Surgical Repair Options for Ventral Wall Hernia
Primary Recommendation
Prosthetic mesh repair is the definitive treatment for ventral wall hernias, with synthetic mesh strongly recommended in clean surgical fields (CDC wound class I) due to significantly lower recurrence rates compared to tissue repair, without increasing infection risk. 1
Surgical Approach Selection Algorithm
For Uncomplicated/Elective Ventral Hernias
Laparoscopic approach is preferred for stable patients with reducible ventral hernias, offering significantly lower postoperative pain, fewer wound complications, shorter hospital stays (2.91 vs 4.70 days), and comparable recurrence rates to open repair. 2, 3
- Minimally invasive techniques (laparoscopic or robotic eTEP) allow placement of larger meshes compared to open approaches without increasing morbidity, despite longer operative times (72 vs 59 minutes). 2, 3
- Laparoscopic repair demonstrates a 3.4% recurrence rate with mean hospital stay of 1.8 days and 13% complication rate in large series. 4
- Robotic eTEP provides lower pain scores at discharge compared to open Rives-Stoppa technique, with no difference in hospital stay or complications. 3
For Incarcerated Ventral Hernias (Without Strangulation)
Laparoscopic repair can be safely performed in incarcerated ventral hernias when there are no signs of strangulation or need for bowel resection. 1, 5
- Success rate of 91.9% for laparoscopic completion in incarcerated hernias, with mean hospital stay of 2.8 days and 20.5% complication rate. 5
- Diagnostic laparoscopy may be useful to assess bowel viability after spontaneous reduction of incarcerated hernias. 1
- Key technical factors include careful bowel reduction with adhesiolysis and mesh placement with 5-cm overlap in uncontaminated abdomen. 5
For Emergency/Complicated Hernias
Immediate emergency repair is mandatory when intestinal strangulation is suspected, with approach determined by CDC wound classification. 1
Repair Technique Based on CDC Wound Classification
Clean Surgical Field (CDC Class I)
Prosthetic repair with synthetic mesh is strongly recommended (Grade 1A) for patients with intestinal incarceration but no signs of strangulation or concurrent bowel resection. 1
- Synthetic mesh is associated with significantly lower recurrence rates (0% vs 19% with tissue repair) without increased wound infection risk. 1
- Mesh overlap of at least 5 cm is critical for successful outcomes. 5
Clean-Contaminated Field (CDC Class II)
Emergent prosthetic repair with synthetic mesh can be performed (Grade 1A) even with intestinal strangulation and/or concomitant bowel resection without gross enteric spillage, associated with significantly lower recurrence risk regardless of hernia defect size. 1
- No significant increase in 30-day wound-related morbidity compared to non-mesh repair. 1
- 48-hour antimicrobial prophylaxis is recommended for intestinal strangulation and/or concurrent bowel resection. 1
Contaminated Field (CDC Class III) or Dirty Field (CDC Class IV)
Primary tissue repair is recommended when defect size is small (<3 cm). 1
- When direct suture is not feasible, biological mesh may be used for repair. 1
- Choice between cross-linked and non-cross-linked biological mesh depends on defect size and degree of contamination. 1
- If biological mesh unavailable, polyglactin mesh repair or open wound management with delayed repair are viable alternatives. 1
Specific Repair Techniques
Open Sublay Repair (Rives-Stoppa Technique)
Effective for ventral hernias with shorter operative time (58.79 vs 72.11 minutes) but higher postoperative pain and longer hospital stay compared to laparoscopic approach. 2
- Recurrence rate of 8% in some series, with higher wound complication rates. 2
- Appropriate for defects >5 cm where mesh is recommended by 90% of surgeons for incisional hernias. 6
Laparoscopic Sublay/eTEP Repair
Preferred minimally invasive technique offering lower postoperative pain (VAS 5.15 vs 7.91 on Day 1), shorter hospitalization (2.91 vs 4.70 days), and fewer complications (4% vs 8%). 2
- Zero recurrence in some comparative series at 6-month follow-up. 2
- Allows placement of larger meshes (mean 379 cm² with range 225-780 cm²) compared to open approach. 3, 5
Component Separation Technique
Useful and low-cost option (Grade 1B) for repair of large midline abdominal wall hernias when primary fascial closure is not possible. 1
Management of Unstable Patients
Open management is recommended for unstable patients experiencing severe sepsis or septic shock to prevent abdominal compartment syndrome. 1
- Intra-abdominal pressure may be measured intraoperatively. 1
- Early definitive closure should be attempted following patient stabilization. 1
- When early fascial closure not possible, progressive closure can be gradually attempted at every surgical wound revision. 1
- Skin-only closure is viable when definitive fascial closure cannot be achieved, with subsequent eventration managed later with delayed abdominal closure and synthetic mesh repair. 1
Defect Size-Based Recommendations
Small Defects (<2 cm)
Suture repair is significantly more likely to be used by surgeons for all ventral hernias with defects <2 cm. 6
Medium Defects (2-5 cm)
Opinion divided between suture and mesh repair, with no consensus among practicing surgeons. 6
Large Defects (>5 cm)
Mesh repair recommended by 90% of surgeons for incisional hernias, 81% for epigastric hernias, and 76% for para-umbilical hernias. 6
Critical Technical Considerations
Mesh Fixation
Adequate mesh overlap of at least 5 cm is critical for preventing recurrence. 5
- Combination of sutures and staples is recommended; using stapling device alone was associated with higher recurrence (6 of 14 recurrences occurred when only staples used). 4
Bowel Management
Careful assessment of bowel viability is essential before mesh placement in incarcerated hernias. 5
- Inadvertent enterotomy occurs in approximately 3.6% of cases during bowel reduction and adhesiolysis. 5
- Limited conversion may be required for resection of nonviable bowel (occurred in 2.7% of cases). 5
Antimicrobial Prophylaxis
Short-term prophylaxis recommended for patients with intestinal incarceration with no evidence of ischemia and no bowel resection (CDC wound class I). 1
48-hour antimicrobial prophylaxis recommended for patients with intestinal strangulation and/or concurrent bowel resection (CDC wound class II). 1
Full antimicrobial therapy required for patients with peritonitis from bowel perforation (CDC wound class IV). 1
Common Pitfalls to Avoid
Inadequate mesh overlap (<5 cm) significantly increases recurrence risk. 5
Using staples alone for mesh fixation without sutures is associated with higher recurrence rates. 4
Delaying repair of strangulated hernias leads to bowel necrosis and increased morbidity/mortality. 1
Attempting laparoscopic repair when strangulation is suspected or bowel resection anticipated; open preperitoneal approach is preferable in these scenarios. 1
Placing mesh in contaminated fields (CDC class III/IV) with large defects increases infection risk; biological mesh or delayed repair preferred. 1