Zhang Weidong1 Wu Yanchun1 Fan Youben2 Zhang Fangfang1 Chen Jian1 Min Meilin1 Department of Surgery, Wuxi Hospital of Traditional Chinese Medicine Zhang Weidong1. Hospital of Nanjing University of Traditional Chinese Medicine Wuxi Hospital of Traditional Chinese Medicine (214001), 2. Department of General Surgery, Shanghai Sixth People’s Hospital Abstract: Objective To explore the predisposing factors, pathogenesis and prevention methods of incisional hernia of the abdominal wall. Methods The clinical data of 26 patients with giant abdominal wall incisional hernia admitted from October 2000 to September 2005 were retrospectively analyzed. Results All cases underwent tension-free repair of giant incisional hernia with patch, including 17 cases with Marlex mesh and 9 cases with composite patch (Composix patch), and the whole group was discharged with no serious complications, with a follow-up of 6~35 months and an average of 26 months without recurrence and satisfactory results. Conclusion Increased intra-abdominal pressure, postoperative incisional infection and irregular surgical operation are the main reasons for the occurrence of giant incisional hernia of the abdominal wall; perioperative management, including dealing with the adverse effects of intra-abdominal pressure changes on the body, antibiotic use to actively prevent and control incisional infection, and postoperative rehabilitation guidance are the keys to prevent the occurrence of this disease and determine its treatment prognosis; the application of artificial patch for repairing giant incisional hernia of the abdominal wall is a safe, reasonable and effective treatment method. It is also the direction of development for the treatment of this disease. Keywords: abdominal wall incisional hernia; patch; hernia repair CICS: R656.2 Document ID: A Article ID: 15440Experience of remedy for abdominal giant incisional hernia by patch Zhang Wei-dong , Wu Yan-chueng , Zhang Fang-chueng , Fan You-ben , Zhang Fang-fang , Chen Jian , Min Mei-lin . Department of General Surgery, WuxiHospitalof Traditional Chinese Medicine ofNanjingUniversityof Traditional Chinese Medicine,Wuxi214001, China Abstract: [Objective] To explore the etiology , prevention and treatments of abdominal giant incisional hernia (AGIH). [Methods] The clinic data of 26 cases with AGIH treated in our hospital from Oct.2000 to Sep.2005 were analyzed retrospectively. [Results] All the cases All the cases were successfully treated by using tension-free herniorrhaphy with the Patch, 17 of them chose the Composix patch ,and 9 chose the Marlex patch. None of the cases recurred during a follow-up of 6 to 35 months and the effect was satisfied The increase of intra-abdominal pressure, the infection of incision and the irregular operation are the main reasons of AGIH; The perioperative management is of great importance to the prevention and prognosis of AGIH , it mainly includes the management of adverse effects to the body because of the changes of intra-abdominal pressure , the use of prophylactic antibiotics to prevent incisional infection and the education of postoperative convalesce guide; Repairing AGIH with artificial patch is a safe, rational and effective measure, also the direction indicator of AGIH Key Word: abdominal incisional hernia; patch; herniorrhaphy Incisional hernia is one of the common complications after abdominal surgery, with an incidence of about 2-11%, especially huge incisional hernia with a maximum diameter of hernia ring ≥10 cm, which is more difficult to treat and has a higher recurrence rate, and the initial traditional method There is a 30-50% recurrence rate after repair [1], which causes great physical pain and psychological trauma to patients, while the use of artificial patch (mesh) tension-free repair reduces the recurrence rate of incisional hernia to 0-10%. From October 2000 to September 2005, 26 cases of giant incisional hernia of the abdominal wall were treated with the composite patch (Composix patch) or Marlex mesh produced by Bard, USA, with satisfactory results, which are reported as follows: 1. Clinical data 1.1 General data The 26 patients in this group, including 14 males and 12 females, aged 39-81 years, average 65 The average age was 65 years. The diameter of the hernia ring ranged from 11 to 23 cm averaging 14.2 cm. 16 cases had initial incisional hernia and 10 cases had recurrent hernia, including one case with 3 recurrences. The type of surgical incision: median incision in 15 cases, trans-rectus abdominis incision in 9 cases, and subcostal incision in 2 cases. Causes of morbidity were increased intra-abdominal pressure due to cough, constipation and poor urination in 13 cases, incisional infection in 7 cases, diabetes mellitus in 5 cases and long-term glucocorticoid use in 1 case. The coexisting diseases included chronic bronchitis and emphysema in 16 cases, hypertension in 13 cases, prostatic hyperplasia with chronic urinary retention in 8 cases, excessive obesity in 7 cases, diabetes mellitus in 5 cases, hypoproteinemia in 4 cases, hepatic insufficiency in 2 cases, and lupus erythematosus and aspergillosis in 1 case each. The onset of disease was 1.5 to 9 months after surgery. The repair material was a composite patch (Composix patch) or polypropylene mesh (Marlex mesh) manufactured by Bard, USA. 1.2 Methods Continuous epidural anesthesia or general anesthesia was used to keep the abdominal muscles fully relaxed, and a shuttle-shaped incision was made to excise the original surgical scar and excess skin and subcutaneous tissue, and a layered incision was made to reach the anterior sheath of the rectus abdominis muscle or the fascia of the external oblique abdominal muscle to reveal the hernia sac and the hernia ring, and the hernia sac was incised The neck of the hernia sac is incised, and a free zone of at least 5 cm is separated from the peritoneum and along the circumference of the abdominal wall defect. Depending on the defect of the peritoneum, either a polypropylene mesh (Marlex mesh) or an expanded polypropylene and PTFE double-sided composite patch (Composix patch) is selected.1 If the peritoneum is intact or the hernia sac wall can act as part of the peritoneum to close the abdominal cavity smoothly, a polypropylene mesh is selected and laid flat in front of the peritoneum, behind the abdominal wall muscles, and 3-5 cm beyond the defect edge, and a 1-0 Prolene suture, the Rives-Stoppa technique, is used to close the abdominal cavity. Rives-Stoppa technique, the cut mesh is flatly U-shaped suspension sutured and fixed on the anterior and posterior sheaths of the rectus abdominis muscle or the tendon membrane of the external oblique abdominal muscle, or on the whole abdominal wall below the subcutaneous tissue, with the entry point generally 1.0-1.5 cm from the edge of the patch and the needle spacing between 0.5-1.0 cm, and finally the edge of the defect is intermittently fixed with the mesh for one week, so that the patch and the abdominal wall are “If the peritoneal defect is large and the abdominal cavity cannot be closed, the large omentum can be taken to fill the defect and fixed with the edge of the defected peritoneum to isolate the contact between the polypropylene mesh and the abdominal organs, and the above steps are repeated to complete the operation. If the peritoneal defect cannot be closed and the greater omentum cannot be utilized, an anti-adhesive expanded polypropylene and polytetrafluoroethylene double-sided composite patch (Composix patch) is selected for repair. The patch was placed flatly into the abdominal cavity first, with the Teflon surface facing the intestinal canal and the polypropylene mesh facing the abdominal wall, at least 3-5 cm beyond the edge of the defect, and the patch was sutured with 1-0 Prolene synthetic sutures in a flat U-shaped suspension and fixed to the full abdominal wall except for the skin and subcutaneous tissue, with the entry point generally 1.0-1.5 cm from the edge of the patch and the needle spacing between 0.5-1.0 cm 1.3 Results Three cases in this group had subcutaneous seroma and effusion, which were cured after repeated puncture and aspiration and pressure dressing, and the rest of the patients had one-stage wound healing and were discharged with no serious recent complications. No serious recent complications occurred; most of the abdominal drains were removed at 3~5 d, and 6 cases were removed at 7 d postoperatively due to daily drainage flow ≥20 ml. In 7 of the patients, there was a sensation of abdominal constriction and hardness, which seemed to be a foreign body pressing on the abdomen, but it did not affect life and daily work, and the above sensation disappeared after 18 months. 2. Discussion 2.1 Pathogenetic factors The occurrence of incisional hernia of the abdominal wall is closely related to the systemic and local factors associated with the original surgery and the medical factors caused by the surgery. The occurrence of incisional hernia in the abdominal wall is closely related to the systemic and local factors associated with the patient at the time of the original surgery and the medical factors caused by the surgery. The older the patient is, the more coexisting diseases there are, the worse the tissue regeneration capacity and the lower the wound healing capacity, increasing the chance of incisional hernia formation [2]. ② The local factors for the occurrence of incisional hernia are mainly local injury to the abdominal wall caused by surgery, hematoma formation and infection, of which infection is the most critical. The occurrence of 7 cases in our group was related to incisional infection. ③Surgical operations: burns to the peri-incisional tissues caused by the widespread use of electric knife, damage to blood vessels and nerve tissues caused by rough clamping, large ligatures, and forced pulling, as well as improper suture selection, lack of suture technique, and poor tissue alignment, which affect the wound healing ability, or excessive tension in the incision and failure to use a reduction suture, resulting in reduced strength of the abdominal wall after suturing, are all medical factors for the occurrence of incisional hernia. ④ Poor anesthesia and reluctant closure of the abdomen: excessive tension of the surgical incision can easily lead to incisional suture cutting and tearing of the abdominal wall tissue. ⑤ Factors of increased intra-abdominal pressure after surgery: slow recovery of intestinal function or abdominal distension, intestinal paralysis, frequent vomiting after surgery; patients with prostatic hyperplasia and chronic constipation, forceful urination and defecation after surgery; persistent cough caused by old chronic branch, emphysema, asthma and lung infection, etc., can cause increased intra-abdominal pressure, leading to suture cutting and tearing, tissue tearing and incisional hernia. (6) Incision type and suturing method: longitudinal incision is prone to damage the neurovascular and transverse abdominal muscles of the abdominal wall, so the incidence of hernia is higher than that of transverse incision; the upper abdomen is subjected to higher abdominal pressure, so the incidence of hernia in the upper abdominal incision is higher than that in the lower abdomen; interrupted suturing is better than continuous suturing because if one of the sutures is detached or broken in continuous suturing, it is prone to splitting of the whole abdominal wall, while interrupted suturing can avoid this situation. 2.2 Advantages of hernia patch repair Once an incisional hernia occurs, it only tends to continue to increase in size and rarely heals on its own. According to the principle of hernogenesis, a hernia must have an incisional abdominal wall defect, and reinforcing and enhancing the abdominal wall defect with a patch is in accordance with the principle of tension-free repair of incisional hernia, so large or huge incisional hernia and recurrent incisional hernia are treated with patch repair with the best efficacy [3]. The advantages are as follows: (i) tension-free or reduced-tension repair, strengthening the thin tendon sheath or tendon membrane with a patch, avoiding tension sutures to cut the tissue and tension pain, and preventing postoperative recurrence. ②Light postoperative pain, fast recovery, free to get out of bed after 12 h, and discharge from hospital in about a week. ③Low recurrence rate and few complications. ④Avoid taking autologous femoral tendon membrane, which increases the trauma and pain of patients. ⑤ The patch is a polypropylene or double-sided material compounded with PTFE, which has good flexibility and tissue compatibility, high tension strength, can be cut arbitrarily, no rejection reaction, polymorphonuclear granulocytes can freely enter and exit, bacteria are not easily adhered, has a certain anti-infection ability, even if infection occurs, it does not necessarily need to be removed [4]; at the same time, the polypropylene surface also has the ability to allow the circulation of body fluids, stimulate the fibroblastic tissue to grow into the patch. At the same time, the polypropylene surface also has the characteristics of allowing the flow of body fluids and stimulating the growth of fibrous granulation tissue into the patch to form a local “reinforced cement” structure [5], which helps to reduce infection and recurrence, while the PTFE surface has the function of preventing adhesions between the intra-abdominal organs and the patch. (6) It is especially suitable for huge or recurrent incisional hernia cases. Seven cases in our group were multiple recurrent incisional hernias with up to four operations. The results of treatment with this procedure were satisfactory, with no recurrence at 35 months of follow-up, avoiding the difficulties and pain of reoperation. (7) With the maturity of laparoscopic technology, laparoscopic repair of giant incisional hernia with patch [6] has been gradually carried out in clinical practice, which has the advantages of less trauma, less pain, faster recovery, shorter hospital stay, lower recurrence rate, and almost no serious complications compared with open surgery, achieving a truly minimally invasive effect. 2.3 Preoperative preparation Incisional hernia of the abdominal wall is common in the elderly, who mostly have muscle atrophy, tendon and fascia relaxation degeneration, and with coexisting diseases such as cardiopulmonary decompensation, old and slow branch, diabetes mellitus, hypoproteinemia, prostatic hyperplasia and chronic constipation. Therefore, for huge incisional hernia, adequate preoperative preparations should be performed, including: ① Obese patients should appropriately restrict caloric intake and strengthen exercise to reduce body weight. ② Performing abdominal dilation and increasing abdominal muscle compliance training: patients with long-term giant incisional hernia are basically adapted to the double abdominal low abdominal pressure formed by the hernia, and once the hernia contents are retracted into the abdominal cavity, it will lead to a sudden increase in intra-abdominal pressure and diaphragm uplift, which can lead to acute cardiopulmonary failure in severe cases [7]. During the period of 2-3 weeks before surgery, the abdominal volume can be gradually restored by means of hernia retraction, abdominal pressure bandaging, and artificial pneumoperitoneum, which can, on the one hand, increase the shrunken abdominal volume, improve the compliance of the abdominal wall muscles, and allow patients to adapt to the feeling of abdominal constriction, and on the other hand, promote patients to be able to adapt to the high abdominal pressure state after surgery and prevent accidents. ③Improve the patient’s general condition and perform appropriate exercises to improve cardiopulmonary function. ④Correct and control the comorbidities: keep the bowel and stool unobstructed, abstain from smoking for 2 weeks before surgery, control cough, asthma, respiratory infection, correct blood sugar, hypoproteinemia, improve liver and kidney function, etc. ⑤ Pay attention to the local skin preparation of the incision to prevent postoperative incisional infection; ⑥ Grasp the timing of surgery: after incisional hernia formation, the tissue at the edge of the hernia ring has to go through a remodeling period before it can reach a certain toughness and withstand a certain tension, and this process takes about 6 months or more, so do not rush to surgical repair unless there are special circumstances; ⑦ Fully understand the condition of the hernia ring: do a good physical examination before surgery to clarify the 2.4 Surgical precautions Surgical operation technique is an issue that should not be neglected and is directly related to the quality of surgery, patient’s recovery and postoperative recurrence, etc. The following matters should be noted: ① Electrocoagulation should be used to stop bleeding as much as possible during surgery, no large ligatures should be made, and if there are threads left over from the previous surgery, they should be removed thoroughly to prevent postoperative infection and sinus tracts. In case of threads left over from the previous surgery, they should be completely removed to prevent postoperative infection and sinus tract formation. (2) If intraoperative adhesions of hernia contents with the hernia sac and hernia ring are found, the adhesions need to be separated, and the separation should be 3-5 cm beyond the edge of the defect; at the same time, the hernia ring edge tissues in giant incisional hernia of the abdominal wall are mostly uneven, uneven in thickness and strength, and should not be overly trimmed intraoperatively to avoid enlargement of the defect and destruction of the hernia ring tissues, which will increase the difficulty of repair. If the peritoneum is intact or the hernia sac wall can act as part of the peritoneum to close the abdomen smoothly, then inexpensive polypropylene mesh can be used for repair; if the peritoneal defect is large and cannot be closed, large omentum can be used as an isolator between the polypropylene mesh and abdominal organs because it has good effects of preventing intestinal adhesions, absorbing subcutaneous exudate leaking from the mesh hole, preventing the formation of subcutaneous fluid and wound infection. In this group of 9 patients, no subcutaneous fluid, wound infection, intestinal obstruction or intestinal fistula occurred with this procedure; if the peritoneal defect was large, the large omentum could not be utilized, and the abdominal cavity could not be closed smoothly, an anti-adhesive expanded polypropylene and PTFE double-sided composite patch (Composix patch) was selected for repair. ④ Select a patch of appropriate size, with the perimeter of the patch extending at least 5 cm beyond the edge of the abdominal wall defect. ⑤ It is most reasonable to place the patch behind the muscular layer of the abdominal wall and in front of the peritoneum, because in this position, the mesh is pressed against the posterior abdominal wall by intra-abdominal pressure, which directly blocks the impact of intra-abdominal pressure on the abdominal wall and facilitates U-shaped suturing and “double concentric circle-like “The intra-abdominal organs are not easy to pass out from between the sutures. (6) Using a 1-0 nonabsorbable synthetic suture, the patch is fixed with a flat, U-shaped suture at a needle spacing of 0.5-1.0 cm, with the point of entry 1.0-1.5 cm from the edge of the patch; the final defect edge is then fixed with a polypropylene mesh interrupted for one week, so that the patch is fixed to the abdominal wall in a “double concentric circle pattern”, which disperses This can disperse the tension of the abdominal wall and enhance the strength of the abdominal wall after repair, which is conducive to improving the success rate of surgery. (7) The polypropylene mesh surface should not touch the abdominal organs, and the sutures should be fixed on the polypropylene mesh surface and should not penetrate the smooth PTFE surface of the composite patch, otherwise the smooth PTFE surface will be destroyed and intestinal adhesions or even intestinal perforation will be easily formed. (8) After complete hemostasis, two negative pressure drains were placed between the patch and the subcutaneous tissue layer, and another hole was poked above and below the incision to lead to extracutaneous fixation to keep it unobstructed and sterile, and the negative pressure drains were observed for 3~5 d after pressure bandaging of the abdominal wall, and the drains could be removed only after no accumulation of fluid. If blood or fluid accumulation occurs after removal of the tube, puncture and aspiration, drainage and pressure bandaging should be performed in a timely manner, and skin drainage should not be cut to avoid increasing the chance of infection and leading to surgical failure. 2.5 Prevention of incisional hernia The causative factors of incisional hernia of the abdominal wall are closely related to the systemic and local factors of the patient at the time of the original operation. The prevention of incisional hernia is important, and the key lies in the correct treatment and rehabilitation guidance during the perioperative period according to the etiology: (1) preoperative active treatment of the primary disease and concomitant diseases, control of blood pressure and blood sugar, improvement of the respiratory tract, and keeping the bowel and stool unobstructed, etc. ② Strict aseptic operation during surgery, effective protection of the tissues around the incision, avoiding contamination of gastrointestinal contents and lesion contents as much as possible, and using effective antibiotics intraoperatively and postoperatively to prevent the occurrence of incisional infection, which is the primary condition to prevent the formation of incisional hernia. We advocate that antibiotics should be pushed intravenously for 30 min before surgery and repeatedly strengthened intraoperatively so that the effective drug concentration is always maintained in the tissues around the incision to reduce the chance of incisional infection; for patients with obvious contamination of the surgical area, antibiotics should be selected according to bacterial culture and drug sensitivity results after surgery, and necrotic tissues and hematomas in the surgical field must be completely removed, which is beneficial to wound healing and can also reduce the postoperative incision infection rate and ultimately also reduce the formation of incisional hernia. ③ The surgical incision should not be too long if allowed, and a transverse incision should be used to open the abdomen as much as possible to avoid cutting the lateral traveled peritoneum, muscle fibers and the nerves between them. ④ Anesthesia requires complete muscle relaxation and strives to achieve tension-free sutures. When closing the abdomen, the anatomical level should be clear, the sutures should be proper, so that they are sparse, loose and tight, and enough tissues are sutured to achieve the corresponding tension after knotting; if the patient is obese, has tension in the abdominal wall incision or has a weak constitution and poor tissue healing ability, the sutures should be added for tension reduction. ⑤ Postoperative perioperative management is also quite important. Special attention should be paid to the treatment of constipation, dyspareunia and chronic respiratory diseases in patients, especially in elderly patients, with frequent turning and patting of the back, antiemetic, reducing the chance of pulmonary infection, and assisting patients to successfully complete their first bowel movement. (6) Encourage patients to move appropriately early to promote recovery of intestinal function and reduce gastrointestinal distention. (7) When patients show increased intra-abdominal pressure such as coughing and vomiting, in addition to active symptomatic treatment, patients and their families should be instructed to pay attention to the protection of the incision, and they can use both hands to hold the incision internally to reduce the tension that the incision is under [8]. (8) For patients with poor nutrition or combined hypoproteinemia, from the beginning of the perioperative period to the postoperative recovery period, the application of TPN and EN should be strengthened to supplement sufficient energy, vitamins, trace elements, and protein to improve the patient’s physical condition, enhance immunity, and promote wound healing as much as possible. ⑨ When there is infection or fluid accumulation in the incision, change the medication and drainage in a timely manner, remove necrotic tissue, and delay the removal of stitches. ⑩Because within 1 year after surgery, the incision is still in the period of repairing and remodeling of the injury, and increasing intra-abdominal pressure at this time may easily lead to incisional hernia [9], it is best to use a lap band with appropriate pressure for 3-6 months after surgery, pay attention to the factors that prevent increasing abdominal pressure, and try to avoid physical activities that increase intra-abdominal pressure, etc.