Long-term outcome of incisional hernia using the Erlangen Inlay Onlay Mesh (EIOM) techniqe

Abstract

ABSTRACT 1.1. Background and objectives The development of an incisional hernia is one of the most common complications after abdominal surgery. An incidence of up to 20% has been reported in the literature. Incisional hernia, which is considered as a morbidity following abdominal wall surgery is commonly assoicated with pain, intestinal obstruction, and ischemia of the hernia contents. Several techniques to repair incisional hernia have been reported in the literature. However, all repair techniques require surgical intervention, and include open technique with or without mesh and laporoscopic mesh technique. Despite the improvement in hernia repair in the last few decades, the recurrence rates remain high and can reach up to 36% with the mesh repair technique. The open mesh repair using the sublay technique is considered the gold standard for incisional hernias. Here, a mesh is placed in the posterior rectus sheath after dissecting the subcutaneous tissues and approximating the fascial margins. With this technique, the greater the overlapping of the defect walls, the lower the recurrence rate. However, complications such as chronic pain, hematoma and seroma can occur due to the the extended preparation of the abdominal wall required in this technique as well as the oversized foreign material used. To overcome these complications, and to improve the results of fascial closure by minimizing tension on the repair site, the University of Erlangen-Nürnberg developed in the early 90s the so called „Erlangen Inlay Onlay Mesh Repair“ (EIOM Repair). Here, an overlap of 2cm fascia is required, and suitable for all forms of incisional hernia. However, information about the long-term outcome of this technique is lacking. Therefore, the objective of this study was to investigate the long-term outcome of incisional hernias treated with the Erlangen Inlay Onlay Mesh (EIOM) repair technique, taking into account recurrence, complications and patient satisfaction. 1.2. Material and Methods Medical records of 443 patients treated in the surgical department of the Erlangen university hospital with the EIOM repair between the years 1996 and 2009 were collected retrospectively. After drop-outs, a final number of 163 patients were evaluated and included in the statistical analysis. This corresponds to a response rate of 74%. Data were collected from the patients or their life partners with means of a telephone interview and transferred successfully to a questionnaire specifically designed for the study. Subsequently, the obtained date were incorporated into the IBM SPSS statistics program version 19. The level of significance was determined by the Chi-square test and set at p ≤ 0.05. 1.3. Results A total of 163 patients with incisional hernias and treated between 1996 and 2009 with the Erlangen Inlay-Onlay-Mash Repair (EIOM-Repair) were reached. The collected data revealed a mean follow-up period of 70 (18-190) months. About a third of the operations were performed by assistant doctors under guidance. The average age of the included patients was 60 years, including slightly more male 53% (n = 87) than female patients (46% (n = 76). The average body mass index (BMI) was 30 (16-57). Thirteen patients were a second recurrence. The average size of the abdominal defect was 119cm2 (range: 4-900cm2). The duration of the surgery was 105 minutes (range: 21-353). General complications included pulmonary complications, cardiovascular complications, and neurological problems. Incisional hernia recurrence after EIOM repair was observed in 6 (3.7%) patients after a mean observation period of 70 months (18-190) postoperatively. The recurrence rate increased significantly when the body mass index (BMI) was higher than 32 kg/m2. Here, a recurrence rate of 10.5% for BMI> 32 versus 1.7% with BMI 32 was reported. There were no significant differences in hernia recurrence if haven’t been operated by an assistant under supervision or by a consultant. All of the patients had to undergo surgery again. Depending on the intraoperative findings, the mesh was either completely or partially removed. The closure of the hernia was performed again with EIOM repair. In regard to patient satisfaction, 91% of patients included in this study were satisfied with the surgical outcome. The pain sensation at rest decreased continuously postoperatively. In eight patients (5%), chronic pain also occurred 3 years postoperatively. Of these, four patients (2.7%) continued to take painkillers. Movement-dependent pain was reported by 24 patients (15.7%), from which 12 patients experienced pain during daily activities. Long-term intestinal motility was unremarkable in 133 patients (90%). On average, patients were able to complete their work in 8 weeks (range: 1-52) postoperatively. 1.4. Conclusion The EIOM procedure is a safe surgical technique that can be defined as an assistant intervention. All types of abdominal wall hernias can be treated with this technique. Cases with larger abdominal wall defects can be safely treated with EIOM without causing additional symptoms to the patients. Body mass index showed to play a significant role in recurrence. Complications such as the occurence of an enterocutaneous fistula due to direct contact between the prosthetic mesh and intestines could not be observed. Therefore, EIOM can be considered as a safe alternative method to the recommended sublay technique.

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