Ventral Herniorrhaphy

Published on 11/04/2015 by admin

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CHAPTER 5 Ventral Herniorrhaphy

Joshua Fosnot, Matt L. Kirkland, III

Case Study

A 67-year-old male with a history of a laparotomy presents with a complaint of a “large bulge” in the midline of his abdomen. He has always had mild discomfort over his incision; however, this bulge has been getting larger over the past year and now causes significant discomfort with activity. On examination, he has a large nontender reducible incisional hernia. A large midline fascial defect is appreciable. He denies any episodes of abdominal distention, nausea, or vomiting.

BACKGROUND

A variety of abdominal wall hernias (ventral hernias) are commonly treated by the general surgeon (Fig. 5-1). Umbilical hernias are common in young children; most close by 2 years of age, and repair is rarely considered before 5 years of age. Umbilical hernias in adults are most commonly acquired and typically develop in patients with elevated intra-abdominal pressure (e.g., from obesity, pregnancy, or ascites). Epigastric hernias are found in the midline, superior to the umbilicus, and are often small and multiple. Pain may result from incarceration of properitoneal fat. Spigelian hernias result from herniation at the lateral border of the rectus sheath (linea semilunaris). A bulge is rarely apparent because these hernias usually dissect behind the external oblique aponeurosis. Incisional hernias are a common complication of abdominal surgery, occurring after up to 10% of abdominal wall closures. Technical error (e.g., excessive tension on the abdominal closure and inadequate approximation of the fascial edges) is the major etiology. Factors that result in increased intra-abdominal pressure (e.g., obesity, pregnancy, and ascites) and compromise wound healing (e.g., malnutrition and immunosuppression) may be contributory.

Figure 5-1 Different types of ventral hernias.

(From Roberts JR, Hedges JR, Chanmugam AS, et al [eds]: Clinical Procedures in Emergency Medicine, 4th ed. Philadelphia, Saunders, 2004.)

Spigelian hernias should be repaired because of the high associated risk of incarceration.

The repair of all abdominal wall hernias involves reduction, closure of the fascial defect, and in many cases, reinforcement with a mesh prosthesis. Primary closure (without mesh) may be considered for defects smaller than 4 cm in diameter. Primary closure of larger defects is prone to failure, relating to the degree of tension on the repair, and should be avoided.

INDICATIONS FOR VENTRAL HERNIA REPAIR

I. Reducible Hernias: Ventral hernias are associated with a small risk of incarceration (i.e., entrapment of the contents of a hernia within the fascial defect). Generally, small hernias are more likely to become incarcerated than are larger hernias. In patients without significant comorbidity, ventral hernias may be repaired electively to minimize this risk, to alleviate associated symptoms (e.g., discomfort), or to improve cosmesis. A role for observation of asymptomatic and minimally symptomatic hernias has emerged in patients with significant comorbidity and those willing to accept the small risk of incarceration.

II. Incarceration: Incarceration of bowel within a hernia may result in intestinal obstruction or compromise of the blood supply to the hernia contents (i.e., strangulation). Acute incarceration generally mandates urgent surgical intervention. In the absence of associated symptoms, chronically incarcerated ventral hernias may be managed expectantly.

PREOPERATIVE EVALUATION

I. History: Symptoms suggesting incarceration or intestinal obstruction (e.g., abdominal pain, nausea, vomiting, and constipation) and factors that may contribute to abdominal wall herniation (e.g., chronic cough, constipation, or previous abdominal surgery) should be elicited.

Does your patient have symptoms consistent with intestinal obstruction?

II. Physical Examination: The goals of the physical examination are: (1) to determine the size of the hernia defect, (2) to distinguish a true hernia from a diastasis, and (3) to distinguish a reducible hernia from an incarcerated hernia. In the patient with an acutely incarcerated hernia, signs consistent with strangulation should be elicited (e.g., focal abdominal tenderness or peritonitis).

Rectus diastasis is thinning of the linea alba and lateralization of the rectus muscles without a fascial defect.

III. Imaging: In the setting of an incarcerated ventral hernia, plain abdominal radiographs may show dilated bowel or air–fluid levels consistent with intestinal obstruction. Ventral hernias are often better assessed with a CT scan, which may help to characterize the contents of the hernia (e.g., bowel vs. fat), localize and delineate the degree of bowel obstruction in the setting of incarceration, or identify signs consistent with strangulation (e.g., bowel wall edema).

IV. Laboratory Studies: In the patient with an incarcerated hernia, leukocytosis and elevated lactate levels should raise concern for bowel strangulation. Importantly, these signs are typically late findings and may reflect irreversible ischemia.

COMPONENTS OF THE PROCEDURE AND APPLIED ANATOMY

Ventral hernias may be repaired using a variety of approaches. Factors that influence the choice of approach include the size of the defect, the integrity of the abdominal wall fascia surrounding the hernia, and surgeon preference (Fig. 5-2).

Figure 5-2 Anatomy of the anterior abdominal wall. A, Transverse section through the rectus sheath above the arcuate line. The external oblique and internal oblique aponeuroses contribute to the anterior sheath. The internal oblique and transversus abdominis aponeuroses contribute to the posterior sheath. B, Below the arcuate line (halfway between the umbilicus and pubis), there is no posterior rectus sheath.

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