59 - Ventral hernia repair

Summary

Ventral hernias encompass a wide variety of abdominal wall defects, including incisional, epigastric, umbilical, and spigelian types; for the purposes of this chapter, the term ventral hernia is restricted to the incisional type. A ventral hernia with a small ring predisposes patients to incarceration and possible strangulation of a segment of small or large intestine. Patients with significant ascites are at risk for rupture of a ventral hernia if there is only skin covering the defect. Those with large ventral hernias have difficulty wearing regular clothes and are often embarrassed by their appearance. For these reasons, elective repair of ventral hernias is indicated in patients who are healthy enough to undergo mechanical bowel cleaning and general anesthesia. Over 100 000 such repairs are performed in the USA each year.

At the time of ventral herniorrhaphy performed through an open approach, the thinned-out skin covering the hernia sac itself and all scar tissue back to normal-appearing rectus or other muscles of the abdominal wall are excised. Once the true size of the hernia defect is seen, a decision is made regarding primary repair versus insertion of a prosthetic patch. Primary repair is possible even with defects as wide as 5–6 cm using lateral divisions of the external oblique muscles from within the incision or the “components separation” technique. Because of the size of many ventral hernias after debridement, patches made of polypropylene (porous) or polytetrafluoroethylene (non-porous) are frequently inserted to fill the musculofascial defect.