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INDICATIONS

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Ventral hernias in the anterior abdominal wall include both spontaneous or primary hernias (e.g., umbilical, epigastric, and spigelian) and, most commonly, incisional hernias that occur after an abdominal operation. It is estimated that 2% to 13% of all abdominal operations result in an incisional hernia. Risk factors for the development of an incisional hernia include obesity, multiple abdominal procedures, diabetes, wound infections, and the use of immunosuppressive medication(s). Small primary ventral hernias are often successfully closed with primary tissue repairs. Repair of incisional hernias often utilizes synthetic or biologic mesh to decrease recurrence rates. In some patients, the use of mesh is contraindicated or not desired and the hernia defect is too large or extensive to allow for appropriate primary closure. In the event of real or potential contamination, the use of synthetic mesh may be contraindicated. In addition, patients may request or require a more cosmetic repair of their abdominal wall as part of their treatment with “medialization” of their abdominal wall musculature that was previously displaced due to the ventral/incisional hernia. In patients whom synthetic mesh cannot be utilized, native abdominal wall fascia and musculature must be used to close the hernia defect and reapproximate the abdominal wall components while minimizing the potential for hernia recurrence. Open component separation is used almost exclusively for midline ventral hernia defects, whether they are single or multiple, when the use of synthetic or biologic mesh is not an option for repair. Component separation enables the detection and repair of multiple defects—a common finding in midline incisional hernias.

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PREOPERATIVE PREPARATION

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The patient must be free of active infections, especially in the skin. Respiratory function should be optimized with cessation of smoking and appropriate pulmonary function evaluation. If bowel is contained with the hernia, endoscopic visualization, contrast studies, or imaging may be performed preoperatively and the patient may be given a bowel preparation with a liquid diet and cathartics for 1 or 2 days prior to surgery. The major factors in the occurrence of this hernia, as well as the preceding operative note(s), should be reviewed.

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ANESTHESIA

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General anesthesia with an endotracheal tube is required.

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POSITION

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The patient is placed in a supine position with a pillow placed to produce mild flexion of the hips and knees. This helps to relax the abdominal wall and take some tension off of any repair performed.

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OPERATIVE PREPARATION

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The patient is given perioperative antibiotics. An orogastric tube is passed for gastric decompression. If significant dissection is anticipated, a nasogastric tube may be placed for postoperative decompression of the stomach in the event of an ileus. A Foley catheter may be placed and pneumatic sequential stockings are applied. The skin is prepared in the routine manner with attention to prepping the patient’s abdominal wall laterally as this may be accessed as ...

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