Original Article A LONG TERM FOLLOW UP: MESH VERSUS MAYO S REPAIR IN PARA- UMBILICAL HERNIA.

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1 Original Article VERSUS MAYO S REPAIR IN PARA- UMBILICAL HERNIA. Abdul Qayoom Daudpoto *, Shahid Mirani **, Rafique Ahmed Memon ***, Dr Qarib Abbas **** * Assistant Professor Surgery (Former)Department Of Surgery Unit II ** Assistant Professor Surgery, Department Of Surgery Unit II *** Associate Professor Surgery, Department Of Surgery Unit II **** Professor Surgery, Department Of Surgery Unit II Ghulam Muhammad Mahar Medical College Hospital Sukkur. A Long Term Follow up: Mesh versus Mayo s repair in Para-umbilical Hernia. ABSTRACT Objectives: To compare the results of Complication length of follow up and recurrence rate in between two groups of mesh repair and mayo s repair in adult para-umlical hernia. Material and method: A comparative study is carried out in surgical unit 2 Department of surgery Ghulam Muhammad Maher Medical College Sukkur from Feb to Jan Sixty eight patients were randomly assigned into 2 groups. Group A underwent onlay mesh repair while Mayo s repair was used in group B patients. All patients having Para umbilical hernia having defect in linea Alba less than 2 cm, irreducible, incarcerated hernia were excluded. Median follow up was 30 months and data collected regarding to size of hernia, type of operation, complications, length of follow up and recurrence rate. Results: More than 60 were above the age of 41 year, male female ratio was 1:7, and supra umbilical swelling was common presentation in (72). Post operative Complications reported in group A and 9.32 in group B including recurrence. There was no significant difference at surgical site, in scar cosmetic results, abdominal wall discomfort during breathing and over all patient satisfaction between both groups. The recurrence rate was 2.7 in mesh repair and 9.3 in mayo s repairs cases with 30 months median long term follow up. Conclusion: Even After Higher Complication rate, mesh repair is superior in terms of recurrence and under certain circumstances suture repair has place, insignificant infection rate less costly and simple. Key words: Paraumbilical Hernia, Mesh repair, Mayo s repair. INTRODUCTION Adult para umbilical hernia described as a acquired defect through decussating fibers of linea alba either above or below the Corresponding Author: Dr. Abdul Qayoom Daudpoto Flat# C-92 Sheraton Heights, Gulshan-e-Iqbal Karachi. Cell No: [email protected] umbilicus 1. It is more common in female 2, abdominal pressure increases in multiparty and obese case, heavy work lifting are pre disposing factors to develop the para umbilical hernia 3. This is second most common variety of ventral hernias, overall 0.3 of all hernias operations performed in UK 4. Elective surgery is a treatment of choice due to recognized risk of obstruction, incarceration and strangulation 5, the choice of appropriate 12 JUMDC Vol. 4, Issue 1, Jan-June 2013

2 surgical procedure is still subject of debate. The established and simplest method of Mayo s repair in which transverse overlapping of defect with non absorbable suture material is carried out 6. The use of mesh to repair the hernia defect either open or laparoscopic is widely used now a day 7, the result of recurrence are lower in mesh repair with drain in para umbilical hernia repair cases 8. The wound infection is common among the post operative complications in both type of repair. The long term follow up show excellent results in mesh repair either open or laparoscopic, however persistent low grade abdominal pain discomfort in breathing during abdominal wall movement, scar formation, disfiguration at surgical site may be develop in both varieties of repair 9,10. This study is carried out to see in long term outcome of mayo s verses mesh repair in elective cases of para umbilical hernia. MATERIAL AND METHOD Study Design: Prospective comparative. Study setup: Department of Surgery Ghulam Muhammad Maher medical college hospital sukkur from Feb: 2008 to Jan: All the patient of uncomplicated para umbilical hernia, having linea alba defect more than 2 cm were included. Exclusion criteria were previous recurrence obesity (BMI of 30 are above) Diabetes Mellitus, anticoagulation and steroid therapy and unfit for general anesthesia. The demographic information and predisposing factors are shown in table I. Detailed History was recorded; general physical examination abdominal and rectal examination was done and recorded on Performa. For concomitant diseases CVS, CNS respiratory tract examination was done the relevant investigation were performed for pre operative evaluation and fitness for general anesthesia. Patient were randomly chosen by closed envelop technique to undergo open onlay mesh repair (Group A) or classical mayo s repair (Group B). For mesh group closure of hernia defect with 2/0 prolene followed by an onlay poly propylene mesh, while for the mayo s repair classical steps were applied in which transverse double breasting repair with non absorbable suture material prolene used, in both groups 16 fr size suction Redivac drain kept in subcutaneously and was removed when effluent was nil/24 hrs. Comparison between 2 groups was done in term of complications, length of follow up and recurrence. Follow up was performed during return visits by telephone calls by simple questionnaire surveys for surgical site discomfort, scar, and discomfort in breathing. RESULTS In this series of 68 patients, the age rangeed from 22 to 75 year, and male female ratio 1:7. In 54 (>79.5) cases predisposing factors like relative multiparty obesity and heavy weight lifting were the commonest (Table-I), and in remaining 14 cases (20.5) may be due to unknown reasons. The supraumbilical swelling in both groups (A&B) reveled 71.4 to 82.2 of patients where as infra umbilical swelling found in 28.6 to 17.8 patients. In group A operative findings showed 2-4 cm defect of linea alba in 23 cases (63.81) and 4 6 cm defect in 13 cases (36.19) where as in group B 2-4 cm was seen in 25 cases (78.12) and 4-6 cm defect in 7 cases (21.88). All cases of both group A&B were operated in general anesthesia the operative time was longer in group A (mesh repair 55.55) ie minutes as compared to Group B (Mayo s repair 68.7) minutes. Hospital stay was longer in group B 5.5 day as compared to group A in which average Hospital stay was 4.5 days. (Table II). Post operative complications in both groups were encountered in 8 cases of group A in 6 cases of group B. In group A wound infection in 4 cases (11.11) and in group B it was in 2 cases (6.22). All these patient treated by antibiotic and local wound care as per pus culture sensitivity reports. Haematoma and seroma developed in 3 cases (5.55, 2.71) in group A and 1 case (3.1) in group B. (Table III). Average hospital stay period was 4.5 days in group A and 5.5 days in group B, the median follow up was 30 months. Three patients of mayo s repair (9.37) developed recurrence while 1 patient (2.71) in mesh repair cases. JUMDC Vol. 4, Issue 1, Jan-June

3 Three cases developed recurrence within 12 months and one patient of mayo s repair had recurrence within 16 months during their follow up. Four case declined follow up after 12 months, 2 died of causes that were unrelated to surgery after 12 months, before completing the follow up. The self administered questionnaire data was collected on patient satisfaction, for indicated 5 proposed items, Clinical characteristics (Table I) the recurrence, degree of late pain (by visual analogue scale) subjective umbilical region discomfort during breathing, scar quality and cosmetic results. During long term follow up this survey was done on their visits and no significant difference found in these items except recurrence which was higher (9.37) in mayo s suture repair then open mesh onlay (2.7) procedures. Characteristic Group A n=36 Group B n=32 Age Sex M:F ratio 1:7 Predisposing factors (n=54) : Multiparty Heavy work lifting Obese Ch cough /smoker BPH yrs (Mean 55 yrs) 33 Female 03 Male 31 Female 01 male Operative Data (Table II) Items Hernia defect 2-4 cm 4-6 cm Operation time 45 to 60 min 61 to 80 min Group A Group B Mesh(n=36) Mayoz (n=32) Hospital stay (Average in days) Post operative complication (Table III) Complications GURUP A (n=36) No Of cases GURUP B (n=32) NO OF CASES Wound infection hematoma Seroma Recurrence Period of follow up In months JUMDC Vol. 4, Issue 1, Jan-June 2013

4 DISCUSSION The trust of surgeons is increasing for mesh repair, in most of abdominal hernias either open or Laparoscopic, reflect the confidence among surgeons. Historical review of literature suggest that these hernias are common in female than male (8:1) 11 and majority of patient are above the age of 40 years 12. In our study the female to male ratio was 7:1 and 60 cases were above the age of 40 years. Mayo s suture repair will take shorter operative time minutes in 68.7 and minutes in 31.4 in group B and in group A mesh repair slight lengthy procedure in which minutes in and in cases it was minutes operative time in our study. Most of studies show that mesh repair is lengthy procedure. Post operative complications like wound infection was in 4 cases (11.11) in group A and in 2 cases (6.2) in group B, which were treated conservatively. Hematoma and seroma was higher in Group A ( ) and lower in group B ( ). Complication rate was higher in group A mesh repair as compare to group B, all were managed conservatively as reported in other studies 13,14. In long term follow up the recurrence was higher in mayo s suture repair (group B 9.3) as compared to mesh repair (Group A 2.3) in our studies. Arroyo in 2001 and Asalani in 2010 reported lower recurrence in open onlay mesh repair than mayo s suture overlap method 15,16. Kingsnorth et al in UK 17 shows 3.4 recurrence in mesh onlay repair and almost double in suture repair method, these results mimiks with our results of recurrence in mesh repair 2.7 and 9.7 in mayo s suture. Another study done by Muller- Riemenschneider et al shows the lower recurrence, short Hospital stay and less pain in case of mesh repair 18, the mesh repair in good in obstructed/strangulated para umbilical hernias repair, as in elective cases 19. Our results of recurrence & Hospital stay in both groups are compareable with national and international studies. More studies are needed to understand the effect of predisposing factors like obesity, multiparity, hernia defect size, cough/smoking, Diabetes Mellitus 20, weight loss in obese patients may reduce the chances of recurrence and post operative complication 21. No significant difference found in this study as well as previous studies in late post operative conditions like scar pain, discomfort in mobility of anterior abdominal wall, disfiguring of belly in both groups. Our results favor for onlay mesh repair procedure in adult pare umbilical hernias repair and mayo s suture techniques may be applied in certain circumstances. CONCLUSION This study concludes, that mesh onlay repair has low recurrence rate, with minimum complications in cases of adult para umbilical hernias. In certain circumstances the mayo s suture repair will not be disqualified even having high recurrence rate. REFERENCE 1. Walmsley R. The Sheath of the Rectus Abdominis, Journal of Anatomy, 1937; 71, (3): Ellis H, Watson c. hernia. In: lecture notes of surgery; 10 th Ed. U.S.A: Blackwell publishing company; 2002: Sukeik M, Alkari B. and Ammori B.J., Abdominal Wall Hernia during Laparoscopic Gastric Bypass: A Se-rious Consideration, Obesity Surgery. 2007; 17, (6): Raftery TA. Hernias and abdominal wall. In Churchill s surgery 2 nd Ed. New York: Churchill s livingstone, 2001: Mahadeevan V. Anatomy of anterior abdominal wall and groin. J. surg international; 2006; 74: Cuschieri A. Disorders of abdominal wall and peritoneal cavity. In: Cuschieri essential surgical practice 4 th ed: London: Arnold (hodder Headline Group); 2002; I: Aslani N and Brown C.J, Does Mesh Offer an Advantage over tissue in the Open Repair of Umbilical Hernias. A Systematic review and Meta-Analysis, Hernia, 2010; 14, (5): JUMDC Vol. 4, Issue 1, Jan-June 2013

5 8. Sauerland S, Schmedt C.J, Lein S, Bernhard J.L and R.Bittner, Primary Incisional Hernia Repair with or without Polypropylene Mesh: A Report on 384 Patients with 5-Year Follow-up, Langenbeck s Archives of Surgery, 2005: 390, (5): Gould J. laparoscopic versus open inguinal hernia repair. Surg clin north Am. 2008; oct; 88(5): Jacobus W. A. B, Luijendijk R. W, Hop W. C. J., Halm J. A., Verdaasdonk E. G. G and Jeekel J, Long-Term Follow-up of a Randomized Controlled Trial of Suture versus Mesh Repair of Incisional Hernia, Annals of Surgery, 2004; 240,(4) : Talamani MA. Chandrakanth. Laparoscopic hernia repair. In: shackleford s Surgery 5 th ed: London: W.B Saunders company 2002; Berrevoet F.concering: Laparoscopic inguinal hernia repair. actachir belg may-jun; 108(3): Bringman S, ramel S, Nyberg B, introduction of herniorrhaphy. Eur j Surg; 2000; 166: Snjay P, reid TD, davies EL, Arumugam PJ, woodward A. retrospective comparison of mesh and sutured repair for adult umbilical hernias. Hernia, 2005 Oct; 9(3):248: Arroyo A, et al., Mesh versus Suture Repair for Umbilical Hernias a Prospective Randomized Clinical Trial Comparing Suture and Mesh Repair of Umbilical Hernia in Adults, British Journal of Surgery, 2001; 88,(10): Menon V.S and Brown T.H, Umbilical Hernia in Adults: Day Case Local Anesthetic Repair, Journal of Postgraduate Medicine, 2003; 49 (2): Kingsnorth A.N, Shahid M.K, Valliattu A.J, Hadden R.A and Porter C.S, Open Onlay Mesh Repair for Major Abdominal Wall Hernias with Selective Use of Components Separation and Fibrin Sealant, World Journal of Surgery, 2008; 32, (1): Muller-Riemenschneider F, Roll S, Friedrich M, Zieren J, Reinhold T, von der J.M, Schulenburg, Greiner W and Willich S.N, Medical Effectiveness and Safety of Conventional Compared to Laparoscopic Inci-sional Hernia Repair: A Systematic Review, Surgical Endoscopy, 2007; 21, (12): Abdel-baki NA, bessa SS Abdel-razzak AH. Comparision of prosthetic mesh repair and tissue repair in the emergency management of incarcerated paraumblical hernia: A prospective randomized study hernia.2007 apr; 11(2): Ching S.S, Sarela A.I, Dexter S.P, et al., Comparison of Early Outcomes for Laparoscopic Ventral Hernia Repair between Non obese and Morbidly Obese Patient Populations, Surgical Endoscopy, , (10), 2008: Vilallonga R, Fort J.M, Gonzalez O, Baena J.A, Lecube A and Armengol M, Management of Patients with Hernia or Incisional Hernia Undergoing Surgery for Morbid Obesity, Journal of Obesity, 2011, Submitted for publication: Accepted for publication: LIVE AMONGST PEOPLE IN SUCH A MANNER THAT IF YOU DIE THEY WEEP OVER YOU AND IF YOU ARE ALIVE THEY CRAVE FOR YOUR COMPANY. Hazrat Ali (Karmulha Wajhay) UNFORTUNATE IS HE WHO CANNOT GAIN A FEW SINCERE FRIENDS DURING HIS LIFE AND MORE UNFORTUNATE IS THE ONE WHO HAS GAINED THEM AND THEN LOST THEM (THROUGH HIS DEEDS). Hazrat Ali (Karmulha Wajhay) 16 JUMDC Vol. 4, Issue 1, Jan-June 2013