Ventral hernias in the anterior abdominal wall include both spontaneous or primary hernias (e.g., umbilical, epigastric, and spigelian) and, most commonly, incisional hernias after an abdominal operation. Small primary ventral hernias less than 2½ cm in diameter are often successfully closed with primary tissue repairs. However, larger ones have a recurrence rate of up to 30% or 40% when a tissue repair alone is performed. It is estimated that 2% to 10% of all abdominal operations result in an incisional hernia. This explains the predominance of such hernias. Fortunately, the use of mesh has revolutionized the repair of abdominal wall hernias. Anterior placement of polypropylene mesh as an onlay to the primary repair is helpful and a retrorectus muscle placement is even better. However, the development of dual-sided mesh has allowed for an improved placement of mesh behind the abdominal wall and hernial defect. These meshes present an intraperitoneal nonadherent surface to the bowel and an open synthetic mesh grid or screen for adherence and incorporation into the peritoneum and posterior abdominal wall fascia. The dual-sided meshes can be placed laparoscopically for almost any ventral hernia, but extremely large hernias with loss of abdominal domain or those associated with extensive, dense intra-abdominal adhesions (e.g., peritoneal dialysis, prior peritonitis) are relative contraindications. The meshes are very expensive; however, operating room time and hospital length of stay are shortened. The laparoscopic incisions cause less pain and there is a faster return to normal activities or work. Finally, laparoscopic repair enables the detection and repair of multiple defects—a common finding in midline incisional hernias.
The patient must be free of 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 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, should be reviewed.
General anesthesia with an endotracheal tube is required.
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. For ventral hernias that are not midline, the patient may be positioned with pillows for some lateral elevation of the chest, flank, and hips.
The patient is given perioperative antibiotics. An orogastric tube is passed for gastric decompression. A Foley catheter is placed and pneumatic sequential stockings are applied. The skin is prepared in the routine manner.