Ventral Incisional Hernias Ventral Incisional Hernias Ventral Incisional Hernias Ventral Incisional Hernias –––– Etiology and Repair Options Etiology and Repair Options Etiology and Repair Options Etiology and Repair Options

OBJECTIVESOBJECTIVESOBJECTIVESOBJECTIVES

• EpidemiologyEpidemiologyEpidemiologyEpidemiology• Etiology Etiology Etiology Etiology • AnatomyAnatomyAnatomyAnatomy• Preoperative evaluationPreoperative evaluationPreoperative evaluationPreoperative evaluation• Operative StrategiesOperative StrategiesOperative StrategiesOperative Strategies

Ventral Incisional HerniaVentral Incisional HerniaVentral Incisional HerniaVentral Incisional Hernia

Defect formed at a prior Defect formed at a prior Defect formed at a prior Defect formed at a prior abdominal incision siteabdominal incision siteabdominal incision siteabdominal incision site

Ventral Incisional HerniaVentral Incisional HerniaVentral Incisional HerniaVentral Incisional Hernia• 4-5 million laparotomies/year4-5 million laparotomies/year4-5 million laparotomies/year4-5 million laparotomies/year1,21,21,21,2

• 400-500,000 incisional hernias develop400-500,000 incisional hernias develop400-500,000 incisional hernias develop400-500,000 incisional hernias develop3333

• 200,000 incisional hernia repairs/yr200,000 incisional hernia repairs/yr200,000 incisional hernia repairs/yr200,000 incisional hernia repairs/yr1-31-31-31-3

• Common occurrence after abdominal Common occurrence after abdominal Common occurrence after abdominal Common occurrence after abdominal surgery (up to 13% of laparotomy surgery (up to 13% of laparotomy surgery (up to 13% of laparotomy surgery (up to 13% of laparotomy incisions)incisions)incisions)incisions)4,54,54,54,5

1. National Centre for Health Statistics. Combined surgery data (NHDSand NSAS) data highlights. Available at: http://www.cdc.gov/nchs/about/major/hdasd. 1996. Accessed September 14,2007.

2. Lomanto, S. Surg Endosc 2006;20:1030 –5.3. Burger J. Ann Surg. 2004;240:578-585.4. Mudge, M. Br J Surg 1985;72:70 –1.5. Lewis, RT. Can J Surg 1989;32:196 –200.6. Hoer, J. Chrirug 2002;73:474–480.

Why fix them?Why fix them?Why fix them?Why fix them?• Increase in size over timeIncrease in size over timeIncrease in size over timeIncrease in size over time• Can lead to: Can lead to: Can lead to: Can lead to:

- obstruction- obstruction- obstruction- obstruction- incarceration- incarceration- incarceration- incarceration- strangulation- strangulation- strangulation- strangulation- enterocutaneous fistula- enterocutaneous fistula- enterocutaneous fistula- enterocutaneous fistula- chronic back/abd pain- chronic back/abd pain- chronic back/abd pain- chronic back/abd pain- loss of abdominal domain- loss of abdominal domain- loss of abdominal domain- loss of abdominal domain- poor pulmonary function- poor pulmonary function- poor pulmonary function- poor pulmonary function

Why do they form?Why do they form?Why do they form?Why do they form?• Multi-factorial processMulti-factorial processMulti-factorial processMulti-factorial process• Technique is not the sole causeTechnique is not the sole causeTechnique is not the sole causeTechnique is not the sole cause• Primary fascial pathology due toPrimary fascial pathology due toPrimary fascial pathology due toPrimary fascial pathology due to1-21-21-21-2::::

- Abnormal collagen metabolism and production (found even in - Abnormal collagen metabolism and production (found even in - Abnormal collagen metabolism and production (found even in - Abnormal collagen metabolism and production (found even in sites remote from hernia)sites remote from hernia)sites remote from hernia)sites remote from hernia)- Increased matrix metalloproteinase (MMP) activity- Increased matrix metalloproteinase (MMP) activity- Increased matrix metalloproteinase (MMP) activity- Increased matrix metalloproteinase (MMP) activity

• Secondary fascial pathology due to:Secondary fascial pathology due to:Secondary fascial pathology due to:Secondary fascial pathology due to:- loss of normal tissue architecture - loss of normal tissue architecture - loss of normal tissue architecture - loss of normal tissue architecture -replacement of fascial planes with scar-replacement of fascial planes with scar-replacement of fascial planes with scar-replacement of fascial planes with scar

• MechanotransductionMechanotransductionMechanotransductionMechanotransduction- mechanical forces (coughing, straining, stretching) induce - mechanical forces (coughing, straining, stretching) induce - mechanical forces (coughing, straining, stretching) induce - mechanical forces (coughing, straining, stretching) induce changes in fibroblast functionchanges in fibroblast functionchanges in fibroblast functionchanges in fibroblast function3-43-43-43-4

- loss of this during primary healing leads to weaker tissue- loss of this during primary healing leads to weaker tissue- loss of this during primary healing leads to weaker tissue- loss of this during primary healing leads to weaker tissue- early laparotomy failure has significant incidence of recurrent - early laparotomy failure has significant incidence of recurrent - early laparotomy failure has significant incidence of recurrent - early laparotomy failure has significant incidence of recurrent herniaherniaherniahernia

1. Read RC. Hernia 2006;10(6):454–5.2. Peacock J. Fascia and muscle. Wound repair. 3rd edition. Philadelphia:W.B. Saunders; 1984. p. 332–623. Skutek M. Eur J Appl Physiol 2001;86(1):48–524. Katsumi A. J Biol Chem 2005;280(17):16546–9

Collagen I and IIICollagen I and IIICollagen I and IIICollagen I and III

• Collagen Type I Collagen Type I Collagen Type I Collagen Type I –––– mature collagen, mature collagen, mature collagen, mature collagen, greatest strength component of ECMgreatest strength component of ECMgreatest strength component of ECMgreatest strength component of ECM

• Collagen Type III Collagen Type III Collagen Type III Collagen Type III –––– immature isoform, immature isoform, immature isoform, immature isoform, weaker, less crosslinkingweaker, less crosslinkingweaker, less crosslinkingweaker, less crosslinking

• Low ratios of CI:CIII have been Low ratios of CI:CIII have been Low ratios of CI:CIII have been Low ratios of CI:CIII have been demonstrated in scar plates of demonstrated in scar plates of demonstrated in scar plates of demonstrated in scar plates of recurrent herniasrecurrent herniasrecurrent herniasrecurrent hernias

1. Read RC. Hernia 2006;10(6):454–5.2. Peacock J. Fascia and muscle. Wound repair. 3rd edition. Philadelphia:W.B. Saunders; 1984. p. 332–623. Skutek M. Eur J Appl Physiol 2001;86(1):48–524. Katsumi A. J Biol Chem 2005;280(17):16546–9

MMP-2MMP-2MMP-2MMP-2•Encoded by Encoded by Encoded by Encoded by MMP2MMP2MMP2MMP2 gene gene gene gene•Involved with tissue remodelingInvolved with tissue remodelingInvolved with tissue remodelingInvolved with tissue remodeling•Breakdown collagen and otherBreakdown collagen and otherBreakdown collagen and otherBreakdown collagen and otherextracellular matrix proteinsextracellular matrix proteinsextracellular matrix proteinsextracellular matrix proteins•Found to be elevated in patientsFound to be elevated in patientsFound to be elevated in patientsFound to be elevated in patientswith recurrent herniaswith recurrent herniaswith recurrent herniaswith recurrent hernias1111

•Mesh prosthesis interfere with MMP-2 regulation due Mesh prosthesis interfere with MMP-2 regulation due Mesh prosthesis interfere with MMP-2 regulation due Mesh prosthesis interfere with MMP-2 regulation due to soluble factors, ECM modification or cell cross-talkto soluble factors, ECM modification or cell cross-talkto soluble factors, ECM modification or cell cross-talkto soluble factors, ECM modification or cell cross-talk2222

1.1.1.1. Smigielski J. Eur J Clin Invest. 2011 Feb 8. EpubSmigielski J. Eur J Clin Invest. 2011 Feb 8. EpubSmigielski J. Eur J Clin Invest. 2011 Feb 8. EpubSmigielski J. Eur J Clin Invest. 2011 Feb 8. Epub2.2.2.2. Shumpelick. Recurrent Hernias. Page 66-68. 2007.Shumpelick. Recurrent Hernias. Page 66-68. 2007.Shumpelick. Recurrent Hernias. Page 66-68. 2007.Shumpelick. Recurrent Hernias. Page 66-68. 2007.

Collagen and MMP2sCollagen and MMP2sCollagen and MMP2sCollagen and MMP2s

CI/III - 14 CI/III – 3.6

MMP2

Wound Healing BiologyWound Healing BiologyWound Healing BiologyWound Healing Biology

• Healthy tissue replaced by fibrotic Healthy tissue replaced by fibrotic Healthy tissue replaced by fibrotic Healthy tissue replaced by fibrotic tissue (fibrinogens and collagens)tissue (fibrinogens and collagens)tissue (fibrinogens and collagens)tissue (fibrinogens and collagens)

• Relies on formation of sufficient scar Relies on formation of sufficient scar Relies on formation of sufficient scar Relies on formation of sufficient scar tissuetissuetissuetissue

• Greater collagen III deposition in scar between tissue or tissue/mesh, Greater collagen III deposition in scar between tissue or tissue/mesh, Greater collagen III deposition in scar between tissue or tissue/mesh, Greater collagen III deposition in scar between tissue or tissue/mesh, it can separate easier from itself and/or mesh edge (hence the greater it can separate easier from itself and/or mesh edge (hence the greater it can separate easier from itself and/or mesh edge (hence the greater it can separate easier from itself and/or mesh edge (hence the greater overlap suggested in underlay repairs)overlap suggested in underlay repairs)overlap suggested in underlay repairs)overlap suggested in underlay repairs)

• Low quantity of collagen I helps explain the slow linear increase in Low quantity of collagen I helps explain the slow linear increase in Low quantity of collagen I helps explain the slow linear increase in Low quantity of collagen I helps explain the slow linear increase in recurrence over time recurrence over time recurrence over time recurrence over time

• Correlates with high frequency of VIH in those with AAACorrelates with high frequency of VIH in those with AAACorrelates with high frequency of VIH in those with AAACorrelates with high frequency of VIH in those with AAA• Correlates with sooner to recur hernias in multiply repaired herniasCorrelates with sooner to recur hernias in multiply repaired herniasCorrelates with sooner to recur hernias in multiply repaired herniasCorrelates with sooner to recur hernias in multiply repaired hernias• MMP-2, degrade collagen, higher in recurrent hernia patientsMMP-2, degrade collagen, higher in recurrent hernia patientsMMP-2, degrade collagen, higher in recurrent hernia patientsMMP-2, degrade collagen, higher in recurrent hernia patients1111• With large VIH, have loss of mechanotransduction => loss of fibroblast With large VIH, have loss of mechanotransduction => loss of fibroblast With large VIH, have loss of mechanotransduction => loss of fibroblast With large VIH, have loss of mechanotransduction => loss of fibroblast

signaling leading to disuse atrophy, fibrosis and muscle fiber signaling leading to disuse atrophy, fibrosis and muscle fiber signaling leading to disuse atrophy, fibrosis and muscle fiber signaling leading to disuse atrophy, fibrosis and muscle fiber changes changes changes changes 2-32-32-32-3

1.1.1.1. Smigielski J. Eur J Clin Invest. 2011 Feb 8. Epub.Smigielski J. Eur J Clin Invest. 2011 Feb 8. Epub.Smigielski J. Eur J Clin Invest. 2011 Feb 8. Epub.Smigielski J. Eur J Clin Invest. 2011 Feb 8. Epub.2.2.2.2. Schmidt C. Journal of Biological Chemistry.1998;273:5081Schmidt C. Journal of Biological Chemistry.1998;273:5081Schmidt C. Journal of Biological Chemistry.1998;273:5081Schmidt C. Journal of Biological Chemistry.1998;273:5081––––5. 5. 5. 5. 3.3.3.3. Dubay DA. Ann Surg January;2007 245(1):140Dubay DA. Ann Surg January;2007 245(1):140Dubay DA. Ann Surg January;2007 245(1):140Dubay DA. Ann Surg January;2007 245(1):140––––6.6.6.6.

Wound Healing BiologyWound Healing BiologyWound Healing BiologyWound Healing Biology

Franz M. The Biology of Hernia Formation. Surg Clin N Am 88 (2008) 1–15

VIH formationVIH formationVIH formationVIH formation

• Cascade begins with early laparotomy Cascade begins with early laparotomy Cascade begins with early laparotomy Cascade begins with early laparotomy wound failure (~11%)wound failure (~11%)wound failure (~11%)wound failure (~11%)

• During lag phase of healing (weakest)During lag phase of healing (weakest)During lag phase of healing (weakest)During lag phase of healing (weakest)• 94% develop VIH w/in 3 years94% develop VIH w/in 3 years94% develop VIH w/in 3 years94% develop VIH w/in 3 years• These represent occult dehiscencesThese represent occult dehiscencesThese represent occult dehiscencesThese represent occult dehiscences• Most occult dehiscences occur w/in 30 Most occult dehiscences occur w/in 30 Most occult dehiscences occur w/in 30 Most occult dehiscences occur w/in 30

days of wound closuredays of wound closuredays of wound closuredays of wound closure

Pollock AV, Evans M. Early prediction of late incisional hernias. Br J Surg 1989;76:953–4.

If purely technicalIf purely technicalIf purely technicalIf purely technical…………

J Min Access Surg 2006;2:151-4J Min Access Surg 2006;2:151-4J Min Access Surg 2006;2:151-4J Min Access Surg 2006;2:151-4

Failure that is multifactorialFailure that is multifactorialFailure that is multifactorialFailure that is multifactorial…………

J Min Access Surg 2006;2:151-4

Hernia recurrence dataHernia recurrence dataHernia recurrence dataHernia recurrence data…………

Flum DR. Surgery 2005;138:821-8.Junge K. Hernia 2006;10:309-15

Anatomy of the Abdominal WallAnatomy of the Abdominal WallAnatomy of the Abdominal WallAnatomy of the Abdominal Wall

Anatomy of the Abdominal WallAnatomy of the Abdominal WallAnatomy of the Abdominal WallAnatomy of the Abdominal Wall

AnatomyAnatomyAnatomyAnatomy

Function of Musculofascial Function of Musculofascial Function of Musculofascial Function of Musculofascial LayersLayersLayersLayers

• 5 paired muscles (3 flat, 2 vertical)5 paired muscles (3 flat, 2 vertical)5 paired muscles (3 flat, 2 vertical)5 paired muscles (3 flat, 2 vertical)• 3 flat 3 flat 3 flat 3 flat –––– int/ext oblique and transversalis int/ext oblique and transversalis int/ext oblique and transversalis int/ext oblique and transversalis• Increase abdominal pressure to facilitate Increase abdominal pressure to facilitate Increase abdominal pressure to facilitate Increase abdominal pressure to facilitate

defecation, micturition, and parturitiondefecation, micturition, and parturitiondefecation, micturition, and parturitiondefecation, micturition, and parturition• Stabilizes trunk Stabilizes trunk Stabilizes trunk Stabilizes trunk • 2 vertical 2 vertical 2 vertical 2 vertical –––– rectus abdominus and rectus abdominus and rectus abdominus and rectus abdominus and

pyramidalispyramidalispyramidalispyramidalis• Rectus - tensor of the abdominal wall, flexor Rectus - tensor of the abdominal wall, flexor Rectus - tensor of the abdominal wall, flexor Rectus - tensor of the abdominal wall, flexor

of the vertebrae, stabilize the pelvis during of the vertebrae, stabilize the pelvis during of the vertebrae, stabilize the pelvis during of the vertebrae, stabilize the pelvis during walking, protects the abdominal viscera, aids walking, protects the abdominal viscera, aids walking, protects the abdominal viscera, aids walking, protects the abdominal viscera, aids in forced expirationin forced expirationin forced expirationin forced expiration

Innervation of Abdominal WallInnervation of Abdominal WallInnervation of Abdominal WallInnervation of Abdominal Wall

• T7-L2 T7-L2 T7-L2 T7-L2 • Nerves lie in space b/w internal oblique Nerves lie in space b/w internal oblique Nerves lie in space b/w internal oblique Nerves lie in space b/w internal oblique

and transversalisand transversalisand transversalisand transversalis• At risk for injury during component At risk for injury during component At risk for injury during component At risk for injury during component

separationseparationseparationseparation

Predictors of VIHPredictors of VIHPredictors of VIHPredictors of VIH• ObesityObesityObesityObesity• Pulmonary diseasePulmonary diseasePulmonary diseasePulmonary disease• Wound infectionWound infectionWound infectionWound infection• Intra-abdominal sepsisIntra-abdominal sepsisIntra-abdominal sepsisIntra-abdominal sepsis• MalnutritionMalnutritionMalnutritionMalnutrition• AnemiaAnemiaAnemiaAnemia• Corticosteroid dependencyCorticosteroid dependencyCorticosteroid dependencyCorticosteroid dependency• Prior VIH repairPrior VIH repairPrior VIH repairPrior VIH repair• Collagen vascular diseasesCollagen vascular diseasesCollagen vascular diseasesCollagen vascular diseases• AAAAAAAAAAAA• Low CI:CIII ratios and elevated MMPsLow CI:CIII ratios and elevated MMPsLow CI:CIII ratios and elevated MMPsLow CI:CIII ratios and elevated MMPs

Goals of VIHRGoals of VIHRGoals of VIHRGoals of VIHR• Restore abdominal wall continuityRestore abdominal wall continuityRestore abdominal wall continuityRestore abdominal wall continuity• Restore function to abdominal wall viaRestore function to abdominal wall viaRestore function to abdominal wall viaRestore function to abdominal wall via

- Recreate linea alba with primary - Recreate linea alba with primary - Recreate linea alba with primary - Recreate linea alba with primary fascial closurefascial closurefascial closurefascial closure- preservation of blood supply and - preservation of blood supply and - preservation of blood supply and - preservation of blood supply and nerve innervationnerve innervationnerve innervationnerve innervation- Durable repair- Durable repair- Durable repair- Durable repair

• No tensionNo tensionNo tensionNo tension• Close abdominal woundClose abdominal woundClose abdominal woundClose abdominal wound

1.1.1.1. Plast. Reconstr. Surg. 98: 464, 1996

2.2.2.2. Plast. Reconstr. Surg. 72:170, 1983

Appeal of Restoration of Linea AlbaAppeal of Restoration of Linea AlbaAppeal of Restoration of Linea AlbaAppeal of Restoration of Linea Alba

Functional Repair Functional Repair Functional Repair Functional Repair

• Patients with VIHR have lower peak Patients with VIHR have lower peak Patients with VIHR have lower peak Patients with VIHR have lower peak torque generation by hip flexors vs torque generation by hip flexors vs torque generation by hip flexors vs torque generation by hip flexors vs controlscontrolscontrolscontrols

• Functional repair has greater torque vs Functional repair has greater torque vs Functional repair has greater torque vs Functional repair has greater torque vs nonfunctional repairnonfunctional repairnonfunctional repairnonfunctional repair1111

• Clinical utility of torque measured here Clinical utility of torque measured here Clinical utility of torque measured here Clinical utility of torque measured here is unclearis unclearis unclearis unclear

1. Hartog D. Hernia. 2010:14:243-247.

Preoperative GoalsPreoperative GoalsPreoperative GoalsPreoperative Goals• Optimize patient physiologyOptimize patient physiologyOptimize patient physiologyOptimize patient physiology• Optimize nutritionOptimize nutritionOptimize nutritionOptimize nutrition• Define anatomyDefine anatomyDefine anatomyDefine anatomy• Remove septic sourcesRemove septic sourcesRemove septic sourcesRemove septic sources• Identify fistulasIdentify fistulasIdentify fistulasIdentify fistulas• Explant any involved prosthesesExplant any involved prosthesesExplant any involved prosthesesExplant any involved prostheses• Review all operative reportsReview all operative reportsReview all operative reportsReview all operative reports• Review all imaging (i.e. CT)Review all imaging (i.e. CT)Review all imaging (i.e. CT)Review all imaging (i.e. CT)• Weight lossWeight lossWeight lossWeight loss• Smoking cessationSmoking cessationSmoking cessationSmoking cessation

Issues with repairIssues with repairIssues with repairIssues with repair

• No universal technique for repairNo universal technique for repairNo universal technique for repairNo universal technique for repair• Functional repair versus prosthetic Functional repair versus prosthetic Functional repair versus prosthetic Functional repair versus prosthetic

coveringcoveringcoveringcovering• High recurrence rate (RR) for repairsHigh recurrence rate (RR) for repairsHigh recurrence rate (RR) for repairsHigh recurrence rate (RR) for repairs

- Primary suture repair near ~50% RR - Primary suture repair near ~50% RR - Primary suture repair near ~50% RR - Primary suture repair near ~50% RR 1-31-31-31-3

- Mesh repair 2-36% RR - Mesh repair 2-36% RR - Mesh repair 2-36% RR - Mesh repair 2-36% RR

1. Mannien MJ. Eur J Surg 1991;157:29 –31 2. Anthony T. World J Surg 2000;24:95–10003. Luijendijk RW. N Engl J Med 000;343:392–8.4. Neth J Surg 1988;40:127–9.5. Br J Surg 1994;81:248 –96. Lagenbecks Arch Surg 2002;387:246–8.

TechniquesTechniquesTechniquesTechniques• Primary Suture RepairPrimary Suture RepairPrimary Suture RepairPrimary Suture Repair• Open vs Laparoscopic vs Endoscopic Open vs Laparoscopic vs Endoscopic Open vs Laparoscopic vs Endoscopic Open vs Laparoscopic vs Endoscopic • No separation + prosthetic (onlay, sublay, No separation + prosthetic (onlay, sublay, No separation + prosthetic (onlay, sublay, No separation + prosthetic (onlay, sublay,

inlay)inlay)inlay)inlay)• Component Separation Technique (CST) Component Separation Technique (CST) Component Separation Technique (CST) Component Separation Technique (CST)

+/- prosthetic+/- prosthetic+/- prosthetic+/- prosthetic• Endoscopic CST +/- prostheticEndoscopic CST +/- prostheticEndoscopic CST +/- prostheticEndoscopic CST +/- prosthetic• Rives-Stoppa/Retrorectus repair Rives-Stoppa/Retrorectus repair Rives-Stoppa/Retrorectus repair Rives-Stoppa/Retrorectus repair • Autologous tissue repairAutologous tissue repairAutologous tissue repairAutologous tissue repair• Preoperative PneumoperitoneumPreoperative PneumoperitoneumPreoperative PneumoperitoneumPreoperative Pneumoperitoneum

Prosthetic RepairProsthetic RepairProsthetic RepairProsthetic Repair• Polypropylene (PP) has greatest tissue in-growth of Polypropylene (PP) has greatest tissue in-growth of Polypropylene (PP) has greatest tissue in-growth of Polypropylene (PP) has greatest tissue in-growth of

all meshes available, ideal in non-to-limited all meshes available, ideal in non-to-limited all meshes available, ideal in non-to-limited all meshes available, ideal in non-to-limited contaminated cases, minimal degradationcontaminated cases, minimal degradationcontaminated cases, minimal degradationcontaminated cases, minimal degradation

• PP lowers hernia recurrence in VIHRPP lowers hernia recurrence in VIHRPP lowers hernia recurrence in VIHRPP lowers hernia recurrence in VIHR• Polyester has hydrolytic breakdown overtimePolyester has hydrolytic breakdown overtimePolyester has hydrolytic breakdown overtimePolyester has hydrolytic breakdown overtime1111

• ePTFE has fewest bowel complications due to its ePTFE has fewest bowel complications due to its ePTFE has fewest bowel complications due to its ePTFE has fewest bowel complications due to its nonadhesiveness to bowel (no ingrowth)nonadhesiveness to bowel (no ingrowth)nonadhesiveness to bowel (no ingrowth)nonadhesiveness to bowel (no ingrowth)

• Absorbable/biologic meshes only used in cases Absorbable/biologic meshes only used in cases Absorbable/biologic meshes only used in cases Absorbable/biologic meshes only used in cases where mesh infection is a significant risk and cannot where mesh infection is a significant risk and cannot where mesh infection is a significant risk and cannot where mesh infection is a significant risk and cannot perform primary closureperform primary closureperform primary closureperform primary closure

1. Eur J Vasc Endovasc Surg 13, 540-548 (1997)

Primary Suture RepairPrimary Suture RepairPrimary Suture RepairPrimary Suture Repair

• Unless < 5cm transverse = >50% RRUnless < 5cm transverse = >50% RRUnless < 5cm transverse = >50% RRUnless < 5cm transverse = >50% RR

Sublay or Bridge RepairSublay or Bridge RepairSublay or Bridge RepairSublay or Bridge Repair

• Recommended repair w/mesh

• Lowest RR• Lowest mesh

infection

J Am Coll Surg. 2010 May;210(5):648-55, 655-7.

Onlay RepairOnlay RepairOnlay RepairOnlay Repair

• Primary fascial closure • Mesh is sutured to anterior rectus sheath• Advantage - keeps mesh separated from

abdominal contents• Disadvantage – wound repair under

tension, and mesh infection when surgical wound is infected

InlayInlayInlayInlay• Hernia sac excised and fascial margin is

identified around the hernia defect.• Mesh is sutured circumferentially to fascial edge.• Polypropylene would be used when omentum

can be placed between intestine and mesh;• ePTFE should be used when there is no

omentum available• Exceedingly high recurrence rate and should be

an abandoned practice

Retrorectus RepairRetrorectus RepairRetrorectus RepairRetrorectus Repair

• Retrorectus repair: aka Rives-Stoppa technique. • This technique utilizes the hernia sac to separate the mesh from the

intra-abdominal contents. • Superior to the umbilicus, dissection is performed above the

posterior rectus fascia and under the rectus muscle.• Below the umbilicus, dissection occurs in the preperitoneal space

due to the lack of a posterior rectus sheath. • A large piece of mesh is placed in the newly formed space, and

fixated to the muscle layer above. • This repair has low recurrences (<5%) and complications

Rene Stoppa

Component Separation Component Separation Component Separation Component Separation TechniqueTechniqueTechniqueTechnique

• Described by Ramirez, Ruas and Dellon Described by Ramirez, Ruas and Dellon Described by Ramirez, Ruas and Dellon Described by Ramirez, Ruas and Dellon in 1990in 1990in 1990in 19901111

• Involves incising aponeurosis of Involves incising aponeurosis of Involves incising aponeurosis of Involves incising aponeurosis of external oblique muscle and the external oblique muscle and the external oblique muscle and the external oblique muscle and the posterior rectus sheathposterior rectus sheathposterior rectus sheathposterior rectus sheath

• Must raise large lipocutaneous flapsMust raise large lipocutaneous flapsMust raise large lipocutaneous flapsMust raise large lipocutaneous flaps• Risk injuring perforating vessels and Risk injuring perforating vessels and Risk injuring perforating vessels and Risk injuring perforating vessels and

nervesnervesnervesnerves

1. Plast Reconstr Surg 1990; 86868686: 519–526.

Shestak. Plast Reconstr Surg. 2000 Feb;105(2):731-8Shestak. Plast Reconstr Surg. 2000 Feb;105(2):731-8Shestak. Plast Reconstr Surg. 2000 Feb;105(2):731-8Shestak. Plast Reconstr Surg. 2000 Feb;105(2):731-8

CSTCSTCSTCST• Major wound morbidity in 30-40% Major wound morbidity in 30-40% Major wound morbidity in 30-40% Major wound morbidity in 30-40% 1-31-31-31-3

- seromas- seromas- seromas- seromas- subcutaneous abscesses- subcutaneous abscesses- subcutaneous abscesses- subcutaneous abscesses- flap necrosis- flap necrosis- flap necrosis- flap necrosis

• Low recurrence rate, ~8.5%Low recurrence rate, ~8.5%Low recurrence rate, ~8.5%Low recurrence rate, ~8.5%4444

1. Plast Reconstr Surg 2003;112:106 –142. Plast Reconstr Surg 2000;105:720 –303. J Am Coll Surg 2003;196:32–74. Plast. Reconstr. Surg. 98: 464, 1996.

Endoscopic Component Endoscopic Component Endoscopic Component Endoscopic Component Separation Separation Separation Separation

• AdvantagesAdvantagesAdvantagesAdvantages1,21,21,21,2 - less wound surface area- less wound surface area- less wound surface area- less wound surface area- less skin flap necrosis- less skin flap necrosis- less skin flap necrosis- less skin flap necrosis- fast- fast- fast- fast- totally extraperitoneal- totally extraperitoneal- totally extraperitoneal- totally extraperitoneal- preserved epigastrics and perforators- preserved epigastrics and perforators- preserved epigastrics and perforators- preserved epigastrics and perforators

• DisadvantagesDisadvantagesDisadvantagesDisadvantages1,21,21,21,2

- increased cost- increased cost- increased cost- increased cost- doesn- doesn- doesn- doesn’’’’t provide as much advancement as open t provide as much advancement as open t provide as much advancement as open t provide as much advancement as open (86%)(86%)(86%)(86%)1111

• However Roth et al demonstrated equal However Roth et al demonstrated equal However Roth et al demonstrated equal However Roth et al demonstrated equal advancement compared to open in cadaver modeladvancement compared to open in cadaver modeladvancement compared to open in cadaver modeladvancement compared to open in cadaver model2222

1. 1. 1. 1. Am J Surg. 2007 Sep;194(3):385-9.Am J Surg. 2007 Sep;194(3):385-9.Am J Surg. 2007 Sep;194(3):385-9.Am J Surg. 2007 Sep;194(3):385-9.2. Roth JS. Hernia (2007) 11:1572. Roth JS. Hernia (2007) 11:1572. Roth JS. Hernia (2007) 11:1572. Roth JS. Hernia (2007) 11:157––––161161161161

Laparoscopic VIHR IPOMLaparoscopic VIHR IPOMLaparoscopic VIHR IPOMLaparoscopic VIHR IPOM• Prosthetic mesh placed over defect Prosthetic mesh placed over defect Prosthetic mesh placed over defect Prosthetic mesh placed over defect

with 3-5-cm overlap from hernia orificewith 3-5-cm overlap from hernia orificewith 3-5-cm overlap from hernia orificewith 3-5-cm overlap from hernia orifice• Circumferential transfascial suture Circumferential transfascial suture Circumferential transfascial suture Circumferential transfascial suture

fixation at 4 sites, tack restfixation at 4 sites, tack restfixation at 4 sites, tack restfixation at 4 sites, tack rest• Limits excessive tissue dissectionLimits excessive tissue dissectionLimits excessive tissue dissectionLimits excessive tissue dissection• Less wound complications and painLess wound complications and painLess wound complications and painLess wound complications and pain• Shorter LOSShorter LOSShorter LOSShorter LOS• Risk of bowel injury ~3.5% Risk of bowel injury ~3.5% Risk of bowel injury ~3.5% Risk of bowel injury ~3.5% 1111• DoesnDoesnDoesnDoesn’’’’t restore function to abdominal t restore function to abdominal t restore function to abdominal t restore function to abdominal

wallwallwallwall1. Muhammed. Am J Surg. 2009:197, 64-72

Just cover the holeJust cover the holeJust cover the holeJust cover the hole

Laparoscopic Medialization of Laparoscopic Medialization of Laparoscopic Medialization of Laparoscopic Medialization of RectusRectusRectusRectus

• Carter-Thomason suture passer using Carter-Thomason suture passer using Carter-Thomason suture passer using Carter-Thomason suture passer using monofilament suturemonofilament suturemonofilament suturemonofilament suture

• Horizontal mattress suturesHorizontal mattress suturesHorizontal mattress suturesHorizontal mattress sutures• 2 cm bites2 cm bites2 cm bites2 cm bites• 2-3 cm travel2-3 cm travel2-3 cm travel2-3 cm travel• Lower insufflation pressure and tie Lower insufflation pressure and tie Lower insufflation pressure and tie Lower insufflation pressure and tie

suturessuturessuturessutures• If unable to close, may need ECSTIf unable to close, may need ECSTIf unable to close, may need ECSTIf unable to close, may need ECST• Reinforce repair with prostheticReinforce repair with prostheticReinforce repair with prostheticReinforce repair with prosthetic

Lap VIHR IPOM w/ECSTLap VIHR IPOM w/ECSTLap VIHR IPOM w/ECSTLap VIHR IPOM w/ECST

• Ideal for large defect <~15 cm in Ideal for large defect <~15 cm in Ideal for large defect <~15 cm in Ideal for large defect <~15 cm in midlinemidlinemidlinemidline

• First eCST performedFirst eCST performedFirst eCST performedFirst eCST performed• Transfasical horizontal mattress Transfasical horizontal mattress Transfasical horizontal mattress Transfasical horizontal mattress

sutures place to close midline fascial sutures place to close midline fascial sutures place to close midline fascial sutures place to close midline fascial defectdefectdefectdefect

• IPOM mesh placement with 5 cm IPOM mesh placement with 5 cm IPOM mesh placement with 5 cm IPOM mesh placement with 5 cm overlapoverlapoverlapoverlap

What to do with significant loss What to do with significant loss What to do with significant loss What to do with significant loss of domain?of domain?of domain?of domain?

Gradual Tension MethodsGradual Tension MethodsGradual Tension MethodsGradual Tension Methods

• Serial excisionSerial excisionSerial excisionSerial excision1111

• Requires many operations (~7) and 30 Requires many operations (~7) and 30 Requires many operations (~7) and 30 Requires many operations (~7) and 30 day LOSday LOSday LOSday LOS

• Whittman patchWhittman patchWhittman patchWhittman patch• Velcro like reapprox toolVelcro like reapprox toolVelcro like reapprox toolVelcro like reapprox tool• Sewn to fascia, adjusted daily to bring Sewn to fascia, adjusted daily to bring Sewn to fascia, adjusted daily to bring Sewn to fascia, adjusted daily to bring

fascia closer together fascia closer together fascia closer together fascia closer together • 82% fascial closure rate 82% fascial closure rate 82% fascial closure rate 82% fascial closure rate 2222

1. Rosen. Am J Surg. Jan 2008;195(1)84-88.2. Tieu BH. J Trauma. Oct 2008;65(4):865-70

Tissue ExpandersTissue ExpandersTissue ExpandersTissue Expanders• Expansible prosthesis placed under tissue to be Expansible prosthesis placed under tissue to be Expansible prosthesis placed under tissue to be Expansible prosthesis placed under tissue to be

stretched through repeated instillationsstretched through repeated instillationsstretched through repeated instillationsstretched through repeated instillations• Advantages include innervated, vascularized, Advantages include innervated, vascularized, Advantages include innervated, vascularized, Advantages include innervated, vascularized,

autologous tissue autologous tissue autologous tissue autologous tissue • Provides dynamic, tension-free support without free Provides dynamic, tension-free support without free Provides dynamic, tension-free support without free Provides dynamic, tension-free support without free

tissue transfer.tissue transfer.tissue transfer.tissue transfer.• Disadvantages: 20% early exposure/infection rate Disadvantages: 20% early exposure/infection rate Disadvantages: 20% early exposure/infection rate Disadvantages: 20% early exposure/infection rate 1111 • Requires many treatmentsRequires many treatmentsRequires many treatmentsRequires many treatments• Have been used to cover large defects Have been used to cover large defects Have been used to cover large defects Have been used to cover large defects 22221. Mastery of Plastic and Reconstructive Surgery, Vol. 1,

1st Ed.1994.2. Plast. Reconstr. Surg. 94: 379, 1994.

Preoperative Progressive Preoperative Progressive Preoperative Progressive Preoperative Progressive Pneumoperitoneum (PPP)Pneumoperitoneum (PPP)Pneumoperitoneum (PPP)Pneumoperitoneum (PPP)

•First described in 1940 by Dr. Ivan Goni-Moreno for giant ventral First described in 1940 by Dr. Ivan Goni-Moreno for giant ventral First described in 1940 by Dr. Ivan Goni-Moreno for giant ventral First described in 1940 by Dr. Ivan Goni-Moreno for giant ventral herniasherniasherniashernias•Used as early as 1954 Koontz AR Used as early as 1954 Koontz AR Used as early as 1954 Koontz AR Used as early as 1954 Koontz AR Ann Surg. Ann Surg. Ann Surg. Ann Surg. 1954;140:7591954;140:7591954;140:7591954;140:759––––762.762.762.762.•increases the capacity of the retracted abdominal cavity, increases the capacity of the retracted abdominal cavity, increases the capacity of the retracted abdominal cavity, increases the capacity of the retracted abdominal cavity, performs a pneumatic lysis of intestinal adhesions, allows the performs a pneumatic lysis of intestinal adhesions, allows the performs a pneumatic lysis of intestinal adhesions, allows the performs a pneumatic lysis of intestinal adhesions, allows the reduction of the hernia contents, and improves diaphragmatic reduction of the hernia contents, and improves diaphragmatic reduction of the hernia contents, and improves diaphragmatic reduction of the hernia contents, and improves diaphragmatic functionfunctionfunctionfunction1-31-31-31-3

•Contraindicated in cardiac and pulmonary insuff, infected Contraindicated in cardiac and pulmonary insuff, infected Contraindicated in cardiac and pulmonary insuff, infected Contraindicated in cardiac and pulmonary insuff, infected abdominal wall and incarcerated herniasabdominal wall and incarcerated herniasabdominal wall and incarcerated herniasabdominal wall and incarcerated hernias1. Willis S. 1. Willis S. 1. Willis S. 1. Willis S. Hernia. Hernia. Hernia. Hernia. 2000;4:1052000;4:1052000;4:1052000;4:105––––111.111.111.111.2.2.2.2. Mayagoitia JC. Mayagoitia JC. Mayagoitia JC. Mayagoitia JC. Hernia. Hernia. Hernia. Hernia. 2006;10:2132006;10:2132006;10:2132006;10:213––––217.217.217.217.3.3.3.3. Murr MM. Murr MM. Murr MM. Murr MM. Obes Surg. Obes Surg. Obes Surg. Obes Surg. 1994;4:3231994;4:3231994;4:3231994;4:323––––327. 327. 327. 327.

PPPPPPPPPPPP

• Many catheters used (foley, dialysis Many catheters used (foley, dialysis Many catheters used (foley, dialysis Many catheters used (foley, dialysis catheter, central venous catheter, catheter, central venous catheter, catheter, central venous catheter, catheter, central venous catheter, veress needle)veress needle)veress needle)veress needle)

• Gases used are, ambient air, NO and Gases used are, ambient air, NO and Gases used are, ambient air, NO and Gases used are, ambient air, NO and CO2. NO lasts longer.CO2. NO lasts longer.CO2. NO lasts longer.CO2. NO lasts longer.

• After 4 days, no real increase in After 4 days, no real increase in After 4 days, no real increase in After 4 days, no real increase in expansion expansion expansion expansion 1111

1. Ann Saudi Med. 2010 Jul1. Ann Saudi Med. 2010 Jul1. Ann Saudi Med. 2010 Jul1. Ann Saudi Med. 2010 Jul––––Aug; 30(4): 317Aug; 30(4): 317Aug; 30(4): 317Aug; 30(4): 317––––320320320320

HSV – hernia sac volume

ACV – abdominal cavity volume

VR – volume ratio

HSV >25% ACV -> PPP

•500 ml initially of gas

•Then 500 ml daily until volume reached

•OR after HSV reached

Autologous Grafts and Flap Autologous Grafts and Flap Autologous Grafts and Flap Autologous Grafts and Flap ClosureClosureClosureClosure

• Use native tissueUse native tissueUse native tissueUse native tissue• Tensor fascia lata graft (often a free Tensor fascia lata graft (often a free Tensor fascia lata graft (often a free Tensor fascia lata graft (often a free

fascial graft) fascial graft) fascial graft) fascial graft) • Flap selection based on location and Flap selection based on location and Flap selection based on location and Flap selection based on location and

arc of rotation arc of rotation arc of rotation arc of rotation

Common flaps used Common flaps used Common flaps used Common flaps used

Free tissue transferFree tissue transferFree tissue transferFree tissue transfer

• Requires adequate recipient vesselsRequires adequate recipient vesselsRequires adequate recipient vesselsRequires adequate recipient vessels• Allows to transfer innervated muscleAllows to transfer innervated muscleAllows to transfer innervated muscleAllows to transfer innervated muscle• Technically more demandingTechnically more demandingTechnically more demandingTechnically more demanding• Required for large abdominal wall Required for large abdominal wall Required for large abdominal wall Required for large abdominal wall

defects (loss of abdominal wall from defects (loss of abdominal wall from defects (loss of abdominal wall from defects (loss of abdominal wall from trauma, cancer resections, etc)trauma, cancer resections, etc)trauma, cancer resections, etc)trauma, cancer resections, etc)

Autodermal GraftsAutodermal GraftsAutodermal GraftsAutodermal Grafts• Use of full thickness skin as bridgeUse of full thickness skin as bridgeUse of full thickness skin as bridgeUse of full thickness skin as bridge• Skin graft over defect excisedSkin graft over defect excisedSkin graft over defect excisedSkin graft over defect excised• Several ways to prepare graft:Several ways to prepare graft:Several ways to prepare graft:Several ways to prepare graft:

- remove subq layer, implant upside down- remove subq layer, implant upside down- remove subq layer, implant upside down- remove subq layer, implant upside down- perforate skin - perforate skin - perforate skin - perforate skin - boil in NS x 5 seconds, use scalpel to - boil in NS x 5 seconds, use scalpel to - boil in NS x 5 seconds, use scalpel to - boil in NS x 5 seconds, use scalpel to remove epidermisremove epidermisremove epidermisremove epidermis- soak in 96% ethanol x 3 min, rinse in - soak in 96% ethanol x 3 min, rinse in - soak in 96% ethanol x 3 min, rinse in - soak in 96% ethanol x 3 min, rinse in saline, perf skinsaline, perf skinsaline, perf skinsaline, perf skin

• Used as onlay repairsUsed as onlay repairsUsed as onlay repairsUsed as onlay repairs

Hernia ProphylaxisHernia ProphylaxisHernia ProphylaxisHernia Prophylaxis

• Placement of mesh at the time of index Placement of mesh at the time of index Placement of mesh at the time of index Placement of mesh at the time of index laparotomy is safe and low hernia RR at laparotomy is safe and low hernia RR at laparotomy is safe and low hernia RR at laparotomy is safe and low hernia RR at 1 year 1 year 1 year 1 year 1-21-21-21-2 (particularly in obese) (particularly in obese) (particularly in obese) (particularly in obese)

• Animal models with growth factor and Animal models with growth factor and Animal models with growth factor and Animal models with growth factor and cytokine injection in abdominal wall or cytokine injection in abdominal wall or cytokine injection in abdominal wall or cytokine injection in abdominal wall or growth factor impregnated mesh after growth factor impregnated mesh after growth factor impregnated mesh after growth factor impregnated mesh after laparotomy decrease incisional hernias laparotomy decrease incisional hernias laparotomy decrease incisional hernias laparotomy decrease incisional hernias 3-53-53-53-5

1. Curro G. Obes Surg. 2010 Sep 19. Epub.

2. Strzelczyk JM. Br J Surg. 2006. Nov;93(11):1347-50.

3. Heybeli T. Chirurgia. 2010 Nov-Dec;105(6):809-16

4. Robson MC. Wound Repair Regen. 2004 Jan-Feb.;12(1):38-43.

5. Franz MG. J Surg Res. 2001. May 15;97(2):109-16

Technical KeyTechnical KeyTechnical KeyTechnical Keys to Success s to Success s to Success s to Success for Preventionfor Preventionfor Preventionfor Prevention

• For primary fascial closure at index For primary fascial closure at index For primary fascial closure at index For primary fascial closure at index laparotomy:laparotomy:laparotomy:laparotomy:- 4:1 suture:wound length - 4:1 suture:wound length - 4:1 suture:wound length - 4:1 suture:wound length - monofilament non/slowly absorbable - monofilament non/slowly absorbable - monofilament non/slowly absorbable - monofilament non/slowly absorbable suturesuturesuturesuture- 1 cm bites with 1 cm travel- 1 cm bites with 1 cm travel- 1 cm bites with 1 cm travel- 1 cm bites with 1 cm travel

AlgorithmAlgorithmAlgorithmAlgorithmSurgery. 2010 Sep;148(3):544-58. Epub 2010 Mar 20.

ConclusionsConclusionsConclusionsConclusions• Wound biology holds key to lessening Wound biology holds key to lessening Wound biology holds key to lessening Wound biology holds key to lessening

recurrencerecurrencerecurrencerecurrence• Functional restoration should be Functional restoration should be Functional restoration should be Functional restoration should be

standard approachstandard approachstandard approachstandard approach• All VIH should consider reinforcement All VIH should consider reinforcement All VIH should consider reinforcement All VIH should consider reinforcement

with prosthetic (bridge/underlay)with prosthetic (bridge/underlay)with prosthetic (bridge/underlay)with prosthetic (bridge/underlay)• Suture repair and inlay repair of VIH Suture repair and inlay repair of VIH Suture repair and inlay repair of VIH Suture repair and inlay repair of VIH

should be abandonedshould be abandonedshould be abandonedshould be abandoned• VIHR should be customized to each VIHR should be customized to each VIHR should be customized to each VIHR should be customized to each

patientpatientpatientpatient