Incisional hernia is the most challenging problem in abdominal surgery. Open method provides the most sound and longlasting cure to the problem. The recurrence rate with a well done open technique is very low.

1. Repair of Incisional Hernia!
A anatomical and technical challenge.
Dr.Ketan Vagholkar
MS,DNB,MRCS,FACS
Consultant General Surgeon
&
Professor of Surgery

2. Clinical History
A 55 year old lady presented
with a swelling 5 months
following an operation of
open cholecystectomy done 1
year back.
The elliptical marking
highlights the scar of previous
surgery which was excised.
(patient is in supine position
with head end towards the
left)
The sac was superolateral to
the scar marked by the dotted
line.

3. Identification of the hernial sac
After careful and
meticulous dissection
of the subcutaneous
tissues the sac is
identified and
dissected upto the
neck.

4. Herniotomy
Sac dissected all around and
opened.
Contents were omentum and
colon which was reposited
back into the abdomen after
adhesiolysis.
Sac closed with vicryl and
redundant part of the sac
excised.
A part of the adherent muscle
fibers of the internal oblique
and transversus abdominis
also included into the suture
line to give additional
strength.

5. Identification and dissection of
individual layers for repair
A plane of dissection
identified and dissected for
about 5 cms around the neck
of the sac or the defect.
The purpose of the dissection
was to create a place for the
safe placement of the mesh.
A prolene mesh place on the
closed defect and spread
symmetrically al around and
fixed with 2-0 prolene
stitches.
A negative suction drain
placed over the mesh and
brought out through a seperate
incision.

6. Repair of the external oblique layer
of muscle.
Interrupted horizontal
mattress sutures taken
with 1-0 prolene to
approximate the
musculoaponeurotic
layer of the external
oblique.
Approximation of this
layer lead to covering of
the entire mesh and its
isolation from the
subcutaneous tissues.

7. Advantages of this technique
Open repair is the best option for incisional
hernia.
It is technically a sound repair and provides
added protection both anatomically as well as by
virtue of the fibrosis initiated by the mesh.
It is technically demanding. Only a skilled and
experienced surgeon can deliver such good
dissection and results.
The incidence of complications including the
recurrence rate with this technique is very low