Ventral/Incisional Hernias
Differential
· Ventral/incisional hernia
· Diastasis Recti – fascia intact, common in post-partum women and obese men
· Umbilical Hernia, Epigastric hernia
Workup
· H&P
o Previous surgeries, complications
o Activity level
o BMI
o Identify risk factors – smoking, obesity, DM, steroids, immunosuppressed, poor nutrition
o Distinguish between chronically incarcerated vs. acutely incarcerated hernia
· Imaging
o CT scan
o RUQ US to rule out other causes of abdominal pain
· Labs – LFTs, amylase, WBC – rule out other causes of abdominal pain.
Diagnosis & Tx
· Symptomatic ventral hernia
· Asymptomatic ventral hernia
· Incarcerated ventral hernia
Surgical approach
· Open Technique
o Inlay (bridging the defect with Mesh-not recommended for permanent repair, highest rates of recurrence)
o Onlay (Covering defect with Mesh and Fascia overlap)
o Underlay (placing mesh in a retrorectus position or intraperitoneally with fascial overlap-method with least recurrences and recommended if feasible)
· Components Separation – The fascia may be re-approximated using this technique.
o Often used in conjunction with Mesh placement.
· Laparoscopic Repair
o Insufflate abdomen, place ports lateral enough to allow for at least 4 cm of mesh to fascia overlap.
o Perform sharp/blunt adhesiolysis of viscera. Minimize electrocautery use.
o Identify and mark boundaries of hernia defect on anterior abdominal wall.
o You may or may not re-approximate the edges of the defect.
o Select and size mesh to allow 4-5 cm overlap. Prepare mesh with sutures and insert through 10 mm port or incision.
o Insert Mesh, unroll, and use a suture passer to pass tacking sutures through anterior abdominal wall.
o Once mesh positioned appropriately, use a 5mm circular tacker to secure Mesh at 1 cm intervals to ensure all defects are covered.
Postoperative management
§ Transabdominal sutures and tacks can lead to significant post-op pain.
§ Pts undergoing extensive adhesiolysis should be observed as an inpatient.
§ Seromas are common (as the hernia sack is not excised). The vast majority resolve spontaneously by 3 months. Aspiration should be avoid.
§ Post op use of abdominal binder may help prevent seroma formation.
§ Complications: ileus (2-3%), hematoma, trocar site infection, missed enterotomy, pulmonary complications.
Important Points
Incisional hernias are common after laparotomy.
Repair usual performed for symptoms, rather than incarceration or strangulation.
Avoidance of enterotomy/contamination is critical.