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Best Practice Management of Incisional Hernia

Kevin Sexton Bonus Conference February 2013

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Disclosure: None for this presentation.

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Incisional hernia is any gap in the abdominal wall with or without a bulge in the area of a postoperative scar that can be seen or palpated on clinical exam or imaging.

Sanders DL, Kingsnorth AN. The modern management of incisional hernias. BMJ 2012;344(may09 1):e2843–3.

herniagigante.com

A gentleman is someone who owns land. -Tarp

Definitions:

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Is timing important? What separates incisional hernia from dehiscence?

Sanders DL, Kingsnorth AN. The modern management of incisional hernias. BMJ 2012;344(may09 1):e2843–3.

herniagigante.com

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Risk ??%

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Incidence 3-60%

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1. de Vries Reilingh TS, van Goor H, Rosman C, et al. “Components separation technique” for the repair of large abdominal wall hernias. J Am Coll Surg 2003;196:32–37. 2. Dumanian GA, Denham W. Comparison of repair techniques for major incisional hernias. Am J Surg 2003;185:61–65. 3. Dunne JR, Malone DL, Tracy JK, et al. Abdominal wall hernias: risk factors for infection and resource utilization. J Surg Res 2003;111:78–84. 4. Flum DR, Horvath K, Koepsell T. Have outcomes of incisional hernia repair improved with time? A population-based analysis. Ann Surg 2003;237:129–135. 5. Gecim IE, Kocak S, Ersoz S, et al. Recurrence after incisional hernia repair: results and risk factors. Surg Today 1996;26:607– 609. 6. George CD, Ellis H. The results of incisional hernia repair: a twelve year review. Ann R Coll Surg Engl 1986;68:185–187. 7. Goodney PP, Birkmeyer CM, Birkmeyer JD. Short-term outcomes of laparoscopic and open ventral hernia repair: a metaanalysis. Arch Surg 2002;137:1161–1165. 8. Koehler RH, Voeller G. Recurrences in laparoscopic incisional hernia repairs: a personal series and review of the literature. JSLS 1999;3:293–304.

9. Luijendijk RW, Hop WC, van den Tol MP, et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med 2000;343:392–398. 10. Manninen MJ, Lavonius M, Perhoniemi VJ. Results of incisional hernia repair. A retrospective study of 172 unselected hernioplasties. Eur J Surg 1991;157:29–31. 11. McGreevy JM, Goodney PP, Birkmeyer CM, et al. A prospective study comparing the complication rates between laparoscopic and open ventral hernia repairs. Surg Endosc 2003;10:10. 12. Paul A, Korenkov M, Peters S, et al. Unacceptable results of the Mayo procedure for repair of abdominal incisional hernias. Eur J Surg 1998;164:361–367. 13. Raftopoulos I, Vanuno D, Khorsand J, et al. Comparison of open and laparoscopic prosthetic repair of large ventral hernias. JSLS 2003;7:227–332. 14. Vrijland WW, Jeekel J. Prosthetic mesh repair should be used for any defect in the abdominal wall. Curr Med Res Opin 2003;19: 1–3.

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Average 25%

Hawn MT, Snyder CW, Graham LA, Gray SH, Finan KR, Vick CC. Long-term follow-up of technical outcomes for incisional hernia repair. Journal of the American College of Surgeons 2010;210(5):648–55–655–7.

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50% are detected within one year of initial operation. 2% risk per year after.

Mudge M, Hughes LE. Incisional hernia: a 10 year prospective study of incidence and attitudes. Br J Surg 1985;72(1):70–1. Bucknall TE, Cox PJ, Ellis H. Burst abdomen and incisional hernia: a prospective study of 1129 major laparotomies. Br Med J (Clin Res Ed) 1982;284(6320):931–3.

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348,000 repairs annually in US 154,000 inpatient ($15,900) 194,000 outpatient ($3,800) $3.2 billion in annual cost

Poulose BK, Shelton J, Phillips S, et al. Epidemiology and cost of ventral hernia repair: making the case for hernia research. Hernia 2012;16(2):179–83.

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Prevention • Continuous Closure with Running

Suture • Monofilament slowly absorbable

suture (PDS) #1 or 2 • Suture:Wound Length < 4:1

van ‘t Riet M, Steyerberg EW, Nellensteyn J, Bonjer HJ, Jeekel J. Meta-analysis of techniques for closure of midline abdominal incisions. Br J Surg 2002;89:1350-6. Hodgson NC, Malthaner RA, Ostbye T. The search for an ideal method of abdominal fascial closure: a meta-analysis. Ann Surg 2000;231:436-42. Ceydeli A, Rucinski J, Wise L. Finding the best abdominal closure: an evidence-based review of the literature. Curr Surg 2005;62:220-5

The only way not to spill water is not to carry water. -Tarp

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Stitch Length • 1 cm from edge 1 cm apart • Shorter may be better

• 5 mm bites 5 mm apart • 730 patient RCT

• Incisional hernia 6% vs 18% • SSI 5% vs 10%

Harlaar JJ, van Ramshorst GH, Nieuwenhuizen J, Ten Brinke JG, Hop WC, Kleinrensink GJ, et al. Small stitches with small suture distances increase laparotomy closure strength. Am J Surg 2009;198:392-5. Millbourn D, Cengiz Y, Israelsson LA. Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial. Arch Surg 2009;144:1056-9.

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Millbourn D, Cengiz Y, Israelsson LA. Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial. Arch Surg 2009;144:1056-9.

Complication Long Short P Wound Dehiscence

1/381 0/356 .99

SSI 35/343 (10.2) 17/326 (5.2) .02 Incisional Hernia

49/272 (18) 14/250 (5.6) <.001

Liars figure and figures lie. -Tarp

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Prediction: • SSI double the risk • Increased intrabdominal pressure

post op • Ileus, urinary retention, coughing,

vomiting, mechanical vent >48hrs • BMI • Wound Epithelialization > 16 days

Veljkovic R, Protic M, Gluhovic A, Potic Z, Milosevic Z, Stojadinovic A. Prospective clinical trial of factors predicting the early development of incisional hernia after midline laparotomy. J Am Coll Surg 2010;210:210-9.

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Hernia 603 Patients

When do we fix it?

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‣ Most frequent indication is symptomatic hernia (20 – 50%)

• Most common symptom is pain

‣ 6 - 15% for strangulation or obstruction

Sanders DL, Kingsnorth AN. The modern management of incisional hernias. BMJ 2012;344(may09 1):e2843–3. Mudge M, Hughes LE. Incisional hernia: a 10 year prospective study of incidence and attitudes. Br J Surg 1985;72(1):70–1. Kingsnorth A. The management of incisional hernia. Ann R Coll Surg Engl 2006;88(3):252–60.

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“A commonsense approach is advocated. If the patient can safely have general anesthesia and the chance of successful repair is reasonable, then surgery is indicated. If the patient presents a high anesthetic risk or surgical repair will be technically difficult, then the size of the fascial defect relative to the hernia, the symptom complex, the patient’s age, and the patient’s preferences must be carefully considered. In such cases, conservative management may be more appropriate. This decision making process is patient specific and therefore we recommend that all patients are referred for a specialist opinion.” -David Sanders and Andrew Kingsnorth

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“You need to fit your suit to the cloth.” -Tarp

How do we maximize our chances for a successful repair?

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‣ Study it like a racing card.

‣ Get in the habit of having good habits.

‣ The pleural of anecdote isn’t data.

-Tarp

Use mesh in anything > 3 cm.

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David R Flum KHTK. Have Outcomes of Incisional Hernia Repair Improved With Time?: A Population-Based Analysis. Annals of Surgery 2003;237(1):129. Luijendijk RW, Hop W, van den Tol MP. A comparison of suture repair with mesh repair for incisional hernia. NEJM 2000;

But what if I cause an enterotomy?

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Choi JJ, Palaniappa NC, Dallas KB, Rudich TB, Colon MJ, Divino CM. Use of Mesh During Ventral Hernia Repair in Clean-Contaminated and Contaminated Cases. Annals of Surgery 2012;255(1):176–80.

Data on IHR and Small Bowel Resection

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Xourafas D, Lipsitz SR, Negro P, Ashley SW, Tavakkolizadeh A. Impact of mesh use on morbidity following ventral hernia repair with a simultaneous bowel resection. Arch Surg 2010;145(8):739–44.

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Living under Damocles’ sword. -Tarp

Mesh in an infected field

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Biologic Mesh

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http://www.sageswiki.org/

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‣ Use in hernia repair in the non contaminated setting not justified due to increased cost without benefit.

‣ Ideal use as reinforcement of repair

• Don’t bridge the gap with biologic mesh

‣ Only level one study comparing mesh to tissue repair (PEH) showed no difference in recurrence at 5y. Sageswiki Oelschlager BK, Pellegrini CA, Hunter JG, et al. Biologic Prosthesis to Prevent Recurrence after Laparoscopic Paraesophageal Hernia Repair: Long-term Follow-up from a Multicenter, Prospective, Randomized Trial. Journal of the American College of Surgeons 2011;213(4):461–8. Oelschlager BK, Pellegrini CA, Hunter J, et al. Biologic prosthesis reduces recurrence after laparoscopic paraesophageal hernia repair: a multicenter, prospective, randomized trial. Annals of Surgery 2006;244(4):481–90.

Biologic Mesh Summary

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More on Biologics:

Smart NJ, Marshall M, Daniels IR. Biological meshes: A review of their use in abdominal wall hernia repairs. The Surgeon 2012;10(3):159–71.

Laparoscopic vs Open Repair

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Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez M. Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. The Cochrane Library 2011;

Laparoscopic vs Open Repair

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Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez M. Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. The Cochrane Library 2011;

Laparoscopic vs Open Repair

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Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez M. Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. The Cochrane Library 2011;

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Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez M. Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. The Cochrane Library 2011;

Laparoscopic vs Open Repair

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Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez M. Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. The Cochrane Library 2011;

‣ No clearly defined difference in long term outcomes.

‣ Lower risk of wound infection

‣ Increased enterotomies

‣ Less pain and hospital stay

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Where do I put the mesh? Onlay Inlay

Sublay Oy Vey

Sanders DL, Kingsnorth AN. The modern management of incisional hernias. BMJ 2012;344(may09 1):e2843–3.

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Technique Recurrence Notes Inlay 44% Adhesions

Erosions Not recommended

Onlay 5.5-14.8% Have to close abdominal wall

Sublay 1-23% European Hernia Society Standard

Rives Stoppa 1-8% difficult

Sanders DL, Kingsnorth AN. The modern management of incisional hernias. BMJ 2012;344(may09 1):e2843–3. Yaghoobi Notash A, Yaghoobi Notash A Jr, Seied Farshi J, Ahmadi Amoli H, Salimi J, Mamarabadi M. Outcomes of the Rives–Stoppa technique in incisional hernia repair: ten years of experience. Hernia 2006;11(1):25–9.

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‣ Hernias are common, morbid, and costly.

‣ Best chance of success is mesh repair in an uncontaminated field.

• Laparoscopic vs Open still debated

• Sublay vs Onlay

• Rives Stoppa = one shot

What can’t be cured must be endured.

“Swamp/Alligator argument” –Tarp

When you are up to your ass in alligators, it’s hard to remember you came to drain the swamp.

Summary

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American Hernia Society Quality Collaborative (AHSQC).

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Discussion

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‣ 1. Beck WC, Holzman MD, Sharp KW, Nealon WH, Dupont WD, Poulose BK. Comparative Effectiveness of Dynamic Abdominal Sonography for Hernia vs Computed Tomography in the Diagnosis of Incisional Hernia. Journal of the American College of Surgeons 2013;216(3):447–53.

‣ 2. Smart NJ, Marshall M, Daniels IR. Biological meshes: A review of their use in abdominal wall hernia repairs. The Surgeon 2012;10(3):159–71.

‣ 3. Sanders DL, Kingsnorth AN. The modern management of incisional hernias. BMJ 2012;344(may09 1):e2843–3.

‣ 4. Altom LK, Graham LA, Gray SH, Snyder CW, Vick CC, Hawn MT. Outcomes for incisional hernia repair in patients undergoing concomitant surgical procedures. Am Surg 2012;78(2):243–9.

‣ 5. Choi JJ, Palaniappa NC, Dallas KB, Rudich TB, Colon MJ, Divino CM. Use of Mesh During Ventral Hernia Repair in Clean-Contaminated and Contaminated Cases. Annals of Surgery 2012;255(1):176–80.

‣ 6. Gurusamy KS AVSK. Wound drains after incisional hernia repair. 2011;:1–21.

‣ 7. Oelschlager BK, Pellegrini CA, Hunter JG, et al. Biologic Prosthesis to Prevent Recurrence after Laparoscopic Paraesophageal Hernia Repair: Long-term Follow-up from a Multicenter, Prospective, Randomized Trial. Journal of the American College of Surgeons 2011;213(4):461–8.

‣ 8. Kulacoglu H, Oztuna D. Growth and trends in publications about abdominal wall hernias and the impact of a specific journal on herniology: a bibliometric analysis. Hernia 2011;15(6):615–28.

‣ 9. Bansal VK, Misra MC, Kumar S, et al. A prospective randomized study comparing suture mesh fixation versus tacker mesh fixation for laparoscopic repair of incisional and ventral hernias. Surg Endosc 2011;25(5):1431–8.

‣ 10. Snyder CW, Graham LA, Gray SH, Vick CC, Hawn MT. Effect of Mesh Type and Position on Subsequent Abdominal Operations after Incisional Hernia Repair. ACS 2011;212(4):496–502.

‣ 11. Harth KC, Blatnik JA, Rosen MJ. Optimum repair for massive ventral hernias in the morbidly obese patient—is panniculectomy helpful? AJS 2011;201(3):396–400.

‣ 12. Millbourn D, Cengiz Y, Israelsson LA. Risk factors for wound complications in midline abdominal incisions related to the size of stitches. Hernia 2011;15(3):261–6.

‣ 13. Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez M. Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. The Cochrane Library 2011;

‣ 14. Hartog D den DATWKR. Open surgical procedures for incisional hernias. 2010;:1–36.

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‣ 15. Verma R NR. Prophylactic nasogastric decompression after abdominal surgery. 2010;:1–50.

‣ 16. Xourafas D, Lipsitz SR, Negro P, Ashley SW, Tavakkolizadeh A. Impact of mesh use on morbidity following ventral hernia repair with a simultaneous bowel resection. Arch Surg 2010;145(8):739–44.

‣ 17. DiCocco JM, Magnotti LJ, Emmett KP, et al. Long-Term Follow-Up of Abdominal Wall Reconstruction after Planned Ventral Hernia: A 15-Year Experience. ACS 2010;210(5):686–95.

‣ 18. Hawn MT, Snyder CW, Graham LA, Gray SH, Finan KR, Vick CC. Long-term follow-up of technical outcomes for incisional hernia repair. Journal of the American College of Surgeons 2010;210(5):648–55–655–7.

‣ 19. Veljkovic R, Protic M, Gluhovic A, Potic Z, Milosevic Z, Stojadinovic A. Prospective Clinical Trial of Factors Predicting the Early Development of Incisional Hernia after Midline Laparotomy. ACS 2010;210(2):210–9.

‣ 20. Millbourn D, Cengiz Y, Israelsson LA. Effect of Stitch Length on Wound Complications After Closure of Midline IncisionsA Randomized Controlled TrialStitch Length and Midline Incision Complications. Archives of Surgery 2009;144(11):1056–9.

‣ 21. Harlaar JJ, van Ramshorst GH, Nieuwenhuizen J, et al. Small stitches with small suture distances increase laparotomy closure strength. AJS 2009;198(3):392–5.

‣ 22. Muysoms FE, Miserez M, Berrevoet F, et al. Classification of primary and incisional abdominal wall hernias. Hernia 2009;13(4):407–14.

‣ 23. Nemeth NL, Butler CE. Complex torso reconstruction with human acellular dermal matrix: long-term clinical follow-up. Plastic and Reconstructive Surgery 2009;

‣ 24. Rauth TP, Poulose BK, Nanney LB, Holzman MD. A comparative analysis of expanded polytetrafluoroethylene and small intestinal submucosa--implications for patch repair in ventral herniorrhaphy. Journal of Surgical Research 2007;143(1):43–9.

‣ 25. Kurzer M, Kark A, Selouk S, Belsham P. Open Mesh Repair of Incisional Hernia Using a Sublay Technique: Long-Term Follow-up. World J Surg 2007;32(1):31–6.

‣ 26. Bingener J, Buck L, Richards M, Michalek J, Schwesinger W, Sirinek K. Long-term Outcomes in Laparoscopic vs Open Ventral Hernia Repair. Archives of Surgery 2007;142(6):562–7.

‣ 27. Weyhe D, Belyaev O, Müller C, Meurer K. Improving outcomes in hernia repair by the use of light meshes—a comparison of different implant constructions based on a critical appraisal of the literature. World journal of … 2007;

‣ 28. Yaghoobi Notash A, Yaghoobi Notash A Jr, Seied Farshi J, Ahmadi Amoli H, Salimi J, Mamarabadi M. Outcomes of the Rives–Stoppa technique in incisional hernia repair: ten years of experience. Hernia 2006;11(1):25–9.

‣ 29. Oelschlager BK, Pellegrini CA, Hunter J, et al. Biologic prosthesis reduces recurrence after laparoscopic paraesophageal hernia repair: a multicenter, prospective, randomized trial. Annals of Surgery 2006;244(4):481–90.

‣ 30. Kingsnorth A. The management of incisional hernia. Ann R Coll Surg Engl 2006;88(3):252–60.

‣ 31. Rudmik LR, Schieman C, Dixon E, Debru E. Laparoscopic incisional hernia repair: a review of the literature. Hernia 2006;

‣ 32. Klinge U, Conze J, Krones CJ, Schumpelick V. Incisional Hernia: Open Techniques. World J Surg 2005;29(8):1066–72.

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‣ 33. Conze J, Kingsnorth AN, Flament JB, et al. Randomized clinical trial comparing lightweight composite mesh with polyester or polypropylene mesh for incisional hernia repair. Br J Surg 2005;92(12):1488–93.

‣ 34. Millbourn D, Israelsson LA. Wound complications and stitch length. Hernia 2004;8(1):39–41.

‣ 35. Sanchez LJ, Bencini L, Moretti R. Recurrences after laparoscopic ventral hernia repair: results and critical review. Hernia 2004;

‣ 36. Rutkow IM. Demographic and socioeconomic aspects of hernia repair in the United States in 2003. Surgical Clinics of NA 2003;83(5):1045–51–v–vi.

‣ 37. David R Flum KHTK. Have Outcomes of Incisional Hernia Repair Improved With Time?: A Population-Based Analysis. Annals of Surgery 2003;237(1):129.

‣ 38. Bencini L, Sanchez LJ, Boffi B, Farsi M, Scatizzi M. Incisional hernia repair. Surgical … 2003;

‣ 39. Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic repair of ventral hernias: nine years' experience with 850 consecutive hernias. Annals of Surgery 2003;

‣ 40. Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic Repair of Ventral Hernias. Transactions of the Meeting of the American Surgical Association 2003;121:85–94.

‣ 41. van 't Riet M, Steyerberg EW, Nellensteyn J, Bonjer HJ, Jeekel J. Meta-analysis of techniques for closure of midline abdominal incisions. Br J Surg 2002;89(11):1350–6.

‣ 42. Goodney PP, Birkmeyer CM, Birkmeyer JD. Short-term outcomes of laparoscopic and open ventral hernia repair: a meta-analysis. Archives of Surgery 2002;

‣ 43. Korenkov M, Paul A, Sauerland S. Classification and surgical treatment of incisional hernia. Archives of Surgery 2001;

‣ 44. Welty G, Klinge U, Klosterhalfen B, Kasperk R. Functional impairment and complaints following incisional hernia repair with different polypropylene meshes. Hernia 2001;

‣ 45. Nicole C F Hodgson RAMTØ. The Search for an Ideal Method of Abdominal Fascial Closure: A Meta-Analysis. Annals of Surgery 2000;231(3):436.

‣ 46. Luijendijk RW, Hop W, van den Tol MP. A comparison of suture repair with mesh repair for incisional hernia. … England Journal of … 2000;

‣ 47. Mudge M, Hughes LE. Incisional hernia: a 10 year prospective study of incidence and attitudes. Br J Surg 1985;72(1):70–1.

‣ 48. Bucknall TE, Cox PJ, Ellis H. Burst abdomen and incisional hernia: a prospective study of 1129 major laparotomies. Br Med J (Clin Res Ed) 1982;284(6320):931–3.