Surgical Options in the Repair of Ventral and
Perhaps in all aspects of surgery, hernia repair provides the
greatest conundrum with respect to choices of materials to use (or not) and
techniques that may be utilized to achieve the desired result. When it
comes to discussing the component separation technique, even the desired result
has been changed. I am going to attempt to explain each of the options for
ventral abdominal wall hernia repairs with respect to advantages and
disadvantages, indications and contraindications for each of the methods to be
To Mesh or Not to Mesh?
For the overwhelming majority of ventral hernias, some
sort of mesh will be necessary. Pulling tissue together under tension that
for some reason has already developed a defect assuredly will only lead to a
recurrence. Not to mention the pain caused by pulling the abdominal wall
tightly closed. Additionally, the pressure applied on intra-abdominal
organs will push on the diaphragm and may lead to respiratory difficulties.
In fact, it is the development of mesh that has lead to the ability to
effectively repair large abdominal wall defects in a single procedure. The
possible exception to this is the case of a small umbilical hernia in which many
cases the defect is only about the size of a quarter or even smaller.
Under these circumstances the tissues are easily re-approximated in a double
layer of fascia with sutures and without tension. Some surgeons will place
a small mesh plug in these defects and suture that in place for the repair.
Under these specific circumstances, I will usually avoid a mesh and rely on a
mesh only in the event of a recurrence.
Choice of Mesh
Now begins the fun. There are at least 50 different
varieties of mesh available on the market, and I have representatives from each
of these companies coming to my office weekly to tout the benefits of their
mesh. So, which to choose?
The main disadvantage of any mesh is the possibility of
infection because of placement of a foreign body. There are four basic
categories of mesh and I will discuss each of these with respect to risk of
infection, cost and efficacy.
Plastic Mesh- Prolene, Mersilene or other types of
plastic mesh are very inexpensive and are effective in repairing even large
abdominal defects. They cannot be left in direct contact with abdominal
viscera because the adhesion formation will be intense and the risk of a
fistula development is significant. Either of these complications can
be extremely difficult to treat in the face of an incorporated mesh. The
mesh causes a very intense reaction with tissue and the mesh becomes invested
within a very dense scar which leads to a good repair of the hernia.
Gortex- For the fellow skiers out there, this is what
your gloves are made of. In the case of hernia repair, a gortex patch
makes an effective repair of a hernia defect and it may be left in contact with
the abdominal viscera. It does not incorporate into tissue like prolene,
and it often causes the formation of
seroma. In the event of an infection involving a gortex patch, the
gortex separates easily from the surrounding tissues unlike prolene or mersilene.
Gortex is slightly more expensive than prolene or mersilene mesh. Because
gortex does not incorporate as intensely into tissue, it is not a good choice for
large hernias, as the repair will always be dependent on your fixation sutures
and not the dense scar that forms with mesh.
Collagen- Collagen is the protein matrix that
all of our cell sit upon. Without collagen we would disintegrate. In
fact there are many diseases of collagen metabolism which cause a variety of
maladies for the human species, but this is for an entirely different
discussion. Collagen matrices are used for hernia repairs and can be
obtained from a variety of human and non-human sources. They are very
expensive. For example a piece of plastic mesh that costs a couple of
hundred dollars may be $10,000 if it is made of collagen. Collagen mesh;
however is very resistant to infection. One's own cells grow into the
collagen matrix and serve as the basis for the hernia repair. Because of
its cost, collagen mesh is most useful in situations where there is
contamination or infection already present where a hernia needs to be repaired.
The typical circumstance is an incarcerated, strangulated ventral hernia where
there is gangrenous intestine that must be removed. Placement of a prolene
of gortex mesh carries virtually 100% risk of infection (Nothing is ever 100%, but
you get my drift). Before the advent of collagen mesh one would either
just pull the wound together under tension, or use an absorbable mesh and accept
the immediate recurrence of the hernia in about 3 to 6 weeks. Collagen
mesh allows for the repair of the hernia even under these circumstances with
a < 10% risk of infection. Even if an infection occurs it can be
treated with antibiotics and local wound care with an acceptable result.
Aside from the cost of collagen mesh, they also tend to be
rather lax and tend to stretch over a short period of time. So while they
may help repair a complex abdominal wound, the result may still be a
bulging abdomen which may later need another repair with a synthetic material.
Composites- The development of laparoscopic techniques for the repair of
ventral hernias has necessitated the development of mesh products appropriate
for those techniques. As stated above, prolene causes a very intense
reaction from tissues it is left in contact with but when placed adjacent to
bowel may cause serious complications. Gortex doesn't adhere to the bowel,
but it doesn't really integrate with the tissue of the abdominal wall very well
and may not be reliable for repairing a large defect. Collagen is very
expensive and may stretch over time and once it is incorporated into the
patient's own tissues may in fact become just a large hernia sac.
What if a mesh could be made that takes advantages of
properties of one type of mesh on one side and another type of mesh on the
other? That is what a composite is. There are composites of gortex
and prolene, gortex and "other plastic" mesh, collagen and "plastic mesh" etc.
Thus on one side you have a component that is safe to leave within the abdomen
as it will not cause too severe adhesions with the intestines, while the other
side will evoke an intense reaction with the abdominal wall leading to a good
It should be noted that the
peritoneum will rapidly grow over a collagen or gortex mesh left on the
inside of the abdominal wall and protect the abdominal viscera. Prolene or
Mersilene however, though they also will become peritonealized, still evoke a
very strong inflammatory response resulting in dense adhesions.
Choice of Fixation Material-
As we are beginning to see the topic of hernia surgery is
rife with choices.
Non-absorbable sutures- Most commonly utilized with
open methods for fixing a hernia by direct tissue approximation with or without
a mesh. One would want to use a non-absorbable suture to give lasting
strength to the points of fixation of the mesh as well as tissue to tissue.
Chief disadvantage is that the tails of the suture where they are tied, if left
poking upwards toward the skin, particularly in a thin person, may cause
discomfort if they begin to erode into the skin. They may even come to
poking through the skin necessitating a minor procedure to trim back the tails.
However; sutures poking through the skin may provide a pathway for bacteria to
invade and cause a mesh infection. Fortunately, with just a little care
and forethought, there are techniques for placing the sutures in such a way that
the tails are buried in the subcutaneous tissue rendering this complication one
of academic importance only.
Absorbable sutures- These have the advantage of
disappearing over time but also have the disadvantage of disappearing over time.
If your entire repair depends on the fixation of the mesh to native tissue with
sutures I would be a bit hesitant to use sutures that will be gone in a short
period of time. On the other hand, as I will discuss below, depending on
the surgical method to be employed for repair of the hernia, there may be a
place for absorbable sutures.
Titanium, non-absorbable tacks- Laparoscopic Hernia
repair is much more easily performed because of the development of tacks for
fixation of the mesh. These are tiny cork screw shaped tacks which are
deployed through the mesh and fixate the mesh to the abdominal wall. The
titanium tacks are non-absorbable, are compatible with MRI and are completely
inert in tissue. They have two main disadvantages. Firstly, should a
tack cause pain because of its placement, the pain is not likely to resolve
short of injection of the local nerve supply to the area. Secondly, and
more theoretically, the ends of the tack are sharp, and I for one am a little
reticent placing a sharp tack in the abdominal wall where the abdominal viscera
may rub against it. To my knowledge there has never been perforation of
intestine or a fistula that has developed because of a hernia tack.
Absorbable Tacks- These are made of material similar
to absorbable suture. The tacking device with tacks, are at least double
the cost of the equivalent device with titanium tacks. However; in my
humble opinion, the cost is worth the diminished worrying about placing 30 or 40
sharp tacks around a hernia repair, in the abdomen. I have no hesitation
in using titanium tacks, however when doing a
Laparoscopic Extra-peritoneal Hernia
Repair with mesh as these tacks are outside of the abdominal cavity and are
in contact with nothing. Absorbable tacks are gone in about 6 weeks,
have a flat head but do no burrow as deep into tissue as do the titanium tacks,
thus possibly necessitating the use of more of them.
Choice of Suture Method-
This is probably beyond the scope of an article intended for a lay audience but
I can't seem to help myself. There is some contrary about what follows but
I include it for the sake of completeness.
Interrupted Suture- Throw a stitch and tie it, plain
and simple. The disadvantage is that for a large defect, you have to throw
and tie a lot of sutures. This can be rather slow and tedious. The
advantage is that if any one stitch should break or the knot should slip, your
whole repair is not disrupted.
Running Suture- Throw the stitch, tie the knot and
throw, throw, throw through mesh and tissue all the way around until you come
back to your starting point where you tie the ends together. Much quicker
to perform than interrupted suturing but should the stitch break or come loose
through weak tissue at any point, you run the risk of your entire repair coming
undone. Also, if you pull a running suture too tight as you go you may
ischemia in the native tissue to which you are suturing your mesh.
This may be a cause of recurrence.
Combination- There are all kinds of combinations that
exist. This may consist of U- sutures, figure of eights or running sutures
to each quarter of the mesh or part way down a wound.
Choice of Surgical Methods-
Confused yet? Read on. There are several options
for where to place the mesh and how to do so. These are influenced by the
size of the defect, the patients underlying condition and overall medical status
and of course, surgeon preference. I will discuss each of these with the
advantages and disadvantages of each.
(see a) The subcutaneous tissue is
dissected off of the hernia sack and off of the external fascia layer several
centimeters back from the edge of the defect all around the entire defect.
The hernia sack may then be opened to dissect adhesions if the patient is having
obstructive symptoms. The sack should be preserved and closed so as to
provide a barrier between the mesh and the abdominal viscera. If the
fascia will come together without undue tension this can then be done. A
mesh is placed over the fascia and sutured in place with two rows of suture.
If the defect was not repaired primarily, then it is essential that the
first row of sutures be placed around the defect and close together so as not to
allow the sack or abdominal contents to pass between the anterior fascia and the
mesh. Then an outer layer of sutures is placed along the edge of the mesh
to secure the mesh to the fascia.
Advantages- Easy to perform. Does not require
extensive undermining of extra-peritoneal layer.
Disadvantages- Requires a lot of suturing to secure
the mesh around the defect and then onto the surface of the fascia.
Significant incidence of
seroma formation over the mesh. May require placement of drains over
mesh to avoid seroma formation. Most important is the fact that mesh
secured to the outside of the abdomen is at a mechanical disadvantage against
intra-abdominal pressure and gravity pushing against the mesh, and may lead to
(see b) Essentially the
same as the onlay method except that the mesh is secured to the edges of the
Advantages- Easy to perform. Does not require
extensive undermining of extra-peritoneal layer. May be adequate for relatively
small defects. Less mesh in patient therefore less seroma formation and
perhaps less risk of infection.
Disadvantages- Suturing to the edge of the defect may
involve sutures in attenuated and abnormal tissue. Again there is a
mechanical disadvantage against intra-abdominal pressure and gravity which may
lead to recurrence, especially if this method is used over large defects.
(see c) The mesh is
placed inside the fascia in the extra-peritoneal plane.
Advantages- Mechanical advantage against
intra-abdominal pressure and gravity obtained by placing mesh inside of defect
with large overlap of mesh under fascia. Mesh not in subcutaneous tissue
may result in lower risk of seroma and/or infection
Disadvantages- Difficult dissecting pre-peritoneal
space over broad area to make room for mesh. Difficulty in suturing or
tacking mesh under fascia (though there are mesh products that make this
Using a camera and small
incisions mesh is placed in the peritoneal cavity over the defect with large overlap.
Advantages- Again achieves mechanical advantage against
intra-abdominal pressure and gravity by placing mesh inside defect with large
overlap. Small punctures only for instruments used to do surgery. As with
all Laparoscopic procedure there is a shorter recovery and return to normal
Disadvantages- Placement of mesh can be difficult but there are
techniques for making this fairly routine. Since the mesh is under the
peritoneum, virtually all patients develop a seroma. Some surgeons will
aspirate the seroma in the office though in most cases the seroma resolves on
its own over time, but sometimes a long time.
The subcutaneous tissue is
dissected off the fascia beyond the edge of the insertion of the external
oblique fascia into the rectus sheath. A relaxing incision is made in the
external oblique fascia just beyond that insertion point and continued along the
entire length of the muscle from the costal margin (just below the ribcage) to
the iliac crest (the pelvic bone). The layer under the external oblique
muscle is then freed up separating the external oblique muscle from the internal
oblique and allowing the rectus to move several centimeters toward the midline.
Another similar incision may then be made internally through the inner rectus
fascia allowing that layer to be turned toward the midline and both sides
sutured together. This may be combined with an underlay mesh and/or an
overlay mesh sutured to the cut edge of the external oblique. There is a
laparoscopic method for performing the dissection of the external oblique fascia
which may lessen some of the risks of this surgery.
Advantages- Unlike any of the other procedures discussed
prior, this operation brings the rectus muscle back to the midline and returns
to the patient a functional abdominal wall. Results are excellent even for
patients with huge hernias.
Disadvantages- This is extensive surgery and is best for those with a
primary incisional hernia involving most or all of the mid-line. Recurrent
ventral hernias often involve missing tissue and this procedure may not be
suitable for patients who have had a prior incisional hernia repair if there is
significant loss of rectus fascia. The undermining of the skin and subcutaneous
tissue as extensively as described may carry the risk of cutting off the blood
supply to the skin and subcutaneous tissue overlying this area. This risk
is higher in thinner patients. The results could be quite problematic
especially if one has left a plastic mesh overlay as it will now be exposed if
the skin should undergo
In writing this article my intent has
been to educate and not to confuse. I hope I have done more of the former
than the latter. Understand that there are no absolutes and the final
choice of which method to use for any particular patient's hernia will of course, be
between the patient and the surgeon. There is more information about the
anatomy and causes of
As always, I am more than happy to
answer questions via phone or E-mail.
Steven P. Shikiar, MD, FACS