Open Abdomen pp 237-246 | Cite as

Definitive Closure, Long-Term Results, and Management of Ventral Hernia

  • Leonard Frederik KroeseEmail author
  • Johannes Jeekel
  • Johan Frederik Lange
Part of the Hot Topics in Acute Care Surgery and Trauma book series (HTACST)


After treatment of open abdomen, large defects remain, often with loss of domain and without the possibility of tension-free closure. Loss of domain, in combination with other factors, increases the risk of complications after closure surgery.

To achieve definitive closure of the abdominal wall, advancement of the abdominal wall has to be performed with mesh placement. Possible techniques to gain advancement are Rives–Stoppa, anterior component separation (modified Ramirez), or posterior component separation (transverse abdominis release (TAR)).

When tension-free closure is still not possible, additional treatments like bridging with mesh, preoperative progressive pneumoperitoneum, and/or botulin toxin injections can be helpful.


  1. 1.
    de Vries Reilingh TS, Bodegom ME, van Goor H, Hartman EH, van der Wilt GJ, Bleichrodt RP. Autologous tissue repair of large abdominal wall defects. Br J Surg. 2007;94(7):791–803. doi: 10.1002/bjs.5817.CrossRefPubMedGoogle Scholar
  2. 2.
    Ramirez OM, Ruas E, Dellon AL. “Components separation” method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg. 1990;86(3):519–26.CrossRefPubMedGoogle Scholar
  3. 3.
    Shestak KC, Edington HJ, Johnson RR. The separation of anatomic components technique for the reconstruction of massive midline abdominal wall defects: anatomy, surgical technique, applications, and limitations revisited. Plast Reconstr Surg. 2000;105(2):731–8. quiz 739.CrossRefPubMedGoogle Scholar
  4. 4.
    Helgstrand F, Rosenberg J, Kehlet H, Jorgensen LN, Bisgaard T. Nationwide prospective study of outcomes after elective incisional hernia repair. J Am Coll Surg. 2013;216(2):217–28. doi:10.1016/j.jamcollsurg.2012.10.013 [pii] S1072-7515(12)01294-X.CrossRefPubMedGoogle Scholar
  5. 5.
    de Vries Reilingh TS, van Goor H, Charbon JA, Rosman C, Hesselink EJ, van der Wilt GJ, Bleichrodt RP. Repair of giant midline abdominal wall hernias: “components separation technique” versus prosthetic repair: interim analysis of a randomized controlled trial. World J Surg. 2007;31(4):756–63. doi: 10.1007/s00268-006-0502-x.CrossRefPubMedGoogle Scholar
  6. 6.
    Dragu A, Klein P, Unglaub F, Polykandriotis E, Kneser U, Hohenberger W, Horch RE. Tensiometry as a decision tool for abdominal wall reconstruction with component separation. World J Surg. 2009;33(6):1174–80. doi: 10.1007/s00268-009-9991-8.CrossRefPubMedGoogle Scholar
  7. 7.
    Borud LJ, Grunwaldt L, Janz B, Mun E, Slavin SA. Components separation combined with abdominal wall plication for repair of large abdominal wall hernias following bariatric surgery. Plast Reconstr Surg. 2007;119(6):1792–8. doi:10.1097/ 00006534-200705000-00024 [pii].CrossRefPubMedGoogle Scholar
  8. 8.
    Hesselink VJ, Luijendijk RW, de Wilt JH, Heide R, Jeekel J. An evaluation of risk factors in incisional hernia recurrence. Surg Gynecol Obstet. 1993;176(3):228–34.PubMedGoogle Scholar
  9. 9.
    Deerenberg EB, Timmermans L, Hogerzeil DP, Slieker JC, Eilers PH, Jeekel J, Lange JF. A systematic review of the surgical treatment of large incisional hernia. Hernia. 2015;19(1):89–101. doi: 10.1007/s10029-014-1321-x.CrossRefPubMedGoogle Scholar
  10. 10.
    Sabbagh C, Dumont F, Robert B, Badaoui R, Verhaeghe P, Regimbeau JM. Peritoneal volume is predictive of tension-free fascia closure of large incisional hernias with loss of domain: a prospective study. Hernia. 2011;15(5):559–65. doi: 10.1007/s10029-011-0832-y.CrossRefPubMedGoogle Scholar
  11. 11.
    Sanders DL, Kingsnorth AN. The modern management of incisional hernias. BMJ. 2012;344:e2843.CrossRefPubMedGoogle Scholar
  12. 12.
    Kingsnorth AN, Sivarajasingham N, Wong S, Butler M. Open mesh repair of incisional hernias with significant loss of domain. Ann R Coll Surg Engl. 2004;86(5):363–6. doi: 10.1308/147870804236.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Slater NJ, Montgomery A, Berrevoet F, Carbonell AM, Chang A, Franklin M, Kercher KW, Lammers BJ, Parra-Davilla E, Roll S, Towfigh S, van Geffen E, Conze J, van Goor H. Criteria for definition of a complex abdominal wall hernia. Hernia. 2014;18(1):7–17. doi: 10.1007/s10029-013-1168-6.CrossRefPubMedGoogle Scholar
  14. 14.
    Usher FC, Ochsner J, Tuttle LL Jr. Use of marlex mesh in the repair of incisional hernias. Am Surg. 1958;24(12):969–74.PubMedGoogle Scholar
  15. 15.
    Jin J, Rosen MJ. Laparoscopic versus open ventral hernia repair. Surg Clin North Am. 2008;88(5):1083–100. viii. doi:10.1016/j.suc. 2008.05.015 S0039-6109(08)00084-4 [pii].CrossRefPubMedGoogle Scholar
  16. 16.
    Klinge U, Conze J, Krones CJ, Schumpelick V. Incisional hernia: open techniques. World J Surg. 2005;29(8):1066–72. doi: 10.1007/s00268-005-7970-2.CrossRefPubMedGoogle Scholar
  17. 17.
    Stoppa R, Moungar F, Verhaeghe P. [Surgical treatment of supraumbilical eventrations] Traitement chirurgical des eventrations medianes sus-ombilicales. J Chir. 1992;129(6-7):335–43.Google Scholar
  18. 18.
    Rives J, Pire JC, Flament JB, Convers G. [Treatment of large eventrations (apropos of 133 cases)] Le traitement des grandes eventrations (a propos de 133 cas). Minerva Chir. 1977;32(11):749–56.PubMedGoogle Scholar
  19. 19.
    Louis D, Stoppa R, Henry X, Verhaeghe P. [Postoperative eventrations. Apropos of 247 surgically treated cases] Les eventrations post-operatoires (E.P.O.). A propos de 247 cas operes. J Chir. 1985;122(10):523–7.Google Scholar
  20. 20.
    Berry MF, Paisley S, Low DW, Rosato EF. Repair of large complex recurrent incisional hernias with retromuscular mesh and panniculectomy. Am J Surg. 2007;194(2):199–204. doi:10.1016/j.amjsurg.2006.10.031 S0002-9610(07)00304-2 [pii].CrossRefPubMedGoogle Scholar
  21. 21.
    Tonante A, Lo Schiavo MG, Bonanno L, D’Alia C, Taranto F, Gagliano E, Sturniolo G. [Complications of open prosthetic surgery for large incisional hernias] Le complicanze della chirurgia protesica “open” dei grandi laparoceli. Chir Ital. 2004;56(5):629–37.PubMedGoogle Scholar
  22. 22.
    Toniato A, Pagetta C, Bernante P, Piotto A, Pelizzo MR. Incisional hernia treatment with progressive pneumoperitoneum and retromuscular prosthetic hernioplasty. Langenbeck’s Arch Surg. 2002;387(5-6):246–8. doi: 10.1007/s00423-002-0316-8.CrossRefGoogle Scholar
  23. 23.
    Trivellini G, Bagni CM, Sollini A, Senni M, Leone S, Contessini Avesani E. Repair of giant hernias using more prosthesis. Hernia. 2001;5(3):124–8.CrossRefPubMedGoogle Scholar
  24. 24.
    Ladurner R, Chiapponi C, Linhuber Q, Mussack T. Long term outcome and quality of life after open incisional hernia repair--light versus heavy weight meshes. BMC Surg. 2011;11:25. doi:10.1186/1471-2482-11-25 1471-2482-11-25 [pii].CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Albanese AR. [Gigantic median xipho-umbilical eventration; method for treatment] Eventracion mediana xifoumbilical gigante; metodo para su tratamiento. Rev Asoc Med Argent. 1951;65(709-710):376–8.PubMedGoogle Scholar
  26. 26.
    van Geffen HJ, Simmermacher RK, Bosscha K, van der Werken C, Hillen B. Anatomical considerations for surgery of the anterolateral abdominal wall. Hernia. 2004;8(2):93–7. doi: 10.1007/s10029-003-0191-4.CrossRefPubMedGoogle Scholar
  27. 27.
    Saulis AS, Dumanian GA. Periumbilical rectus abdominis perforator preservation significantly reduces superficial wound complications in “separation of parts” hernia repairs. Plast Reconstr Surg. 2002;109(7):2275–80. discussion 2281–2272.CrossRefPubMedGoogle Scholar
  28. 28.
    de Vries Reilingh TS, van Goor H, Rosman C, Bemelmans MH, de Jong D, van Nieuwenhoven EJ, van Engeland MI, Bleichrodt RP. “Components separation technique” for the repair of large abdominal wall hernias. J Am Coll Surg. 2003;196(1):32–7. doi:S1072-7515(02)01478-3 [pii].CrossRefPubMedGoogle Scholar
  29. 29.
    Espinosa-de-los-Monteros A, Dominguez I, Zamora-Valdes D, Castillo T, Fernandez-Diaz OF, Luna-Torres HA. Closure of midline contaminated and recurrent incisional hernias with components separation technique reinforced with plication of the rectus muscles. Hernia. 2013;17(1):75–9. doi: 10.1007/s10029-012-1012-4.CrossRefPubMedGoogle Scholar
  30. 30.
    Mazzocchi M, Dessy LA, Ranno R, Carlesimo B, Rubino C. “Component separation” technique and panniculectomy for repair of incisional hernia. Am J Surg. 2011;201(6):776–83. doi:10.1016/j.amjsurg.2010.04.013 S0002-9610(10)00340-5 [pii].CrossRefPubMedGoogle Scholar
  31. 31.
    Yegiyants S, Tam M, Lee DJ, Abbas MA. Outcome of components separation for contaminated complex abdominal wall defects. Hernia. 2012;16(1):41–5. doi: 10.1007/s10029-011-0857-2.CrossRefPubMedGoogle Scholar
  32. 32.
    Dietz UA, Winkler MS, Hartel RW, Fleischhacker A, Wiegering A, Isbert C, Jurowich C, Heuschmann P, Germer CT. Importance of recurrence rating, morphology, hernial gap size, and risk factors in ventral and incisional hernia classification. Hernia. 2014;18(1):19–30. doi: 10.1007/s10029-012-0999-x.CrossRefPubMedGoogle Scholar
  33. 33.
    Luijendijk RW, Hop WC, van den Tol MP, de Lange DC, Braaksma MM, IJzermans JN, Boelhouwer RU, de Vries BC, Salu MK, Wereldsma JC, Bruijninckx CM, Jeekel J. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med. 2000;343(6):392–8. doi: 10.1056/NEJM200008103430603.CrossRefPubMedGoogle Scholar
  34. 34.
    Albino FP, Patel KM, Nahabedian MY, Sosin M, Attinger CE, Bhanot P. Does mesh location matter in abdominal wall reconstruction? A systematic review of the literature and a summary of recommendations. Plast Reconstr Surg. 2013;132(5):1295–304. doi:10.1097/PRS.0b013e3182a4c393 00006534-201311000-00047 [pii].CrossRefPubMedGoogle Scholar
  35. 35.
    Krpata DM, Blatnik JA, Novitsky YW, Rosen MJ. Evaluation of high-risk, comorbid patients undergoing open ventral hernia repair with synthetic mesh. Surgery. 2013;153(1):120–5. doi:10.1016/j.surg.2012.06.003 S0039-6060(12)00290-5 [pii].CrossRefPubMedGoogle Scholar
  36. 36.
    de Vries Reilingh TS, van Geldere D, Langenhorst B, de Jong D, van der Wilt GJ, van Goor H, Bleichrodt RP. Repair of large midline incisional hernias with polypropylene mesh: comparison of three operative techniques. Hernia. 2004;8(1):56–9. doi: 10.1007/s10029-003-0170-9.CrossRefPubMedGoogle Scholar
  37. 37.
    Rohr S, Vogt F, Thiry CL, Dai B, Meyer C. [Parietal prosthetic mesh in the treatment of large incisional hernias] Le pontage prothetique parietal dans le traitement des grandes eventrations. J Chir. 1993;130(1):37–40.Google Scholar
  38. 38.
    Moreno IG. Chronic eventrations and large hernias; preoperative treatment by progressive pneumoperitomeum; original procedure. Surgery. 1947;22(6):945–53.PubMedGoogle Scholar
  39. 39.
    McAdory RS, Cobb WS, Carbonell AM. Progressive preoperative pneumoperitoneum for hernias with loss of domain. Am Surg. 2009;75(6):504–8. discussion 508-509.PubMedGoogle Scholar
  40. 40.
    Lopez Sanclemente MC, Robres J, Lopez Cano M, Barri J, Lozoya R, Lopez S, Vasco MA, Buqueras MC, Subirana H, Jorba R. [Progressive preoperative pneumoperitoneum in patients with giant hernias of the abdominal wall] Neumoperitoneo preoperatorio progresivo en pacientes con hernias gigantes de la pared abdominal. Cir Esp. 2013;91(7):444–9. doi:10.1016/j.ciresp.2012.08.004 S0009-739X(12)00318-1 [pii].CrossRefPubMedGoogle Scholar
  41. 41.
    Caldironi MW, Romano M, Bozza F, Pluchinotta AM, Pelizzo MR, Toniato A, Ranzato R. Progressive pneumoperitoneum in the management of giant incisional hernias: a study of 41 patients. Br J Surg. 1990;77(3):306–7.CrossRefPubMedGoogle Scholar
  42. 42.
    Quraishi AH, Borkar MM, Mastud MM, Jannawar GG. Pre-operative progressive pneumoperitoneum for repair of a large incisional hernia. Updat Surg. 2013;65(2):165–8. doi: 10.1007/s13304-012-0134-7.CrossRefGoogle Scholar
  43. 43.
    Murr MM, Mason EE, Scott DH. The use of pneumoperitoneum in the repair of Giant Hernias. Obes Surg. 1994;4(4):323–7. doi: 10.1381/096089294765558278.CrossRefPubMedGoogle Scholar
  44. 44.
    Alam NN, Narang SK, Pathak S, Daniels IR, Smart NJ. Methods of abdominal wall expansion for repair of incisional herniae: a systematic review. Hernia. 2016;20(2):191–9. doi:10.1007/s10029-016-1463-0.CrossRefPubMedGoogle Scholar
  45. 45.
    Zendejas B, Khasawneh MA, Srvantstyan B, Jenkins DH, Schiller HJ, Zielinski MD. Outcomes of chemical component paralysis using botulinum toxin for incisional hernia repairs. World J Surg. 2013;37(12):2830–7. doi: 10.1007/s00268-013-2211-6.CrossRefPubMedGoogle Scholar
  46. 46.
    Smoot D, Zielinski M, Jenkins D, Schiller H. Botox A injection for pain after laparoscopic ventral hernia: a case report. Pain Med. 2011;12(7):1121–3. doi: 10.1111/j.1526-4637.2011.01147.x.CrossRefPubMedGoogle Scholar
  47. 47.
    Barwood S, Baillieu C, Boyd R, Brereton K, Low J, Nattrass G, Graham HK. Analgesic effects of botulinum toxin A: a randomized, placebo-controlled clinical trial. Dev Med Child Neurol. 2000;42(2):116–21.CrossRefPubMedGoogle Scholar
  48. 48.
    Ibarra-Hurtado TR, Nuno-Guzman CM, Miranda-Diaz AG, Troyo-Sanroman R, Navarro-Ibarra R, Bravo-Cuellar L. Effect of botulinum toxin type A in lateral abdominal wall muscles thickness and length of patients with midline incisional hernia secondary to open abdomen management. Hernia. 2014;18(5):647–52. doi: 10.1007/s10029-014-1280-2.CrossRefPubMedGoogle Scholar
  49. 49.
    Ibarra-Hurtado TR, Nuno-Guzman CM, Echeagaray-Herrera JE, Robles-Velez E, de Jesus Gonzalez-Jaime J. Use of botulinum toxin type a before abdominal wall hernia reconstruction. World J Surg. 2009;33(12):2553–6. doi: 10.1007/s00268-009-0203-3.CrossRefPubMedGoogle Scholar
  50. 50.
    Zielinski MD, Goussous N, Schiller HJ, Jenkins D. Chemical components separation with botulinum toxin A: a novel technique to improve primary fascial closure rates of the open abdomen. Hernia. 2013;17(1):101–7. doi: 10.1007/s10029-012-0995-1.CrossRefPubMedGoogle Scholar
  51. 51.
    Dressler D. Clinical applications of botulinum toxin. Curr Opin Microbiol. 2012;15(3):325–36. doi:10.1016/j.mib.2012.05.012 S1369-5274(12)00066-5 [pii].CrossRefPubMedGoogle Scholar
  52. 52.
    Elstner KE, Read JW, Rodriguez-Acevedo O, Cosman PH, Dardano AN, Jacombs AS, Edye M, Zea A, Boesel T, Mikami DJ, Ibrahim N. Preoperative chemical component relaxation using Botulinum toxin A: enabling laparoscopic repair of complex ventral hernia. Surg Endosc. 2016;28:1–8. doi:10.1007/s00464-016-5030-7.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Leonard Frederik Kroese
    • 1
    Email author
  • Johannes Jeekel
    • 2
  • Johan Frederik Lange
    • 1
    • 3
  1. 1.Department of SurgeryErasmus University Medical Center RotterdamRotterdamThe Netherlands
  2. 2.Department of NeuroscienceErasmus University Medical Center RotterdamRotterdamThe Netherlands
  3. 3.Department of SurgeryHavenziekenhuis RotterdamRotterdamThe Netherlands

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