BACKGROUND

A variety of abdominal wall hernias (ventral hernias) are commonly treated by the general surgeon (Fig. 5-1). Umbilical hernias are common in young children; most close by 2 years of age, and repair is rarely considered before 5 years of age. Umbilical hernias in adults are most commonly acquired and typically develop in patients with elevated intra-abdominal pressure (e.g., from obesity, pregnancy, or ascites). Epigastric hernias are found in the midline, superior to the umbilicus, and are often small and multiple. Pain may result from incarceration of properitoneal fat. Spigelian hernias result from herniation at the lateral border of the rectus sheath (linea semilunaris). A bulge is rarely apparent because these hernias usually dissect behind the external oblique aponeurosis. Incisional hernias are a common complication of abdominal surgery, occurring after up to 10% of abdominal wall closures. Technical error (e.g., excessive tension on the abdominal closure and inadequate approximation of the fascial edges) is the major etiology. Factors that result in increased intra-abdominal pressure (e.g., obesity, pregnancy, and ascites) and compromise wound healing (e.g., malnutrition and immunosuppression) may be contributory.

Figure 5-1 Different types of ventral hernias.

(From Roberts JR, Hedges JR, Chanmugam AS, et al [eds]: Clinical Procedures in Emergency Medicine, 4th ed. Philadelphia, Saunders, 2004.)

The repair of all abdominal wall hernias involves reduction, closure of the fascial defect, and in many cases, reinforcement with a mesh prosthesis. Primary closure (without mesh) may be considered for defects smaller than 4 cm in diameter. Primary closure of larger defects is prone to failure, relating to the degree of tension on the repair, and should be avoided.

INDICATIONS FOR VENTRAL HERNIA REPAIR

PREOPERATIVE EVALUATION

COMPONENTS OF THE PROCEDURE AND APPLIED ANATOMY

Ventral hernias may be repaired using a variety of approaches. Factors that influence the choice of approach include the size of the defect, the integrity of the abdominal wall fascia surrounding the hernia, and surgeon preference (Fig. 5-2).

Figure 5-2 Anatomy of the anterior abdominal wall. A, Transverse section through the rectus sheath above the arcuate line. The external oblique and internal oblique aponeuroses contribute to the anterior sheath. The internal oblique and transversus abdominis aponeuroses contribute to the posterior sheath. B, Below the arcuate line (halfway between the umbilicus and pubis), there is no posterior rectus sheath.

(From Drake RL, Vogl W, Mitchell AWM: Gray’s Anatomy for Students. Philadelphia, Churchill Livingstone, 2005.)

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