Rives technique is the gold stardard for incisional hernioplasty.

Rives technique is the gold stardard
for incisional hernioplasty.
Ann. Ital. Chir., 2011 82: 313-317
An institutional experience
Angelo Forte*, Antonio Zullino*, Simone Manfredelli, Gioacchino Montalto, Francesco Covotta,
Piergiorgio Pastore, Marcello Bezzi
IV Scuola di Specializzazione in Chirurgia Generale (Direttore Prof Marcello Bezzi)
*Department of Surgery “F. Durante”, Sapienza University, Rome, Italy
Rives technique is the gold stardard for incisional hernioplasty. An institutional experience
AIM: We report our clinical experience with incisional hernia surgery and we retrospectively analyze the outcomes obtained
with the different techniques of repair used, confirming that Rives-Stoppa procedures actually represent the gold standard
for incisional hernia.
MATERIAL OF STUDY: 334 patients were observed for incisional hernioplasty at our Department of Surgery from 1996
to 2007. They were treated according to the following surgical procedures: 44 primary direct closures; 246 Rives-Stoppa
procedures; 9 Chevrel procedures; 35 intraperitoneal repairs. The outcomes were considered in terms of postoperative surgical complications.
RESULTS: In total, we had 13 cases of hernia recurrence (3.9%), 14 cases of infections (4.2%), 7 cases of seroma/hematoma
(2.9%) and one case of acute respiratory insufficiency.
DISCUSSION: The choice of the surgical technique depends on several factors, such as the size of the hernia defect and
the representation of the anatomical structures, essential for the reconstruction of the abdominal wall. We abandoned
Chevrel technique due to high rate of recurrence and infective complications and reserved the intra-peritoneal repair only
for cases where a fascial layer could not be reconstructed. Instead, the primary direct closure should be considered for
high risk patients because of its low surgical impact, although it is characterized by higher incidence of recurrence.
Combining the Rives-Stoppa technique with some personal technical modifications, we obtained acceptable results in terms
of recurrence rate and morbidity.
CONCLUSIONS: Rives-Stoppa procedures are the current standard of care for the surgical repair of incisional hernia and
our treatment of choice.
KEY
WORDS:
Incisional hernia surgery, Prosthetic mesh, Rives-Stoppa technique.
Introduction
Incisional hernia is the most common complication of
abdominal surgery occuring within six months after
Pervenuto in Redazione: Dicembre 2010. Accettato per la pubblicazione Febbraio 2011
Correspondence to: Angelo Forte and Antonio Zullino, Department of
Surgery “F. Durante”, Sapienza University of Rome, Viale del Policlinico,
00161 Rome, Italy (e-mail: [email protected] - [email protected])
surgery in 50% of cases and within the first year in 75%
1-8. Despite the introduction of “tension free” techniques
of repair, the use of suction drainages, antibiotic prophylaxis and accurate asepsis, its incidence has not really decreased over the last years: it still reaches 8-10%
after elective surgery and 10-40% after emergency or
complicated surgery 6,8.
The main problem in treating this complication is the
loss of wall substance caused by muscular detachment
and the following defect during the muscular traction.
The surgeon will have to reconstruct the abdominal wall
without any tension, in order to avoid a reduction of
abdominal diameters and the possible appearance of a
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restrictive respiratory syndrome which increases the risk
of hernia recurrence 1-10. This can be partly achieved by
the use of prosthetic materials whose introduction has
resulted in a reduction of recurrence rate from 30-50%
(reported for direct suture repair) to 5-10% (mesh repair)
in most series 6-9, although the use of mesh itself does
not imply a good outcome unless associated with a
meticulous surgical technique 11-13. The availability of
meshes suitable for contact with abdominal viscera has
further reduced the rate of complications 1-5.
Nowadays the most common incisional hernia repair
techniques include pre-fascial (Chevrel), pre-peritoneal
(Rives-Stoppa) and intraperitoneal mesh placement.
Implanting the mesh over the fascial plane has a very
limited use in surgical practice, given the infection risk
and occurrence of seroma. Intraperitoneal mesh placement can be necessary when the peritoneal layer cannot
be reconstructed; however, despite the wide range and
reliability of prosthetic materials, foreign body reaction
and postoperative adhesions are still matter of concern.
Rives-Stoppa technique, avoiding contact with the
abdominal bowels and minimizing the risk of infection,
seems to offer the best guarantees of successful repair.
All patients underwent anesthesia preoperative evaluation
and respiratory function tests were carried out in case
of large ventral hernia. All patients underwent antibiotic prophylaxis with the exception of high risk patients
who received postoperative antibiotic treatment.
We performed a primary direct closure without any mesh
in 44 of the 78 patients referring with small incisional
hernias (13.2%). A polypropylene mesh was used for a
pre-peritoneal repair in 246 cases (73.7%): 194 (78.9%)
had a Rives repair, 27 patients (11%) had a Stoppa repair
and 25 patients (10.1%) had a pre-peritoneal repair with
the prosthesis left in partial contact with subcutaneous
tissues (Fig. 1). Some cases of hernia recurrence were
observed amongst the first 21 patients treated according
this procedure, always at the top of the midline scar;
this event carried us to modify the technique by modulating the mesh with two vertical incisions, to the upper
Material and methods
The study group includes 334 patients with abdominal
wall hernia, observed at our Institution from January
1996 to December 2007. Patients’ characteristics are
illustrated in Table I: 78 (23.4%) had a small laparocele (up to 5 cm on the largest diameter), 126 (37.7%)
middle laparoceles (from 5 to 10 cm) and 130 (38.9%)
large laparoceles (over 10 cm); 295 of them had a midline localization (139 epigastric, 41 hypogastric, 55 periumbilical and 60 above-below umbilical), 22 subcostal
(whose 13 on the trocar port site after laparoscopic
surgery) and 17 on the flank. 33 patients (9.9%) had
already undergone at least one surgical intervention for
hernia in the same site.
Fig. 1: Rives-Stoppa technique “with partial contact”.
TABLE I - Patients’ demographics and hernia characteristics.
Surgical technique
n
s
Rives-Stoppa technique
(with partial contact)
Hernia size
m
rec
F
M
w.i.
m.i.
s/h
r.i.
l
246
(25)
23
(1)
104
(3)
119
(21)
2
–
130
(14)
115
(11)
8
(1)
2
–
4
(1)
1
2
Chevrel technique
9
6
3
–
3
5
4
1
2
1
–
Primary direct closure
44
44
–
–
8
25
19
1
–
–
–
Intraperitoneal repair
35
334
5
78
19
126
11
130
–
13
20
180
16
154
–
10
–
4
2
7
–
1
s: small; m: middle; l: large; rec: recurrence; F: female; M: male; w.i.: wound infection; m.i.: mesh infection; s/h: sieroma/haematoma;
r.i.: respiratory insufficiency
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Ann. Ital. Chir., 82, 4, 2011
Rives technique is the gold stardard for incisional hernioplasty. An institutional experience
failure caused by pulmonary embolism occurred on the
second postoperative day, was treated with intravenous
anticoagulant teraphy. No bowel obstruction or fistulas
were observed.
Mean operating time was 100 minutes (range 70-130)
in prosthetic repairs, 30 minutes (range 15-45) for primary direct closures.
Discussion
Fig. 2: A personal expedient to reduce the hernia recurrence rate at the
top of the midline scar with a forklike insertion of the prosthesis.
and lower pole of it, and then inserting it, forklike, in
the midline over the surgical incision to reinforce the
hernia defect poles (Fig. 2). In all cases the mesh was
positioned far beyond the lateral margin of the rectus
muscles, underneath the large muscles of the abdomen.
Finally, in 9 cases (2.7%) Chevrel repair was performed
and in 35 cases (10.5%) intraperitoneal Dual-Composix
mesh were used because we were unable to reconstruct
the fascial layer.
At least one suction drain was placed in peri-prosthetic
site and left in all patients for 2-6 days after surgery.
No superficial drains were positioned. All patient had
early mobilization and low molecular weight heparin was
given only to high risk patients.
All patients underwent post-operative follow-up for a
period of time ranging between one and four years, and
outpatient clinic appointments were given at one, three
and twelve months and, annually where indicated. About
50% of patients attended the follow-up for the first year.
Our experience, developed through different techniques,
showed that Rives-Stoppa procedure, with some modifications, can offer good guarantees of successful repair
and low short and long-term complications 14-16.
We decided to abandon Chevrel technique due to frequent deep infections and high recurrence rate. The
intraperitoneal mesh placement was reserved only for cases where the pre-peritoneal layer could not be reconstructed. With regards to the cases with no mesh repair
(in all cases for very small hernia defects), a high recurrence rate was observed but this should be compared
with the short operating time (always under 30 minutes)
and the possibility to operate under local anesthesia 17.
Thus, the 18% recurrence rate might be acceptable as
first option especially for high risk patients 17-20.
The Rives-Stoppa technique, positioning the mesh
between the rectus muscles and the posterior rectus
sheath or peritoneum, can be considered the “gold standard” of hernia repair; once the plan between posterior
rectus sheath and pre-peritoneal plan is developed, the
opposite layers have to be sutured in order to obtain a
Results
No perioperative mortality was observed and the mean
hospital stay was 7 days (range 4-18). We observed thirteen cases of hernia recurrence (3.9%), 8 in patients with
no mesh repair (18.2%), 3 in patients with Chevrel
repair (33.3%) and 2 recurrences occurred amongst the
246 patients who underwent pre-peritoneal mesh repair
(0.8%).
Other complications observed were: 10 superficial infections (3%), 4 deep infections (1.2%), 7 seromas (2.1%)
and one case of respiratory insufficiency. Patients with
wound dehiscence were treated in outpatient clinics. Of
4 deep infections, 2 were observed in patients undergoing Chevrel technique and 2 in the Rives-Stoppa group.
The seromas were all treated successfully with ultrasoundguided aspiration. Finally, the single case of respiratory
Fig. 3: Mesh-fascia “sandwich” repair.
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A. Forte, et al.
complete separation from the intra-abdominal content
and to offer a barrier against bacterial contamination.
The prosthesis has to be fixed by a U-stitch suture: anterior muscles sheath → large muscles → mesh and viceversa. Polypropylene meshes have a macroporous structure, allowing the macrophages, fibroblasts, neo-formed
vessels and collagen fibers incorporation into the host
tissue.
Obviously, the choice of the repair technique is substantially indicated by the tissue representation. The size
of the hernia defect and the available anatomical structures are essential for the reconstruction of the abdominal wall. In some cases, the tension of the fascial layer
repair requires lateral relaxing incisions or a components
separation technique as described by some authors 21,22.
In some cases, we used the hernia sac to reapproximate
the peritoneal layer. After skin and subcutaneous dissection, the hernia sac is isolated and incised in the midline
obtaining two opposed fibrotic flaps. Then, an incision is
practiced on the lateral border of both fibrotic flaps, opening the anterior rectus sheath on one side and the posterior on the contra-lateral side. The intervention is concluded by a mesh-fascia “sandwich” repair (Fig. 3), with
the prosthesis placed between the two fascial layers.
Conclusion
Combining the Rives-Stoppa technique with some personal technical modifications, we obtained acceptable
results in terms of recurrence rate (only two cases) and
morbidity. We conclude that this surgical approach is
the current standard of care for the surgical treatment
of incisional hernia.
Riassunto
OBIETTIVO: Il laparocele rappresenta ancora oggi un problema di frequente riscontro in chirurgia generale con
un’incidenza pari a circa l’8-10% dopo chirurgia elettiva
e il 10-40% dopo chirurgia d’urgenza e complicata.
L’introduzione delle tecniche chirurgiche tension free e la
disponibilità attuale di dispositivi protesici idonei alle
diverse situazioni ha apportato migliorie indiscusse nei
risultati chirurgici ottenibili, riducendo il tasso di recidive e complicanze generiche rispetto al passato. La tecnica
di Rives-Stoppa è considerata in letteratura, quando praticabile, la più sicura ed efficace nel trattamento delle ernie
incisionali. In questo studio abbiamo rivisitato la nostra
esperienza istituzionale (dodicennale), esponendo i risultati chirurgici riscontrati con le diverse tecniche adottate e
soffermandoci sulla descrizione di alcune novità tecniche
personali apportate alla metodica di Rives-Stoppa.
MATERIALI E METODI: Dal gennaio 1996 al dicembre
2007, 334 pazienti (180 donne e 154 uomini) consecutivi sono stati sottoposti a plastica della parete addo-
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Ann. Ital. Chir., 82, 4, 2011
minale per laparocele. Si è trattato di 295 laparoceli
mediani (139 a localizzazione epigastrica, 41 ipogastrica,
55 peri-ombelicali e 60 sopra- e sotto-ombelicali), 22
sottocostali (di cui 13 insorti sull’incisione della porta
del trocar dopo chirurgia laparoscopica), 17 della regione del fianco. In 33 pazienti si trattava di laparoceli recidivi, con almeno un pregresso tentativo di riparazione.
Sulla base dimensionale abbiamo riscontrato 78 piccoli
laparoceli (fino a 5 cm), 126 medi (tra 5 e 10 cm) e
130 grandi (maggiori di 10 cm). In 44 casi (tutti interessati da piccoli laparoceli) è stata effettuata una plastica senza protesi, in 246 casi si è proceduto con la tecnica di Rives-Stoppa, in 9 casi è stata confezionata una
plastica secondo Chevrel e in 35 casi si è resa necessaria una plastica con protesi intraperitoneale.
RISULTATI: Nei 246 pazienti sottoposti a plastica addominale secondo la tecnica Rives-Stoppa sono state registrate due sole recidive (su tredici in totale), otto infezioni superficiali e due profonde, risolte con medicazioni ed antibioticoterapia, quattro sieromi e una complicanza respiratoria (embolia polmonare trattata con terapia anticoagulante).
CONCLUSIONI: I risultati del nostro studio confermano
che la tecnica di Rives-Stoppa rappresenta il “gold standard” nel trattamento delle ernie incisionali e dimostrano che, con opportuni accorgimenti tecnici, possa avere
margini di miglioramento in termini di riduzione di
complicanze a breve e lunga distanza.
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