الفهرس Only 14 pages are availabe for public view
 |  | from | 194 |  |  |
| | | from | 194 | | |
Abstract
Surgeons often face patients with ventral hernia, which can usually be closed by primary closure or with synthetic mesh after adequate undermining. The goal of ventral hernia repair is to achieve sound abdominal wall and to decrease the incidence of recurrence. Although different procedures were designed to avoid the application of alloplastic materials such as mesh, and durable skin coverage with local innervated tissues, the results were not satisfactory (Nho et al., 2003).
Ventral incisional hernia is a common problem encountered by surgeons (Millikan, 2003). Ventral hernia usually occur as a result of inadequate healing of a previous incision or excessive strain at the site of an abdominal wall scar (Eubanks, 2001).
An incisional hernia usually starts as a symptomless partial disruption of the deeper layers of a laparotomy wound during the immediate or very early postoperative period (Bennett and Kingsnorth, 2004). It is the most common postoperative wound complication after abdominal surgery, developing in 2% to 11% of ventral laparotomy incisions (Iskit et al., 1998 and Mark et al., 2002).
Much evidence suggests that hernia formation and recurrence depends in part on a systemic predisposition due to an abnormal metabolism of the connective tissue and in part on other risk factors, surgical and as well as nonsurgical (Sorensen et al., 2002):
Tensile strength of wound is highly dependent on stable collagen molecules. Hydroxylation of proline and lysine plays a role in stabilizing collagen as this process produces inter- and intramolecular cross-linking and glycosylisation of collagen (Pans et al., 1997).
Synthetic mesh material used in hernia repair induces a foreign body reaction with intense inflammatory response and secondary fibrillogenesis and connective tissue deposition. However, the tissue response depends on the implanted mesh material (Pans et al., 1997).
The structure of polypropylene allows penetration of newly formed vessels and a total integration with reparative tissue, whereas the ePTFE mesh is embedded sandwich-like by orderly connective tissue on the internal and external surface. However, all types of mesh material provide a scaffold for the reparative processes, creating a firm fibrotic scar (Bellon et al., 1995).
The management of major anterior abdominal wall ventral incisional hernia continues to be a fundamental and challengable problem for surgeons (Bauer et al., 1999).
Not all postoperative ventral hernia need to be repaired. One frequently finds a low, wide bulge down the length of the old incision, when it does not bother the patient and shows no signs of growing, there is no indication for re-operating. For most other types, repair should be undertaken (Abrabamson, 1997). Small ventral hernia may be temporarily controlled, but no spontaneous cures can be expected. A wide belt or corset gives a patient with a large hernia some comfort and may be used for palliation when surgical treatment is contraindicated, although it hides potential problems (Read, 1996). The abdominal belt is sometimes satisfactory, especially in cases of a hernia through an upper abdominal incision (Bennett and Kingsnorth, 2004)
Incisional ventral hernia repair vary from primary closure only, primary closure with relaxing incisions, primary closure with an onlay mesh reinforcement, onlay mesh placement only, inlay mesh placement, retrorectus mesh placement, and intraperitoneal mesh placement. Combinations of the above types of repair include a sandwich technique in which mesh is placed as both an onlay and either retrorectus or intraperitoneal, and a cuff technique in which mesh is placed around the muscle on each side of the defect and then the mesh-reinforced edges are primarily closed (Millikan, 2003).
Primary closure techniques can vary from surgeon to surgeon. The most simple closure technique involves using continuous or interrupted sutures to approximate the edges of the fascial defect (Millikan, 2003). This type of closure is usually performed for small fascial defects less than 5cm in greatest diameter. Even for small hernia defects, recurrence