|Year : 2013 | Volume
| Issue : 1 | Page : 25-31
Postoperative complications of mesh hernioplasty for incisional hernia repair and factors affecting the occurrence of complications
Karan Vir Singh Rana, Gurjit Singh, Niteen A Deshpande, Viju K Bharathan, Srihari Sridharan
Department of Surgery, Padmashree Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, India
|Date of Web Publication||14-Mar-2013|
Karan Vir Singh Rana
Department of Surgery, Padmashree Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune
Source of Support: None, Conflict of Interest: None
Context: Incisional hernia is one of the common postoperative complications of abdominal surgery. Mesh hernioplasty represents the standard of care for incisional hernia repair. Aims: We report our experience with the use of mesh for hernia repair, with respect to the postoperative complications and factors affecting the occurrence of complications. Settings and Design: Fifty four cases of incisional hernia presenting to the institute between April 2008 and September 2010 were included in the study. Materials and Methods: The predisposing risk factors were identified. Mesh hernioplasty was done by the onlay technique and the patients followed up for at least 6 months. Statistical Analysis Used: An association of complications with various risk factors was explored with chi-square test and odds ratio with 95% confidence interval. Results: Twenty four patients developed at least one complication, the most common being seroma (12 cases) and surgical site infection (9 cases). The factors that showed a significant relationship with the occurrence of complications were diabetes mellitus, obesity, smoking, hypoproteinemia, advanced age, size of fascial defects, and number of defects. The recurrence rate was 3.7% (mean follow up: 13.05 months). Conclusions: Mesh hernioplasty gives acceptable results for incisional hernia repair. A sound understanding of the factors affecting the occurrence of complications and recurrence is required to improve the results of the procedure.
Keywords: Incisional hernia, mesh repair, onlay repair, postoperative complications
|How to cite this article:|
Rana KV, Singh G, Deshpande NA, Bharathan VK, Sridharan S. Postoperative complications of mesh hernioplasty for incisional hernia repair and factors affecting the occurrence of complications. Med J DY Patil Univ 2013;6:25-31
|How to cite this URL:|
Rana KV, Singh G, Deshpande NA, Bharathan VK, Sridharan S. Postoperative complications of mesh hernioplasty for incisional hernia repair and factors affecting the occurrence of complications. Med J DY Patil Univ [serial online] 2013 [cited 2017 Mar 27];6:25-31. Available from: http://www.mjdrdypu.org/text.asp?2013/6/1/25/108634
| Introduction|| |
Incisional hernia is one of the common postoperative complications of abdominal surgery.  Despite the advances in the understanding of the anatomy and physiology of the abdominal wall, the choice of suture materials and the knowledge of closure techniques, the incidence of incisional hernias continues to be 2-11% after laparotomy.  An incidence of 0.5-1.5% has been reported in laparoscopic surgery as well.  These are serious surgical problems owing to their propensity to enlarge and cause complications, association with common systemic disorders and the technical difficulties associated with their successful repair.
The phrase "if there are multiple ways of fixing a problem then there is not one good way" holds very true in incisional hernia repairs.  Several methods of repair of incisional hernias have been proposed, each with its own merits and de-merits. Mesh hernioplasty is the standard of care at present for repair of incisional hernias.  However, this technique has also been associated with recurrence rates of up to 32% on 10 year follow up. 
Although prosthetic repair of incisional hernia is tension free and gives acceptable recurrence rates, despite this significant benefit, it is a foreign material and susceptible to infection, sinus formation, enteric fistulization and possible extrusion.  In this article, we report our experience with the use of onlay mesh hernioplasty for incisional hernia repair.
The article studies the postoperative complications and recurrence rates of mesh hernioplasty for incisional hernias by the onlay technique. The various factors that could predict the occurrence of postoperative complications have also been studied.
| Materials and Methods|| |
A total of 54 cases of incisional hernia presenting to the institute during a period of two and a half years (April 2008 to September 2010) were included in the study. The patients were subjected to detailed clinical examination and relevant investigations. Data regarding the previous surgery and its associated complications was recorded. The co-existing co-morbid conditions and predisposing risk factors were identified and the entire data was tabulated. Obesity was defined as a Body Mass Index greater than 29.99 kg/m 2 . Operative repair was performed at least 1 year after the index surgery, as this time was required for scar maturation.
The surgery was performed under general or spinal anesthesia, in view of the adequate muscle relaxation required. A single dose of intravenous third generation cephalosporin (Intravenous Cefotaxime 1 gm) was administered at the time of skin incision. Intraoperatively, the sac was identified and delineated. The sac was opened. The contents of the sac were reduced [Figure 1]. If omentum was adherent to the sac and could not be reduced, it was ligated and excised. The fascial defect was identified all around. The maximum dimension of the fascial defect was measured in centimeters. The edges of the defect were approximated with simple sutures with non-absorbable suture material (Polypropylene, size: No. 1). The sutures were passed at a distance of 1.5 cm from the edge of the defect, and the distance between adjacent sutures was 1 cm. The sutures were tied just tight enough to approximate the edges. After approximation of the edges, a polypropylene mesh of suitable size was placed over the rectus sheath (Onlay technique) so as to overlap the healthy fascia by at least 5 cm all around [Figure 2]. The mesh was anchored in place by suturing it to the rectus sheath with Polypropylene suture of size 1.0. Hemostasis was attained. A suction drain was placed superficial to the mesh, and the wound was closed.
|Figure 2: Approximation of the edges of the fascial defect placement of onlay mesh.|
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Postoperatively the patient was administered intravenous antibiotics. The antibiotics routinely used were intravenous Cefotaxime (1 gram Q12h) and intravenous Gentamicin (80 mg Q12h) for a period of 5 days and intravenous Metronidazole (500 mg Q8h) for a period of 2 days. Postoperative analgesia was provided by administering tramadol (50 mg intravenous Q8h) in the immediate postoperative period (first 24 hours), followed by oral analgesics thereafter when the patient had pain. The drain was removed after the drain output was less than 20 ml per day for at least 2 days. Sutures were removed on the eighth postoperative day.
The patients were followed up for a minimum of 6 months. The postoperative complications and recurrence rate were recorded.
An association of complications with various risk factors was explored with the chi-square test and odds ratio with 95% confidence interval.
| Results|| |
Of the 54 patients included in the study, 25 were males and 29 were females. The average age of the patients was 55.03 years. The average age of males was 61.5 years and the average age of females was 47.5 years. There was no case of complicated hernia in the study. The most common predisposing risk factors were advanced age, diabetes mellitus, and postoperative wound infection [Table 1]. The incidence of incisional hernia was higher after emergency surgery. The most common emergency surgery leading to incisional hernia was emergency laparotomy (40.7%) and the most common elective surgery was total abdominal hysterectomy (14.8%). The most common incision was infraumbilical midline incision [Chart 1] [Additional file 1].
Intraoperatively the mean defect size in largest dimension was 7.92 cm. A single defect was noted in 44% cases, and multiple defects were noted in 56% cases. The content of the hernia sac was omentum in 54% cases.
The mean follow up period was 13.05 months. The standard deviation was 5.6 months. The patients were followed up for a period ranging from 6 to 27 months with a median of 18 months. The postoperative complications include seroma and superficial surgical site infection [Table 2]. There were two cases of recurrence [Table 3]. The risk factors associated with recurrence were diabetes mellitus, obesity, smoking, postoperative straining, and advanced age [Table 4].
|Table 4: Factors affecting the occurrence of postoperative complications after mesh hernioplasty for incisional hernias|
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| Discussion|| |
Incisional hernia occurs due to a biomechanical failure of the acute fascial wound early in the healing period, when the wound tensile strength is low or absent.  It is the most common complication by a 2:1 ratio over bowel obstruction, and is the most common indication for reoperation by a 3:1 ratio over adhesive small bowel obstruction.  The incidence of incisional hernias was 13% at 5 years, occurring during the first 24 months in 80% of cases. A majority of these hernias occur within the first year of the abdominal surgery. 
Even though simple suture repair was considered the gold standard for incisional hernia repair in the 1990s, the high recurrence rate with this technique was always a concern for the surgeon. Burger et al. had reported that the 10 year cumulative recurrence rate with suture repair was 63%.  This has led to the widespread acceptance of mesh repair. Even though several prosthetic materials had already been used for incisional hernia repair, the modern era of hernia repair with prosthetic material started in 1959, when Usher FC introduced the polyamide mesh as a prosthetic graft. He tried it as "onlay" and "inlay" methods.  He later introduced the knitted polypropylene meshes in 1963, these have some advantages such as less tissue reaction, excellent tensile strength, easy sterilization, and easy use.  The use of mesh has increased from 34.2% in 1987 to 65.5% in 1999. 
Apart from the polypropylene mesh which has stood the test of time, Polyester meshes and Polytetrafluoroethylene meshes are also used. Laparoscopic repair of incisional hernia needs intraperitoneal placement of a material which has both high tissue ingrowth toward the abdominal wall and nonadhesiveness on the other side to prevent bowel adhesions, which are satisfied by composite/Dual meshes.
Composite meshes  used are:
The most common method of mesh hernioplasty used by most surgeons today is the onlay technique.  In this technique, the placement of the mesh is anterior to the anterior sheath, with an overlap of 5 cm. This method avoids contact with the bowel, hence there is no chance of enterocutaneous fistula. It is also a tension free method. Multiple defects are highly likely to be detected because of the wide undermining done.  This however, can lead to increased seroma formation. Critics of this method also propose that the mesh placed in this method has very little support from the rest of the abdominal wall, hence can be displaced easily.  The weakest point of the repair that is most prone to recurrence is the mesh-tissue interface. 
- Light weight composite meshes without barrier that are partially absorbable. Induces a better tissue ingrowth of a strong three-dimensional collagen fiber network and allow optimum mobility to the abdominal wall.
- Absorbable barrier composite meshes - These are dual meshes, one side of which gets absorbed. Lightweight and leaves behind less residual foreign body reaction.
- Nonabsorbable barrier composite meshes -It is designed to be implanted with the smooth surface against the visceral organs-tissue to which no or minimal adhesion is desired-and the other surface against which tissue incorporation is desired.
Laparoscopic ventral hernia repair [LVHR] is a recent effective way of treating incisional hernia. It involves using a large mesh, adequate overlap of the defect without tension. In this, the mesh is placed intraperitoneally and extensive soft tissue dissection is eliminated and thus wound complication rate, patient discomfort, length of hospital stay, and recurrence rates are all reduced.  The success of this technique lies on smaller incisions, wide overlap of defects, correction of unpalpable defects and use of large non-absorbable sutures for stronger patch fixation.
In the present series, wound complications were noted in 44.4% of patients. White et al. noticed wound complications in 44% patients of mesh repair in their study.  The most common complication noticed was seroma formation. Seroma formation is one of the most commonest complications associated with onlay mesh hernioplasty because of the wide undermining involved.  The cases of seroma in our study were noticed between 3 rd and 7 th postoperative day, needed aspiration and resolved within a week with pressure dressing. No case of wound hematoma was noticed.
The next most common complication was surgical site infection. All the infections were superficial, and responded well to dressings and antibiotics. There was no case with deep infection or extrusion of the mesh. Chew et al., reported that if mesh was infected, incorporation rather than rejection usually can be expected; the prosthesis is not floating free in the wound but is in firm contact with healthy tissue. 
The incidence of tissue necrosis at the wound edge was 9.3%. The occurrence of wound edge necrosis is due to disturbance of the blood supply of the tissue at the wound margins due to the large size of skin and subcutaneous flap raised during the repair. This can be prevented by placing moist laparotomy pads over the edge of the wound and meticulous dissection of flaps. 
The most important complication of incisional hernia repair is recurrence of the hernia.  The recurrence rate in the study was 3.7%. While this is partly due to the shorter followup periods, it may also be due to the sound surgical technique used in the repair. This indirectly establishes that in spite of the introduction of newer methods of repair, onlay mesh hernioplasty is still an acceptable method for incisional hernia repair.
The rate of postoperative complications and recurrence are comparable to that of other studies that have used onlay method for mesh hernioplasty [Table 5] and [Table 6].
|Table 5: Recurrence rates and follow up periods in patients who underwent meshplasty for incisional hernias|
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|Table 6: Incidence of postoperative complications after mesh hernioplasty for incisional hernias|
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There is no real agreement on the factors that predict the occurrence of postoperative complications or recurrence after mesh repair of incisional hernia. , Out of the two cases of recurrence in our study, one was associated with SSI and the other had post-operative straining [Table 3]. Diabetes mellitus is well known to increase the incidence of postoperative complications of all types of surgery including mesh repair. Hawaz Al-Hawaz reported that among the patients who developed postoperative complications, about 60% were diabetics.  In the present series, diabetes was associated with increased incidence of wound complications and recurrence (P=0.000).
Obesity is also a factor that can increase the occurrence of postoperative complications and recurrence of incisional hernia.  The association was found to be statistically significant in the present study (P = 0.001). Turkcapar et al. also reported that obesity and wound sepsis are the two most important risk factors for recurrence in incisional hernia repair.  Vidovic et al. also proved that obesity was associated with higher risk for complication in incisional hernia repair.  In a study on factors affecting recurrence of incisional hernias, Murariu et al. reported that the most important factor was obesity. 
The detrimental effect of smoking on the healing of the acute fascial wound has been well documented. Smoking and peripheral tissue hypoxia, which may be caused by smoking, increase the risk of wound infection and dehiscence presumably through reduction of the oxidative killing mechanism of neutrophils, which constitute a critical defense against surgical pathogens. In addition, decreased collagen deposition and the reduced collagen I-collagen III ratio may also be attributed to smoking. Degradation of connective tissue caused by an imbalance between proteases and their inhibitors has also been postulated.  In the present study, smoking was significantly associated with the occurrence of postoperative complications.
Poor nutritional status has been implicated in the occurrence of incisional hernias, , but not much data exists, that correlates this factor with the incidence of postoperative complications after surgery. Veljkovic et al. have highlighted hypoproteinemia as a risk factor for ventral herniation.  In our series, hypoproteinemia contributed to complications in incisional hernia repair in a significant way. Murariu et al. also proposed that hypoproteinemia contributes to recurrence of incisional hernias.  The association is most likely to be due to the impairment of wound healing that occurs due to hypoproteinemia.
Corticosteroids are known to impair wound healing through several mechanisms. In our series, there was a significant correlation between corticosteroid use and the occurrence of postoperative complications. Hawaz Al-Hawaz et al. noted that 50% of all patients who developed postoperative complications were steroid users.  Similar findings were also published by Murariu and coworkers. 
Advanced age has been highlighted as a significant factor for the occurrence of incisional hernia in almost all reviews. ,, However, the relation between advanced age and the occurrence of complications in incisional hernia repair has not been well highlighted. Murariu et al. also reported old age as one of the factors that can increase the risk of complications and recurrence.  In our series also, there was a significant association between old age and postoperative complications. However, no association could be established between gender and the occurrence of complications.
Of all the factors implicated in the occurrence of complications such as seroma and wound edge necrosis, the most extensively studied factors are the size of the defect and number of defects. Several studies have reported that the larger the defect, the more likely are the complications of the repair procedure. , The larger the defect and the higher the number of defects, the larger is the size of mesh required and the greater is the degree of undermining required. This explains the greater incidence of seroma, hematoma, and wound infections. Al-Hawaz also reported that among the patients who developed wound complications, a large size of the mesh had been used.  This further justifies our findings.
Thus, although the type and technique of repair have been the most emphasized factors that decide the outcome of incisional hernia repair, it has to be emphasized that patient related factors and comorbidities do play a very important role in determining the success of repair. Adequate control of these factors can go a long way in improving the overall results of the repair procedures.
| Conclusions|| |
The postoperative complications associated with mesh hernioplasty were seroma and surgical site infection. The technique of onlay repair was associated with acceptably low recurrence rates, thus establishing its efficacy as an optimal method for incisional hernia repair. The important factors affecting the occurrence of complications were diabetes mellitus, obesity, smoking, hypoproteinemia, size of fascial defect, and number of defects. A sound understanding of the factors affecting the occurrence of complications and recurrence is required to improve the results of the procedure.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]