Ali A Warsi, Mr Dr, Andrew N Kingsnorth, Professor. Department of General Surgery, Derriford Hospital, Plymouth, U.K.
A 58 year lady first presented to her general surgical outpatient department in September 1995 then aged 44 years, with a large incisional hernia. She previously underwent multiple operations, including a hysterectomy and oophorectomy in 1985 and an open appendicectomy in 1993. Between the years of 1995 and 2004, she had multiple incisional hernia repairs- twelve in total for recurrences, despite using various meshes- including prolene and Dacron.
She had numerous admissions to hospital with intermittent small bowel obstruction. She was then referred to the Plymouth Hernia Service in April 2009. Examination revealed a wide separation of the rectus abdominis muscles and loss of substance of this muscle on the right side. These findings were confirmed on CT scan.
Three months later and a targeted minimum pre-operative weight loss of approximately 2 stones, the patient underwent elective surgery in September 2009. Four previous meshes were carefully dissected and removed. Necessary adhesiolysis was performed taking great care to avoid any enterotomies. Intra-operative findings were a 16cm separation of the rectus abdominis muscles. A tension free midline closure was made possible following components separation by relaxing incision in the external oblique aponeurosis. The defect in the external oblique was reinforced with biological mesh. The rectus sheath closure was reinforced with an onlay prolene mesh. Appropriate panniculectomy was performed. Drains were inserted intra-operatively and removed on day 13. The immediate post-operative recovery was uneventful. The discharge was delayed due to serous fluid drainage from the drains. The patient also reports a good functional result and that her gastrointestinal function has returned to normal.
There are numerous surgical techniques available in the repair of an incisional hernia. A review in the Annals of RCS 2006 by Kingsnorth, suggests that, small incisional hernias upto 3cm can be repaired with just sutures. Those up to 10cm diameter can be repaired laparoscopically but larger ones invariably require open repair using mesh- onlay, inlay or sublay techniques. Those above 15 cms need supplementary components separation operation.
However, despite the use of meshes, recurrence and complication rates remain significant, especially in complex hernias with loss of domain. In 1990, Ramirez, Ruas and Dellon introduced the “components separation” method for closure of large abdominal wall defects. It allows tension-free approximation of the abdominal wall and therefore eliminating the risk of abdominal compartment syndrome.
Complex recurrent incisional hernias are a challenge. We have carried out more than 60 repairs using the component separation technique with good outcome. Most of these cases have been referred to us from across the country with multiple attempts at repair with disappointing results.This case had been particularly bad with 12 failed previous attempts. We would say the patient’s lucky number was 13!
An experienced surgical team, patient counseling and pre-operative optimization, physiotherapy and wound care team are essential for optimal results in the repair of large complex hernias. Pre-operative CT scan is invaluable in delineating the hernial anatomy.
Program Number: P516