Vol.2, No.2, 162-169 (2010)
Copyright © 2010 Openly accessible at http://www.scirp.org/journal/
Modified rives-stoppa repair for abdominal incisional
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.
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-
Keywords: Incisional Hernia Repair; Mesh;
Rives-Stoppa Repair; Abdominal Wall Defects
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
P. Nau et al. / Health 2 (2010) 162-169
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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
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)
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,
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
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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-
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 /
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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
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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.
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
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Table 4. Studies of the rives-stoppa open mesh repair
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-
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
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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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