title: Long-term follow-up of technical outcomes for incisional hernia repair.
abstract: BACKGROUND
  Incisional hernia repair (IHR) is plagued by high recurrence rates and lack of long-term outcomes data to guide repair technique. Mesh repair reduces recurrence rates but lacks standardization of technique. We investigated long-term outcomes of elective IHR, focusing on technical predictors of recurrence.
  
  
  METHODS
  This retrospective multicenter cohort study included elective IHR performed at 16 Veterans Affairs hospitals between 1997 and 2002. Hernia characteristics and operative details were abstracted from operative notes, and chart review was performed to identify recurrence and complications. Kaplan-Meier curves and Cox regression models were used to evaluate the effects of hernia characteristics and operative technique on recurrence.
  
  
  RESULTS
  There were 1,346 elective IHRs, of which 22% were recurrent hernias. Repair technique was primary suture in 31%, open inlay or onlay mesh in 30%, open underlay in 30%, and laparoscopic in 9%. At median follow-up of 73.4 months, there were 383 recurrences (28.5%), 23 mesh removals (1.7%), and 7 enterocutaneous fistulas (ECF) (0.5%). On Cox regression modeling with adjustment for hernia and Veterans Affairs site characteristics, the effectiveness of mesh varied by position. Compared with suture repair, laparoscopic (hazard ratio = 0.49; 95% CI, 0.28-0.84) and open underlay mesh repair (hazard ratio = 0.72; 95% CI, 0.53-0.98) substantially reduced the recurrence risk, but onlay or inlay mesh repair did not. Mesh position did not affect mesh removal or ECF rates.
  
  
  CONCLUSIONS
  Underlay technique, either laparoscopic or open, for mesh implantation during elective IHR substantially reduces the risk of recurrence, without increasing the risk of serious mesh infection or ECF.
authors.affiliation: Center for Surgical, Medical Acute Care Research and Transitions (C-SMART), Birmingham Veterans Affairs Hospital, Birmingham, AL, USA. mhawn@uab.edu
authors.forename: Mary T
authors.initials: MT
authors.lastname: Hawn
authors.forename: Christopher W
authors.initials: CW
authors.lastname: Snyder
authors.forename: Laura A
authors.initials: LA
authors.lastname: Graham
authors.forename: Stephen H
authors.initials: SH
authors.lastname: Gray
authors.forename: Kelly R
authors.initials: KR
authors.lastname: Finan
authors.forename: Catherine C
authors.initials: CC
authors.lastname: Vick
mesh_terms: D000368:Aged; D018572:Disease-Free Survival; D005260:Female; D005500:Follow-Up Studies; D006555:Hernia, Ventral / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D012008:Recurrence; D012189:Retrospective Studies; D013526:Surgical Mesh; D013536:Suture Techniques; D016896:Treatment Outcome