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29717 Femoral Hernia
All these variants are best managed using either the extra-
peritoneal mesh prosthetic operation described in Chap.
13
or the laparoscopic methods described in Chap. 14 .
With all methods of femoral hernia repair, it is important for the surgeon to be aware of the risk of vascular
injury during these operations. The risk of injury to the
femoral vein or artery is several fold higher than that for
inguinal repair [ 80 ] . This may be related to the high rate of
emergency presentation with this hernia and the fact that
relatively inexperienced surgeons often undertake repair
without senior supervision.
Conclusions
Femoral hernia is a common clinical problem, which warrants urgent elective repair to avoid the complication of
strangulation.
The mechanism of femoral herniation, a distension and
failure of the fascia transversalis in the femoral sheath, is
described.
Methods of repair are outlined—the low, crural operation
is least traumatic and gives lower recurrence rate. The laparoscopic method has proven to be a viable alternative to the
surgeon that is pro fi cient with that technique.
The crural operation is not suitable in multiple hernias or
when resection of gut is required. In these circumstances, the
surgeon must have the ability to perform the appropriate
operation for the patient. The options include a formal laparotomy or either the extraperitoneal or inguinal operations as
described above. Laparoscopy is well suited for the patient
with multiple hernias, bilateral hernias, or a recurrent femoral herniation.
Strangulated femoral hernia carries a high morbidity and
mortality in the elderly. Early diagnosis and repair by an
experienced surgeon are required to reduce such unfavorable
outcomes.
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Br J Surg. 2000;87:1722–6.
Umbilical, Epigastric, and Spigelian Hernias
Benjamin S. Powell and Guy R. Voeller
1 8
Introduction
Primary anterior abdominal wall defects such as Spigelian,
epigastric, and umbilical hernias are less common than their
inguinal counterparts. However, a thorough knowledge of
the causes and treatment of these hernias is paramount for
any practicing general surgeon. These primary abdominal
wall hernias oftentimes need to have a high index of suspicion especially epigastric and Spigelian hernias. Umbilical
hernias typically account for approximately 10% of all hernias and are more likely to be frequently seen by the general
surgeon. This chapter will discuss the presentation of these
hernias as well as causes and the different treatments that are
currently available.
Embryology
A thorough understanding of the development of the abdominal wall is necessary to appreciate the nature of the hernia
defects this chapter discusses. Abdominal wall development
and bowel development happen conjointly from the third
week of gestation until the 12th week. At the third week, the
embryo has cephalic, caudal, and lateral folds (Fig.
The cephalic fold is anterior and contains the foregut, stomach, and mediastinal contents. Somatic layer defects in the
cephalic fold can give rise to diaphragmatic, thoracic wall,
cardiac or pericardial defects. The caudal fold contains the
colon, rectum, bladder, and the hypogastric abdominal wall.
Defects in the caudal fold can cause bladder exstrophy. The
lateral folds become the lateral abdominal wall and future
umbilical ring. Defects in the lateral fold typically give rise
to umbilical hernia or an omphalocele. Umbilical herniation
B. S. Powell , MD (*) • G.R. Voeller
Department of Surgery , University of Tennessee Health Science
Center–Memphis , Memphis , TN , USA
e-mail: grvoeller@gmail.com
18.1 ).
of the abdominal contents occurs around week 6–7 due to the
fact that the embryonic abdominal wall is too small to hold
the abdominal contents at this point. At weeks 10–12 the
abdominal viscera undergo a counterclockwise rotation and
return to the abdominal cavity. Typical abdominal wall
defects encountered at birth include omphalocele as well as
gastroschisis. Omphalocele by de fi nition is herniation of
abdominal contents into the umbilical cord, typically greater
than 4 cm in size. Gastroschisis is a full-thickness abdominal
wall defect almost always to the right of the umbilicus without a covering membrane. A bridge of skin separates the
defect from the umbilicus. These congenital defects are discussed further in other chapters.
Anatomy of the Abdominal Wall
Abdominal wall anatomy is fairly complex and a good
understanding of the layers and insertions of the musculature as well as aponeurosis is the key to performing hernia
surgery.
The abdominal wall is a hexagonal con fi guration and is
bordered caudally by the pelvic wall and pubic symphysis,
cranially by the costal margin and xiphoid, and laterally by
the midaxillary line. The rectus abdominis runs vertically
from the costal margin to the pubis surrounding the linea
alba in the midline (Fig. 18.2 ). Each rectus muscle has its
origin on the fi fth, sixth, and seventh rib and the xiphoid. The
rectus abdominis inserts onto the pubic bone via a 3-cm band
inserting at the pubis. The three-layer lateral portion of the
abdominal wall is made up of the external oblique, internal
oblique, and the transversus abdominis. Each layer of these
muscles runs in different directions with the fi bers of the
external oblique running downward and forward; the internal
oblique runs forward and upward and the transversus abdominis runs horizontally (Fig.
uncommon through these muscle groups; typically they
occur through the linea alba or the semilunar line for obvious
reasons. Each of these muscles is surrounded by a wide
18.3 ). Primary hernias are very
A.N. Kingsnorth and K.A. LeBlanc (eds.), Management of Abdominal Hernias,
DOI 10.1007/978-1-84882-877-3_18, © Springer Science+Business Media London 2013
299
300 B.S. Powell and G.R. Voeller
4
2
6
5
1
Fig. 18.1 Formation of ventral abdominal wall. 1 . Yolk sac 2 . Surface
endoderm 3 . Amniotic cavity 4 . Neural tube 5 . Splanchnic mesoderm
6 . Somatic mesoderm
aponeurosis. However the transversus abdominis is surrounded by both an anterior and posterior aponeurosis.
The linea alba is formed from the aponeurosis of the rectus sheath. It also represents the insertion point in the midline
of the lateral fl at muscles. It is a median raphe running vertically through the abdominal wall. It is by far the most common site of hernias on the anterior abdominal wall. Most
open operations use a midline incision for access to the
abdominal cavity leading to most incisional hernias being in
the midline. Most primary anterior abdominal wall hernias
occur through the linea alba as well. Above the umbilicus the
linea alba is typically wider than below it, hence the higher
incidence of primary midline hernias such as epigastric hernias in this position. Its average width in cadaver studies is
approximately 1.7 cm above and about 0.7 cm below.
The semilunar (Spigelian) line is a semiconcave line that
runs lateral to the rectus muscle on either side of the abdomen. It is classically described as a boundary between transversus abdominis muscle body and its aponeurosis. The
Spigelian line is not a true line due to the fact the myoaponeurotic borders of the external oblique and the internal oblique
do not intersect like the linea alba. The intersection of the
Spigelian line and the arcuate line (line of Douglas) is a point
of weakness in the abdominal wall. This area is often referred
to as the Spigelian hernia belt (Fig. 18.4 ). The inferior epi-
gastric vessels run in the lateral rectus sheath at this point in
the abdominal wall and many anatomists propose that this
contributes to the relative weakness. A triangle is formed by
the inferior epigastric vessels medially, the Spigelian line laterally, and the arcuate line superiorly.
3
Spigelian Hernia
De fi nition and Epidemiology
Spigelian hernias occur through slit-like defects along the
Spigelian (semilunar line) lateral to the rectus sheath. These
hernias for the most part typically present below the umbilicus
where there is absence of the posterior sheath; however, there
are reports of the hernia above the umbilicus as well. The
semilunar line as described previously runs from the ninth
costal cartilage to the pubic bone inferiorly along the lateral
border of the rectus muscle. It has a semiconcave shape; hence,
it was given the semilunar nomenclature. Anatomists say that
the semilunar line is formed from the branching of the internal
oblique aponeurosis with reinforcement anteriorly by the
external oblique aponeurosis. The upper two thirds of the
abdominal wall is reinforced with the transversus abdominis
posteriorly; hence, hernias above the umbilicus are subsequently extremely rare. Spigelian hernias are typically found
below the line of Douglas in the lower abdomen [ 1, 2 ] .
The incidence of Spigelian hernias in children is very low.
Occasionally they are caused by trauma and abdominal wall
surgery and are typically repaired primarily in this age group.
Spigelian hernias are most frequently found in adults from
ages 40 to 70. It has been theorized that these hernias may be
related to the stretching of the abdominal wall caused by previous surgery, collagen disorders, obesity, COPD, or pregnancy. The most likely cause is due to weaknesses (due to
whatever reason) in the internal oblique muscle that allow
interdigitations of fat that act as a lead point for the hernia.
The male to female ratio is 1:1.8 and some authors estimate
that it comprises about 0.12% of all abdominal wall hernias.
The hernia is typically a well-de fi ned hernia sac in the transversus aponeurosis. These hernias rarely penetrate the thick
external oblique fascia. Usually it is an intraparietal hernia
into the rectus muscle, which can make diagnosis very
dif fi cult; hence, a good clinical suspicion is necessary to
diagnose these patients. Ultrasound and CT scan are useful
aids in diagnosis, but as shown by the Mayo study below,
there are false negatives with these tests.
History
The Spigelian or semilunar line was fi rst described by
Adriaan van den Spieghel in the seventeenth century as
the medial concave line that is the boundary between the
30118 Umbilical, Epigastric, and Spigelian Hernias
Aponeurosis of external
oblique muscle Anterior layer of rectus sheath
Aponeurosis of internal
oblique muscle
Aponeurosis of transversus
abdominis muscle
Peritoneum
Extraperitoneal fascia Transversalis fascia
Fig. 18.2 The rectus abdominis surrounding the linea alba in the midline where epigastric and umbilical hernias arise
Serratus
anterior
Section above arcuate line
Rectus abdominis muscle Skin
Linea alba
Posterior layer
of rectus sheath
Falciform ligament
Internal oblique muscle
abdominis muscle
Subcutaneous
tissue (fatty layer)
Pectoralis major
External oblique muscle
Transversus
Linea alba
Transversus
abdominis
Internal oblique
External oblique
Aponeurosis
of the external
oblique
Fig. 18.3 Orientation of the internal oblique, external oblique fi bers, and the transversus abdominis of the abdominal wall
muscle and the anterior aponeurosis of the transversus
Current Literature
Tendinous
intersection
Rectus
abdominis
Inguinal ligament
(formed by free
interior border of
the external
oblique
aponeurosis)
abdominis. Klinkosch however fi rst described the
Spigelian hernia in 1764. In the early nineteenth century
Sir Astley Cooper had described 23 hernias that occurred
along the Spigelian line. Some historical terminology to
describe these defects is “spontaneous ventral hernia” or
“hernia of the semilunar line” [
3, 4 ] .
Literature on Spigelian hernias tends to be limited to
small case series and the types of repairs that have been
performed to fi x these somewhat rare hernias. Most
papers on Spigelian hernia started appearing in the
1930s. Louis River wrote a paper in 1942 that discussed
302 B.S. Powell and G.R. Voeller
Fig. 18.4 Spigelian hernia belt. External and internal oblique are cut
away in this fi gure. 1 : Transversus abdominis. 2 : Dorsal lamella of the
rectus sheath. 3 : Semicircular line of Douglas. 4 : The semilunar line.
5 : Spigelian aponeurosis. 6 : Spigelian hernia belt. 7 : Hesselbach’s tri-
angle. 8 : Inferior epigastric vessels. 9 : anterior superior iliac spine.
10 : Interspinal plane
the associated anatomic defects and symptoms that are
associated with this hernia. He also presented fi ve cases
and described in detail each patients’ clinical course and
operation. Watson, Read, and Weiss all published papers
discussing patient presentations as well as repair of these
hernias. All of the repairs were performed prior to the
commonplace use of mesh, and each of the hernias was
repaired primarily. Current controversies in management
of these hernias tend to center around exactly what type
of repair to perform. Some authors favor the laparoscopic
approach while others favor an open approach. Some
papers suggest not using mesh to fi x these hernias. Hsieh
recently published a paper out of Taiwan in which 11
cases of Spigelian hernias were reviewed [ 5 ] . Four of the
patients underwent open preperitoneal repair with mesh
while the other seven had open primary repair. Mean
follow-up was 8.5 years for the non-mesh group, and the
follow-up for the mesh group was 6.7 years. They found
no recurrences in either group. The paper unfortunately
illustrates the low number of these hernias repaired by
any one group, so it is dif fi cult to say one repair is superior to another. One of the larger series was published
from Turkey in 2006. It was a prospective multicenter
study with 34 patients [
6 ] . The most common method of
repair was open intraperitoneal mesh placement. The
most common presenting symptom was painful abdominal mass and preoperative diagnosis could be made in 31
of the patients. The largest series of Spigelian hernias
was reported by Larson from the Mayo clinic in 2002.
There were 81 hernia repairs over a 20-year time period.
Mass, pain, or bowel obstruction were the most common
symptoms. Preoperative imaging was done in 21 patients
and was positive in 15. Suture repair was used in 75
patients, mesh repair in 5, and laparoscopic in one. Mean
follow-up for 76 patients was 8 years and 3 hernias
recurred, all in the suture repair group [
7 ] .
Spigelian hernia does lend itself to a laparoscopic extraperitoneal hernia repair as published by Koksal et al. [ 8 ] . They
describe an approach in which the trocar setup is virtually
identical to a traditional TEP inguinal hernia repair. The preperitoneal space is dissected and used to allow space for
mesh placement. The mesh is placed a little more cephalad
than when done for an inguinal hernia. We have repaired 17
Spigelian hernias found during TEP inguinal hernia repair in
this fashion with no known recurrences to date.
Moreno-Egea et al. showed that laparoscopic repair might
be more bene fi cial to patients in regard to morbidity and
length of stay in the hospital [ 9 ] . Twenty two patients in their
study underwent elective repair of Spigelian hernia; 11 had
open preperitoneal repair while the other 11 had laparoscopic
repair. In the laparoscopic group eight were performed via
the TEP method while the other three underwent intra-abdominal mesh placement. Average length of stay in the open
group was 5 days while the laparoscopic approach was one
day, with a p value <0.001. There were no postoperative
complications in the laparoscopic approach, but the conventional method had four patients with hematomas. This chapter makes a strong case for laparoscopic repair due to the fact
many of these can be done as an outpatient procedure with
less morbidity. An approach we have also used is a combined
laparoscopic and open approach. We place a 5 mm scope to
evaluate the hernia and then make a small incision over the
hernia and repair it with a Ventralex-type patch. This allows
excision of the hernia sac and closure of the fascia over the
patch. This approach is excellent for the large hernia sac that
may lead to seromas and bulging if not excised.
Epigastric Hernia
De fi nition and Epidemiology
Epigastric hernias are primary hernias found in the anterior
abdominal wall between the xiphoid and umbilicus. They are
usually in or near the linea alba, linea semilunaris, or one of
the linea transversus of the rectus sheath [ 10 ] . Most of these
hernias are single in nature and quite small in size. However,
30318 Umbilical, Epigastric, and Spigelian Hernias
they can be multiple in number and on occasion quite large.
Initially epigastric hernias start out with preperitoneal fat
protruding through the linea alba; however, they can grow to
include a hernia sac which becomes subcutaneous in the
midline or interstitial in the rectus sheath. The incidence of
epigastric hernias is largely unknown and they are typically
infrequent in children. Usually they are found in adults with
a male to female ratio of around 3:1. In the few studies that
are available they account for approximately 1–5% of
abdominal wall hernias. One autopsy series of 10,000 hernias found that only 116 were epigastric hernias with 105
being in males. Another autopsy series found epigastric hernias in 5–10% of the bodies examined. They often are found
in young men such as athletes or soldiers who do a large
amount of strenuous exercise.
Several theories regarding the cause of epigastric hernias
have been put forward since the early 1900s. Originally it
was theorized by Witzel that a small defect in the deep fascia
of the abdominal wall leads to preperitoneal tissue protruding through the defect. This tissue can lead to peritoneum
being forced through defect and having a hernia sac. Most
authors now believe that preperitoneal fat penetrates the fascial openings where the vessels and nerves of the abdominal
wall penetrate. Continued intra-abdominal pressure leads to
sac formation and a hernia. This also explains why these hernias are multiple in up to 20% of patients.
Heredity and smoking might share some importance as
well in the formation of these hernias, but increased intraabdominal pressure is a de fi nite factor. This coupled with
diminished resistance of the abdominal wall fi bers can play
an important role in their production. Hence, these hernias
can be seen in young active males as well as obese relaxed
females. Askar dissected a large number of cadavers and
emphasized the importance that fi bers crossing the midline
play in reinforcing the linea alba. He showed that epigastric
hernias were more likely in those where fi ber decussation
was minimal [
Epigastric hernias can have symptoms out of proportion
to their relative size. Historically patients can have vomiting
after meals, indigestion, colic, and occasionally constipation.
Other symptoms involving depression, neurasthenia, and
other nervous symptoms have been related to epigastric hernias. Curiously, these symptoms resolve after repair.
Preperitoneal fat can become incarcerated causing strangulation of this fat. With strangulation of this fat it becomes tender and edematous. Patients will often have severe abdominal
pain at this point due to compression of the contents and/or
the neurovascular bundle. Patients do need a full examination to rule out other causes of abdominal pain as well.
Epigastric hernias can mimic other intra-abdominal pathology such as symptomatic cholelithiasis and peptic ulcer disease. Often patients, especially thin women, desire repair for
cosmetic reasons.
11 ] .
History
Epigastric hernias were fi rst described in 1285 by Arnaud de
Villeneuve in France, but not until 1742 did Rene’ de
Garengeot clearly de fi ne the hernia. He fi rst theorized that
the hernias were due to pathology from the abdominal organs.
Leveille fi rst used the term epigastric hernia in 1812 and the
fi rst successful repair of an epigastric hernia was described
in 1802. The procedure was abandoned for a time due to the
iatrogenic injury of intra-abdominal viscera. Not until 1885
did Terrier operate for the cure of the epigastric hernia. His
fi rst publication and elimination of the pain associated with
epigastric hernias called attention to the treatment of these
hernias.
Literature
There are relatively few recent studies looking at just pure
epigastric hernias. Stabilini recently published a study comparing suture repair against open preperitoneal mesh placement with polypropylene mesh [ 12 ] . The mean hernia defect
size was 2.5 cm (range of 0.5–10 cm). Recurrence rate was
14.7% in the suture repair group vs. 3.1% in the mesh group.
There were a few more local wound complications with the
mesh group; however, this does not seem to offset the recurrence risk in the suture group. Unfortunately most other data
on epigastric hernias in the last 20 years is isolated to interesting case reports [ 13, 14 ] . There are studies that lump epi-
gastric hernias into papers addressing all anterior wall hernias
and laparoscopy [ 15 ] . These will be discussed later.
Umbilical Hernia
De fi nition and Epidemiology
Umbilical hernias are frequent pathology seen by most
general surgeons. Not nearly as common in frequency as
inguinal hernias they nonetheless can cause signi fi cant
morbidity. They are obviously related to our embryological
development and are not that uncommon in the pediatric
population.
As discussed earlier, the embryology of the abdominal
wall is fairly complicated. Umbilical hernias form through
defects in closure of the abdominal ori fi ce where the umbilical cord emerges after the celomic sac is obliterated. Three
weeks into development, the skin and fascial coverings of the
abdominal wall form to cover the intra-abdominal contents.
The intestines and other abdominal viscera are extruded into
the celomic sac, and then they subsequently return to the
abdominal cavity. Failure of this process leads to numerous
abdominal wall defects. The lower portion of the umbilicus
304 B.S. Powell and G.R. Voeller
has the vitelline duct, paired umbilical arteries, and the
umbilical vein. These structures leave the inferior portion of
the umbilicus fairly well protected from changes in intraabdominal pressure and hernia. The superior portion of the
umbilicus has a thinner aponeurosis, which makes it more
vulnerable to hernia and changes in intra-abdominal pressure. The advent of laparoscopic surgery coupled with a typical periumbilical incision can lead to incisional hernias at the
umbilicus. These port-site hernias tend to be amenable to
surgical repair similar to an umbilical hernia.
The female to male ratio in adults for umbilical hernias is
typically 3:1, mostly due to the increased pressure caused
from pregnancy. Other factors that can contribute to umbilical hernia are malignancies, ascites, and of course obesity.
There does not appear to be a strong relationship between
childhood and adult umbilical hernias. Typically only about
10% of adults with umbilical hernias had them as children.
History
Stoser performed the fi rst umbilical hernia repair in the
United States in 1894. Cheselden reported an early repair in
1740, and initially the surgical repair included ligation and
fi xation of the hernia sac. This often led to necrosis and further advancements were made in the late 1800s. Mayo
described his technique of overlap in 1898, called the “vestover-pants” technique [ 16 ] ; this operation was widely done
and was seen as a technical breakthrough since it signi fi cantly
reduced the morbidity over earlier approaches. Most surgeons tend to favor a tension-free repair with mesh at this
point in time.
Umbilical Hernia and Cirrhosis
Umbilical hernia in a patient with cirrhosis and ascites
bears special mentioning. These patients are dif fi cult treatment dilemmas due to the inherent operative risk in these
patients, coupled with ascites and possible chance of hernia
recurrence [ 17, 18 ] . Figure 18.5 shows a picture of what an
epigastric hernia occasionally looks like in a cirrhotic.
Traditional dogma has been that umbilical hernias in Child’s
C cirrhotics or patients with ascites should be watched due
to the risk of general anesthetic in these patients. There are
several case reports of complications after elective hernia
repair in these patients, including emergency liver transplantation [ 19 ] . There are also multiple reports of bowel
evisceration in patients that do not undergo repair [ 20– 24 ] .
There are several studies looking at the optimal time to
repair these hernias, if at all. Telem recently published a
retrospective review of 21 umbilical herniorrhaphies done
from 2002 through 2008 [
25 ] . Fifteen of the patients pre-
Fig. 18.5 Umbilical hernia in a cirrhotic patient with ascites
sented with incarceration, while six had umbilical rupture.
They found that their mortality rate was 5% with a morbidity rate of 71%. In conjunction with the hernia repair they
did TIPS preoperatively in six patients and postoperatively
in two patients. Due to the low number of patients, it was
dif fi cult to draw any de fi nitive conclusions about how to
lower complication rates in this population since all of the
patients in this study had emergent repairs. Gray et al. performed a study in 2008 from the VA National Surgical
Quality Improvement Program looking on the outcomes of
cirrhotic patients vs. non-cirrhotic patients with either elective or emergent umbilical herniorrhaphies [
26 ] . A number
of cases (1,421) were reviewed with 127 of the patients
having cirrhosis (8.9%). Cirrhotics were much more likely
to undergo emergent repair (26.0% vs. 4.8%) along with
higher rates of bowel resection, return to the OR, and
increased postoperative stay. From this data they found that
cirrhosis was not a signi fi cant predictor of postoperative
complications overall. Cirrhosis was strongly predictive of
postoperative complications in emergent repairs. They theorized that earlier elective repair may improve overall outcomes for patients with cirrhosis. Marsman et al. also
reported their data on patients with umbilical hernia and
cirrhosis [ 27 ] . Their group searched their hospital database
over a 14-year period and 34 patients with an umbilical hernia and cirrhosis were identi fi ed. Half of the patients had
elective repair, while 13 others had conservative therapy.
Four other patients underwent hernia repair during liver
transplantation. Of the patients with elective hernia repairs,
30518 Umbilical, Epigastric, and Spigelian Hernias
4 of the 17 had recurrences. In the conservative therapy
group, 10 of the 13 went on to have incarceration; two
patients in this group died from complications of the hernia. Other groups have even advocated laparoscopic repair
of these hernias electively and shown decent results in a
small cohort of patients [ 28 ] . From these studies it can be
shown that emergent repair of umbilical hernias is laden
with complications. Obviously careful patient selection in
these patients is the key since this is a dif fi cult patient population with which to deal.
Current Literature
Current discussion in regard to umbilical hernias deals
mainly with mesh placement vs. suture repair along with
when laparoscopic repair is appropriate. Most of the data
currently available shows that the recurrence rates with mesh
use are less than suture repair of the hernia. This has to be
balanced with the potential complications of mesh
placement.
Asolati looked at predictors of recurrence for patients
with umbilical hernias. It was a retrospective study looking
at all umbilical hernia repairs in a VA over a 6-year span
[ 29 ] . Two hundred and twenty nine patients were followed
with 97 undergoing suture repair and the others receiving
mesh repair. Seven patients in the suture repair group had
recurrences vs. four in the mesh repair group (7.7% vs. 3%).
In their patient population African-American gender, diabetes, and hyperlipidemia were found to be the factors that
were signi fi cant for recurrence. Smoking, obesity, type of
hernia, nor size were found to be signi fi cant in their study.
Eryilmaz looked at their experience of repairing umbilical
hernias with either mesh or suture repair [ 30 ] . Over a fi ve-
year span they did suture repair on any hernia less than 3 cm
and polypropylene mesh repair on any hernia larger than
3 cm. Primary repair was performed in 63 patients, with
mesh repair in 48 patients. The recurrence rate in the suture
repair group was 14% vs. 2% in the mesh group. They concluded that mesh should be used in all umbilical hernias.
Arroyo in 2001 and Sanjay in 2005 [ 31, 32 ] both showed
lower recurrence rates with the use of mesh for repair of
umbilical hernia. Sanjay had a follow-up of 4.5 years.
Schumacher [ 33 ] in 2003 found that in patients with a
BMI >30 the recurrence rate of umbilical hernia was 32% vs.
only 8% in those with a BMI <30. He also found that the
larger the hernia, the higher chance of recurrence if the repair
was done without mesh.
In 2008 we published a paper looking at the use of
Ventralex mesh in umbilical and epigastric hernia repairs
[ 34 ] . It was a retrospective review of our experience of
eight-eight patients. The average BMI was 32 in our patients.
Twenty-two percent of the patients were females and the
mean age was 52. Our average OR time was 52 min and the
f/u at that time ranged from 8 days to 3 years. No hernia
recurrences were found in follow-up. Two patients had mesh
infection requiring removal. From our experience with this
composite patch we concluded it has a valuable role in epigastric and umbilical hernia repairs. In addition, we compared this experience to our experience with a similar number
of umbilical hernia repairs using the laparoscope. The laparoscopic group had no recurrences and no mesh infections
but was $1200 more expensive than the open approach using
the Ventralex patch.
Presentation and Diagnosis of Anterior Abdominal Wall Hernias
Patients can present with a variety of different symptoms
when they have primary anterior abdominal wall hernias
depending on hernia location and hernia contents. Umbilical
hernias tend to be the most common anterior abdominal wall
hernias and often are easier to diagnose than their Spigelian
and epigastric hernia counterparts. Typically they present
with a reducible bulge at the umbilicus that can at times be
tender. If patients have an acute incarceration/strangulation
of omentum, they can present with pain and erythema, but
more frequently it is a chronic incarceration without signs of
strangulation. Incarcerated small intestine can present as a
bowel obstruction or perforation. If the hernia is very large,
it can contain multiple viscera with a variety of related
symptoms.
Epigastric hernias can at times be dif fi cult. Often a thorough history is the best clue with patients complaining of a
bulge and/or pain in the epigastrium. Physical exam is helpful if the defect is large enough to palpate and con fi rms the
diagnosis. If there is still concern about the true etiology of
the pain, an abdominal ultrasound or CT scan can be helpful
in the diagnosis [
in nature and often only have preperitoneal fat in the hernia.
However, the size of the hernia can vary widely and contain
a variety of tissues including preperitoneal fat, omentum,
stomach [ 37 ] , liver [ 38 ] , colon, or small intestine. There have
even been reported epigastric hernias causing pancreatitis
[ 39 ] . Due to this fact, a variety of symptoms can be present.
Spigelian hernias are often dif fi cult to diagnose due to
their relative rarity and low clinical suspicion, especially in
obese patients. Presentation is often similar to the abovementioned hernias except they are found along the Spigelian
line and not in the midline. Patients’ presentations will be
different depending on hernia sac contents as well. Once
again ultrasound and CT scan have aided in the diagnosis,
but there are false negatives with these methods, and diagnostic laparoscopy is an excellent diagnostic tool in the
patient with pain in this area and a negative work-up.
1, 35, 36 ] . Most epigastric hernias are small
306 B.S. Powell and G.R. Voeller
Preoperative Planning
Most anterior abdominal wall hernias can be repaired with
similar techniques that are applicable to each type. As with
most hernias, a tension-free repair is ideal so mesh is usually
used unless there is a clear contraindication to doing so.
The next question is should the repair be done open or with
the laparoscope. We tend to recommend open repair in most
primary anterior abdominal wall defects due to our success
using the Ventralex-type patch with most of these hernias.
The patients have similar or less pain than their laparoscopic
counterparts; it is less expensive and it is an easy repair to
perform. These patches allow a sublay repair through a small
incision with minimal morbidity. For larger hernias we typically favor the laparoscopic approach due to wider overlap of
the hernia and decreased wound infection and mesh infection
rates.
Treatment of Anterior Abdominal Wall Hernia
Open hernia repair has long been the mainstay of treatment
for anterior abdominal wall hernias. Before Mayo began his
“vest-over-pants” repair there was a high morbidity and mortality with this defect. The trend in recent repairs of umbilical hernias has been continued evolution to tension-free
techniques due to high recurrence rates with primary closure.
Most authors advocate fi xing the hernia with mesh if the
defect is larger than 2 cm with mesh. Other authors fi x all
defects with mesh.
Patients undergoing a typical open anterior abdominal
wall hernia repair at our institution receive a cephalosporin
or vancomycin if they are penicillin allergic. We use an
Ioban to minimize the contact of the mesh with the skin if
mesh is to be used. The appropriate incision is made and
the hernia sac is dissected from the subcutaneous tissues
and transected at fascial level. The skin and fat are then dissected off of the fascia for 2–3 cm to get back into good,
healthy fascia (Fig. 18.6 ). The appropriate size circular
patch is selected to provide a good amount of sublay beyond
the hernia defect. It is placed into the peritoneal cavity, and
the surgeon makes sure it is completely opened and abuts
the peritoneal surface of the abdominal wall 360° without
any viscera interposed between the patch and the abdominal wall. We use 2–0 double-armed Prolene sutures to place
U-stitches at the 12, 3, 6, and 9 o’clock positions. These
sutures include the polypropylene part of the Ventralex
patch only and then a good purchase back into good fascia
18.7 ). We use stitches at the 12 and 6 o’clock posi-
(Fig.
tions only for the small patch. The fascia is then closed over
the mesh to add another barrier of protection from possible
wound infections (Fig. 18.8 ). The skin is closed based on
Fig. 18.6 Placement of the Ventralex patch into the hernia defect
Fig. 18.7 After the Ventralex patch has been placed with four Prolene
U-stitches securing it in place
the type of hernia repaired. We use a compression dressing
to help with hemostasis and to decrease seroma formation
and have the patient wear an abdominal binder postoperatively. We do not routinely leave drains unless there is a
large dead space. If there is evidence of ischemic bowel at
any point of the procedure, synthetic mesh should not be
used. The surgeon should decide whether to use a biologic
mesh or perform a primary repair.