Open Onlay Hernia Repair for Recurrent Incisional Hernia

Abstract

An 80-year-old patient underwent an open onlay repair of a recurrent incisional hernia. This approach was chosen due to the patient’s prior retromuscular repair, age, history of adhesions, and religious preference against blood products. Following safe abdominal entry and adhesiolysis, a subcutaneous pocket extending 5 centimeters in all directions from the hernia was created. Fascia was closed using mesh-suture and a 12 x 12-centimeter macroporous, medium-weight polypropylene mesh was secured to the anterior fascia with staples and fibrin glue. A subcutaneous drain was placed. This case highlights the utility of an onlay approach for selected circumstances.

Keywords

Incisional hernia; ventral hernia; onlay repair; mesh suture; recurrent hernia.

Case Overview

Background

Incisional hernia is a common complication of abdominal surgery. Most incisional hernias are repaired using mesh in the interest of reducing the risk of hernia recurrence. Mesh may be placed in a number of different positions or planes within the abdominal wall. Advanced techniques that separate components of the abdominal wall to reduce tension on fascial closure and facilitate mesh overlap are used more and more commonly. Despite use of these techniques, hernias may recur due to technical issues, such as inadequate mesh overlap, or due to mesh failure, which may occur due to mesh fracture or due to the mesh being incised during subsequent abdominal operations. In this case, an onlay mesh repair is used to repair a hernia recurrence in a patient who had undergone a prior retromuscular repair.

Focused History of the Patient

The patient is an 80-year-old woman with BMI of 30 kg/m² and an ASA class II with comorbidities significant for hypothyroidism and provoked pulmonary embolism. Additionally, she is a Jehovah’s Witness. She had undergone a prior open partial colectomy for volvulus after which she developed an incisional hernia. This hernia was repaired with a robotic-assisted intraperitoneal underlay approach in which the surgeon achieved fascial closure, but did not adequately overlap the fascial closure with mesh. This resulted in recurrent hernias above and below her mesh, as well as a lateral, Spigelian-type port site hernia. She was therefore seen at our center and underwent an open retromuscular incisional hernia repair with transversus abdominis release (TAR) in 2021. She recovered well from this, but approximately 18 months later developed a bowel obstruction with concern for closed loop physiology and underwent exploratory laparotomy and lysis of adhesions. Despite her fascia being closed with Prolene suture, she developed a hernia recurrence in her lower abdomen that was painful and associated with partial obstructive symptoms. Notably, the patient is a roller coaster enthusiast and had been cautioned by her primary care team and outside surgeon that she should not ride any roller coasters until her hernia was repaired.

Physical Exam

On exam, she had a reducible ventral hernia underlying her laparotomy incision inferior to her umbilicus. There were no significant soft tissue changes in this region.

Imaging

CT scan of the abdomen demonstrated some changes that are typical of a prior retromuscular hernia repair including midline rectus-to-rectus approximation without a distinct linea alba as well as a posterior abdominal wall with “waves” in the lower abdomen. At the site of her bulge and pain, the patient was seen to have a midline recurrent hernia measuring 3.5 to 4 centimeters in width and containing a loop of bowel that was not clearly obstructed, though some changes of fecalization were noted.

Natural History

Hernias in adults may do one of two things—stay roughly the same size or gradually enlarge. Some patients may be relatively asymptomatic, while others may cause pain or bowel obstruction. Hernias do not resolve on their own and require surgery to repair. Repair is typically recommended in symptomatic hernias unless there are significant medical comorbidities that would make surgery unsafe.

Options for Treatment

This patient was symptomatic with pain and partial obstructive symptoms, and therefore surgery was indicated. Factors including hernia size, location, and an individual’s operative history, including prior hernia repairs, are important to consider. Wound morbidity is a major consideration, and in general, hernia repair approaches that minimize the risk of surgical site complications are preferred. Considered in isolation, the size and location of this hernia would be amenable to a number of different surgical approaches, which would include minimally-invasive intraperitoneal, preperitoneal, retromuscular, and onlay approaches. These options would entail placing mesh inside of the abdominal cavity, outside of the abdominal cavity separated by the innermost peritoneal lining of the abdomen, outside of the abdominal cavity in a plane behind the rectus muscles, or on top of the anterior fascia, respectively. 

Rationale for Treatment

For any hernia, the goals are to alleviate the symptoms that the hernia is causing, to provide a durable repair, and to avoid wound complications. Additionally, the patient wanted to have her hernia repaired so that she could ride roller coasters and be worry free about developing an acute issue. In this case, this patient was known to have fairly significant intra-abdominal adhesive disease, which would make a minimally-invasive intraperitoneal hernia repair more challenging and higher risk. Given her age, a lower complexity surgical intervention and shorter general anesthesia would be preferred. Much of her retromuscular repair was intact, and redo retromuscular repairs are associated with significantly higher risk of wound morbidity and likely blood loss.¹ Additionally, for a Jehovah’s Witness who would not accept blood products, it was preferable to perform an operation in which any bleeding would be more easily controlled and less likely to result in a life-threatening situation compared to intraperitoneal or retroperitoneal bleeding. In the interest of avoiding issues with adhesions, using a plane that had not been used before, and limiting operative complexity and potential for bleeding complications, an onlay approach was selected.

Special Considerations

Small- to medium-sized recurrences after retromuscular hernia repair can be fixed with intraperitoneal or onlay approaches. An onlay repair may be an appropriate choice for patients who are known or suspected to have significant intra-abdominal adhesive disease, or who have medical comorbidities that make abdominal insufflation unsafe. It should be noted that patients with prior vertical, off-midline incisions are at high risk for skin ischemia when skin flaps are raised in the midline due to absence of lateral blood flow, and other repair options may be more appropriate. Additionally, patients with prior aortic repair and ligation of the lumbar collateral vessels are at similarly elevated risk for skin flap necrosis due to interrupted lateral blood flow. A successful onlay approach is also predicated on a successful primary fascial closure, and therefore an onlay approach should only be selected in patients for whom primary fascial closure is expected to be obtained based on hernia size. Active smoking is also considered to be a relative contraindication to an onlay approach due to impaired tissue blood supply and oxygenation, and patients are strongly advised to quit smoking prior to hernia repair. A body mass index (BMI) of 35 or less and a hemoglobin A1c of 8 or less are ideal.

Discussion

Review of the patient’s preoperative CT scan as well as physical exam were used to identify the location of the expected hernia. After skin preparation, this site and any prior scars were marked and the operative site was covered with an iodinated drape.

An incision was made incorporating the patient’s prior midline scar over the expected site of the hernia. Extreme care was taken dissecting through subcutaneous tissue until the level of the hernia sac was reached. Atraumatic instruments were used to elevate the hernia sac. The hernia sac was palpated and then entered sharply in the interest of avoiding any potential thermal injury to underlying viscera. In many circumstances, we will try to enter the abdomen above where anyone has been before, in an area of intact fascia. In this particular case, this was not an option and would have resulted in further disruption of this patient’s otherwise intact retromuscular repair.

After the hernia sac was entered, adhesiolysis was performed to free the bowel from the hernia sac and the abdominal wall with several aims. First, to ensure that there is no issue with ongoing obstruction in this area that was secondary to adhesions rather than secondary to the hernia itself. Second, to permit excision of the hernia sac. And finally, to establish adequate free space on the posterior abdominal wall to allow fascial closure. This is more difficult through a limited incision and it may be necessary to modify exposure frequently to permit safe conduct of this portion of the operation. In this particular case, it appeared that a portion of remaining intraperitoneal mesh was the location of much of her adhesions.

Following completion of adhesiolysis, a countable sponge was placed into the abdominal cavity to protect and contain the viscera. It is critical to remember to remove this prior to fascial closure.

The abdominal wall was debrided circumferentially around the site of the hernia in the interest of removing the hernia sac and identifying usable anterior fascia for closure. This pocket above the healthy anterior fascia was dissected for a distance of approximately 5 centimeters circumferentially around the hernia, with careful attention to hemostasis.

The hernia itself in this case was measured to be approximately 4 cm by 4 cm. A #1 strand of mesh-suture was used to close the anterior fascia as well as muscle and mesh in a running fashion. When closing mesh, a permanent suture is recommended as mesh will not grow into mesh. While there is not strong data to support use of mesh-suture in this context as opposed to closure with standard Prolene suture, our group is actively investigating use of mesh-suture and feels that there may be benefit in certain higher risk closures such as this. If this patient did not have existing mesh, #1 PDS suture would likely have been used for fascial closure.

A 12 x 12-centimeter, medium-weight macroporous polypropylene mesh was fashioned and placed in the pocket and secured to the anterior fascia using a combination of skin staples and Tisseel fibrin glue. An ancillary benefit of Tisseel in this case is additional hemostatic effect.

A 19 French round channel drain was placed over the mesh and secured with a nylon suture, with plans to remove once the output was approximately 10 cc per day for 2 days in a row.

The skin was closed in layers using 2-0 and 3-0 Vicryl suture and 4-0 Monocryl. Surgical glue was used to cover the incision.

This patient’s postoperative course was uneventful. She was seen in follow-up at one month postoperatively and had no active issues. Her drain was removed at this time and she has had no further issues. She was contacted at 6 months by telephone with no ongoing concerns and will be seen back for a 1-year planned follow-up visit in person.

While not demonstrated in this video, external oblique release may be performed if necessary during an onlay repair to achieve midline fascial closure. This would require creation of a larger subcutaneous dissection plane, typically several centimeters lateral to the semilunar line and superiorly to the level of the costal margin and inferiorly to the level of the inguinal ligament. At a point 1–2 centimeters lateral to the linea semilunaris, the external oblique aponeurosis is divided. This release may be extended superiorly to the costal margin and down to the inguinal ligament. These releases are typically performed in a sequential fashion where the amount of tension on the fascia is re-evaluated after a unilateral release before committing to a bilateral release. If external oblique release were performed, the mesh would be sized to cover not only the midline closure but also the external oblique release(s). For larger onlay repairs, additional drains, up to four, may be used to help avoid issues with seroma.² 

There are potential downsides to an onlay approach. First, there can be issues related to skin and soft tissue ischemia and infection. If and when these occur, it is important to explore the wound, debride devitalized tissue, and determine whether the mesh can be salvaged. If the mesh appears to be incorporating well, it may be possible to manage the wound with wet to dry dressing changes or a wound vac, depending on the level of contamination. If this occurs very early prior to significant mesh incorporation, the mesh could be removed in the interest of avoiding ongoing issues with mesh infection. Second, a large subcutaneous space is created which can predispose to seroma. This is typically managed proactively with ongoing binder use for longer than might be recommended after other types of repairs (e.g. 6–8 weeks) and by leaving one or more drains in place until their output decreases to consistently less than 10 cc per day.

Despite concerns regarding potential wound morbidity with the onlay approach, there is data suggesting that in patients with a clean wound class undergoing elective open ventral hernia repair with synthetic mesh, outcomes with regard to 30-day surgical site infections, occurrences, and occurrences requiring procedural intervention are similar compared to patients undergoing sublay hernia repair (retromuscular and/or preperitoneal).³ There is also data from one expert center in 97 patients undergoing onlay repair indicating that despite a 21.6% seroma rate and 9.3% reoperation rate due to complications, there were no recurrences or mesh explants at 3-year follow up.⁴ 

While the use of minimally-invasive and retromuscular approaches for hernia repair is increasing, not every patient is a great candidate for every repair. An onlay repair remains a useful tool in a surgeon’s arsenal and should be strongly considered when dealing with recurrent hernias after prior retromuscular repair.

Equipment

• Mesh-suture - #1 Duramesh mesh-suture, MSI.
• Mesh - 15 x 15 centimeter Bard Soft mesh, BD.

Disclosures

Dr. Zolin has no disclosures.

Dr. Pauli has the following disclosures: speaker for Becton-Dickinson and Medtronic, consultant for Boston Scientific Corp., Actuated Biomedical, Inc., Cook Biotech, Neptune Medical, Surgimatix, Noah Medical, Allergan, Intuitive Surgical, ERBE, Integra, Steris, Vicarious Surgical, Telabio and Mesh Suture Inc. He has royalties in UpToDate, Inc. and Springer and financial interests in IHC, Inc., Cranial Devices Inc, Actuated Medica.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

Acknowledgements

We would like to thank the patient, Angelle Steinmetz, who graciously participated in this study and wanted to be mentioned by name.