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BACKGROUND

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Prosthetic materials for abdominal wall reconstruction and hernia repair have been available to surgeons for repair of the groin and abdominal wall since the mid-twentieth century. Indeed, use of these materials by either an open or laparoscopic technique is the standard method of repairing incisional or groin hernia in most centers in North America and Europe. The first prosthetic materials used for hernia repair were synthetic meshes made of polypropylene or polyester.1,2 They were introduced in an attempt to decrease the high risk of recurrent hernia observed in patients undergoing direct suture repair. Eventually, prospective randomized trials were conducted that demonstrated repair of even small incisional hernias without the use of mesh (primary closure repair) was associated with a significantly higher risk of recurrence (Figure 20-1), and nonmesh repair of all but the smallest abdominal wall defects was abandoned.3,4,5

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Fig. 20-1.

Prospective randomized trial of 181 patients with primary or initial recurrent midline incisional hernia were randomized to undergo repair with mesh or by primary suture without mesh. The 10-year cumulative rate of recurrence was 63% for suture repair and 32% for mesh repair (P < .001). (Reprinted with permission from: Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel J. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg. 2004;240:578-83.)

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Initially, mesh repair of abdominal wall defects was accomplished by sewing the edges of the defect to the prosthetic material, which served to “bridge” the defect, much as a cloth patch repairs a defect in a garment (Figure 20-2). Although this was an improvement compared with primary closure, recurrence rates remained high. In the 1980s, surgeons in Europe and then in the United States began to place the mesh in a “sublay” position, allowing a generous underlay of mesh beyond the fascial defect, usually posterior to the rectus abdominus muscle of the abdominal wall (Figure 20-3). This placement utilized the physical forces of the abdominal wall and peritoneal cavity to hold the prosthetic in place, resulting in an effective repair, and dramatically lower rates of recurrence. An additional advantage of this technique, the “Stoppa” repair (named for Rene Stoppa, a French surgeon), was that the mesh was placed in an extraperitoneal position, essentially replacing the transversalis fascia in the pelvis or abdomen.6 In this setting bowel loops were not in contact with the mesh, and the risk of fistula and/or bowel adhesion and subsequent obstruction was minimized. In addition, the “Stoppa” or “Stoppa repair,” or giant prosthetic repair of visceral sac (GPRVS), was popularized in the United States by Wantz7 and could be applied to reconstruction of large groin hernias, particularly when bilateral or recurrent. This was accomplished by placing mesh in the extraperitoneal pelvis posterior to the pubis, anterior to the bladder, and extending into the iliac fossa bilaterally. Again, the extraperitoneal location of the mesh allowed a large sheet to be placed and minimized the potential for ...

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