Introduction

A Ventral Hernia is defect in the anterior abdominal wall.

Types of Ventral Hernias

Ventral hernias comprise primary and acquired subtypes. Primary hernias commonly include umbilical and epigastric with secondary hernias including traumatic or incisional.

Pathogenesis

Primary hernias may be congenital especially at the level of the umbilicus where there is a defect from the umbilical cord. Incisional hernias are believed to be the failure of laparotomy closure with risks factors for hernia formation including wound infection, diabetes, increased intra-abdominal pressure, obesity, malnutrition, comorbid conditions, and medications such as steroids. There is also probably a genetic component with “hernia formers” which still has to be studied.

Symptoms

Patients complain of a bulge or pain related to the protrusion. Some patients complain of vague abdominal symptoms. In an acute situation, a ventral hernia may present with a bowel obstruction from incarcerated or strangulated bowel.

Preop Operative Considerations

Imaging including CT scan may be invaluable in assessing a morbidly obese patient without clear evidence of a palpable defect on exam. Imaging in other cases may not be necessary. Preoperative preparation of the patient should include medical optimization, and lifestyle modification if necessary, such as smoking cessation and weight loss.

Methods of Hernia Repair

Open hernia repairs have been performed initially with simple suture repair and “vest over pants” techniques. These have been reported to have a recurrence rate as high as 30-50%. Open mesh repair has decreased the recurrence rate to less than 10%, but is associated with a wound complication rate over 10%. The gold standard of open hernia repair is the Rives Stoppa repair with retrorectus placement of mesh.

History of Laparoscopic Ventral Hernia Repair

Laparoscopic ventral hernia repair was first described in 1992 by Karl Leblanc. It is based on the tenets of the open Rives Stoppa repair that placement of mesh in preperitoneal/intraperitoneal location provides even force distribution which may lead to greater strength and lower recurrence rates.

Contraindications for Laparoscopic Ventral Hernia Repair

Absolute contraindications include a patient with any contraindications to laparoscopy, and an unstable patient. Relative contraindications include loss of domain hernia, and incarceration.

Method of Laparoscopic Hernia Repair

Patient positioning is usually supine with arms tucked or out as necessary. Lateral positioning may be used for flank hernias. Preoperative antibiotics are administered and antiembolic measures are taken. A bladder catheter is often placed in cases with a large or lower abdominal hernia. Access may be gained either in a open fashion or with veress needle in a location which is remote from other incisions and the hernia. Left and right upper quadrants are often chosen locations. Once access is gained into the peritoneal cavity, adhesions are taken down, and the hernia is reduced. The defect in the abdominal wall is measured, and mesh is sized to provide coverage 3-5 cm to healthy fascia. Some surgeons close the midline defect either intraperitoneally or by using transfascial sutures. Mesh designed for intraabdominal placement is then chosen, marked, and inserted into the peritoneal cavity. It is then fixed in place using point and suture fixation.

Outcomes

There is limited data from randomized trials, but a meta-analysis including 700 patients which included both laparoscopic and open groups demonstrated a lower rate of perioperative complications and hospital stay, with a longer operative time. A comparison of selected large case series also shows a lower infection rate and recurrence rate.

References

1. 1. LeBlanc, K A. Booth, W V. Laparoscopic repair of incisional abdominal hernias using expanded polytetrafluoroethylene: preliminary findings.Surg Laparosc Endosc. 3(1):39-41, 1993 Feb.
2. 2. Goodney, Philip P. Birkmeyer, Christian M. Birkmeyer, John D. Short-term outcomes of laparoscopic and open ventral hernia repair: a meta-analysis. Arch Surg. 137(10):1161-5, 2002 Oct.
3. 3. Cobb, William S. Kercher, Kent W. Heniford, B Todd. Laparoscopic repair of incisional hernias. [Review] Surg Clin North Am. 85(1):91-103, ix, 2005 Feb.