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84
Lower risk of wound infection compared to open repair and allows
While there are published reports of use of lightweight
polypropylene mesh in the setting of contamination, the lower risk of
hernia recurrence associated with the permanent prosthetic must be
weighed against the risk of chronic infection and need for
subsequent procedures particularly with combined colon surgery. If a
recurrence occurs (higher risk with a bridging repair), recurrent
hernia repair could then be performed laparoscopically or open with
presumably less bioburden of infection
Addresses chronic infection which is likely the main complaint.
Thorough preoperative discussion and education is vital to patient
satisfaction especially if staged repair beginning with bridging
biologic mesh repair is indicated. Components separation can be
performed but if it is apparent that midline closure is not achievable,
this should be reserved for later defi nitive repair
Addresses chronic infection which is likely the main complaint. Of
the open repair options, rectorectus repair appears favorable in terms
for wide overlapping mesh repair
of infection risk
G.L. Adrales
the midline with a lower risk of hernia recurrence and skin
complications compared to onlay or underlay mesh placement
Addresses patient priorities of repair of symptomatic hernia and scar
revision/panniculectomy with lowest infection risk for open repair
Avoids prior operative fi eld and repair associated with equivalent
recurrence risk but lower infection risk. Caution should be exercised
with adhesiolysis after prior intraperitoneal mesh
Intraperitoneal mesh may complicate future surgery and could
become the site of infection with subsequent bowel surgery.
Lightweight polypropylene mesh may be salvageable after surgical
site infection
Open retrorectus repair with biologic graft or bioabsorbable
synthetic mesh. Bridging or partially bridging repair may be
Concern Author’s preferred approach based on available evidence Author’s reasoning
Table 9.1 Author’s approach to ventral hernia repair and mesh placement
needed depending on hernia defect size
Contaminated ventral hernia
repair
Open repair and removal of foreign body with retrorectus or
underlay biologic or bioabsorbable mesh reinforcement +/-
components separation if midline closure or partial fascial closure
can be achieved. Otherwise bridging underlay repair reserving
defi nitive treatment after infection is cleared
Chronically infected mesh with
recurrent hernia with wide
defect
underlay intraperitoneal mesh repair with primary closure of
smaller defects
Open repair and removal of foreign body with retrorectus or
underlay biologic or bioabsorbable mesh +/- components
separation
Chronically infected mesh with
recurrent small defect
Obesity Preoperative risk modifi cation (weight loss) and laparoscopic
Open retrorectus repair with permanent synthetic mesh Addresses laxity issue and functionality through reconstruction of
Healthy active patient with
Open retrorectus repair with permanent synthetic mesh with or
without components separation depending on defect size
combined with plastic surgery
Laparoscopic repair if failed open repair (onlay repair,
components separation with/without mesh, or primary repair)
Open retrorectus repair with permanent synthetic mesh
ventral hernia and main
complaint of laxity
Ventral incisional hernia
without infection with
undesired redundant skin and
wide scar
Recurrent ventral hernia after
failed open repair
Ventral incisional hernia with
(lightweight macroporous polypropylene mesh)
expectation of subsequent
laparotomy (e.g., Crohn’s
disease)
9 Abdominal Wall Spaces for Mesh Placement: Onlay, Sublay, Underlay
Allows wide mesh overlap even under rib margin and bony/
ligamentous fi xation
Addresses underlying problem and patient prioritized problem of
morbid obesity while allowing the most effective hernia repair
optimally performed after weight loss
85
Laparoscopic repair with bony mesh fi xation for suprapubic and
lateral or fl ank hernias
Bariatric surgery fi rst (laparoscopic sleeve gastrectomy if bowel
herniation or extensive adhesions); If hernia does not need to be
addressed (e.g., herniated omentum) then the defect is left
Morbid obesity bariatric
surgery candidate with
Concern Author’s preferred approach based on available evidence Author’s reasoning
Atypically located ventral
hernia (high epigastric,
suprapubic, lateral or fl ank)
non-obstructed ventral hernia
unrepaired. If the defect is disturbed (contents reduced), it is
repaired with underlay bridging biologic mesh deferring defi nitive
repair until after weight loss
86
G.L. Adrales
(eg.morbid obesity, smoking, diabetes, skin disease)
yes no
Risk modification
Education
Re-assessment
obese
prior but resolved infection
desires midline closure and smaller defect
reoperation for co-morbid disease (eg.Crohn’s) not a concern
laparoscopic underlay mesh repair
Patient assessment
Modifiable Co-morbidities?
Patient goals and Hernia traits?
removal of mesh
skin excision
active infection
desires midline closure
defect too large for laparoscopic closure (>5cm)
open retrorectus repair
can close midline cannot close midline
add components separation
open retrorectus repair
infection risk?
lower higher
macroporous permanent mesh biologic or bioabsorbable synthetic mesh
Fig. 9.2 Algorithm for technique/mesh selection
References
1. Burger JWA, Halm JA, Wisjmuller AR, ten Raa S,
Jeekel J. Evaluation of new prosthetic meshes for ventral hernia repair. Surg Endosc. 2006;20:1320–5.
2. Cassar K, Munro A. Surgical treatment of incisional
hernia. Br J Surg. 2002;89:534–45.
3. Poulose BK, Shelton J, Phillips S, Moore D, Nealon
W, Penson D, Beck W, Holzman MD. Epidemiology
and cost of ventral hernia repair: making the case for
hernia research. Hernia. 2012;16(2):179–83.
4. Burger JW, Luijendijk RW, Hop WC, Halm JA,
Verdaasdonk EG, Jeekel J. Long-term follow-up of a
randomized controlled trial of suture versus mesh
repair of incisional hernia. Ann Surg.
2004;240(4):578–83.
5. Muysoms F, Campanelli G, Champault GG, DeBeaux
AC, Dietz UA, Jeekel J, Klinge U, Köckerling F,
Mandala V, Montgomery A, Morales Conde S, Puppe
F, Simmermacher RK, Śmietański M, Miserez
M. EuraHS: the development of an international
online platform for registration and outcome measure-
ment of ventral abdominal wall hernia repair. Hernia.
2012;16(3):239–50.
6. Ventral Hernia Working Group, Breuing K, Butler
CE, Ferzoco S, Franz M, Hultman CS, Kilbridge JF,
Rosen M, Silverman RP, Vargo D. Incisional ventral
hernias: review of the literature and recommendations
regarding the grading and technique of repair. Surgery.
2010;148(3):544–58.
7. Hawn MT, Snyder CW, Graham LA, Gray SH, Finan
KR, Vick CC. Long-term follow-up of technical outcomes for incisional hernia repair. J Am Coll Surg.
2010;210(5):648–55.
8. de Vries Reilingh TS, van Geldere D, Langenhorst B,
de Jong D, van der Wilt GJ, van Goor H, Bleichrodt
RP. Repair of large midline incisional hernias with
polypropylene mesh: comparison of three operative
techniques. Hernia. 2004;8(1):56–9.
9. Timmermans L, de Goede B, van Dijk SM,
Kleinrensink GJ, Jeekel J, Lange JF. Meta-analysis of
sublay versus onlay mesh repair in incisional hernia
surgery. Am J Surg. 2014;207(6):980–8.
10. Rives J, Lardennois B, Pire JC, Hibon J. Large incisional hernias. The importance of fl ail abdomen and
9 Abdominal Wall Spaces for Mesh Placement: Onlay, Sublay, Underlay
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of subsequent respiratory disorders. Chirurgie.
1973;99(8):547–63.
11. Stoppa RE. The treatment of complicated groin and
incisional hernias. World J Surg. 1989;13(5):545–54.
12. Iqbal CW, Pham TH, Joseph A, Mai J, Thompson GB,
Sarr MG. Long-term outcome of 254 complex incisional hernia repairs using the modifi ed Rives- Stoppa
technique. World J Surg. 2007;31(12):2398–404.
13. Salvilla SA, Thusu S, Panesar SS. Analysing the benefi ts of laparoscopic hernia repair compared to open
repair: a meta-analysis of observational studies.
J Minim Access Surg. 2012;8(4):111–7.
14. Forbes SS, Eskicioglu C, McLeod RS, Okrainec
A. Meta-analysis of randomized controlled trials comparing open and laparoscopic ventral and incisional hernia repair with mesh. Br J Surg. 2009;96(8):851–8.
15. Hilling DE, Koppert LB, Keijzer R, Stassen LP, Oei
IH. Laparoscopic correction of umbilical hernias using
a transabdominal preperitoneal approach: results of a
pilot study. Surg Endosc. 2009;23(8):1740–4.
16. Blatnik J, Jin J, Rosen M. Abdominal hernia repair
with bridging acellular dermal matrix—an expensive
hernia sac. Am J Surg. 2008;196(1):47–50.
17. Heniford BT, Park A, Ramshaw BJ, Voeller
G. Laparoscopic repair of ventral hernias: nine years’
experience with 850 consecutive hernias. Ann Surg.
2003;238(3):391–9.
18. Albino FP, Patel KM, Nahabedian MY, Sosin M,
Attinger CE, Bhanot P. Does mesh location matter in
abdominal wall reconstruction? A systematic review
of the literature and a summary of recommendations.
Plast Reconstr Surg. 2013;132(5):1295–304.
19. Rosen MJ, Denoto G, Itani KM, Butler C, Vargo D,
Smiell J, Rutan R. Evaluation of surgical outcomes of
retro-rectus versus intraperitoneal reinforcement with
bio-prosthetic mesh in the repair of contaminated ventral hernias. Hernia. 2013;17(1):31–5.
20. Carbonell AM, Criss CN, Cobb WS, Novitsky YW,
Rosen MJ. Outcomes of synthetic mesh in contaminated ventral hernia repairs. J Am Coll Surg.
2013;217(6):991–8.
21. Helgstrand F, Rosenberg J, Kehlet H, Jorgensen LN,
Bisgaard T. Nationwide prospective study of outcomes after elective incisional hernia repair. J Am
Coll Surg. 2013;216(2):217–28.
22. Lomanto D, Iyer SG, Shabbir A, Cheah
WK. Laparoscopic versus open ventral hernia mesh
repair: a prospective study. Surg Endosc.
2006;20(7):1030–5.
23. Sauerland S, Walgenbach M, Habermalz B, Seiler
CM, Miserez M. Laparoscopic versus open surgical
techniques for ventral or incisional hernia repair.
Cochrane Database Syst Rev. 2011;3, CD007781.
24. den Hartog D, Dur AHM, Tuinebreijer WE, Kreis
RW. Open surgical procedures for incisional hernias.
Cochrane Database Syst Rev. 2008;3, CD006438.
25. Snyder CW, Graham LA, Gray SH, Vick CC, Hawn
MT. Effect of mesh type and position on subsequent
abdominal operations after incisional hernia repair.
J Am Coll Surg. 2011;212(4):496–502.
26. Halm JA, de Wall LL, Steyerberg EW, Jeekel J, Lange
JF. Intraperitoneal polypropylene mesh hernia repair
complicates subsequent abdominal surgery. World
J Surg. 2007;31(2):423–9.
Reconstructive Options for Small Abdominal Wall Defects
Parag Bhanot and Ryan Ter Louw
Introduction
Ventral hernias represent an incredibly varied
clinical entity with a wide spectrum of disease.
It is important for the surgeon to be comfortable
with several techniques as specifi c interventions
may prove more or less favorable for a given
hernia. Consequently, the reconstructive options
for hernia repair are diverse and must be tailored
to a given clinical situation. Patient comorbidities, hernia characteristics, and skin/soft tissue
factors will each impact the technique chosen
for the repair. In addition, intra-operative fi ndings should guide the reconstructive approach to
optimize outcomes. It is critical to perform the
fi rst hernia repair with the proper approach, technique, and mesh selection to avoid even higher
failure rates with subsequent repairs [ 1 ]. This
chapter will outline the authors’ approach and
management of the common small fascial defects
P. Bhanot , M.D., F.A.C.S. (*)
Department of Surgery , Medstar Georgetown
University Hospital , 3800 Reservoir Road, PHC
Building, 4th Floor , Washington, DC 20007 , USA
Parag.Bhanot@medstar.net
e-mail:
R. Ter Louw , M.D.
Department of Plastic Surgery , Medstar Georgetown
University Hospital , 3800 Reservoir Road ,
Washington, DC 20007 , USA
rpt2@gunet.georgetown.edu
e-mail:
1 0
encountered in umbilical, epigastric, and small
incisional hernias.
Patient Selection
Results following AWR are variable. Differences
in surgical outcomes are partially attributed to
differences in patient demographic. Age, gender,
obesity, smoking, and medical comorbidities
each independently impact outcomes following
ventral hernia repair. (Table 10.1 ) Age is an inde-
pendent risk factor for hernia recurrence, 30-day
major morbidity, and mortality.
Postoperative morbidity following VHR is
increased for each decade after 50 (OR 1.63),
preoperative (partial or total) functional dependence (2.34), presence of ascites (9.71), pulmonary compromise (2.47), acute renal failure
(11.45), and hyponatremia (3.34). The risk of
hernia recurrence increases proportionately with
the number of prior failed repairs; patients presenting for an initial hernia repair are much less
likely to develop a postoperative complication.
The success of surgical repair is inversely related
to the number of prior surgical attempts at
VHR. Functional status is another critical element to consider as patients who are not functionally independent are signifi cantly more likely
to develop complications following hernia repair.
Inactive and sedentary patients may not require
surgical repair if there is no involvement of bowel
Y.W. Novitsky (ed.), Hernia Surgery, DOI 10.1007/978-3-319-27470-6_10
89© Springer International Publishing Switzerland 2016
90
Table 10.1 Demographic variables associated with inferior surgical outcomes (30-day major morbidity, 30-day mortality, and/or hernia recurrence)
Age Ascites Coronary artery disease
Functional
dependence
Obesity Acute renal failure Chronic steroid dependence
Nicotine consumption Hyponatremia Immunosupression
COPD Anemia Reactive airway disease
Pulmonary
compromise
P. Bhanot and R. Ter Louw
Hypoalbuminemia
within the hernia sac. It is critical to optimize the
medical management of patient’s comorbid conditions prior to surgery through a multidisciplinary approach for preoperative risk
reduction, select patients for hernia repair with a
baseline functional capacity warranting surgery,
and determine the safest surgical procedure to
ensure a successful repair [ 2 ].
Approach (Open or Laparoscopic)
In addition to patient demographics, hernia
morphology affects outcomes and should also
dictate treatment. It is critical that the surgeon
personally review the imaging study, if available, to determine the extent of the structural
involvement to formulate the surgical plan.
However, the authors do not advocate the routine use of imaging for small noncomplicated
hernias. The factors that need to be considered
include: (1) defect size (2) number of defects,
and (3) location of the defect(s).
In general, repairs can be classifi ed as static or
functional (Fig.
re-approximate muscle and fascia and most laparoscopic repairs are considered static repairs
because they do not restore the inherit anatomy
of the abdominal wall. Small defects may be
amenable to closure with a laparoscopic approach
as well and possibly offer additional advantage
over traditional repair.
The following represents the authors’ algorithm based on personal clinical experience and a
review of the literature. A primary, single defect
<3 cm in a non-obese patient may be repaired
with suture repair alone (Fig.
tion represents a compromise between a slightly
10.1 ). Open repairs that do not
10.2 ). This situa-
higher recurrence rate and the avoidance of mesh
related complications. It is critical to assess the
quality of the fascia if mesh is excluded from the
repair. The approximation of poor quality tissue,
regardless of the fascia defect size, will lead to an
unacceptable recurrence rate. In addition, a rectus diastasis should be addressed as well [ 3 ].
All other patients, in the optimal setting,
should have a mesh reinforcement of the repair.
The decision to proceed with a laparoscopic versus open approach is dependent not only on the
size of the defect, but also on the quality of the
skin and soft tissue coverage (Fig. 10.3 ).
Adequate Skin/Soft Tissue Coverage
In these patients, the decision to proceed with a
laparoscopic or open approach is dependent on
the size of the defect. Recurrent hernias, single
defects between 3–10 cm, several midline defects
(“swiss-cheese type”), or primary defects less
than 3 cm in a morbidly obese individual are
ideal for a laparoscopic approach with synthetic
mesh (Fig.
10.4 ). The presence of a signifi cant
rectus diastasis may prompt an open approach.
Inadequate Skin/Soft Tissue Coverage
Regardless of the size of the defect, if there is a
potential for exposure of the synthetic mesh or
the repair is performed in the setting of contamination, we would favor the open approach with
the use of a biological mesh. There is currently
no data to support the use of a biological product
via a laparoscopic approach.
10 Reconstructive Options for Small Abdominal Wall Defects
91
Fig. 10.1 There are a myriad of techniques available for
AWR. Small defects are amenable to both an open and
laparoscopic approach. Larger defects may require a more
Fig. 10.2 CT scan image of small fascial defect (<3 cm)
Location of Mesh Placement
After selecting the ideal mesh product to reinforce a given VHR, the material may be placed
in a number of different locations within the
abdominal wall for reinforcement [ 4 ]. Mesh may
be sutured superfi cial to the primarily closed fascia (onlay), directly to the fascial edges as a
bridged repair (interposition), posterior to the
rectus abdominis muscle (sublay), or deep to the
peritoneum (underlay). Each of these has dis-
complex operation for adequate repair. With increasing
complexity of technique, the surgeon should expect a
higher morbidity rate
tinct advantages given a particular clinical situation. In general, underlay or retrorectus mesh
placement results in the lowest complication
rates including less infection, seroma, and hernia
recurrence as compared to onlay or interposition
mesh placement. Within the context of biologic
mesh, interposition mesh placement when primary fascial approximation is not feasible will
result in the highest rate of hernia recurrence,
approaching 100%.
Specifi c Hernias
Umbilical Hernias
Hernias involving the umbilicus can be congenital or occur spontaneously. Many congenital
umbilical hernias will spontaneously close by
2–3 years of age. The repair of the pediatric hernia is not the focus of the following discussion. In
adults, multiparity, obesity, ascites, as well as any
other pathology that elevates intra-abdominal
pressure, increase the risk of a fascial defect.
Though umbilical hernias are common, the differential diagnosis should include soft tissue
tumors and urachal cysts. The contents of an
92
P. Bhanot and R. Ter Louw
MIDLINE
Fig. 10.3 Algorithm for AWR for small to moderate size defects
Primary
BMI<30
Single defect
Small (upto 2 cm)
Recurrent
BMI>30
Single defect (2 to 5cm)
Several small defects
No rectus diasthesis
Recurrent
BMI>30
Single defect (5 to 10cm)
Rectus diasthesis
High risk of SSO/SSI
Grade 1,2 and
Low risk of SSO/SSI
Fig. 10.4 CT scan image of moderate fascial defect
(3–8 cm)
umbilical hernia may include pre-peritoneal fat,
mesenteric fat, and/or bowel.
As discussed, the size of the defect, comorbidities, and the skin factors should be considered in the choice of surgical technique. With
our established algorithm, most of the umbilical
hernias repaired in our practice in the non-obese
population are a primary suture repair without
mesh reinforcement. This does represent a compromise between recurrence rates and mesh
related complications. A randomized study by
Arroyo et al. showed that umbilical hernia repair
with prosthetic mesh had a recurrence rate of 1%
Open Approach
Suture repair
Grade 1,2 and
Low risk of SSO/SSI
Grade 2,3 or
Laparoscopic Approach
Synthetic mesh repair
Open Approach
Biologic mesh repair
Open Approach
Synthetic mesh repair
at 64 months compared to 11% with direct suture
repair alone. Complications in both groups were
similar [ 5 ].
Given the same small defect size in an obese
individual, mesh reinforcement is necessary. The
protocol for synthetic versus biological mesh has
been previously discussed. In the setting of appropriate skin coverage, a laparoscopic approach is
recommended with synthetic mesh [ 6 ]. Typically,
these cases are short and can be performed as a
same day operation. With less than ideal skin
coverage, absent or attenuated skin, a laparoscopic approach is not recommended. An open
repair with reduced-weight polypropylene mesh
or biological mesh is appropriate.
Epigastric Hernias
Epigastric hernias are another common fascial
defect encountered by general surgeons and
may be present in up to 2% of the population.
They mostly occur spontaneously as a function
of the anatomy of the linea alba which becomes
thinner and wider cephalad from the umbilicus.
These hernias have a male prevalence and can
have multiple defects in upto 20% of patients.
Given the small defect size which often has a
10 Reconstructive Options for Small Abdominal Wall Defects
93
small piece of incarcerated preperitoneal fat,
the level of discomfort can be more than
expected. The diagnosis is usually made with
the clinical exam confi rming a palpable bulge.
Imaging is not necessary, but can be obtained if
the exam is equivocal.
The algorithm for repair has been described in
the preceding section [ 7 ]. As with umbilical her-
nias, the authors recommend repair of any associated rectus diastasis to minimize recurrence or
development of metachronous defects.
Incisional Hernias
Incisional hernias develop in up to 20% of patients.
The associated pathology is quite variable and thus
so is the technique utilized for repair. A recent
Cochrane database review of open surgical techniques for incisional hernias has shown that even
in small defects, the use of suture repair was associated with less surgical site infection and seroma
but an increased rate of recurrence [ 8 ]. Therefore,
mesh reinforcement is advocated for in all incisional hernias, regardless of defect size [ 9 ].
There are multiple randomized controlled trials evaluating laparoscopic versus open repair of
abdominal wall hernias. The laparoscopic
approach provides for lower overall complication
rates, decreased wound complications, decreased
length of stay, and decreased recurrence rates.
However, there is a higher rate of bowel injury
with inexperienced surgeons [ 10 ].
Technique for Open Repair With/ Without Mesh Reinforcement
1. An incision is made over the fascial defect to
provide proper exposure in either a vertical or
horizon fashion. For umbilical hernias, the
umbilical stalk is dissected free from the hernia
sac. It is important not to button-hole the skin.
2. The hernia sac/ contents are dissected away
from the edges of the fascia. Without the
involvement of omentum or bowel, violation
of the peritoneal cavity should be avoided.
Especially important are individuals with the
presence of ascites.
3 .
(a) The fascial edges are clearly delineated.
With a less than 2 cm defect, a primary
repair is carried out using absorbable
suture such as 0-PDS fi gure of eight
sutures transversely. We typically place
our corner sutures beyond the defect
(Fig. 10.5a, b ).
(b) With a defect larger than 2 cm and/or
accounting for patient risk factors, mesh
can be utilized. The authors recommend
underlay mesh (intraperitoneal or sublay) rather than an onlay technique. The
size of the mesh should allow for at
least 3–4 cm support circumferential.
Fig. 10.5 ( a ) The small defect size is clearly delineated after the fascial edge is cleared circumferentially. ( b ) A pri-
mary suture repair is performed in a transverse fashion with fi gure-of-8 PDS sutures starting beyond the actual defect
94
P. Bhanot and R. Ter Louw
The mesh is secured with at least 0-PDS
sutures transfascial. The fascia is then
re-approximated over the mesh.
(Fig. 10.6a–c ).
4. Closure of the incision . For umbilical hernias,
the umbilicus is tacked back down to the linea
alba with absorbable suture.
Technique for Laparoscopic Repair with Mesh Reinforcement
1. The authors prefer to gain access to the peritoneal cavity via a Veress needle at the anterior
axillary line, but is based on surgical history.
2. Trocar placement is based upon surgical history. 3 (5 mm) and 1 (12 mm) trocars are
required. It is important to place the trocars at
ample distance from the actual defect to allow
appropriate overlap with the mesh.
3. A lysis of adhesions is usually not required in
the absence of previous surgery. However, we
prefer to take down the falciform ligament
from the posterior sheath with ultrasonic
shears to allow adequate penetration by tacking device (Fig. 10.7a–f ).
4. The hernia contents should be fully reduced.
If possible, the hernia sac can be excised.
5. The fascial defect is measured by a standard
technique previously described using a spinal
needle. It is up to the surgeon’s preference
whether to close the small defect or not.
Fig. 10.6 ( a ) A 5 cm fascial defect is exposed at site of
prior incision. ( b ) Mesh reinforcement is utilized given
the defect size and association with prior incision.
Location is intraperitoneal. The mesh is parachuted in
after placement of #1-PDS sutures transfascial. ( c ) After
securing the mesh, the fascia is then re-approximated with
additional #1-PDS sutures, providing autologous tissue
coverage