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Controversies and Techniques in the Repair of Abdominal Wall Hernias

Journal of Gastrointestinal Surgery volume 23, pages 837–845 (2019)Cite this article

Abstract

Abdominal wall hernia repair is one of the most common operations done by general surgeons today. Patients with incisional hernias can be extremely challenging to manage due to a number of factors that include obesity, prior hernia repairs, previous mesh placement, loss of domain, and other variables. The approach to patients with incisional hernias has evolved considerably over the last 20 years due to both advances in mesh technology and surgical approaches. Key factors in a successful outcome include modification of risk factors prior to surgery such as smoking cessation and weight reduction, selection of mesh appropriate to the hernia type and planned location of the mesh, and broad overlap of mesh beyond the margins of the hernia defect. Newer techniques such as transabdominis release and component separation with retrorectus mesh placement and robotic approaches to abdominal wall hernia are being increasingly utilized in these patients. This article reviews these aspects of abdominal wall hernia repair with a discussion of recent results and the importance of quality improvement and monitoring of outcomes.

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Author information

Affiliations

  1. Department of Surgery, Section of Minimally Invasive Surgery, Washington University School of Medicine, 660 S Euclid Ave., Box 8109, St. Louis, MO, 63110, USA

    Jeffrey A. Blatnik & L. Michael Brunt

Authors
  1. Jeffrey A. Blatnik
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  2. L. Michael Brunt
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Corresponding author

Correspondence to L. Michael Brunt.

Additional information

CME Questions

1. Which of the following is an advantage of a robotic approach to laparoscopic inguinal hernia repair over conventional laparoscopic techniques?

a. Lower hernia recurrence rates

b. Less postoperative pain

c. Fewer complications

d. Enhanced ability to suture mesh

2. A 56 year old male with a BMI of 35 presents with a large incisional hernia from a midline laparotomy for a left colon resection 5 years previously. The hernia is cantaloupe size and on CT contains multiple loops of small intestine and the rectus muscles are separated by a distance of 7cm. The most suitable approach for management of this patient is?

a. Laparoscopic incisional hernia repair with barrier coated mesh

b. Open incisional hernia repair with onlay mesh

c. Open incisional hernia repair retrorectus approach with transversus abdominis release and permanent synthetic mesh placement

d. Open incisional hernia repair retrorectus approach with transversus abdominis release and biologic mesh

3. Which of the following mesh choices would not be appropriate for a sublay repair with intraperitoneal mesh placement for an incisional hernia?

a. Barrier coated synthetic mesh

b. Uncoated polypropylene mesh

c. PTFE mesh

d. Composite mesh

4. Which of the following factors is most likely to be associated with increased complications after incisional hernia repair.

a. Well controlled diabetes

b. Obese patient with BMI 31

c. Moderate alcohol use

d. Currently smoking

5. Which of the following is an advantage of laparoscopic incisional hernia repair over open repair for a patient with a moderate sized periumbilical incisional hernia?

a. Reduced risk of infection

b. Less prolonged procedure site pain

c. Lower rate of seroma formation

d. Achieves a more functional abdominal wall

6. The precise location of the mesh in a retrorectus incisional hernia repair is which of the following?

a. Intraperitoneal

b. Preperitoneal deep to the posterior rectus sheath

c. Anterior to the posterior rectus sheath and completely covered by the rectus muscle

d. Superficial to the anterior rectus sheath

7. Which of the following meshes could be considered in repair of a large incisional hernia in the setting of an accompanying enterocutaneous fistula?

a. PTFE mesh

b. Heavyweight polypropylene mesh

c. Polyester mesh

d. Lightweight polypropylene mesh

8. Which of the following databases currently captures surgeon and patient reported outcomes for abdominal wall hernia repair?

a. ACS-NSQIP

b. Nationwide Inpatient Sample

c. AHSQC

d. Vizient

CME questions for this article are available to SSAT members at http://ssat.com/jogscme/

Learning Objectives:

1. Discuss different surgical options for repair of abdominal wall hernias and the role of modifiable risk factors for surgery.

2. Review the various mesh options available for abdominal wall hernia repair.

3. Identify newer methods for abdominal wall reconstruction that includes transverse abdominus release and robotic retrorectus repair.

Disclosure Information

Authors: L. Michael Brunt, MD has nothing to disclose; Jeffrey A. Blatnik, MD has nothing to disclose. Editors-in-Chief: Richard A. Hodin, MD, Timothy M. Pawlik, MD, MPH, PhD has nothing to disclose. CME Overseers: Arbiter: Timothy M. Pawlik, MD, MPH, PhD has nothing to disclose; Vice Arbiter: Melanie Morris, MD, has nothing to disclose; Question Reviewers: Melanie Morris, MD has nothing to disclose; Luca Stocchi, MD, has nothing to disclose.

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Blatnik, J.A., Michael Brunt, L. Controversies and Techniques in the Repair of Abdominal Wall Hernias. J Gastrointest Surg 23, 837–845 (2019). https://doi.org/10.1007/s11605-018-3989-1

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  • DOI: https://doi.org/10.1007/s11605-018-3989-1

Keywords

  • Abdominal wall hernia
  • Mesh
  • Component separation