Introduction

Ventral hernias of the abdomen are defined as a non-inguinal, nonhiatal defect in the fascia of
the abdominal wall. Annually, there are about 350,000 ventral hernia operations. The repair
of these abdominal wall defects is a common surgery performed by general surgeons. Surgery
is typically recommended for individuals with acceptable operative risk, symptomatic
hernias, or those at elevated risk of developing complications from a hernia. They can affect
an individual’s quality of life and can lead to hospitalizations and even death in some
cases.[1][2][3]

Etiology
Etiologies of a ventral hernia can be broken down into 2 main categories; acquired or
congenital. The vast majority of hernias that general surgeons see and treat are acquired;
however, some individuals live with their ventral hernias from birth for prolonged periods of
time before having them surgically repaired. Common causes of acquired ventral hernias
include previous surgery causing an incisional hernia, trauma, and repetitive stress on
naturally weak points of the abdominal wall. These naturally occurring weak points in the
abdominal wall include the umbilicus, semilunar line, ostomy sites, bilateral inguinal regions,
and esophageal hiatus. Obesity is a large component of hernias as well because it stretches
the fascia of the abdomen causing it to weaken. Specifically, the action of repetitive weight
gain and loss leads to weakening.[4]
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Epidemiology
In 2006, 348,000 ventral hernia repairs were performed in the United States, and it was
estimated to cost approximately $3.2 billion. This is a large burden on the healthcare system
with the majority of the cost coming from emergency repairs or complications postsurgically.
In the post-operative setting, patients have an approximately 10% risk of developing a hernia
following a midline laparotomy, 5% following a transverse muscle splitting incision, and less
than 1% following laparoscopic repair.[5][6]
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Pathophysiology
The anterior abdominal wall is made of many layers including skin, fat, fascia, muscle, and
peritoneum. The order of the layers change depending on the location you enter the abdomen
perpendicularly. A point approximately midway between the umbilicus and pubic symphysis
is an imaginary line called the arcuate line. At this point, the layers of the abdomen, with
respect to the rectus, change in orientation. Above the arcuate line, the fascia of the internal
oblique aponeurosis envelops the rectus muscle. The external oblique aponeurosis always
lays anterior to the internal oblique aponeurosis and the transversus abdominis aponeurosis
always posterior to it. However, below the arcuate, line all 3 layers of aponeurosis become
anterior to the rectus muscle, and it is no longer enveloped. Instead, the only fascial layer
below the rectus is the transversalis fascia which is separate from the transversus abdominis
aponeurosis.[7][8]
Repetitive stresses on the abdominal wall from increased intra-abdominal pressure lead to
microscopic tears of tissue. Over time this can decrease the strength of tissue, predisposing
individuals to hernia formation. Several instances cause increased intra-abdominal pressures
that place individuals at increased risk including constipation, physical labor, childbirth,
excessive coughing from lung disease or even frequent vomiting from diseases like bulimia
nervosa.
Tissue strength following surgery can only achieve an 80% tensile strength of the previous
maximum. This effect is additive as well, so after a second midline laparotomy, the
maximum tissue strength would be 80% of 80%, which is 64%. This 80% predicted tensile
strength is under perfect conditions as well assuming no evidence of malnutrition or
infectious complications.
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Histopathology
It is common practice to send the hernia sac from ventral wall hernias. A large
retrospective review showed that 7 of 576 ventral wall hernias revealed a malignancy. Five of
these lesions were not seen on examination. Other pathologies that were revealed
included appendicitis, endometriosis, a perivascular epithelioid cell tumor, and
pseudomyxoma peritonei. The review led to the conclusion that ventral hernias should be
submitted for histologic evaluation.
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History and Physical

The presentation of an abdominal wall hernia is usually pain, swelling or fullness at the site
of occurrence that can change with position or Valsalva. In some cases when a hernia is
incarcerated or strangulated, the enlargement may be erythematous or cause an asymmetry. In
most cases, the diagnosis of an abdominal hernia can be made by history and physical exam
but severe obesity, which is a major risk factor, can limit the exam. It is very important that
during the exam the patient is examined in multiple positions as hernias can change
with exertion or even standing.
There are additional questions that should be explicitly asked of patients presenting with
ventral hernias. Beginning with the history of present illness, details surrounding the hernia
should include the first time they noticed it, any inciting events, associated pain, erythema,
constipation, nausea or vomiting, size of the bulge, change in size, what causes the change in
size, history of previous hernias, weight change and a detailed surgical/medical history.
Important social questions including the patient's occupation, dietary habits, exercise habits,
smoking history, and alcohol consumption should also be included in the history. Patients
should be asked specifically about the family history of a connective tissue disorder as this is
typically hereditary and can lead to hernia formation.
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Evaluation
Multiple adjunct examinations can be performed to assist with diagnoses including
ultrasound, CT scan or MRI. If the diagnosis is in question or even the size of the hernia
defect in unclear these studies can be ordered to aid in diagnosis or preoperative planning.
Preoperative medical clearance is another important aspect in operative planning. Each
surgeon should follow a set of guidelines for this and assume the need for a general
anesthetic. It is possible to do open ventral hernia repairs without general sedation; however,
it is unlikely the patient will be completely relaxed, and therefore, it makes the operation
more challenging with a possibly inferior result. The risk of ventral hernia repair varies
greatly from low risk with a small umbilical hernia to a major risk with a large component
separation. Patients with lung disease of a prolonged history of smoking would benefit from
pulmonary function tests pre-operatively. It is also important to make sure that any screening
exams are performed before abdominal surgery, it would be unfortunate to have to perform a
colectomy for colon cancer on a patient 6 months after doing a ventral hernia repair. There
should be strict adherence to discontinuation of antiplatelet and anticoagulation medications
secondary to hematoma formations increasing the probability of infectious
complications.[9][10]
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Treatment / Management
The most common treatment of ventral hernias includes surgery. Asymptomatic hernias are
repaired on an elective basis, but those presenting with strangulation require immediate
surgery. Incarceration without strangulation is not a surgical emergency; however, the risks
and benefits of surgery should be discussed with the patient, and a patient with reasonable
operative risk should have their hernia repaired within a sensible time frame. Non-surgical
management of abdominal wall hernias with the use of binders, trusses, or corsets is not
considered to be effective. However, this may be the only option in a patient who is not a
reasonable candidate for surgery. [11][12][13]
Over the years, many types of surgical techniques have been developed to repair hernias.
There are many tenants of hernia repair. The most important being a tension-free closure, but
others include the use of a mesh with 3 to 5 cm of overlap, meticulous handling of the mesh,
preventing surgical site infections, and using a sublay technique with the closure of the fascia
if possible. The most basic approach is a primary open repair without mesh, which should
typically be reserved for defects in the fascia of less than 2 cm. An open repair with mesh has
several options including what type of mesh and where to place the mesh.
Laparoscopic ventral hernia repair when compared against open techniques has consistently
showed decreased overall complication rates, decreased hospital length of stay, and a quicker
return to work. Although it has not been consistently statistically significant, a large portion
of available literature shows the recurrence rates are slightly lower in laparoscopic repair. The
disadvantages of laparoscopy include a higher potential for visceral injury and it is
technically more difficult. There has been development of wristed laparoscopic instrument
that give additional freedom of motion during operating but additional research is needed to
detect significant benefit.
Robotic ventral hernia repairs have also become popular secondary to increased freedom of
motion during surgery. Closing the fascial defect robotically is far easier from a technical
standpoint than attempting it with classical laparoscopic instruments. The benefits of
laparoscopy are retained secondary to the smaller incisions that can be maintained. Robotic
surgery is typically more expensive and has longer operative times than laparoscopy, and at
this point, no landmark trials have demonstrated superiority of robotic surgery in comparison
to laparoscopy.
Component separations can be performed several different ways and are typically reserved
for large defects in which a tension-free closure cannot be achieved. All of the techniques
require adhesiolysis with reduction of the hernia and typical mesh placement. The open
technique with an onlay mesh consists of developing large skin flaps, about 5 cm beyond the
midline, exposing the lateral portions of the rectus. The external oblique is then incised 2 cm
lateral to linea semilunaris and extended superiorly and inferiorly while separating it from the
internal oblique. This allows medialization of the rectus muscle and closure of the defect.
Mesh is then used to reinforce the closure in an onlay fashion. It is estimated to allow for
tension-free closure of defects up to 10 cm in diameter. During the endoscopic component
separation the hernia is reduced after adhesiolysis and incisions are made laterally to the
rectus. The external oblique fascia is incised and the muscle is split all the way to the
posterior fascia. A balloon is then inserted along the posterior fascia and inflated underneath
of the external oblique muscle down the level of the anterior superior iliac spine creating a
large space. Using additional ports the external oblique can then be incised to allow
medialization of the rectus and repair of the hernia.
Transversus abdominis muscle release (TAR), also known as a posterior component
separation, is another option for large hernias and consists of developing the retro-muscular
space from the medial rectus into the space between the transversus abdominis and internal
oblique. After the posterior rectus sheath is released, it is incised laterally, and the transversus
abdominis is released medial to the linea semilunaris to expose a broad plane that extends
from the central tendon of the diaphragm superiorly, to the space of Retzius inferiorly, and
laterally to the retro-peritoneum on both sides. This preserves the neurovascular bundles
innervating the medial abdominal wall. The mesh is placed in a sublay fashion above the
posterior fascial layer but below the rectus and internal oblique muscles. The posterior rectus
fascia then is advanced medially and closed while the linea alba is restored anterior to the
mesh. These cases can be very long cases and technically very challenging.
A different type of a hernia that can affect the abdominal wall is a parastomal hernia. It is
estimated that up to 30% of patients with ostomies can develop parastomal hernias. Some
types of ostomies are at higher risk than others. Loop colostomies are at the highest risk
followed by end colostomies, loop ileostomies, and end ileostomies. Currently, the only
strategy to prevent hernia formation is the use of a prophylactic mesh when the ostomy is
created. Patients that are planning an ostomy reversal typically have the repair delayed until
the reversal of the ostomy, but sometimes the repair can be an emergency. There are multiple
types of repairs, and the 2 that will be discussed here include the modified Sugarbaker and
keyhole techniques. Both procedures can be performed laparoscopically or open. After
adhesiolysis, the modified Sugarbaker technique consists of lateralizing the bowel by tracking
the bowel from the hernia sac between the abdominal wall and the prosthesis into the
peritoneal cavity. Essentially putting a patch over the defect and having the bowel enter the
abdominal cavity laterally to the mesh. The keyhole technique is performed by making a slit
in the mesh and fitting the mesh around the bowel before fixating the mesh, thereby patching
the defect. In some studies the Sugarbaker technique had a lower incidence of recurrence but
larger studies are needed to achieve statistical significance.
Mesh can be divided into synthetic or biologic. The decision of which mesh to use is mainly
up to the surgeon, but there are instances where one should be used over the other. Most
synthetic prosthetic grafts can be categorized as derived from polypropylene, polyester, or
polytetrafluoroethylene (PTFE). In the late 1990s, lightweight mesh came in the market and
has now been widely accepted as a superior mesh, but it still can become infected and have
recurrences. The size of the pores in the mesh has also come under scrutiny and they have
discovered there is a major benefit to macro-porous mesh, defined as pores larger than 3 mm.
These cause fewer incidences of infection, and if the do become infected, there is a much
higher chance that treatment with antibiotics can prevent explantation. Mesh composed of
ePTFE has a good profile for adhesion risk but a high risk of infection. In contrast,
polypropylene mesh has a lower infection risk but little flexibility and a high adhesion risk.
There is also 2-sided mesh designed for intra-peritoneal placement in which one side is
coated with an anti-adhesive barrier. This is not 100% successful, but studies have shown
decreased adhesion formations and easier adhesiolysis of those that do form. There is also
sutureless mesh that sticks to the tissues designed to reduce post-operative pain and prevent
mesh migration. Absorbable mesh-like vicryl can be used in infected fields, but it will absorb
over time leaving only native tissue.
The number and type of biologic grafts has expanded greatly over the last decade. The huge
downside to biologic meshes is they are typically very expensive. They are usually reserved
for infected or contaminated fields and the strength of the repair is considered inferior to
synthetic mesh placement. They typically consist of an acellular collagen matrix derived from
human dermis or porcine small intestine submucosa. These biologic meshes still generate a
foreign body reaction as well so they can cause adhesions but are unlikely to become
infected.
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Differential Diagnosis
The differential diagnosis of a hernia should be a relatively short list. Additional pathologies
would include diastasis recti, abscess, muscle strain, seroma, wound hematoma,
lymphadenopathy, soft tissue malignancy, and rectus sheath hematomas.
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Staging
Unfortunately, there is not currently a universal classification system for ventral hernias. One
of the more accepted classification systems is the European Hernia Society (EHS)
classification system. They separated the system into primary abdominal wall hernias and
incisional abdominal wall hernias. A primary ventral hernia that not associated with a
previous operation is usually in a limited number of locations, subdivided into midline and
lateral, while the classification can be limited to 2 variables: length and width. The
classifications of incisional abdominal wall hernias are more complicated as they can occur
anywhere on the abdomen, but again, they are documented in terms of length and width. The
limitation of this system is that it does not include individual patients risk factors and wound
classification. However, a classification complex enough to encompass all of the important
variables would be difficult to remember and unlikely to be embraced by the surgical
community. In instances where a significant amount of the visceral contents are in the hernia
sac, some sources define this as half of the abdominal contents; it is considered to be a ventral
hernia with loss of domain.
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Prognosis
Patients have varying prognoses after ventral hernia repair. The circumstances surrounding
the original operation have the highest predictive value of post-operative complications.
Emergency operations for strangulation that require bowel resection are associated with
higher morbidity and recurrence secondary to the face at a minimum the case has become
cleanly contaminated, and synthetic mesh should not be used. Wound class is an important
variable in determining the risk of morbidity from an operation and should be documented in
the operative record. A clean wound (class I) is an incision where no inflammation is
encountered, there was no break in sterile technique, and the respiratory, alimentary and
genitourinary tracts were not entered. A clean-contaminated wound (class II) is an
incision where the respiratory, alimentary, or genitourinary tract is entered under controlled
conditions but with no contamination encountered. A contaminated wound (class III) is an
incision where there could have been a major break in sterile technique, obvious spillage
from the gastrointestinal tract, or an incision in which acute, nonpurulent inflammation is
encountered. Open traumatic wounds that are more than 12 to 24 hours old also fall into this
category. A dirty or infected would (class IV) is an incision where the viscera may have been
perforated, acute inflammation with pus is encountered during the operation and for traumatic
wounds where treatment is delayed, or there is fecal contamination/devitalized tissue
present.[14]
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Complications
Recurrence of a ventral hernia after the repair has varying rates over time, but with the
introduction of mesh, the recurrence rates have dropped significantly. Recurrence rates differ
among the type of repairs: in laparoscopic repairs with mesh are around 10% to 12%, open-
mesh repair 13% to 15%, and open-tissue repair 18% to 20%. Component separation
estimates recurrence rates as high as 20% in large studies, but this is not comparable with
other operations secondary to large defects and need for reconstruction of the abdominal wall.
Mesh infection is a catastrophic complication of ventral hernia repairs because it is typically
followed by a second operation that is more complex and associated with a high chance for
recurrence of a hernia. There are many risk factors including a high body mass index (BMI),
chronic obstructive pulmonary disease (COPD), abdominal aortic aneurysm repair, prior
surgical site infection, mesh type, longer operative time, lack of tissue coverage of the mesh,
enterotomy, and surgical site infections. With a mesh infection, it is much more common to
require explantation of the mesh, but salvage is a possibility with antibiotics.
Respiratory morbidity following ventral hernia repair is specifically a concern of abdominal
wall reconstruction secondary to decreasing the volume of the abdominal cavity. This
exerts upward pressure on the diaphragm and can lead to hypoxia and intubation. There are
institutions with protocols to prevent morbidity after these demanding surgeries. Evidenced-
based literature to prevent respiratory morbidity includes sufficient pain control using PCA,
regional blocks or epidurals, early ambulation after surgery, and not
routinely using nasogastric tubes. Evidence does not support the use of lung expansion
therapies such as deep breathing exercises, incentive spirometry, and CPAP, but they are still
commonly used.
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Postoperative and Rehabilitation Care

Patients should limit themselves to a 10-pound lifting restriction within the first week, 20
pounds for the second week, and slowly advance to full activity over a period of 6 weeks. It is
important to limit the narcotics during the postoperative phase secondary to addiction
potential and also to prevent constipation. Multi-modal pain control with acetaminophen,
anti-inflammatory, neuropathic, and muscle-relaxing medication, in addition to narcotics,
have been shown to decrease opiate usage. Additional adjuncts including regional blocks,
long-acting, local anesthetics, as well as post-surgical nerve blocks have also been successful
in decreasing opiate usage. Stool softeners and laxatives in the postoperative phase are
common practice to prevent straining and bloating. There are typically no dietary restrictions,
but patients should eat a high fiber diet in the postoperative period. Patients can shower in the
24 to 48 hours window following surgery. It is useful to provide patients with postoperative
instructions at multiple points throughout their preoperative and postoperative course.
Offering literature on the topics is useful as well. Patient education has been shown in
multiple specialties to help prevent postoperative complications.
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Deterrence and Patient Education

Prevention of acquired ventral hernias is difficult because it is mainly focused on prevention
of incisional hernias. Enforcing or monitoring whether patients adhere to the instructions is
impossible. Meticulous closure of the abdomen should be performed with a suture length to
wound length ratio of greater than 4. Also, each bite of fascial closure should travel
longitudinally along the incision and have a bite depth between 5 and 10 mm. It is very
important that during the procedure, surgeons obtain a tension-free closure and close all port
site 10 mm or larger. Incisional hernias have been documented to occur in port sites smaller
than 10 mm, but these are rare. The closure of larger abdominal incisions also needs further
studies to define the best suture for closure. However, there have been many evidence-based
papers that recommend a running slowly absorbable or non-absorbable monofilament sutures
for incision closure. The non-absorbable suture has achieved the lowest rates for hernia
formation but at an increased risk of chronic pain and sinus drainage from fistula to the
suture. The benefit of monofilament suture is secondary to a decreased infection risk when
compared with multi-filament suture.
The most important aspect of preventing a ventral hernia is to prevent a wound infection in a
surgical setting. Wound infections increase the chance of hernia development by a
statistically significant amount. It is also associated with higher mesh infections that have a
higher likelihood of requiring a second surgery. Laparoscopic repairs have been consistently
linked with lower wound infections than open repairs. Patient optimization prior to surgery
has also consistently been linked to lower rates of infections. Encouraging smoking cessation,
improved nutrition, weight loss, physical rehabilitation, and tight glycemic control helps, as
well as overall patient selection. There are also many preoperative and intraoperative
measures to decrease surgical site infection, for example, preoperative antibiotics, prevention
of hypothermia, sterile technique, skin preparation and many others. The use of abdominal
binders has not been shown to decrease the incidence of ventral hernia occurrence or
recurrence. The only consistent benefit of abdominal binders has been the patients
subjectively feel more comfortable.
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Pearls and Other Issues

Tension-free repair with mesh for ventral hernias over 2 cm in size is the standard of care. A
retro-rectus mesh placement in the pre-peritoneal space has become the optimal placement
for the mesh. Loss of abdominal wall domain requires a complex operation with high
morbidity to achieve a tension-free repair. Port sites 10 mm and higher should have fascial
closures; some port site hernia can occur at smaller sizes.
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Enhancing Healthcare Team Outcomes

Ventral hernias are very common and do present a challenge because of the risk of
recurrence. Besides the surgeon, these hernias are ideally managed by a dietitian, nurse, and a
physical therapist. Patient education has been a very popular topic in literature and hospital
settings. Giving patients literature and discussing outcomes with instructions on multiple
aspects throughout their encounters has shown to be very effective. Also providing patients
with available resources to ask questions or contact a healthcare provider has been shown to
decrease returns to the emergency room within 30 days.
The outcome of ventral hernias depends on the size and other patient comorbidity. Elective
hernia repair has the best outcomes, but for patients with incarceration or strangulation, the
outcomes are guarded. Mortality rates in excess of 5% have been reported in presence of a
strangulated hernia. While laparoscopic herniorrhaphy has led to relatively easy repair, the
procedure has been known to be associated with serious complications that have been related
to bowel injury from the instrumentation.[15][16][17]
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Questions
To access free multiple choice questions on this topic, click here.
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