What are the surgical steps for a supraumbilical ventral hernia repair?

Surgical Steps for Supraumbilical Ventral Hernia Repair

The standard surgical approach for supraumbilical ventral hernia repair involves mesh placement with at least 5-cm overlap of the defect, with laparoscopic repair preferred for stable patients without signs of strangulation due to shorter hospital stays, fewer complications, and lower recurrence rates compared to open repair. 1

Preoperative Considerations

• Patient optimization is essential before elective repair:
  • Smoking cessation
  • Diabetes control (HbA1C <7%)
  • Weight management (BMI <40 kg/m²) 1
• Emergency indications include:
  • Incarceration (if manual reduction fails)
  • Strangulation
  • Intestinal obstruction
  • Skin complications (ulceration/necrosis) 1

Surgical Approach Selection

• Laparoscopic approach is recommended for:

  • Hemodynamically stable patients
  • Clean operative fields without contamination
  • Absence of bowel compromise 1

• Open approach is preferred for:

  • Hemodynamically unstable patients
  • Suspected bowel compromise requiring resection
  • Severe sepsis or septic shock 1

Laparoscopic Repair Technique

1. Patient positioning and port placement:

   • Supine position
   • Establish pneumoperitoneum (usually at Palmer's point)
   • Place 3-4 trocars in a triangular or diamond configuration

2. Adhesiolysis and hernia sac management:

   • Carefully reduce hernia contents
   • Perform adhesiolysis to free the hernia sac
   • Take care to avoid inadvertent enterotomy 1

3. Defect measurement and mesh preparation:

   • Measure the fascial defect intracorporeally
   • Select mesh size to allow at least 5-cm overlap on all sides 1

4. Mesh placement and fixation:

   • Position the mesh (typically IPOM technique)
   • Secure with transfascial sutures at cardinal points
   • Complete fixation with tacks, avoiding placement near the pericardium 2
   • Ensure at least 5-cm overlap of the defect on all sides 1

Open Repair Technique

1. Incision and exposure:

   • Make a midline incision over the hernia
   • Identify and isolate the hernia sac

2. Hernia sac management:

   • Dissect the sac from surrounding tissues
   • Open the sac and reduce contents
   • Excise redundant sac tissue

3. Fascial closure:

   • Identify healthy fascial edges
   • Close the defect primarily with non-absorbable sutures when possible 2

4. Mesh reinforcement:

   • For defects >3 cm that cannot be closed primarily, mesh reinforcement is essential 1
   • Place mesh in preperitoneal or onlay position with 3-cm overlap 1
   • Secure mesh with non-absorbable sutures
   • For larger defects (>8 cm or area >20 cm²), interposition of a graft is recommended 2

Mesh Selection

• Clean fields: Synthetic non-absorbable mesh preferred
• Contaminated/dirty fields: Biologic or biosynthetic meshes recommended 2
• Mesh should overlap the defect edge by 1.5–2.5 cm 2

Technical Considerations

• Primary repair with non-absorbable sutures should always be attempted when possible 2
• For defects larger than 8 cm or area >20 cm², interposition of a graft is recommended 2
• Mesh can be fixed using tackers or transfascial sutures, but avoid tackers near the pericardium 2
• The "sandwich mesh technique" has shown favorable long-term outcomes for primary ventral hernias 3

Postoperative Management

• Pain management: Multimodal analgesic regimen including acetaminophen and NSAIDs 1
• Early mobilization to prevent respiratory complications
• Monitor for complications:
  • Seroma (more common with laparoscopic repair) 4
  • Surgical site infection (more common with open repair) 4
  • Recurrence (rates of 2.9-9.4%, with higher rates in laparoscopic repair) 4

Common Pitfalls and Caveats

• Seroma formation: More common in laparoscopic repairs (13.9% vs 4.3% in open repairs) 4
• Mesh infection: More common in open repairs 5
• Recurrence risk factors: BMI, defect size, and inadequate mesh overlap 2
• Enterotomy risk: Slightly higher in laparoscopic repair during adhesiolysis 6
• Intra-abdominal pressure: Monitor in unstable patients to prevent abdominal compartment syndrome 2

The choice between open and laparoscopic approaches should be based on patient factors, with laparoscopic repair showing benefits of shorter hospital stays and fewer wound infections, while open repair may have lower recurrence rates and better long-term quality of life outcomes 4.