Chapter 41. Ventral Hernia Repair

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

Absolute

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

Relative

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

Expected Benefits

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

Potential Risks

• 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).

• 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 ...