What are the recommended approaches and management strategies for ventral hernia repair?

Recommended Approaches for Ventral Hernia Repair

Laparoscopic repair should be considered the procedure of choice for ventral hernia repair in stable patients without signs of strangulation, as it results in shorter hospital stays, fewer complications, and lower recurrence rates compared to open repair. 1, 2

Diagnostic Evaluation and Surgical Decision-Making

• Clinical Assessment for Complications:

  • Check for signs of strangulation: severe pain, tenderness, erythema, and systemic inflammatory response syndrome (SIRS) 1
  • Evaluate for incarceration, intestinal obstruction, skin ulceration/necrosis 1
  • Laboratory markers: Arterial lactate ≥2.0 mmol/L suggests non-viable bowel strangulation 3
  • CT findings: Reduced wall enhancement is the most significant predictor of bowel strangulation (56% sensitivity, 94% specificity) 3

• Surgical Approach Selection Algorithm:

  1. Emergency Surgery Required (immediate intervention):

     • Strangulated hernia
     • Incarcerated hernia with unsuccessful manual reduction
     • Skin complications (ulceration, necrosis, rupture of hernia sac)

  2. Approach Based on Patient Condition:

     • Open repair preferred for:
       • Hemodynamically unstable patients
       • Suspected bowel compromise requiring resection
       • Severe sepsis/septic shock
     • Laparoscopic repair preferred for:
       • Stable patients without signs of strangulation
       • Clean operative field without contamination

Surgical Techniques

Laparoscopic Repair

• Intraperitoneal Onlay Mesh (IPOM) technique is standard for laparoscopic approach 2
• Key Technical Points:
  • Careful bowel reduction with adhesiolysis
  • Mesh placement with at least 5-cm overlap of defect 3
  • Avoid inadvertent enterotomy during adhesiolysis 3
  • Benefits: shorter hospital stay (2.7 vs 4.7 days), fewer complications (24% vs 30%), and lower recurrence rates (2% vs 10%) compared to open repair 2

Open Repair

• Recommended Techniques:
  • Rives-Stoppa technique with preperitoneal mesh placement 2
  • For defects >3 cm that cannot be closed primarily, mesh reinforcement is essential 1
• Mesh Selection:
  • Clean field: Polypropylene mesh
  • Clean-contaminated/contaminated: Biologic or biosynthetic meshes 1

Special Considerations

High-Risk Populations

• Cirrhotic Patients with Ascites:

  • Optimize ascites control before repair
  • Consider multidisciplinary team discussion
  • Risk factors for mortality: Child-Pugh-Turcotte class C, ASA score ≥3, MELD score ≥20 1

• Pregnant Women:

  • Emergency repair if incarcerated/strangulated
  • Elective repair if symptomatic
  • Postpone repair for asymptomatic hernias until after childbirth 1

Postoperative Management

• Pain Management:

  • Multimodal analgesic regimen to minimize opioid use
  • First-line: Acetaminophen and NSAIDs
  • Consider dexamethasone to reduce postoperative nausea and vomiting 1

• Recovery Protocol:

  • Early mobilization
  • Evaluate wound healing within first week
  • Assess functional recovery at 2-4 weeks
  • Progressive strengthening exercise program after 3-6 months 1

Common Pitfalls and Caveats

1. Laparoscopic Approach Risks:

   • Higher risk of intraoperative enterotomy compared to open repair 4
   • Higher incidence of seroma formation 5
   • Technically more demanding and may have longer operative times 5, 6

2. Mesh-Related Complications:

   • Infection risk is significantly lower with laparoscopic approach 4
   • Fistula formation is a concern but rare in elective cases 7

3. Long-Term Outcomes:

   • Despite promising short-term results for laparoscopic repair, long-term follow-up (>2 years) is needed to fully establish efficacy 4

By following these evidence-based recommendations and considering patient-specific factors, ventral hernia repair can be performed safely with optimal outcomes for morbidity, mortality, and quality of life.