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10 Reconstructive Options for Small Abdominal Wall Defects
95
Fig. 10.7 ( a ) Adhesions from prior surgery will need to
be addressed to expose the small fascial defect. ( b ) A
single small fascial defect is visualized measuring
5 × 5cm. ( c ) Given the small defect size and compliance of
the abdominal wall, closure of the defect is performed
prior to mesh placement. A suture passer device is utilized
to place several fi gure-of-8 sutures. ( d ) Depicted are the
sutures placed prior to tying them down. ( e ) The small
defect has been re-approximated without exceeding physiological tension. ( f ) The mesh is then placed in a standard
laparoscopic fashion. With the small defect reapproximated, less mesh material is needed to provide the
proper overlap
96
P. Bhanot and R. Ter Louw
Fig. 10.8 ( a ) A 2 cm fascial defect is isolated after reduc-
tion of omentum. The fascia is attenuated with a 3 cm
wide thin linea alba. ( b ) The defect is closed in a trans-
verse fashion with fi gure-of-8 0-PDS sutures. Mesh is not
utilized given the defect size. ( c ) An additional suture line
is placed in a vertical fashion to plicate the rectus muscles
over the fi rst suture line to provide additional support
10 Reconstructive Options for Small Abdominal Wall Defects
97
6. The mesh is selected and measured to allow
for at least 5 cm overlap.
7. The mesh is fi xated with both transfascial
sutures as well as circumferential tacks. The
authors prefer an absorbable tacker given the
intraperitoneal location of the mesh.
Technique for Repair of Rectus Diastasis
1. The incision is a vertical midline incision to
provide proper exposure from the xiphoid process infra-umbilical. The small fascial defect
is repaired as described above with or without
mesh reinforcement (Fig. 10.8a–c ).
2. The extent of the diastasis is delineated to
allow for maximal plication.
3. Either a single or double row of sutures can be
utilized depending upon surgeon preference.
The authors prefer either a single row of
fi gure- of- 8 #1-PDS sutures or a double row
consisting of fi gure-of-8 0-PDS sutures followed by running #1-PDS. Additional onlay
mesh reinforcement is not necessary.
Summary
Reconstructive options for AWR are vast and
should start with optimizing patient selection. It is
important to note that not all patients require
repair and the decision to offer surgery should be
based on reasonable expectations. The surgeon
should have within his/her armamentarium a myriad of options to perform the optimal surgery. An
algorithm should be incorporated into clinical
practice based on high level data that will allow
the surgeon to defi ne which approach, technique,
and mesh reinforcement should be utilized for
each individual patient. The ultimate goals of ven-
tral hernia repair are (1) prevent complications
from the hernia, (2) restore functional abdominal
wall, (3) improve cosmesis, and (4) minimize
future complications including recurrence.
References
1. Flum DR, Horvath K, Koepsell T. Have outcomes of incisional hernia repair improved with time? A populationbased analysis. Ann Surg. 2003;237:129–35.
2. Breuing K, Butler CE, Ferzoco S, et al. Incisional
ventral hernias: review of the literature and recommendations regarding the grading and technique of
repair. Surgery. 2010;148(3):544–58.
3. Köhler G, Luketina RR, Emmanuel K. Sutured repair
of primary small umbilicaland epigastric hernias:
concomitant rectus diastasis is a signifi cant risk factor
for recurrence. World J Surg. 2015;39(1):121–6.
4. Albino FP, Patel KM, Nahabedian MY, et al. 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.
5. Arroyo A, García P, Pérez F, et al. Randomized clinical trial comparing suture and mesh repair of umbilical hernia in adults. Br J Surg. 2001;88(10):1321–3.
6. Sauerland S, Walgenbach M, Habermalz B, et al.
Laparoscopic versus open surgical techniques for
ventral or incisional hernia repair. Cochrane Database
Syst Rev. 2011; 3.
7. Christoffersen MW, Helgstrand F, Rosenberg J, et al.
Lower reoperation rate for recurrence after mesh versus sutured elective repair in small umbilical and epigastric hernias. A nationwide register study. World
J Surg. 2013;37(11):2548–52.
8. den Hartog D, Dur AH, Tuinebreijer WE, et al. Open
surgical procedures for incisional hernias. Cochrane
Database Syst Rev. 2008;3.
9. Nguyen MT, Berger RL, Hicks SC, et al. Comparison
of outcomes of synthetic mesh vs suture repair of elective primary ventral herniorrhaphy: a systematic review
and meta-analysis. JAMA Surg. 2014;149(5):415–21.
10. Pierce RA, Spitler JA, Frisella MM, et al. Pooled data
analysis of laparoscopic vs. open ventral hernia repair:
14 years of patient data accrual. Surg Endosc.
2007;21(3):378–86.
Onlay Ventral Hernia Repair
Nathaniel Stoikes , David Webb , and Guy Voeller
11.1 Introduction
There are many ways to approach the repair of a
ventral or incisional hernia (VIH). Varying techniques are based on where the mesh is placed in
relation to the abdominal wall. Furthermore, there
is a relationship between the repairs and their histories. Options include intraperitoneal placement
of mesh, retrorectus or retromuscular placement
(Rives 1973) and premuscular or onlay mesh
placement (Chevrel 1979). The two major techniques described by Rives and Chevrel occurred in
the 1970s and essentially run parallel to each other.
In their time, both techniques maintained popularity and had similar outcomes. However, during the
past 20 years retromuscular mesh placement as
described by Rives has become the standard of
care for ventral hernias while Chevrel’s onlay technique was forgotten. The lack of popularity of the
onlay repair in the USA has a historical basis. The
Rives retrorectus repair was brought to the United
Electronic supplementary material: The online ver-
sion of this chapter (doi:
contains supplementary material, which is available to
authorized users.
N. Stoikes , M.D. (*) • G. Voeller , M.D.
Department of Surgery , University of Tennessee
Health Science Center , Germantown , TN , USA
nstoikes@uthsc.edu
e-mail:
D. Webb , M.D.
Baptist Memphis and Methodist Germantown ,
Memphis , TN , USA
10.1007/978-3-319-27470-6_11 )
11
States in the 1980s by George Wantz, who was a
hernia surgeon from New York. Dr Wantz travelled to France to learn many of their hernia repair
methods. One of our mentors, Eugene Mangiante,
brought Dr. Wantz to our institution in the early
1980s and taught the senior author the Rives’ sublay repair. This repair became our repair of choice
and is taught to our residents to this day. As we
developed our laparoscopic repair we realized that
suture fi xation would be critical to long term success and we used pictures in the hernia atlas produced by Dr. Wantz of the Rives repair to show
how the two repairs were similar. The main difference is that the mesh is behind the rectus muscles
in the Rives repair and intraperitoneal in the laparoscopic. The fi rst laparoscopic ventral hernia
repair course ever taught was in Memphis, TN in
the mid 1990s; at this course and many others that
followed, American surgeons were introduced to
the open Rives repair as the basis for laparoscopic
ventral hernia repair. At this time, most V/I hernia
repairs in the USA were done as an inlay with the
mesh being sewed to the edges of the hernia defect.
As more surgeons learned the laparoscopic repair
and were exposed to the Rives open repair, the
Rives repair became the standard for most herniologists in the USA. In the process, Chevrel’s
onlay technique, which was not known in the USA
had been more or less forgotten except by its practitioners in France. In 2003 we began using fi brin
glue for mesh fi xation for our TEP inguinal hernia
repairs and this stimulated our interest in Chevrel’s
onlay method for V/I hernia repair.
© Springer International Publishing Switzerland 2016
Y.W. Novitsky (ed.), Hernia Surgery, DOI 10.1007/978-3-319-27470-6_11
99
100
N. Stoikes et al.
11.2 Chevrel’s Logic
In the classic Chevrel repair, the primary goal is
to recreate the linea alba. Chevrel based this on
biomechanical studies which he and Rath conducted to identify the strongest and weakest portions of the abdominal wall. In these studies, they
evaluated the abdominal wall above and below
the arcuate line of Douglas as well as the anterior
and posterior sheaths. When looking at breaking
strain and deformability, the anterior sheaths and
posterior sheaths were similar above and below
the arcuate line. However, differences were found
in bursting strength. The strongest area was the
supraarcuate anterior sheath, which was signifi cantly stronger than the infraarcuate anterior
sheath. The supraarcuate posterior sheath was
stronger than the infraarcuate posterior sheath
but was not statistically signifi cant. In all, the
supraarcuate anterior sheath was stronger than
the posterior sheath at all levels [ 1 ].
Chevrel also studied the linea alba and found
that the infraumbilical linea alba was stronger
(linear traction) than the supraumbilical linea
alba. He then compared this to the rectus sheath
and found the anterior rectus sheath to have the
most comparable values. The results of the posterior sheath values are the most compelling in that
the posterior sheath is weaker on all levels than
the linea alba but especially the infraumbilical
posterior sheath ( P < 0.01) [ 2 ].
These studies form Chevrel’s logic for a premuscular prosthesis. First, the anterior rectus
sheath is the strongest and best tissue to use for
recreation of the linea alba. Second, a premuscular prosthesis placement is favorable to the retrorectus location due to the weakness of the
posterior sheath. In reference to retrorectus prosthesis placement, Chevrel stated “The posterior
sheath then becomes the layer which separates
the prosthesis from the peritoneum and the viscera, and the fi rst to sustain the action of the
intraabdominal pressure.” He goes on to conclude: “this layer is thus weaker than the underlying prosthesis and will give way under an increase
in intraabdominal pressure, risking exposing the
viscera to the prosthesis.” Chevrel also felt infections were easier to treat in a premuscular than a
retromuscular prosthesis and the retromuscular
mesh may have to be removed while that is rarely
necessary when the mesh is premuscular [ 3 ]. In
our clinical experience with onlay ventral hernia
repair, we have found the management of wound
infections to be straight forward with salvage of
mesh in all cases .
11.3 Chevrel’s Technique
As previously stated, the goal of Chevrel’s technique is to reconstruct the linea alba. After making
skin fl aps, this is accomplished by creating a four
layer reconstruction that includes three tissue layers
and a premuscular prosthesis. The three tissue layers are accomplished by fi rst closing the midline
fascia. Chevrel used Gibson or Clotteau-Premont
type relaxing incisions if required to get the midline
closed. Vertical incisions are then made along the
rectus muscles bilaterally 2 cm from their medial
borders and these fl aps are folded over each other
and sutured. The lateral edges of each fl ap of rectus
sheath are rolled toward the midline and sutured
with two rows of interrupted “u” stitches. These
fl aps create the second and third tissue layers. The
prosthesis in the onlay position is the fourth layer
(Fig. 11.1 ). The periphery of the mesh is fi xated
with running absorbable suture and the middle portion of the mesh is molded to the midline closure by
spraying 2 mL of fi brin glue. Chevrel did this to fi x
the mesh to the midline closure which took tension
off of the midline closure immediately until granulation tissue served that function. Two to four closed
suction drains are then placed and the skin is closed
in two layers. Chevrel left his drains until there was
no drainage for 48 hours and he maintained an
abdominal truss day and night for 2 months. He felt
it took this long for adequate granulation tissue to
grow through the mesh [ 3 ].
11.4 Clinical Data
Looking at Chevrel’s original series, it is important to note that he compiled other techniques
with the technique just described and treated 426
incisional hernias from 1979 to 1998. He used
11 Onlay Ventral Hernia Repair
101
Fig. 11.1 Chevrel’s technique for recreation of the linea alba
the fi brin glue technique in 143 repairs and they
followed up 93% of them for between 1 and 20
years. His recurrence rate was 4.9% and no prosthesis was lost to mesh infection. He also found
that seroma formation was greater when larger
amounts of fi brin glue were used [ 3 ].
Kingsnorth in 2007 published a series of ventral hernia repairs using mesh onlay, components
separation, and suture and fi brin glue. The technique included midline closure and selective use
of Ramirez type component separation. The mesh
was fi xated with running sutures on the periphery
of the mesh. With regard to fi brin glue use, it was
directed for treatment of the skin fl aps instead of
mesh fi xation. The study population included 116
patients with a median follow up of 15.2 months.
Seroma rate was 9.5% and skin infection rate was
8.6%. There were no mesh infections. The recurrence rate was 3.4% over the follow up period [ 4 ].
Stoikes et al. published their initial series of
50 patients of an onlay technique using fi brin
glue alone for mesh fi xation. Our technique differs from the classic Chevrel in that it utilizes an
onlay of the mesh prosthesis, however, it is positioned initially with skin staples and then fi xated
to the entire anterior fascia with fi brin glue alone.
The senior author noticed when he fi rst did this
that there was immediate strong fi xation of the
mesh over the entire abdominal wall and stress
was immediately taken off of the midline suture
closure. The technique includes tension free primary closure of the midline with selective use of
myofascial advancement fl aps when required.
Mean follow up was 19.5 months with no known
recurrences identifi ed. The seroma rate was 16%
and skin infection rate was 6%. There were no
mesh infections [ 5 ]. An update to the data is in
process and now numbers over 100 patients. New
data includes use of the technique in cleancontaminated and contaminated scenarios with
no associated infectious complications or reoperations. Overall skin infection rate is 4 with
102
N. Stoikes et al.
100% salvage of mesh in all situations with infection. BMI is the only risk factor linked to infection and reoperation .
11.5 Logic and Technique
for Onlay Ventral Hernia
Repair with Fibrin Glue
Fixation
The key to a successful onlay ventral hernia
repair is a tension free primary midline closure.
Accomplishing this requires the use of advancement fl aps in the form of external oblique releases
and posterior rectus fascia releases in a selective
manner as described by Ramirez. Independently,
the mesh should be viewed as a buttress that integrates into the abdominal wall for long-term
strength and recurrence prevention. The addition
of fi brin glue to fi xate the mesh is what provides
immediate fi xation to all surfaces thereby allowing immediate load sharing and reduced tension
on the midline in the short-term.
Understanding the principles, one should
select patients with defect sizes where the surgeon believes that the midline can be recreated
with acceptable tension on the primary midline
closure. This means that good quality fascia can
be brought together or overlapped with acceptable tension. In our practice, this generally
applies to patients with defect widths of 15 cm or
less. Other applications for onlay include offmidline hernias such as fl ank hernias or paramedian defects where there may be insuffi cient
space for appropriate sublay of mesh or fi xation
of mesh .
operate on smokers unless they stop for 2 months
and this is especially true for the onlay method
where the skin fl aps will be compromised. We
also try to avoid operating on the morbidly obese
hernia patient until they lose weight since these
fl aps can be compromised. Generally speaking,
we would like patient BMI to be optimized to 35
or less, but in some cases that is not possible
given the characteristics of the hernia or symptoms. Regardless, we exhaust all avenues for
weight loss including diet, exercise, and bariatric
referral coupled with offi ce follow up for weight
monitoring. Unfortunately, there are cases where
patients are noncompliant in which case they
only receive a hernia repair in the emergency setting. At each step of medialization of the fascial
edges, the defect edges should be assessed for
tension as they are brought together. While tension free midline advancement is important, any
component release principally weakens the native
abdominal wall in another region, so it should not
be done dogmatically. Ramirez described a stepwise approach for myofascial advancement
beginning with skin fl ap creation. If this is not
enough, then the posterior rectus fascia is incised
on one side, making sure to release each inscription (one sees a “pop” of the fascia when these
are cut). If necessary the other rectus fascia is
released and then if required the external releases
are done one at a time. Generally this will address
elliptical defects up to 15 cm wide. A running or
interrupted primary closure of #1 nonabsorble
suture is then used to close the midline (Fig. 11.2 ).
11.5.1 Technique Description
After a reduction of the hernia and lysis of adhesions, the hernia defect is delineated and skin
fl aps are made generally out past the semilunar
line. Since the onlay technique requires creation
of skin and subcutaneous fl aps, it should not be
done in patients who have had the collateral circulation to the skin compromised, i.e., those that
have had aortic surgery where the lumbar collaterals have been sacrifi ced. In addition, we do not
Fig. 11.2 Closure of the midline after myofascial
advancement
11 Onlay Ventral Hernia Repair
103
A macroporous, light weight (or microporous,
heavier mesh if necessary) polypropylene mesh
is then placed in the onlay position such that it
covers the entire area of exposed fascia and any
external releases. Overlap of the midline closure
should be a minimum of 8 cm. A simple skin stapler is used as a placeholder for proper positioning of the mesh. Fibrin glue is then applied fi rst to
the midline. The glue typically has a dual nozzle
with an attachable common spout. We prefer to
allow the glue to be applied through the dual nozzle and use our hands to mix and massage the
glue components into the mesh and abdominal
wall. In this way, the mesh is fi rst molded to the
midline closure as Chevrel originally described.
The remaining mesh is then completely covered
with the fi brin glue to fi xate all aspects
(Fig. 11.3a–d ). Staples are used at the periphery
as well as the central area of the mesh. If external
oblique releases have been done we use a running
absorbable suture to sew the mesh to the lateral
edge of the release on each side (Fig. 11.4 ). Two
to four large bore drains are placed in the subcutaneous space and secured with nylon sutures.
The skin and remaining hernia sack is then
debrided and subsequently closed in two layers.
Absorbable 3-0 sutures are used to close the dermal layer and then a running absorbable 4-0
suture is used to close the skin or a combination
of nylon sutures and skin staples. We use a
BioPatch (Ethicon, Cincinnati, OH) around each
drain with a Tegaderm (3M, St. Paul, MN) and
change these weekly. Patients are sent home on
minocycline as long as the drains are in place.
Fig. 11.3 ( a )–( d ) Onlay ventral hernia repair with fi brin glue fi xation of mesh
104
N. Stoikes et al.
Fig. 11.4 Onlay mesh placement fi xated with skin staples, fi brin glue, and running absorbable suture along the
external oblique release
Post-operatively the patients are kept NPO
until bowel function resumes and the patient
wears an abdominal binder at all times. We have
no strict numbers as to when drains are removed.
Since seromas are more common with skin fl ap
creation we leave drains in until almost nothing is
coming out from the drains. This will help limit
seroma formation. As a general rule, drains
should be kept in for 10–14 days at minimum.
11.6 Discussion
When thinking about mesh fi xation in ventral
hernias, one must keep in mind that risks factors
and inherent genetics contribute to hernia formation. Whether a sublay or onlay is used, mesh has
to be anchored and typically by mechanical fi xation. The problem with mechanical fi xation is
that one relies on inherent tissue strength to support the mechanical anchoring that is being done,
which in a way perpetuates the problem of recurrence in a patient who is already prone to hernia
formation. This line of thought led our group to
the use of adhesives, which has been shown by
multiple investigators to be an excellent fi xation
method for inguinal hernia repairs.
To better understand adhesive fi xation, Stoikes
et al. compared fi brin glue fi xation of mesh to
suture fi xation with an onlay model in Mongrel
pigs. At 24 hours, 7 days, and 14 days, the two
groups were evaluated with biomechanical shear
testing and histology. Biomechanically, shear
strengths were stronger at 24 hours for the sutured
group but by 7 days the groups were equal.
Specifi cally, by 7 days the lightweight macroporous mesh was so integrated into the abdominal
wall that the mesh/fascia interface was found to
be stronger than the mesh or fascia itself. Coupled
with similar histologies and no mesh migrations
with glue, it was concluded that fi brin glue fi xation has excellent fi xation properties. Another
interesting point studied was that the contraction
rate of mesh was less with the glue group, though
it did not reach statistical signifi cance. It was
speculated that this was due to the advantage of
having all surfaces of the mesh fi xated as opposed
to point fi xation with sutures, which allows for
mesh to ripple and fold as it scars into the abdominal wall [ 6 ].
Understanding the principles and application
of adhesives for mesh fi xation allows for a different perspective on ventral hernia repair: suture
fi xation is a function of suture strength and tissue
strength; whereas adhesive fi xation is a function
of surface area alone . One can see how adhesive
use coupled with a broad premuscular prosthesis
could have distinct advantages for ventral hernia
repair. We have been impressed at the immediate
strength one sees of the repair when the mesh is
fi xated with fi brin glue. We have had cases where
the muscle relaxant has worn off intraoperatively
after the mesh has been glued, the patient “bucks”
on the endotracheal tube and generates tremendous intraabdominal pressure. The mesh will not
budge and the suture closure of the midline shows
no stress. There is no need to wait for tissue
ingrowth for stress to be removed from the midline suture closure and this is the key in our
method of onlay repair.
Future directions of the adhesive advantage
could include prevention of mesh contraction as
it relates to chronic pain. An article recently published by Bendavid et al. discussed mesh contraction and fi xation as a cause of chronic pain in
inguinal hernia repairs. While the article focuses
on inguinal hernia, the discoveries about mesh
and how it potentially causes chronic pain,
directly translates to ventral hernia as well.
11 Onlay Ventral Hernia Repair
105
Bendavid concluded that part of the problem was
deformation and contraction of mesh, which created pockets and warped surface areas for potential nerve impingement or ingrowth [ 7 ]. Such
fi ndings are consistent with point fi xation of
mesh. Because adhesive fi xation results in complete fi xation of all portions of the mesh, contraction and deformation may be preventable and
needs further evaluation.
Clinically, we have observed anecdotal evidence that patients have signifi cantly less postoperative pain and less narcotic requirement
compared with intraperitoneal or retrorectus
repairs. Intuitively, it makes sense for several reasons including that there is no muscle and fascia
penetration by sutures that strangulate tissues and
entrap nerves. In addition, complete fi xation creates a better load sharing environment compared
to point fi xation which may cause a patient to
experience pulling and tugging at the various fi xated locations.
Another advantage of onlay ventral hernia
repair is that mesh is not located intraabdominally or separated from the viscera by the weakest layer of the abdominal wall where viscera and
mesh can come into contact with one another as
in the Rives repair. Reoperations for other pathologies are less technically demanding and also the
risks of mesh complications are less. Most importantly, in situations of post-operative infection or
intraoperative contamination we have had a
100% salvage rate of the mesh and clearance of
infection. The combination of the onlay location
of mesh and selection of a macroporous confi guration allows for quick integration of the mesh
with vacuum wound systems.
References
1. Rath A, Zhang J, Chevrel J. The sheath of the rectus
abdominis muscle: an anatomical and biomechanical
study. Hernia. 1997;1:139–42.
2. Rath A, Attali P, Dumas J, et al. The abdominal linea
alba: an anatomo-radiologic and biomechanical study.
Surg Radiol Anat. 1996;18:281–8.
3. Chevrel J, Rath A. The use of fi brin glues in the surgical treatment of incisional hernias. Hernia.
1997;1:9–14.
4. Kingsnorth A, Shahid M, Valliattu A, et al. Open
onlay mesh repair for major abdominal wall hernias
with selective use of components separation and fi brin
sealant. World J Surg. 2008;32:26–30.
5. Stoikes N, Webb D, Voeller G, et al. Preliminary
report of a sutureless onlay technique for incisional
hernia repair using fi brin glue alone for mesh fi xation.
Am Surg. 2013;79:1177–80.
6. Stoikes N, Sharpe J, Voeller G, et al. Biomechanical
evaluation of fi xation properties of fi brin glue for ventral incisional hernia repair. Hernia. 2015;19(1):161–6.
7. Bendavid R, Lou W, Koch A, et al. Mesh related SIN
syndrome. A surreptitious irreversible neuralgia and
its morphologic background in the etiology of postherniorraphy pain. Int J Clin Med. 2014;5:799–810.