Advances in Complex Abdominal Reconstruction

Surgical repair of a ventral/incisional hernia has evolved significantly in just the last decade. Driven by poor outcomes -including recurrence, mesh complications, and poor functional results - the techniques employed by surgeons dedicated to abdominal wall reconstruction have evolved to meet the needs of patients.

Mesh engineering has improved with extensive research on the strength of the prosthetic material, tissue ingrowth, and deployment technologies to assist with proper positioning and fixation of mesh. Instrumentation allowing for minimally invasive techniques has served to improve outcomes and enhance recovery.

New anatomic research has led to novel methods of reconstructing complex incisional hernias to provide for more physiologic results. This includes even those formerly thought not to be amenable to surgical repair due to loss of abdominal domain. Minimally invasive techniques have been developed that may be appropriate for some patients. We hope to cover these in future newsletters.

Methods to repair larger abdominal wall hernias, especially complex and multiply recurrent hernias, have evolved significantly. We now know that “bridging” of abdominal wall defects without actually reapproximating muscular elements results in diastasis and poor abdominal-wall compliance. Improved anatomic understanding of the layers of the abdominal wall has provided opportunities to improve on our results for both the risk of recurrence and enhanced functional outcomes. 

Component separation has become a standard for reconstruction of the abdominal wall for complex hernias. Separation of the lateral abdominal muscle layers (obliques and the transversus abdominis) allows for advancement of the rectus muscles to the midline for re-approximation. This recreates the normal physiology of the abdominal muscle envelope, resulting in an improved function. Placing the mesh within the rectus sheath behind the rectus muscles ensures exclusion of the mesh from the peritoneum while providing for quality reinforcement of the hernia repair to reduce recurrence.

Loss of abdominal domain is often a concern in treating these large and often chronic hernias. When this is a concern, techniques may be employed to expand the abdominal compartment prior to surgery to improve the chances for closure without tension or risk for abdominal compartment syndrome. These techniques might include tissue expanders in various muscle layers or the use of abdominal insufflation with the implantation of an infusion device into the abdomen. These patients may require multiple procedures and multidisciplinary care from not only the abdominal wall reconstruction surgeons but also plastic surgery, anesthesia, physical therapy, pain management and rehabilitation. Some patients with morbid obesity may derive benefit from an evaluation from our bariatric surgeons to prepare them for hernia surgery.

These procedures result in significant dissection of the space occupied by the hernia. The skin overlying the hernia and hernia sac is at risk for ischemia. Additionally, the hernia space is at risk for seroma. Consequently, excision of the redundant skin and soft tissues is often recommended to alleviate this risk. In some cases, this can provide for a secondary benefit in removing old scars. If the hernia is low in the abdomen, a panniculectomy may be appropriate, providing the patient with a cosmetic as well as functional result of the hernia repair.

The abdominal wall reconstruction program at CHI Health Creighton University Medical Center-Bergan Mercy offers patients personalized treatment that starts with a thorough preoperative assessment by our experienced surgeons. This includes an initial examination, an in-depth review of the previous abdominal surgeries, a review of previous attempts at reconstruction and the appropriate use of abdominal imaging. 

For the convenience and comfort of our patients, we offer virtual care where appropriate, via phone or through video visits. From our patients’ first visit to their last follow-up, state-of-the-art care is our standard in treating these complex and challenging conditions.

To refer a patient to our Abdominal Wall Reconstruction experts, call (402) 717-4900.

 

Gregg A. Drabek, MD, FACS

General Surgery