History of evolution of ventral hernia repair

1. vivkaje@gmail.com
Evolution of Ventral Hernia
Repair
Dr Vivek Kaje

2. vivkaje@gmail.com
Introduction
• “Ventral hernia” - protrusion of loops of intestine, fat, or fibrous tissue through a defect
or weakened region of the abdominal wall
• Ventral and incisional hernia repair - one of the most common operations
• Common long-term complication of abdominal surgery
• Incidence of 11–20% after laparotomy incisions
• 50% of incisional hernias develop within the first 2 years
• 74% develop after 3 years

3. vivkaje@gmail.com
• Several factors contribute to incisional hernia
• Patient factors
• high BMI, smoking history, history of malignancy
• comorbidities - diabetes, pulmonary diseases, and connective tissue disorders
• Surgeon factors
• laparotomy closure technique, choice of suture material and surgeon’s
experience
• Some of these can be controlled and some cannot

4. vivkaje@gmail.com
History of Ventral Hernia
• Sushrutha had mentioned hernia description in his Sushruta Samhita
• The anterior abdominal wall was first described in the 16th century B.C.E. in
the Ebers Papyrus
• Suggested heat application to epigastric swelling to arrest illness in the
patients’ belly
• Beatus Ignatius La Chausse first defined ventral hernia as any hernia that is
not inguinal, umbilical, or femoral

5. vivkaje@gmail.com
• Celsus 100AD described the technique of closure of the
abdomen by layers
• Galen 200AD described mass closure of the abdominal wall
• The first documented surgery for incisional hernia - Pierre Nicholas
Gerdy (1836)
• Completed the surgery by inverting the Hernial sac through the hernia into
the abdominal cavity that includes the skin
• Sutured the edges together and injected ammonia into the sac to cause
adhesions

6. vivkaje@gmail.com
Simple Suturing
• Popular during the 18th and 19th centuries
• Technique - Simple suturing of the lateral edges of the hernia
together or performing a layered aponeurotic repair
• Popularized by Maydl (1856) and Quenu (1893)
• Frappier - advocated mass closure of the hernia defect by placing
sutures in a figure eight

7. vivkaje@gmail.com
• Jonnesco recommended using U stitches through the rectus sheath
• 1899 - Mayo described the technique of overlapping the aponeurotic
layer transversely to repair an umbilical hernia
• 1954 - Maingot described - keel technique in repairing incisional
hernias
• All of the suturing techniques resulted in unsatisfactory results

8. vivkaje@gmail.com
Grafting
• 1910 - Kirshner used all types of grafts
• Only autologous grafts offered promising results
• Loewe (1913) – Skin grafts to repair incisional hernias
• Nutall (1926) used rectus muscle
• Grafts - the fascia lata, dura, cartilage, periosteum, and decalcified bone

9. vivkaje@gmail.com
• Grafting brought new problems
• Defects in the donor site
• Functional problems due to vascular and denervation
• Autologous grafts still yielded high recurrence rates

10. vivkaje@gmail.com
Prosthetics In Hernia Repair
• Metals such as gold, silver, tantalum, and alloys such as brass
• Resulted in a high recurrence rate
• Abdominal wall stiffness
• Fragmentation
• Severe foreign body reaction
• Synthetic materials introduced 1940
• Aquaviva, Bonnet, and Maloney used nylon
• 1961 - polypropylene was discovered by Giulio Natta and Karl Ziegler
• It was popularized for hernia use in 1963 by Francis Usher

11. vivkaje@gmail.com
• Francis C. Usher - a general surgeon in Houston, Texas USA with
a degree in pharmacology, on the part-time staff of Baylor University and
the Veterans Hospital
• Became interested in plastic prostheses after poor results with dural grafts
• Used custom made polypropylene mesh made out of knitting suture into
mesh on animals before applying it on humans
• Went on to say that in order to prevent the recurrence mesh needed to be
underlaid

12. vivkaje@gmail.com
• Prosthetic materials have been proven to decrease the incidence of
recurrence after ventral hernia repair
• Burger et al did a comparison between mesh repair and sutured
repair showed a recurrence of 32% as compared to 63% for sutured
repair during a 6–7-year follow-up
• Issue that surgeons faced - ideal space for placement of the mesh

13. vivkaje@gmail.com
• Popularized by Chevrel in 1979
• Onlay placement positions the mesh over the sutured anterior fascia
and under the subcutaneous tissue
• Recurrence rate – 11%
Chevrel JP The treatment of largemidline incisional
hernias by
“overcoat” plasty and prothesis (author’s transl). Nouv

14. vivkaje@gmail.com
• Mesh placed between the medial edges of the hernia defect
• Anchored with a circumferential stitch
• The mesh acts as a bridge between the two fascial edges
• Recurrence rate is 17%

15. vivkaje@gmail.com
• Sublay placement of the prosthetic material
• Mesh placed in the retromuscular space beneath the rectus muscle
• Mesh placed in the preperitoneal space

16. vivkaje@gmail.com• Rives et al placed the mesh in the retromuscular space
• Stoppa placed it in the preperitoneal space or retrofascial space
• The limitation of the repair by Rives et al.
• the mesh can only be placed within the limits of the rectus muscle width
• Meta-analysis by Holihan et al. in 2015
• sublay placement - lowest risk for recurrence and surgical-site infection
1.Rives JJ, Flament JB,Delattre JF et al. La chirurgiemoderne des hernies de l’aine. Cah Med 1982; 7: 1205–1218.
2.Stoppa RE The treatment of complicated groin and incisional hernias. World J Surg 1989; 13: 545–554.
3.Holihan JL, Nguyen DH, Nguyen MT et al. Mesh location in open ventral hernia repair: A systematic review and network meta-analysis. World J Surg

17. vivkaje@gmail.com
• Anterior component separation technique
• 1990 - Ramirez et al. developed the anterior component separation technique
• Dissection of the subcutaneous space above the rectus muscle fascia to expose the
lateral border of the rectus muscle and the medial border of the external oblique muscle
• External oblique is then incised 2 cm lateral from the rectus muscle border
• Space between the internal and external oblique is dissected
• Midline is sutured back together - placing the rectus muscle back to the midline
Component Separation Techniques
1. Ramirez OM, Ruas E, Dellon AL "Components separation" method for closure of abdominal-wall defects: An anatomic and clinical study. Plast Reconstr Surg 1990; 86: 519–5

18. vivkaje@gmail.com
• 8–10-cm of defect can be covered
• 7%–32% recurrence rate
• 50% complication rate
• Majority of complications - wound complications

19. vivkaje@gmail.com
Laparoscopic Ventral Hernia Repair
• Need for an extensive dissection associated with postoperative wound
related complications - to search for new technique
• First laparoscopic ventral hernia repair done by LeBlanc and Booth in 1993
• At present 20% to 27% of repairs are performed laparoscopically
• Various aspects have been developed
• Transfascial fixation
• Tackers (absorbable and non absorbable)
• Intracorporeal sutures

20. vivkaje@gmail.com
• Primary closure of the defect + mesh placement
• 721 cases with 185 recurrent ventral hernias
• 93 had previous hernioplasty and 92 with previous suture repair

21. vivkaje@gmail.com
• Developed to address repairs of large abdominal wall hernias
• Involves putting the rectus back to the midline
• Using a prosthetic material with a wider space of mesh coverage

22. vivkaje@gmail.com

23. vivkaje@gmail.com
• Studied in 20 patients
• Mean defect area of 223 cm2
• Mean mesh area of 698 cm2.
• None complained of long-term pain or abdominal wall deformity
• Mean 12-month follow-up.
• 15% complication rate
• 5% recurrence rate

24. vivkaje@gmail.com
• Compared 43 patients with 50 patients with open sublay repair
• Hospital stay was shorter in study group
• No difference postoperative complications, use of analgetics, foreign body
sensation, and paresthesiabetween the two groups.
• Found one long-term hematoma in the laparoscopy group
• one seroma in the open group
• No recurrences and no wound infections

25. vivkaje@gmail.com

26. vivkaje@gmail.com

27. vivkaje@gmail.com

28. vivkaje@gmail.com
Posterior Component Separation With
Transversus Abdominis Release
• Treatment of complicated hernias with loss of domain
• Provides significant mobilization of the posterior rectus sheath
• Extensive lateral dissection between the transversus abdominis and
either the transversalis fascia or the peritoneum with preservation of
the neurovascular bundle
• Offers a wider space of dissection than posterior component
separation

29. vivkaje@gmail.com

30. vivkaje@gmail.com
• Perform a midline laparotomy with complete adhesiolysis
• Laterally dissect the retromuscular space up to the level of the
epigastric vessels and preserve the neurovascular bundle
• Incise the posterior rectus sheath medial to the semilunaris to
expose the transversus abdominis muscle
• Incise the transversus abdominis muscle to expose the underlying
transversalis fascia
• Dissect the space up to the level of the space of Retzius

31. vivkaje@gmail.com
• Provides a wide mobilization of the posterior rectus sheath
enabling closure of midline
• Close the posterior rectus sheath with a continuous absorbable
suture
• Wide piece of mesh to cover the space created at the
retromuscular space up to the lateral border of dissection
• Approximate the anterior rectus sheath in the midline
• Wound complication rate - 45% recurrence rate - 3%

32. vivkaje@gmail.com

33. vivkaje@gmail.com
• Unilateral TAR can achieve up to 7 cm of fascial medial mobilization.
• Degree of mobilization also depends on patient’s abdominal wall

34. vivkaje@gmail.com
• Report included 3 patients
• Mean operation room time of 329 minutes
• Estimated blood loss 91.7cc Length of stay - 4.7 days
• No subcutaneous flaps were raised avoiding the need for subcutaneous drains
• No perioperative complications
• On initial follow-up visit at 3 weeks - no evidence of wound complications,
bulging, or hernia recurrences

35. vivkaje@gmail.com
Thank you