Types of Abdominal Wall Repair
For patients with a history of abdominal surgery or trauma, abdominal wall repair is stratified by wound contamination status and defect size, with synthetic mesh repair being the gold standard for clean fields, while biological mesh or primary repair is reserved for contaminated/dirty wounds.
Repair Classification by Wound Status
Clean Surgical Fields (CDC Class I)
Prosthetic repair with synthetic mesh is the first-line treatment for all abdominal wall hernias in clean surgical fields, demonstrating significantly lower recurrence rates (0% vs 19% with tissue repair) without increased infection risk 1, 2.
For defects <3 cm, primary repair with non-absorbable sutures can be attempted when tension-free closure is achievable 1, 3, 4.
For larger defects (>3 cm or >20 cm²), synthetic mesh reinforcement is mandatory with a minimum overlap of 1.5-2.5 cm beyond the defect edge 1, 3.
Clean-Contaminated Fields (CDC Class II)
Synthetic mesh repair can be safely performed in patients with intestinal strangulation and/or bowel resection without gross enteric spillage, showing significantly lower recurrence rates without increased 30-day wound-related morbidity 1.
48-hour antimicrobial prophylaxis is required for this wound class 1, 3.
Contaminated/Dirty Fields (CDC Class III-IV)
For stable patients with bowel necrosis, gross enteric spillage, or peritonitis, primary repair is recommended when defect size is small (<3 cm) 1.
When direct suture is not feasible, biological mesh (cross-linked or non-cross-linked depending on defect size and contamination degree) should be used 1.
If biological mesh is unavailable, polyglactin mesh repair or open wound management with delayed repair are viable alternatives 1.
For unstable patients with severe sepsis or septic shock, open management is mandatory to prevent abdominal compartment syndrome, with intra-abdominal pressure monitoring intraoperatively 1.
Surgical Approach Selection
Laparoscopic/Minimally Invasive Approach
Laparoscopic repair (TEP or TAPP) is the preferred approach for uncomplicated hernias in stable patients, offering faster recovery, reduced postoperative pain, significantly lower wound infection rates (P<0.018), and in-hospital mortality of 0.14% 1, 2, 4.
Laparoscopic approaches allow identification of occult contralateral hernias present in 11.2-50% of cases 1, 2, 4.
Repair of incarcerated hernias may be performed laparoscopically in the absence of strangulation and suspicion of bowel resection need 1.
Mesh should be fixed using tackers or transfascial sutures, but tackers must be avoided near the pericardium due to cardiac complication risk 1, 3.
Open Approach
Open anterior approach (Lichtenstein technique) is the most extensively evaluated mesh repair method, particularly advantageous in elderly patients and those with significant comorbidities 2.
For unstable patients or those with signs of strangulation/perforation, primary abdominal approach through laparotomy is required 1, 3.
Open preperitoneal approach is preferable when bowel resection is suspected 1.
Component Separation Technique
Component separation is a useful and low-cost option for large midline abdominal wall hernias, sometimes combined with mesh reinforcement 1, 5.
This technique enables fascial closure at midline with innervated abdominal musculature, providing good functional outcomes 5.
Anesthesia Selection
Local anesthesia should be used for open repair in the absence of bowel gangrene, providing effective anesthesia with fewer postoperative complications, shorter hospital stay (P=0.001), lower cost (P=0.000), and faster recovery time (P=0.000) compared to general anesthesia 1, 2, 4.
General anesthesia is mandatory when bowel gangrene is suspected, intestinal resection is needed, or peritonitis is present 1.
Critical Technical Considerations
Mesh Overlap Requirements
Mesh must overlap the defect edge by at least 4 cm to significantly reduce recurrence risk, with overlap ≥4 cm serving as a protective factor 6.
For defects >8 cm or area >20 cm², mesh interposition is required when tension-free primary closure is difficult 1, 3.
Fixation Methods
Non-absorbable fixing devices are mandatory, as absorbable devices represent a significant risk factor for recurrence (odds ratio: 9.06, P<0.001) 6.
Avoid plug repair techniques due to higher erosion incidence compared to flat mesh 2, 4.
Emergency Presentations
Immediate surgical intervention is mandatory when intestinal strangulation is suspected, as delayed diagnosis (>24 hours) is associated with significantly higher mortality rates 1, 2, 4.
SIRS criteria, elevated lactate, CPK, D-dimer levels, and contrast-enhanced CT findings predict bowel strangulation 1, 4.
Diagnostic laparoscopy is useful for assessing bowel viability after spontaneous reduction of strangulated hernias 1.
Damage Control Surgery
In critical patients with severely injured abdominal organs, damage control surgery with open abdomen management is life-saving 1.
Following stabilization, early definitive closure should be attempted when risk of excessive tension or recurrent intra-abdominal hypertension is minimal 1.
When early fascial closure is impossible, progressive closure can be attempted at each surgical revision, with cross-linked biological meshes considered for delayed reconstruction 1.
When definitive fascial closure cannot be achieved, skin-only closure is viable with subsequent eventration managed later using delayed abdominal closure and synthetic mesh repair 1.
Common Pitfalls to Avoid
Inadequate mesh overlap (<4 cm) significantly increases recurrence risk 3, 6.
Using absorbable fixation devices increases recurrence risk 9-fold 6.
Failing to inspect the contralateral side during TAPP misses occult hernias in up to 50% of cases 2, 4.
Delaying surgery in strangulated hernias beyond 24 hours dramatically increases mortality 2, 4.
Placing tackers near the pericardium risks cardiac complications 1, 3.