Recent trends in the management of incisional herniation.

There is a high incidence of risk factors for incisional herniation in hospitalized veterans. Almost half the defects appear more than 12 months after celiotomy. "Buttonholing" of the rectus sheath by a sawing motion of the continuous nonabsorbable suture may be responsible for this later herniation. Suturing with synthetic, slowly absorbed monofilament may reduce delayed herniation. The recurrence rate after primary repair was 24.8% (n = 206), and after a second repair the recurrence rate was 41.7% (n = 36). Plastic prostheses, used only in difficult cases (18% of the sample), were associated with a recurrence rate similar to that associated with sutures because of protrusion around the edge. The use of larger and better fixed ("sandwich") polypropylene mesh (Marlex) is indicated. Subxiphoid epigastric hernias following sternotomy do not require prosthetic herniorrhaphy.