Modied Technique for Repairing Large Incisional Hernias S. Katsaragakis, A. Manouras, K. M. Stamou and G. Androulakis From the A’ Propaedeutic Surgical Clinic, Ippokrateion Hospital, Athens, Greece Eur J Surg 2001; 167: 458–460 INTRODUCTION About 1.7% of all abdominal wall hernias are incisional hernias and they have an expected incidence of 2–5% in uncomplicated abdominal operations which rises to 10%–15% in operations complicated by infection. It is estimated that incisional hernias will complicate 9% of all major abdominal operations and 30% of these hernias show thenselves within the rst 30 postoperative months (1, 5). Risk factors for hernia occurrence are infection and wound dehisence, length of the primary incision, and the use of corticoids during primary operation; in addition, obesity, postoperative cough or high intra-abdominal pressure, and technical errors all predispose to the development of a post- operative incisional hernia (3, 6). Large incisional hernias, apart from physical dis- comfort and deformity, are the cause of “Eventration Disease” according to Rives (8), which induces multi- ple symptoms from different systems. Important symptoms derive from pulmonary dysfunction, but symptoms from the gastrointestinal tract, skeletal pain and abdominal skin atrophy are not to be under- estimated. Patients operated on for a large abdominal wall hernia face a high incidence of postoperative morbidity, mainly from pulmonary dysfunction, wound infection and the sudden rise in intra-abdominal pressure (10), despite the use of “progressive pneumo- peritoneum”, which is a useful technique for preparing patients with large abdominal hernias. Many techniques have been used for repairing these large hernias but recurrence rates remain high, reaching 50% for the Mayo procedure (2, 7). The use of synthetic materials improved the recurrence rates but the results are not yet wholly satisfactory (4). Large incisional hernias pose a challenge in their repair technique and demand a thorough preoperative evaluation of the patient as regards respiratory func- tion, prophylaxis of deep venous thrombosis and infection. Any postoperative complication might jeo- pardise the outcome. METHODS The main technical challenge in repairing an incisional hernia is the approximation of the separated abdominal wall hemispheres and their tension-free suture. The use of non-absorbable mesh is inevitable but raises two issues in the procedure: the protection of the viscera from straight contact with the mesh, and the possible contamination and inammation of both the subcuta- neous tissue and the mesh. If either occurs, the success of the repair is threatened and the risk of postoperative morbidity increases. Rives et al. (8), and Stoppa (9) proposed placing the mesh within layers of the rectus sheath in order to protect both mesh and viscera. Our technique follows the same principles, and introduces the use of the hernia sac as suturing material for the protection of the mesh. According to our technique: The perimeter of the sac is carefully dened and dissected in the midline. The peritoneal cavity is then reached and adhesions separated. (Fig. 1). The rectus sheath is then opened in its posterior border on one side and in its anterior border on the opposite side, so that the divided sac is retained as an extension of the posterior lamina of the rectus sheath on the one side and as an extension of the anterior lamina of the rectus sheath on the opposite side (Fig. 2). The posterior lamina of the rectus sheath is sutured to the retained hernial sac on the opposite side (Fig. 3). The mesh is placed and sutured on the posterior layer of the sheath (Fig. 4). Finally, the anterior lamina of the rectus sheath is sutured to the retained hernia sac on the opposite side. The sac therefore covers the mesh and approximates the abdominal wall causing less tension than expected (Fig. 5). The technique was initially used for patients with more than about 300 cm 2 of hernia surface. It can be easily used for both vertical and transverse abdominal incisions as well as possibly in separations of the rectus. We used braided polyester mesh (Mersilene, Ó 2001 Taylor & Francis. ISSN 1102–4151 Eur J Surg 167 SURGICAL TECHNIQUE