Page 178 - Prevention and Treatment of Incisional Hernia- New Techniques and Materials

Chapter 8
In the vast majority of articles recurrence was determined by physical examination. The use of radiological examination in the diagnosis of hernias is very useful in obese patients and for the detecting of smaller hernias. The sensitivity and speci city of ultrasonography and CT-scan for incisional hernias is very high(95). Since radiological examination was not standard performed the recurrence rates might be underestimated.
Another limitation was the availability of only a few prospective series and mainly retrospective series for inclusion. Postoperative complications are an important outcome parameter in comparing repair techniques but are likely to be underestimated, especially in retrospective studies(96). In addition possible patient selection bias and publication bias of good results might be present. Publication bias was reduced by excluding small series. For this reason not all possible techniques for large hernia repair are covered. Recently a systematic review was published which focussed on giant incisional hernia repair techniques(97). Although some of the conclusions drawn from that paper are similar to the conclusions made in this review, there are several limitations in that study. Firstly, a de nition was used which does not correspond with the EHS guidelines. In addition, due to some of their exclusion criteria several articles were not included in their review. This resulted in them including only 14 papers whereas this review included 55. Furthermore their conclusions are based mainly on their expert opinion, whereas this study’ conclusions are based on statistical analysis with a generalized linear model.
Also, the universal lacking consensus on terminology for mesh positions and the large variety of meshes for hernia repair on the market worldwide add di culty in comparing repair techniques. Terms as ‘inlay’ ‘underlay’, ‘overlay’ and ‘subfascial’ are used without clarity about the position of the mesh to the abdominal wall. To minimize confusion the terminology proposed by the EuraHS working group was used ( gure 4)(98). The choice of mesh material in abdominal wall repair is still debatable, especially in a complex LIH or infected environment. The studies included in this review reported more frequently mesh infections for PE meshes than PP meshes in LIH. This corresponds with the increased complication rate of PE meshes in smaller incisional hernia repair(99). The high rate of ePTFE mesh infections in complex LIH was the reason for premature termination of the RCT of the Vries Reilingh et al(11). Recently, biological meshes have been introduced into LIH repair which might induce better results with regards to infections and incorporation. The rst
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