Recurrent hernias and complex abdominal wall hernias are challenging cases. Patients have overcome challenging life obstacles of cancer or another intra-abdominal process. The patient may have become frustrated with its recurrence or development. Unfortunately, many of these patients present with ongoing or recurrent comorbidities which need to be controlled or optimized prior to embarking on abdominal wall reconstruction. It is important for members of the general surgery and plastic & reconstructive team to have an understanding of each other’s roles, approaches, and concerns, as well as how treatment decisions impact the patient's overall abdominal core health and aesthetic results.
We found that when planning these complex abdominal wall repairs, following a systematic method optimizes the likelihood that the procedure is performed safely and maximizes restoration of abdominal core health and aesthetic outcomes. We also plan with the intention to help patients understand the process and with the education that minor complications such as seroma or small wound dehiscence are commonplace given their challenging problem.
Step 1. Where is the location of the hernia on the abdominal wall ? Are there multiple hernias? Is the hernia close to the umbilicus and can the umbilicus remain viable with undermining or need to be translocated?
Invariably, the first step in the examination of a hernia patient is an examination of the CT-scan. When patients are referred to us, often their CT-scans arrive in the mail before the patients and/or we review the CT-scan of the abdomen on the computer prior to seeing the patient in the exam room. The important information to be gathered is the dimensions of the hernia, usually the widest part, and then the location. Hernias close to the umbilicus, while large can often be easily closed as there is a greater degree of laxity of the abdominal wall. There is less laxity at the costal margin and at the location of the iliac crests.
If multiple hernias are present, this may prevent the excursion of the abdominal wall and limit approximation of healthy tissue and closure. It is helpful to understand these dimensions and possibilities pre-operatively. Repairing lateral defects or subcostal defects with acellular dermal matrix or individual component separation may inhibit closure of a midline defect as there is now less laxity. This should be accounted for and may leave a midline abdominal wall defect with a bridged repair that is not dynamic. This may increase recurrence or even seroma formation post-operatively.
Both the general surgeon and plastic and reconstructive surgeon need to know the location of the hernia relative to the umbilicus. The proximity of the hernia to the umbilicus may make keeping it very unrealistic as undermining may devascularized it. Keeping it on a widely undermined flap pedicle may create an unreasonable position, or maintaining it on the abdominal wall may devascularize it after the placement of muscular or transfascial sutures.
Step 2. What are the physical examination findings?
The physical examination commences after the standard history is taken in the office. During the physical examination, we ask the patient about their current height and weight. This is converted directly into BMI. The BMI is explained to the patient and their risks for postoperative complications such as seroma and wound dehiscence which are likely to occur but which will be addressed early or possibly later in the post-operative course, if appropriate.
During physical examination, we measure the hernia defect and then when applicable bring the ends of the hernia musculature together with the patient standing. This maneuver tends to be more difficult with the patient standing compared to when the patient is supine on the operating table against the effects of gravity.
After this point in the examination, the decision tree adjusts as to the incision choice and exposure used to gain access to the hernia or hernias.
Step 3. Has the patient had a prior C-section scar, how lateral does the C-section scar extend, and does the patient have lower abdominal skin laxity? Has the patient had a prior abdominoplasty?
Discerning early if the patient has a lower abdominal incision will often determine which incision pattern will be used. In the patient with a previous abdominoplasty or extended C-section the superficial inferior epigastric vessels or superficial circumflex epigastric have been divided and the lower abdominal skin will not remain viable if undermining is accomplished superior to this. In these cases, the abdominoplasty incision should be utilized or the extended c-section scar incorporated into the exposure. Assessing the distal viability of the skin in these cases is critical and in some cases there may be a need to return to the operating room in the postoperative period to freshen up wound edges and re-close the skin. This early potential return to the operating room can potentially prevent mesh, suture, or seroma colonization and a low threshold should be maintained for a return to the operating room for skin changes. Lengthy discussions of this possibility is helpful in the consultation process to maintain patient confidence in the surgical team in the highly comorbid and possibly already frustrated patient. C-section scars that do not extend laterally often keep the superficial epigastric vessles intact and the lower abdominal skin can be maintained preventing wound complications.
In the absence of abdominoplasty incisions or extended C-section scars, the previous midline incision is utilized. We typically undermine lateral to the anterior axillary line for component separation keeping the lateral intercostal blood supply intact after sacrificing the blood supply from the rectus muscle perforators. An intact superficial inferior epigastric system allows venous drainage of the skin flaps and healing occurs readily with minimal skin necrosis.
If there is a question of dead space after the undermining and concern of seroma formation or skin viability, the excess skin can be excised, and a midline horizontal incision can be closed. Drains are used in all cases and abdominal binders are used for six weeks to help prevent seroma formation.
Step 4. What are the comorbidities that the patient presents with and what needs to be optimized prior to surgery?
Both general surgeons and plastic & reconstructive surgeons need to pay attention to the comorbidities of the patient. Not only does this prevent complications associated with treatment, but it can also facilitate treatment. For abdominal wall reconstruction we use the following rules for patients undergoing abdominal wall reconstruction.
Smoking needs to be stopped for 6 weeks before surgery and 6 weeks after surgery. Hyperbaric oxygen consultation is required for patients with a history of smoking.
All patients are instructed to begin a diet of 1–2 g/kg/day of protein intake, which usually tends to be roughly 80–100 grams of protein per day. We use the rule of 20’s: a can of tuna fish is 25 grams, a chicken breast is 25 grams, three eggs are 25 grams, and a protein shake at night is 25 grams, totaling 100 grams. This not only increases protein stores in the patient preoperatively, but also, we have found patients frequently begin to lose weight. Often these same habits persist post-operatively and can theoretically reduce hernia recurrence if patients continue to lose weight.
Referral to their primary medical doctor for clearance is paramount. Patients are optimized with respect to HgA1c and all other medical comorbidities. Anticoagulation is appropriately bridged per hematologists, cardiologists, etc.
Step 5. After the patient is cleared medically for surgery, what are the next steps we need to do to prepare for surgery?
Once the patient has been cleared for surgery, we generally see the patient in our office two weeks prior to surgery for a pre-operative appointment. During the pre-operative appointment, we assess patient’s intake of protein over the past several months. Three days prior to surgery the patients consume protein shakes and smoothies and are placed on clear liquids for two days prior to surgery. The patients are given neomycin and erythromycin on the day prior to surgery and on the morning of surgery the patients are instructed to take Emend 40 mg with a sip of water prior to coming to the hospital. We find that this regimen prevents nausea and distension post-operatively and ultimately protects our repair. When feasible the patients receive a spinal anesthetic prior to surgery. The spinal has been helpful for preventing opiate use post-operatively with the intention of facilitating early return of bowel function.
Step 6. What are the intra-operative steps that will take place during surgery?
In the preoperative holding area the abdominal incisions are re-traced or marked on the abdominal wall as well as an outline of the hernia.[Figure A] The hernia outlines are marked while the patient is supine as well as after being intubated on the operating room table to demarcate area of dissection.[Figure B] Typically the operative procedure commences in the following order.
The skin is incised at the location of the previous incisions and extended to the marked incisions. Dissection with cautery proceeds down to the intact portion of the abdominal wall superior to the abdominal wall hernia. From this point we begin undermining the abdominal flap off of the abdominal wall laterally toward the anterior axillary line. This is done bilaterally. The skin incision is then directed to the abdominal wall inferior to the level of the hernia and then the abdominal wall skin is undermined laterally toward the anterior axillary line, bilaterally. The known superior and inferior dissections around the hernia defect are then joined with the hernia defect itself. At this point, elevating the skin off the hernia sac can be performed safely with good exposure of any bowel or intra-abdominal contents.[Figure C] The skin flaps are then mobilized away from the defect and kept moist with wet lap sponges. [Figure D]
The intra-abdominal component of the procedure commences and the hernia sac is entered and the hernia sac is excised from the abdominal wall.[Figure E] Lysis of adhesions of loops of bowel from the anterior abdominal wall and often occurs in concert with the removal of any abdominal wall mesh or intra-abdominal mesh. The loops of bowel are then examined, and any lysis of adhesions occurs in symptomatic patients.
After this is completed we proceed with component separation of the layers of the rectus sheath for subcostal/lateral hernias and then with release of the external oblique aponeurosis to medialize the rectus muscles.[Figure D, E] This can be done unilaterally or bilaterally. The rectus muscles are approximated with Kocher clamps to determine the give of the abdominal wall and to determine the size of mesh needed for underlay. [Figure F] When possible it is best to have the transfascial suture knots rest on the lateral aspect of excised external oblique aponeurosis or fascia. Knots resting in these lateral core muscles, we believe, can lead to a small amount of muscle necrosis and enzyme leak.
Prolene sutures are then pre placed via U stitch on the Strattice acellular dermal matrices or synthetic mesh [Figure G] and then passed through the anterior abdominal wall in either the intraperitoneal location or in the retro-rectus space depending on the location of the hernia being repaired. [Figure H] These sutures are then tied and we proceed with the approximation of the rectus muscles to re-create a dynamic abdominal wall. [Figure I] Pre-mapping the location of the transfascial suture placement is helpful. It is important to mark the location of the suture to be passed through the abdominal wall when the midline is closed. [Figure J] Now the abdominal core musculature is restored and there is load sharing between the midline repair and the acellular dermal matrix.[Figure K] JP drains are placed between the acellular dermal matrix and abdominal wall and placement of drains in the subcutaneous space.[Figure L] We then excise any devitalized skin or excess skin to obliterate dead space.[Figure M,N] The incisions are all closed and bacitracin ointment, Xeroform gauze, and an abdominal binder is placed.
Multiple options exist to repair ventral hernias with posterior and anterior component separations offering different advantages. While the anterior component separation offers the advantage of direct visualization of the external obliques, there is a potential dead space created where fluid can accumulate. Controlling the excess subcutaneous tissue can lead to an abdominal contour improvement which is an advantage of the anterior component release. [Figures O-R}
Step 7. What are the immediate and longer term post-operative care measures for the patient?
The patients are admitted to the floor post-operatively. The patients ideally are given spinal for anesthetic and a post-operatively includes IV Tylenol. The patients are encouraged to ambulate post-op day 1. On post-op day two the foley is discontinued and when urinating, Toradol is added for pain control in addition to IV Tylenol. All efforts are made to minimize narcotic use for the resumption of bowel function. Patients are kept npo until passage of flatus. At that point a clear liquid diet is started followed by a regular diet the following day if appropriate. Oral pain meds are initiated when clear liquid diet commences. Patients are allowed to shower on post-op day number 2. JP drains are kept in place until after discharge.
The activity regimen consists of purposeful walking the first week home from the hospital. Patients are told they can walk to the bathroom, walk to eat dinner, and walk to check the mail. The abdominal binder is worn at all times except to shower for six weeks. In the second week the patients are allowed to walk as if they were shopping at the mall. This level of activity continues until the six-week mark. Drains are removed based on output of < 30 cc per drain for three consecutive days and no signs of edema in the tissues.
On the six-week post-operative visit the abdominal binder is discontinued for normal activities of daily living. The patient begins isometric core strengthening with physical therapy at the six-week mark. The patient wears the abdominal binder at physical therapy for two weeks until the eight weeks with the intention of removing the binder for physical therapy at eight weeks. The patients are seen again at 3 months 6 months 12 months and then 2 years. Patients are instructed to come back every year after that, but most people find that their abdominal core health has recovered, and they have moved on with their lives.