Perioperative management - Incisional hernia repair with open, retromuscular mesh augmentation

According to the guidelines of the EHS and AHS, the open sublay technique is an option for the treatment of primary and secondary abdominal wall hernias with defects between 4 and 10 cm.

With a retromuscular mesh positioning behind the rectus abdominis muscle, this technique is particularly suitable for midline defects.

In the situation of incarceration, depending on the degree of contamination, treatment with a synthetic mesh is indicated only with great caution.

The demonstration of the retromuscular layer as an optimal mesh bed has led to a renaissance of the open sublay procedure in incisional hernia surgery in recent years.

The sublay technique describes a retromuscular preperitoneal position of the mesh, ideally involving a midline reconstruction with closure of the fascia over the mesh. This achieves a good mesh support, with the intra-abdominal pressure on the mesh acting as the strongest component of the closure and supporting its fixation.

In principle, the indication for the repair of an abdominal wall hernia is always given, as the hernia gap and extra-abdominal organ volume will usually continue to enlarge. In larger defects, ventral stabilizing elements of the trunk musculature are lacking. Physically demanding activities and sports may be severely restricted to impossible.

The only exception is an incidental finding in the context of cross-sectional imaging for other reasons. In the absence of symptoms, there is not necessarily an indication for surgery.

For elective procedures, infection-free skin conditions are mandatory; pressure ulcers and superficial skin infections should initially be treated conservatively. The indication for hernia repair in patients with liver cirrhosis and ascites should be critically evaluated, and preoperative optimization of liver function should be considered if necessary. In cases of severe coagulation disorders (Quick < 50%, PTT > 60 s, platelets < 50 /nl) and pronounced portal hypertension with caput medusae, surgery should be avoided, particularly due to the risk of uncontrollable bleeding from abdominal wall vessels. It is also important to ensure a good respiratory situation that is not compromised by acute infections. In the presence of respiratory infections, an elective procedure must be postponed.

An abdominal wall hernia is a clinical diagnosis and can often be easily recognized in a standing patient. It is advisable to additionally examine the patient in a relaxed, lying position. When the patient is asked to lift the upper body, the fascial edge, the extent of the fascial defect, and the surrounding muscles can usually be assessed in reducible incisional hernias.

For smaller primary hernias, abdominal ultrasonography is a significant imaging modality.

To determine the defect location and extent, especially in incisional hernias, and to depict the abdominal wall anatomy, CT is the best diagnostic procedure, alternatively an MRI.

For previous incisional hernia repairs, a corresponding surgical report is often helpful, especially if a mesh repair has already been performed. Here, besides the exact surgical technique (extra- or intraperitoneal mesh placement, augmentation, or bridging of the fascial defect), the type of mesh material is also important.

In extensive findings, thorough cardiopulmonary function diagnostics are recommended due to the increase in pressure after repositioning the protruded viscera.

To better characterize the present hernia, the EHS classification should be used.

Classification of primary ventral hernias

Classification of secondary ventral hernias (incisional hernias)

The classification of secondary abdominal wall hernias is initially based on a medial or lateral defect location in the abdominal wall.

The defect location of medial hernias is then more precisely delineated as subxiphoid, epigastric, umbilical, infraumbilical, and suprapubic. Laterally, the defects are classified as subcostal, lateral, iliac, and lumbar.

Further consideration is given to the defect width of incisional hernias: W1 (< 4 cm), W2 (4 - 10 cm), and W3 (> 10 cm).

If multiple hernia defects exist (mesh-related hernia, Swiss-cheese hernia), their size is determined by the total length and width.

• Control of infection situations
• Medication management in immunosuppression or anticoagulation
• Control of cardiac and pulmonary risk factors
• In advanced eventration of the intestines, conditioning of the abdominal wall through progressive pneumoperitoneum or injection of botulinum toxin into the lateral abdominal muscles.
• Bowel evacuation is advisable, preoperative bowel lavage is not required.
• Single-shot antibiotic i.v. perioperatively (due to the use of foreign material/mesh), continuation of therapy if there are intraoperative signs of inflammation or bacterial contamination.

General:

• Pneumonia
• Bleeding, rebleeding, hematoma
• Wound infection/wound healing disorder
• Thrombosis/embolism
• Excessive scar formation

Specific:

• Implantation of synthetic material
• Nerve injury/chronic pain
• Seroma (typically present, usually without therapeutic consequence)
• Infection of the implant with the consequence of needing to remove it again.
• Bowel passage disorder (atony/ileus)
• Recurrent hernia
• Bowel perforation
• Subsequent interventions
• Lethality