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  • Incarceration.
  • Strangulation.
  • Bowel obstruction.
  • Functional or cosmetic deformity.
  • Threatened overlying skin.
  • Pain.

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Absolute

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  • Inability to tolerate general anesthetic (cardiopulmonary risk).
  • Absence of tissue for reconstruction (myofascia or skin).
  • Massive loss of peritoneal domain.

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Relative

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  • Infection.
  • Moderate loss of peritoneal domain.
  • Morbid obesity.
  • Malnutrition.
  • Tobacco use.
  • Bleeding diathesis.
  • Ascites.

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Expected Benefits

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  • Restoration of the structure and therefore function of the abdominal wall by reestablishing myofascial continuity and preventing evisceration.

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Potential Risks

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  • Recurrence rates are as high as 50% depending on the type of repair (primary vs mesh, open vs laparoscopic).
  • Complications include:
    • Surgical site infection.
    • Mesh-associated infection and fistulization.
    • Bleeding.
    • Seroma formation.
    • Damage to adjacent structures.
    • Hernia recurrence.
    • Risks related to any major operation (myocardial infarction, pneumonia, and venous thromboembolism).

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  • No special equipment is required for an open repair.
  • Laparoscopic repair utilizes standard laparoscopic equipment, including camera (30 degree), monitor, and appropriately sized ports (5 or 10 mm) with associated trocars.
  • Mesh selection is complex and should be based on an understanding of mesh material properties and their effect on wound healing.
    • Meshes may be made of permanent synthetic plastics, rapidly absorbed polymers, or biologic extracellular matrices.

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  • The number of previous attempts at hernia repair should be elicited, including whether or not mesh was used.
  • If the patient smokes or is overweight, lifestyle changes should be recommended prior to the operation.
  • Nutrition should be optimized and medications adjusted as necessary (eg, discontinuing methotrexate and steroids) to decrease the likelihood of wound healing problems.
  • Visual inspection should include looking for existing abdominal scars that may influence the operative plan.
  • The fascial defect should be palpated to determine if the contents of the hernia sac are reducible.
  • CT imaging is helpful for outlining the exact size and location of the fascial defect, which is often larger than it may appear on clinical examination.
  • CT imaging also reveals the contents of the hernia sac, condition of the abdominal wall musculature for reconstruction, and the presence of other hernias.

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  • The patient should be supine for the most common midline incisional hernias.
  • Modified decubitus positions are used for flank incisional hernia repairs, with appropriate pressure points padded.
  • Limited hip flexion can help relax the abdominal wall musculature.
  • Tilting the head of the operating table up or down, left or right, aids in gravity-assisted retraction of the abdominal viscera and reduction of the hernia sac contents.

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  • Figure 41–1: Sharp dissection is carried down through the skin and subcutaneous tissue to the underlying fascia.
    • The hernia sac (blue) can sometimes be difficult to expose, especially if its contents are already reduced secondary to proper patient positioning.
    • If present, the thin layer of overlying fascia is delicately teased off the hernia sac and dissected back to fascia with sufficient bulk and robust blood supply to ...

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