[Incisional hernia. Patient management. Approach to the future operated patients]

Incisional hernia, an abnormal orifice of the midline abdominal wall secondary to an operation, presents in a wide range of forms to the plastic surgeon: small orifice (< 6 cm) in a young, muscular subject, or vast defect (> 10 cm) in an obese subject who has undergone multiple operations, or who presents one or more diseases. Regardless of this presentation, the approach to the patient must always be just as rigorous, based on a precise assessment of the clinical signs. This clinical examination is irreplaceable, but is often insufficient, incomplete, and misleading. Only CT imaging of the abdominal wall provides a good analysis of the damage. Beyond the simple orifice, a large incisional hernia is responsible for a whole range of disease. This "incisional hernia disease", with its visceral and respiratory components, requires a multidisciplinary assessment. The anaesthetist and respiratory physician must assess the repercussions of this lesion and detect any risk factors. Based on this assessment, major incisional hernias (2/3 of the 350 operated patients of our series) require specific preparation involving the following elements: eradication of any site of wound infection, weight loss, muscle building, abdominal and chest physiotherapy, and pneumoperitoneum. Pneumoperitoneum according to the Goni Moreno protocol is an essential element of the preparation of the most difficult forms (irreducible, double, or complicated incisional hernias). Only this gaseous expansion of the abdomen can facilitate reintegration of the viscera and reconstruction of the abdominal wall. In our practice, the operation itself consists of 2 types of procedures: simple local abdominoplasty (e.g. Judd's technique) for small incisional hernias (about 20% of cases), or a combination of reconstitution of the deep fascia by extensive cleavage of the posterior sheath of the rectus abdominis and prosthesis. This prosthesis, which lines the fascial plane, is placed extraperitoneally. This technique, with several variants described here, is based on a similar concept to that promoted by Rives et al. and Stoppa et al. It is the preferred procedure in all large incisional hernias (80% in our experience). Patient selection, intensive preparation, meticulous technique, and intensive postoperative nursing give stable, solid results (90% of patients) and ensure optimal security, bearing in mind that repair of a large incisional hernia is always difficult and sometimes dangerous (1% mortality, 6 to 10% morbidity in all large series).