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Closing the Gap: Medialization of the Rectus Abdominis with Laparoscopic Incisional Hernia Repair
*Lucian Panait, Robert L Bell, Kurt E Roberts, Andrew J Duffy
Yale School of Medicine, New Haven, CT

Objective: Laparoscopic incisional hernioplasty (LIH) bridges the fascial gap between the rectus muscles with a posteriorly placed mesh, and is a low recurrence alternative to other reconstructions. It is unclear if this repair optimizes the function of the abdominal wall. We hypothesize that significant medialization of the fascial edges occurs in patients who undergo LIH.
Design: Retrospective study
Setting: Academic hospital
Patients: 258 patients underwent LIH by a single surgeon between 2004-2012. 49 of these (the study group) had pre and post-operative CT scans that illustrated the gap between the rectus muscles.
Interventions: All 49 patients underwent LIH with polyester composite mesh, with suture and tack fixation.
Main Outcome Measures: The distance between the fascial edges on the pre and postoperative CT scans was compared. Percent medialization was calculated for each defect.
Results: Average fascial separation reduction was 0.72 cm (6.27 to 5.55 cm, 11.41% medialization, p<0.0001). 39 of 49 patients demonstrated a reduction in hernia defect width (79.6%): these defects reduced 1.05 cm (6.25-5.20cm, 16.81% medialization, p<0.0001). In defects wider than than 5 cm, the width reduced by 0.87 cm (8.9 cm to 7.31cm, n=29, 10.6% medialization, p=0.003). The use of meshes ≥ 500 cm2 reduced the defect by 0.95 cm (8.42 cm to 7.47 cm, 11.23% medialization, n=22, p<0.005).
Conclusions: Significant medialization of the rectus muscles is evident in most patients undergoing LIH. Although the rectus muscles are not ideally approximated, this may help improve the function of the anterior abdominal wall. Alternate techniques of abdominal wall reconstruction may provide more complete anatomic and functional repairs for selected patients. Further technical refinements and material improvements may improve the reconstructive results of the LIH.

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