Abdominal Wall: Ventral Hernia Repair

Open Umbilical Hernia Repair (UHR)

• Make a Supraumbilical or Infraumbilical Incision Based the Site of the Hernia
• Dissect Down to Fascia
• Free the Umbilical Stalk Circumferentially
• Dissect the Hernia Sac off the Umbilical Stalk
• Incise the Fascia Around the Umbilical Ring
  • *Planes are Fused
• Reduce the Hernia Sac
• Bluntly Dissect the Preperitoneal Space
• Place Mesh into the Preperitoneal Space
• Close the Fascial Defect
• Close Skin

Simple Open Ventral Hernia Repair (VHR)

• Make a Vertical Incision Over the Hernia Site
• Dissect the Hernia Sac Free from Surrounding Tissue
• Dissect Down to Fascia, Avoiding Opening of the Hernia Sac
• Incise the Fascia Around the Sac without Penetrating the Peritoneum
• Reduce the Hernia Sac
  • *Do Not Need to Incise the Fascia – Planes Are Not Fused
• Bluntly Dissect the Preperitoneal Space
• Place Mesh into the Preperitoneal Space
• Close the Fascial Defect
• Close Skin

Rives-Stoppa-Wantz (Retrorectus) Repair

• Often Referred to as Only a “Rives-Stoppa Repair”
• Considered the Gold Standard Repair for Moderate-Large or Complex Midline Hernias
• Technique:
  • Midline Abdominal Incision
  • Dissect & Excise the Hernia Sac (Preserve the Lateral Edges of the Hernia Sac for Closure)
  • Incise the Posterior Rectus Sheath Close to its Junction of the Anterior Rectus Sheath
    • Goal to Preserve Largest Area of Posterior Sheath as Possible without Sacrificing any of the Anterior Sheath
  • Separate the Posterior Rectus Sheath Away from the Rectus Muscle to Create the Retrorectus Space
  • Close the Posterior Rectus Sheath
  • Place a Large Mesh into the Retrorectus Space
    • Consider Fixation Using Suture but Not Always Mandatory
  • Close the Anterior Rectus Sheath
  • Close Skin
• Drains:
  • Consider a Retrorectus Drain Over the Mesh
  • Consider a Subcutaneous Drain in the Fat

MIS (Laparoscopic/Robotic) Ventral Hernia Repair

• Place Ports (2-3 Ports in the LUQ or Left Flank)
• Preform Adequate Lysis of Adhesions & Reduce Any Herniated Bowel
• Incise the Peritoneum Circumferentially Around the Hernia Defect, 2-3 cm from the Edge
• Reduce the Hernia Sac with Any Preperitoneal Fat
• Close the Hernia Defect
  • *Necessity is Debated
• Place Preperitoneal Mesh with Circumferential Tacks or Sutures
  • Should Allow At least 3-5 cm of Mesh Overlap
• Close Peritoneal Defect
• Close Skin

Abdominal Wall Reconstruction/Component Separation

• *See Abdominal Wall: Abdominal Wall Reconstruction/Component Separation