What is the recommended treatment for a ventral hernia?

Treatment of Ventral Hernia

Mesh repair is strongly recommended for ventral hernia repair as it is associated with a significantly lower recurrence rate compared to tissue repair, without increasing wound infection rates. 1

Classification and Assessment

Before deciding on treatment, it's important to assess:

• Presence of intestinal strangulation (requires immediate surgery)
• CDC wound classification (clean, clean-contaminated, contaminated, or dirty)
• Size of hernia defect
• Patient stability

Treatment Algorithm

1. For Uncomplicated Ventral Hernias (CDC Wound Class I)

• First-line treatment: Prosthetic repair with synthetic mesh 1
  • Significantly lower recurrence rate compared to tissue repair
  • No increased risk of wound infection
  • Can be performed via open or laparoscopic approach

2. For Complicated Hernias with Intestinal Strangulation (CDC Wound Class II)

• Recommended approach: Emergency prosthetic repair with synthetic mesh 1
  • Even with concomitant bowel resection (without gross spillage)
  • Associated with lower recurrence risk regardless of defect size

3. For Contaminated Fields (CDC Wound Class III/IV)

• For small defects (<3 cm): Primary repair is recommended 1
• For larger defects: Biological mesh may be used 1
  • Choice between cross-linked and non-cross-linked biological mesh depends on defect size and contamination degree
  • If biological mesh unavailable: Consider polyglactin mesh or open wound management with delayed repair

4. For Unstable Patients with Sepsis/Septic Shock

• Initial management: Open management to prevent abdominal compartment syndrome 1
• After stabilization: Attempt early definitive closure when risk of excessive tension is minimal 1
• When early closure not possible: Progressive closure at each surgical wound revision 1

Surgical Approach Options

Laparoscopic Approach

• Recommended for incarcerated hernias without strangulation 1
• Benefits:
  • Lower wound infection rates compared to open repair 1, 2
  • Shorter hospital stay in most cases 2
• Limitations:
  • Technically more demanding 3
  • Higher risk of intraoperative enterotomy (though rare) 2
  • Higher in-hospital costs 2

Open Approach

• Preferred for cases with suspected bowel strangulation requiring resection 1
• Preperitoneal approach is recommended when bowel resection is needed 1
• Component separation technique is useful for large midline abdominal wall hernias 1

Antimicrobial Prophylaxis

• Clean field (CDC class I): Short-term prophylaxis 1
• Clean-contaminated/contaminated field (CDC classes II/III): 48-hour antimicrobial prophylaxis 1
• Dirty field (CDC class IV): Full antimicrobial therapy 1

Important Considerations and Pitfalls

• Recurrence risk increases with each repair: With each failed repair, subsequent operations become more complex and have higher complication rates 4
• Long-term outcomes: Up to 37% of primary ventral hernias and 64% of incisional hernias recur within 140 months 4
• Diagnostic vigilance: When intestinal strangulation is suspected, CT findings, lactate, CPK, and D-dimer levels are predictive of bowel strangulation 1
• Anesthesia choice: Local anesthesia can be used for emergency inguinal hernia repair without bowel gangrene, providing fewer postoperative complications 1
• Diagnostic laparoscopy: Useful tool to assess bowel viability after spontaneous reduction of strangulated hernias 1

Emerging Techniques

Several minimally invasive techniques have evolved to improve outcomes:

• eTEP, MILOS/eMILOS, and other advanced approaches aim to reduce tissue tension and allow placement of large synthetic meshes without extensive tissue dissection 5
• These techniques require advanced laparoscopic skills and understanding of abdominal wall spaces 5

Remember that optimizing patient-related risk factors before elective surgery is important to decrease complication rates 3, though emergency cases require immediate intervention when strangulation is suspected 1.