Ventral Hernia Operations

Mesh repairs are considered the standard by most in the surgical community for hernia defects larger than 1-2 cm. In most studies, the use of mesh did not result in a statistically significant increase in chronic pain or complications. The use of mesh however was correlated with a lower recurrence rate (about 1-5%). There are rare cases of well-documented mesh-related illness due to uncommon immune reactions.

Open repair with mesh
Benefits of this repair include not requiring general anesthesia and intubation. Generally, the mesh can be kept away from the bowel by either utilizing the preperitoneal or onlay position. Open approaches are generally a better choice in the presence of many intrabdominal adhesions. Typical meshes used include Ventralex ST, Prolene, or Bard Soft Mesh.

Robotic repair with mesh (IPOM+/IPUM)
Benefits of this repair include probably slightly less pain for larger defects. General endotracheal anesthesia is required. Here the mesh is placed intra-peritoneally (though sometimes it is placed pre-peritoneally), but certain modern anti-adhesive barriers appear quite effective at allowing the mesh to re-peritonealize (be covered with peritoneum and thus excluded from the intestine). A typical mesh used would be Ventralight ST.

Robotic TAR with mesh
This repair is useful for large (8-10+ cm) or recurrent hernias and keeps the mesh away from the peritoneal cavity. This operation is more involved and generally a little longer than other ventral hernia repairs. It is similar to open TARs but leverages the benefits of minimally-invasive surgery in what would otherwise require a large incision. Typical meshes used include light-weight or medium-weight non-coated polypropylene large pore meshes.

Many studies demonstrate that non-mesh repairs are comparable to mesh repairs for small hernias. For larger hernias, alternative techniques must be utilized -- there is no definitive consensus in the surgical community as to which technique is best. Most agree that these repairs should either not be used or used with caution in patients with risk factors for recurrence (e.g. recurrent hernias, obesity, and smoking). 

Open primary repair
This is most appropriate in smaller hernias 1-2 cm in size. This is our preferred technique for small umbilical hernias without significant associated rectus diastases. An absorbable mesh may or may not be used to buttress the repair -- doing so would likely decrease recurrence rates with no notable increased risk of complications.

Robotic primary repair
This is most appropriate in smaller hernias 1-2 cm in size in obese patients. An absorbable mesh may or may not be used to buttress the repair -- doing so would likely decrease recurrence rates with no notable increased risk of complications.

Open two-layer no mesh repair
This repair is for larger hernia defects and utilizes a muscle plication technique similar to what is done during abdominoplasties. By plicating the rectus muscles above and below the hernia, we are able to close the hernia primarily. Recurrence rates are slightly higher than in mesh repairs. We recommend this technique be performed with permanent sutures and that the repair be buttressed with an absorbable mesh such as Phasix or Phasix ST.

A rectus diastasis (RD) is a separation of the rectus abdominis muscles, most commonly in the upper midline. This can occer in both sexes and can occur postpartum in women. Addressing RDs have had a growing interest in the surgical community as a hernia in the setting of an RD has been found to have a higher recurrence rate if the associated RD is not treated. There are two main approaches to repairing RDs outlined below.

Anterior plication
This is where the rectus diastasis is repaired from anteriorly using plicating sutures of the anterior sheath at the medial edge of the separated rectus muscles. There is a great experience with anterior plication in cosmetic surgery due to the rising use of "tummy tucks". There are other anterior repairs such as Desarda and Rives-Stoppa and open TAR. There is also a question as to the role of mesh vs multi-layered suture repairs. Furthermore, there are minimally invasive options for anterior plication such as SCOLA and MILOS.

• PROS: 

  • Can address removal of excess skin (e.g. panniculectomy) and do repair through that exposure.

  • Avoids peritoneal cavity entry.

  • SCOLA keeps the incisions very small and low on abdomen.

• CONS:

  • Extensive subcutaneous dissection has higher seroma risk and generally requires drain placement.

  • Traditional techniques require large incisions and/or large dissection spaces.

  • Some techniques incise rather than purely plicate the anterior sheaths which may have little to no consequence.

Posterior plication
This is where the rectus diastasis is repaired from posteriorly most commonly using robotic surgery. Experience with this approach is growing as more general surgeons adopt this at time of ventral hernia repairs. This approach may in theory have slightly higher recurrences than the open approach since it may be more difficult to get good suture bites of the anterior sheath. There is also a question as to the role of mesh vs multi-layered suture repairs.

• PROS: 

  • Small incisions.

  • No subcutaneous dissection / seroma spaces and thus no drains required.

  • eTEP does not require intraperitoneal access.

• CONS:

  • TAPP or preperitoneal appraoch requires intraperitoneal access.

  • eTEP incises the posterior sheaths which may have little to no consequence

Is this a recurrent hernia?
If the answer is yes, we generally recommend using a permanent mesh such as a light-weight or medium-weight mesh (and coated if intraperitoneal, although we generally recommend exclusing the mesh from the peritoneal cavity).

How big is the hernia (the actual defect or "hole" in the fascia)?
If the hernia is small (<1.5 cm), generally mesh is not needed. If the hernia is small-medium sized, 1.5-4 cm, a mesh is recommended but non-mesh techniques can be used with a higher recurrence rate. If the hernia is medium-large or larger (>4cm), use of permanent mesh is strongly recommended.

We use the following size scheme for ventral hernias:

• Small: <1.5 cm

• Small-medium: 1.5-4 cm

• Medium-large: 4-8 cm

• Large: 8+ cm

Is there an associated rectus diastasis?
If the answer is yes, we recommend reparing the RD at the time of hernia operation.

When is robotic surgery better?
We believe if an extensive dissection or large piece of mesh is needed, we tend to favor robotic repairs due to less subcutaneous dissection and seromas. Furthermore, we prefer robotic surgery in obese patients although ideally patients lose weight to a near normal weight. In general we prefer robotic repairs in the following situations:

• Patient is obese

• Recurrent hernia where previous approach was anterior

• Medium-large and larger hernias (4+ cm)

• Associated rectus diastasis

When is open surgery better?
We tend to favor open surgery in small simple hernias due to its simplicity and minimal morbidity and lesser anesthesia requirements. Sometimes open surgery is better in larger operations when hernias are giant or there are extensive intrabdominal adhesions (scar tissue around the bowel). In general we prefer robotic repairs in the following situations:

• Patient is thin

• Primary hernia

• Small-medium and smaller henias (<4 cm)

• No associated significant rectus diastasis

• Patient frail and use local anesthetic

What are the robotic surgery options?
Robotic repairs have several features:
✓ Can address rectus diastasis
✓ Keeps incision small in obese patients
✗ Requires general anesthesia

• Small hernias <1.5 cm: preperitoneal suture repair (rTAPP), SCOLA

• Small-medium hernias 1.5-4 cm: preperitoneal mesh repair (rTAPP), SCOLA

• Medium-large hernias 4-8 cm: preperitoneal mesh repair (rTAPP)

• Large hernias 8+ cm: transversus abdominus release (rTAR), eTEP

• We are no longer routinely offering IPOM/IPOM+/IPUM repairs as we feel rTAPPs are generally superior.

What is SCOLA?
SCOLA stands for Subcutaneous Onlay Laparoscopic Approach -- it is an approach that replicates the anterior plication of RD and repair of hernias traditionally done through larger incisions, through a few small incisions using laparoscopy, or in our case, the surgical robot. It is an extra-peritoneal approach and can be done with or without mesh.

What are the open surgery options?
✓ Less anesthesia
✓ Stays extra-peritoneal
✗ Rectus diastasis repair requires larger incision
✗ Obese patients require larger incisions

• Small hernias <1.5 cm: no mesh or Phasix ST absorbable mesh

• Small-medium hernias 1.5-4 cm: Ventralex ST mesh or suture 2 layer repair

• Medium-large and large hernias 4+ cm: TAR, onlay, mesh techniques

• Rectus diastasis: vertical incision, mini-incision, traditional abdominoplasty incision 

• Stony Brook Center for Abdominal Core Health and Complex Hernia Repair

• Classification of Rectus Diastasis—A Proposal by the German Hernia Society (DHG) and the International Endohernia Society (IEHS)

• MILOS

• Early results of eTEP access surgery with preperitoneal repair of primary midline ventral hernias and diastasis recti. A 33 patient case series of "PeTEP"

SCOLA

• Subcutaneous Onlay Laparoscopic Approach (SCOLA) for Ventral Hernia and Rectus Abdominis Diastasis Repair: Technical Description and Initial Results

• A Novel Modification of Subcutaneous Onlay Endoscopic Repair of Midline Ventral Hernias With Diastasis Recti: An Indian Experience

• A systematic review and meta-analysis of subcutaneous onlay laparoscopic (SCOLA) approach for diastasis recti with or without mesh reinforcement

• SAGES video