The document discusses the epidemiology, risk factors, classifications, diagnosis, and treatment of incisional hernias, which occur in 10-15% of patients with prior abdominal incisions. Treatment options include operative repair with various types of mesh, emphasizing that mesh repair is preferred for larger hernias due to lower recurrence rates. It also outlines surgical techniques and approaches, including open, laparoscopic, and robotic repairs, while highlighting the importance of mesh type and placement in achieving successful outcomes.

1. REPAIR OF INCISIONAL
HERNIA
Dr. Saujanya Jung Pandey
Resident General Surgery

2. •The muscles of the abdominal wall:
✔ Medially: Rectus abdominus and
✔ Laterally: External oblique, internal
oblique, and transversus abdominis

3. Sabiston’s textbook of surgery-21st Edition

4. EPIDEMIOLOGY
• Incisional hernia occurs in approximately 10 to 15 percent of patients with
a prior abdominal incision(1)
• The incidence depends upon the location and size of the incisions
• Incisional hernias can also develop at some laparoscopic trocar sites
1. Nachiappan S, Markar et al.Prophylactic mesh placement in high-risk patients undergoing elective laparotomy:
a systematic review. World J Surg. 2013 Aug;37(8):1861-71. doi: 10.1007/s00268-013-2046-1. Erratum in:
World J Surg. 2013 Jul;37(7):1747. Karthikesaligam, Alan [corrected to Karthikesalingam, Alan]. PMID:
23584462.

5. Ameta analysis of 11 studies examining the incidence of ventral hernia formation
after various types of abdominal incisions has concluded that the risk is
10.5% for midline,
7.5% for transverse, and
2.5% for paramedian incisions
Carlson MA, Ludwig KA, Condon RE. Ventral hernia and other complications of 1,000 midline incisions. South
Med J. 1995;88:450–453.

6. Risk factors
Patient factors
• old age
• obesity
• smoking
• malnutrition
• immunosuppressive therapy and
• connective tissue disorders
Technical factors
• Wound infection
• Suboptimal fascial closure
• Abdominal fascial dehiscence
• Type of abdominal surgery

7. CLASSIFICATION
• Incisional hernias can be classified by anatomical or clinical criteria.
• Anatomical classification:
• The European Hernia Society (EHS) classification for incisional abdominal
wall hernias divides the abdomen into a medial zone and a lateral zone

8. Anatomical classification:
• The medial zone: defined as medial to the
lateral margin of the rectus sheath
• It is subdivided into five subzones (subxiphoid,
epigastric, umbilical, infraumbilical, and
suprapubic).
• The lateral zone is subdivided into four
subzones (subcostal, flank, iliac, and lumbar)

9. European Hernia Society Classification

11. CLASSIFICATION
• As an indication of its size, the width of a hernia is classified into three categories
of <4 cm, 4 to 10 cm, and >10 cm
• Clinical classification:
Based on the clinical presentation, incisional hernias can be asymptomatic,
reducible, incarcerated, or strangulated.
• A population study of over 23,000 patients undergoing nonoperative management
of an incisional hernia reported a cumulative incarceration rate of 1.24 percent at
one year and 2.59 percent at five years*
• Although rare, incarcerated incisional hernia can be associated with a high all-
cause mortality (7.2, 10, and 14 percent at 30, 90, and 365 days, respectively).
*Dadashzadeh ER, Huckaby LV, et al. The Risk of Incarceration During Nonoperative Management of
Incisional Hernias: A Population-based Analysis of 30,998 Patients. Ann Surg. 2022 Feb
1;275(2):e488-e495. doi: 10.1097/SLA.0000000000003916. PMID: 32773624; PMCID: PMC8917417.

12. Clinical features of
incisional hernia
• Localized swelling or diffuse bulging
• Peristalsis may be seen in the
underlying intestine
• Dermatitis
• Partial intestinal obstruction are common
• Strangulation is less frequent (broad-
necked)

13. • Combined from Ventral hernia
working group grading scale and
EHS classification (table)
• The Ventral hernia working group
grading scale uses patients
comorbidities and wound class to
predict SSO risk
• EHS assesses hernia width and
location.

14. DIAGNOSIS
• clinically in most patients without obesity
• computed tomography (CT) of the abdomen and/or pelvis to confirm the
presence of a hernia and identify any contents that might be contained
within the hernia sac

15. Treatment of incisional hernia
• Asymptomatic incisional hernias:
✔ may not require treatment at all.
✔ The wearing of an abdominal binder
or belt
Operative repair:
✔Small (≤2–3 cm in diameter):
Primary repair
✔Larger defects (>2–3 cm in diameter):
are repaired with a mesh

16. MESH repair
• The lightweight mesh < 40 g/m2;
• medium weight mesh, 40 to 60 g/m2; and
• intermediate weight mesh, 60 to 75 g/m2 with
• heavy weight mesh weighing more than 75 g/m2.
• These lightweight mesh products often have an absorbable component of
material that provides initial handling stability, typically composed of Vicryl
(polyglactin 910) or Monocryl (poliglecaprone 25; Ethicon, Somerville, NJ).

17. • In a randomized controlled trial evaluating lightweight versus heavyweight
polypropylene mesh for ventral hernia repair, the recurrence rate in the
lightweight group was more than twice that in the heavyweight group
• (17% for lightweight mesh vs. 7% for heavyweight mesh), which
approached statistical significance (P = 0.052). (1)
• In a recent randomized controlled trial, heavyweight mesh has been
shown to exhibit less recurrence and chronic pain 2 years after
laparoscopic TEP inguinal repair compared to lightweight mesh. (2)
1. Burgmans JP, Voorbrood CE, Simmermacher RK, et al. Long-term results of a randomized double-blinded
prospective trial of a lightweight (Ultrapro) versus a heavyweight mesh (Prolene) in laparoscopic total
extraperitoneal inguinal hernia repair (TULP-trial). Ann Surg. 2016;263:862–866.
2. Melkemichel M, Bringman SAW, Widhe BOO. Long-term comparison of recurrence rates between different
lightweight nd heavyweight meshes in open anterior mesh inguinal hernia repair: a nationwide population-
based register study. Ann Surg. 2019.

18. Prosthetic material
• Three general categories of mesh used in the repair of ventral hernias are
synthetic mesh, biologic mesh, and biosynthetic mesh
• Permanent Synthetic Materials:
• Synthetic meshes are either woven from an extruded monofilament (eg,
polypropylene or polyester) or created from expanded
polytetrafluoroethylene (ePTFE) and
• can be subcategorized by weight/density (ultra-lightweight to super-heavy
weight) as well as by material; composition; pore characteristics; and
mechanical parameters, including tensile and burst strength, elasticity, and
stiffness
• In extraperitoneal position: macroporous unprotected mesh is appropriate
like polypropylene and polyester

19. • Intraperitoneal position:
• A single sheet of mesh with both sides constructed to reduce adhesions
and a composite-type mesh with one side made to promote tissue
ingrowth and the other to resist adhesion formation are available
• composed of expanded polytetra fluoroethylene (ePTFE).
• This prosthetic has a visceral side that is microporous (3 μm) and an
abdominal wall side that is macropoous (17–22 μm) and promotes tissue
ingrowth.

20. Biologic Materials
• Nonsynthetic, natural tissue mesh
• These products can be categorized on the basis of the source material
(e.g., human, porcine, bovine),
• postharvesting processing techniques (e.g., cross-linked, non–cross-
linked), and
• sterilization techniques (e.g., gamma radiation, ethylene oxide gas
sterilization, nonsterilized).
• These products are largely composed of acellular collagen and
theoretically provide a matrix for neovascularization and native collagen
deposition
• Advantages in infected or contaminated cases in which synthetic mesh is
thought to be contraindicated

21. Absorbable Synthetic Materials
• Long-acting resorbable meshes are synthetically derived products with
resorption profiles between 6 and 36 months.
• Polyglactin
• Variations of this material have been produced, resulting in slower
hydrolysis and better handling characteristics at the time of implantation.
• In a prospective case series, slowly resorbable polyglactin mesh was
found to have an acceptable recurrence rate of 17% when placed in a
retromuscular position during contaminated complex ventral hernia repair*
*Rosen MJ, Bauer JJ, Harmaty M, et al. Multicenter, prospective, longitudinal study of the recurrence, surgical site
infection, and quality of life after contaminated ventral hernia repair using biosynthetic absorbable mesh: the
COBRA Study. Ann Surg. 2017;265:205–211.

22. Mesh location
• The mesh can be placed above the fascia (onlay),
• between the rectus muscles and peritoneum/posterior rectus sheath
(sublay),
• below the peritoneum (underlay or intraperitoneal onlay), or
• in between fascial edges (inlay)

24. Mesh size
• The mesh used for ventral hernia repair should be sufficiently large to
permit >2 cm overlap for open repair of small primary ventral hernias (<1
cm in diameter)
• >3 cm overlap for open repair of medium primary ventral hernias (1 to 4
cm in diameter)
• >5 cm overlap for open repair of large primary ventral hernias (>4 cm in
diameter) or ventral incisional hernia
• and >5 cm overlap for all laparoscopic repairs
Henriksen NA, Montgomery A, et al. European and Americas Hernia Societies (EHS and AHS).
Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and
Americas Hernia Society. Br J Surg. 2020 Feb;107(3):171-190. doi: 10.1002/bjs.11489. Epub 2020
Jan 9. PMID: 31916607.

25. Mesh versus nonmesh repair
• For all ventral hernias with a defect >1 cm in a clean field, a mesh repair is
preferred over nonmesh repair
• Mesh is a required element of all laparoscopic or robotic ventral hernia
repairs
• and has been shown to decrease recurrences after open ventral repair of
various types of ventral hernias
• On the other hand, mesh repairs are associated with a higher rate of
wound complications including infections than repairs without mesh

26. Operative Technique
• repaired with sutures, mesh, component separation, or any
combination of the above.
• Simple suture repair is performed using an open approach
• Mesh repair and component separation can be performed open,
laparoscopically, or robotically.

27. Myofascial releases
• Fascial layer being separated from a muscular layer in the
abdominal wall.
• To reestablish the linea alba
• Protects the mesh from superficial wound issues, and might
result in a more durable repair.

28. COMPONENT SEPARATION
• Ramirez first described the term ‘component separation’ in 1990 as a way
large abdominal wall defects can be reconstructed with functional transfer
of abdominal wall components.
• Purpose of component separation:
1. Relieve tension on midline fascial closure
2. Facilitate the retromuscular mesh placement

29. Techniques of component separation
• Anterior component separation
• Posterior component separation
• Both allow for a maximum bilateral rectus advancement of approx. 20 cm
• TAR (transversus abdominis release) allows significant posterior fascial
advancement > 20 cm
• Both component should not be performed concomitantly

30. Anterior component separation
• separating the lateral muscle layers of the abdominal wall to allow their
advancement.
• Primary fascial closure at the midline is often possible.
• Performed by raising large subcutaneous flaps above the external oblique
fascia
• Flaps are carried laterally past the linea semilunaris
• Relaxing incision is made 2 cm lateral to the linea semilunaris on the
lateral external oblique aponeurosis from several centimeters above the
costal margin to the pubis

32. • Although this technique often allows tension-free closure of these large
defects, recurrence rates as low as 20% have been reported with the use
of prosthetic reinforcement in large hernias
• To date, no randomized controlled trials have supported a lower
recurrence rate with biologic prosthetic reinforcement.
• If a bioprosthetic is placed, it can be secured with an underlay or onlay
technique.
• No comparative data exist demonstrating the superiority of either repair
technique.

33. Posterior component separation
• In larger hernias or in those patients with atrophic narrowed
rectus muscle
• Rives-Stoppa retrorectus dissection
• TAR

34. Rives-Stoppa retrorectus dissection
• In 1980s by Jean Rives and rene stoppa, french
• Medial division of posterior rectus sheath
• Lateral extents is limited by linea semilunaris

35. transversus abdominis release (TAR)
• Division of TA muscle, conferred the name TAR
• advancement can be obtained by incising the posterior rectus sheath
approximately 1 cm medial to the linea semilunaris.
• At this location, the posterior leaflet of the internal oblique and the
transversus are incised to gain access to either the pretransversalis plane
or the preperitoneal space.
• Provide adequate mesh overlap and facilitate posterior sheath closure
• Well vascularized plane

36. Indication for TAR
• Large or complex hernia
• Subxiphoid hernia
• Parastomal hernia
• Flank hernia
• Suprapubic hernia

37. Choosing a surgical approach
• Open versus laparoscopic repair
• Robotic versus laparoscopic repair

38. Open versus laparoscopic repair
• Several prospective randomized trials have compared laparoscopic and
open ventral hernia repairs
• Although most of these studies were small, with fewer than 100 patients,
the results tend to favor a laparoscopic approach for small to medium
sized defects.
• The incidence of postoperative complications and recurrence were less in
hernias repaired laparoscopically

40. Robotic versus laparoscopic repair
• Two trials published so far mostly < 4cm showed the robotic repair with
intraperitoneal mesh had similar outcome to its laparoscopic counterpart.
• Required longer operative time and higher cost.

41. References
• Williams N, O’Connell PR, McCaskie AW. Bailey & Love’s Short Practice of
Surgery. 27th edition. Florida (US): CRC Press; 2017. Chapter 60, Abdominal
wall, hernia and umbilicus; p. 1022-46.
• Townsend CM et al. Sabiston: Textbook of Surgery: The Biological Basis of
Modern Surgical Practice. 21st edition. Missouri (US): Elsevier; 2022. Chapter 45,
Hernia; p. 1105-33

42. THANK YOU!