Abdominal Wall: Ventral Hernia Repair

Ventral Hernia Repair

Open Umbilical Hernia Repair (UHR)

  • Make a Supraumbilical or Infraumbilical Incision Based the Site of the Hernia
  • Dissect Down to Fascia
  • Free the Umbilical Stalk Circumferentially
  • Dissect the Hernia Sac off the Umbilical Stalk
  • Incise the Fascia Around the Umbilical Ring
    • *Planes are Fused
  • Reduce the Hernia Sac
  • Bluntly Dissect the Preperitoneal Space
  • Place Mesh into the Preperitoneal Space
  • Close the Fascial Defect
  • Close Skin

Simple Open Ventral Hernia Repair (VHR)

  • Make a Vertical Incision Over the Hernia Site
  • Dissect the Hernia Sac Free from Surrounding Tissue
  • Dissect Down to Fascia, Avoiding Opening of the Hernia Sac
  • Incise the Fascia Around the Sac without Penetrating the Peritoneum
  • Reduce the Hernia Sac
    • *Do Not Need to Incise the Fascia – Planes Are Not Fused
  • Bluntly Dissect the Preperitoneal Space
  • Place Mesh into the Preperitoneal Space
  • Close the Fascial Defect
  • Close Skin

Rives-Stoppa-Wantz (Retrorectus) Repair

  • Often Referred to as Only a “Rives-Stoppa Repair”
  • Considered the Gold Standard Repair for Moderate-Large or Complex Midline Hernias
  • Technique:
    • Midline Abdominal Incision
    • Dissect & Excise the Hernia Sac (Preserve the Lateral Edges of the Hernia Sac for Closure)
    • Incise the Posterior Rectus Sheath Close to its Junction of the Anterior Rectus Sheath
      • Goal to Preserve Largest Area of Posterior Sheath as Possible without Sacrificing any of the Anterior Sheath
    • Separate the Posterior Rectus Sheath Away from the Rectus Muscle to Create the Retrorectus Space
    • Close the Posterior Rectus Sheath
    • Place a Large Mesh into the Retrorectus Space
      • Consider Fixation Using Suture but Not Always Mandatory
    • Close the Anterior Rectus Sheath
    • Close Skin
  • Drains:
    • Consider a Retrorectus Drain Over the Mesh
    • Consider a Subcutaneous Drain in the Fat

MIS (Laparoscopic/Robotic) Ventral Hernia Repair

  • Place Ports (2-3 Ports in the LUQ or Left Flank)
  • Preform Adequate Lysis of Adhesions & Reduce Any Herniated Bowel
  • Incise the Peritoneum Circumferentially Around the Hernia Defect, 2-3 cm from the Edge
  • Reduce the Hernia Sac with Any Preperitoneal Fat
  • Close the Hernia Defect
    • *Necessity is Debated
  • Place Preperitoneal Mesh with Circumferential Tacks or Sutures
    • Should Allow At least 3-5 cm of Mesh Overlap
  • Close Peritoneal Defect
  • Close Skin

Abdominal Wall Reconstruction/Component Separation

Rives-Stoppa-Wantz Repair 1

Mesh Placement

Placement Technique

  • Onlay (Subcutaneous) – Skin & Anterior Rectus Sheath
  • Inlay (Interposition) – Within Rectus Muscle Defects
    • Higher Recurrence Rate
  • Sublay (Retro-Rectus) – Between Rectus Muscle & Posterior Rectus Sheath
    • “Rives-Stoppa-Wantz” Repair
    • Lowest Recurrence Rate
  • Underlay (Preperitoneal) – Behind Posterior Rectus Sheath, Before Peritoneum
  • Intraperitoneal Onlay Mesh (IPOM) – In Abdominal Compartment

Mesh Considerations

  • Ventral Hernia Overlap Goal: Minimum of 3-5 cm
  • Use Permanent or Long-Acting Sutures for Securement
  • Permanent Mesh is More Susceptible to Infection
    • Better to Use Absorbable in Contaminated Field
  • If Inadvertent Enterotomy is Made (Without Gross Spillage) Synthetic Mesh Can Still Be Used
  • Routine Drain Placement Has Increased Risk of Infection

Prophylactic Mesh Placement

  • Decreases Risk of Recurrence
  • Onlay Appears to Be Superior
  • Complications:
    • Increased Risk of Seroma
    • No Increased Risk of Infection
  • *Use is Debated and Not Clearly Defined

Mesh Placement Techniques 2

Mesh Properties

Mesh Properties

Brand Names

Postoperative Wound Infection

Risk Factors

  • *See Wound Care: Surgical Site Infection (SSI)
  • Open Repair Has Higher Risk than Laparoscopic Repair
  • Higher Risk with Microporous Mesh (PTFE) – Allow Bacteria Free Passage but Block Neutrophils & Macrophages
  • Drains May Increase Risk

Diagnosis

  • Mesh Infections Typically Have a Delayed Onset (> 1 Month) Compared to Non-Mesh Associated Surgical Site Infections
  • Dx: Clinical, May Need CT to Evaluate Mesh Infection

Treatment

  • Superficial: ABX for 10-14 Days
    • Consider Surgical Drainage or Percutaneous Aspiration of Any Fluid Collection
  • Deep (Mesh Infection): ABX
    • Systemic Signs: Debridement & Mesh Explantation (Removal of Mesh)
    • No Systemic Signs: Consider Percutaneous Drainage (57% Success)
      • If Fails: Debridement & Mesh Explantation

References

  1. Bueno-Lledó J, Torregrosa A, Arguelles B, Carreño O, García P, Bonafé S, Iserte J. Progrip self-gripping mesh in Rives-Stoppa repair: Are there any differences in outcomes versus a retromuscular polypropylene mesh fixed with sutures? A “case series” study. Int J Surg Case Rep. 2017;34:60-64. (License: CC BY-NC-ND-4.0)
  2. Parker SG, Wood CPJ, Sanders DL, Windsor ACJ. Nomenclature in Abdominal Wall Hernias: Is It Time for Consensus? World J Surg. 2017 Oct;41(10):2488-2491. (License: CC BY-4.0)