What is the best approach for repairing a large abdominal wall hernia in a patient with potential underlying medical conditions such as diabetes (Diabetes Mellitus) or hypertension (High Blood Pressure)?

Repair of Large Abdominal Wall Hernias

For large abdominal wall hernias, laparoscopic repair with synthetic mesh placement is the preferred approach in stable patients with clean surgical fields, offering superior outcomes including lower recurrence rates, reduced postoperative pain, shorter hospital stays, and fewer wound complications compared to open repair. 1, 2, 3

Defining "Large" Hernias and Initial Assessment

• Large hernias are typically defined as defects >5 cm in diameter or >20 cm² in area, requiring mesh interposition rather than simple primary repair 1
• Assess for signs of incarceration or strangulation: SIRS criteria, elevated lactate, CPK, D-dimer levels, and contrast-enhanced CT findings indicating bowel wall ischemia mandate immediate surgery 4
• Classify the surgical field using CDC wound classification, as this directly determines mesh selection and surgical approach 1

Surgical Approach Algorithm

For Uncomplicated Large Hernias (Clean Field - CDC Class I)

Laparoscopic repair is the first-line approach when surgical expertise is available:

• Laparoscopic intraperitoneal onlay mesh (IPOM) or sublay techniques demonstrate significantly shorter hospital stays (2.7 vs 4.7 days), lower pain scores at 72 hours, fewer complications (24% vs 30%), and lower recurrence rates (2% vs 10%) compared to open repair 2, 3
• Synthetic mesh is mandatory for defects >3 cm to avoid the 42% recurrence rate associated with primary suture repair 1, 5
• Mesh must overlap the defect edge by at least 1.5-2.5 cm on all sides to prevent recurrence 1, 5
• Mean operative time for laparoscopic repair is comparable to open repair (approximately 54-90 minutes) 6, 3

For Complicated Hernias with Incarceration (Clean-Contaminated Field - CDC Class II)

• Emergent prosthetic repair with synthetic mesh can still be performed even with intestinal strangulation and/or concomitant bowel resection without gross enteric spillage, and is associated with significantly lower recurrence risk regardless of hernia defect size 1
• Laparoscopic approach is appropriate for incarcerated hernias without strangulation when there is no suspicion of bowel necrosis 1, 4
• Open preperitoneal approach is preferable when strangulation is suspected or bowel resection may be needed 1, 4

For Contaminated/Dirty Fields (CDC Class III-IV)

• For stable patients with small defects (<3 cm) and bowel necrosis or peritonitis, primary repair is recommended 1
• When direct suture is not feasible, biological mesh should be used, with choice between cross-linked and non-cross-linked depending on defect size and contamination degree 1
• If biological mesh is unavailable, polyglactin mesh repair or open wound management with delayed repair are viable alternatives 1

Component Separation Technique for Very Large Defects

• The component separation technique is a useful and cost-effective option for large midline abdominal wall hernias, particularly when defects are >8 cm or primary closure would create excessive tension 1
• This technique reduces tension in the suture line and allows for tension-free closure in defects that would otherwise be impossible to repair primarily 7

Special Considerations for Patients with Diabetes and Hypertension

Diabetes Management

• Optimize glycemic control preoperatively to reduce infection risk, as synthetic mesh in clean-contaminated fields shows no increased 30-day wound-related morbidity when properly managed 1
• Short-term antimicrobial prophylaxis is recommended for uncomplicated hernias; 48-hour prophylaxis for intestinal strangulation or bowel resection 1, 4

Hypertension Considerations

• Laparoscopic approach may be preferable as it avoids extensive tissue dissection and flap creation, reducing hemodynamic stress 3
• Local anesthesia can be used for open repair in select cases, providing effective anesthesia with fewer cardiac and respiratory complications 4

Technical Execution Principles

• For defects >5 cm, ensure mesh overlap of at least 5 cm to minimize recurrence risk, as overlap <5 cm is associated with higher recurrence rates 6
• Mesh can be fixed using tackers or transfascial sutures, but avoid tackers near vital structures 1, 5
• Consider preoperative transversus abdominis plane (TAP) block to reduce postoperative pain and shorten hospital stay (mean 2 days vs 5 days without block) 6

Risk Factors for Recurrence

• Defect size >5 cm, mesh overlap <5 cm, BMI ≥30 kg/m², and significant comorbidities (ASA score 3) are independent predictors of recurrence 6
• Patients with these risk factors require meticulous surgical technique with adequate mesh overlap and consideration of component separation techniques 6

Postoperative Management

• Encourage acetaminophen and NSAIDs as primary pain control, limiting opioid prescribing to minimize dependence risk 4
• Monitor for wound infection, seroma formation, and early signs of recurrence during follow-up 2, 6
• For unstable patients requiring open management, attempt early definitive fascial closure when risk of excessive tension or intra-abdominal hypertension is minimal 1

Critical Pitfalls to Avoid

• Delaying repair of strangulated hernias beyond 24 hours is associated with significantly higher mortality rates 4, 8
• Inadequate mesh overlap (<1.5-2.5 cm) dramatically increases recurrence risk 1, 5, 6
• Using primary suture repair for defects >3 cm results in unacceptably high recurrence rates (up to 42%) 1, 5
• Attempting laparoscopic repair when bowel resection is anticipated or active strangulation is present increases morbidity 4