Repair of Abdominal Wall Hernias with Restoration of Abdominal Wall Function

Abstract

Our operative approach to the repair of abdominal wall hernias has changed tremendously over the last two decades based on our ongoing insight into the etiopathogenesis of their development. For instance, 20 years ago, use of alloplastic prosthetic material in the repair of direct inguinal hernias was rare, but currently, the accepted standard of care involves routine use of prosthetic material to “repair” the defective inguinal floor. Repair of incisional hernias of the anterior abdominal wall is undergoing a similar transition with our appreciation of recurrence rates of >50% in long-term follow-up studies of autogenous tissue repairs. Moreover, research into the inherent metabolic abnormalities in wound healing in the majority of patients developing incisional hernias in the absence of technical errors or tissue loss had led to evidence-based support for the use of prosthetic material in the repair of incisional hernias. Indeed, most herniologists today believe that prosthetic material to repair or reinforce the repair of incisional hernias is imperative in these patients to assure the best results. In addition, interest in the biomechanics of the abdominal wall and its musculature has altered the operative approaches as well. For instance, the technique of components separation offers restoration of medialization of the rectus muscles, but this repair is an autologous repair despite the concept of it being a “tension-free” repair. With these considerations in mind, this technique-based manuscript will describe the open and laparoscopic techniques we utilize for repair of incisional hernia. While we have our own parochial beliefs, we believe strongly that the literature supports the concepts of (1) a sublay repair (versus an onlay or inlay repair), (2) wide lateral overlap of prosthesis to maximize surface ingrowth and/or sublay support, and (3) restoration of reapproximation of the rectus musculature whenever possible. With these approaches and employing the above concepts, recurrence rates should be about 5%.