Technical consideration for subxiphoidal incisional hernia repair.
BACKGROUND
The main principle of incisional hernia repair with mesh augmentation is a wide overlap of at least 5 cm in all directions. This is complicated when cartilaginous or osseous structures border the fascial defect, most notably at the xiphoid after sternotomy or in large proximal incisional hernias.


METHODS
We performed an anatomic investigation of this "problematic" area with its different structures and layers that form the retroxiphoidal space.


CONCLUSIONS
The posterior lamina of the rectus sheath inserts on the posterior side of the xiphoid. This lamina inhibits a sufficient mesh placement. By sharp dissection dorsal the xiphoid process, the posterior lamina of the rectus sheath can be detached. This way the retroxiphoidal space can be opened. Further development of this space can be made by blunt dissection. In some cases, with retroxiphoidal scar formation after sternotomy, a sharp dissection might be necessary. This enables a combined retromuscular-retroxiphoid mesh augmentation repair with a sufficient underlay of at least 5 cm, according to the principles of sublay technique.
Conze
J
J
Surgical Department and Institute for Anatomy, Rhenish Westphalian Technical University, Pauwelsstrasse 30, 52074 Aachen, Germany. jconze@ukaachen.de
Prescher
A
A
Kisielinski
K
K
Klinge
U
U
Schumpelick
V
V
D002102:Cadaver; D002921:Cicatrix / Q000473:pathology / Q000601:surgery*; D006555:Hernia, Ventral / Q000209:etiology / Q000473:pathology / Q000601:surgery*; D006801:Humans; D019919:Prosthesis Implantation / Q000295:instrumentation; D017568:Rectus Abdominis / Q000033:anatomy & histology / Q000601:surgery; D012008:Recurrence; D012086:Reoperation; D013526:Surgical Mesh; D013514:Surgical Procedures, Operative / Q000379:methods* / Q000592:standards; D013909:Thorax / Q000033:anatomy & histology; D014989:Xiphoid Bone / Q000033:anatomy & histology* / Q000601:surgery