Surg Clin N Am 88 (2008) 61–83

Open Repair of Ventral Incisional
Hernias
Dan H. Shell IV, MDa, Jorge de la Torre, MDa,*,
Patricio Andrades, MDa,b, Luis O. Vasconez, MDa
a
Division of Plastic Surgery, University of Alabama at Birmingham,
510 20th Street S, Birmingham, AL 35294-3411, USA
b
Division of Transplant Immunology, University of Alabama at Birmingham,
510 20th Street S, Birmingham, AL 35294-3411, USA

Incisional hernia is a common and often debilitating complication after
laparotomy. Despite significant advances in many areas of surgery, correc-
tion of incisional hernias continues to be problematic, with recurrence rates
ranging from 5% to 63% depending on the type of repair used [1–8]. Recur-
rence rates are likely underestimated because of a lack of long-term follow-
up and objective criteria in the literature to determine true recurrence.
More than 2 million laparotomies are performed annually in the United
States, with a reported 2% to 11% incidence of incisional hernia [1,5,9–11].
It is the most common complication after laparotomy by a 2:1 ratio over
bowel obstruction and is the most common indication for reoperation by
a 3:1 ratio over adhesive small bowel obstruction [12]. Approximately
100,000 hernia repairs are performed annually in the United States [13].
The associated morbidity secondary to incarceration, strangulation, and
bowel obstruction is significant. In a retrospective review of 206 patients
who underwent incisional hernia repair, Read and Yoder [9,10] found
that strangulation or incarceration was the indication for repair in 17%
of patients. The gradual enlargement of the hernia over time results in a rel-
ative loss of abdominal domain, with adverse effects on postural mainte-
nance, respiration, micturition, defecation, and biomechanical properties,
which have a profound impact on patients’ overall physical capacity and
quality of life. As patients are forced to alter their lifestyle, their ability to
work becomes impaired, which has negative economic consequences. Pro-
gressive enlargement of the hernia also results in a cosmetic deformity,
which is detrimental to patients’ self-esteem.

* Corresponding author.
E-mail address: jdlt@uab.edu (J. de la Torre).

0039-6109/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.suc.2007.10.008 surgical.theclinics.com

62 SHELL et al

Incisional hernias are the only abdominal hernias that are iatrogenic [10].
Controversy exists regarding the ideal treatment of incisional hernias. No-
where in surgery does the phrase ‘‘if there are multiple ways of fixing a prob-
lem then there is not one good way’’ hold true more so than with incisional
hernia repair. The approach to incisional hernia repair is often based on tra-
dition rather than evidence. Several important contributions to the literature
in recent years have helped our understanding of the causes of incisional
hernia formation and the important physiologic and functional properties
of the abdominal wall. An appreciation for the dynamic function of the ab-
dominal wall has led to technical refinements and the recognition of impor-
tant principles that are necessary for successful repair.

Etiology
Many patient-related risk factors have been implicated in the develop-
ment of incisional hernias, including obesity, smoking, aneurismal disease,
chronic obstructive pulmonary disease, male gender, malnourishment,
corticosteroid dependency, renal failure, malignancy, and prostatism
[1–8,10,11,14–23]. Many of these risk factors may contribute to the develop-
ment of an incisional hernia, but no single factor is so regularly associated
that it may be declared as serving a truly etiologic role [22].
In a study by Condon and colleagues [21] of complications associated
with closure of 1000 midline laparotomies, no single factor was associated
with incisional hernia on univariate analysis. On multivariate analysis,
only the combination of reopening and reclosing previous incisions coupled
with wound infection influenced the development of incisional hernia. Post-
operative wound infection has been found in additional studies to be the sin-
gle most significant prognostic factor in the development of incisional hernia
[1,7,10,14,19,21]. Bucknall and colleagues [1] reported a 23% incidence of
incisional hernia formation in patients who developed a wound infection.
Obesity often has been cited as a risk factor, with an incisional hernia rate
of 15% to 20% [24–26]. In a prospective, randomized evaluation that com-
pared fascial closure techniques, Brolin [24] found a reduction in incisional
hernia occurrence from 18% to 10% with the use of double-stranded #1
PDS placed in continuous fashion compared with #1 Ethibond placed in in-
terrupted figure-of-eight fashion. Aneurysmal disease also has been found in
multiple studies to be an independent risk factor in the development of inci-
sional hernias [22,27–29]. A recent multicenter, prospective study by Rafetto
and colleagues [22] found a 28.2% incidence of incisional hernia formation
in patients undergoing surgery for aortic aneurysm repair. After correcting
for other risk factors, this figure represents a ninefold increase in the inci-
dence of incisional hernia formation compared with surgery for aortic occlu-
sive disease. It has been suggested that a defect in collagen metabolism with
a decreased ratio of type I to type III procollagen may play a role; however,

Poole [32] concluded in a comprehensive review that local technical factors were of greater signif- icance than patient-related conditions in the development of incisional her- nias. Playforth and colleagues [31] applied radiopaque staples to the margins of incised fas- cia. They also found nonabsorbable suture in continuous fashion to be the material and tech- nique of choice.5% with transverse incisions and 2. Closure under tension results in fascial strangulation and hernia formation.30]. Presentation and natural history Patients typically present with a bulge in a portion of the healed surgical incision.6. This finding supports faulty surgical tech- nique as the primary cause of early wound failure. and paramedian incisions. These findings implicate technical factors in early wound failure and patient-related factors in late wound failure. controlled trials that compared suture material and technique found that abdominal fascial closure with nonabsorbable monofilament su- ture in a continuous fashion had a significantly lower rate of incisional her- nia [33]. Mid- line incisions had the highest hernia rated10.5. In work that has been reinforced by others. OPEN REPAIR OF VENTRAL INCISIONAL HERNIAS 63 further studies are needed before a causal relationship can be established [22. Serial radiographs were taken at time intervals up to 1 year.5% compared with 7. Surgeon-related technical errors are responsible for most inci- sional hernias. it is incumbent on surgeons to identify and use appropriate techniques and materials to minimize the incidence of incisional hernias. bites should encompass 1 cm of tissue at 1-cm intervals with attention to simply approximate the fascia. Complaints of dull abdominal discomfort and associated nausea are common and are related to stretching of the bowel mesentery as it pro- trudes through the defect [10.11].11]. transverse.11]. In patients who developed incisional hernias at 1 year. To use this length of suture. Incisional hernias differ from other abdominal wall hernias in their iatro- genic origin.5% with paramedian incisions. there was separation of the sta- ples at 1 week postoperatively. Bowel obstruction may result from incar- ceration in the hernia sac but is more often caused by twisting of the bowel around adhesions at the lateral margins of the hernia defect [10. with continued failure rates of 2% per year thereafter [2. Controversy exists regarding the optimal closure material and technique used to avoid incisional hernias. The nat- ural history of incisional hernias is gradual enlargement. Studies have shown that 50% of hernia recurrences are detected in the first postoperative year. and 90% are detected at 3 years. Jenkins [34–36] found that a suture length-to-incision ratio of 4:1 was optimal for fascial closure. A meta-analysis of randomized. The linea alba serves as the midline anchor for the aponeurotic insertions of the rectus . Carlson and colleagues [21] compared the incisional hernia rate of midline. 75% are detected at 2 years. Given these findings.

In a study by Toranto [43]. the diaphragm loses synergy with the abdominal wall. . as evi- denced by paradoxic abdominal respiratory motion [37]. which renders it susceptible to ulceration and infection. The lateral pull of the internal oblique-transversus abdominus musculature on the lumbodorsal fascia is responsible for a reduction in intervertebral joint stress [46]. task-dependent functions of the abdominal wall musculature are interfered with and significant phys- iologic derangements occur [11.64 SHELL et al sheath and oblique musculature [37]. micturition. Disruption results in gradual enlarge- ment of the hernia defect because of unopposed lateral contraction of the oblique musculature. This resolution is postulated to result from a restoration of the counterbalancing effect of the abdominal wall muscles with the back musculature. The abdominal wall plays an important role in posture maintenance and support of the lumbar spine [43–45]. As the hernia defect widens. the hernia will only enlarge in size and lead to progressive physiologic derangements. Expulsive functions are compromised and may become problematic as the hernia enlarges. Blon- deel and colleagues [42] demonstrated in isokinetic dynamometric studies that displacement of the oblique fibers insertions results in statistically sig- nificant reductions in trunk rotation. Patients with large incisional hernias of- ten have significant lumbar lordosis and disabling back pain. Puckree and col- leagues [39] demonstrated that the internal oblique and transversus abdominus muscles receive neural impulses from central expiratory neurons. Contraction of the abdominal wall musculature and generation of intra-abdominal pressure are important in functions such as coughing. Dermatologic changes may occur as the hernia enlarges. Children with prune belly syndrome are functionally impaired by the associated scoliosis [45]. As the overlying skin is stretched. and defecation. Ramirez and colleagues [46] demonstrated complete relief of back pain after repair of large incisional hernias by restoration of midline myofas- cial continuity. Trunk motion abnormalities are common in patients with incisional hernias. The abdominal wall has important functions in respiration. resolution of back pain was observed in 24 of 25 patients after wide rectus plication. As the hernia defect widens. Myrinkas and colleagues [41] measured stretch re- flexes of the rectus abdominus muscles and found that a crossed monosyn- aptic communication exists between the right and left rectus muscles. which controls trunk flexion and extension.39]. Misuri and colleagues [40] demonstrated by ultrasound assessment that the transversus abdominus muscle is a major contributor to the generation of expiratory forces. Repair principles The presence of an incisional hernia is an indication for repair. Trunk rotation results from joint con- traction of one external oblique and the contralateral internal oblique. the subcutaneous tissue atrophies and the skin at the apex becomes ischemic.38.

11]. Several important principles have been defined to aid in the surgical approach to this difficult problem [48–51]. OPEN REPAIR OF VENTRAL INCISIONAL HERNIAS 65 The actual size of the hernia is defined by the size of the parietal defect to be repaired. Prevention of visceral eventration 2.4. In a study that compared mesh and primary suture repair for incisional hernias smaller than 6 cm in greatest dimension. extrusion. such as infection.’’ An expert panel on incisional hernior- rhaphy concluded that primary suture repair should be used only for small (! 5 cm) hernias and if the repair is oriented horizontally with nonresorb- able. prospective. are signif- icant problems. simple suture repair of incisional hernias was the gold standard. which is often significantly larger than the palpable clinical defect. and fistula formation. A long-term follow-up of the study by Burger and colleagues [4] revealed a 10-year cumulative rate of recurrence of 63% for the suture repair group compared with 32% for the mesh repair group. mesh-related complications. Multiple retrospective studies in the literature have demonstrated high recurrence rates (25%–63%) of primary suture repair of even small (! 5 cm) fascial defects [3. The high recurrence rates of primary suture repair were supported in a large. This includes all secondary hernias and zones of weakened fascia [47]. In a study of recurrent her- nias by Girotto and colleagues [55]. there is lack of a general consensus regarding the optimal technique. Mul- tiple repair techniques have been used in the past. however. they found a 46% recurrence rate in the primary suture repair group compared with 23% in the mesh repair group [3].9. Incorporation of the remaining abdominal wall in the repair 3. monofilament suture with a suture-to-wound length ratio of 4:1 [56]. the continued presence of tension at the site of repair has led to high recurrence rates (Table 1). 50% of patients were noted to have more than one hernia at the time of exploration. however. This approach has resulted in a decline in recurrence rates. which led the authors to conclude that ‘‘primary suture repair of incisional hernias should be completely abandoned. Restoration of abdominal wall continuity in a tension-free manner The high recurrence rates with primary suture repair have led to an in- creased use of prosthetic mesh to provide for a ‘‘tension-free’’ repair. Recent emphasis on the importance of restoration of mid- line myofascial continuity and dynamic abdominal wall support has led to the application of numerous techniques of autologous reconstruction. Additional hernias and areas of fascial weakening may not be appreciated by the limited exposure of primary su- ture repair and may result in future recurrences.7. Primary suture repair Until the 1990s. randomized trial by Luijendijk and colleagues [3]. . however. The goals of hernia repair should be as follows: 1. Various techniques have been applied. Provision of dynamic muscular support 4.

The ideal prosthetic material should be non- toxic. Surgical treatment of incisional hernia. nonimmunogenic.5 Adapted from Cassar K. In an average-sized human. et al. Flagstaff. the maximum required tensile strength to maintain abdominal closure is 16 N/cm [59]. et al. Munro A.66 SHELL et al Table 1 Results of primary suture repair techniques Author/Year N Recurrence (%) Follow-up (mo) Langer. In general. Placement of mesh allows for a tension-free restoration of the structural integrity of the abdominal wall. Studies have shown ePTFE prosthesis to be stronger than marlex . 1988 [52] 151 49 39 Read.L. The use of synthetic mesh in incisional hernia repairs increased from 34. Gore and Associates.8 Gecim. Polypropylene was first introduced in the 1950s by Usher [62]. and nonreactive [59. 1996 [15] 109 45 7–92 Luijendijk. 1986 [2] 81 46 14 Van der Linden. prosthetic materials have a tensile strength more than 32 N/cm [61]. Recurrences seen after mesh repair typically occur laterally at the mesh-tissue interface. ePTFE (Goretex. 1989 [9] 206 24. 2000 [3] 97 46 36 Burger. which provides greater resistance to infection. 2005 [53] 305 18 60 Al-Salamah.2% in 1987 to 65. Tensile strength of the abdominal wall may be calculated as the product of tension strength according to LaPlace’s formula (DP ¼ 2T/r) and the area of cross-section of the abdomen [59]. 2004 [4] 97 63 120 Sauerland. The ultimate goal when us- ing mesh is for it to become incorporated into the surrounding tissues. et al.60]. et al. The American Hernia Society has de- clared that the use of mesh currently represents the standard of care in inci- sional hernia repair [58]. The large pore size of the polypropylene mesh allows for macrophage and neutrophil infiltration. Mesh repair High recurrence rates associated with primary suture repair have led to an increased application of prosthetic mesh for the repair of incisional her- nias. Arizona) has a microporous structure that minimizes cellular infiltration and tissue incor- poration. Tensile strength is another important property of the synthetic material. with permission of Blackwell Science Ltd. Advantages to the use of mesh include availability. et al. and strength of the repair [59]. Rarely is there a true failure of the mesh material. 2006 [54] 72 20.89:534–45. et al. The phys- ical properties of this interface are important in determining the ultimate strength and durability of the repair. The two most commonly used permanent prosthetic materials are poly- propylene and expanded polytetrafluoroethylene (ePTFE). 1985 [6] 154 31 48–120 George.8 37. et al. et al. Br J Surg 2002. W. Its porosity also allows for better fibrovascular ingrowth and a reduced incidence of seroma formation [59]. et al.5% in 1999 [57]. absence of donor site morbidity.

The disadvantages of ePTFE are related to its microporous structure. comparative studies with long-term follow-up are still needed.79]. Knowledge of the structural anatomy and an appreciation of the physiology of the abdominal wall are necessary for successful abdominal wall reconstruction. which may predispose to wound-related complications. Their technique consisted of relaxing incisions in the anterior rectus sheath with primary approximation of the linea alba and medial turnover of the anterior rectus sheath followed by mesh placement. which are large enough for bacteria (1 mm) to infiltrate but too small for macrophages (O 50 mm) [59].78. 1B). Retrorectus placement of mesh. Chevrel and Rath [76. The disadvantages are that it requires wide tissue undermining. and intraperitoneal underlay. activ- ities that increase intra-abdominal pressure impart significant tension to the mesh-fascial interface. research has focused on the development of composite materials that combine nonabsorbable and absorbable materials. Recurrence after mesh repair is rarely caused by intrin- sic failure of the prosthetic material. In a survey of more than 1000 surgeons. OPEN REPAIR OF VENTRAL INCISIONAL HERNIAS 67 and equivalent to polypropylene in terms of suture retention strength [63]. 1A) is popular among surgeons because it avoids direct contact with the bowel and imparts less tension on the repair. High re- currence rates of 10% to 20% have resulted in use of other techniques to optimize strength of the mesh-fascia interface [3. Failure to identify healthy fascia and technical error in securing the mesh to the fascia commonly lead to recur- rence at the mesh-fascia interface (Table 2). with the most common being mesh onlay. and conforming qualities and minimal tissue ingrowth.77] reported their results of 389 patients and found a recurrence rate of 18. which prevents host tissue incorporation and leads to seroma formation.11]. ePTFE requires explantation. Without the overlying support of the anterior abdominal wall. The onlay technique (Fig. As a result of its flexible. The inlay technique involves excision of the hernia sac and identification of healthy fascial margins (Fig. Once infected. The micropores range from 3 to 41 mm in size.5% (n ¼ 133) with the use of polypropylene onlay mesh and 0. has been used with increasing frequency [11. it can be placed directly on bowel [59]. popularized by Rives and Stoppa. Milliken [11] reported that 50% of surgeons use this repair without closing the fascial defect. Well-designed. which is the weakest point of the repair [76]. retrorectus placement. and that the pres- sure required to disrupt the mesh from the anterior abdominal wall is less than other repairs. mesh inlay. Several methods of securing the mesh to the fascia have been described. The material is virtually im- penetrable. the hernia sac is preserved and used as a buffer between the mesh and underlying viscera. This technique provides for a tensionless repair at the time of surgery and avoids the wide undermining of the onlay repair. soft. In an effort to reduce mesh-related complications and more closely dupli- cate abdominal wall physiology.4% (n ¼ 153) without the use of mesh compared with 5. In this technique.97% (n ¼ 103) with the use of fibrin glue in addition to the mesh. The mesh is .

which pro- vides for a more secure and physiologic repair. 1991 60 Polpropylene Extraperitoneal 0 36–84 et al [65] 2-cm overlap Temudom. the mesh is placed in the preperitoneal space. 1998 45 Polypropylene 2 36 et al [70] Arnaud. By placing the mesh beneath the abdom- inal wall.to 4-cm overlap Burger. 1999 84 PTFE Intraperitoneal 2 12–36 et al [73] 5. Proponents of this technique cite that the ability to place the mesh with a large underlay allows for better tissue ingrowth and a more . 2000 52 PTFE 8 – et al [74] Luijendijk. 1996 50 Polypropylene Extraperitoneal 4 24 et al [66] ePTFE 4. Intraperitoneal under- lay placement is a common technique used in open and laparoscopic ap- proaches. 1999 98 PTFE Extraperitoneal 10 72 et al [72] Utrera Gonzalez. and the pressure-induced apposition promotes fibrous ingrowth at the mesh-fascial interface [59]. 2004 84 Polypropylene Extraperitoneal 32 120 et al [4] 2.to 6-cm overlap Gillion.to 6-cm overlap Balen. It is generally recommended to place the mesh with at least 4 cm of contact between the mesh and fascia. Recurrence rates of less than 10% have been reported with this technique [66. 1C). 1998 45 PTFE Extraperitoneal 2 39 et al [69] 2-cm overlap Turkcapar. which allows for distribution of pressure over a wider area (Pascal’s principle). 1999 250 Dacron Intraperitoneal 3 97 et al [71] 10-cm overlap Bauer. with permission of Blackwell Science Ltd. 2001 152 Polypropylene Extraperitoneal 1 72 et al [75] Adapted from Cassar K.81]. 1997 158 PTFE 4 37 et al [67] McLanahan.to 7-cm overlap Chrysos. 1981 25 Polypropylene Intraperitoneal 8 27 et al [64] 3-cm overlap Matapurkar. Br J Surg 2002. Below the arcuate line. placed above the posterior rectus sheath and beneath the rectus muscle (Fig. 2000 84 Polypropylene Extraperitoneal 23 23 et al [3] 2. Munro A.to 4-cm overlap Martin-Duce. the repair is bolstered by the anterior abdominal wall. It has also been experimentally demonstrated that prolene may shrink up to 30% after implantation [80.68 SHELL et al Table 2 Results of open mesh repair of incisional hernias Recurrence Follow-up Author Year N Mesh Technique (%) (mo) McCarthy. Surgical treatment of incisional hernia.89:534–45. 1997 106 Polypropylene Extraperitoneal 4 24 et al [68] 4.68].

Infection is one of the most feared complications after mesh placement. and reduced wound complication rates as advantages.88–90] and depends on the type of mesh used. (B) Inlay technique. the use of mesh is associated with specific compli- cations that may range from being relatively minor to life threatening. Recur- rence rates of less than 5% have been reported with this technique [82]. The average rate of early and late mesh infections is approximately 7% [8. The most common . OPEN REPAIR OF VENTRAL INCISIONAL HERNIAS 69 Fig. (A) Onlay technique. Advocates of this technique cite lower recurrence rates of 2% to 4%. Although the application of mesh has resulted in a significant improve- ment in recurrence rates. 1. shorter hospital stay. Fixation techniques vary from approx- imation at the fascial margins to full-thickness lateral fixation [82]. secure mesh-fascial interface [11]. This technique in- volves intraperitoneal mesh placement. (C) Retrorectus underlay technique.72. Advances in laparoscopic surgery have led to an increased application of this technology to the treatment of incisional hernias. Mesh placement techniques. which is secured with either a tacking device or transabdominal sutures or both. Several comparative studies have concluded that it is a superior technique [83–87]. decreased infec- tion rate.59. Restoration of dynamic abdominal wall function by midline myofascial ap- proximation and cosmetic improvement of the abdomen by excision of ex- cess tissue and scar are important objectives of hernia repair that are not accomplished by the laparoscopic approach [58].

Bioprosthetics Justified concern regarding mesh-related complications has led to the search for more biocompatible prosthetic material. Disadvantages are the high cost and lack of long-term follow-up studies. Reduction of the hernia leaves a potential space for fluid accumulation. It was particularly helpful in obese patients and patients with multiple or recurrent hernias. most authors agree that mesh removal is indicated. and mechanical stability when used in incisional hernia repair. These materials differ in that they heal by a re- generative process rather than by scar tissue formation. how- ever. Less pliable materials. this complication results in fluid accu- mulation [59]. Leber and colleagues [8] demonstrated that excision of the hernia sac. in most cases mesh removal is required [91].88. dis- ruption of lymphatics.107]. When extrusion is noted. The collagen-based extracellular matrix is preserved. Seromas often resolve with time. The evolution of the components separation technique is based on early descriptions by Vasconez and colleagues [108] of transverse . are associated with a higher extrusion rate. Law [92] examined the effects of infection on the mesh-fascial interface and found significant weakening. 2). These mate- rials have demonstrated resistance to infection. continued pros- thetic irritation may result in persistent seroma requiring surgical drainage. Components separation technique A significant contribution to the repair of incisional hernias was the de- scription by Ramirez and colleagues [46] of the components separation tech- nique (Fig. and continued irritation caused by the foreign body reaction from the prosthetic material. which predisposes to higher recurrence rates. and the presence of a fascial gap were factors associated with a higher incidence of fistula formation. Combined with inflammation. Inadequate soft tissue coverage may result in mesh extrusion. which allows for maintenance of mechanical integrity while providing a scaffold for host tissue regeneration. Seroma is a common complication after hernia repair and comprises up to 16% of the overall complications [8. however. lack of omental interposition. Robertson and colleagues [93–106] demonstrated that isolation of the incision away from the hernia repair through an abdominoplasty approach is associated with lower complication and recurrence rates. Reports exist in the literature of mesh salvage in the face of infection.70 SHELL et al organisms are Staphyloccocus aureus and Staphylococcus epidermidis [59]. Advances in tissue engi- neering technology have led to the development of biomaterials derived from human and animal tissues. such as marlex. En- teric fistula formation is a potentially devastating complication that occurs when the prosthetic material erodes into the underlying bowel. tolerance of cutaneous expo- sure.

(A) The abdominal wall formed by overlapping mus- cle layers that may be separated. Components separation technique. rectus abdominus myocutaneous closure that involves separation of the ex- ternal and internal oblique musculature and release of the posterior sheath. elevation of the external . Ramirez and colleagues [46.51.109. specifically. (C) Rectus is released form the posterior sheath. (D) Medial advancement of rectus muscle and attached internal oblique–transversus abdominus complex.110] noted that the abdominal wall is formed by overlapping muscle layers that may be separated while preserving their innervation and blood supply. OPEN REPAIR OF VENTRAL INCISIONAL HERNIAS 71 Fig. 2. (B) Elevation of the external oblique off the internal oblique.

restoration of dynamic abdominal wall function. which is more easily compressed than solid structures. and 6 to 8 cm in the suprapubic region. and improvement in back and postural abnormalities have been cited in the literature (Table 3). which travels in a segmental fashion between the internal oblique and transversus abdominus. In a recent review. A lower hernia recurrence rate. Fabian and colleagues [111. Unilateral advancement of 5 cm in the epigastric region. Once this procedure is accomplished. The rectus then can be released from the posterior sheath. The iliolumbar bipedicled flap based on the superficial circumflex iliac and lumbar perforators may be used for middle third . which restricts horizontal motion and thereby facilitates expansion. 10 cm at the umbilicus. 3. Translation of the muscular layer of the abdominal wall to enlarge the tissue surface area. avoidance of prosthetic material. Fasciocutaneous flaps may be used to reconstruct partial-thickness defects of the skin and subcu- taneous tissues and full-thickness defects when used in combination with mesh. which allowed for unilateral advancement of 8 to 10 cm in the epigastric area. Disconnection of the muscle unit from its fascial sheath envelope. Wound-related complications have been problematic with this technique and are related to the wide undermining required. and 3 cm in the suprapubic region has been de- scribed. Recent work has demonstrated a reduc- tion in wound-related complications with preservation of periumbilical per- forators [121]. 10 to 15 cm in the mid abdomen. Separation of muscle layers that allows for maximal individual expan- sion of each muscle unit. 2. Abdominal wall musculature in approximately 70% of its surface is cov- ering hollow viscus. 4. medial ad- vancement of a compound flap of rectus muscle and attached internal obli- que-transversus abdominus complex can be used to cover large midline abdominal defects. 5. Bilateral mobilization works more efficiently than unilateral advance- ment by equilibrating forces of the abdominal wall and centralizing the midline.72 SHELL et al oblique off the internal oblique while maintaining the neurovascular supply to the rectus abdominus.112] described a modification that in- volved division of the internal oblique of the anterior rectus sheath. Flap reconstruction Local and distant flaps have been used to reconstruct hernia defects in which there is significant absolute loss of domain and in lateral defects that are not amenable to advancement techniques. The thoracoepigastric flap is useful for defects of the upper third of the abdominal wall. Ramirez [110] attributed the success of the procedure to five principles: 1.

CS þ subfascial tissue expansion (TE) ¼ 6. 2001 [126] 29l 12–36 1 (3) Shestak. 2000 [128] 37o 12 4 (11) Girotto.Table 3 Results of components separation technique Author/year n Mean follow-up (mo) Recurrence n (%) a Hultman. h Standard CS ¼ 25. CS þ Goretex graft ¼ 4.6 1 (10) Jernigan. modified (periumbilical perforator preservation) ¼ 41. CS þ vicryl onlay ¼ 12. et al. Clin Plastic Surg 2006. et al. CS þ transversalis division ¼ 2. 1993 [133] 7u 18 0 Ramirez. et al. g CS ¼ 4. approximation of medial border of posterior sheath to lateral border of anterior sheath. et al. f Mesh onlay when necessary. staggered release of tranversalis/external oblique. 2003 [118] 11g 10 1 (9) de vries Reilingh. n  Mesh. e Modified ¼ internal oblique divided. et al. et al. 1999 [131] 37 21 2 (5) Kuzbari. CS þ TE ¼ 3. et al.33:255. et al. CS þ mesh ¼ 1. CS þ mesh ¼ 10. r Modified ¼ complete rectus release from anterior and posterior sheaths. et al. s CS ¼ 20.5 3 (10) Lindsey. approximation of medial border of posterior sheath to lateral border of anterior sheath. 2003 [117] 10d 18. 2003 [119. 2001 [124] 9 14. 1998 [132] 10r 28. CS þ mesh onlay ¼ 1. From Nguyen V. Shestak KC.7 1 (5) Maas. et al. et al. et al. 2003 [112] 73e 24 4 (5) Girotto.6 1 (20) Sukkar. CS þ surgisis ¼ 2. et al. 2000 [109] 22m 52 1 (5) Mathes. CS þ mesh/Alloderm onlay ¼ 5. et al. with permission. 2003 [55] 96f 26 21 (22) Ewart. et al. CS þ mesh ¼ 5. modified periumbilical perforator preservation. CS þ Goretex onlay ¼ 3. 1996 [50] 35s 22 3 (9) Fabian. et al. CS þ lateral abdominal wall flap ¼ 1.6 12 (32) Saulis. endoscopically assisted ¼ 6. Separation of anatomic components method of abdominal wall reconstruction: clinical outcome analysis and an update of surgical modifications using the technique. p CS ¼ 8. 1999 [130] 4q 18 0 Girotto.2 0 Levine. et al. 1990 [46] 11 4–42 0 a Component separation (CS) alone ¼ 3. o CS ¼ 20. CS þ fascia lata graft ¼ 6. 2001 [125] 10k ? 0 Cohen. et al. 2004 [115] 18c 48 2 (11) Lowe. modified () internal oblique release. 2005 [113] 13 11. CS þ mesh onlay ¼ 4.7 4 (15) Lowe. et al.8 0 Dibello. et al. m CS ¼ 21. et al. et al. u CS ¼ 7. b CS ¼ 23. k CS ¼ 9. CS þ mesh ¼ 2. . 2003 [116] 30 9. 2002 [121] 66h 12 3 (8) Maas. endoscopically assisted þ mesh ¼ 1. modified ¼ rectus sheath incised anteriorly and/or posteriorly or flipped medially (open book) and transversalis incised. CS þ mesh onlay ¼ 12. et al.120] 38 15. 2000 [127] 26n 13. j CS ¼ 41. 2001 [123] 47j 24 1 (2) Voigt. l CS ¼ 24. q Modified ¼ external oblique transected via separate lateral incision. i Endoscopically assisted. et al.5 2 (15) Vargo. d Abdominal wall partitioning (accordion). 1994 [111] 9t 11 1 (11) Thomas. 2000 [129] 20p 25. c CS ¼ 12. et al. t Modified ¼ internal oblique divided. et al. 2004 [114] 27b 6–27 2 (7) Howdieshell. 2002 [122] 5i 10.

skin Fig. The external oblique flap based on lateral cutaneous branches of the pos- terior intercostal arteries has been used as a rotational flap to cover upper abdominal wall defects and as an advancement flap to cover paramedian de- fects.127. fascial. Distant muscle flaps as either free flaps or pedicled flaps have been used for musculofascial defects not amenable to closure with local flaps or ad- vancement techniques [145.141. Spear and colleagues [144] reported a 3% recurrence rate at 12-month follow-up with the use of this flap. Superficial inferior epigastric artery and deep inferior epigastric artery flaps are useful for lower abdominal and groin defects [134. including hematoma. Its use is complicated by a 15% to 20% incidence of donor site morbidity. 3. Local muscle flaps are useful for musculofascial defects of the lateral ab- dominal wall (Fig. 3).146]. It has the advantage of being dispensable and has a good arc of rotation. (A) Tensor fascia lata. or fasciocutaneous flap [145.142]. which may reach to the umbilicus [49. The flap has a large arc of rotation capable of reaching the entire ab- domen [134.74 SHELL et al defects.138–140]. It does not provide for a dynamic reconstruction. This technique has a reported 13% recurrence rate and a 25% incidence of local wound complications [143].135. The rectus abdominus is a commonly used pedicled flap based on either the superior epigastric or deep inferior epigastric ar- teries. seroma.134–137]. It is based on the ascending branch of the lateral femoral circumflex artery and may be used as a muscle. (B) Anterolateral thigh.146]. Lower third defects may be covered with a groin flap. The rectus also may be separated completely from the posterior rectus sheath and turned medially based on a medial row of perforators to reconstruct midline defects. (C) Rectus femoris. . Flaps in abdominal wall reconstruction. and its distal third is unreli- able with a 20% to 25% rate of necrosis. The tensor fascia lata has been used suc- cessfully as a pedicled and free flap and as an autologous fascial patch.

Electromyographic studies have documented motor function of the transferred muscle. It can be designed as a musculofascial or musculofasciocutaneous flap based on the location and extent of the defect [149–151]. With the adjunctive use of mesh. Its use has been . this technique has demonstrated low recurrence rates in small series. In 1979. The area of coverage can be increased by including the pregluteal and lumbodorsal fascia. No flap failures were reported. In 1998. The gracilis muscle has been used to reconstruct lower third abdominal wall defects. It is based on the thoracodorsal pedicle and can be designed as either a pedicled or a free flap. It does not have a fascial component and its use is pri- marily reserved for salvage situations [155]. The rectus femoris muscle has been used successfully as either a free flap with preservation of the motor nerve or as a pedicled flap in reconstruction of the lower two thirds of the abdomen. Recurrence rates are also significant and range from 9% to 42% in the literature [145. and lateral knee instability [145. It also may be used in combination with the tensor fascia lata to provide a compos- ite graft up to 35  20 cm in dimension. Bostwick [152] reported the use of the lat- issimus as a free flap for abdominal wall reconstruction.148]. It can be designed as either a muscular or musculofasciocutaneous flap and is limited to small defects because of its size and the poor reliability of its distal skin [154]. and electromyographic testing demonstrated reinnervation of the muscle.146]. Ninkovic [153] reported the use of a free.147. narrow. OPEN REPAIR OF VENTRAL INCISIONAL HERNIAS 75 graft loss. In small series. It is a thin. The vastus lateralis can be used as a muscular flap for reconstruction of lower third ab- dominal wall defects. It is based on the lateral femoral circumflex artery and has a large arc of superior and contralateral rotation. its arc of rotation is limited to coverage of upper abdominal wall de- fects. The latissimus dorsi muscle has been used as a musculocutaneous flap for defects of the upper third of the abdomen. Tissue expansion Tissue expansion has been used to provide well-vascularized. innervated latissimus flap in conjunction with prolene mesh for abdominal wall reconstruction. Reports have indicated a weakness in terminal knee exten- sion after muscle harvest. As a pedicled flap. innervated tissue for abdominal wall reconstruction. the use of this tech- nique has demonstrated no recurrences or flap loss in follow-up up to 24 months [134. dispensable muscle based on the ascending branch of the medial circumflex femoral artery.146]. The anterolateral thigh flap has been used in the reconstruction of lower abdominal wall defects as either a free or pedicled flap based on septocuta- neous perforating branches of the transverse and deep branches of the lat- eral femoral circumflex artery [147]. It is a dispensable muscle with a con- sistent anatomy. which can be minimized by approximating the vastus medialis and lateralis. autologous.

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