Postoperative Hernia

Simple nonprosthetic repair

Simple nonprosthetic repair of an incisional hernia is reserved for only the least complicated defects, because in large series of unselected patients, the recurrence rate ranges from 25 to 55%.

If there is a solitary defect 3 cm or less in diameter, primary closure with nonabsorbable suture material is appropriate.

Some surgeons use Mayo’s “vest-over-pants” repair. Various advancement and darn procedures have also been described.

A more substantial repair for these defects was popularized by Ramirez. In this operation, known as the component separation technique, the abdominal wall is lengthened by allowing the muscle to separate on either side of a defect. The hernia can then be repaired primarily with less tension on the repair. This procedure is especially useful at contaminated hernia sites.

A similar procedure is the keel operation of Maingot, which was popular in the middle of the 20th century. The anterior rectus sheath is incised longitudinally, and the medial edge is allowed to rotate behind the rectus abdominis. This, in effect, lengthens the posterior rectus sheath, allowing it to be closed under less tension. The lateral edges of the incised rectus sheath on each side are then approximated to each other.

Onlay prosthetic repair

In this technique, a prosthetic onlay is placed over any of a wide variety of simple repairs. Large series of selected patients have documented acceptable results with onlay prosthetic repair, but most surgeons feel that this technique offers little advantage over the simple repair that the prosthesis overlies.

Prosthetic bridging repair

Prosthetic bridging repair became popular in the 1990s, in keeping with the tension-free concept for inguinal herniorrhaphy.

When a hernia defect is bridged with a mesh prosthesis, every attempt should be made to isolate the material from the intraabdominal viscera to prevent erosion and subsequent fistula formation or adhesive bowel obstruction. This can be accomplished by means of a peritoneal flap constructed from the peritoneal sac or omentum. When contact with intra-abdominal organs cannot be avoided, expanded polytetrafluoroethylene (e-PTFE) should be strongly considered for the prosthesis. Most authorities feel that complications are less likely with e-PTFE, though this has not been unequivocally shown to be the case.

Combined fascial and mesh closure

The issue of contact between the intra-abdominal viscera and the prosthesis has been further addressed by techniques that combine features of the component separation technique with the tension-free concept. The posterior fascia is closed primarily, but the anterior fascia is allowed to remain open, so that there is no tension at all. The anterior fascia is then bridged with a prosthesis.

Sublay prosthetic repair

Sublay prosthetic repair, sometimes referred to as the retromuscular approach, is characterized by the placement of a large prosthesis in the space between the abdominal muscles and the peritoneum.

The posterior rectus sheath is opened on each edge of the hernia defect and dissected away from the undersurface of the recti or a distance of 10 to 15 cm. The posterior rectus sheaths are hen approximated to each other primarily. A large mesh prosthesis (composed of e-PTFE if the approximation of the posterior rectus sheath is inadequate) is then placed in this space outside he repaired posterior sheath but beneath the recti. The mesh is secured in this position with several sutures that are placed with a suture passer through small stab incisions at the periphery of he prosthesis and tied in the subcutaneous tissue above the fascia.