Once a ventral hernia has been diagnosed and the goals and objectives have been explicitly defined and aligned, planning may begin for either concomitant or deferred repair.

One must assess the existing problems and make a determination regarding the urgency of both the hernia repair in the colorectal procedure. An estimate of the complexity of the hernia repair will be required to make an appropriate determination. In general, large, incisional hernias (particularly recurrent with previous prosthetic repair) are the most difficult to fix. While there are no well-defined size parameters, ventral hernias larger than 5 cm in width are more difficult to repair, and hernias greater than 10 cm in width generally require a surgeon with hernia specific training and expertise.

Deferred repair should be considered if the patient is a poor surgical candidate, or the existing colorectal problem does not allow enough time to coordinate the operation with a surgeon that specializes in complex ventral hernia repair and:

Under these circumstances, the primary goal of the operation would be a successful colorectal procedure. The addition of a separate, complex abdominal operation may be too risky, and put both procedures at risk for failure. Leaving the hernia alone for repair in the future will, however, require some planning regarding the incision. It would generally be safe to open the skin over the hernia sac and simply close the sac, subcutaneous tissues and skin at the end of the procedure, leaving the abdominal wall defect alone. This strategy should have a high success rate as long as the integrity of the skin is good.

Concomitant repair should be considered if: (a) the patient is a reasonable surgical candidate, and the hernia associated with an existing problem requires attention in a similar timeframe that colorectal problem does, or (b) the hernia is asymptomatic and there will be a multidisciplinary approach with a surgeon(s) specializing in abdominal wall reconstruction.

Selecting the proper technique for hernia repair will depend on the clinical scenario as a whole, in addition to the specific goals and objectives for the operation. The size of the hernia, however, will be one of the primary factors that will limit the available techniques. If there is an incisional hernia of any size, we know that recurrence rates will be much lower if a prosthetic is used compared to primary closure with “standard” suturing techniques which typically utilize at least 1 cm bites of tissue and advance at least 1 cm between sutures. Thus, the presence of an incisional hernia will either require a different suturing technique and/or prosthetic placement to maximize the successful closure of the abdominal wall.

If the prosthetic is going to be used, the choice of the specific prosthetic and placement location should be planned before the operation commences. This type of preoperative planning will help avoid intraoperative delays due to missing supplies and/or instrumentation. For example, if a retromuscular, extraperitoneal placement of a polypropylene prosthetic is planned, but intraoperative circumstances favor and intraperitoneal placement, but the operating room does not have a prosthetic designed for intraperitoneal use, the surgeon will be faced with the choice of significantly altering the technique, or utilizing a prosthetic in a manner in which it was not intended.

Ventral hernias with defects greater than 5 cm in width may also require a component separation prior to closure and prosthetic placement. Component separation requires the separation of the internal and external oblique muscles, division of the insertion of the external oblique, and sometimes mobilization of the posterior rectus sheath. This allows the rectus muscles to be advanced to the midline in the vast majority of cases, and may be used in combination with a prosthetic. Component separation techniques that preserve the blood supply to the skin significantly reduce the risk of wound complications. To accurately measure the size and shape of the defect, as well as to investigate for defects in other areas of the anterior abdominal wall, a CT scan without oral or IV contrast can be quite helpful. It may also sometimes be helpful to perform the scan with and without Valsalva maneuvers to look at the abdominal wall in a more dynamic fashion. If there is going to be a CT scan performed for other reasons,
such as searching for metastatic disease, the proper CT protocol for that reason should be followed, and the abdominal wall may still be assessed. If a component separation is planned, a multidisciplinary approach is typically employed and will require substantial preoperative planning to align the operative plan and schedules.

In summary, the issues to be dealt with during the preoperative planning process include: