Hernia (2005) 9: 238241 DOI 10.

1007/s10029-005-0326-x

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

V. K. Shukla R. Mongha N. Gupta V. S. Chauhan Puneet

Incisional herniacomparison of mesh repair with Cardiff repair: an university hospital experience

Received: 2 November 2004 / Accepted: 10 February 2005 / Published online: 19 May 2005 Springer-Verlag 2005

Abstract Background: Incisional hernia is a frequent complication of abdominal surgery. Various types of repair are recommended for incisional hernia. Suture and mesh repair are compared in the present study. Method: One hundred seventy one patients with incisional hernia underwent Cardi repair (far and near sutures with reinforcement sutures) which was used as an open suture repair while onlay polypropylene mesh was used in the mesh repair technique. Result: Cardi repair was performed in 116 patients with no mortality with recurrence in two patients with mean follow up of 7.1 years. Both these patients with recurrence had a defect measuring more than 10 cm in width. Mesh repair was carried out in 55 patients with no recurrence in mean follow up of 37 months. Seroma formation was noted in 7 (12.72%) with mesh repair as compared to 4 (3.44%) patients with Cardi repair. Conclusion: We recommend Cardi repair for primary and small to medium size incisional hernias. Onlay polypropylene mesh is ideal for tension-free hernia repair, recurrent incisional hernia and hernia defects wider than 10 cm. Keywords Hernia Cardi repair Mesh

Introduction
Incisional hernia is a frequent complication of abdominal surgery and it develops in up to 11% patients [1]. The incidence of incisional hernia is higher in the presence of wound infection (23%) and depends upon a number of factors such as age, sex, obesity, bowel surgery, type of suture, presence of chest infection and
V. K. Shukla (&) R. Mongha N. Gupta V. S. Chauhan Puneet Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221 005, India E-mail: vkshuklabhu@satyam.net.in Tel.: +91-542-2307507/+91-542-2307510 Fax: +91-542-2367568/+91-542-2368174

abdominal distension [2]. Ninety percent of incisional hernias occur within 3 years of surgery [1]. Repair of incisional hernia is a dicult surgical problem with recurrence being a common outcome. Recurrence rates up to 33% after the rst repair and 44% after second repair were reported [3, 4]. A considerable proportion of patients presents with incarceration and strangulation requiring emergency surgery. Various surgical techniques are recommended for the repair of incisional hernia ranging from open suture repair to prosthetic mesh repair. Laparoscopic repair was also used for incisional hernia. Open suture repairs were associated with high recurrence rates ranging between 744% [5, 6]. However, some studies have reported low incidence of recurrence with open suture repair [7, 8]. In our own series published earlier, we have recommended Cardi repair, far and near abdominal wall closure with reinforcement sutures. We did not observe any recurrence in 50 patients after a mean follow up of 52 months [9]. The introduction of non-absorbable synthetic mesh by Usher in 1963 revolutionized the repair of abdominal wall defects [10]. The most commonly used mesh is the polypropylene mesh, which meets most of the requirements of an ideal mesh. The next popular prosthesis used is multilament polyester ber thread (Dacron, Mersilene) and polytetrauoroethylene (PTFE). In almost all of the reported series using mesh repair, sac is opened, adhesionolysis is done and mesh is placed onlay, inlay or underlay [1116]. The recurrence rate in most of these series ranges between 010%. The aim of this study was to compare the results of mesh repair with Cardi repair.

Materials and methods

The period of study was from January 1991 to August 2003. Ninety-nine patients with incisional hernia between January 1991 to April 1999 underwent Cardi repair as a unit policy. Between May 1999August 2003, 17 patients underwent Cardi repair using prolene no. 1 su-

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Fig. 1 Figure showing Cardi repair: a Peritoneum closure. b Near far suture tied. c Double mattress suture tied. d Far nearnear far suture e Far near nearfar, farnearnear far suture (Double mattress) f Subcutaneous tissue g Musculoaponeurotic edge h Peritoneum

ture (Fig. 1) and 55 patients underwent mesh repair. From May 1999 onwards mesh repair was the preferred method and Cardi repair was only done in patients who could not aord the mesh or if infection was present. (Table 1). The patients characteristics which were taken into consideration were age, sex, obesity, cough, constipation, prostatism, diabetes mellitus, smoking and the nature of previous abdominal surgery (Fig. 2). Patients with obesity (BMI>30) were urged to loose weight and smokers were advised to abstain from smoking. Patients with prostatism were evaluated and medical treatment started. The informed consent was obtained from all patients. Intra-operative details taken into consideration were site of scar, length of defect and width of defect. In Cardi repair, defect was sutured with no. 1 polypropylene (prolene) by the far and near technique. Reenforcement sutures were inserted in between in order to distribute the tension. Release incision was given in four patients, who had large defects so as to reduce the tension on the suture repair. In the patients who underwent mesh repair, skin aps were raised after excision of the previous scar. The hernial sac was opened, adhesiolysis done and the redundant sac was excised. Musculoaponeurotic edges in small and medium size defects were approximated in midline with continuous polydioxanone suture. However, no attempt was made to approximate the edges if the defect was large. Onlay polypropylene mesh was placed over the defect with at least 45 cm of overlap over the original size of defect. The mesh was xed with interrupted polypropylene 30

Table 1 Details of patients who underwent incisional hernia repair Number Sex Male Female Mean age (years) Range Mean body mass Index Range Incision Midline Para median Pfannensteil Kocher Mcburney Mean duration of herniation (months) Range Mean length of defect (cm) Range Mean width of defect (cm) Range No. of previous attempts at repair Operating time (min) Hospital stay (days) Range

Mesh repair (%) 55 8 (13.5) 47 (85.5) 42 2570 24.24+3.8 2033.4 kg/m2 30 (54.54) 14 (25.45) 10 (18.18) 1 (1.81) 0 17.5 934 14.5 520 10.6 118 8 patients 62 6.2 414

Cardi repair (%) 116 23 (19.82) 93 (80.17) 37 1675 27.30+2.8 2430.4 kg/m2 70 (60.32) 31 (26.72) 10 (8.62) 3 (2.58) 2 (1.72) 15 240 10.8 314 9.4 120 27 patients 54 5.3 313

v2/t test v2=0.13 t=1.86 t=4.94

P value NS NS <0.001

v2=5.54

0.04

t=3.61 t=5.09 t=2.69 v2=0.44 t=3.23 t=2.79

<0.001 <0.001 <0.01 NS <0.01 <0.01

240 Table 2 Post operative complications Mesh (%) (n=55) Wound infection Flap necrosis Sinus formation Seroma 2 (3.64) 3 (5.45) 7 (12.72) Cardi (%) (n=116) 17 (14.65) 16 (13.79) 2 (1.72) 4 (3.45)

Ten patients had both wound infection and ap necrosis

Fig. 2 Distribution of previous procedures

suture at a distance of 23 cm. Patients were followed up 14 days, 1 month, 3 months, 6 months and a year, there after till 36 months. All patients were followed up in the surgery out patient department. Patients complaint of any recurrence was noted. In these patients, who complained of abdominal discomfort or doubtful recurrence and in whom the physical examination was negative, ultrasonographic evaluation was done. The mean duration of follow up for Cardi repair is 7.1 years (range 20 months to almost 14 years) and that for mesh repair, the mean duration is 37 months (range 12 months74 months). The statistical analysis was done by applying the chi-square and students t-test.

of >30 kg/m2. The mean duration of hospital stay of patients undergoing mesh repair was 6.2 days (range 414 days). One patient with mesh repair expired on sixth postoperative day due to respiratory complications. The patient was operated for obstructed incisional hernia. She had undergone exploratory laparotomy 9 months earlier for Kochs abdomen (abdominal tuberculosis). She had also received radiotherapy for carcinoma cervix. The mean operative time for Cardi repair was 54 min and that for mesh repair was 62 min. Mesh repair was more expensive in comparison to Cardi repair, the cost varied with the size of mesh used.

Discussion
The cause of recurrence in suture repair is approximation under tension and wound infection, closure under tension increases the risk of ischemia, and cut through of sutures leading to repair failure. Size of hernia, the width of defect, chronic obstructive pulmonary disease, smoking, constipation, occupational weight lifting and aortic aneurysm have also been associated with recurrence following repair of incisional hernia [17, 18]. The distance of overlap of mesh over the musculoaponeurotic edges is associated with recurrence incisional hernia. The mesh should overlap the original size of defect by at least 34 cms on all sides [19]. This decreases the incidence of hernia at the lateral edge of the mesh and also takes care of the shrinkage of mesh that was shown in experimental in vivo studies [20]. Liakakos et al. [21] carried out a prospective comparison of primary closure against the use of mesh and showed that recurrence was less with mesh at a mean duration of 7.6 years of follow-up [2224]. Similarly, Koller et al. [22] found PTFE mesh repair superior to suture after 24 months of follow up. Flum et al. demonstrated no improvement in reoperation rate after the introduction of mesh in incisional hernia repair. The technique used for suture or mesh repair might be as important as mesh or no mesh [25]. Seroma formation is a common complication associated with mesh repair and was present in 15% of patients in our study. The seroma formation usually occurs 317 days after operation and is managed by aspiration. The proper management of seroma is an expectant approach with a resolution of 90% in 3 months [26, 27]. One interesting nding in our study

Results
The mean age of the patients who underwent mesh repair was 42 years (range 2570 years) and Cardi repair was 37 years (range 1675 years) (P=NS). The mean body mass index in patient with mesh repair was 24.243.8 kg/m2 and with Cardi repair was 27.302.8 kg/m2. The length of the defect in patients with mesh and Cardi repair was 14.5 cm (range 520) and 10.8 cm (range 314), respectively (P<0.001) and width was 10.6 cm (range 18) and 9.4 cm (range 120), respectively (P<0.01). There was no mortality in 116 patients who underwent Cardi repair. The mean duration of hospital stay was 5.3 days (range 313 days). Twenty-eight (24.14%) patients developed early complication and 2 (1.72%) patients developed recurrence. Most common complications with Cardi repair were wound-related (Table 2). In both patients who had recurrence, the width of defect was more than 10 cm. Out of 55 patients with mesh repair, 12 (21.8%) patients developed local complications and with one mortality. Two patients developed wound infection, in which wounds were debrided, and allowed to heal by secondary intention. No mesh extrusion was noted. Seven (12.72%) patients developed seroma on rst follow up after 14 days. All patients with seroma had BMI

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was that all patients who had seroma formation were obese with BMI >30. Some authors have reported that use of nonabsorbable sutures to x the mesh resulted in more pain because of greater tension [12, 15, 16], and have recommended the use of polyglactin sutures to x the mesh. We recommend xation of mesh with polypropylene 30 suture at a distance of 23 cm. Various techniques were used for the placement of mesh and all have given good results. The rate of recurrence has not varied with the site of placement of mesh. However, rate of seroma formation is less in deeper position of mesh. Intraperitoneal mesh placement, however, carries the risk of development of enterocutaneous stula [28, 29]. PTFE is the preferred mesh for intraperitoneal placement as it causes the least tissue reaction but it is much more expensive than polypropylene mesh. We prefer the onlay mesh repair with regards to its simplicity and acceptable results. No case of mesh migration extrusion or enterocutaneous stula was noted in the present study. Conclusion Since the introduction of mesh in 1963, mesh repair has replaced the conventional hernia repair as the preferred technique. We recommend Cardi repair as an excellent form of suture repair in primary hernias particularly those with small and medium size defects. It can also be done in patients who cannot aord mesh or if infection is present. The onlay polypropylene mesh is recommended for large size defects and recurrent hernia as it oers tension free repair with acceptable complication rates.

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