Evaluation of double mesh modification of Chevrel’s technique in management of midline incisional hernia
Hazem Nour, Hany Mohamed, Mohamed I Farid.
Department of General Surgery, Faculty of Medicine, Zzagazig University, Egypt.
Hazem Nour, Department of General Surgery, Faculty of Medicine, Zzagazig University, Egypt.
Background: Chevrel technique provides tension free repair of midline incisional hernia, but wide skin and subcutaneous dissection increases complications rate, here we are evaluating the double mesh modification of Chevrel technique in midline incisional hernia repair. Patients and methods: 22 patients with midline incisional hernia underwent double mesh modification of Chevrel technique, after excision of hernial sac with minimal dissection of the skin and subcutaneous tissue, the anterior rectus sheath is incised on both sides to create a medial flaps that are sutured to each other, both recti abdominis muscles were dissected off the posterior rectus sheath opening the retrorectus space , prolene mesh was fixed in the retrorectus space with prolene sutures, then a prolene mesh was tailored to cover the bare area of anterior surface of both recti muscles, and fixed to the lateral flaps of the anterior rectus sheath with interrupted prolene sutures . Results: We got no recurrences, no skin necrosis, two cases of seroma, one case of superficial wound infection and one case of temporary chronic pain. Conclusion: Double mesh modification of Chevrel technique is an efficient method for treatment of midline incisional hernia with minimal surgical site occurrences.
Keywords: Chevrel technique, double mesh technique, midline incisional hernia.
Ann Afr Surg. ****; **(*):***
Conflicts of Interest: None
© 2020 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.
Incisional hernia represents the most frequent late complication of abdominal surgery, occurring in 2–23% of all laparotomies it represents about 10% of all abdominal hernias (1-2). This rate increases in the presence of systemic or local risk factors, even; the laparoscopic approach is not free from this event (0.8–1.2%) (3-4).
Recurrence rate of incisional hernia is always a serious problem, the introduction of mesh repair, while reducing the recurrence rate to 0-10% increased wound complications, ranging between 3% and 27% (5,6, 7- 8).
Different techniques with different sites for prosthetic mesh placement do exist such as; premusculo-aponeurotic position (onlay, and Chevrel’s technique) (4, 8, 9, 10- 11), retromuscular-prefascial and preperitoneal (Rives technique, Stoppa technique) (4, 8, 12-13). Intraperitoneal insertion can be done via open or laparoscopic approach (2, 4, 6- 14).
In large hernias, sublay position is frequently used in combination with other repairs such as the (endoscopic) anterior or posterior component separation technique (15-16). These techniques require dissection beyond the lateral border of the rectus muscles, increasing the risk of damage to the perforating epigastric arteries and nerves, increasing wound complications and bulging of the lateral abdominal wall (15- 17).
Chevrel’s technique entails dissection of the skin and subcutaneous tissue beyond the lateral border of the anterior rectus sheath increasing the risk of skin necrosis and seroma formation (15).
Our modification of Chevrel’s techniques offers a tension free repair of midline incisional hernia without far lateral dissection of skin and subcutaneous tissue decreasing rate of skin necrosis and rate of recurrence.
This study is a clinical trial carried out in the period between January 2017 and December 2018, on 22 patients with midline incisional hernia, hernioplasty performed using the double mesh modification of Chevrel’s technique, and all the procedures were performed by the same group of surgeons.
The objective of this study is to evaluate the efficacy of double mesh modification of the Chevrel’s technique in treatment of midline incisional hernia, the primary outcome of this study is hernia recurrence (detected by clinical and abdominal wall ultrasound examination), and necrosis of the midline wound edges (detected by clinical examination), seroma, wound infection, chronic pain, corsage feeling are considered as secondary outcome. Follow up was carried out on outpatient clinic visits by a working team member, one week after discharge, after 3 months, and later on every 6 months.
The exclusion criteria were;
American Society of Anesthesiologists (ASA) class 3 and 4.
Inflammatory bowel disease.
Recurrences and previous abdominal neoplasms with high risk of local recurrence (rectal cancer).
A written informed consent was obtained from all patients participating in the study.
The study was approved from IRB (institutional review board) and the ethical committee of our university hospital. Also, study is registered in clinical trials under identifier number; NCT04166201, there is no conflict of interest.
All the patients received an intravenous antibiotic prophylaxis with subcutaneous administration of fractionated heparin before surgery when indicated.
All the patients were operated on with the double mesh modification of Chevrel’s technique. The previous scar was excised then, dissection of the subcutaneous space was performed deep to the neck of the hernia, not wider than 1cm from the edges of the defect, then the sac was opened and resected, the defect size was measured, the skin and subcutaneous tissue was dissected off the anterior rectus sheath only allowing dissection of an anterior rectus sheath flap just sufficient to close the defect without tension (figure 1).
After that a bilateral longitudinal incisions was done on the anterior surface of the anterior rectus sheath and a medial anterior rectus sheath flap was dissected off the rectus abdominis muscle, both recti muscles were dissected off the posterior rectus sheath opening the retrorectus space, each of the medial anterior rectus sheath flaps was sutured to its fellow of the other side with slowly absorbed sutures closing the defect without any tension and reforming the posterior rectus sheath, (figure 2 and 3).
A sizable prolene mesh was fixed with prolene sutures in the retrorectus space spreading between lateral ends of the space and tunneled up 4 cm in the retrorectus space far from vertical edges of the defect, figure 4. Then the anterior rectus sheath was closed using a prolene mesh tailored to the size of the space between the lateral flaps of both sides and sutured to the edges of the lateral flaps with interrupted non-absorbable sutures figure 5.
The whole technique is illustrated in figure 6, a suction drain is left in site, subcutaneous tissue was closed with Vicryl (3\0), skin was closed with prolene (3\0), drain was removed when the amount of drainage is below 30 ml \ day.
All patient’s data including demographic data, preoperative investigations, operative findings as defect size, operative time, and follow up data as; early postoperative findings as skin edges viability, wound infection, seroma and early hernia recurrence, late postoperative findings as late hernia recurrence. All were collected, properly presented and analyzed using the SPSS package 22.
In our study we got 22 patients with mid line incisional hernia (figure 7, 8 before and after repair), all underwent double mesh modification of Chevrel’s technique.
The mean patient’s age was 52.36 ± SD 8.7 years, 12 were male and 10 females, BMI mean 30.1 ± SD 2.8. Two of the patients were diabetic and two were receiving anticoagulant therapy. Demographic data and associated diseases presented in table 1.
The intraoperative findings (defect size and multiple defects encountered during surgery) recorded in table 2, the sizes of defects ranged between 2.5cm and 13 cm the mean diameter was 8.4cm ± SD =2.8 cm, multiple defects found in 8 patients, dermolipectomy was done in 3 patients and the operative time ranged between 95 minutes and 140 minutes with mean time 110.5 ± SD 10.7.
The follow up period ranged between 7 and 31 months with mean follow up time 23.4 ± SD 7.8 months, by that period there was no recurrence and there was no skin necrosis but we encountered seroma in 2 patients, which resolved after two times aspiration within two weeks after suction drain removal, superficial wound infection in one patient which resolved with conservative measures, chronic pain occurred in one patient and disappeared after 6 months, corsage feeling occurred in one patient and disappeared after 5 months. As shown in table 3
Incisional hernia may be a very serious and disabling disease, and even its treatment is very challenging, because improper surgery may imply a high recurrence rate (up to 50%), with unacceptable morbidity and mortality, (7,8- 9).
The Chevrel’s and onlay techniques were used to repair wide incisional hernias, both differs in terms of operative details, in the Chevrel’s technique; the defect is closed with sliding myofascial flaps obtained from incision of the anterior layers of rectus sheaths (18). A common feature of both techniques is placement of the mesh in the onlay position on the fascia (5- 19).
Previous studies reported a high wound complication rate after the original Chevrel’s technique, as well as the other onlay techniques that includes, skin necrosis, seroma formation and wound infection, which was attributed to the extensive subcutaneous dissection to facilitate overlap of the mesh beyond the lateral border of the rectus abdominis muscles. (16).
In terms of recurrence Chevrel’s technique had achieved a good outcome as the repair carries no tension on the closure of the hernial defect, in our study we offered a double mesh modification of Chevrel’s technique , in both sublay and onlay positions with minimal dissection of skin flaps, and we obtained a good results in the follow up time, as the rate of seroma formation, superficial wound infection even in the presence of DM or anticoagulant therapy, is comparable to the study of Köckerling (19), on Chevrel’s technique, also the corsage feeling and chronic pain which disappeared after 6 months were close to the results of most of the studies on that issue.
The most important results we achieved throughout this technique is the zero recurrence rate in the period of follow up, this may be due to the augmentation of the newly formed posterior rectus sheath with non-absorbable mesh in the sublay position together with the onlay mesh sutured to the edges of the anterior rectus sheath covering the dissected surface of the rectus abdominis muscle , this double mesh technique offers tension free repair of the wide incisional hernia defects and avoids the future need for augmentation of the widened newly formed posterior rectus sheath, as in the study of Mummers et al.in 2016 (16) .
Mladenovikj et al (20), reported skin necrosis 4 %, here in our study we have no skin flap necrosis this may be due to the minimal dissection of the skin and subcutaneous tissue from the anterior rectus sheath thus preserving blood vessels supplying the skin.
In conclusion we can say that double mesh modification of Chevrel’s technique offers an efficient tension free repair with low complications rate, for treatment of midline incisional hernia.
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