Page 176 - Prevention and Treatment of Incisional Hernia- New Techniques and Materials

Chapter 8
was 0.4%, increasing to 5.4% in patients with a complex LIH. The mortality after simple LIH repair is comparable to mortality of small incisional hernia repair (ranging 0.16-0.4%)(87-89). In patients with simple LIH or small hernias the cause of death is generally of cardiovascular origin. Patients with complex LIH frequently generally have more co-morbidities and mortality is related to multi-organ failure, bowel necrosis, bowel obstruction, mesh infection and sepsis(9, 31, 43, 45, 57, 62, 64).
Wound complications
Infection, seroma, hematoma and skin necrosis were observed frequently after LIH repair. Between simple and complex LIH a sizeable di erence in wound complications was found. The degree of intra-operative contamination increases the risk of prosthetic infection and often results in a chronic a ection with sinus formation or loss of prosthesis. For these reasons, the majority of patients with a complex LIH were repaired with an open technique without mesh implantation and overall wound complications for these techniques ranged between 13 and 48%. One of the more frequently used open non- mesh techniques in common practice is the CST. During CST the blood supply of the abdominal wall by the epigastric perforating arteries is endangered. Damage to these arteries may endanger the blood supply of the skin (then only depending on blood ow from the intercostal arteries) and interfere with wound healing and increase the risk of infection (6, 31, 90). Furthermore, the intercostal arteries might have been damaged during former operations, giving rise to even more complications(11, 90). Therefore, new endoscopic CST, minimally invasive CST and posterior CST have been developed and promising results of reduced wound infections and necrosis have been described(58-61).
Pulmonary complications
Postoperative pulmonary complications after LIH repair, such as insu ciency and pneumonia, were reported frequently, sometimes requiring reoperation or prolonged ventilatory support up to two weeks(9, 66). In patients with LIH lateral migration of the rectus muscles in conjunction with ank muscle contraction leads to a progressive decrease in the volume of the abdominal cavity and worsening protrusion of the viscera. Repositioning the viscera in a sti abdominal cavity can lead to decreased perfusion of the intestine and elevation of the diaphragm, which in turn can lead to ventilatory di culties
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