Complex Incisional Hernias

Abstract

The universe of incisional hernias is complex in its essence, as there are many possible variables related to the patient and to the hernia itself. Classically, re-recurrent hernias, lumbar and supra-pubic hernias, peritoneostomy sequels and traumatic hernias are considered complex cases. But the association of frequent conditions, such as loss of domicile, stomas, enteric fistulas and chronic infection, play the real challenges in ventral hernia surgery. The main controversies related to complex ventral hernia repair include: mesh repair techniques against component separation techniques; single versus staged operations; the choice for synthetic or biologic mesh; mesh type and positioning; and the use of mesh in contaminated and infected settings. Despite controversies, there is consensus that complex hernia repair must be cost-effective, with reproducible techniques and results. The goals of hernia repair are to perform an anatomical reconstruction, restoring functionality and improving aesthetics. An adequate and long-term follow-up is required to evaluate results. The development and improvement of a surgical standardized method enabled us to treat challenging cases with very good results. Our approach includes a primary anatomical repair with onlay and sometimes underlay reinforcement using standard heavyweight polypropylene mesh, in a single staged operation. We encourage the use of synthetic mesh both in contaminated and infected settings. Since mesh reinforcement causes a certain shielding of the abdominal wall, we do treat all possible surgical conditions simultaneously. Preoperative pneumoperitoneum and visceral resection are valuable adjunctives in the repair of hernias with loss of domicile. Bowel resection, colostomy takedown and mesh replacement after removal of infected mesh, are some of the procedures usually considered contraindicated, that we associate routinely with synthetic mesh reinforcement. In complex incisional hernia surgery, mesh-less repairs, laparoscopy and robotics techniques, and the choice for lightweight and biologic mesh should not be considered, in the repair of these challenging defects.