A ventral hernia can be diagnosed during physical examination. Certain maneuvers will accentuate the hernia such as examining the patient while he or she is standing up, Valsalva maneuver, or abdominal flexion. Although most incisional hernia can be diagnosed without imaging and there is no rule against obtaining one, the authors are proponents of liberal usage of preoperative computed tomography (CT) scan for several different reasons.

The issue first is the inaccuracy of physical examination in determining the size and content of the hernia. This information is important when discussing the subtle details of the procedure with the patient. The size of the mesh, likelihood of bowel injury, and the level of complexity are examples of topics that can be discussed in full detail with the imaging. Also, the patient’s condition may inhibit surgeons from performing a thorough and accurate physical examination such as when the patient is morbidly obese, has severe arthritis, and is wheel chair bound or bed bound secondary to the patient’s existing medical conditions. There are several different imaging techniques available but the author prefers to use the CT as the primary imaging modality.

Once the ventral hernia is diagnosed, it is important to establish the goal of care from both the hernia and colorectal disease standpoint with the patient. The hernia surgeon needs to determine the acuity and the complexity of the hernia and generate a reasonable plan to address it with the patient in terms of overall goal with the colorectal disease as a part of the equation. It is prudent to coordinate with the colorectal department if the surgeon is being referred for the hernia specifically, to address the hernia concomitantly or deferred until the later date. It is common for patients to have temporary ostomy after a colorectal procedure as a protective measure; and for these patients, it is reasonable to wait until the time of the reversal or even later to address the hernia. Also, it is important to know if the primary surgery is going be done laparoscopically or open because it may change the timing and the level of complexity of subsequent procedure depending on the method of the index procedure. Also, it is critical to coordinate with the colorectal surgeon because the hernia operation will most likely require a mesh, due to the infection risk, it is advisable to defer if a colon resection is planned.

The patient should follow the National Surgical Quality Improvement Program (NSQIP) protocol as far as the venous thromboembolism prophylaxis and perioperative antibiotics are concerned. Patients should receive subcutaneous heparin injection or its equivalent; and during the surgery, a sequential compression device should be placed on the patient’s lower extremities. It is the authors’ preference prophylactically to use cefazolin as the antibiotic of choice as long as the patient has no allergy to β-lactam-based antibiotics; and if so, other antibiotics should be given according to the NSQIP guideline. Appropriate aspiration precaution should be followed during intubation. Usually, patients at the author’s institution have a bladder catheter placed for two reasons; to decompress the bladder in case it is necessary to enter the space of Retzius to place the mesh and to accurately measure the urine output.