Hernia

HERNIA
By Dr. Mengistu.K 12/18/2020Dr.mengistu
1

HERNIA
• A hernia is a protrusion of a viscus or part of a viscus
through an abnormal opening in the walls of its
containing cavity.
• The external abdominal hernia is the most common
form, the most frequent varieties being the inguinal,
femoral and umbilical, accounting for 75% of cases .
• The rarer forms constitute 1.5%, excluding incisional
hernias.
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• 75% of all recurrences are due to infection and
inadequate repair material fixation and/or
overlap.
• Midline laparotomies for nonhernia surgery
carry a 25% risk of developing an incisional
hernia
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Wound status Risk of infection
Clean wounds 1% to 5%
Clean-contaminated wounds 3% to 11%
Contaminated wounds 10% to 17%
Dirty or infected wounds: greater than 27%
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The Ventral Hernia Working Group (VHWG) classification system
Grade 1Hernias: low risk, no comorbidities, no history of prior wound
infection, or current contamination
Grade 2 hernias include patients with comorbidities without current wound
contamination or infection
Grade 3 hernias include those with a history of prior wound infection,
presence of a stoma, or concurrent violation of the gastrointestinal tract
Grade 4 hernias are classified as infected with known mesh infections or
septic dehiscence
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Topographic classification
• Midline hernias: from the xiphoid process to the
pubic bone and medial to the lateral margin of
the rectus sheath on both sides.
• Lateral hernias: from costal margin to inguinal
region and from the lateral margin of the rectus
sheaths to the lumbar region.
• By size: W1, 1 to 4 cm; W2, 4 to 10 cm; and W3,
greater than or equal to 10 cm as well as
recurrent nature
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Optimizing known risk factors
• DIABETES MELLITUS
▫ Perioperative hyperglycemia ≥ 160 mg/dL
▫ HbA1c greater than 6.5% was associated with increased
rates of dehiscence
• Outpatient management of diabetes target
▫ HbA1c less than 7%
▫ Preprandial blood glucose level of 90 to 130 mg/dL, and
▫ A peak postprandial blood glucose level of less than 180
mg/dL.
Obtaine HbA1c levels on all patients with BMI greater
than 30 kg/m
• 2
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Smoking and alcohol cessation
• Effects of nicotine on a cellular level
▫ Vasoconstriction and tissue level hypoxia
▫ Increased platelet aggregation, and
▫ reduced fibroblast migration
• Smoking one cigarette decreases cutaneous and
subcutaneous blood flow by 38.1%.
• Smoking cessation of 4 weeks preoperatively
has been shown to reduce wound infection rates
from 12% in 1 pack per day smokers to 1%
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• Alcohol abuse is categorized as ingestion of five
or more drinks (60 g of ethanol) a day.
• Abstinence from alcohol for 1 month
preoperatively reduces postoperative morbidity
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Weight optimization
• BMI should be evaluated in the context of
individual patient and hernia characteristics
• At higher BMI level laparoscopic approach is
considered safe due to the reduced likelihood of
postoperative infections
• In general, a BMI of less than 40 may be
considered safe
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Hernia prevention
• Rate of hernia occurrence after laparotomy
approaches 25% by 3 years
Suture selection
▫ No difference in the hernia rate between permanent
versus absorbable sutures
▫ Short-acting absorbable sutures have higher rates of
hernia formation
Stitch length
▫ Suture-to-wound length ratio greater than 4 : 1
reducing laparotomy failure
Mesh reinforcement
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MANAGEMENT OF A HERNIA
• Options are :
▫ Direct suture repair
▫ Repair using prosthetic material (synthetic,
biologic, or composite mesh)
▫ Using local fascial flap
▫ Mobilization of anatomic layers, or a combined
procedure
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Principles of mesh overlap
• Depends on the size of the defect and vary from
2 to 5 cm, with a 5-cm mesh overlap accepted as
an ideal.
• Ventral hernia defect area will increase with a
rise in intraabdominal pressure (IAP)
• Resting IAP is 2 to 4 mm Hg during jumping
(IAP of 170 mm Hg), coughing (IAP of 100 mm
Hg), Valsalva maneuver (IAP of 40 mm Hg), and
standing (IAP of 20 mm Hg
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Mesh location
• Onlay repair
▫ Secures mesh to the anterior fascia and primary
closure of the fascia below the mesh.
▫ Recurrence: 5%
• Inlay repair
▫ Places the mesh within the hernia defect, securing
it circumferentially to the edges of the fascia
without mesh-tissue integration.
▫ Risk of recurrence: 12.7% due to mesh-to-fascia
interface
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• Sublay repair (retrorectus or Rives-
Stoppa):
▫ Mesh located beneath the rectus complex and
primary closure of fascia over the mesh
▫ Recurrence: 4.4 %
• Underlay:
▫ Deep to the peritoneum
▫ Advantages ; low superficial SSI and lack of skin
flaps
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Algorithm for abdominal wall reconstruction involving
midline defects.
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Mesh material
Classiffication
• Synthetic: polypropylene, polyester, or
polytetrafluoroethylene
• Both polypropylene and polyester are not suitable for
placement within the peritoneal cavity adjacent to the
intestines without the addition of an adhesion barrier.
• Contraindicated in the presence of any degree of
contamination
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• Biologic: like dermis, small intestine
submucosa, urinary bladder, pericardium, and
liver
• Bioabsorbable meshes derived from polylactic
acid, polyglycolic acid,trimethylene carbonate,
silk, and poly-4-hydroxybutyrate.
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Hernia repair algorithm for clean fields. LVHR, Laparoscopic ventral
hernia repair; MIS, minimally invasive surgery; RS,
Rives-Stoppa; TAR, transversus abdominis release

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Hernia repair algorithm for contaminated fields. TAR,
Transversus abdominis release; STORRM, Stapled transabdominal
ostomy reinforcement with retromuscular mesh.

Inguinal anatomy
• Inguinal canal
▫ Cone shaped 4- to 6-cm long
▫ Boundaries
 Anteriorly : external oblique aponeurosis
 Laterally: internal oblique muscle
 Posteriorly: transversalis fascia and transversus
abdominis muscle
 Superiorly: internal oblique and transversus abdominis
muscle, and
 Inferiorly : inguinal (Poupart’s) ligament
▫ Spermatic cord contains three arteries, three veins,
two nerves, the pampiniform venous plexus, and the
vas deferens.
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• Direct hernias protrude within Hesselbach’s
triangle.
• The borders of the triangle are
▫ Inferiorly: inguinal ligament
▫ Medially: lateral edge of rectus sheath and
▫ Superolaterally: inferior epigastric vessels
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• Iliopubic tract :
▫ Aponeurotic band that begins at the anterior
superior iliac spine and inserts into Cooper’s
ligament from above
▫ Forms on the deep inferior margin of the
transversus abdominis and transversalis fascia
▫ Form the inferior margin of the internal inguinal
ring and anteromedial border of the femoral canal
27

• Lacunar(Gimbernat) ligament
▫ Triangular fanning of the inguinal ligament as it
joins the pubic tubercle
• Cooper’s (pectineal) ligament
▫ Lateral portion of the lacunar ligament that is
fused to the periosteum of the pubic tubercle
28

Triangle of Doom
39
Contents
•External iliac vessels
•Deep circumflex iliac vein
•Femoral nerve, and
•Genital branch of the
genitofemoral nerve.

Triangle of pain
40
Contents
•Lateral femoral cutaneous,
•Femoral branch of the
genitofemoral and
•Femoral nerves.

Circle of death
A vascular continuation formed by the common
iliac, internal iliac, obturator, inferior epigastric,
and external iliac vessels
41

INGUINAL HERNIAS
• It is estimated that 5% of the population will develop
an abdominal wall hernia, but the prevalence may be
even higher.
• The male-to-female ratio is greater than 10:1.
• The lifetime prevalence is estimated to be 25% in
men and 2% in women.
• Two-thirds of incident inguinal hernias are
indirect whereas nearly two-thirds of recurrent
hernias are direct.
• Approximately 10% of inguinal hernias will
become incarcerated, and a portion of these may
become strangulated.
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• Recurrence rates after surgical repair are less
than 1% in children and vary in adults related to
the method of hernia repair.
• About 75% of all hernias occur in the inguinal region.
Two thirds of these are indirect, and the remainder
are direct inguinal hernias.
• Men are 25 times more likely to have a groin hernia
than are women.
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• An indirect inguinal hernia is the most common
hernia, regardless of gender. In men, indirect hernias
predominate over direct hernias at a ratio of 2 : 1.
• Although femoral hernias occur more frequently in
women than in men, inguinal hernias remain the most
common hernia in women.
• Femoral hernias are rare in men.
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• Both indirect inguinal and femoral hernias occur
more commonly on the right side.
• This is attributed to a delay in atrophy of the
processus vaginalis after the normal slower descent
of the right testis to the scrotum during fetal
development.
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• The predominance of right-sided femoral hernias is
thought to be due to the tamponading effect of the
sigmoid colon on the left femoral canal.
• Most strangulated hernias are indirect inguinal
hernias; however, femoral hernias have the highest
rate of strangulation (15%-20%) of all hernias, and
for this reason, it is recommended that all femoral
hernias be repaired at the time of discovery.
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Essential steps
• Do≈ 6–8 cm transversely
or slightly curvilinear
skin incision one to two
fingerbreadths above the
inguinal ligament
• Dissect down through the
subcutaneous and
Scarpa’s layers
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Operative Repair
A

• Identified the external
oblique aponeurosis and
clean inferomedially to
identified external ring
• Incise aponeurosis
sharply and opened along
its length through the
external ring
NB: avoid injury to
iliohypogastric and ilioinguinal
nerves
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B

• Exposed the inguinal canal
and mobilized spermatic cord
• Skeletonize spermatic cord
and defined internal ring and
posterior wall of the canal.
• Dissected the sac and free of
the cord elements
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C
D
E

• Invaginate the sac
• Dissect the sac free close to
the internal ring.
• Transect the sac the and
proceed to specific pure tissue
repair or mesh repair
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F
G
H

Shouldice repair
• Pass two pairs of scissors
posterior to transversalis
fascia at medial aspect of
internal ring to separate it
from preperitonial fat
• Incise transversalis fascia
along entire inguinal floor to
pubic tubercle
• NB: care on inf.epigastric
vessels
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• First layer: free edge of the
lower transversalis flap to the
posterior surface of the upper
flap of transversalis fascia
and lateral part of posterior
rectus sheath from pubic
tubercle to internal ring
continuously.
• Second layer: the upper
transversalis flap to the base
of lower edge and inguinal
ligament on running suture
with out tying first layer.
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• Third layer: continuous
suture conjoined tendon
medially to inguinal
ligament laterally from
tightened internal ring to
pubic tubercle
• Fourth layer: returns to
the internal ring suturing
anterior rectus sheath
medially with the
posterior aspect of the
external oblique
aponeurosis laterally.
54

• Finally : External oblique
aponeurosis is closed in one
to two additional continuous
layers extending down to the
external ring
• Outcome : recurrence rates
less than 1%
55

Bassini repair :
• Is performed by suturing the transversus abdominis
and internal oblique musculoaponeurotic arches or
conjoined tendon (when present) to the inguinal
ligament.
• This once popular technique is the basic approach to
nonanatomic hernia repairs and was the most popular
type of repair done before the advent of tension-free
repairs.
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McVay repair
• Particularly suited for strangulated femoral
hernias
Steps
• Open transversalis fascia and clean posteriorly
• Made 2–4 cm relaxing vertical incision at the
lateral border of the anterior rectus sheath
beginning 1 cm above the pubic tubercle
• Identify cooper’s ligament and dissect free of its
fibrous and fatty attachment
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• Repair the defect using interrupted suture by
affixing the upper boarder of transversalis fascia
to cooper’s ligament from pubic tubercle to
femoral sheath.
• Close the femoral canal by suturing femoral
sheath to cooper’s ligament
• Continue by suturing transversalis fascia to
iliopubic tract laterally until insertion of cord.
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Desarda Repair
• Oblique skin incision
• Dissect down to the external
oblique fascia
• Incise cremasteric muscle and
separated the spermatic cord
from the inguinal floor
• Excise the sac
• Suture medial leaf of the
external oblique aponeurosis to
the inguinal ligament using
interrupted sutures
• Put first two sutures at the
junction of the anterior rectus
sheath and EOA.
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• Each suture is passed first
through the inguinal ligament,
then the transversalis fascia,
and then the EOA
• Do splitting incision at EOA,
medially up to the pubic
symphysis and laterally 1 to 2
cm beyond the reconstructed
abdominal ring.
• Suture free border of the strip
of the EOA to the internal
oblique or conjoined tendon
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LICHTENSTEIN REPAIR
• Tension-free repair of the inguinal floor by
buttressing the floor with a large prosthetic
mesh
• Overlap:
 2 cm onto the pubic tubercle,
 4 cm above Hesselbach triangle, and
 5 to 6 cm lateral to the internal ring.
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Steps
• First secure the mesh
▫ Inferiorly :
 To pubic tubercle on either side and
 Inguinal ligament until it is at least 1 cm lateral to
the insertion of IOM continuously
▫ Superiorly
 To rectus sheath and subsequently to the internal
oblique aponeurosis with interrupted sutures
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• Reconstructs the internal ring
▫ Create two tails by incising from its lateral edge
▫ Encircling the cord
▫ Suture the tails together and tucking the ends of
the tails under the external oblique aponeurosis
▫ Secure superior and inferior tails to the underlying
internal oblique and fascia
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Plug-and-patch (rutkow–robbins) repair
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Complications
• Surgical site infection
▫ Estimated to be up to 5% after open repair.
▫ Mesh infection may lead to a chronically draining
sinus tract and ultimately require mesh
explantation.
• Recurrence
▫ After open tension-free inguinal hernia repair :
1% to 2%
▫ Most common with direct hernias and occur near
the pubic tubercle at the medial border of the
repair.
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• Chronic pain (inguinodynia)
▫ Pain lasting longer than 3 months postoperatively
▫ Occur in 15% to 33% of patients and severe in 2%
to 4%
▫ Commonly affected nerve are ilioinguinal,
iliohypogastric, and genital branch of the
genitofemoral nerves
▫ Debilitating complications of inguinal hernia
repair.
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▫ Nerve injury can occur from traction, mesh or
suture entrapment, electrocautery, and
transection.
▫ May also result from hernia recurrence, mesh-
related problems, and infection.
• Rx : antiinflammatory agents, analgesics, and
anesthetic nerve blocks
• If nerve entrapment suspected: reexploration
and neurectomy.
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• Cord and testicular injuries
▫ Ischemic orchitis
 usually occurs between 1 and 5 days after surgery
 Results from the thrombosis of small veins of the
pampiniform plexus
 Presented with swollen and painful testis with possible
low-grade fever.
 Usually self-limited and managed conservatively
 process may continue for an additional 6 to 12 weeks &
lead to testicular atrophy and
 Most commonly seen after the repair of a recurrent
hernia.
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• Vas deferens injury
▫ Lead to dysejaculation syndrome, likely resulting
from a stenotic lesion
▫ Ipsilateral vas deferens transaction can led to
infertility as a result of sperm antibody
▫ If recognize immediately reanastomosis should be
attempted
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Femoral hernia
• Second most common abdominal wall hernia,
makes up only 5–10% of all hernias.
• 4:1 female predominance in middle-aged to
older women
• High propensity for incarceration and
strangulation
• Primary etiology:- natural loss of tissue strength
and elasticity
• Unlikely to be of congenital
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Anatomy of the femoral hernia
• Femoral canal boundary
▫ Anteriorly: inguinal
ligament
▫ Laterally : femoral vein
▫ Posteriorly: pubic ramus
and Cooper’s ligament
▫ Medially lacunar ligament.
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Treatment
• Transverse incision just below
inguinal ligament or standard
groin hernia incision
• Found the sac dissected, and
reduced into the peritoneal
cavity
Repair options
1. Cooper ligament repair
(McVay )
2. Tacking the inguinal
ligament anteriorly to
Cooper’s ligament
3. purse-string suture: inguinal
ligament...>lacunar
ligament…> pectineal
ligament….> through the
fascia medial to the femoral
vein and back to the inguinal
ligament
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Complication
• Unique complication from suture repair of the
femoral hernia defect is bleeding from an aberrant
obturator artery
• This vessel originates from the inferior epigastric
rather than the internal iliac artery and traverses a
space medial to the femoral hernia defect adjacent to
the pubic ramus.
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Umbilical hernia
• Occurs when the umbilical scar closes incompletely in
the child
• Congenital and are common in infants
• In adults are largely acquired.
• Female: male ratio of 3:1
• Close spontaneously in most cases by the age of 2
years
• Frequently repaired surgically if persist after the age of
5 years
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Treatment
• Made short curvilinear
(smile) incision is just
inferior to the umbilicus in
the typical skin crease.
• Raise a skin flap cephalad
using blunt dissection and
low-level electrocautery
• Dissect through the
subcutaneous tissues and
down to the fascial level
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• Dissect the sac free of its
umbilical attachments, reduced
or inverted into the peritoneal
cavity
• Close fascial defect transversely
with interrupted sutures in a
horizontal mattress fashion
• Tacke the skin of the umbilicus to
fascia layer using a single suture
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Epigastric hernia
• Midline hernia from the xiphoid process superiorly to
the umbilicus inferiorly.
• A paraumbilical hernia is an epigastric hernia that
borders on the umbilicus.
• Incidence: 3% to 5% commonly in middle age males
by a ratio of 3:1
• Twenty percent of epigastric hernias may have
multiple defect.
• In most cases, the hernia is filled by a small amount
of preperitoneal fat only and no peritoneal sac is
present.
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• Midline defect is usually
elliptical in nature, with the
long axis oriented
transversely
• Epigastric hernias that
involve a peritoneal sac
usually contain only
omentum and rarely small
intestine.
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Treatment
• Performed as a day-surgery
procedure under local
anesthesia unless large,
complicated or pediatric
population
• Close the defect transversely
with a few interrupted or
continuous sutures of
polypropylene or nylon
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Obturator hernia(“the little old lady’s
hernia”)
• Protrusion of intra-abdominal contents through the
obturator foramen in the pelvis
• Rare defects represent only 0.05% to 1.4% of all
hernias
• Female: male ratio of 6:1 in the seventh and eighth
decades
• Bilateral in 6% of cases
• Gender discrepancy is often by a broader and
wide pelvis, horizontally inclined obturator canal,
and the increase in pelvic diameter brought
about by pregnancy in female
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Anatomy
Obturator foramen created by
▫ Superiorly superior pubic
ramus
▫ Interiorly: body and inferior
ramus of the pubic bone, and
▫ Inferiorly: ramus and body of
the ischium.
• The canal is ˜3 cm in length, and
the obturator vessels and nerve
lie posterolateral to the hernia
sac in the canal.
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The direction of the obturator hernia
through the obturator canal.

• Hernia sac protrudes along with anterior division of the
obturator nerve, lying beneath the pectineus muscle of
the thigh.
• Hernia sac usually contains small bowel
85

• An alternative pathway is between the upper and
middle fasciculi of the external obturator muscle
along the posterior division of the obturator nerve
• Sac can be found situated posterior to the adductor
brevis muscle
• Least frequent pathway: sac between the internal and
external obturator muscles.
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Clinical presentation
• The natural development of an obturator hernia
▫ First stage: bulging of preperitoneal fat through
the obturator foramen.
▫ Second stage : prolongation of the peritoneum and
formation of a true hernia sac
▫ Third stage : protrusion of viscera and the onset of
clinical symptoms.
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Diagnosis
• Requires a high clinical suspicion
• Intestinal obstruction: most common clinical
manifestation(80%)
• Howship–Romberg sign(15% to 50%)
▫ Pathognomonic of obturator herniation.
▫ Pain in the medial thigh from obturator nerve
compression elicited by extension, abduction, and
medial rotation of the ipsilateral lower extremity.
• Hannington-Kiff sign
▫ An absent adductor reflex
▫ Percussing the medial thigh (over the adductor
muscles) 5 cm above the patellar tendon
89

• Repeated episodes of bowel obstruction that
pass quickly and without intervention.
• Palpable mass found only in an estimated 20%
of patients.
• Occult bilateral obturator hernias in 50% to 63%
• CT is the preferred diagnostic modality with
accuracy of >90%
90

Treatment
• Urgent surgical intervention is crucial b/c rate of
strangulation reaches 50% to 75%
• Operative approaches
▫ Lower midline transperitoneal approach
▫ Lower midline extraperitoneal approach
▫ Anterior thigh exposure.
▫ Laparoscopic transabdominal repair
91

• Lower midline transperitoneal approach
▫ The most common method for repair of obturator
hernias
92

Lower midline extraperitoneal approach
• When the diagnosis of obturator hernia has been
made preoperatively.
• It allows complete exposure of the opening of
the obturator canal.
• Made midline incision from the umbilicus to the
pubis.
• Enter preperitoneal plane deep to the rectus
muscle, and peel bladder from the peritoneum.
• Open the space to expose superior pubic ramus
and the obturator internus muscle
93

Anterior thigh approach
• Made vertical incision in the upper medial thigh
placed along the adductor longus muscle
• Retract the muscle medially to expose
the pectineus muscle, cut across its width to
expose the sac.
• Carefully incise the sac , inspecte the
content,reduced if viable, and excise the sac.
• Close the hernial opening with a continuous
suture layer.
• Midline laparotomy if bowel is not viable
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• Incise sac at the base, reduce the content and
transect the neck of the sac.
• Close internal opening of obturator canal with a
continuous suture include a bite to periosteum
of the superior pubic ramus and the fascia on the
internal obturator muscle
NB: Avoid injury to the obturator vessels and nerve
95

96
The thigh approach for repair of
the obturator hernia

Lumbar hernia
Anatomy and classification
Superior lumbar
triangle(Grynfelt)
o Inverted triangle
o Borderes
o Superiorly: 12th rib
o Anterolaterally: Internal
abdominal oblique muscle
o Posteromedially: quadratus
lumborum muscle
o Roof :latissimus dorsi ms
o Floor: aponeurosis of the
transversalis muscle.
Inferior
triangle(Petit)
o Upright triangle
o Borderes
▫ Inferiorly : iliac crest
▫ Anterolaterally: external
abdominal oblique muscle
▫ Posteromedially: latissimus
dorsi
▫ Floor: lumbodorsal fascia
and transversalis muscl
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• Based on the cause
▫ Congenital hernia: 10% to 20% of lumbar hernias.
▫ Acquired lumbar hernias
 Primary : 55%
 Secondary :diffuse, extending beyond the margins of
the lumbar triangle and rare complication of surgical
procedures involving flank incisions
100

Clinical presentation and diagnosis
• Commonly males in their fifth or sixth decade of
life
• May also have gastrointestinal complaints
• Urinary obstruction or oliguria may be the
presenting symptoms
• Computed tomography (CT) is the preferred
diagnostic modality
• Ultrasonography is an alternative imaging
modality in emergency base
101

• Natural progression: gradual increase in size
over time
• 25% of patients will present with incarcerated
bowel, and
• 10% to 18% will demonstrate evidence of
strangulation
102

Treatment
• Repair of a lumbar hernia is challenging
• Techniques of repair
▫ Simple repair
▫ Musculofascial flaps
▫ Free grafts, and
▫ Repair using synthetic mesh.
103

Open or anterior technique
Traditional approach of lumbar hernia repair
Preferable for hernias with small defect and
well defined with adequate surrounding
musculoaponeurotic tissue.
• Place the patient in the lateral decubitus
position
• Made generous lumbar incision and exploration
of the hernia
104

• Define the edges of the fascial defect
circumferentially.
• Identify the hernia sac, reduce the content,
excise or invert the sac
• If the defect is small, repaire primarily with
nonabsorbable sutures
• For larger defects :-mesh-enforced repair with
reapproximation of the overlying muscle
layers.
Laparoscopic transabdominal andretroperitoneoscopic approaches
105

Spigelian hernias
• Accounting for 0.1% to 2% of all abdominal wall
hernias
• Occur in the sixth and seventh decades
• Affect both sexes and sides equally
• Nearly 50% of patients have a history of previous
laparotomy or laparoscopy
• Diagnosis requires a high index of suspicion
• More than half of all spigelian hernias are
diagnosed intraoperatively.
107

Treatment
• Incidental spigelian hernias should be repaired
electively to avoid incarceration.
• 20% to 30% require emergency intervention.
• Transverse incision and primary repair with low,
but real recurrence rate of about 4%.
• Mesh-based repair (either open or laparoscopic)
is not clear at present for the treatment
108

Incisional Hernia
• Occur as a result of excessive tension and inadequate
healing of a previous incision, which is often
associated with surgical site infection
• Midline laparotomies for nonhernia surgery
carry a 25% risk of developing an incisional
hernia
• 75% of all recurrences are due to infection and
inadequate repair material fixation and/or
overlap
109

Primary suture repair
• Done when the defect is small (≤2 cm in diameter)
• Open the skin through the previous incision and
dissect through the subcutaneous tissues.
• Identify the sac and cleared of its attachments to the
fascia using electrocautery
• Reduce the sac fully to abdominal cavity
• Cleared of the fascia both anteriorly and posteriorly
for at least a 3–4 cm margin
• Close using an interrupted layer of non absorbable
suture
• Confirm that no additional defects
110

• If there is tension:- component separation
• Technique:
▫ Mobilization of the skin and soft tissue off of the
underlying fascia
▫ The fascia of the external oblique is then incised
lateral to the rectus abdominis and the external
oblique is dissected free from the internal oblique
in a relatively avascular plane
• Recurrence rates of primary repair have
approached 30–50% in some series
111

112
Separation of components of the abdominal wall to mobilize the
fascia toward the midline

Mesh repair
• Incisional hernias with a diameter greater than 4 cm
should be repaired with mesh
• Technique:
▫ Old scar is incised and the soft tissue dissected down to the
level of the anterior rectus sheath
▫ Reduce the sac fully to abdominal cavity
▫ Cleared of at least a 3–4 cm rim of healthy fascia
circumferentially
▫ The mesh is then cut to fit the defect with a margin of 3–4
cm on each side
▫ Suture mesh in an interrupted fashion in multiple sites
throughout the entire circumference
• Wound infection :˜5%
• Recurrence: 10%
113

Laparoscopic repair
• The defect is repaired posteriorly and no
dissection within the scarred layer of anterior
fascia
• Allow for identification of additional hernia
defects
• Challenge: port access into a peritoneal cavity-
use LUQ at AAL
• Use same steps as open mesh repair
• Hernia recurrence: 0–11%.
114

Reference
• Shackelford’s surgery of the alimentary tract, 8th
edition
• Maingot’s Abdominal Operations 12th edition
• Schwartz’s Principles of Surgery 11th edition
• Sabiston Textbook of Surgery 20th edition
115

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