Basic cardiac and pulmonary risk stratification are essential.

Skin preparation is critical, and an experienced wound care nurse is invaluable. Treating any subcutaneous cellulitis or breakdown can significantly improve soft tissue coverage at the time of formal reconstruction.

Optimization of nutritional status is also important. This can include supplemental, enteral, or parenteral feeding when necessary. It is also important to point out that patients with an ongoing infectious nidus, particularly infected synthetic mesh, can be very difficult to obtain a positive nitrogen balance.

Many patients with large ventral hernias also suffer from morbid obesity. The ideal approach to managing obesity in the setting of a complex ventral hernia is challenging. No doubt, substantial weight loss prior to surgical intervention is optimal. However, the best approach is unclear, but options include medically supervised weight loss or bariatric surgery. This can be particularly challenging in symptomatic incarcerated hernias in which there is little time to achieve or obtain clearance for weight loss surgery.

Preoperative smoking cessation is mandatory in our practice prior to complex abdominal wall reconstruction. Smoking has been clearly linked to impaired wound healing and in the author’s opinion is an absolute contraindication to complex abdominal wall reconstruction.

Obtaining and reviewing all old operative records is extremely important. Understanding what type of mesh and in what layer in the abdominal wall it was placed can help guide your approach. In addition, it is important to clarify if one of the lateral abdominal wall muscles were already released because it can lead to lateral abdominal wall laxity if it is rereleased. Likewise, the surgeon might choose another muscle to release to access an undissected plane.

Routine radiologic imaging with an abdominal-pelvic computed axial tomography (CAT) scan is particularly useful in complex ventral hernia repairs. These scans can provide valuable information as to the size of the defect and presence of loss of domain, the absence or destruction of important components of the abdominal wall, and the presence of remnant prosthetic materials.

More advanced radiologic imaging such as magnetic resonance imaging (MRI) or angiogram to look for periumbilical perforator vessels is not routinely performed in our practice.

Preoperative antibiotic and deep venous thrombosis prophylaxis is routinely given. Typically, a first-generation cephalosporin will suffice, but in cases of prior or active methicillin-resistant Staphylococcus aureus (MRSA) infection, Vancomycin is added.

Nasogastric tube decompression and Foley catheters are routinely inserted.

Perioperative anesthesia management is critical to success in large abdominal wall reconstructions. It is important that the patient remains completely relaxed during the procedure as this greatly improves exposure of the abdominal wall. In addition, in larger abdominal wall reconstruction, there is often some level of compartment syndrome at the conclusion of the procedure. It is important to keep these patients intubated for a 24- to 48-hour period until their airway pressures normalize.

As with any hernia repair, it is critically important that the surgeon has a firm understanding of the anatomy of the abdominal wall prior to manipulation. The abdominal wall is basically composed of the two rectus muscles running longitudinally and the three lateral muscles on each side of the abdominal wall. Each performs a valuable function for the abdominal wall, and any disruption can cause impairment in core physiology. Understanding the neurovascular anatomy of the anterior abdominal wall is particularly important for optimizing the results of each of these approaches. The rectus muscle receives its innervation from the T7-T11 intercostal nerve routes. These nerves run above the transversus abdominis and below the internal oblique muscles in the lateral abdominal wall. They penetrate the linea semilunaris and segmentally innervate the rectus muscle. It is very important to preserve these nerves in any reconstruction; otherwise, the rectus muscle will atrophy and prevent any hope for a functional abdominal wall (FIG 1). One important consideration for a posterior component separation is that the transversus abdominis muscle actually forms the posterior sheath of the rectus muscle in the upper two-thirds of the abdomen.

The blood supply of the anterior abdominal wall is slightly more complex (FIG 2). The rectus muscle receives its blood supply both laterally from the intercostal vessels and from a superior and inferior branch of the inferior epigastric vessel. The blood
supply to the skin and subcutaneous tissues of the midline is also important to understand to limit ischemic problems during reconstruction. The skin does receive some limited supply from the lateral intercostal vessels, but the majority comes from deep inferior epigastric perforator vessels. These vessels typically lie within 5 cm cephalad and caudad to the umbilicus. This relationship is particularly useful when performing a periumbilical perforator sparing component separation.