What is the best course of treatment for a patient with a ventral hernia, considering their medical history and symptoms?

Management of Ventral Hernias

Emergency vs. Elective Repair Decision

Patients with suspected intestinal strangulation require immediate emergency hernia repair 1. The timing of intervention is the most critical initial decision that directly impacts mortality and morbidity.

Indicators for Emergency Surgery

• Immediate repair is mandatory when:
  • Intestinal strangulation is suspected based on clinical examination 1
  • Systemic inflammatory response syndrome (SIRS) is present 1
  • Elevated lactate, CPK, or D-dimer levels suggest bowel compromise 1
  • Contrast-enhanced CT shows signs of bowel strangulation 1
  • Elevated white blood cell count with fibrinogen elevation (independently predictive of strangulation and associated with higher morbidity) 1

Elective Repair Indications

• Symptomatic ventral hernias causing discomfort should undergo elective repair to prevent life-threatening complications of incarceration and strangulation, which carry significantly higher mortality risk in emergency settings 2
• Asymptomatic hernias may be observed, but patients must be educated to recognize warning signs requiring immediate surgical attention 2

Surgical Approach Selection

Laparoscopic repair is the preferred approach for ventral hernias in stable patients without signs of strangulation or need for bowel resection 1, 3. This represents the gold standard with superior outcomes.

Laparoscopic Approach

• Indicated for:

  • Incarcerated hernias (both ventral and groin) without strangulation 1
  • No suspicion of bowel resection requirement 1
  • Clean surgical fields (CDC Class I) 1
  • Defects between 5-15 cm diameter 4
  • "Swiss cheese" multiple defects 4
  • Obese patients 4

• Benefits include:

  • Lower wound infection rates compared to open repair 1
  • Shorter hospital stays 3
  • Excellent safety profile with 0.14% in-hospital mortality 3
  • No higher recurrence rates versus open approach 1

Open Preperitoneal Approach

• Preferred when:
  • Strangulation is present or suspected 1
  • Bowel resection is anticipated 1
  • Patient is unstable with severe sepsis or septic shock 1

Mesh Selection Based on Wound Classification

Clean Fields (CDC Class I)

Synthetic mesh repair is strongly recommended for all ventral hernia repairs in clean surgical fields 1, 5. This provides the lowest recurrence rates without increasing infection risk.

• Prosthetic repair with synthetic mesh is indicated for intestinal incarceration without signs of strangulation or bowel resection 1
• Mesh reinforcement decreases hernia recurrence (number needed to treat = 7.9) but slightly increases SSI risk (number needed to harm = 27.8) 5
• Sublay (retromuscular) position is preferred as it may decrease both recurrence and SSI compared to onlay or underlay placement 5, 4

Clean-Contaminated Fields (CDC Class II)

Synthetic mesh can be safely used in patients with intestinal strangulation and/or bowel resection without gross enteric spillage 1. This approach significantly lowers recurrence risk without increasing 30-day wound-related morbidity 1.

Contaminated Fields (CDC Class III) and Dirty Fields (CDC Class IV)

Primary repair is recommended when defect size is small (<3 cm); biological mesh should be used when direct suture is not feasible 1.

• Cross-linked biological meshes have the lowest failure rates in contaminated and infected fields 1
• Biosynthetic, biologic, or composite meshes are preferred due to lower recurrence rates and higher infection resistance 3
• If biological mesh is unavailable, polyglactin mesh repair or open wound management with delayed repair are viable alternatives 1
• Critical caveat: Biological mesh use shows wound infection rates of approximately 30% and recurrence rates of 27% at 27-month follow-up, with dirty surgical fields being an independent risk factor 1

Technical Considerations for Mesh Placement

Mesh Overlap Requirements

Mesh must overlap defect edges by at least 5 cm to minimize recurrence risk 4. This is a critical technical factor.

• Overlap of <5 cm is independently associated with higher recurrence rates 4
• Mesh should overlap by 1.5-2.5 cm minimum per guidelines, though clinical data suggests 5 cm is optimal 3, 4
• Use interrupted non-absorbable sutures (2-0 or 1-0 monofilament) in two layers for primary crural closure 3

Risk Factors for Recurrence

Defect size >5 cm, BMI ≥30 kg/m², mesh overlap <5 cm, and ASA score ≥3 are independent predictors of recurrence 4.

• Primary repair alone has a 42% recurrence rate 3
• At 140 months follow-up, 37% of primary ventral hernias and 64% of incisional hernias recur 6
• Each subsequent repair increases complication rates, creating a vicious cycle—IHR3 (third-time repairs) have 73% recurrence rates 6

Special Populations

Giant Ventral Hernias

Giant ventral hernias are defined as defects >10 cm with loss of domain (hernia volume >30% of abdominal volume) 7.

• Require preoperative CT scan (98% consensus), functional respiratory testing (71%), and cardiology consultation (50%) 7
• Respiratory and cutaneous preparations should be performed preoperatively (91% and 56% respectively) 7
• Non-resorbable mesh in retromuscular position is used by 71% of surgeons for these cases 7

Unstable Patients

Open management is mandatory for unstable patients with severe sepsis or septic shock to prevent abdominal compartment syndrome 1.

• Intra-abdominal pressure should be measured intraoperatively 1
• Following stabilization, attempt early definitive closure only when risk of excessive tension or recurrent intra-abdominal hypertension is minimal 1

Anesthesia Considerations

Local anesthesia can be safely used for emergency inguinal hernia repair in stable patients and provides less cardiac complications, fewer respiratory complications, shorter ICU and hospital stays, lower costs, and faster recovery compared to general anesthesia 1.

• General anesthesia is mandatory when bowel gangrene is suspected, intestinal resection is needed, or peritonitis is present 1
• Transversus abdominis plane (TAP) block reduces postoperative pain and shortens hospital stay (mean 2 days vs. 5 days) 4

Preoperative Optimization

All patients should undergo medical optimization before elective surgery to minimize perioperative risk 2, 8.

• Optimizing patient-related risk factors (obesity, diabetes, smoking, immunosuppression) is essential to decrease complication rates 1, 8
• Previous hernia repair, high ASA score, smoking, diabetes, and chronic immunosuppression are independently associated with wound complications 1

Critical Pitfalls to Avoid

• Never use mesh in dirty fields with unstable patients—this leads to catastrophic complications 1
• **Never accept <5 cm mesh overlap** in defects >5 cm—this dramatically increases recurrence 4
• Never delay emergency repair when strangulation is suspected—mortality increases exponentially with delay 1
• Never place mesh in onlay position when sublay is feasible—this increases both infection and recurrence rates 5