Atlas of Abdominal Wall Reconstruction

CHAPTER
8
Open Ventral Hernia
Repair With Onlay Mesh
David L. Webb, MD, FACS, Nathaniel F. Stoikes, MD, FACS, and Guy R. Voeller, MD, FACS
1. Clinical Anatomy
s Thorough knowledge of the abdominal wall anatomy is needed when performing a v entral
hernia repair.
s The rectus abdominis consists of a pair of vertically oriented muscles that span the length
of the abdominal wall and are separated by the linea alba. The rectus muscles arise from
the symphysis pubis and insert onto the fifth, sixth, and seventh costal cartilages and xi-
phoid process.
s The lateral abdominal wall muscles are three broad, flat muscles: the external oblique,
internal oblique, and transversus abdominis.
s The rectus sheath is formed by the fusion of the aponeuroses of the three lateral abdominal
wall muscles and encloses the rectus abdominis muscle.
s Above the arcuate line, the anterior rectus sheath is made up of the aponeuroses of the ex-
ternal oblique and an anterior layer of the internal oblique. The posterior rectus sheath is
made up of the aponeuroses of a posterior layer of the internal oblique and the transversus
abdominis.
s Below the arcuate line, the anterior rectus sheath is made up of the aponeuroses of all
three lateral abdominal wall muscles. The posterior rectus sheath is absent, and the rec-
tus muscle lies directly on top of the transversalis fascia.
2. Preoperative Considerations
1. Preoperative Imaging
s Computed tomography (CT) of the abdomen and pelvis is typically performed preopera-
tively in patients being considered for ventral hernia repair. CT helps with preoperative
planning by allowing for assessment of fascial defect size and the integrity of the remain-
ing abdominal wall musculature. CT may also help determine the presence of previously
placed mesh and any occult defects that may be present.
s In patients with particularly large defects or potential loss of domain, CT scan may help
determine the need for preoperative interventions, such as progressive preoperative pneu-
moperitoneum or chemical component paralysis with botulinum toxin (Botox) injections,
which may help facilitate primary fascial closure.
150
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Chapter 8 • Open Ventral Hernia Repair With Onlay Mesh 151
2. Patient Selection
s The goal of any hernia repair is to provide patients with a durable repair while minimizing
the potential for postoperative complications. Proper patient selection and preoperative
optimization of modifiable risk factors are crucial when considering a patient for open
ventral hernia with mesh onlay.
3. Hernia Type and Location
s Overall, we consider the open mesh-onlay repair to be an extremely versatile method of

hernia repair that can be applied to virtually any type of ventral hernia that a surgeon may
encounter in everyday practice. To date, we have applied our method of open mesh-onlay
repair to ventral/incisional hernias at any location of the abdominal wall; this includes
midline hernias with significant subxiphoid or suprapubic components, epigastric her-
nias, flank hernias, and parastomal hernias.
4. Defect Size
s The open mesh-onlay technique is predicated on mesh reinforcement of a primary fascial

closure. With this in mind, it is necessary to select patients with a defect size that will allow
for a tension-free primary fascial reapproximation.
5. Preoperative Risk Modification
s
Several patient comorbid conditions are associated with an increased risk of complica-
tions after ventral hernia repair. Complications are mainly related to the creation of wide
skin flaps and resultant potential for flap ischemia and wound infection. These comorbid
conditions need to be considered when evaluating a patient for an open mesh-onlay repair.
Recognizing the presence of these potentially complicating factors and optimizing them
before surgery will ideally increase the success of surgery while minimizing the potential
for postoperative complications.
s For example, we consider previous aortic surgery to be a relative contraindication to this
type of repair. Patients with previous aortic surgery have compromised collateral circula-
tion to the skin that results from ligation of the lumbar collaterals, and raising wide skin
flaps in this setting should not be performed because of the risk of skin flap ischemia and
necrosis.
152 Section III • Open Repairs
Smoking Cessation
s Cigarette smoking is associated with increased risk of perioperative morbidity, particularly

hernia recurrence and postoperative wound infection, after ventral hernia repair. Smok-
ing significantly impairs cutaneous tissue oxygenation and can impair the immune system
and prevent appropriate wound healing. Smoking is a modifiable risk factor, and smoking
cessation is mandated in all patients scheduled to undergo elective ventral hernia repair.
Patients must stop smoking a minimum of 6 weeks before elective hernia repair. Serum or
urine cotinine levels are checked preoperatively to confirm patient compliance.
Morbid Obesity
s Morbid obesity is another modifiable risk factor associated with increased risk of hernia
recurrence and postoperative wound complications. Patients are thoroughly educated on
the associated risks and strongly encouraged to lose weight preoperatively. They are coun-
seled in making lifestyle changes necessary to promote healthy weight loss, including
both dietary modification and increased physical activity. Patients with a body mass index
greater than 45 who are unable to lose weight independently are referred to a bariatric sur-
geon for evaluation for a surgical weight loss procedure before hernia repair. Patients are
monitored to assess their progress toward their individual weight loss goals, and as long as
they are losing weight, surgery is delayed.
s Ideally, patients are optimized to a body mass index of 35 or less, but in some cases this
is not possible given the characteristics of the hernia or associated symptoms. In cases of
patient noncompliance, hernia repair is performed only in the emergency setting.
Diabetes Mellitus
s Hyperglycemia can impair immune system function and prevent proper wound healing.
Patients with uncontrolled diabetes mellitus are at increased risk for postoperative wound
complications after ventral hernia repair. Surgical intervention is typically delayed until
optimal blood glucose control can be obtained. A hemoglobin A1c level less than 7% is
ideal 30-60 days before surgery.
s Postoperative glycemic control is also important, and therapy should be directed to main-
tain blood glucose levels in the range of 80-150 mg/dL.
3. Operative Steps (Video 8.1)
1. Skin Preparation
s The procedure begins with proper skin preparation. The skin is thoroughly cleaned with
an antimicrobial solution, and prophylactic antibiotics are administered.
s The operative site is covered with an Ioban Antimicrobial Incise Drape (3M, St. Paul, MN).
This protective barrier provides a sterile surgical site and reduces the risk of surgical site
contamination and potential mesh infection.
2. Incision
s
The patient’s abdomen is explored through a generous midline laparotomy incision.
revious midline scars and any areas of attenuated, redundant, or ulcerated skin are incor-
P
porated into the incision and excised.
3. Hernia Reduction and Adhesiolysis
s
The hernia sac is entered using sharp dissection. Any incarcerated hernia content is
typically reduced or excised as needed. The redundant hernia sac is excised, and the edges
of the fascial defect are defined. All intra-abdominal adhesions are taken down from the
undersurface of the abdominal wall to facilitate advancement of the abdominal wall mus-
culature toward midline for subsequent closure.
4. Creation of Skin Flaps
s The skin and subcutaneous fat are undermined from the fascial edges of the hernia defect
until the fascia of the anterior rectus sheath is visualized. This dissection is performed cir-
cumferentially around the entire hernia defect, and care must be taken to avoid dissecting
through the anterior rectus sheath during this process. Once the anterior rectus fascia is
properly identified, dissection is continued out laterally in the same plane until the lateral
border of the rectus sheath is reached.
s Depending on the size and complexity of the hernia, the skin flaps may be developed further
superiorly up over the costal margin and inferiorly down to the inguinal ligament. The skin
flaps may also be extended laterally out to the anterior axillary line, but one must consider
the increased risk for wound complications and skin flap ischemia associated with extensive
cutaneous undermining. In our practice, if external oblique releases are required, the skin
flaps are typically developed several centimeters lateral to the linea semilunaris.
5. Component Separation
s
For larger hernia defects, component separation is often required to allow adequate
a dvancement of the fascial edges back together at the midline to facilitate a tension-free
closure. In doing so, one must also consider that each component release imparts some
degree of morbidity with it by weakening the native abdominal wall at the site of the
release. We believe that component separation should be performed in a systematic, step-
wise fashion as described by Ramirez. Tension on the fascial closure should be assessed
after each individual release is completed, and the smallest number of releases needed for
a tension-free closure should be performed.
s The first step in component separation is the creation of wide skin flaps.
s If tension remains and further medialization is required, we proceed with individual pos-
terior rectus sheath releases, one side at a time. The posterior rectus sheath is typically
incised 1-2 cm lateral from the midline and divided from the costal margin down to its in-
ferior border (Fig. 8.1). This posterior rectus sheath release allows advancement of the rec-
tus abdominis complex relative to the lateral abdominal wall and usually provides 1-2 cm
of fascial advancement per side.
Edge of fascial defect

Anterior rectus sheath
Skin/subcutaneous fat flap
Linea semilunaris
Caudal
Cephalad
Rectus muscle
Posterior rectus
sheath release
A Peritoneum
B
Fig. 8.1
s
If reapproximation is still impossible, we perform individual external oblique releases,
one side at a time. The external oblique aponeurosis is divided 1-2 cm lateral to the linea
semilunaris and can be extended superiorly up over the costal margin and inferiorly down
to the inguinal ligament, as dictated by the size and location of the hernia defect (Fig. 8.2).
This includes division of the actual muscular fibers of the external oblique that course
over the costal margin. The external oblique release typically provides a fascial advance-
ment of 3-5 cm in the upper abdomen, 7-10 cm at the waistline, and 1-3 cm in the lower
abdomen.
6. Fascial Closure
s Primary closure of the midline fascia is performed using nonabsorbable suture. Depend-
ing on the surgeon’s preference, the fascial closure is typically performed using either a
running No. 1 polypropylene suture or interrupted No. 0 braided, polyester sutures. If
the primary closure is performed with interrupted polyester sutures, the initial suture
line is imbricated with an additional layer of adjacent fascia using a running absorbable
polydioxanone suture.
External oblique release
Skin/subcutaneous fat flap
Internal oblique muscle
Linea semilunaris
Edges of fascial defect
Posterior rectus
sheath release
A (phantom)
B
Fig. 8.2
7. Mesh Onlay
s A medium-weight, macroporous polypropylene mesh is brought into the operative field

and placed as an onlay. Mesh size varies depending on the size of the hernia being re-
paired. Typically, the mesh used is large enough to provide wide overlap of the midline
fascial closure as well as the sites of external oblique releases if they were required (Fig.
8.3).
8. Mesh Fixation
s Our preferred method of mesh fixation is derived from the onlay repair first described by
Chevrel in 1979. Chevrel’s technique included a three-layer tissue reconstruction of the
linea alba reinforced with a premuscular mesh prosthesis. The mesh onlay was fixated cir-
cumferentially along its peripheral edges and to the midline with absorbable sutures. The
medial portion of the mesh was then fixated to the recreated linea alba with aerosolized
fibrin glue.
s Our technique expands on Chevrel’s original mesh onlay repair. Similar to Chevrel, we
use a prosthetic mesh onlay to reinforce a tension-free primary fascial closure. However,
our technique differs in that we use fibrin glue as the sole method of fixation for the entire
piece of mesh to the underlying fascia and forgo the use of routine suture fixation, as
Chevrel originally described.
s For our technique, the mesh prosthetic is positioned as an onlay and temporarily secured
to the underlying muscle fascia by placing metallic skin staples along the peripheral edges
and on either side of the midline repair. We find the skin staples beneficial to help prevent
shifting of the mesh during definitive fixation with the surgical adhesive. Starting at the
midline, fibrin glue is applied directly onto the mesh. The glue is smoothed out evenly and
the mesh is conformed to the primary fascial closure (Fig. 8.4). During this process, direct
pressure is applied to the mesh, ensuring that the mesh and underlying fascia are in close
apposition with one another to allow proper fixation (Fig. 8.5). In a similar fashion and
working medially to laterally, the remaining mesh is fixated to the underlying fascia. Any
excess mesh is trimmed along the lateral edges to prevent it from folding once retraction
of the skin flaps is released (Fig. 8.6). If external oblique releases have been performed, the
Fig. 8.3 Fig. 8.4
Fig. 8.5 Fig. 8.6
mesh is secured to the lateral edge of the release on each side using a running absorbable
suture (Fig. 8.7).
s We believe that this method of onlay mesh fixation with fibrin glue is advantageous
because it provides immediate and uniform fixation of the prosthesis to the entire fascial
surface. We believe this fixation functions to decrease stress on the midline repair by
redistributing the force generated by intra-abdominal pressure over a broader surface area
compared with mesh fixated with sutures alone. We use TISSEEL or TISSUCOL (Baxter
Healthcare Corporation, Deerfield, IL) as our preferred fibrin glue product for mesh fixa-
tion. Although the optimal amount of fibrin glue needed for mesh fixation has not yet been
determined, we typically use approximately 20 mL of the ready-made formulation for our
standard ventral hernia repairs.
s We published our initial series of 50 patients using this technique of ventral hernia repair
with mesh onlay using fibrin glue alone for fixation. The mean follow-up time was 19.5
months with no known recurrences identified. The seroma rate was 16%, and the skin
infection rate was 6%; both figures are comparable to the published rates associated with
other methods of repair. There were no mesh infections. An update to our initial series is in
process and includes more than 100 patients. The new data include use of this technique
in clean-contaminated and contaminated cases. Overall, the skin infection rate is 4% with
100% salvage of mesh in all situations with infection. Body mass index is the only risk
factor linked to infection and reoperation.
9. Drain Placement
s
Two to four large-caliber Jackson-Pratt closed-suction drains are typically placed within
the subcutaneous space on top of the mesh. The drains are secured to skin with nylon
sutures and dressed with a BIOPATCH (Ethicon, Somerville, NJ) and Tegaderm (3M).
10. Skin Closure
s The skin incision is typically closed in two layers. The dermis is closed with interrupted
absorbable 3-0 sutures, and the skin is closed with a running subcuticular absorbable 4-0
suture. Alternatively, the skin may be closed with a combination of interrupted nylon su-
ture and skin staples.
4. Postoperative Care
s
Patients are admitted postoperatively for pain control and wound inspection. Diet is
r esumed slowly. Early ambulation and physical therapy are encouraged.
s Although no data currently exist showing a statistical benefit, we routinely use abdominal
binders in the postoperative setting. We believe that they help decrease postoperative pain
and may play a role in reduction of seroma formation. Patients are encouraged to wear the
abdominal binder at all times postoperatively.
Posterior rectus Medium-weight,

sheath release macroporous polypropylene
mesh onlay
fixated to underneath
External oblique release fascia with fibrin glue
Midline fascia repair

with interrupted #0 braided,
polyester sutures
Mesh attached to lateral

edge of external oblique
release with absorbable
locking running suture
Metallic skin staples

help position and hold
mesh in place while
applying glue adhesive
B
Fig. 8.7
s Patients are educated on proper drain care before discharge and instructed to keep a daily
log of individual drain output. The drains are removed when output is consistently less
than 20 mL/day.
s Patients are placed on prophylactic antibiotics (minocycline 100 mg orally daily) until the
subcutaneous drains have been removed.
s Patients are instructed to limit strenuous physical activity and avoid heavy lifting for
6-8 weeks postoperatively.
s Patients are followed closely in the office setting during the early postoperative period.
Most patients are seen once weekly until drain removal. A final follow-up visit is scheduled
at 6-8 weeks postoperatively, and patients subsequently can follow up on an as-needed
basis.
Pearls and Pitfalls
1. Patient Selection and Risk Modification
s Proper patient selection and preoperative optimization of modifiable risk factors are of the
utmost importance when evaluating a patient for ventral hernia repair with mesh onlay.
Recognizing the presence of potentially complicating risk factors and optimizing them
before surgery will ideally increase the success of surgery while minimizing the potential
for postoperative complications.
2. Management of Seroma
s
Postoperative seroma is a potential drawback of the mesh onlay repair. We believe this
problem can be avoided with proper drain management and the routine use of abdominal
binders postoperatively. Drain output is monitored closely in the immediate postoperative
period, and closed-suction drains are typically left in place until the output stops. Drains
are interrogated and flushed with sterile saline at each postoperative office visit to ensure
the drains are patent and functioning properly. If serous fluid reaccumulates in the subcu-
taneous space after drain removal, patients may require serial aspiration in the office. If the
accumulation persists, drains occasionally need to be replaced using ultrasound guidance.
We also encourage patients to wear their abdominal binders at all times typically for a full
8 weeks after hernia repair.
3. Management of Wound Complications
s Skin flap ischemia and superficial wound infections are other potential complications as-
sociated with raising wide skin flaps during ventral hernia repair. Wound infections and
operating in a contaminated field may also lead to an increased risk of mesh infection. If
these problems are encountered, management consists of operative wound exploration,
débridement and irrigation of all devitalized tissue, and application of a negative-pressure

wound therapy system for vacuum-assisted closure. In our experience, this management
algorithm has led to a 100% salvage rate of the mesh and clearance of infection.
Selected References
Alexandre JH: Jean-Paul Chevrel (1933–2006), Hernia 11:293–296, 2007.
Chevrel JP: The treatment of large midline incisional hernias by “overcoat” plasty and prosthesis, Nouv Presse Med 8:695–696, 1979.
Chevrel JP, Rath AM: The use of fibrin glues in the surgical treatment of incisional hernias, Hernia 1:9–14, 1997.
Katkhouda N, Mavor E, Friedlander MH, et al.: Use of fibrin sealant for prosthetic mesh fixation in laparoscopic extraperitoneal inguinal
hernia repair, Ann Surg 33:18–25, 2001.
Kingsnorth A, Shahid M, Valliatu A, et al.: Open onlay mesh repair for major abdominal wall hernias with selective use of components
separation and fibrin sealant, World J Surg 32:26–30, 2008.
Licheri S, Erdas E, Pisano G, Garau A, Ghinami E, Pomata M: Chevrel technique for midline incisional hernia: still an effective procedure,
Hernia 12:121–126, 2008.
Phillip S: Patient comorbidities complicating hernia repair: the preoperative workup and postoperative planning. In Jacob BP, Ramshaw B,
editors: The SAGES Manual of Hernia Repair, New York, 2013, Springer Science, pp 271–282.
Rath AM, Zhang J, Chevrel JP: The sheath of the rectus abdominis muscle: anatomical and biochemical study, Hernia 1:139–142, 1997.
Stoikes N, Sharpe J, Tasneem H, et al.: Biomechanical evaluation of fixation properties of fibrin glue for ventral incisional hernia repair,
Hernia 19:161–166, 2015.
Stoikes N, Webb D, Powell B, Voeller GR: Preliminary report of sutureless onlay technique for incisional hernia repair using fibrin glue
alone for mesh fixation, Am Surg 79:1177–1180, 2013.

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CHAPTER

3. Hernia Type and Location

s Overall, we consider the open mesh-onlay repair to be an extremely versatile method of

s The open mesh-onlay technique is predicated on mesh reinforcement of a primary fascial

5. Preoperative Risk Modification

s Cigarette smoking is associated with increased risk of perioperative morbidity, particularly

3. Operative Steps (Video 8.1)

3. Hernia Reduction and Adhesiolysis

4. Creation of Skin Flaps

Edge of fascial defect

Skin/subcutaneous fat flap

External oblique release

Skin/subcutaneous fat flap

Internal oblique muscle

Edges of fascial defect

s A medium-weight, macroporous polypropylene mesh is brought into the operative field

Fig. 8.3 Fig. 8.4

Fig. 8.5 Fig. 8.6

10. Skin Closure

Posterior rectus Medium-weight,

Midline fascia repair

Mesh attached to lateral

Metallic skin staples

Pearls and Pitfalls

1. Patient Selection and Risk Modification

3. Management of Wound Complications

débridement and irrigation of all devitalized tissue, and application of a negative-­pressure

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s Overall, we consider the open mesh-onlay repair to be an extremely versatile method of

s The open mesh-onlay technique is predicated on mesh reinforcement of a primary fascial

s Cigarette smoking is associated with increased risk of perioperative morbidity, particularly

s A medium-weight, macroporous polypropylene mesh is brought into the operative field

débridement and irrigation of all devitalized tissue, and application of a negative-pressure