Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)
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STEP 4: POSTOPERATIVE CONSIDERATIONS
Drains usually may be safely removed once the output declines to less than 30 mL per day.
STEP 5: PEARLS AND PITFALLS
In a contaminated field (e.g., resection of gangrenous intestine), an absorbable or biologic fascia substitute may be used with the expectation that a recurrence of the hernia is likely but may be repaired later after the eradication of the contamination.
Polypropylene mesh should not be placed within the peritoneal cavity. If there is insufficient peritoneum to close in the midline, an expanded polytetrafluoroethylene mesh product may be placed, because formation of adhesions to this surface or erosion into adjacent viscera is unlikely.
SELECTED REFERENCES
1. Radhakrishnan J: Umbilical hernia. In Nyhus LM, Condon RE (eds): Hernia, 4th ed. Philadelphia, JB Lippincott, 1995.
2.Skinner MA, Grosfeld JL: Inguinal and umbilical hernia repair in infants and children. Surg Clin North Am 1993;73:439-449.
Xiphoid
Umbilicus
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STEP 2: PREOPERATIVE CONSIDERATIONS
The most important preoperative consideration is whether the hernia should be repaired. Because the risk to the patient from the hernia decreases as its diameter increases, and the chance of recurrence and other surgical complications increases, the risk-to-benefit ratio should be carefully assessed.
In the event repair is deemed desirable, many of these patients have significant comorbidities that must be addressed preoperatively and managed perioperatively. Neglect of these can lead to failure in spite of a technically superb surgical repair.
There are many techniques for repair of incisional hernias, illustrating among other things that no one method has been judged superior. The technique illustrated here is but one of many acceptable available.
STEP 3: OPERATIVE STEPS
1.INCISION
In the case of incisional hernias, the new incision is made by excising the old scar.
In the case of a ventral hernia not related to a previous surgical procedure, the incision is best placed along the longer axis of the fascial defect.
If the fascial defect is circular with no significant difference in the length of axes, transverse incisions leave better scars.
2.DISSECTION
After the hernia sac is identified, its external peritoneal lining is dissected free from surrounding structures, including the innermost fascial layer of the abdominal wall.
Although it is often necessary to open the peritoneum and even resect portions of it, preservation of enough of the peritoneum to close allows the imposition of a tissue layer between the mesh to be used and the contents of the intra-abdominal cavity. The end result is illustrated in Figure 81-3.
Figure 81-4 shows the next step, which is separation of the posterior rectus sheath from the overlying rectus abdominis muscle.
Primarily the cut edges of the posterior sheath are then closed, even if under tension. This closure can be facilitated by application of the techniques of component separation.
C H A P T E R 81 • Incisional/Ventral Hernia—Mesh and Tissue Flap |
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3. CLOSING
Scrupulous attention should be paid to hemostasis, because postoperative hematomas are not uncommon and can create significant problems.
Whether to use drains in any or all of the spaces created by the dissection is the choice of the individual surgeon. The drains are no substitute for good technique and offer a route for the introduction of bacteria.
STEP 4: POSTOPERATIVE CARE
Most patients require a day or two in the hospital for adequate pain control.
Patients are instructed to refrain from lifting or doing strenuous work for 4 to 6 weeks.
SELECTED REFERENCE
1. Zinner MJ, Schwartz SI, Ellis H: Hernias. In Maingot R, Zinner M (eds): Maingot’s Abdominal Operations, vol 1, 10th ed. Stamford, Conn, Appleton & Lang, 1997, pp 479-580.