Retro‐rectus repair of complex incisional hernia leads to low recurrence rate

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Incisional hernia after laparotomy affects up to 20% of unselected patients and up to 50% of high‐risk patients.1 This can lead to significant morbidity including pain, cosmetic deformity and emergency admission with potentially life‐threatening complications. Reported studies have shown widely varying rates of developing an incisional hernia in part because of differences in duration and techniques of follow‐up used for hernia detection.2 Fink et al. recently published that the rate of incisional hernia increased from 12.6% at 1 year to 22.4% after 3 years.4
It is known that the risk of recurrence is significantly higher with a sutured repair than with mesh, but that morbidity is lower.2 A Cochrane review found that a suture repair failed in 54% of patients compared to 32% when mesh was used.5 What is unknown is the ideal technique and position for mesh placement and the type of mesh that should be used. In a review of six trials there was insufficient evidence as to which type of mesh or mesh position (onlay or sublay) should be used.5 The Cochrane review has previously failed to show a difference between retro‐rectus and onlay approaches.5 However, a more recent meta‐analysis and data from the Danish National Hernia Registry have shown a clear benefit in using a retro‐rectus sublay technique compared to onlay.6
In addition to the surgical strategy for mesh placement, the optimal type of mesh is still unknown.5 Biologic and synthetic meshes have been used with variable success; however, research comparing their outcomes in incisional hernia repair is lacking.10 Many studies are of poor quality and as yet there is no published randomized comparative data because the heterogeneity of the patients makes this unfeasible. A systematic review has analysed the published data on the use of biologic meshes in abdominal wall hernia repair and found good outcomes with respect to infection and recurrence rates.12
Part of the reason why our knowledge of the optimal type of hernia repair is unclear is that there are so many patient factors that influence complications and recurrence rates, and this makes it difficult to compare techniques. In 2010, the Ventral Hernia Working Group (VHWG) published a literature review assessing patients undergoing incisional hernia repair.13 They proposed an evidence‐based grading system to offer guidance in mesh choice (Table 1). In patients without co‐morbidities or wound infection who are undergoing incisional hernia repair, they recommend that the choice of material should be guided by surgeon preference. In patients with co‐morbidities that increase the risk of surgical site occurrence but without contamination, they suggest that biologic mesh has potential advantages over synthetic mesh. They propose that patients with potentially contaminated surgical fields may have better outcomes with biologic mesh, and they recommend that synthetic mesh should not be used in obviously contaminated fields. Although these guidelines aid management decisions and should improve comparison of groups of patients, more outcome data comparing synthetic and biologic mesh are needed to define the optimum mesh type for specific patient groups.13
We have been performing abdominal wall reconstruction using either synthetic or biologic mesh in the retro‐rectus space since 2007. The aim of this study was to evaluate this technique with regards to short term morbidity and medium term recurrence.
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