[Incisional hernia of the abdominal wall. Pathophysiology, etiology and prosthetic repair techniques]

Postoperative incisional hernia is defined by 3 essential criteria, based on a perfect clinico-pathological knowledge of the abdominal wall: the site, dimensions, and defect. Two main elements predispose to incisional hernia: infection and mechanical factors. Local and systemic complications, accentuated in large incisional hernias, are respectively defined by two concepts: "incisional hernia lesion" and "incisional hernia disease". Precise assessment of these elements can guide the surgeon's operative strategy. Incisional hernias remain a relatively frequent complication of abdominal surgery. All of these patients generally require surgical repair of the abdominal wall. A French national survey showed that most surgeons now use prosthetic materials in 60% of primary repairs, and in 85% of recurrent cases. After reviewing the biomechanical characteristics and the in vivo behaviour of commercially available prostheses, the technical principles of prosthetic abdominal wall surgery will be considered together with the various implantation sites: retromuscular, intraperitoneal and premuscular. Based on their personal experience of 110 cases of large incisional hernias, treated between 1989 and 1998, the authors recommend the intraperitoneal position using expanded polytetrafluoroethylene, a reliable material which is well tolerated in contact with the viscera.