Primary ventral and incisional hernias: comprehensive review

Abstract

Background: Primary ventral and incisional hernias are frequent conditions that impact the quality of life of patients. Surgical techniques for ventral hernia repair are constantly evolving and abdominal wall surgery has turned into a highly specialized field.

Methods: This is a narrative review of the most recent and relevant literature on the treatment of primary ventral and incisional hernias performed by eight experts in ventral hernia surgery from across the world and includes review of classification systems, preoperative measures, descriptions of surgical techniques, and postoperative complications.

Results: Repairs of primary ventral and incisional hernias range from simple open procedures in healthy patients with small defects to complex procedures when patients are co-morbid and have large defects. Optimizing patient-related risk factors before surgery is important to decrease complication rates. Surgical repair techniques from open repairs to minimally invasive procedures are described in detail in the review. Minimally invasive techniques are technically more demanding and take longer, but decrease the risk of surgical-site infections and shorten the duration of hospital stay.

Conclusion: Treatment of ventral hernias aims to improve the quality of life of patients. The risks and benefits of procedures should be weighed against patients' complaints and co-morbidities. Optimizing patient-related risk factors before surgery is important.

Fig. 1

European Hernia Society classification of the location of incisional hernias on the abdominal wall Reproduced from Muysoms et al..

Fig. 2

European Hernia Society schematic classification of incisional hernias on the abdominal wall Reproduced from Muysoms et al..

Fig. 3

Most used mesh planes EO, external oblique; IO, internal oblique; TA, transversus abdominis; TAR, transversus abdominis release. Artist: Dr Mário R. Gonçalves.

Fig. 4

Overview of preoperative, perioperative, and postoperative measures suggested to improve outcomes after ventral hernia repair in an enhanced recovery protocol NSAIDs, non-steroidal anti-inflammatory drugs; TAP, transversus abdominis plane.

Fig. 5

Open preperitoneal technique with mesh for small defects a Small umbilical hernia. b Sac dissection and exposure of the fascial defect. c Preperitoneal space dissection. d Mesh positioning (zoomed in). Images courtesy of Dr Amedeo Trippel.

Fig. 6

Rives-Stoppa repair a Dissection of the posterior rectus sheath. b Extended dissection via transversus abdominis release. c Closure of the posterior rectus sheath. d Positioning of retrorectus mesh. Images courtesy of Dr Heather Bougard and Dr Mário R. Gonçalves.

Fig. 7

Peritoneal flap repair a The schematic provides an axial view of the abdominal wall, highlighting a giant ventral hernia (the arrow at the top of the schematic indicates the hernia sac opening in the middle, the arrow and broken line on the left-hand side of the schematic show the anterior rectus sheath incision site and dissection of the posterior rectus sheath for posterior flap mobilization, and the arrow and broken line on the right-hand side of the schematic show the posterior rectus sheath incision site and dissection towards the anterior rectus sheath for anterior flap mobilization), and the image below the schematic illustrates the incision of the posterior rectus sheath to mobilize the anterior flap on the left side. b Closure of the posterior layer incorporating the posterior peritoneal flap. c Placement of the retrorectus mesh. d Closure of the anterior layer incorporating the anterior peritoneal flap. Images courtesy of Dr Ritu Khare.

Fig. 8

Intraperitoneal onlay mesh plus technique a Visualization of the abdominal wall defect after the reduction of hernia contents. b Fascial closure. c Positioning of the mesh. d Intraperitoneal mesh properly extended and fixed. Images courtesy of Dr Heather Bougard.

Fig. 9

Transabdominal preperitoneal technique a Visualization of umbilical hernia with omentum. b Ipsilateral peritoneal incision. c Overview of peritoneal flap and reduced hernia sac. d Defect closure. e Mesh placement. f Peritoneal flap closure. Images courtesy of Dr Nadia A. Henriksen.

Fig. 10

Transabdominal retromuscular umbilical prosthetic technique a Visualization of midline hernia with omental adhesions and small bowel. b Lateral posterior rectus sheath incision. c Medial posterior rectus sheath incision. d Midline crossover and hernia sac reduction. e Defect closure. f Mesh placement. Images courtesy of Dr Nadia A. Henriksen and Dr Jenny Shao.

Fig. 11

Extended totally extraperitoneal technique for a lower midline defect a Visualization of the posterior rectus sheath from the highest left port, with dissection proceeding in a caudal direction. b Visualization of the fascial defect after hernia sac dissection. c Extended dissection performed via transversus abdominis release. d Initial stage of fascial closure. e Completion of fascial closure. f Mesh positioning. Images courtesy of Dr Anibal Pimentel.

Fig. 12

Component separation techniques a Anterior component separation (external oblique release). b Posterior component separation (transversus abdominis release). Artist: Dr Mário R. Gonçalves.