- Bowel obstruction.
- Functional or cosmetic deformity.
- Threatened overlying skin.
- Inability to tolerate general anesthetic (cardiopulmonary risk).
- Absence of tissue for reconstruction (myofascia or skin).
- Massive loss of peritoneal domain.
- Moderate loss of peritoneal domain.
- Morbid obesity.
- Tobacco use.
- Bleeding diathesis.
- Restoration of the structure and therefore function of the abdominal wall by reestablishing myofascial continuity and preventing evisceration.
- 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.
- Seroma formation.
- Damage to adjacent structures.
- Hernia recurrence.
- Risks related to any major operation (myocardial infarction, pneumonia, and venous thromboembolism).
- 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.
- 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.
- 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.
- 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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