How to manage an umbilical fat-containing hernia with multi-focal hernia and diastasis using physiologic mesh and IPOM approach?

Management of Umbilical Fat-Containing Hernia with Multi-Focal Hernia and Diastasis Using Physiologic Mesh and IPOM Approach

For umbilical hernias with multi-focal defects along a chevron incision and diastasis recti, a mesh-based repair using physiologic mesh in an IPOM (intraperitoneal onlay mesh) approach is strongly recommended to minimize recurrence rates and optimize patient outcomes. 1

Preoperative Assessment

• Evaluate the extent of:
  • Umbilical hernia defect size
  • Multiple herniation sites along the chevron incision
  • Severity of diastasis recti
  • Presence of adhesions (noted in the case)
• Consider comorbidities that may affect surgical outcomes:
  • Obesity (increases complication risk) 1
  • Previous surgeries (chevron incision mentioned)

Surgical Approach

IPOM Technique with Physiologic Mesh

1. Surgical Access:

   • For stable patients, a minimally invasive laparoscopic approach is preferred
   • This offers lower morbidity (5-6%) compared to open approach (17-18%) 1, 2

2. Adhesiolysis:

   • Carefully take down adhesions to the previous chevron incision
   • Ensure complete visualization of all hernia defects

3. Hernia Defect Management:

   • For defects larger than 3 cm, primary closure may lead to excessive tension
   • Primary suture repair alone has a high recurrence rate (up to 42%) 1
   • When diastasis recti is present, simple suture repair results in significantly higher recurrence rates (31.2% vs 8.3%) 3

4. Mesh Selection and Placement:

   • Use a physiologic/biosynthetic mesh as mentioned in the case
   • Biosynthetic or biologic meshes are recommended due to:
     • Lower hernia recurrence rates
     • Higher resistance to infections
     • Lower risk of displacement 1
   • Ensure mesh overlaps all defect edges by 1.5-2.5 cm 1, 2

5. Mesh Fixation:

   • Secure mesh using appropriate fixation techniques (tackers or transfascial sutures)
   • Avoid placing tackers near vital structures 1

6. Diastasis Recti Repair:

   • Address the diastasis recti component by incorporating it into the repair
   • Consider midline plication of the rectus muscles when possible 4

Special Considerations for Combined Defects

• Multi-focal Hernias Along Incision:

  • Ensure all defects are identified and included in the repair
  • A single large mesh is preferable to multiple smaller pieces

• Diastasis Recti Component:

  • The presence of diastasis recti significantly increases recurrence risk if not properly addressed 3
  • Consider a retromuscular or sublay approach if technically feasible 4

Postoperative Management

1. Pain Management:

   • Implement multimodal analgesia
   • Acetaminophen 500-1000 mg every 6 hours as first-line treatment 2
   • Add tramadol 50-100 mg every 6-8 hours if needed 2
   • Consider gabapentinoids for neuropathic pain components 2

2. Monitoring:

   • Observe for at least 24 hours post-surgery
   • Monitor for surgical site complications, hemodynamic stability, and respiratory function 2

3. Follow-up:

   • Schedule regular follow-ups to monitor for recurrence
   • CT scan if pain persists beyond 1 month 2

Potential Complications

• Wound infection (4-12%)
• Seroma formation
• Mesh-related complications
• Recurrence (approximately 10.6-12.3% with mesh repair vs. 17.1% without mesh) 2

Key Pitfalls to Avoid

1. Inadequate Mesh Overlap: Ensure at least 1.5-2.5 cm overlap beyond all defect margins to prevent recurrence 1

2. Ignoring Diastasis Recti: Failing to address diastasis recti can lead to recurrence rates as high as 31.2% 3

3. Improper Mesh Selection: Using non-physiologic mesh in contaminated fields increases infection risk 1

4. Excessive Tension: Avoid primary closure under tension, especially with larger defects (>3 cm) 1

5. Inadequate Fixation: Poor mesh fixation can lead to mesh migration and hernia recurrence 1

By following this approach, the multi-focal umbilical hernia with diastasis recti can be effectively managed using physiologic mesh in an IPOM approach, minimizing recurrence risk while optimizing functional outcomes.