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General Considerations
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The abdominal wall provides structure, protection, and support for abdominal and retroperitoneal structures and is defined superiorly by the costal margins, inferiorly by the pelvic ring, and posteriorly by the vertebral column. Knowledge of its specific anatomic features is required for management of abdominal wall diseases or during entry into the peritoneal cavity.
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The abdominal wall is an anatomically complex, layered structure with segmentally derived blood supply and innervation (Fig. 35-1). It is mesodermal in origin and develops as bilateral migrating sheets, which originate in the paravertebral region and envelop the future abdominal area. The leading edges of these structures develop into the rectus abdominis muscles, which eventually meet in the anterior midline. The rectus abdominis is longitudinally oriented and encased within an aponeurotic sheath, the layers of which are fused in the midline at the linea alba. The rectus insertions are on the pubic bones inferiorly and on the fifth and sixth ribs, as well as the seventh costal cartilages and the xiphoid process superiorly. The lateral border of the rectus muscles has a curved shape identifiable as the surface landmark, the linea semilunaris. Three tendinous intersections cross the rectus muscles at the level of the xiphoid process, umbilicus, and about halfway between the xiphoid process and the umbilicus (see Fig. 35-1).
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Lateral to the rectus sheath are three muscular layers with oblique fiber orientations relative to one another (Fig. 35-2). These layers are derived from laterally migrating mesodermal tissues during the sixth to seventh week of fetal development. The external oblique muscle runs inferiorly and medially, arising from the margins of the lowest eight ribs and costal cartilages. The external oblique muscles originate on the latissimus dorsi and serratus anterior muscles, as well as on the iliac crest. Medially, the external obliques form a tendinous aponeurosis, which is contiguous with the anterior rectus sheath. The inguinal ligament is the inferior-most edge of the external oblique aponeurosis, reflected posteriorly in the area between the anterior superior iliac spine and pubic tubercle. The internal oblique muscle lies deep to the external oblique and arises from the lateral aspect of the inguinal ligament, the iliac crest, and the thoracolumbar fascia. Its fibers course superiorly and medially and form a tendinous aponeurosis that contributes components to both the anterior and posterior rectus sheath. The lower medial and inferior-most fibers of the internal oblique may fuse with the lower fibers of the transversus abdominis muscle (the conjoined area). The inferior-most fibers of the internal oblique muscle are contiguous with the cremasteric muscle in the inguinal canal. These relationships are of critical significance in the management of inguinal hernias. The transversus abdominis muscle is the deepest of the three lateral muscles and runs transversely from the lowest six ribs, the lumbosacral fascia, and the iliac crest, to the lateral border of the rectus abdominis. The arcuate line (semicircular line of Douglas) lies roughly at the level of the anterior superior iliac spines (Fig. 35-3). Above the arcuate line, the anterior rectus sheath is formed by the external oblique aponeurosis and the external lamina of the internal oblique aponeurosis, whereas the posterior rectus sheath is formed by the internal lamina of the internal oblique aponeurosis and the transversus abdominis aponeurosis. Below the arcuate line, the anterior rectus sheath is formed by the external oblique aponeurosis, the laminae of the internal oblique aponeurosis, and the transversus abdominis aponeurosis. There is no aponeurotic posterior covering of this lower portion of the rectus muscles, although the endoabdominal, or transversalis, fascia provides contiguous coverage of the posterior aspect of the abdominal above and below the arcuate line.
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The blood supply to the muscles of the anterior abdominal wall is derived mainly from the superior and inferior epigastric arteries (Fig. 35-4). The superior epigastric artery arises from the internal thoracic artery, while the inferior epigastric artery arises from the external iliac artery. A collateral network of branches of the subcostal and lumbar arteries also contributes the abdominal wall blood supply. The lymphatic drainage of the abdominal wall is predominantly to the major nodal basins in the superficial inguinal and axillary areas.
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Anterior abdominal wall innervation is segmental. Motor nerves to the rectus, oblique, and transversus abdominis muscles run from the anterior rami of spinal nerves at the T6 to T12 levels. The overlying skin is innervated by afferent branches of the T4 through L1 nerve roots, with T10 nerve roots providing sensation around the umbilicus (Fig. 35-5).
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The rectus muscles, external obliques, and internal obliques work as a unit to flex the trunk anteriorly or laterally. Trunk rotation is achieved by simultaneous contraction of a unilateral external oblique and the contralateral internal oblique (e.g., rotation to the right is produced by contraction of the left external oblique muscle and the right internal oblique). All of the truncal muscles are involved in raising intra-abdominal pressure. Abdominal musculature contraction that occurs when the diaphragm is relaxed will result in expiration of air from the lungs, or a cough if this contraction is forceful. If the diaphragm is contracted when the abdominal musculature is contracted (Valsalva maneuver), the increased abdominal pressure aids in processes such as micturition, defecation, and childbirth.
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Abdominal Anatomy and Surgical Incisions
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Surgeons must deal with the abdominal wall to access pre-, intra-, and retroperitoneal sites. This begs practical questions of where and how to make incisions. Incisions for open surgery are generally located in proximity to the principal operative targets. Laparoscopic port site incisions might be remote from the site of interest and are carefully planned based on the instrument approach angles and working distances both to the operative site and between ports. Orientation of any incision may be determined based on expected quality of exposure, closure considerations including cosmesis, avoidance of previous incision sites, and surgeon preference. In general, incisions for open peritoneal access can be longitudinal (in or off the midline), transverse (lateral to or crossing midline), or oblique (directed either upward or downward toward the flank) (Fig. 35-6). Modifications are numerous and can consist of various extensions to optimize exposure in specific clinical situations. Midline incisions are used for the majority of nonlaparoscopic procedures on the gastrointestinal tract. Incising the fused midline aponeurotic tissue of the linea alba is simple and does not injure skeletal muscle. Paramedian incisions through the rectus abdominis sheath structures have largely been abandoned in favor of midline or nonlongitudinal incisions. Incisions lateral to the midline made with transverse or oblique orientations can either divide the successive muscular layers or bluntly separate the fibers. This latter muscle-splitting approach, exemplified by the classic McBurney incision for appendectomy, may be less destructive to tissue but offers more limited exposure. Subcostal incisions on the right (Kocher incision for cholecystectomy) or left (for splenectomy) are archetypal muscle-dividing incisions that result in transection of intervening musculoaponeurotic tissues, including a portion of the rectus abdominis. These incisions are closed in two layers, the more superficial one incorporating the anterior aponeurotic sheath of the rectus medially, transitioning to external oblique muscle and aponeurosis laterally. The posterior, deeper layer consists of internal oblique and transversus abdominis muscle. Similar anatomic considerations are guide closure of transversely oriented muscle-dividing incisions. The Pfannenstiel incision, used commonly for pelvic procedures, is distinguished by transverse skin and anterior rectus sheath incisions, followed by rectus muscle retraction and longitudinal incision of the peritoneum. Irrespective of the incision type, suture apposition of abdominal wall tissues during closure is accomplished without significant tension and with great precision.
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Abdominal incisions can lead to short- and long-term complications and patient disability. The question of how large an incision ought to be has no simple answer. In general, it is prudent to make incisions no larger than necessary to safely accomplish the operative goals. Laparoscopic and other minimally invasive surgical methods owe their development in large part to the belief that minimizing surgical injury to the abdominal wall is of significant benefit to the patient. For open surgery, a variety of devices are available to retract the abdominal wall and facilitate peritoneal exposure without subjecting the patient to excessively large incisions or surgical personnel to exhausting retraction tasks (Fig. 35-7). Examples include the Bookwalter™, Omni-Tract¯, and Thompson retractors.
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Congenital Abnormalities
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The abdominal wall layers begin to form within in first weeks following conception. In early embryonic development, there is a large central defect through which pass the vitelline (omphalomesenteric) duct and allantois. The vitelline duct connects the embryonic and fetal midgut to the yolk sac. During the sixth week of development, the abdominal contents grow too large for the abdominal wall to completely contain them, and the embryonic midgut herniates into the umbilical cord. While outside the developing abdomen, it undergoes a 270-degree counterclockwise rotation on the developing mesentery. At the end of the twelfth week, it returns to the abdominal cavity. Defects in abdominal wall closure may lead to omphalocele or gastroschisis. In omphalocele, viscera protrude through an open umbilical ring and are covered by a sac derived from the amnion. In gastroschisis, the viscera protrude through a defect lateral to the umbilicus and no sac is present.
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During the third trimester, the vitelline duct regresses. Persistence of a vitelline duct remnant on the ileal border results in a Meckel’s diverticulum. Complete failure of the vitelline duct to regress results in a vitelline duct fistula, which is associated with drainage of small intestinal contents from the umbilicus. If both the intestinal and umbilical ends of the vitelline duct regress into fibrous cords, a central vitelline duct (omphalomesenteric) cyst may occur. Persistent vitelline duct remnants between the gastrointestinal tract and the anterior abdominal wall may be associated with small intestinal volvulus in neonates. When diagnosed, vitelline duct fistulas and cysts should be excised along with any accompanying fibrous cord.
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The urachus is a fibromuscular tubular extension of the allantois that develops with the descent of the bladder to its pelvic position. Persistence of urachal remnants can result in cysts as well as fistulas to the urinary bladder with drainage of urine from the umbilicus. These are treated by urachal excision and closure of any bladder defect that may be present.
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Acquired Abnormalities
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Rectus Abdominis Diastasis
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Rectus abdominis diastasis (or diastasis recti) results from a separation of the two rectus abdominis muscle pillars. This results in the characteristic bulging of the abdominal wall in the epigastrium that is sometimes mistaken for a ventral hernia despite the fact that the midline aponeurosis is intact and no hernia defect is present. Diastasis may be congenital, as a result of a more lateral insertion of the rectus muscles to the ribs and costochondral junctions, but is more typically an acquired condition with advancing age, obesity, or following pregnancy. In the postpartum setting, rectus diastasis tends to occur in women of advanced maternal age, after multiple or twin pregnancies, or in women who deliver high-birth-weight infants. Diastasis is usually easily identified on physical examination (Fig. 35-8). Computed tomography (CT) scanning can provide an accurate measure of the distance between the rectus pillars and will differentiate rectus diastasis from a true ventral hernia if clarification is required. Surgical correction of rectus diastasis by plication of the broad midline aponeurosis has been described for cosmetic indications and for disability of abdominal wall muscular function. However, these approaches introduce the risk of an actual ventral hernia and are of questionable value in addressing any actual pathology.
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Rectus Sheath Hematoma
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Hemorrhage from the network of collateralizing vessels within the rectus sheath and muscles can result in a rectus sheath hematoma. Although a history of trauma might be elicited, other less obvious events including sudden contraction of the rectus muscles with coughing, sneezing, or any vigorous physical activity may also cause this condition. Spontaneous rectus sheath hematomas occur most frequently in the elderly and in those on anticoagulation therapy. Patients frequently describe the sudden onset of unilateral abdominal pain that may be confused with lateralized peritoneal disorders such as appendicitis.
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History and physical examination alone may be diagnostic. Pain typically increases with contraction of the rectus muscles, and a tender mass may be palpated. The ability to appreciate an intra-abdominal mass is ordinarily degraded with contraction of the rectus muscles. Fothergill’s sign is a palpable abdominal mass that remains unchanged with contraction of the rectus muscles and is classically associated with rectus hematoma. A hemoglobin/hematocrit level and coagulation studies should be obtained. Both ultrasonography and CT (Fig. 35-9) can provide confirmatory imaging information and exclude other disorders.
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Specific treatment depends on the severity of the hemorrhage. Small, unilateral, and stable hematomas may be observed without hospitalization. Bilateral or large hematomas will likely require hospitalization, as well as potential resuscitation. Transfusion or coagulation factor replacement may be indicated in some situations. Angiographic embolization is required infrequently, but may be necessary if hematoma enlargement, free bleeding, or clinical deterioration occurs. Surgical therapy is used in the rare situations of failed angiographic treatment or hemodynamic instability that precludes any other options. The operative goals are evacuation of the hematoma and ligation of any bleeding vessel identified. Mortality in this condition is rare, but has been reported in patients requiring surgical treatment and in the elderly.
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Desmoid tumors of the abdominal wall are fibrous neoplasms originating from the musculoaponeurotic structures of the anterior abdomen. They are also referred to collectively as aggressive fibrosis, a term that describes their aggressive and infiltrative local behavior. They do not have metastatic potential, and although there is marked cellularity in biopsy specimens, there are no specific histologic characteristics that suggest malignancy, per se. Desmoid tumors of the abdominal wall have a slight female predominance and occur either sporadically or in the setting of familial adenomatous polyposis (FAP), with the greatest risk incurred in Gardner’s syndrome. As many as 10% to 15% of FAP patients develop desmoid tumors of the abdominal wall, abdomen, or retroperitoneum, and this condition can account for patient mortality from complications of aggressive local growth. In non-FAP settings, abdominal wall desmoids occur most frequently in postpartum women or in surgical scars. Radical resection with frozen section margins and immediate mesh reconstruction of any consequent abdominal wall defect is the most commonly recommended treatment. Involvement of margins is associated with recurrence rates as high as 80%. Extensive infiltration and involvement of peritoneal structures frequently makes desmoid resection technically unfeasible. Medical treatment with an antineoplastic agent such as doxorubicin, dacarbazine, or carboplatin can produce remission for variable periods in up to 50% of patients, although the prognosis of advanced desmoids, particularly in FAP, is poor, with a 5-year mortality rate as high as 50% reported. Combined medical treatments and the addition of imatinib have been used with some success in small numbers of patients; radiation therapy has been used in both adjuvant and palliative roles with high response rates.
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Other Abdominal Wall Tumors
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The abdominal wall may be the site of various benign neoplasms including lipomas and neurofibromas. Surgical treatment is not always mandatory, but local excision is recommended for symptomatic or enlarging lesions. Primary abdominal wall malignancies are exceedingly rare and include subtypes of sarcomas (leiomyosarcoma, malignant fibrous histiocytoma, fibrosarcoma, liposarcoma, and rhabdomyosarcoma), dermatofibrosarcoma protuberans, schwannoma, and melanoma. Magnetic resonance imaging (MRI) or CT is used for tumor staging, and chest CT should be included to rule out pulmonary metastases. These studies define the extent of the tumor and involvement of contiguous structures in anticipation of surgical treatment. Prior to surgery for abdominal wall sarcomas, a core needle biopsy is generally obtained (with image guidance if needed). Once the diagnosis is established, treatment consists of resection with tumor-free margins, applying the same general principles used for extremity sarcoma resection. Meticulous dissection avoiding violation of tumor capsule and maintaining margins greater than 2 cm, if possible, are essential considerations. Extensive resection may leave a considerable abdominal wall defect that will have to be reconstructed. Immediate reconstruction with mesh and/or wound coverage with rotational or free myocutaneous flaps are the best options if primary closure is not feasible. Although these tumors are frequently described as radiation- and chemotherapy-resistant, both modalities have been used in advanced cases in both adjuvant and palliative settings. The very limited experience in these rare conditions makes commentary on the effectiveness of these therapies difficult.
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Abdominal wall resection may also be required with contiguous involvement of gastrointestinal or gynecologic malignancies. Primary closure may be feasible, but prosthetic mesh use (even in the setting of bowel resection), absorbable or biologic mesh reinforcement, and myocutaneous flap reconstruction are also options.
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Abdominal Wall Hernias
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Hernias of the anterior abdominal wall, or ventral hernias, represent defects in the parietal abdominal wall fascia and muscle through which intra-abdominal or preperitoneal contents can protrude. Ventral hernias may be congenital or acquired. Acquired hernias may develop via slow architectural deterioration of the musculoaponeurotic tissues, or they may develop from failed healing of an anterior abdominal wall incision (incisional hernia). The most common finding is a mass or bulge, which may increase in size with Valsalva. Ventral hernias may be asymptomatic or cause a considerable degree of discomfort and will generally enlarge over time. Physical examination reveals a bulge on the anterior abdominal wall that may reduce spontaneously, with recumbency, or with manual pressure. A hernia that cannot be reduced is described as incarcerated and generally requires surgical correction. Incarceration of an intestinal segment may be accompanied by nausea, vomiting, and significant pain, and is a true surgical emergency. If the blood supply to the incarcerated bowel is compromised, the hernia is described as strangulated, and the localized ischemia may lead to infarction and perforation.
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Primary ventral hernias (nonincisional) are generally named according to their anatomic location. Epigastric hernias are located in the midline between the xiphoid process and the umbilicus. They are generally small and may be multiple, and at elective repair, they are usually found to contain omentum or a portion of the falciform ligament. These may be congenital and due to defective midline fusion of developing lateral abdominal wall elements.
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Umbilical hernias occur at the umbilical ring and may be present at birth or develop later in life. Umbilical hernias are present in approximately 10% of all newborns and are more common in premature infants. Most congenital umbilical hernias close spontaneously by 5 years. If closure does not occur, elective surgical repair is usually advised. Adults with small, asymptomatic umbilical hernias should be followed clinically. Surgical treatment is offered if a hernia is observed to enlarge or is associated with symptoms, or if incarceration occurs. Surgical treatment can consist of primary sutured repair or placement of prosthetic mesh for larger defects (>2 cm) using open or laparoscopic methods.
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Patients with advanced liver disease, ascites, and umbilical hernia require special consideration. Enlargement of the umbilical ring usually occurs in this clinical situation as a result of increased intra-abdominal pressure from uncontrolled ascites. First line of therapy is aggressive medical correction of the ascites and paracentesis for tense ascites with respiratory compromise. These hernias are usually filled with ascitic fluid, but omentum or bowel may enter the defect after large-volume paracentesis. Uncontrolled ascites may lead to skin breakdown on the protuberant hernia and eventual ascitic leak, which can predispose the patient to bacterial peritonitis. Patients with refractory ascites may be candidates for transjugular intrahepatic portocaval shunt (TIPS) or eventual liver transplantation. Umbilical hernia repair should be deferred until after the ascites is controlled.
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Spigelian hernias can occur anywhere along the length of the Spigelian line or zone—an aponeurotic band of variable width at the lateral border of the rectus abdominis. However, the most frequent location of these rare hernias is at or slightly above the level of the arcuate line. These are not always clinically evident as a bulge and may come to medical attention because of pain or incarceration. The largest review of surgical management of these hernias suggests that the risk of incarceration is as high as 17% at the time of diagnosis. This has been cited as a justification for mandatory repair of Spigelian hernias after they have been diagnosed. Repair may be accomplished with either open or laparoscopic procedures.
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As many as 10% to 20% of patients may eventually develop hernias at incision sites following open abdominal surgery. The etiology of any given case of incisional hernia can be difficult to determine. Obesity, primary wound healing defects, multiple prior procedures, prior incisional hernias, and technical errors during repair may all be contributory. Repair of incisional hernias can be technically challenging, and a myriad of methods have been described. The most important distinctions in surgical management of incisional hernias are primary versus mesh repair and open versus laparoscopic repair.
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Primary repairs of incisional hernia include both simple suture closure and components separation. Primary repair by simple suture approximation, even for small hernias (defects <3 cm), is associated with high reported hernia recurrence rates. In a randomized prospective study of open primary and open mesh incisional hernia repairs in 200 patients, investigators from the Netherlands found that after 3 years, recurrence rates were 43% and 24%, respectively. Risk factors for recurrence were primary suture repair, postoperative wound infection, prostate problems, and surgery for abdominal aortic aneurysm.
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In an effort to decrease suture line tension associated with primary repair, Ramirez described the components separation technique in 1990. This procedure entailed creation of large subcutaneous flaps lateral to the fascial defect followed by bilateral incision of the external oblique aponeuroses and, if necessary, incision of the posterior rectus sheaths bilaterally. The net effect is up to 10 cm of medial mobilization of the rectus muscles allowing for primary apposition of the fascia. Early reports of components separation demonstrated a high wound infection rate (20%) and an 18.2% hernia recurrence rate at 1 year. However, as the technique evolved, an improved understanding of key operative elements, including maximal preservation of the rectus perforator vessels and minimal dissection of the subcutaneous tissues, has led to fewer postoperative wound complications. In recent years, further modifications have included the endoscopic components separation technique as well as the addition of mesh reinforcement to primary fascial edge closure. Using the former closed technique with videoscopic control, effective external oblique division is achieved without creation of extensive subcutaneous flaps. This has been shown to dramatically decrease wound complications associated with the open procedure. The use of either permanent implant or biologic materials with components separation may lead to a hernia recurrence rate as low as 4% at 1 year of follow-up.
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Mesh repair has become the standard in the elective management of most incisional hernias. Mesh can be placed as an underlay deep to the fascial defect (intra- or preperitoneal), an interlay either bridging the gap between the defect edges or within the abdominal wall musculoaponeurotic layers (intraparietal), or an onlay (superficial to the fascial defect). Laparoscopic repairs use an underlay technique. Each mesh material type has specific density, porosity, and strength characteristics. Some of the commercially available meshes for incisional hernia repair are listed in Table 35-1. Permanent mesh implants are made of prosthetic materials that do not degrade over time. Their principal advantages are ease of use, relatively low cost, and durability. Absorbable meshes are degraded and eliminated from tissues, gradually losing the structural integrity needed for tissue support. They can be useful for temporary abdominal wall closure in contaminated or infected fields but will eventually leave patients with an incisional hernia. Biologic meshes are prepared from collagen-rich porcine, bovine, or human tissues from which all antigenic cellular materials have been removed. These can also be chemically treated to crosslink collagen molecules, increasing strength and durability at the cost of some impairment in host cellular ingrowth. Over time, biologic mesh-derived collagen is incorporated into the host tissue, remodeled, and eventually replaced by host collagen. These characteristics may be useful in the setting of contaminated or infected fields. However, when used to bridge ventral hernia defects, biologic meshes are associated with excessively high hernia recurrence rates and ought to be reserved for tissue reinforcement rather than replacement. Newer prosthetic absorbable mesh materials are now available that share some of the characteristics of biologics (e.g., host tissue ingrowth and replacement with collagen) and can also be used for reinforcement of primary closure at a considerably lower cost.
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In recent years, the trend toward use of minimally invasive surgical methods has exerted a great influence on incisional hernia management. However, open repairs continue to be performed extensively, mostly using a mesh underlay technique, often with extensive dissection of a preperitoneal space to accommodate a large sheet of polypropylene or woven polyester mesh. This method isolates mesh from the peritoneal contents. Although the implications of direct mesh contact with peritoneal structures is somewhat controversial, dense adhesions to intestine may complicate reoperation, and at least anecdotally may predispose to erosion and fistulization even without a concomitant bowel resection. Meshes with adhesion barrier coatings of fish oil, oxidized cellulose, or hyaluronic acid have been offered as solutions for this concern. Expanded polytetrafluoroethylene (ePTFE) prostheses are also used if contact with peritoneal structures is unavoidable because this material tends not to be associated with development of dense adhesions.
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Laparoscopic incisional hernia repair was first described by LeBlanc and Booth in 1993. Since that time, numerous studies have examined early and late results compared to open repair. In 2000, data from 407 patients undergoing laparoscopic incisional hernia as part of a multicenter trial revealed a recurrence rate of only 3.4%, with a mean follow-up of more than 2 years. Of the recurrences noted, the vast majority were felt to be secondary to technical errors committed early in the surgeons’ experience that were avoided during the later cases. Studies using pooled multicenter data or meta-analyses of published reports have tended to strongly favor laparoscopic incisional hernia repairs based on fewer wound complications, fewer overall complications, and lower recurrence rates when compared to the open technique. Authors speculate that these benefits are achieved by eliminating repeated abdominal incisions and improving detection of unsuspected secondary defects that might not otherwise be appreciated during open repair. However, a recent Cochrane database review of studies totaling 880 cases and including the results from 10 randomized controlled trials concluded that short-term recurrence rates did not differ significantly and laparoscopic repairs were associated with higher in-hospital costs despite generally shorter lengths of stay. The major benefit for laparoscopic repairs compared to open repairs was a consistently lower risk of wound infections. In a recent multicenter randomized trial, in addition to lower infection rates, superior early physical function was also demonstrated very early after laparoscopic repairs compared to open repair.
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The technique of laparoscopic incisional hernia repair generally involves laterally placed ports for midline defects and contralaterally placed ports for lateral defects. All adhesions to the anterior abdominal wall are divided, taking great care not to injure the intestine either directly or with thermal or electrical energy. The contents of the hernia sac are completely reduced, but in contrast to open repairs, the sac itself is left in situ. Once the area encompassing all fascial defects is defined, a mesh is fashioned to allow for sufficient overlap (at least 4 cm) under the healthy abdominal wall. After insertion into the abdomen, the mesh is fixed into position with transfascial sutures, placed circumferentially around the mesh, and spiral tacks are placed according to surgeon preference (Fig. 35-10). It has been proposed that transfascial sutures contribute to excessive postoperative pain, and some surgeons have eliminated them from the aforementioned technique, relying solely on spiral tacks for the strength of the repair. LeBlanc reviewed the utility of transfascial sutures and recommended a minimum 5-cm overlap of mesh from defect edge if transfascial sutures are not used.
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