Abdominal wall defects and ventral hernias are common complaints that bring patients to seek surgical attention. In addition to primary defects, studies have shown that about 20% of laparotomies will result in incisional hernias. Patients present with a variety of complaints ranging from asymptomatic bulges to obstructive symptoms with significant limitations on quality of life. With 10-year failure rates of primary suture repair well over 60% (and greater than 30% for mesh repair), this is clearly an area for improvement. Recent investigations, as well as innovative techniques and materials, have sought to improve outcomes. We present our approach to the treatment and management of abdominal wall reconstruction.
Diagnosis can usually be made through a thorough history and physical examination. Often, the defects and any herniating contents are obvious on cursory examination. Imaging with an abdominal computed tomography (CT) can be helpful with more subtle defects, and also in the acute setting, to determine the extent of the defect, presence of multiple defects (“chain of lakes”), and the presence of herniated organs. Evaluation also includes laboratory evaluation and perioperative risk evaluation.
Proper patient selection is crucial in the elective setting, more to optimize potential outcomes rather than to avoid difficult surgery. Even in high-risk patients, repair has been shown to provide a significantly improved quality of life. But as stated before, the high-potential failure rate makes it imperative to identify and address modifiable risk factors preoperatively to provide a lasting and durable repair. These risk factors commonly include ascites, obesity, diabetes, chronic obstructive
pulmonary disease (COPD), and smoking. Every attempt should be made to intervene and to optimize comorbidity before surgery.
Patients with ascites are at particular risk of recurrence and wound complications, leading to poor outcomes. Ascites can lead not only to wound complications but also to subsequent bacterial peritonitis as well as significant morbidity and possible mortality. Medical evaluation is imperative, and therapy to manage the ascites is crucial to favorable outcomes.
Obesity has been shown to be associated with increased wound-healing complications, as well as being a cause for recurrence. If asymptomatic, patients should be encouraged to lose weight through lifestyle modifications, including diet and exercise. Weight loss is not always possible because the abdominal wall defect can often make activity and exercise difficult or near impossible for patients. As such, potential benefits of repair, such as improved activities of daily living need to be balanced against potential weight-related complications. Diabetes is a frequent comorbidity that may exist in the obese patient and is also associated with significant wound-healing complications. Comorbidity risk may improve with weight loss and exercise, but medical evaluation should be performed to optimize glycemic control to limit possible complications.
Smoking and the presence of COPD are risk factors affecting both healing and possible recurrence. Smoking cessation is very important because the vasoconstriction secondary to nicotine and other products of smoking can significantly impair wound healing. This caveat is especially true in patients undergoing component separation, where perforators to the skin flaps are disrupted and circulation can be compromised. The added insult of smoking greatly increases the chances for skin edge ischemia. COPD can increase the chances of recurrence because of the repetitive significant increases in intra-abdominal pressure with coughing.