Study of the outcome of modified shoelace repair for midline incisional hernia
M. A. Joshi, M. B. Singh & M. A. Gadhire
Hernia The World Journal of Hernia and Abdominal Wall Surgery ISSN 1265-4906 Hernia DOI 10.1007/s10029-014-1234-8
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Author's personal copy Hernia DOI 10.1007/s10029-014-1234-8
Study of the outcome of modified shoelace repair for midline incisional hernia M. A. Joshi • M. B. Singh • M. A. Gadhire
Received: 18 August 2013 / Accepted: 27 February 2014 Springer-Verlag France 2014
Abstract Aims and objectives To study the efficacy and short-term sequelae of modified shoelace repair for midline incisional hernias. Materials and methods A prospective non-randomized study of 30 cases of midline incisional hernias was carried out at a public hospital from May 2009 to Oct 2012. Patients underwent modified shoelace repair which comprises reconstruction of linea alba along with the use of polypropylene mesh to reinforce the facial layer. A proforma was maintained for each patient documenting patient details, nature of previous surgery and complications if any, postoperative course, and complications postincisional hernia repair. Results and discussion Thirty patients underwent this repair with no complications and no recurrence for minimum follow-up period of 12 months. Our technique is a simple extra-peritoneal procedure with no extensive tissue dissection and avoids the potential complications of bowel injury and adhesions with the mesh. The principle involved is that during straining, the recti shorten by tonic contraction and approximate toward the midline. An incisional hernia weakens the midline and causes the recti to move laterally with contraction as medial pull is lost. By reforming a strong new linea alba, there is restoration of medial pull on recti. This is further buttressed by the mesh. Conclusion Modified shoelace repair is a simple and safe extra-peritoneal procedure and can be used for all midline incisional hernias.
M. A. Joshi M. B. Singh (&) M. A. Gadhire Department of General Surgery, LTMGH, Sion, Mumbai 400022, Maharashtra, India e-mail: [email protected]
Shoelace repair Midline Incisional hernia
Introduction Incisional hernia is a failure of facial tissues to heal and close following a laparotomy. It occurs in 5–11 % [1–3] of patients subjected to an abdominal operation. Recurrence is seen in up to 44 % of patients , which has decreased to 10–20 % with mesh repair  and 0–11 %  in laparoscopic repair. Since the last century, attempts have been made to develop satisfactory methods for repairing incisional hernias, but most were followed by a high percentage of complications and a high rate of recurrence. With the development of modern synthetic non-absorbable suture material, three basic methods have emerged for the repair of these often distressing hernias: Primary suturing (anatomic repair), open meshplasty, and laparoscopic repair. Abrahamson described shoelace technique for large incisional hernias, which is based on restoring the functional anatomy of the anterior abdominal wall. This study aims at evaluating the outcome of modified shoelace repair for midline incisional hernias. Functional anatomy of the anterior abdominal wall The flat muscles of the abdominal wall are normally in a state of tonic contraction, which tends to shorten them. However, since they are fixed to each other in the midline at the linea alba, they are not able to shorten but pull against each other in a balanced fashion so that they act as a dynamic girdle, flattening the abdominal wall and holding back the contents of the abdomen. With the vertical
Author's personal copy Hernia Fig. 1 Cross section of the abdomen showing the tonic contraction of the flat muscles shortening them and holding back the abdominal contents. With separation of the midline, the tonic contractions cause the sheet muscles to shorten so that the hernia widens
splitting of the midline at operation and separation of the two halves postoperatively as the hernia develops, the flat muscles lose their midline anchor and therefore can no longer pull against each other. Their tonic contraction now causes them to shorten so that the gap between the recti is widened. Each rectus abdominis muscle is pulled laterally and becomes curved with the concave side facing medially, with increase in intra-abdominal pressure centrifugal forces created causes the gap between the recti to widen. There is no loss of tissue in the usual case nor defect of the muscles and fasciae of the abdominal wall, apart from the linea alba along the edges of the hernial opening, which has largely been destroyed when the original sutures tore out and is not suitable for use in repairs (Fig. 1). Abrahamson’s shoelace darn technique  The two basic steps in the repair are as follows: 1.
To reconstitute a strong new midline anchor for the flat muscles of the abdominal wall by reconstructing a new linea alba by suturing together a strip of fascia from the medial edge of each anterior rectus sheath To restore the recti to their normal position and to draw the flat muscles of the abdominal wall back to their former length so that the abdominal wall takes up its normal anatomic state and function. This is done by drawing together the lateral cut edges of the anterior rectus sheaths by a continuous suture of heavy monofilament nylon, which passes to and from between these cut edges and also substitutes functionally and anatomically for the missing anterior rectus sheath.
The operation is entirely extra-peritoneal and involves only two simple suture lines. Consequently the postoperative recovery is smooth and rapid.
It had been suggested by Loh et al.  that the overlapping repair techniques, which includes combining both fascia and mesh repairs, have impressive results and carry the advantage of avoiding excessive tension. Browse and Hurst  described a technique for incisional hernias repair using fascia and polypropylene mesh. This technique was subsequently applied to sub-costal hernias by Whiteley et al. . Khaira et al.  introduce a modification, which involved an overlap and two points of anchor for the mesh. In our technique, the facial defect formed between the lateral cut edges of the rectus sheath is repaired using a polypropylene mesh sutured closely to the edges of the defect with multiple stitches using non-absorbable suture (polypropylene 2–0). This prevents any tension, which is created by closely approximating the edges by shoelace darn. Moreover, in patients suffering from incisional hernia, the abdominal muscles are usually attenuated and patients have poor abdominal muscle tone, as a result attempting to approximate the recti by shoelace darn may further weaken the muscles due to tension created; this is prevented by the placement of a non-absorbable mesh closely sutured to the edges of the facial defect, which provides a strong framework to prevent herniation from the lateral edges and reinforces the abdominal wall. We describe our experience with this technique in 30 patients presenting with midline incisional hernias at our tertiary care center.
Aims and objectives Primary 1.
To study the efficacy and short-term sequelae of modified shoelace repair for midline incisional hernias.
Author's personal copy Hernia
To study the patient profile of patients presenting with midline incisional hernias in terms of a. b. c.
Age Sex Clinical presentation
To study operative factors contributing to the development of incisional hernia in these patients in terms of the following: a. b.
Previous surgery Postoperative complications
Materials and methods A prospective non-randomized study of 30 cases of midline incisional hernias was carried out at a public hospital from May 2009 to Oct 2012. The outcome of modified shoelace repair for incisional hernia was studied on all 30 cases in terms of efficacy of the repair and short-term sequelae. Institutional ethics committee approval was taken for the study. Inclusion criteria Patients suffering from a midline incisional hernia presenting to a tertiary care center: 1. 2.
Fig. 2 Anatomy of the incisional hernia. Shaded area is muscle with the fascial layer anteriorly made up of rectus sheath and aponeurosis of external oblique. The hernial sac is seen protruding through the defect in the muscle and fascia
Age group: 16–65 years Single midline abdominal defect larger than 4 cm
Fig. 3 Anterior fascia flapped medially to meet the fascial flap from the other side. No. 0 polypropylene closure of fascia, reducing the hernia and giving a tension-free fascial closure of the defect. However, muscle of the anterior abdominal wall (shaded area) is now exposed to superficial structures and is without fascial support
Fig. 4 Polypropylene mesh repair (dark shading) of the fascial defect using 2–0 polypropylene. After the insertion of a vacuum drain, the subcutaneous layers are closed and the skin sutured. The procedure is carried out under prophylactic antibiotic cover Table 1 Previous surgery which resulted in incisional hernia
Exclusion criteria 1. \16 and [65 years 2. Defects other than midline 3. Multiple defects 4. Presence of ascites Every patient underwent detailed history taking, clinical examination, and investigations. A day prior to surgery, shaving of the abdomen and genitalia was done, and patient was kept nil by mouth overnight. Broad-spectrum antibiotic was given preoperatively, and patient was catheterized. The procedure was done under general or spinal anesthesia in supine position. Postoperative course was monitored in terms of the following: • • •
Significant pain beyond postoperative day 1 Fever Wound infection
• • • • • •
Wound gape Seroma Drain removal No. of days of postoperative stay Suture removal Recurrence
Author's personal copy Hernia Table 2 Incidence of complications following primary surgery
infection and gape (17 days) which was treated by secondary suturing, and then, patient was discharged; and second one due to paralytic ileus leading to abdominal distension (10 days). Excluding these patients, average duration of postoperative stay was 4.5 days (mean) with mode being 4 days. We had zero incidence of recurrence at a minimum of 12-month follow-up in the 30 cases studied.
Table 3 Incidence of postoperative complications following modified shoelace repair
Results Thirty patients were studied of which 17 were female and 13 were male in ages ranging from 26 to 65 years, commonest age group being 36–45 years (33.33 %). The original operation was an emergency procedure in 60 % of cases. Primary surgery was obstetric and gynecological in 14 of the 17 female patients and bowel-related in all others (Figs. 2, 3, 4). Among female patients, 82.35 % cases were seen following obstetric and gynecological surgeries (Table 1). About 6.67 % patients had suffered a complication in terms of wound infection or wound gape (Table 2). Immediate postoperative complications were seen in 13.33 % patients (Table 3). About 26.67 % patients had pain beyond postoperative day one, which was relieved with oral analgesia; none complained of pain on follow-up in OPD. The probable cause of higher incidence of post-op pain in our study is due to close approximation of the mesh to the lateral cut edges of the rectus sheath in order to provide a strong framework and reinforce the abdominal wall. Suction drain was removed on postoperative day 3 in 33.33 % patients. In our study, postoperative hospital stay ranged from 2 days to 17 days. However, only 2 patients had prolonged stay of more than 7 days: One due to wound
The use of prosthetic mesh to repair large incisional hernias is well established. Different techniques have been described, including a sandwich of mesh and rectus sheath with overlapping and two points of fixation, mesh placed deep to rectus sheath with overlap and mattress suture fixation, a complex mesh peritoneal sandwich, fixation of a large mesh anterior to the rectus sheath with two points of fixation, and a combination of a fascia and mesh [9, 12, 13]. Langer and Christiansen  compared their results using primary repair with historical data using a mesh and suggested that the use of mesh gave a better repair with less recurrence. Loh et al.  in their literature review suggested that the better results with mesh were simply a manifestation of inadequate length of follow-up, and furthermore, they highlighted a number of complications associated with the use of mesh. Liakakos et al.  in a non-randomized study comparing the postoperative complication of primary closure versus the use of mesh found out that the recurrence rate was less with mesh at a mean of 7.6 years of follow-up. In our study of modified shoelace repair for midline incisional hernias, no recurrence was seen in the 30 cases studied at a minimum follow-up period of 18 months, maximum follow-up being of 40 months. In our study, 3.33 % (n = 1) patients developed complications of seroma formation, superficial wound infection, and wound gape each. Matapurkar et al.  reported no seroma formation because their mesh was incorporated into a peritoneal sandwich, thus avoiding subcutaneous irritation. Other investigators [16–18] reported seroma rate between 4 and 15 %. They noted that accumulation of seroma occurred 3–17 days after the operation and that this complication was easily managed by multiple aspirations and usually subsided within a week . Wound infection and infection of the mesh can be grave complications often necessitating removal of the mesh and application of an allogenic tissue graft. Wound infection in open mesh repairs is thought to approximate 5 %. . Loh et al.  reported no recurrence using the combined technique for large incisional hernias, in limited number of patients (13 cases). Likewise, Whiteley et al.  reported no recurrence in ten patients. Khaira et al.  using the
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Fig. 5 Reconstruction of linea alba using continuous suture
Fig. 7 Polypropylene mesh sutured to lateral edges of fascia
rate of 13.33 %, and no recurrence was seen in the 30 cases studied (Figs. 5, 6, 7). Conflict of interest
The authors have nothing to disclose.
Fig. 6 Reconstructed linea alba
same technique as that used in this study reported 6 % recurrence rate in 23 patients. We had zero incidence of recurrence at a minimum of 12-month follow-up in the 30 cases studied. Limitation of the study was small sample size.
Conclusion The modified shoelace repair has been found to be an anatomically sound, easy operative procedure, for midline incisional hernias of the abdomen. It is a simple, extraperitoneal technique with no extensive tissue dissection and thus prevents chance of injury to the bowel during dissection, or postoperatively due to adhesions with the mesh. It restores functional anatomy by creating a new linea alba, which is, further, buttressed by the mesh in a tension-free manner. It carried immediate complication
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