Informace o publikaci
The Possibilities of Mesh Hernia Repair
| Název česky | Možnosti řešení kýl v jizvě |
|---|---|
| Autoři | |
| Rok publikování | 2007 |
| Druh | Článek v odborném periodiku |
| Časopis / Zdroj | Scripta Medica |
| Fakulta / Pracoviště MU | |
| Citace | |
| Popis | The formation of post-operative hernias has been a worldwide problem, mainly in classical open surgery. Incisional hernias usually appear in 11 – 19% of all the patients exposed to laparotomy. As much as 60% of them are symptomatic, but 6 – 15% show incarceration that - in 2% -needs the intestine resection due to strangulation. A lot of patients feel permanent abdominal dyscomfort, and sometimes they become disabled because of the hernia extent. The open suture repair with simple suturing fascial edges is dubious due to recurrence seen in 31 – 60% cases. Kingsnorth and Schumpelick have given the necessity to use a mesh in all the defects above 4 cm in diameter. The repairs are divided into onlay, inlay, sublay and IPOM according to the mesh position in the abdominal wall layers. In onlay repair, the mesh is placed in front of the fasciae in the hypoderm. This repair is technically the simplest method, its advantage being usability in any location with the minimal overlap (the overlap of the mesh or its contact with the firm tissues of the abdominal wall) of 3 – 4 cm. Its disadvantage is the necessary extensive preparation of the hypoderm with frequent formation of seromas and the risk of infectious complications. Inlay repair has been the worldwide least recommended one. Due to small contacts between the mesh and firm tissues, the number of recurrences nearly agrees with simple suturing the fascial edges. The lowest number of recurrence is given by the sublay technique, it is usually by 10%. The mesh is positioned in the middle line within the retromuscular space (technique according to Rives) or preperitoneally in the lateral location (Stoppa). These repairs belong to the most difficult ones, both from the view of technique and time. The overlap for a sufficient repair minimally 5 cm in all directions is recommended in sublay techniques. The intraperitoneal positioning of the mesh (IPOM position) has been nowadays a domain of laparoscopic surgery. The mesh is in the direct contact with the abdominal organs, therefore tissue-separating meshes must be applied (high price). The mesh is fixed with transparietal stitches knotted in the hypoderm or, in smaller defects, only by Protacks. The indication scheme at the 2nd Departement of Surgery is as follows: incisional hernias by 2 cm in size are solved by a suture, defects between 2 – 5 cm by technique using PHS or UHS mesh (sublay technique) – suitable particularly in the port side hernias and recurring umbilical ones. The defects above 5 cm are repaired in the middle line using repair according to Rives, defects located laterally mainly after transversal incisions are indicated for onlay. IPOM is indicated in patients with BMI > 30 or in those with parastomal hernias. Within 2/2004 – 2/2007 (i.e. 3 years), in our Herniacentre at the 2nd Departement of Surgery, St’Annes University Hospital, there were carried out 82 operations of incisional hernias using the technique according to Rives (retromuscular position of the mesh) with 2 successive recurrences (2.44 %) – always under the mesh. The reason was probably an incomplete repair of the original scare. Furthermore,14 repairs were performed with onlay technique (so far without recurrence) and 53 repairs using IPOM method (out of them 2 open operations, the others laparoscopies). In IPOM technique there were seen 2 recurrences (3.77 %) during the post-operative follow-up. The optimistic results in our, still not large, set of patients operated on due to incisional hernias are also caused partially by a short period of post-operative follow-up (median 16 months). |