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Postoperative Ventral Wall {Incisional} Hernia

  1. Introduction
  • It is the result of a failure of fascial tissues to heal & close following laparotomy.
  • Such hernias can occur after any type of abdominal wall incision, although highest incidence is seen with midline & transverse incision.
  • Laparoscopic port sites may also develop hernia defects in the abdominal wall fascia.
  1. Incidence & Etiology
  • Modern rates of incisional hernia ranges from 2% to 11%
  • Once belived that the majority of incisional hernia present within first 12 months following laparotomy, long term data indicate that at least one – third will present 5-10 years post-operatively.
  • Multiple risk factors exist for development of an incisional hernia.
  1. Patient Specific – Advanced Age, Malnutrition, Presence of Ascites, Corticosteroids use, DM, Cigarette Smoking, Obesity, Wound Infection.
  2. Emergency sx is known to increase risk of incisional hernia.
  3. Surgeon Specific – Wound closure under excessive tension are prone to fascial closure disturbance. Therefore continuous closure is advocated to disperse the tension throughout the length of the wound.
  1. Clinical Manifestation
  • Patient complains of bulge in abdominal wall originating deep to the skin scar
  • Symptoms will usually be aggravated by coughing or straining as the hernia contents protrude through abdominal wall defect.
  • In large ventral hernias, skin may present with ischemic or pressure necrosis leading to frank ulceration.
  • May present with incarceration causing bowel obstruction, it may be associated with a history of repected mild attack of colicky dull abdominal pain & nourea consistent with incomplete bowel obstruction
  1. Examination
  • On examination the hernia is usually easy to identity & the edges of the fascial defect can often be defined by palpation.
  • Entire abdominal wall along the length of the incision should be inspected & palpated carefully as multiple hernia are often present in
  • CT-scan of abdomen is best way to visualize intra-abdominal contents within the hernia sac.
  1. Treatment
  • Treatment of ventral hernia is operative repair & three general classes of operative repair have emerged in modern era.
  1. Primary Suture Repair
  2. Open Repair With Prosthetic Mesh
  3. Laparoscopic Incisional Hernia Repair
  1. Laparoscopic Incisional Hernia Repair
  • In this technique, the defect is repaired posteriorly & no dissection within the scarred layer of anterior fascia required.
  • It also allows identification of additional hernia defect in ant. Abdomen wall.
  • One of the challenging aspect of the Laparoscopic repair port access into a peritoneal cavity that has been previously operated.
  • In general , access can be obtained for needle insufflations via the left upper quadrant, placing the port along ant. Axillary line to avoid
  • Then instruments are inserted.
  • Next challenge is lysis of adhesions.
  • Goal is to provide 3-4 cm circumferential area of overlap for the mesh patch beyond the edge of ventral hernia defect.
  • The sac is retracted & excised from within the hernia.
  • Outline of defect is then drawn on ant. Abdomen wall. Edges are confirmed from within the abdomen cavity.
  • While adhesiolysis can be performed at typical pneumoperitoneum pressure of 15 mm Hg, sizing the mesh should be done with abdomen fully deflated.
  • If the mesh is measured with abdomen fully distended, it will be lax once the pneumo is released & patient may feel as if their hernia was never fixed.
  • Mesh is cut to fit this defect with a margin of 3-4 cm each side to provide adequate coverage & to minimize tension.
  • Non-absorbable sutures are placed around the circumference of the mesh & tied. The mesh is rolled so that ant. Surface lies inside the roll &mesh is inserted through 10-12 mm port.
  • Once un-rolled mesh is positioned. A transfascial suture passer can be introduced through small stab incision placed around the marked border.
  • Suture passer retrives the long end of sutures & ends are tied at skin level at 4-6 patient around the repair.
  • After all suturs tied, cut & buried subcutaneously, laparoscopically placed tacks or staples can be used to futher fasten the mesh to ant. Abdominal wall.
  • Post-op patient should be instructed to wear abdominal binders-particularly if a large defect has been repair in an effort to obliterate dead space & prevent seroma formation.
  1. Complications
  • Shares general complication of laparoscopy including port-site herniation vascular injury from trocar placement & inadvertent bowel injury during adhesiolysis.
  • Mesh placed during Laparoscopy are prone to infection.
  1. Pros & Cons of Laparoscopic Ventral Hernia Repair
  1. Pros
  • Accurately identifies all fascial defect
  • May identity unsuspected intraperitoneal pathology
  • Approaches fascia through clean field.
  1. Cons
  • No possible to revise contour of abdomen wall
  • Adhesiolysis may be difficult with increase potential for enterotomy.
  • Hard to get good fixation for defect at margin of abdomen cavity.
  1. Notes
  • In this the mesh is placed directly in contact with the viscera. As in open in lay repairs this carries the risk of development of chronic inflammation, fistula, infection & mesh migration
  • To minimize this, dual sided mesh prosthses have been developed, these implants are coated with materials designed to prevent adhesion
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