Chapter 41. Ventral Hernia Repair

• Incarceration.
• Strangulation.
• Bowel obstruction.
• Functional or cosmetic deformity.
• Threatened overlying skin.
• Pain.

Absolute

• Inability to tolerate general anesthetic (cardiopulmonary risk).
• Absence of tissue for reconstruction (myofascia or skin).
• Massive loss of peritoneal domain.

Relative

• Infection.
• Moderate loss of peritoneal domain.
• Morbid obesity.
• Malnutrition.
• Tobacco use.
• Bleeding diathesis.
• Ascites.

• The patient should be supine for the most common midline incisional hernias.
• Modified decubitus positions are used for flank incisional hernia repairs, with appropriate pressure points padded.
• Limited hip flexion can help relax the abdominal wall musculature.
• Tilting the head of the operating table up or down, left or right, aids in gravity-assisted retraction of the abdominal viscera and reduction of the hernia sac contents.

• Bowel rest until ileus resolves.
• Drains to prevent seroma formation if large flaps are raised.
• Binder for comfort (except after the components separation technique, in which compression may compromise blood flow to the abdominal wall skin flaps).

• Recurrence.
  • Early (within 1 month): usually related to technical issues.
  • Late (after 1 year): most often due to patient factors leading to wound healing problems. The best clinical and preclinical evidence now supports the idea that the majority of incisional hernias are the result of very early laparotomy defects.
• Mesh (wound) infection or mesh extrusion.
• Bowel or bladder injury.
• Hematoma and seroma.
• Pain.