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258
R. Hörmann et al.
22
22.2.3 Hernia Location
ere are certain areas of the abdominal wall that
represent specic challenges that must be addressed
to accomplish as sound and enduring repair. ese
hernias are very likely to recur if adherence of certain
principles is ignored. e two most common loca-
tions are in the upper (subxiphoid) and lower abdo-
men (suprapubic). In both of these locations, a wider
dissection of the tissues will be required. As dis-
cussed in a later chapter, the adipose deposits must
be dissected free from the anterior abdominal wall.
Specically, the falciform ligament and the extra-
peritoneal space above the bladder must be released.
In only this manner will the mesh used be presented
with the most surface area of the abdominal wall to
allow for the most rapid ingrowth of collagen.
Due to the fact that the diaphragm and pericardium lie just above the xiphoid, care must be
taken to avoid placement of any xation device
or suture into or through these structures. It is
preferred to use an extended amount (8 cm) of
fascial overlap of the mesh to minimize the risk
of recurrence. Additionally, I prefer to suture the
cephalad portion of the mesh to the diaphragm.
e suprapubic hernias require the same consideration of larger mesh overlap. In this location,
this means that the prosthetic should be large
enough to extend over to Cooper’s ligament bilaterally. Fixation to this periosteum is required as
well. ese points are critically important.
Hernias in the lumbar regions are similar in
the sense that larger mesh overlap is required, and
careful suture xation to either the diaphragm,
psoas, or iliacus muscle may be necessary. Some
surgeons have advocated the use of bone anchors
to the iliac bone for the inferior lumbar hernias.
It is known that as many as 25% of patients
will have a hernia that has more than one defect.
Usually these are close together and may be
repaired as a single hernia repair. On occasion,
however, there will be two or more fascial defects
that are so separated that more than one mesh
will be necessary to repair them. In these cases,
if it is not feasible to approach them from the
same trocars, additional trocars should be place
appropriately. Sometimes, this requires penetration through the initial prosthetic. If this occurs,
it is important to close this violation of the mesh
unless the trocar used is small. However, to my
knowledge, herniation through such a mesh
defect has not been reported.
22.2.4 Fixation
Currently, nearly all forms of prosthetic materials
are used to repair incisional and ventral hernias.
In all cases, this requires penetration into at least
one layer of the abdominal wall musculature.
When the selection of these devices is made,
the surgeon should be familiar with the depth of
penetration of the fastener itself. e thickness of
the mesh must be taken into account to know the
amount of the transversus fascia and muscle that
is grasped. ere is a possibility that they could
penetrate deeper in thinner patients.
Many surgeons continue to use transfascial sutures. ese, of course, will penetrate
through all layers of the abdominal wall (transversus abdominis, internal oblique, and external
oblique). Because of this, there is a risk of trapping a subcutaneous nerve when the knot is tied.
is is unavoidable and can be the source of pain.
More commonly, however, is the fact that the
suture will cut through the layers of the fascia
and muscle. is will most commonly result in
chronic pain. is is best avoided by making the
knot snug, but not strangulating to the tissues.
22.3 Conclusion
It is important to understand the anatomy of the
abdominal wall to eectively repair the abnormalities that result in the development of herniation.
ere are some special considerations related to
the laparoscopic approach. is review of the
important points should lead the reader to the
investigation of the entire contents of this textbook to ensure a proper repair.
References
1. Leonhardt H, etal. Rauber/Kopsch. Bewegungsapparat-
Thieme, Stuttgart: Anatomie des Menschen. Bd. I; 1987.
2. von Lanz T, Wachsmuth W.Praktische Anatomie Teil 6: Bd.
2. Bauch. Berlin\Heidelberg\New York: Springer; 1993.
3. Caix M. Functional anatomy of the muscles of the
anterolateral abdominal wall: electromyography
and histoenzymology, in hernias and surgery of the
abdominal wall. Heidelberg: Springer; 1998. p.31–44.
4. Gedda S, van der Linden W.What makes the peritoneal
drain work? Pressure in the subhepatic space after bili-
ary surgery. Acta Chir Scand. 1982;149(7):703–6.
5. Southwood W.The thickness of the skin. Plast Reconstr
Surg. 1955;15(5):423–9.
Anatomy oftheAbdominal Wall: What Is Important forLaparoscopic Surgery?
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6. Krackowizer P, Brenner E.Dicke der Epidermis und Dermis. Phlebologie. 2008;37:83–92.
7. Lee Y, Hwang K.Skin thickness of Korean adults. Surg
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9. Fritsch H, Kühnel W.Taschenatlas der anatomie, band
2: innere organe. Stuttgart: Georg Thieme Verlag;
2013. p.224–7.
10. Milloy F, Anson B, McAfee D.The rectus abdominis
muscle and the epigastric arteries. Surg Gynecol
Obstet. 1960;110:293–302.
11. Adachi B, Hasebe K. Das arteriensystem der Japaner.
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Kyoto, in kommission bei “Maruzen Company”; 1928.
12. Stieda H. Über die Arteria circumexa ilium. Anat Verh.
1892;7:232–45.
13. Papadopoulos N, Katritsis E.Some observations on the
course and relations of the iliohypogastric and ilioinguinal nerves (based on 348 specimens). Anat Anz.
1980;149(4):357–64.
14. Barrington M, et al. Spread of injectate after
ultrasound- guided subcostal transversus abdominis
plane block: a cadaveric study. Anaesthesia. 2009;64(7):
745–50.
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anatomy and clinical technique. Reg Anesth Pain Med.
2010;35(5):436–41.
16. Kasseroller R, Brenner E.Kompendium der Lymphangiologie: Manuelle Lymphdrainage-KompressionBewegungstherapie. Stuttgart: Georg Thieme Verlag;
2015.
261
Ventral andIncisional
Hernias: Dierences
andIndications
forLaparoscopic Surgery
FerdinandKöckerling andAnilSharma
23.1 Dierent Diseases?–262
23.2 Indications forLaparoscopic Surgery:
Limitations–262
23.2.1 How Do IDo It?–262
23.2.2 What Is Evidence Based inClinical Practice?–263
23
References–265
© Springer-Verlag GmbH Germany, part of Springer Nature 2018
R. Bittner et al. (eds.), Laparo-endoscopic Hernia Surgery,
https://doi.org/10.1007/978-3-662-55493-7_23
262
F. Köckerling et al.
23
23.1 Dierent Diseases?
FerdinandKöckerling
In a consensus meeting of the European Hernia
Society (EHS), a consensus was reached on the
decision to separate primary ventral hernias
(PVH) and incisional hernias (IH) into two entities, since in the participants’ opinion primary
ventral hernias have a dierent etiopathology
compared with incisional abdominal wall hernias
resulting from failure of a previous incision [1]. A
classication for primary abdominal wall hernias
and a division into subgroups for incisional
abdominal wall hernias, concerning the localization of the hernia, were formulated [1].
Interestingly the outcome and results of laparoscopic repair of PVH and IH have consistently
been pooled together in case series and randomized clinical trials [2–10]. Even recent systematic
reviews and meta-analysis comparing laparoscopic and open hernia repair have included RCTs
that analyzed a mix of PVH and IH in the laparoscopic repair group [2, 11–16]. is meant that
when analyzing the results, no distinction was
made between primary ventral hernias and incisional hernias nor was any information given on
the proportion of umbilical hernias, epigastric
hernias, and incisional hernias identied in the
entire patient group analyzed [17]. It was only at
the beginning of 2015 that Awaiz etal. [17] and Al
Chalabi et al. [18] published the rst metaanalyses and systematic reviews on laparoscopic
vs open incisional hernia repair [19].
Kurian et al. [20], Subramanian et al. [21],
Stirler et al. [2], Lambrecht et al. [22], and
Köckerling et al. [19] showed signicant dierences in the results obtained for primary ventral
hernias compared with incisional hernias.
Subramanian etal. [21] reported that laparoscopic repair of IH is associated with increased
recurrence, greater postoperative pain scores,
chronic pain issues, and lower patient satisfaction
scores.
Stirler et al. [2] found for the laparoscopic
repair of IH in comparison to PVH more requirements for adhesiolysis, a longer procedure time, a
longer hospital stay, a higher recurrence rate, and
a higher complication rate.
Köckerling etal. [19] analyzed the Herniamed
Registry showing the use of laparoscopic IPOM
signicantly more oen for incisional hernias
than for epigastric and umbilical hernias.
Likewise, the open technique with suturing of
defect was signicantly more oen for umbilical
hernias than for epigastric and incisional hernias.
e postoperative complication rates for umbilical and epigastric hernias were signicantly lower
than for incisional hernias. at was also true for
the reoperation rates due to postoperative complications. e 1-year follow-up revealed signicantly higher recurrence rates as well as rates of
chronic pain needing treatment for incisional
hernias, compared with epigastric and umbilical
hernias [19].
Subramanian et al. (2013) concluded that
PVH and IH are dierent. Future studies should
evaluate laparoscopic repair for PVH separate
from those for IH.
Stirler et al. [2] pointed out that his study
showed signicant dierences in baseline characteristics and operative ndings between patients
undergoing PVH repair and those undergoing IH
repair. Continued pooling of data on laparoscopic
repair of PVH and IH combined, commonly
found in the current literature, seems incorrect.
Köckerling etal. [19] concluded that signicant dierences were identied in the therapy and
results between umbilical hernia, epigastric hernia, and incisional hernia, and therefore scientic
studies should be conducted comparing the various surgical techniques only for a single hernia
type (. Fig.23.1).
23.2 Indications forLaparoscopic
Surgery: Limitations
AnilSharma
23.2.1
Laparoscopic repair of incisional and ventral
abdominal wall hernia is required in patients with
pain, discomfort, and disgurement from the hernia. It is also indicated to prevent complications
like incarceration, bowel obstruction, and strangulation. A laparoscopic approach may be considered in all patients for repair of incisional and
ventral abdominal wall hernias unless it is contraindicated.
How Do IDo It?
Ventral andIncisional Hernias
263
23
In our clinical practice, we adhere to the fol-
lowing rules.
Absolute Contraindications
5 Uncontrollable coagulopathy
5 Giant hernia with major loss of abdominal
domain
5 Acute abdomen with abdominal distension
and gross bowel dilatation
5 Major abdominal sepsis
5 Strangulated bowel within the hernia sack
5 Abdominal wall hernia in children
(<12years)
Relative Contraindications
5 Excessive redundant abdominal wall and
tissue. Such a patient would need abdominoplasty to excise redundant abdominal wall
skin folds and provide optimal contouring of
the abdominal wall.
5 Wide divarication of rectus abdominis
muscles from the xiphisternum to the pubis.
A large intraperitoneal sublay mesh repair
with or without approximation of recti
muscles may not be the optimal treatment.
5 Multiple previous abdominal surgery (with or
without previous mesh repairs) may preclude
safe intraperitoneal access. Such a patient
may present widespread, severe intraperitoneal bowel and omental adhesions. e
incidence of inadvertent bowel injury during
adhesiolysis is high in these circumstances.
Such patients are best treated by experienced
surgeons at hernia centers of expertise.
5 A large abdominal wall hernial defect. No
unanimity exists to dene the size of a “large
hernia.” A large hernial defect may be
unsuitable for laparoscopic repair. A large
hernia may be practically dened as a hernia
of such large size that precludes the safe
performance of peritoneal access, reduction
of hernial sac contents, and deployment of a
large mesh with at least 7–8cm of mesh cover
on all sides of the hernia defect.
Indications forHybrid/Combined
Laparoscopic andOpen Approach
A combined laparoscopic and open approach for
incisional and ventral abdominal wall hernias is
sometimes required to facilitate completion of the
surgical procedure and achieve optimal outcomes.
e combined approach involves a limited targeted skin incision at the site of hernia and adjacent abdominal wall along with laparoscopic
adhesiolysis and laparoscopic intraperitoneal
mesh placement. e open approach may be performed for safe reduction of incarcerated bowel,
safe adhesiolysis, bowel inspection ± resection,
primary closure of hernial defect, or excision of
redundant abdominal skin and tissue.
23.2.2 What Is Evidence Based
inClinical Practice?
According to Simon [23] no precise data on the
incidence and prevalence of ventral and incisional
hernias are available. An epidemiologic study
showed an increasing proportion of midline
abdominal wall hernias, with a relative frequency
of 19% for umbilical/par umbilical hernias, 8.6%
for epigastric hernias, and 4.8% for incisional hernias. e incidence for incisional hernia is
10–20%, making it one of the most common surgical complications aer laparotomy. Ventral and
incisional hernias are treated with surgery to
relieve symptoms (pain and discomfort), to prevent complications (strangulation, respiratory
dysfunction, or skin problems), or to resolve acute
complications (incarceration and strangulation).
When developing the IEHS guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias [23] regarding indication and
limitations for laparoscopic surgery, Simon summarized and analyzed the literature in accordance
to the Oxford Classication of evidence and came
to the following “statements” and “recommendations”; however, due to the minor quality of most
of the studies, the level of evidence is rather low:
Statements
5 Level 4: Symptoms develop for 33–78% of
patients with a ventral or incisional hernia.
5 Level 4: Surgery is performed for 5–15%
of patients with a ventral or incisional
hernia because of an acute complication
(obstruction/strangulation).
5 Emergency repairs are associated
with high morbidity.
5 Umbilical hernias obstruct five times
more often than other ventral and
incisional hernias.
23
264
F. Köckerling et al.
costal
arch
epigastric
hernia
umbilical
hernia
incisional
hernia
spigelian
hernia
inguinal
hernia
femoral
hernia
rectus
abdominis
muslce
lateral
abdominal
muslces
peritoneum
aponeurosis
inguinal
ligament
. Fig.23.1 Dierent hernia entities
5 Level 4: The defect size of incisional
hernias predicts recurrence rates.
5 Level 4: Findings seem to indicate no
difference in terms of morbidity or
mortality regarding laparoscopic surgery
for ventral hernias in advanced age.
5 The reduced risk of SSI in laparo-
scopic techniques has an impact
especially for elderly patient.
e statements demonstrate a very low level of
evidence; therefore, no clear recommendations
(Grade D) for treatment can be given:
Recommendations
5 Grade D: Symptomatic ventral and
incisional hernias should be treated
surgically.
5 Grade D: The laparoscopic technique for
ventral and incisional hernias should
preferably be reserved for defect sizes
smaller than 10cm in diameter.
5 Grade D: The laparoscopic technique for
ventral and incisional hernia repair can be
used even for patients advanced in age.
Regarding the size of the defect, some studies show
that laparoscopic surgery is possible in hernias
presenting with a defect size of larger than 15cm,
but studies with a reasonable level of evidence (2B)
show that the rate of recurrence will increase in
patients with a defect size of more than 10 cm
(Bingener/Rohr in [23]). Furthermore the operating time in patients presenting with a large defect
is signicantly longer which indicates that the
operative performance is more dicult. In conclusion patients with a hernia defect of more than
10cm are better be operated by an open technique:
Statements
5 Level 3: Laparoscopic IPOM is feasible for
defects larger than 15cm.
5 Level 2B: Hernia recurrence is more likely
with defects wider than 10cm.
5 Level 3: The operating time is longer
with defects larger than 15cm.
5 Level 4: LVHR is feasible for defects of up
to 880cm
2
.
Literature shows that laparoscopic hernia
repair is feasible even in morbid obese
patients (Bingener/Rohr and Koeckerling
Ventral andIncisional Hernias
265
23
in(23)); however, the complication and
recurrence rates are higher:
Statements regarding feasibility in obese
patients:
5 Level 3: Laparoscopic IPOM is feasible for
obese patients (BMI>30kg/m
2
).
5 Level 3: Laparoscopic IPOM is feasible for
morbidly obese patients (BMI>40kg/m
2
).
5 Level 3: Laparoscopic IPOM is feasible for
super morbidly obese patients
(BMI>50kg/m
2
).
5 Level 4: Laparoscopic IPOM is feasible for
patients with a BMI up to 82kg/m
2
.
Statements regarding safety and
recurrence in obese patients:
5 Level 3: Complication rates in patients
with a BMI≥40kg/m
2
undergoing LVHR
are higher than for patients with a
BMI<40kg/m
2
.
5 Level 2B: The recurrence rate is increased
with BMI>30kg/m
2
.
From these statements the following
recommendations may be drawn:
5 Grade B: Obese patients should be
informed that LVHR is feasible.
5 Grade B: Patients should be informed
that the risk of complications and hernia
recurrence increases with BMI.
5 Grade B: Patients should be informed
that complications and wound infections
are less likely with LVHR for obese
patients than with the open approach.
In summary, laparoscopic repair techniques for
ventral and incisional abdominal wall hernias are
feasible in aged patients, in patients with a large
hernia defect, and in obese patients. e main
advantage in comparison to open surgery is that
aer laparoscopic repair a lower frequency of
complications and wound infections may be
observed. However, it should be kept in mind that
with an increasing defect size or body weight,
both the complication and recurrence rates will
increase as well. Informed consent of the patients
is necessary.
References
Dierent Diseases?
1. Muysoms FE, Miserez M, Berrevoet F, Campanelli G,
Champault GG, Chelala E, Dietz UA, Eker HH, El Nakadi
I, Hauters P, Hidalgo Pascual M, Hoeferlin A, Klinge
U, Montgomery A, Simmermacher RKJ, Simons MP,
Smietanski M, Sommeling C, Tollens T, Vierendeels T,
Kingsnorth A. Classication of primary and incisional
abdominal wall hernias. Hernia. 2009;13:407–14.
https://doi.org/10.1007/s10029-009-0518-x.
2. Stirler VMA, Schoenmaeckers EJP, de Haas RJ, Raymakers JTFJ, Rakic S.Laparoscopic repair of primary and
incisional ventral hernias: the dierences must be
acknowledged. Surg Endosc. 2014;28:891–5. https://
doi.org/10.1007/s00464-013-3243-6.
3. 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.
4. LeBlanc KA, Whitaker JM, Bellanger DE, Rhynes VK.Laparoscopic incisional and ventral hernioplasty: lessons
learned from 200 patients. Hernia. 2003;7(3):118–24.
5. LeBlanc KA.Laparoscopic incisional and ventral hernia
repair: complications– how to avoid and handle. Hernia. 2004;8(4):323–31.
6. Chelala E, Thoma M, Tatete B, Lemye AC, Dessily M, Alle
JL.The suturing concept for laparoscopic mesh xation in ventral and incisional hernia repair: mid-term
analysis of 400 cases. Surg Endosc. 2007;21(3):391–5.
7. Wassenaar E, Schoenmaeckers E, Raymakers J, van der
Palen J, Rakic S.Mesh-xation method and pain and
quality of life after laparoscopic ventral or incisional
hernia repair: a randomized trial of three xation techniques. Surg Endosc. 2010;24(6):1296–302. https://link.
springer.com/article/10.1007%2Fs00464-009-0763-1.
8. Schoenmaeckers EJ, Raymakers JF, Rakic S. Complications of laparoscopic correction of abdominal
wall and incisional hernia. Ned Tijdschr Genesskd.
2010;154(45):A2390.
9. Sharma A, Mehrotra M, Khullar R, Soni V, Baijal M,
Chowbey PK. Laparoscopic ventral/incisional hernia
repair: a single centre experience of 1,242 patients
over a period of 13 years. Hernia. 2011;15(2):131–9.
https://doi.org/10.1007/s10029-010-0747-z.
10. Colavita PD, Tsirline VB, Belyansky I, Walters AL, Lincourt AE, Sing RF, Heniford BT.Prospective, long-term
comparison of quality of life in laparoscopic versus
open ventral hernia repair. Ann Surg. 2012;256(5):714–
22. https://doi.org/10.1097/SLA.0b013e3182734130.
11. Pham CT, Perera CL, Watkin DS, Maddern GL.Laparoscopic ventral hernia repair: a systematic review. Surg
Endosc. 2009;23(1):4–15. https://doi.org/10.1007/
s00464-008-0182-8.
12. Sajid MS, B okhari SA, Mallick AS, Cheek E, Baig MK.Laparoscopic versus open repair of incisional/ventral hernia: a meta-analysis. Am J Surg. 2009;197(1):64–72.
https://doi.org/10.1016/j.amjsurg.2007.12051.
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13. Forbes SS, Eskicioglu C, McLeod RS, Okrainec A.Metaanalysis of randomized controlled trials comparing
open and laparoscopic ventral and incisional hernia
repair with mesh. Br J Surg. 2009;96(8):851–8. https://
doi.org/10.1002/bjs.6668.
14. Sauerland S, Walgenbach M, Habermalz B, Seiler CM,
Miserez M. Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. Cochran
Database Syst Rev. 2011;(3):CD007781. https://doi.
org/10.1002/14651858.CD007781.pub2.
15. Castro PMV, Rabelato JT, Monteiro GGR, del Guerra GC,
Mazzurana M, Alvarez GA.Laparoscopy versus laparotomy in the repair of ventral hernias: systematic review
and meta-analysis. Arg Gastroenterol. 2014;51(3):
205–11.
16. Zhang Y, Zhou H, Chai Y, Cao C, Jin K, Hu Z. Laparoscopic versus open incisional and ventral hernia
repair: a systematic review and meta-analysis. World
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17. Awaiz A, Rahman F, Hossain MB, Yunus RM, Khan S,
Momon B, Memon MA.Meta-analysis and systematic
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18. Al Chalabi H, Larkin J, Mehigan B, McCormick P.A systematic review of laparoscopic versus open abdominal
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doi.org/10.1016/j.ijsu.2015.05.050.
19. Köckerling F, Schug-Pass C, Adolf D, Reinpold W,
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incisional hernia repair acceptable? Front Surg. 2:15.
https://doi.org/10.3389/fsurg.2015.00015.
20. Kurian A, Gallagher S, Cheeyandira A, Joslo R.Laparoscopic repair of primary versus incisional ventral
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2010;14(4):383–7. https://doi.org/10.1007/s10029-
010-0649-0.
21. Subramanian A, Clapp ML, Hicks SC, Awad SS. Liang
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https://doi.org/10.1016/j.jss.2012.06.028.
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Indications for Laparoscopic Surgery: Limitations
23. Bittner R, Bingener-Casey J, Dietz U, Fabian M, Ferzli
GS, Fortelny RH, Köckerling F, Kukleta J, Leblanc K,
Lomanto D, Misra MC, Bansal VK, Morales-Conde S,
Ramshaw B, Reinpold W, Rim S, Rohr M, Schrittwieser
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Pathophysiology and
Diagnostics ofVentral
andIncisional Hernias
RudolfSchrittwieser
24.1 Part I – 268
24.1.1 How IDo It – 268
24.2 Part II – 269
24.2.1 Scientic Evidence – 269
References – 271
267
24
© Springer-Verlag GmbH Germany, part of Springer Nature 2018
R. Bittner et al. (eds.), Laparo-endoscopic Hernia Surgery,
https://doi.org/10.1007/978-3-662-55493-7_24
24
268
R. Schrittwieser
24.1 Part I
24.1.1 How IDo It
ere is very little literature concerning the
pathophysiology of ventral hernias. We must differentiate primary ventral hernias (umbilical hernias, epigastric hernias, lumbar hernia, spigelian
hernias, and other rare primary hernias) as well as
incisional hernias and relapses following the
treatment of ventral hernias. Some authors report
genetic predispositions being a risk factor for the
occurrence of incisional hernias. is is explained
by a change in the type I collagen to type III collagen ratio. Nicotine abuse is a signicant risk factor for the formation of incisional hernias. is is
explained to patients in the course of laparotomy
procedures. Patients are recommended to
urgently quit smoking. In cases where a postoperative wound healing disorder is discovered,
there is a greater chance of an incisional hernia
occurring. Likewise there is an increased likelihood of incisional hernias occurring following
relaparotomies.
e rst diagnostic step comprises of a thorough anamnesis. In addition to inquiring about
the patient’s medical history, risk factors are taken
into account, and furthermore they are asked
about existing complaints, restrictions in daily
life, and, in the case of working-age patients, their
ability to work. With incisional hernias we look at
the reports from previous operations, as far as
they are available, and carry out a review. In cases
of relapses, comprehensive information about the
techniques used in previous operations is important when making decisions about the type of
surgical procedure to implement. In particular,
the use of meshes in previous operations is critical
in inuencing the choice of surgical procedure. In
the case of an intraperitoneal mesh, adhesions are
likely to be required; therefore, particular caution
is necessary when proceeding with adhesiolysis.
Should a mesh be inserted using the sublay technique, then we opt, where possible, for a laparoscopic approach.
e clinical investigation encompasses the
precise palpation of the abdomen and a rough
investigation of the abdominal wall function.
Preoperative photographic documentation can be
helpful.
. Fig.24.1 Ultrasound of rectus diastasis
. Fig.24.2 Ultrasound of rectus diastasis (Valsalva
maneuver)
With a sonographic examination, the hernia
contents are presented as well as a measurement
of the hernia gap size and the number of defects.
A possible additional rectus diastasis can be
detected (
. Figs.24.1 and 24.2). A dierentiation
between the intestine and the greater omentum is
possible in most cases. Particularly with relapses
following laparoscopic repair, sonographic examination can eliminate a pseudo relapse in many
cases. Usually an isolated seroma formation or the
remains of an incarcerated greater omentum can
be identied as the cause of a relapse interpreted
swelling. By means of sonographic examination,
remaining clinically undiscovered hernias can
also be identied. Sonographic examination can
be dicult with obesity. erefore, for very obese
patients, and also in cases of large ventral hernias,
we undertake a CT examination of the abdomen
and the pelvis. e size of the hernia gap can be