Inguinal And Incisional Hernias

In their Seminar (Nov 8, p 1561),1Kingsnorth A LeBlanc K Hernias: inguinal and incisional.Lancet. 2003; 362: 1561-1571Summary Full Text Full Text PDF PubMed Scopus (615) Google Scholar Andrew Kingsnorth and Karl LeBlanc discuss the prevention of incisional hernias, but overlook the most important way of avoiding incisional hernias—ie, by use of the lateral paramedian incision and the avoidance of midline incisions. There is clear evidence from randomised controlled trials2Gilbert JM Ellis H Foweraker S Peritoneal closure after lateral paramedian incision.Br J Surg. 1987; 74: 113-115Crossref PubMed Scopus (33) Google Scholar, 3Guillou PJ Hall TJ Donaldson DR Broughton AC Brennan TG Vertical abdominal incisions—a choice?.Br J Surg. 1980; 67: 395-399Crossref PubMed Scopus (54) Google Scholar, 4Donaldson DR Hegarty JH Brennan TG Guillous PJ Finan PJ Hall TJ The lateral paramedian incision—experience with 850 cases.Br J Surg. 1982; 69: 630-632Crossref PubMed Scopus (32) Google Scholar, 5Ellis H Bucknell TE Cox PJ Abdominal incisions and their closure.Curr Prob Surg. 1985; 22: 1-51Summary Full Text PDF PubMed Scopus (59) Google Scholar that the lateral paramedium incision is far superior to the midline incision, reducing the incidence of incisional hernia to as low as 0·33% at 1 year without a single dehiscence. The additional 10–20 min required by the lateral paramedian incision is far less expensive than the cost of repairing (often unsuccessfully) the roughly 10% or more hernias occurring in midline incisions. It is incredible in this age of emphasis on evidence-based medicine that the midline incision, with its attendant morbidity, is the most commonly employed means of access for this operation.