Modified rives-stoppa repair for abdominal incisional hernias

doi:10.4236/health.2010.22024

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Vol.2, No.2, 162-169 (2010)

doi:10.4236/health.2010.22024

SciRes

Health

Modified rives-stoppa repair for abdominal incisional

hernias

Peter Nau, Clancy J. Clark, Mason Fisher, Gregory Walker, Bradley J. Needleman, E. Christopher Ellison,

Peter Musc ar ella

Department of Surgery, The Ohio State University, Columbus, America; Pete.Muscarella@osumc.edu

Received 26 October 2009, revised 23 December 2009; accepted 24 December 2009.

ABSTRACT

Incisional hernias are a prevalent problem in

abdominal surgery and occur in 11% of patients

who undergo laparotomy. Primary suture clo-

sure of incisional hernias results in a 31%-58%

chance of recurrence. The addition of a pros-

thetic mesh implant decreases recurrence rates

to 8%-10%. Popularized in Europe by Rives and

Stoppa, the sublay technique has proven to be

very effective, with low recurrence rates

(0%-23%) and minimal complications. The pur-

pose of the study was to evaluate the experi-

ence of a single surgeon at a large tertiary care

center performing a modified Rives-Stoppa re-

p air for abdominal incisional hernias. To do this,

the records of all patients undergoing a modi-

fied Rives-Stoppa incisional hernia repair be-

tween January 2000 and August 2003 were ret-

rospectively reviewed. Outpatient clinic notes,

discharge summaries, operative reports, and

laboratory data were reviewed for patient

demographics, surgical data and postoperative

complications. Univariate analysis was per-

formed in order to identify predictors for recur-

rence. During the study period, 83 patients un-

derwent a modified Rives-Stoppa incisional

hernia repair. Nineteen patients were excluded

due to incomplete medical records. No patients

required postoperative exploration for an in-

tra-abdominal catastrophe. Twenty-five percent

(n=16) of patients had a complication as a result

of the hernia repair. Only two patients (3.1%)

developed recurrent incisional hernias. History

of diabetes (p=0.007) and benign prostatic hy-

perplasia (p=0.000) were the only significant

predictors for recurrence. The results presented

here confirm that the modified Rives-Stoppa

retromuscular repair is an effective method for

the repair of incisional hernias. The complica-

tion and recurrence rates compare favorably to

results for currently popular alternative tech-

niques.

Keywords: Incisional Hernia Repair; Mesh;

Rives-Stoppa Repair; Abdominal Wall Defects

1. INTRODUCTION

Incisional hernias are a common problem in abdominal

surgery and occur in up to 11% of patients who undergo

laparotomy [1]. Complications of incisional hernias in-

clude infection, ulceration, incarceration of viscera, and

small bowel obstruction [2-4]. Patients also experience

discomfort and a cosmetically unpleasing bulge at the

incision site. Successful repair of incisional hernias con-

tinues to be challenging. Primary suture closure of inci-

sional hernias results in recurrence rates of 31%-58%

[5-10]. The addition of prosthetic mesh implants has

been shown to decrease the incidence of recurrence to

8%-10% [11-14].

A tension-free prosthetic mesh repair of incisional

hernias dates back the to 1940’s and 1950’s with the

introduction of metal wire mesh and polypropylene

mesh respectively [15-17 ]. With the development of new

prosthetic materials, advances in minimally invasive

techniques, and improvements in open surgical proce-

dures, surgeons continue to debate the appropriate op-

erative technique for the repair of incisional hernias,

particularly regarding the anatomic placement and type

of prosthetic mesh. Various operative techniques for in-

cisional hernia repair use onlay, sublay (retromuscular or

extrafascial), or underlay (intraperitoneal or subfascial)

placement of mesh. Popularized in Europe by Rives and

Stoppa, the sublay technique has proven to be very ef-

fective, with low recurrence rates (0%-23%) and mini-

mal complications [18-25]. Disadvantages include com-

plexity, long operative times, and the possibility of

chronic abdominal pain [26].

The experience of one surgeon at The Ohio State

University Medical Center suggests that a modified

HEALTH /

P. Nau et al. / Health 2 (2010) 162-169

163

Rives-Stoppa incisional hernia repair compares favora-

bly to the standard Rives-Stoppa repair as well as to

other techniques for addressing incisional hernias. The

purpose of this study was to fully characterize the com-

plications and recurrence rates of this surgical technique

by conducting a retrospective review of patients who had

undergone a modified Rives-Stoppa incisional hernia

repair.

2. MATERIALS AND METHODS

Between January 2000 and August 2003, 83 patients in

the practice of one surgeon at a large urban academic

hospital (The Ohio State University Medical Center)

underwent a modified Rives-Stoppa incisional hernia

repair. Of the 83 patients initially identified, 19 patients

were excluded due to incomplete medical records. Out-

patient clinic notes, discharge summaries, operative re-

ports, and laboratory data of 64 patients were reviewed.

There were 20 males and 44 females (mean age 50 years,

range 27-85). The majority of incisional hernias were

midline and supraumbilical, with several (n=3) flank

hernias. Forty-five percent (n=29) of the incisional her-

nias were recurrent (mean 2, range 1-7, S.D.± 1.6). At

the time of repair, most incisional hernias were sympto-

matic and evident on physical exam. Six percent (n=4)

were incarcerated at the time of presentation and one

patient had an inf ected abdominal wound (Table 1).

The operative technique is a variation of the previ-

ously described Rives-Stoppa technique [18,22,27]. All

patients received intravenous prophylactic antibiotics

(Cefazolin, 1 g) prior to incision. Patients were placed

supine for midline hernias, or in lateral decubitus for

flank hernias. The old incision scar and hernia sac were

removed en bloc using an elliptical incision. Dissection

of the hernia sac in all patients required entry into the

peritoneum and division of adhesions to the sac, if iden-

tified. The fascial plane between the rectus muscle and

posterior rectus sheath was dissected as far lateral as

possible, typically 5-10 cm, between eight and ten poly-

butester (Novofil, United States Surgical/Syneture,

Norwalk, CT) “U-stitch” anchoring sutures were placed

only in the posterior rectus sheath, not penetrating the

rectus muscle, anterior rectus sheath or skin. The fascial

defect was closed by reapproximating the posterior rec-

tus sheath with running polybutester suture reinforced

with simple interrupted polybutester suture (Figure 1).

Tension was minimal and the posterior rectus fascia was

closed in all 64 patients. Below the arcuate line, the

peritoneum was carefully reapproximated. Monofila-

ment polypropylene mesh (Bard Mesh Flat Sheets,

Davol Inc., Cranston, RI) was cut to size slightly larger

(5 cm overlap) than the fascial defect and anchored us-

ing the previously placed sutures (Figure 2). Cefazolin

(1 g) powder was placed on the mesh prior to closure of

Table 1. Hernia characteris tics.

N (%)

Recurrent 29 (45.3)

Location

Supraumbilical 42 (65.6)

Umbilical 9 (14.1)

Infraumbilical 8 (12.5)

Paramedian 1 (1.6)

Subcostal 1 (1.6)

Flank 3 (4.7)

Symptomatic 59 (92.2)

Evident on Physical Exam61 (95.3)

Incarcerated 4 (6.4)

Infected 1 (1.6)

Ulcerated 0 (0)

the anterior rectus sheath (Figure 3). In the majority of

the patients (n=46), one to two bulb suction drains were

placed between the skin and the anterior rectus sheath.

The skin was approx imated with interrupted, d ermal 2-0

polyglycolic acid sutures (Dexon II, Syneture, Norwalk,

CT) and staples. Oral prohylactic antibiotics (Cefalexin,

500 mg PO TID) were started postoperatively and con-

tinued until drain removal. Hospital discharge typically

occurred on post-operative day 3 (mean 5, range 2-29,

S.D.± 3.9).

Follow-up information was available for 61 patients,

with mean follow-up of 20 weeks (range 1-144 weeks,

S.D.± 30.1) and mean number of follow-up visits of

three (range 1-13, S.D. ± 2.9). All patients were exam-

ined during follow-up by the surgeon who completed the

operation. Three patients had no follow-up information

available and their records indicated that another physi-

cian is currently following them. Physician correspon-

dence information was reviewed to determine any com-

plications or recurrences in these three patients. One

patient died of causes unrelated to the repair of the inci-

sional hernia, and there is no evidence that any of these

patients developed a recurrent incisional hernia. This

study was approved by the medical center institutional

review board. Statistical analysis was conducted using

SPSS for Windows (Version 11.5.0, SPSS Inc., Chicago,

IL).

3. RESULTS

All 64 patients tolerated the procedure well with no in-

traoperative complications. There were two (3.1%) pe-

rioperative complications. No myocardial infarctions or

cases of pneumonia were recorded. One patient suffered

a pulmonary embolism and was treated with anticoagu-

lant therapy. The second patient was readmitted for

drainage of a rectus sheath hematoma found anterior to

the prosthetic mesh. Three (4.7%) patients required pe-

rioperative packed red blood cell transfusions. Blood

loss was negligible, with a mean post-operative d ecrease

n hemoglobin of 0.8 g/dl (S.D. ±1.3). i

P. Nau et al. / Health 2 (2010) 162-169

164

Figure 1. The posterior rectus sheath is dissected away from the overlying rectus abdominus

muscle on both sides of the defect using electrocautery. The peritoneum is mobilized below

the level of the arcuate line. Care must be taken to ligate and divide perforating blood vessels,

as unidentified injury to these structures could result in the formation of rectus hematomas

postoperatively. The posterior layer is approximated with running suture and reinforced in-

termittently with additional suture in order to avoid excess tension and tearing during ma-

nipulation.

Figure 2. Polypropylene mesh is trimmed and placed into the space behind the rectus muscle.

Previously placed anchoring sutures are passed through the mesh and used for fixation.

Openly accessible at HEALTH /

P. Nau et al. / Health 2 (2010) 162-169

165

Figure 3. Bulb suction drains are placed into the subcutaneous space and brought out of the skin through

separate stab incisions. The skin is approximated with dermal sutures and staples in order to maintain an

adequate seal for drain.

There were complications in twenty-five percent

(n=16) of patients as a result of the hernia repair. The

majority of the complications were minor with only

seven patients requiring admission to the hospital for

management (15.6%). Six patients (9.4%) had superfi-

cial wound or deep mesh infections, defined as purulent

drainage or positive wound cultures. None required re-

moval of the prosthetic mesh and all were successfully

managed with antibiotics and wound management. One

patient developed erythema adjacent to the skin staples,

four (6.3%) developed seromas, and three (4.7%) de-

veloped wound hematomas. In no case was evidence of

infection, including erythema or purulent drainage noted

in those patients with sero mas. Wound cultures were not

performed routinely on suspected seromas in the absence

of clinical signs of infection. A hematoma was defined as

a fluid collection with bloody drainage. Although no

patients developed fistulas, four patients (6.3%) pre-

sented post-operatively with partial small bowel obstruc-

tions, all of who were successfully treated with nasogas-

tric decompression. Fifteen patients (23.4%) are being

managed for chronic abdominal pain (Table 2). In the

subgroup of morbidly obese patients (n=27), there were

two partial small bowel obstructions (7 .4%), one seroma

(3.7%), one hematoma (3.7%), and two surgical site in-

Table 2. Complications.

N (%)

Infection 6 (9.4)

Seroma 4 (6.3)

Hematoma 3 (4.7)

pSBO* 4 (6.3)

Staple Reaction 1 (1.6)

Fistula 0 (0)

Chronic Pain 15 (23.4)

Recurrence 2 (3.1)

*partial small bowel obstruction.

fections (7.4%).Two patients (3.1%) developed recurrent

incisional hernias. The first patient developed a small

(1-2 cm) supraumbilical recurrent hernia 10 months

(post-operative day 285) following the hernia repa ir. The

patient subsequently developed a second small perium-

bilical hernia. The second patient was originally treated

for a recurrent midline incisional hernia and a primary

flank hernia. Recurrence of the flank hernia developed

six weeks post-operatively (post-operative day 42). The

flank hernia has recurred twice and it is believed that

inadequate repair can be attribu ted to insufficient overlap

of mesh and fascia or incomplete coverage of the fascial

defect. Both patients had medical histories significant for

diabetes and a respiratory disorder. The study p opulation

was a typical patient populatio n for recurrent complex

P. Nau et al. / Health 2 (2010) 162-169

166

Table 3. Potential prognostic factors for hernia recurrence.

N (%) p

Smoking 18 (28.1)

COPD* 8 (12.5.) 0.103

Asthma 7 (10.9) 0.072

Diabetes (Type I or II) 14 (21.9) 0.007

Sleep Apnea 12 (18.8) 0.490

Morbid Obesity 27 (42.2) 0.220

Chronic Steroid Use 3 (4.7) 0.750

Benign Prostatic Hyperplasia 2 (3.1) 0.000

Cirrhosis 3 (4.7) 0.750

Malabsorptive Surgery† 30 (46.9) 0.177

*COPD, chronic obstructive pulmonary disease. †Malabsorptive sur-

gery defined as roux-en-Y gastric bypass (25), cystojejunostomy (1),

choledochojejunostomy (3), or vertical banded gastroplasty (1).

incisional hernias, with numerous potential risk factors

for recurrence (Table 3). Forty-two percent of patients

(n=27) were considered to be morbidly obese (BMI > 40

kg/m2) and 46.9% of patients (n=30) had previously

undergone a surgical procedure that could potentially

result in malabsorption (Rouxen-Y gastric bypass,

choledocho-jejunostomy, etc.). In the subgroup of mor-

bidly obese patients, no recurrences were observed. With

univariate analysis, a history of diabetes (p=0.007) or

benign prostatic hyperplasia (p=0.000) were the only

significant pr ognostic factors for recurrence.

4. DISCUSSION

Surgical techniques for the repair of incisional hernias

continue to evolve with advances in prosthetic materials

and minimally invasive technology. Luijendijk et al.

conducted a randomized, multicenter study suggesting

that mesh repair is superior to suture repair [28]. The

optimal technique for mesh placement has not been es-

tablished and re mains controversial. Laparoscop ic repair

appears to have numerous benefits, including low recur-

rence rates, decreased hospital length of stay, decreased

postoperative pain, an d earlier return to work and normal

activities. Although a single randomized trial has been

designed [29], the results are still pending and no ran-

domized controlled trials are available to prove any

benefit of laparoscopic techniques over open repair. A

meta-analysis by Goodney et al. indicated that laparo-

scopic ventral hernia repair may have lower complica-

tion rates [30]. Initial concern for increased fistula for-

mation and small bowel obstruction with the laparo-

scopic underlay techniques have also been raised, but

appear to be less of concern with recent studies and

changes in mesh technology [11]. It has been our ex-

perience that catastroph ic abdominal complications, such

as small bowel perforation, can occur with the laparo-

scopic repair. Although this does not appear to occur

frequently, these types of complications can be disas-

trous in that they may require multiple surgeries, mesh

removal, long-term wound care, and skin grafting pro-

cedures. The end result is usually an incisional hernia

that is larger than the initial hernia. There are currently

no reliable methods fo r selecting appropriate patien ts for

laparoscopic incisional hernia repair. The data from our

study suggests that the technique described here is rarely,

if ever, associated with these types of complications.

The separation of components technique, originally

described by Ramirez et al. in 1990 has recently drawn

interest for complex incisional hernia rep air. After mobi-

lization of skin flaps, the external oblique muscle is re-

leased just lateral to its rectus sheath insertion from the

underlying internal oblique muscle. This enables the

well vascularized rectus abdominis muscle complex to

be advanced medially, allowing for coverage of the her-

nia defect [31]. Up to a 20 cm defect at the waist, 12 cm

in the upper abdomen, and 10 cm in the lower abdomen

can be closed using additional relaxing incisions. Ad-

vantages include utilization of a dynamic muscle group

that remains innervated for closure of the defect, and

potentially improved cosmetic results as excess skin is

commonly excised prior to closure of the wound.

Shestak et al. reported only one recurrence, two superfi-

cial wound infections, and one seroma in 22 patients

undergoing this procedure [32]. In contrast, another

study demonstrated recurrent hernias in 32.0% of pa-

tients and complications, including fascial dehiscence,

hematoma, seroma, wound infection, skin necrosis, and

respiratory insufficiency, in 39.5% of patients [33]. The

modified Rives-Stoppa technique allows for cosmeti-

cally pleasing results, in that redundant skin is removed

en bloc with the underlying hernia sac. Skin necrosis is

rare because large skins flaps are not created and careful

attention is paid to preserving the perforating blood ves-

sels that supply the remaining skin and subcutaneous

tissues. The Rives-Stoppa technique preserves the func-

tionality and integrity of the abdominal wall, factors

considered to be crucial for effective repair of abdominal

wall defects by proponents of the separation of compo-

nents technique. Furthermore, the Rives-Stoppa tech-

nique employs the use of mesh as reinforcement, and

this is generally believed to decrease recurrence rates as

described previously.

The data reported here indicate that a modified

Rives-Stoppa retromuscular repair results in favorable

recurrence and complication rates when compared with

the standard Rives-Stoppa repair as well as other tech-

niques. The experience of a single surgeon’s practice at

The Ohio State University is comparable to previously

reported results (Table 4). Benefits of this technique

include the ability to explore the entire fascial defect and

to identify any potentially weak points in the fascia.

Fenestrations in the peritoneum can be recognized, and

if necessary, selection of a larger mesh implant to cover

P. Nau et al. / Health 2 (2010) 162-169

167

Table 4. Studies of the rives-stoppa open mesh repair

Seroma,

N(%) Infection,

N(%) Recur-

rence, N(%)

Knight et al. 2002 [18] 1 (1.5) 2 (3.1) 0 (0)

Bauer et al. 2002 [19] 7 (12.3) 2 (3.5) 0 (0)

Toniato et al. 2002 [22] -- 6 (7.8) 2 (2.6)

Luijendijk et al. 2000 [21] 4 (4.8) 3 (4) 17 (23)

Balen et al. 1998 [26] 2 (4.4) 1 (2) 1 (2)

McLanahan et al. 1997 [24] 1 (1) 13 (13) 3 (3.5)

Sugerman et al. 1996 [23] 5 (5) 17 (17) 4 (4)

Temudom et al. 1996 [28] 3 (6) 6 (12) 2 (4)

Adloff et al. 1987 [30] -- 3 (2.3) 6 (4)

these areas of potential weakness can be made. Place-

ment of the mesh between the posterior rectus sheath

and the rectus muscle takes advantage of the intra-abd-

ominal pressure to secure the mesh, while minimizing

the risk of adhesion and fistula formation. Unique to this

series of patients was the surgeon’s ability to close the

posterior rectus sheath with suture. Extensive dissection

of the plane between the posterior rectus sheath and the

rectus muscle likely decreases tension when closing this

layer. Inability to close the posterior rectus sheath re-

quires bridging the fascial defect and would likely in-

crease the risk of recurrence.

It should be noted that the majority of the complica-

tions in this series were minor and easily managed on an

outpatient basis. Despite pre- and post-operative pro-

phylactic antibiotics, bulb suction drainage, and direct

placement of cefazolin powder on the prosthetic mesh,

the infection rate still approached 10%. This may be

attributed to patient factors, natural reaction to a foreign

material, and/or long-term placement of bulb suction

drains. Colonization of drain sites increases with time

and they are a potential portal of entry for bacterial in-

fection [34]. Criteria for drain removal generally re-

quired that the drain output be less than 30 ml per day in

an attempt to minimize the incidence of seroma forma-

tion. As a result, drains remained in place for a mean

duration of three weeks (range 7-85 days, S.D. ±15.7).

Removing drains earlier might help to decrease infection

rates. It is also unclear whether continuing oral antibiot-

ics while the drains are in imparts any benefit for the

patient, but was performed in order to decrease the

chance of infection. The direct application of antibiotics

on the mesh at the time of surgery is clearly controver-

sial, but has been described previously [35,36]. The ra-

tionale is to improve the local concentration of antibiot-

ics and this may have potential benefits, particularly for

obese patients in whom systemic antibiotic therapy may

not be as effective. Although post-operative complica-

tions were not significant risk factors for hernia recur-

rence (data not shown), other studies have recognized an

increased risk of recurrence following infection [28,37].

The concern is generally that infected mesh must be re-

moved to successfully treat th e infection and removal of

the mesh results in hernia recurrence. In a study of pa-

tients undergoing concurrent incisional hernia repair and

elective colon resections, the authors concluded that

prosthetic mesh may be employed for incisional hernia

repairs in contaminated fields without increasin g the risk

of complications [38]. In a study comparing different

mesh materials, Leber et al. concluded that multifila-

ment polyester mesh (Mersilene) has a significantly in-

creased risk of infection as compared to double-filament

polypropylene mesh (Prolene) [39]. Infection rates vary

among studies, but this is understandable given varia-

tions in antibiotic usage, drain management, and types of

mesh employed. Considering the current body of evi-

dence, the appropriate prevention and management of

wound infection in patients undergoing mesh incisional

hernia repair remains to be determined.

Chronic pain was a concern of almost a quarter of

study patients, but comparison of pre and post-operative

pain was not available in this study. The concern of

chronic pain has also been raised in previous studies [12,

20]. McLanahan et al. reported that 11% of patients had

moderate to severe pain at 12 months after incisional

hernia repair [20]. In a 1997 symposium on incisional

hernia repair, Schumpelick argued that mesh can limit

range of motion and result in a stiff abdomen [21]. De-

creased abdominal wall compliance has been confirmed

with three dimensional stereography [40]. Given the

potentially negativ e long-term effects of prosthetic mesh

repair, data characterizing the quality-of-life, chronic

pain, and physical limitations of mesh implants should

prove to be helpful.

Although diabetes and benign prostatic hyperplasia

were the only identified risk factors for recurrence in this

study, previously identified risk factors for recurrence

were common in the study population. Considering the

size and non-randomized nature of this study, it is possi-

ble that we did not have sufficient statistical power to

display the significance of these known risk factors.

Sugerman et al. have shown that severe obesity is a

greater risk factor for hernia recurrence than chronic

steroid use [41]. In the subgroup of morbidly obese pa-

tients we expected to see increased rates of recurrence

and infection, however, this was not the case. The ma-

jority of the obese patients who underwent hernia repair

were actively losing weight from recent gastric bypass

surgery. It is possible that weight loss, the presence of

redundant skin, and general changes in body habitus

facilitated the repair and decreased the risk of recur-

rence.

The modified Rives-Stoppa retromuscular repair, as

described here, appears to be an effective treatment for

incisional hernias. These results compare favorably with

other published reports for the Rives-Stoppa repair and

other techniques. The recurrence rate of 3.2% is clearly

P. Nau et al. / Health 2 (2010) 162-169

168

acceptable in this series that includes numerous patients

with multiple risk factors, and a considerable number of

patients who have failed previous attempts at repair. We

also believe that the absence of catastrophic abdominal

events following repair is important to note. Wound in-

fection, chronic pain, and persistent abdominal stiffness

continue to be problematic, but manageable. Random-

ized prospective trials are required to determine the op-

timum technique for incisional hernia repair.

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