Ventral wall hernia repair Flashcards
(15 cards)
What are the 3 key principals of ventral wall hernia repair?
Dissection of hernia sac
Assessment and reduction of hernia contents
Repair of the defect with sublay mesh. Minimizing tension
Operative plan:
Retro-rectus sublay mesh
Give four steps for preoperative preparation
Patient selection: BMI >35 ideally
Patient optimization - wt loss, smoking cessation, diabetes control
Assess Hernia with CT for operative planning
Examine patient awake (both laying and standing), marked out hernia
What is the preferred mesh for ventral wall incisional hernia repair?
Flat sheet mesh - synthetic, macroporous, medium - heavy weight
Or composite ventral patch for small defects
Positioning/in theatre prep
GA. supine, arms out, Ivabx,
Three key steps of procedure
Incision
Exposure - dissection of sac, assessment and reduction of sac contents, repair of defect
Closure
What are the principles for making your incision in this repair?
For incisional hernia excise prior scar
Aim to enter in virgin area
Describe the process of dissecting the sac
Identify Hernia sac. Dissect out sac in entirety down to fascia around whole circumference
Inspect and palpate for other defects as often multiple adjacent
Clear fascia for 3-5cm from defect edge in all directions
Describe assessment and reduction of the sac contents
Place two artery clips on peritoneum, cut inbetween
Examine contents
Do adhesolysis if required
If viable → reduce contents
If non-viable or to large to reduce → resectin.
NB: incisional hernia are usally wide neck so are unlikely to incarcerate or require bowel resection
Close peritonum/hernia sac - absorable vicryl 2/0
How do you repair a small 2-4cm ventral wall defect?
Small hernias 2-4cm
then I will close primarily with the aid of a V-patch composite circular mesh
Mesh placed intra or preperitoneally and secure to fascia
Fascia closed with interrupted 0 PDS over top and mesh tassels removed
How do you repair a 4-10cm ventral wall hernia?
Rectro-rectus repair or pre-peritoneal
Incision in posterior rectus sheath and dissection laterally in retro-rectus plane keepin posterior fascia intact
Continue in all directions around defect
Close posterior sheath with 0 PDS continuous suture
Place mesh in dissected plane on posterior sheath
Aim for ≥5cm overlap with measure defect edge
Secure interrupted tacking 3/0 PDS sutures
Close anterior fascia sheath over mesh with running O PDS continuous suture
How do you close a >10cm/giant ventral wall hernia?
Same principles as for 4-10cm
I leave a SC drain if large hernia and significant potential space
Staples to skin
Post op instructions
No heavy lifting for at least six weeks
Pitfall - you are unable to close the fascia. How do you address this?
Utilisation of facial release/component separation
I start with anterior release in longitudinal fashion 1cm lateral to the Linea Semilunaris from costal margin to level ASIS
Combined with mobilisation lateral in plane between EOA and IO muscle
This should allow up to 5cm each side
Can combine with posterior release also
Pitfall: there is a visceral injury during dissection
Do not place mesh as contaminated field
Suture repair only
Consider mayo repair - overlap/double breasted
