Editing Ventral incisional hernia (section)

== '''Management''' ==

* Principles
** Optimise underlying causative factors
** Re-create linea alba
** Tension-free repair
* Surgical considerations
** Suture vs mesh
*** Mesh indicated >2-3cm or when the hernia was clearly a result of technical error at the primary operation
** Mesh type
*** Permanent synthetic materials
*** Absorbable synthetic materials
*** Biologic materials
*** ''See separate topic under 'operating theatre'''
** '''Mesh placement'''
*** In general, IPOM and retro-rectus have lowest rates of recurrence, infection and seroma
*** '''Onlay'''
**** Primary closure of the defect and placement of mesh over the anterior fascia
**** Advantage - completely outside the abdominal cavity
**** Disadvantages - large subcutaneous dissection, increased likelihood of seroma, superficial location of the mesh, and the repair is usually under tension
**** Retrospective review - recurrence rate of 28%
**** Best to use midweight permanent synthetic mesh - polypropylene or polyester
*** '''Interposition'''
**** Secure the mesh to the fascial edge without overlap
**** Predictably high recurrence rate - mesh often pulls away from the fascial edge
*** '''Sublay'''
**** Prosthesis is placed beneath the fascia (intra-peritoneal, pre-peritoneal, or in the retro-rectus space)
**** Advantage - natural forces of abdomen hold the mesh in place and prevent migration
**** '''Intra-peritoneal'''
***** Composite or dual-type mesh placed below peritoneum with at least 4cm overlap
***** Secure with interrupted mattress sutures
***** Can be done laparoscopically - trocars as far laterally as possible, hernia reduced, adhesions lysed, mesh secured with trans-fascial sutures
***** Probably lower long-term recurrence rate if defect is also closed - meta-analysis 2024
**** '''Pre-peritoneal'''
**** '''Retro-rectus'''
** '''Plan for tension-free closure'''
*** Progressive pneumoperitoneum (over a 3-week period) - particularly suited for small defects and massive sacs
*** Planned open abdomen with progressive closure of PTFE mesh as described under that separate topic - very morbid and time-consuming way to do it
*** Botox - see above under 'pre-op'
*** Tissue expanders
*** Fasciotens
*** '''Myofascial release/component separation'''
**** Allows advancement of rectus muscle by as much as 10cm from each side
**** Is component separation required? Which type?
***** Depends on ability to recreate the linea alba through medialisation of the rectus abdominis muscle while maintaining appropriate tension on the repair
***** Cameron's suggests do a posterior separation when possible, because it provides the benefit of myofascial advancement (as in anterior approach) but also allows wide mesh overlap in a sublay position between the abdominal musculature and the peritoneum while eliminating large skin flaps
***** Anterior release carries the disadvantage of often requiring large skin flaps with significant wound morbidity
**** Options
***** Posterior rectus sheath incision with retro-muscular mesh placement
****** Recurrence rate 14% in large incisional hernias
***** Posterior component separation
***** Anterior component separation
**** See separate topic for technique
*** 'Cytoreductive surgery' - omentectomy/colectomy
*** Other techniques described in SAGES manual of hernia repair
** '''Open vs laparoscopic'''
*** Laparoscopic repair favoured if
**** Potentially more than one defect
**** High risk of SSI
**** High-risk for recurrence
**** Small or medium defect
*** Open favoured if
**** Many adhesions (need to clear for trocar placement and mesh placement)
**** Larger defects - hard to close laparoscopically
** Drains
*** Probably don't need to routinely drain sublay repairs, even with retrorectus dissection - doesn't seem to affect seromas or infections
*** More role for drains in onlay repairs with big subcutaneous dissections
** Recurrent hernias
*** Try to use a different plane - generally use pre-peritoneal for primary repair, then retro-rectus for next repair, and can either try again with retro-rectus or IPOM for the subsequent repair


Approach to open abdominal wall reconstruction

* Midline incision through linea alba and reduction of hernia sacs
* Attempt retro-rectus repair - if unable to close posterior sheath, consider component separation vs fasciotens