Vivian M. Sanchez
Kamal M.F. Itani
Presentation
A 74-year-old male smoker with diabetes, obesity, and hypertension presents to the outpatient clinic with complaints of intermittent periumbilical abdominal pain of 3 months’ duration. The pain is not associated with eating, does not radiate, and is occasionally associated with nausea and emesis. On examination, his vital signs are stable and his body mass index (BMI) is 41. He has a long midline scar with a 5- × 6-cm ventral incisional hernia (VIH) in the periumbilical area (Figure 1). There are no overlying skin changes. The hernia is partially reducible and tender only to deep palpation. He does have loss of abdominal domain. His past surgical history is notable for perforated diverticulitis 5 years prior, requiring emergency colectomy with diverting sigmoid colostomy. His colostomy was reversed 2 years ago and was complicated by a wound infection that healed by secondary intention. The patient is a retired police officer who used to be quite active but has recently been experiencing increased shortness of breath when climbing stairs.
FIGURE 1 • Patient with a previous midline laparotomy an a perumbilical 5-×6-cm ventral incisional hernia.
Differential Diagnosis
In patients presenting with a reducible abdominal bulge, it is not difficult to diagnose a VIH, especially with a history of prior abdominal surgery. However, it is important to distinguish ventral hernias from rectus diastasis (i.e., separation of the right and left recti abdominis muscle from the midline), which is a relatively common problem in postpartum women and obese men. Rectus diastasis presents as a symmetric, midline bulge extending from the umbilicus to the xiphoid process. With rectus diastasis, the fascia is intact and therefore there is no need for surgical repair. It is also important to distinguish a reducible or chronically incarcerated ventral hernia from an acutely incarcerated hernia that would require urgent surgery. Patients with acute incarceration may present with bowel obstruction, an acutely tender bulge, or even erythema of the abdominal wall, particularly if they have progressed to strangulation and compromised bowel.
Workup
The patient undergoes workup of his abdominal pain with laboratory studies, flat and upright films of the abdomen, and right upper-quadrant ultrasound. All studies are normal. A CT scan of the abdomen is obtained to further evaluate the pain. The CT reveals a large 5- × 6-cm ventral hernia along the midline (Figure 2). It contains the transverse colon without adjacent stranding or fluid and without a transition point; there are no gallstones or other abnormalities of the biliary system or pancreas.
FIGURE 2 • CT scan revealing a large 5- × 6-cm ventral hernia along the midline.
Diagnosis and Treatment
The patient has a 5- × 6-cm VIH at his prior laparotomy incision. The hernia is reducible and nontender to palpation. Other causes of periumbilical pain such as biliary colic, pancreatitis, and small bowel obstruction are ruled out. Laboratory tests including liver function tests, amylase, and white blood cell counts are normal. Plain abdominal films and RUQ ultrasound were normal. A CT scan did not demonstrate any evidence of a bowel obstruction or other intra-abdominal pathology. It did demonstrate the hernia defect.
The patient is diagnosed with a symptomatic VIH after other etiologies of his symptoms were ruled out. A laparoscopic VIH repair with mesh is planned. The risks and benefits of the procedures were explained. He was further evaluated by medicine for his shortness of breath, history of diabetes, hypertension and smoking, and the possibility of cardiac symptoms. A cardiac stress test was performed which revealed a fixed myocardial defect, no reversible ischemia, and an ejection fraction of 50%. He was started on beta blockers and categorized as a low/intermediate risk for myocardial event after surgery.
Discussion
VIHs are iatrogenic, occurring after laparotomy with an incidence of 2% to 11%. Most (90%) occur within 3 years of laparotomy but can continue to occur over the lifetime of the patient. Followed by small bowel obstruction, VIH is the most common cause of reoperation postlaparotomy. Strangulation or incarceration is the reason for repair in approximately 17% of patients, whereas gradual enlargement leading to loss of domain, pain, and other structural abnormalities accounts for the majority of hernia repairs. In the absence of prohibitive medical comorbidities, the presence of a ventral hernia after laparotomy is in itself an indication for VIH repair. More specific indications for repair include the following: (1) bothersome symptoms; (2) bulges affecting the patient’s quality of life; (3) hernias with a narrow neck, which are at higher risk for strangulation.
Causes of VIH are multifactorial but most commonly include technical factors during abdominal wall closure, surgical site infections, connective tissue disorders, immunosuppressants, diabetes, obesity or other causes of increased intra-abdominal pressure after surgery, malnourishment, low oxygen tension such as chronic obstructive pulmonary disease (COPD), and smoking. An association with abdominal aortic aneurysms has been described.
This diabetic patient who is also a smoker had an emergency laparotomy in a contaminated field and was therefore at higher risk for developing a VIH.
The utilization of mesh has significantly reduced the recurrence rates of VIH. In a prospective randomized trial of VIH < 6 cm, the recurrence rate was 24% and 43% (at 3 years) and 32% and 63% (at 10 years) for primary repair and repair with mesh, respectively. All current data support the utilization of mesh in VIH repair.
Choice of mesh depends on the surgeon’s preference, technique, and contamination. Polypropylene (PP) and extended polytetrafluoroethylene (ePTFE) meshes are the most commonly used types of meshes. PP meshes should not come in contact with bowel, as they can lead to fistulization. Newer generations of PP meshes contain an adhesive barrier or PTFE on the side exposed to bowel to prevent this dreaded complication. Biologic meshes are useful in cases where there is contamination or when the prosthetic material cannot be covered by skin. Although biologic meshes have performed well in short-term follow-up, long-term results are still unavailable.
Open VIH mesh placement techniques include inlay (bridging the defect with mesh), onlay (covering the defect with mesh and fascia overlap), and underlay repair (placing the mesh in a retrorectus position, above the posterior rectus fascia or intraperitoneally with fascia overlap). The underlay technique is the most widely advocated open technique because of lower recurrence rates. The inlay technique carries the highest rates of recurrence. By definition, a laparoscopic VIH repair involves an underlay intraperitoneal mesh placement.
Surgical Repair of Ventral Incisional Hernias
Open Versus Laparoscopic Approach
Recent studies suggest that laparoscopic repair is the favored approach in experienced hands, with some exceptions. Laparoscopic VIH repair has been shown to be associated with less overall complications than open repair, although the complications of laparoscopic repair tend to be more severe. The risks of postoperative surgical site infections and other wound complications are definitely lower with the laparoscopic repair which also results in a shorter hospital stay, and lower costs. The disadvantage of open repair comes from raising large flaps and/or extensive devitalization of soft tissues. Most importantly, there is a trend toward lower recurrence rates with the laparoscopic approach. The laparoscopic approach provides the ability to better visualize and inspect the abdominal wall and detect clinically silent defects that are likely to be missed with an open repair.
In addition, the laparoscopic approach allows for a large intraperitoneal working space that enables repair of multiple and large hernias alike without the need for an extended incision.
Caution must be exercised when considering a laparoscopic VIH repair in patients with severe COPD or low cardiac reserve as these patients are at risk for CO2 retention and preload reduction/afterload increase, respectively.
The open approach can be beneficial in patients in whom severe adhesions are anticipated or those who have a large loss of domain, making the laparoscopic approach difficult secondary to a lack of working space. In addition, open repair is advocated in patients with incarcerated/ strangulated hernias to avoid damage to the bowel or allow for concomitant procedures. These historical contraindications to laparoscopic surgery have become relative contraindications for experienced laparoscopic surgeons (Table 1).
TABLE 1. Key Steps to Laparoscopic Ventral Hernia Repair
Special Intraoperative Considerations
Intraoperative findings that would change management include an intraoperative enterotomy. If diagnosed, the enterotomy needs to be repaired (either open or laparoscopically) and contamination addressed. The amount of spillage and location of injured bowel (small bowel or colon) determines whether mesh will be utilized. In general, if significant bowel spillage is encountered, one could consider utilizing a biologic mesh (open or laparoscopic). Some surgeons have advocated aborting the procedure after repair of the bowel injury, administering antibiotics for few days in the hospital, and then returning within the same hospitalization once the contamination is clear to place a nonbiologic mesh.
Postoperative Management
Many small VIH repairs are performed as outpatient procedures. However, those patients who require extensive adhesiolysis should be observed overnight. Pain control is the most common postoperative issue after laparoscopic VIH repair. Transabdominal sutures can lead to significant pain. Intraoperative utilization of Marcaine and postoperative administration of Toradol should be considered. Seromas are observed very commonly after laparoscopic repair and the vast majority are self-limited and will resolve over time (1 to 3 months). Aspiration of a seroma should be avoided unless the seroma is symptomatic. Aspiration can lead to infection by inoculating the seroma with bacteria. Utilization of abdominal wall binders is advocated to decrease seroma formation but remains unproven. Other possible complications include ileus (2% to 3%), as well as hematoma, trocar site infections, and pulmonary complications.
Case Conclusion
The patient underwent a laparoscopic repair. The adhesions to the anterior abdominal wall were challenging and were carefully taken down. Intraoperative measurement of the defect revealed a 4- × 5-cm defect necessitating a 12- × 15-cm PP composite mesh with an antiadhesion barrier. A total of 12 transabdominal sutures were placed at approximately 6-cm intervals in addition to the tacks at 1-cm interval circumferentially (Figure 3).
The patient was discharged home on the second postoperative day. On follow-up, he was found to have a seroma that was observed and ended up disappearing after 2 months of follow-up. At 2 years, the patient is doing well with no recurrence.
FIGURE 3 • Completed laparoscopic repair.
TAKE HOME POINTS
· Incisional hernia is a common complication following laparotomy.
· Repair is usually performed for pain/discomfort and gradual loss of domain more frequently than for incarceration or strangulation.
· The laparoscopic repair is safe, allows the surgeon to visualize most defects, and is associated with lesser wound complications, shorter hospitalizations, and equivalent to lower recurrence rates compared to open repairs.
· At least 4- to 5-cm mesh to fascia overlap is needed to ensure the defect is appropriately covered.
· Avoidance of an enterotomy is critical.
SUGGESTED READINGS
Carlson MA, Frantzides CT, Laguna LE, et al. Minimally invasive ventral herniorrhaphy: an analysis of 6,266 published cases. Hernia. 2008;12:9–22.
Flum DR, Horvath K, Koepsell T. Have outcomes of incisional hernia repair improved with time? A population-based analysis. Ann Surg. 2003;237(1):129–135.
Itani KMF, Hawn MT, eds. Advances in abdominal wall hernia repair. Surg Clin North Am. 2008;88:xvii–xix.
Itani KMF, Hur K, Neumayer L, et al. Comparison of laparoscopic and open repair with mesh for the treatment of ventral incisional hernia: a randomized trial. Arch Surg. 2010;145:322–328.
Luijendijk RW, Hop WCJ, van den Tol MP, et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med. 2000;343(6):392–398.