Editing Ventral incisional hernia (section)

== Operation ==

* Open retro-rectus repair
** Midline incision
** Reduce all hernia sacs, preferably without opening, down to pre-peritoneal plane
** Enter the retro-rectus plane by incising from posterior at the level of the umbilicus, 1cm off midline. Find rectus muscle to confirm the correct plane.
** Dissect along the entire length of the incision, moving laterally as far as linea semilunaris, confirmed by seeing the anterior and posterior sheath leaflets coming together. Don't injure nerves and vessels.
** Join dissection planes cephalad and caudad. Leave the linea alba attached to anterior sheath.
** Close posterior sheath with 2/0 Prolene (small stitch technique). If there is too much tension here, a posterior component separation is required to prevent posterior dehiscence and subsequent interstitial hernia.
* Component separation/TAR
** See separate topic
* Suprapubic hernias
** IDC
** Vertical midline over hernia
** Dissect out sac to pre-peritoneal plane, without entering sac
** Dissect peritoneum from posterior sheath as a space for mesh (close any peritoneal defects made)
*** Allow 3-5cm mesh overlap of defect
** Place mesh in plane. Inferior fixation can be a challenge - either sutures to pubis/Cooper's ligament, or bone anchor fixation
** May need fasciotens to anterior sheath
* Sub-xiphoid hernias
** Pre-peritoneal plane is favoured, due to difficulty fixing mesh around xiphoid
* Open repair of irreducible incisional hernia
** Dissect onto sac
** Open sac to examine for bowel strangulation
** May need to increase size of defect to fully visualise
** Resect as needed
** Close defect - mesh if no contamination, as per inguinal hernia topic
* Laparoscopic incisional hernia repair
** Supine, with ports as lateral as possible
** Take down adhesions until the hernia is visible and there is adequate surrounding landing zone - 5cm - consider conversion if very dense or if bowel is difficult to reduce
** Reduce contents of sac, but leave the sac in situ
** Close defect with v-lok suture
** Place a circular mesh inside, orient it centrally, and tack it in place