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Purpose: Lumbar incisional hernias (LIH) are a rare wall defect, whose surgical management is challenging because no recommendation exists. Moreover, LIH are frequently associated with flank bulging which should be taken into account during LIH surgical repair. We aimed to describe a cohort of patients operated on for LIH using a homogeneous surgical technique and to report surgical outcomes., Methods: The records of all consecutive patients operated on in a specialized surgical center between January 2009 and January 2015 were retrospectively reviewed. The same open technique was performed, i.e., using a mesh into the retroperitoneal space posteriorly, placed with the largest overlap inferiorly and posteriorly, and fixed through the controlateral abdominal wall muscles under strong tension to correct the flank bulging., Results: The cohort included 31 patients, of median age 62, who presented two or more comorbidities in 68% of cases. LIH was recurrent in 45% of patients, and was related to nephrectomy in 61% of patients. The mesh was totally extraperitoneal in 65% of patients. The postoperative mortality rate was null. The rate of specific surgical complications was 32.3%, and the rate of overall postoperative morbidity (Clavien-Dindo classification) was 38.7%. After a median follow-up of 27.5 months, the recurrence rate was 6.5% and 9.7% reported chronic pain., Conclusion: The open approach for LIH repair was safe and enabled treating flank bulging simultaneously in all patients. Due to the paucity of adequate scientific studies, this reproducible open method could help moving toward a standardization of LIH surgical management.

Background: Despite the prevalence of complex ventral hernias, there is little agreement on the most appropriate technique or prosthetic to repair these defects, especially in contaminated fields. Our objective was to determine French surgical practice patterns among academic surgeons in complex ventral hernia repair (CVHR) with regard to indications, most appropriate techniques, choice of prosthesis, and experience with complications., Methods: A survey consisting of 21 questions and 6 case-scenarios was e-mailed to French practicing academic surgeons performing CVHR, representing all French University Hospitals., Results: Forty over 54 surgeons (74%) responded to the survey, representing 29 French University Hospitals. Regarding the techniques used for CVHR, primary closure without reinforcement was provided in 31.6% of cases, primary closure using the component separation technique without mesh use in 43.7% of cases, mesh positioned as a bridge in 16.5% of cases, size reduction of the defect by using aponeurotomy incisions without mesh use in 8.2% of cases. Among the 40 respondents, 36 had experience with biologic mesh. There was a strong consensus among surveyed surgeons for not using synthetic mesh in contaminated or dirty fields (100%), but for using it in clean settings (100%). There was also a strong consensus between respondents for using biologic mesh in contaminated (82.5%) or infected (77.5%) fields and for not using it in clean setting (95%). In clean-contaminated surgery, there was no consensus for defining the optimal therapeutic strategy in CVHR. Infection was the most common complication reported after biologic mesh used (58%). The most commonly reported influences for the use of biologic grafts included literature, conferences and discussion with colleagues (85.0%), personal experience (45.0%) and cost (40.0%)., Conclusions: Despite a lack of level I evidence, biologic meshes are being used by 90% of surveyed surgeons for CVHR. Importantly, there was a strong consensus for using them in contaminated or infected fields and for not using them in clean setting. To better guide surgeons, prospective, randomized trials should be undertaken to evaluate the short- and long-term outcomes associated with these materials in various surgical wound classifications., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

In clean surgery (Altemeier Class I), the incidence of infections is not increased by the placement of prosthetic material. Prosthetic mesh infections occur more frequently and are more serious in ventral incisional repair than in inguinal hernia repair. While removal of the mesh resolves the infectious problem, it creates other problems that are equally difficult. This underscores the need to: explore other conservative hernia treatment options; in the end, these are often feasible; respect and implement strict measures to prevent infection., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Large incisional hernias cannot be cured without prosthetic material. A large pore size prosthetic tissue seems to be the best alternative, since connective invasion of the mesh provides a very strong fixation of the prosthesis. In our view, the mesh should be placed in the rectus sheath, in a position we have described as "retromuscular prefascial". With this technique, a good result can be achieved in 98% of very large incisional hernias.

Two French surgical teams particularly interested in hernia problems detail the use of Dacron (Mersilene) mesh in the treatment of groin hernias for the reinforcement or the replacement of the fascia transversalis , as by an artificial endoabdominal fascia. The article reports the experiences and techniques of the two teams, which have used Dacron for 20 years, either by the inguinal or the preperitoneal abdominal approach. The good results reported allow the statement that, without ruling out classic techniques for simpler cases, surgical repair using prostheses offers an excellent opportunity for use and for preventing the recurrence of hernias.