Treatment of Ventral Hernia
Primary Recommendation
Surgical repair with mesh reinforcement is the definitive treatment for ventral hernias, with mesh placement significantly reducing recurrence rates compared to primary suture repair (number needed to treat = 7.9). 1
Treatment Algorithm Based on Clinical Presentation
Elective/Uncomplicated Ventral Hernias
Mesh repair is strongly recommended for all ventral hernia repairs in clean surgical fields, as it decreases hernia recurrence substantially while only modestly increasing surgical site infection risk (number needed to harm = 27.8). 1
Mesh Positioning Strategy:
- Sublay (retromuscular) mesh placement is preferred over onlay or underlay positions, as it may decrease both hernia recurrence and surgical site infection rates. 1
- Retromuscular polypropylene mesh repair is safe and feasible even in morbidly obese patients with massive ventral hernias (mean defect size 240 cm²). 2
Surgical Approach Options:
- Minimally invasive techniques are recommended when technically feasible, as they decrease surgical site infections and shorten hospital stay, though they are more technically demanding and take longer. 3
- Open repair remains appropriate for patients with significant comorbidities or when minimally invasive approach is not feasible. 3
Emergency/Complicated Ventral Hernias
Clean-Contaminated Field (CDC Class II):
- Prosthetic repair with synthetic mesh can be safely performed even with intestinal strangulation and/or bowel resection without gross enteric spillage, with significantly lower recurrence risk regardless of defect size. 4
Contaminated/Dirty Field (CDC Class III-IV):
For small defects (<3 cm):
- Primary repair is recommended when the defect is small. 4
For larger defects when primary suture is not feasible:
- Biological mesh is the preferred option in contaminated fields, though evidence shows pooled hernia recurrence rates of 27.2% with biological mesh versus 3.2% with synthetic non-absorbable mesh. 4
- The choice between cross-linked and non-cross-linked biological mesh should be based on defect size and degree of contamination—cross-linked meshes resist mechanical stress better and longer. 4
- If biological mesh is unavailable, polyglactin mesh repair or open wound management with delayed repair are viable alternatives. 4
Critical Pitfall:
- Emergency ventral hernia repair with mesh can be safely performed without increased 30-day morbidity or mortality even in CDC wound classes III and IV. 4
- For unstable patients with severe sepsis or septic shock, open management is recommended to prevent abdominal compartment syndrome, with intra-abdominal pressure monitoring intraoperatively. 4
Risk Factors Predicting Complications
Factors significantly associated with wound complications in emergency biological mesh repair include: 4
- High ASA score (≥3)
- Smoking
- Diabetes
- Chronic immunosuppression
- Previous hernia repair
- Dirty surgical field
- Sublay extra-peritoneal bio-prosthesis placement
- No anterior fascia closure
Laparoscopic Approach Considerations
Laparoscopic repair is appropriate for incarcerated ventral hernias in the absence of strangulation and when bowel resection is not anticipated. 4
Diagnostic laparoscopy may be useful to assess bowel viability after spontaneous reduction of incarcerated hernias. 4
Open pre-peritoneal approach is preferable when strangulation is suspected or bowel resection may be needed. 4
Watchful Waiting Option
For asymptomatic or minimally symptomatic patients with significant surgical risk, watchful waiting appears safe, with only 19% of incisional hernias and 16% of umbilical/epigastric hernias requiring later surgical repair after 5 years. 5
- The probability of requiring emergency repair when pursuing watchful waiting is only 4% after 5 years for both incisional and umbilical/epigastric hernias. 5
- This strategy should be reserved for patients where surgical risks outweigh benefits, as mesh repair remains the definitive treatment with superior long-term outcomes. 1
Key Technical Points
Preoperative optimization is critical to decrease complication rates, particularly addressing obesity, smoking, diabetes, and immunosuppression. 3
Mesh reinforcement should use at least 5-cm overlap in uncontaminated fields to predict successful clinical outcomes. 4
Component separation techniques may be useful for large midline abdominal wall hernias when primary fascial closure cannot be achieved. 6