Complex Hernia Repair and Abdominal Wall Reconstruction

Complex hernia repair and abdominal wall reconstruction are problems commonly encountered by the general surgeon and the plastic and reconstructive surgeon.

Often patients will have had multiple abdominal operations in the past as well as possible previous hernia repairs. One of the most important aspects of successful hernia repair is wide exposure and visualization of all strong fascial edges.

Adequate exposure of all hernias and fascial edges can be gained through the lower abdominal incision.  Any redundant skin and or fat that would contribute to a pannus or would be devitalized by the exposure can be excised and discarded. In addition, this helps to eliminate dead space and prevent seroma formation.

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Hernia Repair and Abdominal Wall Reconstruction.

Patients can often present with multiple abdominal hernias from previous surgery or previous hernia repairs. It is often best to expose all of the hernias from the same incision and repair each hernia from the same exposure.

 

The abdominal domain can be tightened where necessary or relaxed where appropriate with component separation to allow an appropriate tension repair. Redundant skin than contains scars from previous operations that would not provide stable soft tissue coverage over the hernia repair can be excised.



 

 

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Abdominal Wall Reconstruction

Abdominal wall reconstruction procedures are common. Quite often after abdominal surgery, a patient may develop a hernia. One of the keys points to hernia surgery is to develop adequate exposure so that the hernia can be repaired.The lower abdominal incision affords ample exposure to place underlay mesh as well as close the lower abdomen. This can restore the abdominal muscles back to their original position.

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Abdominal Wall Reconstruction

Abdominal wall reconstruction can be a common procedure after many different types of abdominal surgery.

One of the more important components of abdominal wall reconstruction is to recreate a dynamic abdominal wall so that the musculoaponeurotic system of the trunk can serve its purpose. 

By bringing the rectus muscles back toward the midline of the abdomen, the intraabdominal pressure can equilibrate. That is, when one coughs or strains, the intra-abdominal pressure can be transmitted from the bowel to the abdominal wall and vice versa. 

Often, large defects of the abdominal wall need to be closed with components separation to appropriately bring the rectus muscles back toward the midline of the abdomen.

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Hernia Repair and Abdominal Wall Reconstruction

Abdominal hernias are often uncomfortable for patients. Abdominal or ventral hernias can be repaired in many different fashions. When ventral hernias or incisional hernias have been previously repaired and recur, it is often best to undergo abdominal wall reconstruction with mobilization and medialization of the abdominal muscles and component separation.

The medialization of the abdominal muscles allows for the creation of a dynamic abdominal wall which can now exert an equivalent back pressure on the intra-abdominal contents that tend to move outward with coughing, sneezing, straining, etc. The abdominal wall reconstruction is often a much larger procedure than laparoscopic repair, but allows for the abdominal wall musculature to dynamically contract and prevent hernia repair.

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Repair of Abdominal Wall Hernias with Component Separation

Abdominal wall hernias are best reconstructed by recreating a functional abdominal wall. That is, return all the abdominal wall musculature back to its original position. When patients cough, sneeze, or bear down to have a bowel movement, this increases the intra-abdominal pressure. As the intraabdominal pressure increases, the abdominal wall musculature exerts a back pressure on the viscera. If there is a segment of abdominal wall that is devoid of functional (i.e. contracting muscle) then hernias tend to occur, or can occur in areas of weakness.

Often the hernias can be repaired with an underlay of structure with transfascial sutures and with restoring the abdominal wall musculature over the structure. That is when the abdominal domain is composed of functional muscle, there is a decreased chance of the hernia recurring.

Large hernia surgery typically requires an inpatient stay of three to seven days. During that time we are waiting for bowel function to resume, ambulation to occur, and pain to be controlled on oral pain medications.

An abdominal binder is worn in placed for 8 weeks. after eight weeks patients begin physical therapy to increase core musculature without large ranges of motion (i.e. no crunches or abdominal extension). Once the ore muscle strength is restablished, then patients begin to resume normal activity.

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Incisional Hernia Repair & Abdominal Wall Reconstruction

Incisional hernias can occur after surgery on the abdominal wall. Often a recurrent hernia needs to be repaired differently to prevent the recurrence of the hernia again. Just as important are patient factors that need to be controlled such as weight, protein intake, and cessation of smoking if the patient is a smoker.

If there are multiple hernias of the abdominal wall, it is often advantageous to the surgeons, both general surgeon and plastic and reconstructive surgeon to create adequate and wide exposure of all hernias to allow appropriate reconstruction. The wide exposure can also allow component separation to be performed to facilitate reconstruction of the abdominal wall musculature to create a dynamic abdominal wall.

The wide exposure creates a potential space that must be drained adequately post-operatively with drains. These drains can stay in for approximately 7 days to up to three weeks post-operatively.

Proper protein intake in the post-operative period is important to optimize wound healing.

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