierte NH und 19 Rezidiv-NH in dieser Technik versorgt. Lokale postoperative Komplikationen waren bei 4 Patienten (12 %) zu verzeichnen: 2 oberflächliche Wundheilungsstörungen, 1 revisionspflichtige Nachblutung sowie 1 durch Punktion erfolgreich behandeltes Hämatoserom. Ein Patient verstarb am dritten postoperativen Tag unter dem klinischen Bild einer fulminanten Lungenembolie (3 %). 22 Patienten, deren Operation mindestens 6 Monate zurückgelegen hatte, wurden im Mittel 9 Monate postoperativ (6–17) einer klinischen Nachuntersuchung unterzogen. Bisher wurden keine Rezidive beobachtet. Mit Ausnahme geringer, meist belastungsabhängiger ziehender Schmerzen (n = 6) und einem Gefühl der „straffen Bauchdecke“ (n = 3) wurden keine Beschwerden angegeben. Schlußfolgerung: Die dargestellte Technik der Underlay-Verstärkungsplastik mit Polypropylennetz berücksichtigt die Prinzipien der spannungsfreien anatomischen Bauchwandrekonstruktion und führt auch beim Risiko- und Rezidivpatienten zur Wiederherstellung einer stabilen Bauchdecke.

Die Versorgung komplizierter Narbenhernien mit einem in Underlay-Technik implantierten Polypropylennetz Eine bewährte Technik der französischen Hernienchirurgie: Eine bewährte Technik der französischen Hernienchirurgie

AIM Incisional hernias are often related to longitudinal or transverse laparotomy with an incidence that rises from to 2 to 23 %. The oblique incision often used to surgically treat acute appendicitis has little probability to develop incisional hernia with an estimated incidence less than 2%. Some series report 0.1 - 0.9% of it. Anatomic, physiologic and histologic factors have been implicated in herniation development, such as intra-abdominal pressure or alteration on tissue components; many different risk factors can be taken into account to justify this rare condition such as female gender, diabetes, peritonitis, abscess or appendiceal phlegmon as the cause of the first operation, wound infection, seroma, use of cutgut to suture aponeurosis, interrupted suture to the aponeurotic layer. MATERIAL OF STUDY We present the rare case of young man who underwent surgical operation of acute appendicitis. Mc Burney incision was performed. Successively he underwent re-operation for incisional hernia developed upon McBurney incision and then "recurrence" of the same one. DISCUSSION AND CONCLUSION Histological analysis of scar tissue was done. Alteration on histological pattern protein expression was discovered.

https://iris.unipa.it/bitstream/10447/104204/1/Histologic%20consideration%20about%20a%20rare%20case%20of%20recurrenti%20incisional%20hernia%20on%20mc%20burney%20incision.pdf

Histologic considerations about a rare case of recurrent incisional hernia on McBurney incision.

Very large and complex incisional hernias, especially those with loss of abdominal wall, can be a very interesting and perplexing problem, which present a particular challenge to the surgeon. The reported technique was developed and refined by one of our surgeons, between 1998 and 1999 for the repair of incisional hernias in a selected group of patients with large defects, often with a major loss of abdominal wall, overweight and previous attempts for incisional hernia repair. The technique involves a modified preperitoneal approach and was used on 43 eligible patients between 1999 and 2002. There were 30 females and 13 males at a mean age of 61 years. The median ASA score of the group was 2, with a mean BMI of 30.4 and a mean hernia surface area of 162 cm2. One-third of the patients had one or more previous incisional hernia repair. Mean operating time was 190 min with an average hospital stay of 5.7 days. Postoperative complications occurred in 28% of the patients, most of which were minor and did not necessitate admission to the intensive care unit. None of the patients died. Wound infections occurred in 9.3%, was associated with an increased risk for cutaneous sinus formation, but not for mesh removal or hernia recurrence. A recurrence rate of 12.5% was found after a mean follow-up period of 46 months. We advocate this procedure for the repair of large, complex incisional hernias with loss of abdominal domain in patients with significant risk factors for recurrence.

Treatment of large incisional abdominal wall hernias, using a modified preperitoneal prosthetic mesh repair.

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Treatment of large incisional abdominal wall hernias, using a modified preperitoneal prosthetic mesh repair.