the Management of Ventral Hernia

Ventral hernia is one of the most common general surgical pathologies. An estimated 20 million patients with hernias are operated on worldwide every year, of which approximately 30% are ventral. An incisional hernia will develop in 10–15% of patients with an abdominal incision and the risk increases to up to 23% in those who develop surgical site infection, ^(1&2).  Incidence rates up to 69% have been reported in high-risk patients, ⁽³⁾.

Ventral hernias are defined as a defect of the fascia in the anterior abdominal wall with or without a bulge, ⁽⁴⁾. Clinical presentation varies from small incidental defects to giant and complicated hernias with fistulas and viscera located outside the abdominal cavity covered only by peritoneum and skin (loss of domain), ⁽⁴⁾. The symptoms range from minor cosmetic concerns to severe pain and life-threatening conditions such as bowel obstruction, incarceration, strangulation and perforation, ⁽⁴⁾.

Ventral hernia repairs are mostly elective (90%) procedures, but the repair methods are highly variable, ⁽⁵⁾.

Any injury or incision to the abdominal wall could lead to a hernia. Surgical technique and wound infection are considered the most important preventable causes of an incisional hernia, ⁽⁶⁾.

Many patient-related risk factors have been implicated. Surgical site infections (SSI) are independent risk factors that significantly increase the risk of incisional hernias, ⁽⁷⁾. Other factors are male gender, obesity, ⁽⁸⁾ old age, ⁽⁹⁾ diabetes mellitus, jaundice, ⁽¹⁰⁾ anaemia, the use of vasopressor drugs, ⁽¹¹⁾ smoking, ⁽¹²⁾ postoperative respiratory failure, aneurysmal disease, malnutrition, steroids, kidney failure, malignancy, ⁽⁶⁾. Abdominal distention,⁽¹³⁾ postoperative peritonitis, ⁽¹⁴⁾ and multiple operations through the same incision, ⁽¹⁰⁾. Chronic Obstructive Pulmonary Disease (COPD), benign prostatic hypertrophy, constipation and ascites increase the intra-abdominal pressure, increasing the risk of incisional hernias, but they are not considered independent risk factors. Diastasis of the rectus muscles also predisposes to an incisional hernia, ^(15&16).

According to the European Hernia Society (EHS) classification, it divides hernias into primary and incisional (secondary) and then further subdivides them by anatomical location and size. Incisional hernias are also categorized by recurrence in a binary fashion, ⁽¹⁷⁾, (see Tables 1-4).