Ventral Hernia Repair: Surgical Management and Techniques
Ventral hernia repair is a surgical procedure to fix a defect in the abdominal wall, which can be performed through open or laparoscopic approaches, with mesh reinforcement being the standard of care to reduce recurrence rates. 1
Definition and Types
- A ventral hernia is a protrusion of intra-abdominal contents through a defect in the anterior abdominal wall, which may be primary (occurring spontaneously) or incisional (occurring at the site of previous surgical incision) 2
- Repair techniques include open repair with mesh, laparoscopic repair, and component separation techniques for larger defects 3
Surgical Approaches
Open Repair
- Traditional approach involving direct visualization of the hernia defect through an incision over the hernia site 2
- Mesh is typically placed in one of several positions:
- Onlay (above the fascia)
- Inlay (within the defect)
- Sublay (below the fascia but above the peritoneum)
- Intraperitoneal (inside the peritoneal cavity) 3
- Primary suture repair without mesh is associated with high recurrence rates and is generally not recommended except for very small defects 2
Laparoscopic Repair
- Minimally invasive approach using small incisions and specialized instruments 4
- Advantages include:
- Typically involves intraperitoneal onlay mesh (IPOM) placement with mesh fixation using tacks, sutures, or a combination 3
- Best suited for hernias without strangulation or when bowel resection is not anticipated 5
Mesh Options
Synthetic Mesh
- Standard option for clean surgical fields 1
- Associated with lower recurrence rates (3.2%) compared to biological meshes (27.2%) in contaminated fields 5
- Can be safely used in emergency ventral hernia repair without increased wound-related complications or 30-day morbidity 5
Biological Mesh
- Considered in contaminated or infected fields 5
- Higher recurrence rates but may be necessary in specific situations 5
- Factors associated with recurrence include BMI, defect size, and number of biological meshes used 5
Special Techniques
Component Separation
- Technique to reduce tension in the suture line for large defects 3
- Includes various approaches:
- Anterior component separation (Ramirez technique)
- Posterior component separation (transversus abdominis release)
- Endoscopic component separation 3
Management in Contaminated Fields
- For small defects (<3 cm) with bowel necrosis or peritonitis, primary repair may be considered 1
- When direct suture is not feasible, biological mesh may be used 1
- If biological mesh is unavailable, polyglactin mesh or open wound management with delayed repair are alternatives 1
Outcomes and Complications
Recurrence
- Recurrence rates increase with each subsequent repair, creating a cycle of complications 6
- At 140 months follow-up, 37% of primary ventral hernias and 64% of incisional hernias recur 6
- After third repair, recurrence rates can reach 73% 6
Other Complications
- Surgical site infections (SSI) are more common with open repairs 4
- Risk factors for wound complications include high ASA score, smoking, diabetes, immunosuppression, previous hernia repair, and dirty surgical field 5
- Intraoperative enterotomy (bowel injury) is a risk, particularly with laparoscopic approaches 4
Special Considerations
- For unstable patients with severe sepsis or septic shock, open management is recommended to prevent abdominal compartment syndrome 5
- Intra-abdominal pressure may be measured intraoperatively to assess clinical severity and guide management 5
- Early definitive fascial closure should be attempted when possible; when not feasible, progressive closure can be gradually attempted 1
Emerging Techniques
- Newer minimally invasive approaches include eTEP, MILOS/eMILOS, TAPP, and various hybrid techniques that aim to reduce complications while maintaining the benefits of minimally invasive surgery 3