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tion in abdominal wall reconstruction: a useful adjunct in suprapubic and para-iliac hernia
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P. Dolan and G. Dakin
Recurrent Ventral Hernia Repair
26
CharlotteHorne andAjitaPrabhu
Introduction
Recurrent ventral hernias pose many technical challenges to a general surgeon.
Each year over three billion US dollars are spent on approximately 350,000 ventral
hernia repairs [1]. Reducing recurrence rates by as little as 1% could result in 3.2
million dollars in savings [1, 2]. Although a signicant effort has been put forth to
delineate both patient factors and technical factors that increase likelihood of
recurrence, recurrence still represents a signicant cause of morbidity postoperatively. Risk of recurrence has decreased signicantly with the routine use of prosthetic mesh reinforcement; however, recurrence rates remain high with reported
recurrence rates of 25–44% after second and third repair, respectively [3, 4].
Recurrent hernia repairs are technically difcult operations for many reasons:
there is potential for dense adhesions to the abdominal wall, often mesh has been
placed and anatomical planes have been disturbed by previous dissection, and
there may be device-related complications such as mesh infection or mesh-related
pain. Additionally, there may be concerns for loss of domain and/or potential for
difculty achieving soft tissue coverage of the hernia repair if the overlying skin is
compromised due to infection or ulceration. It is imperative to understand why
possible previous hernia repairs have failed and address any patient factors preoperatively that put patients at increased risk for recurrence. Herein, we present an
algorithm for the workup and management of these complicated patients
(Fig.26.1).
C. Horne, MD · A. Prabhu, MD (*)
Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
e-mail: PRABHUA@ccf.org
© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2019
S. S. Davis Jr. et al. (eds.), The SAGES Manual of Hernia Surgery,
https://doi.org/10.1007/978-3-319-78411-3_26
359
360
Approach to Recurrent Ventral Hernia Repair
polypropylene mesh
Laparoscopic
C. Horne and A. Prabhu
• Obtain previous operative reports
• Pre-operative CT
Recurrent Ventral Hernia
Identify Special Considerations
• Contaminated
Defect > 7cm
• Identify modifiable co-morbidities
Yes
• Loss of Domain
• Extensive soft tissue reapsir required
No
BMI <35
Loss of Domain
Pre-op weight counseling
tissue repair
Contaminated Extensive soft
TAR
Posterior
component
separation or
ACS
Open
retrorectus
approach with
Retrorectus bridged
Plastics involvement
or
Immediate
Staged Repair
repair
Heavy weight
repair
Defect </= 7cm
Onlay
• Non-Diabetic
• Non smoker
• BMI <30
approach
Lap-assisted
approach
Fig. 26.1 Algorithm for ventral hernia approach. ACS (anterior component separation). TAR (transversus abdominis release). Posterior component separation
or TARs should not be performed with concurrent anterior component separation as this may destabilize the lateral abdominal wall, resulting in a ank hernia
26 Recurrent Ventral Hernia Repair
361
Approach tothePatient
When evaluating a patient for recurrent ventral hernia repair, it is important to
determine any modiable risk factors that can increase likelihood of recurrence.
Often, such factors have not been addressed at prior operations and may be
responsible in part for recurrences. Postoperative surgical site infection is one
potentially preventable occurrence that is closely linked to increased risk of recurrence [5]. Potential patient factors that increase likelihood of postoperative infection include obesity with BMI >40, diabetes, COPD, active smoking, and
immunosuppression [6]. Efforts to optimize modiable factors prior to elective
hernia repair should be pursued to ensure a successful subsequent repair.
Furthermore, preventable comorbidities such as smoking, diabetes, and obesity
are also known to directly increase hospital charges, and modication of these
factors preoperatively may therefore help to offset costs of care of these complicated patients [2].
Smoking
Active smoking is known to compromise healing due to peripheral vasoconstriction
as well as reduced cutaneous blood ow [7]. Active smokers have an approximately
2.5 times increase in relative risk of wound complications when compared to nonsmokers [7]. Grade A evidence exists supporting the avoidance of elective hernia
repair in active smokers [8]. Patients should stop smoking at least 4weeks prior to
undergoing elective surgery as this has been shown to decrease postoperative complications [9]. Because there is reasonable data to suggest that the wound healing
problems associated with smoking are likely related to the contents of cigarette
smoke and not the nicotine itself, the authors allow nicotine replacement therapy
with either nicotine gum or patches, but not e-cigarettes as the contents are not standardized. Urine nicotine metabolite testing has the ability to distinguish between
active smoking and nicotine replacement therapy and therefore is the test of choice
used by the authors to ensure smoking cessation compliance. In our practice, smoking cessation is discussed in the ofce as an imperative prior to surgery for complex
abdominal wall reconstruction (it is discussed but not necessarily required for minimally invasive hernia repair). Patients are informed that urine nicotine testing will
be performed if they are active smokers at the time of the ofce visit. Patients are
tested 4weeks prior to their planned surgery dates to allow time for cancellation of
cases in the case of non-compliance.
Diabetes
Diabetes is a common comorbidity that may lend itself to postoperative surgical site
infection in patients with uncontrolled blood glucose undergoing ventral hernia
repair. Specically, a hemoglobin A1C >7 has been found to be associated with
362
C. Horne and A. Prabhu
increased risk of wound infection [10]. Therefore, the authors routinely check Hgb
A1c preoperatively in all patients undergoing recurrent ventral hernia repair, with
the goal of achieving a value of 7 or less. When Hgb A1c is greater than 7, the
authors usually engage the primary care physician and/or an endocrinologist to
assist with improving blood glucose control prior to surgery. In the postoperative
period, hyperglycemia with blood glucose level >140mg/dL has also been found to
be associated with increased risk of surgical site infection [11]. Still, meticulous
glycemic control postoperatively may be complicated by hypoglycemia and is
therefore discouraged as the risk outweighs the potential benets [12]. Some authors
suggest that 140–160mg/dL may be the optimal range for postoperative blood glucose in diabetic patients [13].
Obesity
Addressing weight in the preoperative setting can be a challenging discussion for
both surgeons and patients. Nevertheless, weight loss should be discussed with
obese patients undergoing recurrent ventral hernia repair as obesity is associated
with increased risk of surgical site infection, prolonged hospital stays, and
increased risk of recurrence [14–17]. Obesity increases technical difculty, leads
to increased operative time, and causes increased intra-abdominal pressure and
decreased tissue healing [2]. The best approach to preoperative weight reduction
is still yet to be determined. Some series suggest that a multidisciplinary approach
to weight loss results in sustained weight loss; however, other data suggest that
this weight loss is not durable in the long term [17, 18]. An optimal BMI prior to
surgical intervention has not been established, but it is well known that increasing
BMI correlates with increasing risk of postoperative morbidity [19]. Pernar etal.
set out to determine a BMI threshold at which there was a signicant increase in
postoperative complications. They demonstrated that 16.5% of patients with BMI
>40 that underwent open ventral hernia repair had a postoperative complication
compared to 5.6% in patients with BMI <25. They also showed that when controlled for other medical comorbidities, BMI >40 alone increases odds of postoperative complication 3.4 times [19].
Increased risk of complications is not limited to open repair exclusively, as
patients with BMI >40 have a fourfold increased risk of recurrence when undergoing laparoscopic hernia repair [20]. Bariatric surgery either prior to denitive
recurrent repair or concurrent with laparoscopic hernia repair has been evaluated.
Currently the data is limited to small, single institution retrospective analyses.
There have been promising results in patients who underwent bariatric surgery
prior to complex ventral hernia repair [21]. A study by Newcomb etal. showed no
recurrence at 2–50 months postoperatively, and patients also had a signicant
decrease in BMI from an average of 51kg/m
hernia repair [21]. Although this study showed effective weight loss after bariatric
surgery, patients undergoing concomitant bariatric surgery and ventral hernia
repair are known to have increased 30-day unplanned reoperation, unplanned
2
preoperatively to 33kg/m2 prior to
26 Recurrent Ventral Hernia Repair
363
readmission, and 30-day postoperative complications [22]. Although studies suggest that concomitant laparoscopic ventral hernia repair during bariatric surgery is
safe, the authors prefer to avoid placement of intraperitoneal barrier coated mesh
at the time of a clean-contaminated case as it has been suggested that barrier coating may harbor infection and potentially result in wound complications [23].
Some patients with complex surgical histories and multiply recurrent hernias may
not be candidates for a laparoscopic bariatric intervention. Additionally, adequate
preoperative evaluation with a multidisciplinary team prior to bariatric surgery is
essential, and patients with a recurrent ventral hernia and obstructive symptoms
may not be able to complete the process prior to requiring surgical intervention
for their hernia. Still, in patients that are candidates for bariatric surgery, it is recommended that they undergo bariatric surgery prior to ventral hernia repair when
possible.
Other options for preoperative weight loss for patients who are not candidates for
bariatric surgery include guided lifestyle modication, diet and exercise programs
that may be commercially available, or medical weight loss programs such as the
protein-sparing modied fast [18]. The authors prefer the latter when patients are
able to enroll in the program, as it can be very successful when the patient is engaged
and participating. Protein-sparing modied fast can also allow for a relatively quick
weight loss which may be benecial in patients who are very symptomatic from
their hernias. This may also be an effective weight loss method in patients who are
unable to exercise, often due to joint or back pain caused by obesity. BMI <30kg/
2
is associated with overall improved outcomes and decreased hernia recurrence
m
[2, 15, 20]. In the setting of elective recurrent ventral hernia repair, it is essential to
2
encourage weight loss in patients with BMI >30kg/m
, and it may be reasonable to
defer patients with BMI >50kg/m2 from an operative intervention due to the high
risk of morbidity [2, 7].
The authors feel strongly that to maintain the investment of both the patient and
the surgeon in the weight loss process and preparation for surgery, it is best to discuss the plan for weight loss, document the goal for weight loss including the
expected time frame, and see patients back in the ofce 3 months after setting
weight loss goals. While many patients are not yet ready to schedule surgery at that
point due to remaining excess weight that must be lost, often this signals an ongoing
investment by the surgeon in the patient’s care and can help patients ultimately
reach their weight loss goal.
Choice ofApproach toHernia Repair
When approaching recurrent ventral hernia repair, numerous patient and technical
factors should be considered. Size of defect, location of previous mesh placement,
presence of chronic infection or stulas, and medical comorbidities and BMI all
play roles in determining the best surgical approach. Obtaining previous operative
reports assists in determining what previous prosthetic was utilized and its location
and help to guide operative intervention. CT scan imaging of the abdomen and
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C. Horne and A. Prabhu
pelvis is also very useful in determining the characteristics of the hernia defect and
the surrounding anatomy and is routinely obtained in our practice for evaluation of
recurrent ventral hernias [24].
Laparoscopic Recurrent Ventral Hernia Repair
A laparoscopic approach to the repair of a recurrent ventral hernia has many advantages. Laparoscopic ventral hernia repair has been shown to have decreased wound
events, decreased postoperative pain, and overall decreased length of stay when
compared to an open approach [20, 25]. Data also reports low recurrence rates (3.5–
5.7% at 41months), and, even the setting of multiply recurrent hernias, a higher risk
of recurrence has not been shown after laparoscopic hernia repair [26–28]. Obese
patients may benet from laparoscopic ventral hernia repair over open when managing a recurrent hernia as there is a decreased risk of postoperative wound complications and the ability to recognize smaller fascial defects not previously appreciated
in patients with BMI >30kg/m
These hernia repairs can be completed in an entirely laparoscopic fashion or in a
hybrid open and laparoscopic fashion (lap-assisted hernia repair) where the hernia
contents are reduced through a small laparotomy incision and the mesh is placed
laparoscopically. Regardless of approach, it is imperative that previous operations,
mesh placements, and location of the abdominal wall defect are delineated as these
factors will determine optimal trocar placement.
In patients with signicant intra-abdominal adhesions, a combined laparoscopic
and open approach (hybrid/laparoscopic assisted) may be considered. Laparoscopicassisted approach is similar to laparoscopic approach in that much of the operation
is performed through small incisions. In addition, a small laparotomy incision can
facilitate adhesiolysis and closure of fascial defects with substantial mesh overlap of
the defects while obviating the need for a generous laparotomy incision that might
otherwise be required for an open approach. Advantages to completing the hernia
repair via a hybrid or lap-assisted approach include the ability to perform adhesiolysis in an open fashion which reduces the risk for missed enterotomy as well as the
ability to close the fascial defect [29]. Additionally, this allows the surgeon to place
a mesh with signicant overlap of the defect without making a large laparotomy
incision, which may contribute to wound morbidity and longer recovery time.
The current practice of closure of the fascial defect during laparoscopic hernia
repair is often dependent on the operating surgeon’s routine preference. The benets
of routine closure potentially include an improved cosmetic outcome as well as
potential decreased risk of postoperative seroma formation [30–32]. A meta- analysis
and literature review by Yanaga etal. was conducted which showed fascial closure
(IPOM plus) was associated with decreased risk of recurrence, 0–7.7% risk compared to 4.4–29%, and decreased risk of seroma formation, 0.5–78% compared to
0–11.43% [30]. However, more recent studies showed that there was no signicant
difference in postoperative surgical site infection, hernia recurrence, or seroma formation between a bridged repair or repair with fascial closure [31, 32]. Currently, in
2
[24].
26 Recurrent Ventral Hernia Repair
365
the author’s practice, routine closure of the fascial defect is performed when technically feasible.
One main limitation to laparoscopic hernia repair for recurrent hernias is defect
size. Heniford et al. and Hauters et al. demonstrated that hernia defect size was
associated with increased risk of recurrence after laparoscopic ventral hernia repair
[20, 26]. Hauters etal. found that despite having more than 5cm overlap, when the
mesh size to defect size ratio was less than 8, this was associated with a 70% risk of
recurrence [26]. As defect size increases, laparoscopic bridge repair may result in
mesh eventration, or pseudohernia occurrence, over time, which can be both dissatisfying to patients and ineffective as a long-term repair. Although laparoscopic
repair has been successful with defects that are larger, recurrence rates increase
signicantly as the width of the hernia defect increases [26, 28]. While there is currently no upper limit of defect size that can be approached laparoscopically, we
currently recommend laparoscopic intraperitoneal onlay mesh repair for defects
≤7cm in greatest width.
Open Recurrent Ventral Hernia Repair
Factors that lead to multiply recurrent hernias often necessitate an open repair. For
instance, patients with large or multiple defects, signicant intra-abdominal adhesions, or compromise of the overlying skin integrity may require open approach.
Patients with recurrent hernias and chronically draining sinus tracts, infected mesh,
or enterocutaneous stulas are frequently considered for staged open repairs in the
authors’ practice, as the initial goal of the operation is typically source control for
contamination and infection, with subsequent denitive abdominal wall reconstruction once eradication of infection has been accomplished. There is some recent literature to suggest that permanent synthetic mesh repair may be safe and effective in
clean-contaminated and contaminated cases [33]; however, this has not yet been
widely adopted as standard of care in the United States. Further studies are ongoing
to determine the safety of permanent mesh repair in clean-contaminated and contaminated elds. For patients undergoing denitive abdominal wall reconstruction,
important preoperative considerations prior to attempted repair include location and
type of mesh previously used and presence of concurrent chronically draining sinus
tracts or enterocutaneous stulas as these will determine operative approach and
mesh selection. When performing denitive reconstruction in clean-contaminated
and contaminated cases, the authors use macroporous, midweight polypropylene
mesh for repair.
The goal of an open ventral hernia repair, whether primary or recurrent, is to
optimize patient factors, prepare the wound by taking down adhesions or stulas,
reapproximate midline, and obtain adequate coverage with appropriate reinforcement [34]. Reapproximating the midline should be the goal when safe and feasible
in repairing recurrent ventral hernias. Compared to a bridging technique, fascial
closure has been shown to have a decreased risk of recurrence as well as surgical
site occurrence when compared to bridging the defect [35, 36]. A review of the
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C. Horne and A. Prabhu
current open surgical procedures for incisional hernia showed that recurrence rates
were not statistically different between the mesh placement in a sublay and onlay
position; however, both methods were superior to a bridged or primary closure after
component separation for giant hernia repairs [35]. In the practice of the authors,
onlay mesh repair is generally reserved for small- to medium-sized defects and
clean cases in nonobese, non-smoker, nondiabetic patients. In these cases, a modied Chevrel approach, described by Stoikes etal., is preferred [37]. Bridged intraperitoneal repair is not preferred because the mesh is exposed to both the
intra-abdominal contents and the subcutaneous tissue as well as decreased abdominal wall functionality due to the lack of restoration of normal abdominal wall anatomy [36]. When performing a sublay repair, the authors prefer to place the mesh in
a retrorectus position, which was initially described by Rives in 1973 [38]. This
allows the mesh to be placed in a well-vascularized plane and increases mesh coverage with muscle and soft tissue, which is protective against mesh infections.
To reapproximate the midline and restore the linea alba, a component separation
is sometimes necessary. The rst components separation, external oblique release,
was introduced by Ramirez etal. in 1990 as a method to perform functional transfer
of muscular components of the abdominal wall to close large hernia defects [39].
Other approaches to component separation have been described, including endoscopic, perforator sparing, and posterior. A well-known drawback of anterior component separation is the creation of large subcutaneous aps which have been shown
to result in signicant wound morbidity [40, 41]. Still, this technique can be particularly useful when the hernia sac has dissected into the subcutaneous space, and the
ventral surface of the rectus abdominis is therefore exposed, lending itself to
approaching the external oblique muscle without additional wound morbidity.
Although the Rives-Stoppa repair is an effective method of herniorrhaphy for
many situations, this technique may provide insufcient release in larger hernia
defects [42, 43]. The Rives-Stoppa technique takes advantage of the space in the
preperitoneal plane below the umbilicus. Dissection here allows for signicant
mobilization and midline reapproximation but also creates a space capable of incorporating a sizeable piece of mesh to provide adequate coverage of large ventral
hernias [44]. In addition, posterior component separation with transversus abdominis muscle release allows for even further advancement of the rectus fascia, preserves neurovascular innervation, and provides a space that will accommodate a
sizeable piece of mesh [43]. The authors generally prefer to use a midweight bare
polypropylene mesh for this repair. This technique is becoming increasingly popular due to the ability to create a large space for adequate prosthetic coverage, a previously unviolated anatomical plane even in multiply recurrent hernia repairs, as
well as placing the mesh in the sublay position theoretically decreases risk of postoperative surgical site occurrence and infection. This technical approach to recurrent ventral hernias has many technical advantages as the open approach facilitates
adhesiolysis in complex abdomen, wound morbidity is not increased as with external oblique release, and the space created can accommodate an appropriately sized
mesh for giant ventral hernias which helps to minimize recurrence, and it allows for
placement of mesh in the sublay position [43, 45].
26 Recurrent Ventral Hernia Repair
367
Special Considerations
Contaminated Fields
As surgical site infections are a well-known factor associated with increased hernia recurrence, it is likely that potential contamination will have to be managed
when repairing a recurrent hernia [15, 20]. The type of reinforcement material
utilized in these repairs must be carefully considered to minimize surgical site
infection as well as repeat recurrence. Traditionally, biologic mesh was favored in
contaminated situations due to the high incidence of postoperative wound morbidity. Recommendations from the Ventral Hernia Working Group suggest against
synthetic mesh in both grade 3 (contamination of the wound or suspicion of contamination) or grade 4 (frankly infected wounds) as using biologic mesh in these
situations does not require mesh resection even in the face of active infection [34].
Data in repair of grade 3 and 4 hernia repairs with biologic mesh demonstrates
recurrence rates of approximately 12% and surgical site infection rates of 15–36%
[46, 47]. There is data that supports the safety of using synthetic material in a
contaminated eld. Lopez et al. evaluated placement of synthetic and biologic
meshes in contaminated elds and saw no difference in surgical site infections
(SSI) between the two groups but a 35% recurrence rate in situations when biological cases were used compared to 8.3% when synthetic mesh was used [48].
Introduction of biosynthetic mesh provides another potential option in the repair
of contaminated hernias. One example of biosynthetic mesh, Gore BioA, is composed of an absorbable copolymer that is gradually absorbed by the body in
approximately 6–7months. A multicenter, prospective trial evaluated the use of
this synthetic material in grade 2 and grade 3 [34] hernia repairs. Postoperative
wound events occurred in 28% of patients, and recurrence occurred in 17% of
repairs at 2years [49]. This represents a signicant decrease in surgical site occurrence as well as hernia recurrence when compared to repair with non-cross-linked
porcine dermis [50]. Still, given the somewhat high recurrence rates using biosynthetic mesh in contaminated elds, caution must be used in performing repairs
with absorbable materials and should be saved for select circumstances. Additional
biosynthetic meshes have subsequently been developed, however thus far there is
insufcient literature available to comment on their performance in contaminated
hernia repairs.
Multiple reinforcement techniques have been utilized for contaminated/grade 3
hernia repairs. In these situations, the choice of mesh is at the discretion of the surgeon with knowledge that there is an increased likelihood of recurrence if biologic
mesh is used [34, 47, 48, 50]. When performing recurrent ventral hernia repair in
contaminated elds, it is necessary to be meticulous about decreasing infectious
burden. This includes debridement and/or removal of infected skin and soft tissue
and removal of all infected mesh. Primary repair with staged reconstruction once
infectious burden is eradicated should be strongly considered. Use of prosthesis in
repair should be carefully considered. Synthetic or biosynthetic mesh use in grade 3
hernia repairs is likely safe and has decreased recurrence rates without signicant