What is the recommended treatment for a complex abdominal hernia?

Treatment of Complex Abdominal Hernias

Emergency surgical repair is the recommended treatment for complex abdominal hernias, with the specific approach determined by the degree of contamination and presence of intestinal strangulation. 1

Timing of Intervention

• Patients should undergo emergency hernia repair immediately when intestinal strangulation is suspected (grade 1C recommendation) 1
• Systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, as well as elevated lactate, CPK, and D-dimer levels are predictive of bowel strangulation and should guide urgency of intervention 1, 2

Surgical Approach Based on CDC Wound Classification

Clean Surgical Fields (CDC Class I)

• Prosthetic repair with synthetic mesh is strongly recommended for patients with intestinal incarceration and no signs of strangulation or concurrent bowel resection 1, 3
• Mesh repair is associated with significantly lower recurrence rates compared to tissue repair without increasing wound infection rates 3, 4
• Repair may be performed laparoscopically in the absence of strangulation when bowel resection is not anticipated 1, 5

Clean-Contaminated Fields (CDC Class II)

• For patients with intestinal strangulation and/or concomitant need of bowel resection without gross enteric spillage, emergent prosthetic repair with synthetic mesh is recommended 1, 2
• This approach is associated with a significantly lower risk of recurrence regardless of hernia defect size 1, 3

Contaminated/Dirty Fields (CDC Classes III/IV)

• For stable patients with strangulated hernia with bowel necrosis and/or gross enteric spillage during intestinal resection, or peritonitis from bowel perforation:
  • Primary repair is recommended when the defect is small (<3 cm) 1, 3
  • When direct suture is not feasible, a biological mesh may be used 1
  • If biological mesh is unavailable, polyglactin mesh repair or open wound management with delayed repair are viable alternatives 1

Unstable Patients

• Open management is recommended to prevent abdominal compartment syndrome 1
• Intra-abdominal pressure should be measured intraoperatively 1
• Following stabilization, early definitive closure of the abdomen should be attempted 1
• When early definitive fascial closure is not possible, progressive closure can be gradually attempted at surgical wound revisions 1
• When definitive fascial closure cannot be achieved, a skin-only closure is viable with subsequent eventration managed later with delayed closure and synthetic mesh repair 1

Special Techniques

• Component separation technique may be useful for large midline abdominal wall hernias (grade 1B recommendation) 1, 2
• Diagnostic laparoscopy may be useful for assessing bowel viability after spontaneous reduction of strangulated groin hernias 1, 5
• For parastomal hernias, laparoscopic repair with ePTFE mesh shows promising results with low recurrence rates 6

Antimicrobial Prophylaxis

• For intestinal incarceration without ischemia (CDC class I): short-term prophylaxis 1, 2
• For intestinal strangulation and/or concurrent bowel resection (CDC classes II and III): 48-hour antimicrobial prophylaxis 1, 2
• For peritonitis (CDC class IV): full antimicrobial therapy 1

Anesthesia Considerations

• Local anesthesia can be used for emergency inguinal hernia repair when bowel gangrene is absent, providing effective anesthesia with fewer postoperative complications 1, 2
• General anesthesia should be preferred when bowel gangrene is suspected, intestinal resection is needed, or in cases of peritonitis 1, 2

Outcomes and Complications

• Emergency hernia repairs are associated with higher rates of post-operative complications and longer hospital stays compared to elective repairs 7
• While mesh repairs have lower recurrence rates, they may have higher incidence of post-operative complications in emergency settings 7, 4
• Common complications include wound dehiscence, post-operative collections, delayed recovery, and recurrence 7
• Mortality risk increases with strangulation, especially in elderly patients or those with comorbidities 7, 8

Pitfalls and Caveats

• Delayed diagnosis of strangulated hernias can result in bowel necrosis requiring resection, significantly increasing morbidity and mortality 1, 9
• Fistulization into the abdominal wall is a rare but serious complication of incarcerated hernias that requires staged repair 9
• In morbidly obese patients, complex abdominal wall reconstruction may be necessary following emergent surgery for complicated hernias 9
• Elective repair of abdominal wall hernias should be considered to prevent emergency presentations and their associated complications 7