Page 333 - Prevention and Treatment of Incisional Hernia- New Techniques and Materials

An additional e ect in reducing IH might come from in uencing patient-related factors. Unfortunately, it is not (yet) possible to in uence genetic susceptibility, or the connective tissue disorders that increase the risk of IH in some patients. However, in uencing co-morbidities, nutritional status, and lifestyle choices is possible. As physicians, we should try to optimize patient factors that in uence wound healing positively and negatively before performing surgery. In collaboration with other medical specialists, diabetes regulation should be optimized to improve wound healing; steroid use should be critically evaluated; and chronic pulmonary obstructive disease (COPD) and other lung pathologies should be optimized to minimize postoperative coughing, risk of pneumonia, and steroid use. Furthermore, the patient’s nutritional status should be evaluated in collaboration with a dietician. Optimization of metabolic state prior to major surgery leads to improved surgical outcomes by improving both wound healing and immune function(15). Patients with severe malnutrition and gastrointestinal dysfunction may bene t from preoperative parenteral nutrition. In morbidly obese patients, weight loss should be encouraged before elective surgery, since obesity is a risk factor for the development of IH(16-18). Lifestyle counselling should be provided, and patients should be strongly recommended to stop smoking – smoking is a risk factor for IH, has a detrimental e ect on wound healing, increases the risk of surgical site infection, and is associated with increased coughing(19-21).
An IH generally tends to become symptomatic and require treatment(22). For small and medium-sized hernias, the superiority of open mesh repair over suture repair has been proven by recurrence rates(23-25). However, for large hernias (over 10 cm in diameter), no consensus currently exists. The systematic review performed on the treatment of large ‘giant’ IHs revealed the best results for open repair with mesh in the sublay position. Large IH repair often requires some form of components separation technique (CST). During CST, the blood supply of the abdominal wall by the epigastric perforating arteries is endangered. Damage to these arteries may jeopardise the blood supply to the skin (which then depends solely on blood ow from the intercostal arteries) and thus interfere with wound healing and increase the risk of infection (26- 28). Furthermore, the intercostal arteries might have been damaged during former operations, giving rise to even more complications(26, 29). With this in mind, new endoscopic CST, minimally invasive CST, and posterior CST
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General discussion and future perspectives
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