A 70-year-old woman was admitted to our hospital with a complaint of bulging in the right lower portion of the abdomen. The bulging was in accordance with an old operative scar for appendicitis. The findings of computed tomography (CT) showed defects in the abdominal muscles and the protrusion of the intestine into the subcutaneous fat. The patient was diagnosed with incisional hernia after appendectomy and underwent are pair of the incisional hernia, using the prolene hernia system double-layer mesh. The patient’s post-operative course was excellent. Recently, the prolene hernia system, double-layer mesh was reported to be effective for groin hernias due to its advantageous protection the recurrence through reinforcement of the patient’s myopectrial orifice. It is suggested that this new device is also useful for small incisional hernias

Ishikawa, Masashi

Miyauchi, Takayuki

Tagami, Yoshifumi

Tokushima University Institutional Repository

INTRODUCTIONDespite the developments in surgical techniques,operative devices, and materials, incisional herniaremains an significant problem in abdominal sur-gery because it sometimes complicates the incar-ceration, which may cause severe complications,such as strangulation obstruction and perforationof the intestine (1). Incisional hernias have beentreated using various procedures (2), and are currentlymainly repaired by techniques using a polypropyleneartificial mesh for medium or large incisional her-nias (3). In the treatment of groin hernias, somedevices have recently been investigated with theaim of tension-free (4, 5). In our hospital, we alsotreat groin hernias with such devices, includingthe prolene hernia system double layer device. A70-year-old woman was admitted to our hospital forthe repair of an incisional hernia after a laparotomyfor appendicitis and, we applied the prolene herniasystem in the treatment.We report a new method in the repair of incisionalhernia, using the prolene hernia system.CASE REPORTOn November, 19, 2001, a 70-year-old woman wasadmitted to our hospital with a complaint of bulgingin the right lower portion of the abdomen, whichwas in accordance with the site of the old opera-tive scar for appendectomy. She had undergone theappendectomy at 40 years old at a near hospital,and a hernioplasty for bilateral inguinal hernia at50 years old. The operative course was straightforward after both operations. She had also beensuffering frequently from asthma for 10 years. Inthe spring of 2000, bulging in the right lower por-tion of the abdomen suddenly appeared. The bulgingsometimes appeared with no relation to the posi-tion, walking, or exertion. On admission, the pa-tient was markedly obese. Her height was 143.4cm and her weight was 61.5 kg. Her blood pres-sure was 142/80 mmHg, pulse rate was 64 beatsper minute and irregular, and her body tempera-ture was 36.2 ℃. In a standing posture, the bulgingwas apparent in the right lower portion of the ab-domen, and it was soft on palpation, however, itsCASE REPORTRepair of incisional hernia with prolene hernia systemTakayuki Miyauchi, Masashi Ishikawa, and Yoshifumi TagamiDepartment of Surgery, National Kochi Hospital, Kochi, JapanAbstract : A 70-year-old woman was admitted to our hospital with a complaint of bulgingin the right lower portion of the abdomen. The bulging was in accordancewith an old op-erative scar for appendicitis. The findings of computed tomography (CT) showed defectsin the abdominal muscles and the protrusion of the intestine into the subcutaneous fat.The patient was diagnosed with incisional hernia after appendectomy and underwent arepair of the incisional hernia, using the prolene hernia system double-layer mesh. The pa-tient’s post-operative course was excellent. Recently, the prolene hernia system, double-layermesh was reported to be effective for groin hernias due to its advantageous protection therecurrence through reinforcement of the patient’s myopectrial orifice. It is suggested thatthis new device is also useful for small incisional hernias. J. Med. Invest. 50 : 108-111, 2003Keywords : incisional hernia, prolene hernia systemReceived for publication August 8, 2002 ; accepted September5, 2002.Address correspondence and reprint requests to Dr. TakayukiMiyauchi, Department of Surgery, Tokushima PrefecturalMiyoshi Hospital, Shima, Ikeda-Cho, Miyoshi-Gunn, Tokushima778-0001, Japan and Fax : +81-883-72-6910.The Journal of Medical Investigation Vol. 50 2003１０８border was unclear. On lying down, the bulgingdisappeared and a cavity was detected on palpationin accordance with the site of the oblique scar fromthe operation for acute appendicitis. The otherphysical examinations showed no abnormalities.The abdominal CT findings showed a defect in themuscle layer in accordance with the area of thehernia. Air density from the prolapsed intestine wasfound in the subcutaneous fatty layer, and the ab-dominal muscle was thin (Fig. 1). From these find-ings, the complaint was diagnosed as an incisionalhernia, associated with the operative scar from theold appendectomy. On November 21, 2001, repairof the incisional hernia was repaired under lumbaranesthesia. An 8 cm skin incision was made, cross-ing the old oblique operative scar in the right lowerportion of the abdominal wall. The subcutaneousfat was carefully dissected, and the hernia sac waslocated. The sac was freed from the circumferentialtissue, and we reached the pre-peritoneal space.The size of the anterior orifice of the hernia on theaponeurosis was 3.5×2.0 cm. The hernia sac wasopened, revealing adhesion of the large omentum,which was easily freed from the peritoneum. Aroundthe posterior orifice of the peritoneum, the intes-tine showed no adhesion. We dissected the herniasac and closed the peritoneum using a continuoussuture at the base with No. 3-0 Vicryl (absorbablethread). From the aponeurosis finding, it was sug-gested that the aponeurosis could not ensure thestrength of the tight suture for closing the defectbecause it was thin and weak, furthermore, the mus-cle was also thin and weak around the hernia ori-fice. To reinforce the posterior wall, we decided touse the prolene hernia system. To insert the under-lay patch, the pre-peritoneal fatty tissue was freedfrom the fascia of the transversalis approximately10 cm in diameter. The underlay patch was insert-ed beneath the posterior wall of the transverse ab-dominal muscle with no fixing sutures (Fig. 2).The Onlay patch was placed on the surface of theaponeurosis (Fig. 3) and fixed with interrupted su-tures using No. 3-0 Vicryl (Fig. 2). Two aspirationdrains were placed on the onlay patch, and thenthe subcutaneous layer was closed with No. 3-0Vicryl and the skin with No. 4-0 nylon. The had anexcellent post-operative course with no complications.The sump drains were removed on post-operativeFig. 1. Findings of abdominal CT. The symbol ↓ shows airdensity, which suggests herniated intestine into the subcutaneouslayer.Fig. 2. Operative procedures. The underlay patch was inserted through the hernia orifice and placed in the pre-peritoneal fat layerwith no sutures. The connecter was placed through the hernia canal, and then the onlay patch was placed on the aponeurosis andfixed with No.3-0 Vicryl (absorbable thread).The Journal of Medical Investigation Vol. 50 2003 １０９day 2, and the patient was discharged on post-operativeday 10. Three months after the operation, the pa-tient had not complained of trouble.DISCUSSIONDespite the developments and improvements insuture materials and the closure techniques of ab-dominal incisions, incisional hernia remains a sig-nificant postoperative disorder in abdominal surgery(6, 7).The incidence of incisional hernia ranges from 2to 11% after abdominal operations, however, it de-pends widely on the presence or absence of thefollowing factors : 1) infected and closed wounds ;2) severance of the nerves supplying the musclesin the region of the incision ; 3) dehiscence of wounds ;4) hematoma in the wound ; 5) marked postoperativeabdominal distention ; 6) increased intra-abdominalpressure caused by ascites, intra-abdominal tumors,and postoperative cough ; 7) obesity (8). With respectto the area of the incisional hernia, Flament et al .recently reported ; 30.1% in midline supra-umbilicalhernia, 29.3% in midline infra-umbilical, both 26.9%in supra-and infra-umbilical, 4% in sub-chondral,8.1% in inguinal, and 1.2% in the flank (2).The surgical procedures for incisional herniaare mainly divided into the classic methods andprosthetic repair. The classic methods by simpleclosure are based on aponeurotic or muscular re-constructive surgery using the structures of theabdominal wall (2). Various procedures have beenreported for simple closure, however, these procedurescan be used to treat relatively simple incisionalhernias when there is no true loss of abdominalwall substance or a hernia caused by sclerotic re-traction of the muscles (2).On the other hand, prostheses allow the repairof complex herniations and can be used to treatformidable lesions, often considered beyond thescope of surgical repair (2). The ideal materialshould be as light and as solid as possible, with acertain degree of elasticity and suppleness (2). Itis also important that the material be a fairly openmesh structure so that the connective tissue responseis able to infiltrate the prosthesis (2). Chevrel de-scribed the sites in which prostheses may be insertedas follows : 1. The peritoneal cavity (intra-peritoneal) ;2. The peritoneal space (Stoppa procedure), for lowmidline supra-pubic, or iliac fossa incisional her-nias ; 3. The prefascial space, posterior to rectusabdominus muscle (Rives procedure) (underlay) ;4. Sandwich-like, between two muscle layers, forlateral incisional hernias (interparietal) ; 5. Patch-like,bridging the gap when closure is impossible (inlay) ;6. The premuscular aponeurotic space (Chevrel),for all types of abdominal incisional hernia (onlay)(3).We recently used a new type, the prolene herniasystem double layer device. This new version ofthe polypropylene mesh patch was conceived as athree-dimensional device. It is a three-in-one at-tached device that functions as a unit. It has anunderlay graft and an onlay graft, held together bya connector. The device comes in three sizes, me-dium, large, and extended, as follows : Medium ; onlay,10 cm, underlay, 7.5 cm, connector, 1.5 cm. Large ;10 cm, 10 cm, 1.5 cm, respectively. Extended ; 12.5 cm,10 cm, 1.5 cm, respectively (9). In the repair of groinhernias, the underlay patch is placed in the layerof preperitoneal fatty tissue with no fixing sutures,and the onlay patch is inserted between the exter-nal and internal oblique muscles, and then laid onthe inguinal ligament and the pubic bone surface,with fixing sutures, using the absorbable thread(9). We previously recognized the advantages ofthe prolene hernia system in the repair of direct,indirect and femoral hernias. It is suggested thatits superior advantage is the wide, strong reinforce-ment of the posterior wall, added to the low risk ofpost-operative pain. This case showed marked weak-ness and atrophy in the tissue around the herniaorifice, especially in the anterior oblique aponeurosisand muscle layers. Furthermore, CT revealed promi-nent muscle weakness and atrophy in a wide region.Therefore, we stressed the necessity of reinforce-ment of the posterior wall. Fortunately, the herniaFig. 3. Operative finding. The onlay patch of the prolene her-nia system placed on the aponeurosis.T. Miyauchi et al. Incisional hernia１１０sac was easily freed from the adhesion withoutdamage to the circumferential tissue and we coulddissect and enclose the hernia sac completely. Thesize of the hernia orifice was 3.5×2.0 cm, therefore,we could envelope the hernia orifice by laying theonlay patch on the anterior aponeurosis. The sizesof the devices of the prolene hernia system arelimited, therefore, It is suggested that it might notbe adequate to cover large incisional hernias. For-tunately, the aponeurosis defect was small in thiscase, and the prolene hernia system could be fixedeasily and the implantation of this device was pre-cise. We think double the layer system of the prolenehernia system reinforces the abdominal wall moretightly than the conventional methods, using a meshsheet, and stress that the connecter is useful forsuccessful implantation to protect migration of theonlay and underlay patches. Furthermore, we sug-gest that the addition of prolene mesh to this de-vice may be effective for larger incisional hernias.In conclusion, a new type of prolene hernia sys-tem, a double-layer mesh device, was useful for therepair of a small sized incisonal hernia, which oc-curred at an appendectomy scar. This method is easy,and the reinforcement of the abdominal wall isstrong. Furthermore, this method can be appliedfor the repair of large incisional hernias by the ad-dition of prolene mesh sheet.REFERRENCES1. Feliciano DV : Incisional hernias as emergen-cies. In : Bendavid R, Abrahamson J, ArreguiM, Flament JB, Phillips ED, eds. Emergency sur-gery. Abdominal wall hernias. Springer-VerlagInc, New York, 2001, pp582-587.2. Flament JB, Palot JP, Burde A, Delattre JF,Avisse C : Treatment of major incisional her-nias. In : Bendavid R, Abrahamson J, ArreguiM, Flament JB, Phillips ED, eds. Open techniquesof incisional hernia repair. Abdominal wallhernias. Springer-Verlag Inc, New York, 2001,pp508-516.3. Chevrel JP : Treatment of incisional herniasby an overlapping herniorraphy and onlay pros-thetic implant. In : Bendavid R, AbrahamsonJ, Arregui M, Flament JB, Phillips ED, eds.Open techniques of incisional hernia repair.Abdominal wall hernias. Springer-Verlag Inc,New York, 2001, pp500-503.4. Butkow IM, Robbin A : The Mesh Plug Repair.In : Bendavid R, Abrahamson J, Arregui M,Flament JB, Phillips ED, eds. Techniques ofopen groin hernia repair. Abdominal wall her-nias. Springer-Verlag Inc, New York, 2001,pp382-387.5. Amid PK : Lichtenstein Tension-free hernioplastyfor the repair of primary and recurrent ingui-nal hernias. In : Bendavid R, Abrahamson J,Arregui M, Flament JB, Phillips ED, eds. Tech-niques of open groin hernia repair. Abdomi-nal wall hernias. Springer-Verlag Inc, New York,2001, pp423-427.6. Jenkins TP : The burst abdominal wound : a me-chanical approach. Br J Surg 63 : 873-876, 19767. Israelsson LA, Jonsson T. Closure of midlinelaparotomy incisions with polydioxanone andnylon : the importance of suture technique. BrJ Surg 81 : 1606-1608, 1994.8. Santora TA, Roslyn JJ : Incisional hernia. SurgClin North Am 73 : 557-570, 1993.9. Gilbert AI, Graham MF, Voigt WJ : Gilbert’srepair of inguinal hernias. In : Bendavid R,Abrahamson J, Arregui M, Flament JB, PhillipsED, eds. Techniques of open groin hernia re-pair. Abdominal wall hernias. Springer-VerlagInc, New York, 2001, pp377-381.The Journal of Medical Investigation Vol. 50 2003 １１１

Repair of incisional hernia with prolene hernia system

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Repair of incisional hernia with prolene hernia system

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