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200
K.W. Kercher
Fig. 19.12 Hernia defect closed over mesh patch
Fig. 19.15 The intra-peritoneal space is cleared of
adhesions
Fig. 19.13 Umbilical skin tacked down and closed
Fig. 19.14 Umbilical hernia sack is circumferentially
dissected from the fascia, opened, and resected
Fig. 19.16 Mesh is deployed into the intra-peritoneal
space, just deep to the fascia
to secure the anchoring straps to the fascia.
Whether or not to close the defect is at the surgeon’s discretion. Some surgeons prefer to
separate and fixate the tails of the mesh to the
edges of the fascial defect (Fig. 19.22 ), allow-
ing for a tension-free repair. My personal preference is to close the fascial defect, while
incorporating both mesh tails into the fascial
closure (as demonstrated in Figs. 19.11 and
19.12 ). In all cases, the redundant tails of the
19 Umbilical Hernia Repair: The Spectrum of Management Options
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Fig. 19.17 Anchoring straps (mesh tails) are pulled up to
bring the mesh patch into direct contact with the abdominal wall
Fig. 19.19 Complete circumferential deployment of the
mesh is confi rmed
Fig. 19.18 Mesh patch provides wide overlap of the hernia defect
mesh are trimmed down to the level of the fascia and the wound is closed in layers. Care is
taken to close the scar and the subcutaneous
tissue over the cut tails of the mesh in order to
exclude the mesh tails from the skin closure
(Fig. 19.23 ).
Although the currently available umbilical
hernia patches are designed with a tissueseparating layer to allow for safe insertion into
the abdominal cavity, there is the potential for
bowel adhesions to the mesh, particularly if the
mesh is not well seated against the peritoneal
Fig. 19.20 Using the surgeon’s fi nger to circumferentially
sweep around the edges of the mesh, the prosthetic is confi rmed to lie fl at against the parietal side of the abdominal wall
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K.W. Kercher
Fig. 19.21 Mesh tails are gently elevated to bring the
mesh into apposition with the abdominal wall. Pulling up
too aggressively on the anchoring straps is discouraged, as
excessive traction can deform the mesh
Fig. 19.23 The wound is closed in layers
the peritoneal cavity through the umbilical hernia defect in a standard “open” fashion, but
two additional 5-mm laparoscopic ports and a
laparoscopic tacker are utilized to fi xate the
edges of the mesh under pneumoperitoneum
using laparoscopic guidance (Fig. 19.24 ).
Fig. 19.22 The tails of the mesh are secured to the edges
of the defect with permanent suture
surface deep to the abdominal wall musculature. For this reason, many surgeons will take
additional steps to fi xate the mesh to the peritoneum, either with sutures placed through the
hernia defect or by tacking the periphery of the
mesh using a laparoscopic- assisted approach.
With this technique, the mesh is deployed into
Laparoscopic Techniqu es
While laparoscopic repair of midline incisional/
ventral hernias is a standard practice, the
laparoscopic approach to umbilical hernias is
generally limited to larger defects (>3–5 cm),
recurrent umbilical hernias, or fascial defects
occurring at the site of prior umbilical surgery,
such as the site of a prior laparoscopic access,
and would technically be considered small incisional hernias. For these larger, more challenging
umbilical hernias, two primary approaches can
be considered: laparoscopic- assisted repair with
mesh and primary defect closure (as described
above) or a standard (purely) laparoscopic repair
with mesh.
While strategies vary based upon personal
preference, my approach for laparoscopic
umbilical hernia repair typically involves a
4-port technique that allows for adhesiolysis
and intra-peritoneal mesh deployment with
wide overlap of at least 5 cm beyond the edges
of the hernia defect. A tissue-separating permanent synthetic mesh is used and is deployed
intra- peritoneal as an underlay. Defect closure
19 Umbilical Hernia Repair: The Spectrum of Management Options
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Fig. 19.24 Intra-peritoneal view of umbilical hernia patch and laparoscopic fi xation sites
203
Fig. 19.25 Large chronically incarcerated umbilical hernia prior to repair
Fig. 19.27 Patient positing for laparoscopic repair with
arms padded and tucked
is optional. Four trans-fascial sutures are used
to suspend and secure the mesh in the laparoscopic environment and are reinforced by a
double crown of tacks for mesh fi xation
(Figs.
19.25 , 19.26 , 19.27 , 19.28 , 19.29 , 19.30
and 19.31 ).
Algorithms for the Management
of Umbilical Hernias
As with any surgical intervention, the specifi c technique utilized in any given patient must be indi-
Fig. 19.26 Demonstration of 3–5 cm fascial defect
vidualized. Ultimately, decisions are based upon
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K.W. Kercher
Fig. 19.28 Mesh preparation with four cardinal sutures
Fig. 19.29 Four-port trocar strategy for laparoscopic
umbilical hernia repair
Fig. 19.31 Laparoscopic port and suture fi xation sites at
conclusion of case
the clinical scenario and the surgeon’s own skill set
and experience. There are a number of factors to
consider in individualizing the treatment of umbilical hernias. These include the etiology of the hernia
(primary vs. recurrent/incisional), defect size, body
habitus, fascial quality, tension, patient age, vocation, and co- morbidities as well as the risk for
wound and or mesh complications.
My general approach to umbilical hernias is as
follows: For thin, healthy patients presenting
with a small primary umbilical hernia that can be
easily approximated without tension, a primary
Fig. 19.30 Laparoscopic view of wide intra-peritoneal mesh reinforcement
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205
repair with non-absorbable suture is used. In
heavier patients with larger defects and particularly in those who regularly perform strenuous
physical labor, I generally recommend mesh
reinforcement , utilizing an umbilical hernia patch
placed in the pre-peritoneal space. In the morbidly obese patient or in those with large, recurrent hernia defects, a laparoscopic approach often
provides for greater mesh overlap and the potential advantage of fewer wound complications.
While I believe that it is appropriate to consent
every patient for a potential change in operative
strategy during the procedure, the algorithms
below can guide pre-operative decision-making.
Indications for Primary Repair
– Primary hernia
– “Finger-tip” defect (<1 cm)
– Thin female
– Good fascia
– Minimal tension
Indications for Open Mesh Repair
– Medium-sized defect (2–3 cm)
– Recurrent hernia
– Incisional hernia
– Overweight—mildly obese
– Male
– Laborer
– Thin fascia
– Tension
– Chronic cough
Indications for Laparoscopic Repair with
Mesh
– Morbid obesity
– Large defect (>3 cm)
– High risk for wound complications (steroids,
diabetes, ascites, smoking)
– Recurrent hernia
Summary
A wide variety of options are available for the
repair of umbilical hernias. These surgical techniques range from primary suture repair to rein-
forcement with mesh and can be performed
through open and laparoscopic approaches. At
present, there is no accepted gold standard for
umbilical hernia repair. Recent studies have
shown lower rates of recurrence after mesh repair
when compared with sutures alone, although
confl icting data exist. The potential disadvantages of synthetic mesh placement (including
infection, seroma, foreign body sensation, and
adhesions to underlying viscera) must be recognized and considered; however, pooled data demonstrate no signifi cant differences in complication
rates when comparing mesh to suture repair.
Based upon current evidence, primary repair
remains reasonable and appropriate for small primary umbilical hernias. Mesh reinforcement
should be considered in patients deemed high
risk for recurrence. As always, the specifi c technique for repair should be tailored to the individual patient.
References
1. Arroyo A, Garcia P, Perez F, Anrdreu J, Candela F,
Calpena R. Randomized clinical trial comparing
suture and mesh repair of umbilical hernia in adults.
Br J Surg. 2001;88:1321–3.
2. Abdel-Baki NA, Bessa SS, Abdel-Razek
AH. Comparison of prosthetic mesh repair and tissue
repair in the emergency management of incarcerated
para-umbilical hernia: a prospective randomized
study. Hernia. 2007;11:163–7.
3. Ammar SA. Management of complicated umbilical
hernias in cirrhotic patients using permanent
mesh: randomized clinical trial. Hernia. 2010;14:
35–8.
4. Polat C, Dervisoglu A, Senyurek G, et al. Umbilical
hernia repair with the prolene hernia system. Am
J Surg. 2005;190:61–4.
5. Asolati M, Huerta S, Sarosi G, et al. Predictors of
recurrence in veteran patients with umbilical hernia:
single center experience. Am J Surg. 2006;192:
627–30.
6. Sanjay P, Reid TD, Davies EL, Arumugam PJ,
Woodward A. Retrospective comparison of mesh and
sutured repair for adult umbilical hernias. Hernia.
2005;9:248–51.
7. Berger RL, Li LT, Hicks SC, Liang MK. Suture versus
preperitoneal polypropylene mesh for elective umbilical hernia repairs. J Surg Res. 2014;192(2):426–31.
8. Aslani N, Brown CJ. Does mesh offer an advantage
over tissue in the open repair of umbilical hernias? A
systematic review and meta-analysis. Hernia.
2010;14:455–62.
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K.W. Kercher
9. Halm JA, Heisterkamp J, Veen HF, Weidema
WF. Long-term follow-up after umbilical hernia
repair: are there risk factors for recurrence after simple and mesh repair. Hernia. 2005;9:334–7.
10. Erilymaz R, Sahin M, Tekelioglu MH. Which repair
in umbilical hernia of adults: primary or mesh? Int
Surg. 2006;91(5):258–61.
11. Mayo WJ. An operation for the radical cure of umbilical hernia. Ann Surg. 1901;34:276–80.
Managing Complications of Open
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Hernia Repair
Eric M. Pauli and Ryan M. Juza
Introduction
Abdominal wall hernias are becoming increasingly prevalent as the population ages, surgical
management of intra-abdominal pathology
increases, and medical comorbidities such as obesity, diabetes, and smoking continue to occur with
relatively high frequency in surgical populations
[ 1 – 5 ]. Ventral hernia repairs occur at a rate of
350,000 cases per year in the United States and are
increasing at a rate of 1–2% annually [ 6 , 7 ]. As
such, open ventral hernia repair is one of the most
common elective general surgical procedures performed in the United States every year [ 8 ].
Despite numerous technical advances and
increased awareness of complications of herniorraphy, morbidity following open ventral hernia
repair remains common. Managing these complications is an essential skill of the abdominal wall
surgeon. For component separation herniorraphy
in particular, where 25–50% of patients can be
2 0
expected to have at least one post-operative
occurrence, complication diagnosis and management is a routine part of post-operative care. High
complication rates have led to vast research on
the topic, including the description of novel management strategies, and the establishment of
working groups and risk stratifi cation scores to
guide patient selection and better predict complication rates [ 9 – 11 ]. With reimbursement being
increasingly tied to outcomes, optimizing patient
care in the pre- and post-operative intervals is
now as important as the operative care the patient
receives.
As a group, complications following open
ventral hernia repair are a more common occurrence compared to laparoscopic herniorraphy.
This chapter will review the spectrum of common complications following open ventral hernia
repair with an emphasis on prevention, diagnosis,
and management options.
Risk Factors of Complicatio n
Multiple studies have investigated patient comor-
E. M. Pauli , M.D. (*)
Division of Minimally Invasive and Bariatric Surgery,
Department of Surgery , Penn State Hershey Medical
Center , Hershey , PA , USA
epauli@hmc.psu.edu
e-mail:
R. M. Juza , M.D.
Department of Surgery , Penn State Milton S. Hershey
Medical Center , Hershey , PA , USA
Y.W. Novitsky (ed.), Hernia Surgery, DOI 10.1007/978-3-319-27470-6_20
bidities and their risk for developing postoperative complication following open hernia
repair . The majority of these studies have focused
on the development of surgical site infection, as it
is well established that wound infection signifi cantly increases the risk of hernia recurrence [
Comorbidities shown to increase post- operative
12 ].
207© Springer International Publishing Switzerland 2016
208
E.M. Pauli and R.M. Juza
complication rates in ventral hernia repair
include smoking, diabetes, chronic pulmonary
disease, poor nutritional status (low serum
albumin), immunosuppression (including steroid
use), morbid obesity, coronary artery disease, and
advanced age [ 3 , 13 , 14 ].
Our “prehabilitation” strategy for elective open
ventral hernia repairs focuses on aggressively
managing these comorbidities. Smoking, tobacco
and nicotine cessation (including patches and
electronic cigarettes) is mandatory, and we routinely check blood and urine for nicotine metabolites prior to scheduling and performing complex
open hernia repairs. Long-term control of diabetes is assessed with glycosylated hemoglobin levels (HbA1C), and referrals are made to primary
care physicians or endocrinologists as needed to
achieve an HbA1C ≤ 7.0. Chronic pulmonary dis-
ease (in particular home oxygen use or signifi cant
dyspnea on exertion) may preclude herniorraphy.
Pulmonary function testing and referral to pulmonary medicine are appropriate for risk modifi cation. Nutritional supplementation and
multivitamin administration may be necessary to
increase albumen and correct micronutrient defi ciencies. The degree to which obesity contributes
to hernia recurrence and post- operative wound
and pulmonary complications has not been well
established and no strict guidelines for a body
mass index (BMI) cutoff exist. Our preference is
to perform elective repairs on patients with a
BMI ≤ 40 kg/m 2 . Referral for medically supervised or surgical weight loss procedure (typically laparoscopic sleeve gastrectomy ) may be
necessary. Coronary artery disease should be
investigated and managed as before any major
surgical procedure; cardiology referral, stress
testing, and angiography may be necessary.
Complications and Their
Management
Surgical Site Occurrenc es
Wound-related complications such as erythema,
infection, seroma, hematoma, dehiscence, and
fi stula formation occurring within 30 days of the
principle operation are included in the defi nition
of surgical site occurrences (SSO) as outlined by
the Ventral Hernia Working Group [ 11 ]. The
term surgical site occurrence was established
because of a recognized need for standardization
in the reporting of wound complications following hernia repair. Reports before 2010 had nonstandardized methodology of reporting these
complications and as such, interpretation of the
true rates of SSO is often unreliable. Ideally,
standardized defi nitions and reporting will
improve the reliability of data as future studies
present outcomes in a common language.
Unfortunately, there is still a spectrum of complication severity within each of these categories; a
minor wound separation and a complete wound
separation would both be categorized as a wound
dehiscence within this nomenclature, making it
diffi cult to determine major and minor SSO rates.
Surgical site occurrences complicate 14% of low
risk open hernia repairs, 27% of repairs in
patients with comorbid conditions, and 46% of
contaminated hernia repairs [ 10 ]. The higher
rates of SSO in contaminated repairs are largely
attributable to infections.
Surgical Site Infection
Surgical site infection (SSI) is one of the most
common surgical site occurrences complicating
open ventral hernia repair and is the most signifi cant predictor of hernia recurrence (Fig. 20.1 )
[ 3 ]. It is also the most common reason for hospi-
tal readmission following open ventral hernia
surgery [ 9 , 12 , 15 ]. Open repairs have a signifi -
cantly higher rate of surgical site infections than
laparoscopic repairs [ 16 – 18 ]. SSIs complicate
19% of open ventral hernia repairs, but the incidence varies widely depending on the preoperative hernia grade and method of repair
(Table 20.1 ) [ 9 – 11 , 16 – 22 ].
Surgical site infections are divided into superfi cial and deep incisional and organ space infections as defi ned by the Centers for Disease
Control [ 23 ]. Superfi cial incisional infections
affect the skin and subcutaneous tissue and are
diagnosed by local erythema, swelling, pain, or
purulent drainage. Deep incisional infections
reach the fascial or muscle layers and may be
20 Managing Complications of Open Hernia Repair
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209
associated with abscess formation, or wound separation exposing the deeper tissue layers. Organ
space infections involve non-incisional parts of
the operative fi eld; in the case of open ventral
hernia repair, this is generally the peritoneal or
retroperitoneal spaces.
Management of SSIs follows standard surgical principles. Minor superfi cial infections can be
managed with empiric antibiotics alone, with
special consideration given to patients known to
carry resistant organisms (e.g. methicillinresistant Staphylococcus aureus (MRSA)). More
serious infections may require incision, drainage,
packing, and targeted antibiotic therapy based on
wound cultures. Deep incisional infections generally require drainage (which may be surgical or
Fig. 20.1 Wound ischemia and deep surgical site infection following anterior component separation with external oblique release (Photo courtesy of Dr. Luis J. Garcia,
University of Iowa)
percutaneous) and targeted antibiotic therapy.
Non-viable muscle, fascia, and subcutaneous tissue may need to be aggressively debrided to
eliminate ongoing sources of infection. Organ
space infections are generally treated with percutaneous drainage; however, non-focal infections
may require laparotomy to clear the infection and
permit peritoneal lavage. Special consideration
should be given to a missed enterotomy or leak
from intestinal reconstructive work (anastomosis,
enterotomy repair) done during the course of herniorraphy as the source of an organ space
infection.
Development of an SSI is dictated by a multitude of patient-related and surgical variables similar to other general surgical procedures. For
open mesh repairs, a prior wound infection is
notably not predictive of an SSI [ 24 , 25 ].
Maneuvers to improve microvascular blood fl ow
and optimize native immunity (e.g. smoking cessation) allow better mesh incorporation. When
considering where to place mesh, it therefore
makes sense to place it adjacent to well vascularized tissue to provide a robust interface to allow
immune recognition and reaction to the foreign
body. For incisional infections (both superfi cial
and deep), mesh location within the abdominal
wall must be considered in the management
strategy. Underlay and sublay mesh may not be
involved with the infectious process of incisional
infections, whereas onlay mesh is more likely to
be (Fig. 20.2 ). Surgical management of these
infections may require mesh removal (see Mesh
Infection below).
Table 20.1 Surgical site occurrence, rates following open ventral hernia repair
Anterior component
separation Rectrorectus
Total wound
complications
Seroma
Surgical site
infection
Skin dehiscence
Chronic pain
Skin necrosis
43% Jensen [
49% Krpata [
16% Albino [
13% Jensen [
3% Albino [
13% Jensen [
15% Albino [
0% Jensen [
6% Jensen [
17 ] 26% Krpata [ 78 ] 51% Basta [ 21 ]
78 ] 24% Novitsky [ 20 ] 19% Albino [ 19 ]
19 ] 6% Albino [ 19 ]
17 ] 9% Paajanen [ 22 ] 5% Albino [ 19 ] 8% Basta [ 21 ]
19 ] 3% Albino [ 19 ] 12% Albino [ 19 ]
17 ] 6% Paajanen [ 22 ] 7% Novitsky [ 20 ] 22% Basta [ 21 ]
19 ] 7% Albino [ 19 ] 7% Albino [ 19 ] 12% Albino [ 19 ]
17 ] 35% Basta [ 21 ]
4% Paajanen [
17 ]
22 ]
Posterior component
separation Bridged
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