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Evaluation of Double Mesh Modification of Chevrel’s Technique in Management of Midline Incisional Hernia

Hazem Nour, Hany Mohamed, Mohamed Farid                   

Department of General Surgery, Faculty of Medicine, Zzagazig University, Egypt.

Correspondence to: Dr. Hazem Nour, Email: Hzm_nr@yahoo.com

Received: 01 October 2019; Revised: 30 January 2020; Accepted: 15 April 2020; Available online: 29 May 2020

 

Abstract

Background: Chevrel’s technique provides tension-free repair of midline incisional hernia, but wide skin and subcutaneous dissection increases rate of complications. Here, we evaluate the double mesh modification of Chevrel’s technique in midline incisional hernia repair. Methods: 22 patients with midline incisional hernia underwent double mesh modification of Chevrel’s 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 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, and 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 observed 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. 2021;18(1):18–22

DOI: http://dx.doi.org/10.4314/aas.v18i1.4

Conflicts of Interest: None

Funding: None

© 2021 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.

Introduction

Incisional hernia represents the most frequent late complication of abdominal surgery, occurring in 2–23% of all laparotomies, representing about 10% of all abdominal hernias (1-2). This rate increases in the presence of systemic or local risk factors. Not even the laparoscopic approach is 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 by 3% to 27% (5-8). Different techniques with different sites for prosthetic mesh placement exist, such as premusculo-aponeurotic position (onlay and Chevrel’s technique) (4,8-11), 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, wound complications and bulging of the lateral abdominal wall (15-17).

Chevrel’s technique entails dissecting 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 technique offers tension-free repair of midline incisional hernia without far-lateral dissection of skin and subcutaneous tissue, decreasing the rate of skin necrosis and recurrence.

Methods

This study is a clinical trial carried out between January 2017 and December 2018 on 22 patients with midline incisional hernia. Hernioplasty was 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 was to evaluate the efficacy of double mesh modification of Chevrel’s technique in treatment of midline incisional hernia. The primary outcome of this study was hernia recurrence (detected by clinical and abdominal wall ultrasound examination), and necrosis of the midline wound edges (detected by clinical examination). Seroma, wound infection, and chronic pain, corsage feeling were considered secondary outcomes. Follow-up was carried out in outpatient clinic visits by a working team member, one week after discharge, after 3 months, and later every 6 months.

Exclusion criteria were American Society of Anesthesiologists (ASA) physical status class 3 and 4, inflammatory bowel disease, urgent settings recurrences and previous abdominal neoplasms with high risk of local recurrence (rectal cancer) and pediatric patients. Written informed consent was obtained from all patients participating in the study. The study was approved by the institutional review bo