Subcutaneous extraperitoneal repair of ventral hernias: a biological basis for fascial transplantation.

Two fundamental biological differences between normal fascia and scar tissue are rate of collagen turnover and physical weave of collagen subunits. Both factors account for unsatisfactory results following ventral hernia repair unless scar tissue is excised and normal fiscia used. Removal of scar and identification of normal fascia often require extensive dissection, entrance into the peritoneal cavity, and sometimes requires lysis of intestinal adhesions with occasional injury to bowel. Simple imbrication of the hernia sac, as in treatment of a direct inguinal hernia, without excision usually results in recurrence of the hernia because of remodeling and attenuation of scar tissue. A new procedure, based upon the technique of direct inguinal hernia repair without opening peritoneum, has been performed on 12 patients with large ventral hernias. The procedures, performed entirely in a subcutaneous plane, involves imbrication of scar, transfer of a massive fascial onlay graft, and use of an internal stent. Patients have been followed for one to 5 years; there have been no recurrences. Inductive influence of the fascial transplant has been measured in two patients; a tenfold increase in net collagen synthesis and deposition occurs for at least one year following transplantation of fascia to an imbricated scar recipient area.