Heartsill L, Richards M L, Arfai N, Lee A, Bingener-Casey J, Schwesinger W H, Sirinek K R
Department of Surgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229-3900, USA.
Hernia. 2005 May;9(2):162-6. doi: 10.1007/s10029-005-0319-9. Epub 2005 Feb 19.
The Rives-Stoppa (RS) repair of ventral incisional hernias (VIHR) is technically difficult. It involves the retromuscular placement of mesh anterior to the posterior fascia and the primary closure of the anterior fascia. Recurrence rates are 0-8%. We proposed that the operation could be done with equal success by placing the mesh in an intraperitoneal position and primarily closing the fascia anterior to the mesh.
81 patients who had undergone an open RS-VIHR with intraperitoneal mesh were evaluated for hernia recurrence and factors associated with recurrence.
55 women and 26 men (mean BMI 38+/-9) underwent RS-VIHR (mean age 49+/-11 years). Of these patients, 44 (54%) had a prior VIHR, 30 (37%) had an incarcerated hernia and 34 (42%) had multiple fascial defects. PTFE was used in 83% and Prolene in 12%. Average LOS was 5.8+/-12 days. All received perioperative intravenous antibiotics and 28% were discharged on oral antibiotics. Follow-up averaged 30+/-24 months. Recurrent VIH developed in 12/81 (15%), with three occurring after removal of infected mesh and one after a laparotomy. Excluding these four, the recurrence rate was 10%. There was no correlation between hernia recurrence and age, BMI, hernia size, number of prior repairs, or LOS (t-test p>0.05). Hernia recurrence did not correlate with gender, prior peritoneal contamination, incarceration, multiple defects, adhesions, mesh type, oral antibiotics, cardiac disease, diabetes, tobacco use, or seroma (X(2) p>0.05). Those with a wound infection and/or abscess formation had a significantly higher recurrent hernia rate (60% vs. 8%, X(2) p<0.001). Patients with pulmonary disease had a significantly higher recurrence rate (50% vs. 12%, X(2) p=0.01).
RS-VIHR with intraperitoneal mesh is a successful and less technically challenging method of repair than prior modifications. Aggressive efforts to identify infection and treat early may prevent abscess formation and subsequent recurrent hernia. Patients with chronic pulmonary disease have an unacceptably high recurrence rate and should not be considered as candidates for elective RS-VIHR.
腹直肌后鞘前修补术（Rives-Stoppa，RS）修复腹直肌切口疝（ventral incisional hernia，VIHR）技术难度较大。该手术包括在腹横筋膜前方的肌后间隙放置补片，并一期缝合腹直肌前鞘。复发率为0%-8%。我们提出，通过将补片置于腹腔内位置并一期缝合补片前方的筋膜，该手术也能取得同样的成功效果。
对81例行开放性RS-VIHR并使用腹腔内补片的患者进行了疝复发情况及复发相关因素的评估。
55例女性和26例男性（平均体重指数38±9）接受了RS-VIHR手术（平均年龄49±11岁）。这些患者中，44例（54%）曾有过VIHR，30例（37%）为嵌顿疝，34例（42%）存在多处筋膜缺损。83%的患者使用了聚四氟乙烯（PTFE）补片，12%的患者使用了聚丙烯（Prolene）补片。平均住院时间为5.8±12天。所有患者围手术期均接受了静脉抗生素治疗，28%的患者出院时带口服抗生素。平均随访时间为30±24个月。81例患者中有12例（1⁄5）发生了复发性VIH，其中3例在取出感染补片后复发，1例在剖腹手术后复发。排除这4例后，复发率为10%。疝复发与年龄、体重指数、疝大小、既往修补次数或住院时间之间无相关性（t检验p>0.05）。疝复发与性别、既往腹腔污染、嵌顿、多处缺损、粘连、补片类型、口服抗生素、心脏病、糖尿病、吸烟或血清肿无关（卡方检验p>0.05）。发生伤口感染和/或脓肿形成的患者疝复发率显著更高（60%对8%，卡方检验p<0.001）。患有肺部疾病的患者复发率显著更高（50%对12%，卡方检验p=0.01）。
采用腹腔内补片的RS-VIHR是一种成功的修复方法，与以往的改良方法相比，技术难度更低。积极识别感染并早期治疗可能预防脓肿形成及随后的复发性疝。患有慢性肺部疾病的患者复发率高得令人难以接受，不应被视为择期RS-VIHR的候选者。
