Abdominal Wall: Basic Fascial Closure & Mesh

Fascial Closure

Wound Intention

  • *See Wounds & Infection: Wound Management

Best Technique to Prevent Incisional Hernias

  • Running Suture
  • Small Bites (5-7 mm)
  • Slowly Absorbable Monofilament Suture (PDS)
  • 4:1 Suture:Wound Length

Mesh Properties

Mesh Properties

Brand Names

Mesh Placement

Placement Technique

  • Onlay (Subcutaneous) – Skin & Anterior Rectus Sheath
  • Inlay (Interposition) – Within Rectus Muscle Defects
    • Higher Recurrence Rate
  • Sublay (Retro-Rectus) – Between Rectus Muscle & Posterior Rectus Sheath
    • “Rives-Stoppa-Wantz” Repair
    • Lowest Recurrence Rate
  • Underlay (Preperitoneal) – Behind Posterior Rectus Sheath, Before Peritoneum
  • Intraperitoneal Onlay Mesh (IPOM) – In Abdominal Compartment

Mesh Considerations

  • Ventral Hernia Overlap Goal: Minimum of 3-5 cm
  • Use Permanent or Long-Acting Sutures for Securement
  • Permanent Mesh is More Susceptible to Infection
    • Better to Use Absorbable in Contaminated Field
  • If Inadvertent Enterotomy is Made (Without Gross Spillage) Synthetic Mesh Can Still Be Used
  • Routine Drain Placement Has Increased Risk of Infection

Prophylactic Mesh Placement

  • Decreases Risk of Recurrence
  • Onlay Appears to Be Superior
  • Complications:
    • Increased Risk of Seroma
    • No Increased Risk of Infection
  • *Use is Debated and Not Clearly Defined

Mesh Placement Techniques 1

References

  1. Parker SG, Wood CPJ, Sanders DL, Windsor ACJ. Nomenclature in Abdominal Wall Hernias: Is It Time for Consensus? World J Surg. 2017 Oct;41(10):2488-2491. (License: CC BY-4.0)