Page 100 - Postoperative Intra-Abdominal Adhesions- New insights in prevention and consequences
P. 100

                                Chapter 6
Introduction
Incisional hernia remains a major clinical problem for 2-20% of all patients undergoing abdominal surgery [1, 2]. Even higher incidences reaching 30-37% are reported among obese and aortic aneurysm patients [3, 4]. Despite the high frequency of incisional hernia operations long-term results remain disappointing. Burger et al reported 10-year recurrence rates after primary suture repair up to 63% and after mesh repair up to 32% [5]. In addition, the recurrence rates increase after each reoperation, underscoring the importance of the best evidence- based method at the first operation [6].
In recent years, laparoscopic incisional hernia repair has shown increased popularity. Although laparoscopic repair offers no advantages in terms of recurrence rates, it may be associated with a shorter hospital stay, lower perioperative complication rates, and a shorter mean operation time than open repair [7-9]. In laparoscopic hernia repair direct contact between prosthesis and the abdominal viscera is inevitable. This contact may lead to an inflammatory reaction resulting in abdominal adhesion formation[10], which can induce small bowel obstruction [11], chronic pain [12], infertility, enterocutaneous fistulas [13] and difficulties at reoperation [14]. The latter is illustrated by Halm et al showing that 21% of patients with an intraperitoneal polypropylene mesh required small bowel resection for entrance to be gained entrance into the abdomen at reoperation[15].
Currently, a wide variety of synthetic and biologic hernia reinforcement materials is available on the market, complicating the selection of an appropriate prosthesis [16, 17]. The most commonly used meshes are made of polypropylene. This material is relatively inexpensive, easy to handle and does incorporate well into the abdominal wall. However, when placed in contact with the abdominal viscera polypropylene meshes may be associated with severe adhesion formation [15]. Therefore intraperitoneal utilization should be avoided [18]. Alternatives can be found in composite and biologically derived prosthesis. Composite meshes consist of a synthetic material and an anti-adhesive layer or
98





























































































   98   99   100   101   102