Hernia (2006) 10: 322325 DOI 10.

1007/s10029-006-0097-z

O R I GI N A L A R T IC L E

D. Juris ic B. D. Franjic D. Vidovic E. Glavan M. Ledinsky M. Bekavac-Bes lin

Factors affecting recurrence after incisional hernia repair

Received: 2 November 2005 / Accepted: 13 April 2006 / Published online: 17 May 2006 Springer-Verlag 2006

Abstract Incisional hernias occur primarily as a result of high tension and inadequate healing of a previous incision, the latter of which is frequently related to infection at the surgical site. Despite recent advances in operative techniques, the recurrence rate remains unacceptably high. To evaluate the impact of dierent predisposing factors for the recurrence of incisional hernia, we reviewed retrospectively the medical records of 297 patients who had undergone incisional herniorrhaphy (188 tissue repairs, 109 mesh repairs) in our hospital. Demographic data (age and gender), type of repair, body mass index, hernia size, presence of chronic illnesses and wound complications were evaluated in a univariate and multivariate manner analysis. The overall recurrence rate was 30.3%, with the recurrence rate in patients who underwent tissue repairbeing 39.4% and that in patients following prosthetic repair 14.6%. The recurrence rate was signicantly inuenced by type of repair, obesity, hernia size, wound healing disorders and some chronic comorbidities. We conclude that it is necessary to become familar with the risk factors for recurrence of incisional hernia in order to eliminate or decrease their eect on the positive outcome of incisional herniorrhaphy. Keywords Incisional hernia Mesh repair Recurrence Risk factors Tissue repair

to be surgery of failure due to poor therapy results. Incisional hernias develop in 211% of all patients who undergo laparotomy [1]. Until the 1990s, fascia adaptation and duplication were standard surgical procedures for incisional hernia. However, these procedures were associated with disappointing results, and the recurrence rate was unacceptably high, ranging between 30 and 54% [2]. The development of tension-free incisional hernia repairs employing a prosthesis has been reported to have decreased recurrence rates signicantly to less than 10% [3]. Because of the lower recurrence rates with a prosthesis, some surgeons now use mesh prostheses routinely. However, none of the available prostheses can be considered to be ideal with respect to the patients reaction to foreign bodies and potential complications, such as seroma, mesh infection or intestinal stulization. Flum et al. recently demonstrated that the use of synthetic mesh in incisional hernia repairs increased from 34.2% in 1987 to 65.5% in 1999; however, there has not been a decrease in reoperation rates [4]. Therefore, prosthetic repair can be considered to be an additional option open to surgeons, especially in complicated cases when suture repair cannot be performed without extreme tension. The purpose of this study was to determine the risk factors for recurrence following incisional hernia repair.

Introduction
Incisional hernias can be the most frustrating of hernias to treat. A part of the frustration derives from the fact that surgery for incisional hernia is generally considered
(&) D. Juris ic B. D. Franjic E. Glavan D. Vidovic M. Ledinsky M. Bekavac-Bes lin Department of Surgery, University Hospital Sestre Milosrdnice, Vinogradska 29, 10 000 Zagreb, Croatia E-mail: di_vidovic@yahoo.com Tel.: +385-1-3787322 Fax: +385-1-3768292

Materials and methods

The study cohort comprised 297 consecutive patients who had undergone incisional hernia repair (188 tissue repairs, 109 mesh repairs) at the University Hospital Sestre Milosrdnice, Zagreb, Croatia. The cases of these patients, 58.2% of whom were women and 41.8% were men, with an average age of 61.2 years (range: 22 94 years), were reviewed retrospectively. All patients, both with suture and mesh repair, were invited for follow-up examinations. Another 32 patients

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who did not come to follow-up examinations were not included in this study. The median follow-up period was 42 months (range: 1272 months) for suture repair and 48 months (range: 1284 months) for mesh repair. Recurrence was determined if there was a palpable mass at the site of the previous hernia repair. Onlay (prefascial) and sublay (preperitoneal) positioning of polypropylene mesh were used as well as the Mayo procedure using prolene 2-0 sutures. We used circular suture after xing the four edges of the prosthesis. We did not use glue for mesh xation or bilateral relaxing incisions for onlay repair. During surgery, all patients received a single dose of antibiotics and a suction drainage. The present study included only experienced surgeons that had previously performed at least ten technically challenging sublay mesh repairs. From a total of 13 surgeons in our hospital that have performed mesh repairs, only ve surgeons have reached this level. This same group of surgeons also performed the onlay mesh repairs that were included in the present study. We noted age, gender, type of repair, body mass index, intraoperative hernia size, chronic illnesses and wound healing disorders. Old age was dened as 60 years and older, and obesity was dened as a body mass index >29.9 kg/m2. We classied incisional hernias according to size as small (<5 cm wide or long), medium (510 cm) and large (>10 cm). Chronic illness was dened as the necessity for intermittent or continuous medication. Chronic comorbidities of particular interest to us were chronic pulmonary disease (conrmed by chest X-ray or abnormal pulmonary functional tests), cardiac disease (history of angina pectoris, myocardial infarction or congestive heart failure), prostatic hypertrophy (based on history or results of digital rectal examination), diabetes mellitus (treated with insulin or oral hypoglycemics) and cirrhosis/ascites (history of chronic liver disease with ascites proven by physical or ultrasound examination). Wound healing disorders were classied as follows: seroma (determined as the presence of symptomatic prefascial collection of sterile uid requiring drainage), hematoma (dened as the presence of prefascial clot requiring removal) and infection (the presence of signs of inammation or evident purulent collection in the wound). A logistic regression attempting to identify which factors were associated with a higher likelihood of incisional hernia recurrence was performed. Univariate unconditional logistic regression analysis was used to calculate odd ratios (OR) and their 95% condence intervals (95%CI) for all risk factors. Those with associated p values <0.05 were included in a multivariate logistic regression analysis to obtain the OR adjusted by the eects of the others. Variables without signicant beta coecients were eliminated, producing a reduced model. We also analyzed the dierence in likelihood of recurrence between the two types of prosthetic repair by Yates-corrected chi-square test.

Results
We found an overall recurrence rate of 30.3%. The total recurrence rate following tissue repair was 39.4%, compared to 14.6% after prosthetic repair. The dierence between these two operative methods was statistically signicant (p=0.0058). There was no signicant dierence in recurrence rate between the two types of prosthetic repair (Table 1). Table 2 summarizes the results of the univariate logistic regression analysis. The demographic factors (age and gender) were not statistically related to recurrence. There was no relation between chronic pulmonary disease, cardiac disease or diabetes mellitus and risk of failure; this is in contrast to prostatic hyperplasia and
Table 1 Hernia recurrence in relation to the type of prosthetic repair as analyzed by the Yates-corrected chi-square testa Type of prosthetic repair Onlay Sublay Total
a 2

Recurrence (n) 11 5 16

No recurrence (n) 51 42 93

Total (n) 62 47 109

v =0.585, df=1, p=0.4445

Table 2 Analysisa of risk factors for recurrence after incisional herniorrhaphy Risk factors n Odds ratio 1.017 1.355 1.410 2.339 0.427 0.153 0.285 12.600 0.439 2.279 2.098 0.886 4.279 1.738 9.581 0.248 4.030 3.571 3.464 4.188 95% condence interval 0.9971.018 0.8132.2590 1.2991.5310 1.2814.273 0.2340.781 0.0750.313 0.1420.572 6.92122.940 0.2600.741 1.3503.850 0.7345.998 0.3552.209 1.68110.896 0.6724.497 1.04687.769 0.1370.451 2.2207.317 1.3089.749 1.3388.967 1.46711.955 p 0.1032 0.2430 0.0000 0.0058 0.0058 0.0000 0.0005 0.0000 0.0022 0.0022 0.1662 0.7938 0.0026 0.2531 0.0456 0.0000 0.0000 0.0132 0.0106 0.0076

Age 297 Gender 297 Body mass index 297 Type of repair Tissue 297 Mesh 297 Hernia size (cm) <5 297 510 297 >10 297 Chronic illnesses No 297 Any 297 Chronic pulmonary 297 Disease Cardiac disease 297 Prostatic hyperplasia 124 Diabetes mellitus 297 Cirrhosis/Ascites 297 Wound healing disorders No 297 Any 297 Hematoma 297 Seroma 297 Infection 297
a

Results of univariate logistic regression

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ascites, both of which were found to be signicant risk factors for recurrence. Body mass index was found to be a strong risk factor (p=0.0000) as was large hernias exceeding 10 cm in width or length (p=0.0000). Table 3 summarizes the recurrences rates according to hernia size. The relation between wound healing disorders and increased incidence of recurrence was especially apparent for wound infection (p=0.0076). Table 4 contains the results of the multivariate logistic regression analysis.

Discussion
Surgical management of incisional hernia remains a topical issue due to high recurrence rates despite the number of dierent surgical procedures proposed by numerous authors [57]. However,the impact of potential risk factors, especially various patient-related factors, has received little attention. We found the overall recurrence rate among our patient cohort to be unacceptably high (30.3%). However, this rate is comparable to those reported by authors and conrms recurrence rates found in the literature. Laparoscopic repair of incisional hernias has become increasingly better recognized during this past decade as an alternative procedure with good preliminary results [8]. However, this method must be carefully evaluated under strict protocols so that meaningful data can be obtained. We have recently performed our rst four laparoscopic repairs, so obviously this is not yet a routine procedure in our hospital. Schumpelick et al. stated that the development and introduction of meshes has decreased recurrence rates to 10%, particularly if the retromuscular sublay position was used [9]. In our study there was an obvious benet to using mesh repair, which is associated with a lower likelihood of recurrence relative to tissue repair. We also found fewer recurrences if the sublay position of the
Table 3 Hernia recurrence in relation to hernia size Hernia size (cm) Recurrence n 5 510 > 10 8 14 68 Percentage 6.8 17.5 68.7 No recurrence n 110 66 31 Percentage 93.2 82.5 31.3

prosthesis was used, but we found no statistically signicant dierence between the sublay position and the onlay position of the prosthesis. Low recurrence rates and less abdominal pain have led some surgeons to use prostheses to cover every abdominal wall gap and to abandon suture repair [10]. The ideal mesh should have certain qualities. It should be chemically inert, non-carcinogenic and nonallergenic and it shouldbe able to resist mechanical strains and be sterilized; it should not be physically altered by tissue uids nor produce a foreign body reaction [11]. On the basis of these prerequisites, none of prosthetic materials currently available can be described as being ideal. Hence, the routine use of mesh has no justication, particularly if we consider the potential complications, such as chronic seroma, abdominal wall pain or severe infection. It should also be emphasized that small-to-mediumsized incisional hernias can be successfully repaired by suture repair with an acceptable recurrence incidence [1214]. Our results show a statistically signicant relation between obesity and a high risk of failure after incisional hernia repair that is comparable with the results of similar studies. Sauderland et al. [15, 16] concluded that obesity was the only independent risk factor for recurrence. If the patient were to follow a preoperative weight loss program, it may be possible to reduce both the tension on the repaired incisional hernia and the technical diculties encountered by the surgeon when operating on an extremely obese patient. Some authors even suggest bariatric procedures as an attempt to reduce the impact of morbid obesity on the positive outcome of incisional herrnioraphy. Kaminski concluded that morbidly obese patients can be treated with a gastric restrictive procedure simultaneously with hernia repair in order to both decrease body weightand contribute to the control of ventral hernias [17]. We found large hernia size to be a strong risk factor for recurrence. This same observation has been made in previous studies [18]. There is currently a general consensus among surgeons that large incisional hernias (diameter: >10 cm) should be repaired with a mesh prosthesis [18]. Patients with diabetes mellitus, cardiopathy and chronic lung disease did not appear to have a signicantly higher hernia recurrence rate in our study. This observation supports results reported by van der Linden and van Vroonhoven in an earlier study [19].

Table 4 Analysis of risk factors for recurrence after incisional herniorrhaphy. Model of multivariate logistic regression (n=297, v2 test = 170.759, df=4, p=0.00000)

Risk factor Constant Type of repair Size of hernia >10 cm Body mass index Wound complication

Estimate 11.703 1.177 2.204 0.279 1.434

Standard error 1.472 0.437 0.383 0.044 0.441

t 7.952 2.691 5.763 6.342 3.251

p 0.0000 0.0075 0.0000 0.0000 0.0013

Odds ratio 3.244 9.065 1.321 4.195

95% CIa

Condence interval

1.3727.671 4.270 19.246 1.212 1.441 1.7619.994

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We also postulated that prostatic hyperplasia and ascites are predisposing factors for the development of incisional hernia recurrence, which was later conrmed in our statistical analysis. We investigated the risk for recurrence in patients who had wound-healing disorders in the early postoperative course after incisional hernia repair. Seroma is a relatively frequent complication, and our results show that it is a statistically signicant risk factor; this is also true for hematomas. Other investigators have identied postoperative wound infection as a particularly important risk factor for recurrent incisional hernia [20]. In our series, 9 of 11 patients who had postoperative wound infection developed a recurrence. In conclusion, it is very important to be aware of and respect the risk factors for recurrence following incisional hernia repair in order to be able to comply with three crucial demands: (1) individual approach; (2) preoperative elimination of risk factors that the surgeon can manipulate, such as obesity and prostatic hyperplasia; (3) the selective use of mesh in patients who run a higher risk for recurrence, especially when dealing with an obese patient or one with a large incisional hernia.

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