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81

Incisional/Ventral Hernia Mesh and Tissue Flap

Thomas D. Kimbrough

STEP 1: SURGICAL ANATOMY A midline epigastric incisional hernia is represented in Figure 81-1. Figure 81-2 is a cross-section of the hernia illustrating the relevant layers.

Xiphoid

Umbilicus

FIGURE 811
Posterior rectus sheath

Peritoneum

Anterior rectus sheath

FIGURE 812

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Section XI

Hernias

STEP 2: PREOPERATIVE CONSIDERATIONS The most important preoperative consideration is whether the hernia should be repaired. Because the risk to the patient from the hernia decreases as its diameter increases, and the chance of recurrence and other surgical complications increases, the risk-to-benet ratio should be carefully assessed. In the event repair is deemed desirable, many of these patients have signicant comorbidities that must be addressed preoperatively and managed perioperatively. Neglect of these can lead to failure in spite of a technically superb surgical repair. There are many techniques for repair of incisional hernias, illustrating among other things that no one method has been judged superior. The technique illustrated here is but one of many acceptable available.

STEP 3: OPERATIVE STEPS 1. INCISION In the case of incisional hernias, the new incision is made by excising the old scar. In the case of a ventral hernia not related to a previous surgical procedure, the incision is best placed along the longer axis of the fascial defect. If the fascial defect is circular with no signicant difference in the length of axes, transverse incisions leave better scars.

2. DISSECTION After the hernia sac is identied, its external peritoneal lining is dissected free from surrounding structures, including the innermost fascial layer of the abdominal wall. Although it is often necessary to open the peritoneum and even resect portions of it, preservation of enough of the peritoneum to close allows the imposition of a tissue layer between the mesh to be used and the contents of the intra-abdominal cavity. The end result is illustrated in Figure 81-3. Figure 81-4 shows the next step, which is separation of the posterior rectus sheath from the overlying rectus abdominis muscle. Primarily the cut edges of the posterior sheath are then closed, even if under tension. This closure can be facilitated by application of the techniques of component separation.

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Incisional/Ventral HerniaMesh and Tissue Flap

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Subcutaneous fat Skin

Posterior rectus sheath

Rectus muscles Anterior rectus sheath

Peritoneum

Bowel

FIGURE 813

Subcutaneous fat Skin

Anterior rectus sheath

Rectus muscles

Peritoneum

Posterior rectus sheath

FIGURE 814

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Section XI

Hernias

A sheet of polypropylene mesh is then positioned on top of the posterior sheath and under the rectus muscle. There should be an overlap of 3 to 5 cm on all sides. Some choose to tack the mesh in place with mattress sutures through the rectus muscle and anterior sheath. I have found it sufcient to tack the mesh to the underlying posterior sheath with absorbable sutures. Either way the mesh should be tacked down as tautly as possible. The completion of these steps is illustrated in Figure 81-5. Figure 81-6 shows the completed repair after primary closure of the anterior sheath. Again, fascial release techniques such as component separation can facilitate this process. It is, of course, not always possible to completely close the posterior and anterior fascial layers, even with releases. In that event, as much as possible is closed, even if under tension. Every effort is made to close some type of tissue layer between the abdominal contents and the mesh, and the mesh and the skin. As mentioned earlier, the peritoneum can be used in the rst instance, and the subcutaneous tissues in the latter.

Subcutaneous fat Skin

Anterior rectus sheath

Rectus muscles

Peritoneum

Mesh

Posterior rectus sheath

FIGURE 815

Subcutaneous fat

Anterior rectus sheath Skin

Rectus muscles

Peritoneum

Mesh

Posterior rectus sheath

FIGURE 816

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3. CLOSING Scrupulous attention should be paid to hemostasis, because postoperative hematomas are not uncommon and can create signicant problems. Whether to use drains in any or all of the spaces created by the dissection is the choice of the individual surgeon. The drains are no substitute for good technique and offer a route for the introduction of bacteria.

STEP 4: POSTOPERATIVE CARE Most patients require a day or two in the hospital for adequate pain control. Patients are instructed to refrain from lifting or doing strenuous work for 4 to 6 weeks.

SELECTED REFERENCE
1. Zinner MJ, Schwartz SI, Ellis H: Hernias. In Maingot R, Zinner M (eds): Maingots Abdominal Operations, vol 1, 10th ed. Stamford, Conn, Appleton & Lang, 1997, pp 479-580.