What is the best approach to manage a ventral hernia in a patient with a history of transplant removal, multiple laparotomies, and gastric stimulator placement, who is not a candidate for laparoscopic surgery?

Management of Ventral Hernia in a Patient with Complex Surgical History

For patients with a history of transplant removal, multiple laparotomies, and gastric stimulator placement who are not candidates for laparoscopic surgery, open ventral hernia repair with mesh reinforcement is recommended as the optimal approach to reduce recurrence rates while managing the complex abdominal wall.

Preoperative Assessment and Planning

• Imaging evaluation: CT scan is essential to:

  • Characterize hernia morphology
  • Quantify loss of domain
  • Assess the lateral abdominal wall muscles
  • Evaluate for potential adhesions from previous surgeries 1

• Risk factors requiring attention:

  • Multiple previous laparotomies (increases risk of adhesions)
  • Presence of gastric stimulator (may complicate mesh placement)
  • Potential contamination from previous surgeries

Surgical Approach

Open Repair Technique

1. Mesh selection:

   • In clean surgical fields (CDC wound class I), synthetic mesh is recommended to reduce recurrence rates 2
   • For potentially contaminated fields, biological mesh may be considered, though recurrence rates are higher (27.2%) compared to synthetic non-absorbable meshes (3.2%) 2

2. Mesh placement:

   • Sublay (retrorectus) position is preferred when possible as it's associated with fewer wound complications 2
   • Ensure adequate overlap (minimum 3-5 cm beyond defect margins)
   • Secure fixation to prevent displacement

3. Component separation technique:

   • Consider anterior or posterior component separation for large defects to achieve tension-free closure
   • This approach is particularly valuable in patients with multiple previous surgeries 3

4. Fascial closure:

   • Primary fascial closure should be attempted whenever possible
   • Failure to close the anterior fascia is associated with higher wound complication rates 2

Advanced Techniques for Complex Cases

For extremely challenging cases with significant loss of domain:

• Preoperative botulinum toxin A (BTA): Consider injection into lateral abdominal muscles 2-4 weeks before surgery to lengthen retracted muscles and facilitate closure 4

• Progressive pneumoperitoneum (PPP): May be used in combination with BTA to increase abdominal cavity volume and facilitate closure of large defects 4

Postoperative Management

• Pain management: Multimodal approach with non-opioid medications as first-line treatment 5

• Early mobilization: Encourage ambulation within 24 hours to prevent respiratory complications and DVT

• Wound care: Close monitoring for complications, particularly in patients with multiple previous surgeries

Potential Complications and Management

• Wound infection: Higher risk in patients with multiple previous surgeries (monitor closely)

  • Risk factors include high ASA score (≥3), smoking, diabetes, immunosuppression, and previous hernia repair 2

• Recurrence: Monitor for recurrence, particularly in patients with:

  • High BMI
  • Large defect size
  • Previous failed repairs 2

• Respiratory complications: Common after ventral hernia repair, especially in patients with multiple previous abdominal surgeries 2

Follow-up Care

• Evaluate wound healing and adjust analgesic regimen within the first week
• Assess functional recovery and identify persistent pain between 2-4 weeks
• Monitor for chronic pain and possible recurrence at 3-6 months
• Implement progressive strengthening exercise program after 3 months 5

Key Considerations for This Patient Population

The presence of multiple laparotomies, transplant removal, and gastric stimulator placement significantly increases the complexity of the repair. Open repair with appropriate mesh reinforcement offers the best chance for successful outcomes while minimizing complications in patients who cannot undergo laparoscopic repair.