Open Ventral Hernia Repair With Onlay Mesh

1 Clinical Anatomy

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Thorough knowledge of the abdominal wall anatomy is needed when performing a ventral hernia repair.
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The rectus abdominis consists of a pair of vertically oriented muscles that span the length of the abdominal wall and are separated by the linea alba. The rectus muscles arise from the symphysis pubis and insert onto the fifth, sixth, and seventh costal cartilages and xiphoid process.
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The lateral abdominal wall muscles are three broad, flat muscles: the external oblique, internal oblique, and transversus abdominis.
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The rectus sheath is formed by the fusion of the aponeuroses of the three lateral abdominal wall muscles and encloses the rectus abdominis muscle.
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Above the arcuate line, the anterior rectus sheath is made up of the aponeuroses of the external oblique and an anterior layer of the internal oblique. The posterior rectus sheath is made up of the aponeuroses of a posterior layer of the internal oblique and the transversus abdominis.
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Below the arcuate line, the anterior rectus sheath is made up of the aponeuroses of all three lateral abdominal wall muscles. The posterior rectus sheath is absent, and the rectus muscle lies directly on top of the transversalis fascia.

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Computed tomography (CT) of the abdomen and pelvis is typically performed preoperatively in patients being considered for ventral hernia repair. CT helps with preoperative planning by allowing for assessment of fascial defect size and the integrity of the remaining abdominal wall musculature. CT may also help determine the presence of previously placed mesh and any occult defects that may be present.
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In patients with particularly large defects or potential loss of domain, CT scan may help determine the need for preoperative interventions, such as progressive preoperative pneumoperitoneum or chemical component paralysis with botulinum toxin (Botox) injections, which may help facilitate primary fascial closure.

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The goal of any hernia repair is to provide patients with a durable repair while minimizing the potential for postoperative complications. Proper patient selection and preoperative optimization of modifiable risk factors are crucial when considering a patient for open ventral hernia with mesh onlay.

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Overall, we consider the open mesh-onlay repair to be an extremely versatile method of hernia repair that can be applied to virtually any type of ventral hernia that a surgeon may encounter in everyday practice. To date, we have applied our method of open mesh-onlay repair to ventral/incisional hernias at any location of the abdominal wall; this includes midline hernias with significant subxiphoid or suprapubic components, epigastric hernias, flank hernias, and parastomal hernias.

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The open mesh-onlay technique is predicated on mesh reinforcement of a primary fascial closure. With this in mind, it is necessary to select patients with a defect size that will allow for a tension-free primary fascial reapproximation.

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Several patient comorbid conditions are associated with an increased risk of complications after ventral hernia repair. Complications are mainly related to the creation of wide skin flaps and resultant potential for flap ischemia and wound infection. These comorbid conditions need to be considered when evaluating a patient for an open mesh-onlay repair. Recognizing the presence of these potentially complicating factors and optimizing them before surgery will ideally increase the success of surgery while minimizing the potential for postoperative complications.
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For example, we consider previous aortic surgery to be a relative contraindication to this type of repair. Patients with previous aortic surgery have compromised collateral circulation to the skin that results from ligation of the lumbar collaterals, and raising wide skin flaps in this setting should not be performed because of the risk of skin flap ischemia and necrosis.

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Cigarette smoking is associated with increased risk of perioperative morbidity, particularly hernia recurrence and postoperative wound infection, after ventral hernia repair. Smoking significantly impairs cutaneous tissue oxygenation and can impair the immune system and prevent appropriate wound healing. Smoking is a modifiable risk factor, and smoking cessation is mandated in all patients scheduled to undergo elective ventral hernia repair. Patients must stop smoking a minimum of 6 weeks before elective hernia repair. Serum or urine cotinine levels are checked preoperatively to confirm patient compliance.

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Morbid obesity is another modifiable risk factor associated with increased risk of hernia recurrence and postoperative wound complications. Patients are thoroughly educated on the associated risks and strongly encouraged to lose weight preoperatively. They are counseled in making lifestyle changes necessary to promote healthy weight loss, including both dietary modification and increased physical activity. Patients with a body mass index greater than 45 who are unable to lose weight independently are referred to a bariatric surgeon for evaluation for a surgical weight loss procedure before hernia repair. Patients are monitored to assess their progress toward their individual weight loss goals, and as long as they are losing weight, surgery is delayed.
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Ideally, patients are optimized to a body mass index of 35 or less, but in some cases this is not possible given the characteristics of the hernia or associated symptoms. In cases of patient noncompliance, hernia repair is performed only in the emergency setting.

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