programmed to close. Persistent umbilical hernias require surgery. In older patients, the onset is usually

sudden and the defect is relatively small. There are several syndromes associated with umbilical hernias

such as mucopolysaccharide storage diseases, Beckwith–Wiedemann syndrome, and Down syndrome.

Predisposing factors for the development of umbilical hernias in adults are multiple pregnancies,

obesity, cirrhosis with ascites, and large abdominal tumors, all of which cause an increase in intraabdominal pressure.111 Male gender is also a risk factor with the peak incidence of repair at about age

60 years.112 The differential diagnosis includes the varicosities that extend radially from the umbilicus

in persons with portal hypertension, the so-called caput medusae (Fig. 72-31). The varicosities have a

bluish discoloration and fill when the patient is straining. A metastatic deposit of intra-abdominal cancer

at the umbilicus may mimic umbilical herniation. Cancer cells reach this area via lymphatics in the

falciform ligament. Metastasis presents as a hard nodule, and biopsy is diagnostic. Other periumbilical

masses that can be confused with an umbilical hernia include umbilical granulomas, omphalomesenteric

duct remnant cysts, and urachal cysts.

Figure 72-31. Caput medusae. Large periumbilical collaterals in a patient with portal hypertension.

The management of umbilical hernias is nonoperative in children up to the age of 2 or 3 years

because spontaneous closure is the rule. In those who require surgery, adults or children, the repair

depends on the size of the hernia. An infraumbilical semilunar incision is made and the hernia identified.

There may or may not be a true peritoneal sac, as smaller hernias usually consist of preperitoneal fat

only. If a sac is present, it can be opened and the contents reduced into the abdomen. Alternatively, the

hernia can be dissected circumferentially to the fascial opening and reduced without entering the

peritoneal cavity. The dissection can be continued beneath the fascia creating a preperitoneal space for

the placement of a prosthesis, if needed. Several techniques can be used to close the fascial defect. In

1901, James Mayo described the classic overlapping, vest-over-pants (double-breasting or waistcoat)

technique, which bears the name of his clinic, in which the upper edge of the linea alba overlaps the

lower edge (Fig. 72-32).113 The operation is losing popularity now because it is generally not consistent

with the tension-free concept popular in hernia surgery today.114 It requires more dissection than other

procedures to create the flaps and is therefore more painful. Simple suture herniorrhaphy is the easiest

procedure but has the highest recurrence rate (especially with high body mass index [BMI] and

smoking), and therefore should be used only for small defects. For larger hernias, particularly in adults,

the preperitoneal space can be exploited by bluntly dissecting the peritoneum from the undersurface of

the posterior rectus sheath for enough distance to be able to place an appropriate prosthesis. If the

peritoneum is not entered, a mesh prosthesis is preferred, which is placed in the preperitoneal space and

then the fascial edges closed if the defect is small enough. Otherwise, a bridging technique can be used

with the fascial edges sewn to the underlying mesh. If the peritoneal cavity is entered, then a composite

prosthesis (e.g., ePTFE + polypropylene) or a mesh prosthesis with an adhesion barrier (see prosthetic

materials section) can be placed intraperitoneally with the adhesion barrier facing the viscera. A

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laparoscopic approach for umbilical hernias is a good option for recurrent hernias or hernias with

defects larger than 3 cm and, in retrospective reviews, has been shown to decrease operative times and

result in faster recovery to normal activities. The technical details are similar to those of a laparoscopic

incisional hernia repair (see incisional hernia section).

Table 72-12 Ventral Hernia Working Group (VHWG) Classification of Incisional

Hernia

Figure 72-32. Mayo repair of an umbilical hernia. A: Diagram of longitudinal section through the hernia. B: Subumbilical “smile”

incision. The hernial sac is excised. C: Waistcoat type of closure.

EPIGASTRIC HERNIAS

Epigastric hernias occur through a defect in the linea alba. In the majority of patients, only a single

decussation of the fibers of the linea alba is present rather than the usual triple decussation (Fig. 72-7).

The incidence of epigastric herniation reported varies from less than 1% to as high as 5%. Epigastric

hernias are more common in woman than men with a peak incidence of repair around age 40 years.112

About 50% of them are asymptomatic. Most are less than 1 cm and contain only incarcerated

preperitoneal fat without a peritoneal sac. For this reason, epigastric hernias commonly cannot be

visualized with laparoscopy. Patients complain of a painful nodule in the upper midline. Repair by

reduction of the preperitoneal fat and simple closure of the defect is curative. These hernias are prone

to recur, with rates as high as 10%, which has led many surgeons to routinely include a prosthetic

underlay just as in umbilical or incisional hernias.

Left untreated, an epigastric hernia can become large enough for a peritoneal sac to form, into which

the intra-abdominal contents can protrude. The sac is usually wide, and serious complications are not

common. About 20% are multiple, and this needs to be ascertained prior to operation if all the defects

are to be addressed, because after anesthesia induction, they can be difficult to identify.

In diastasis recti, the two rectus muscles are separated widely. The area of the linea alba is stretched

and protrudes like a fin. The condition almost never produces complications and therefore surgical

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correction is not routinely recommended. However, many patients find the defect unsightly and request

treatment. They should be cautioned that many insurance companies consider this a cosmetic defect and

will not reimburse. Surgery involves removal of a strip of the weakened linea alba and

reapproximation. An alternative is a mesh repair done laparoscopically.

INCISIONAL HERNIAS

Incisional hernias occur as a complication of prior surgery. These hernias can follow any type of

abdominal surgery, regardless of the type of incision. More than 2 million laparotomies are performed

yearly in the United States, and the reported incidence of incisional hernia varies between 2% and

20%115 and is one of the most common reasons for reoperation.109 The highest incidence is with midline

incisions (10.5%) and transverse incisions (7.5%), but hernias are well documented following

paramedian incisions as well (2.5%).116 The cumulative incidence of incisional hernias is linear, as they

can present after considerable delay following the index operation. Poor surgical technique, rough

handling of tissues, use of rapidly degraded absorbable suture materials, closure of the abdomen under

tension, and infection of the wound are technical causes of incisional hernias. Morbid obesity, cigarette

smoking, pulmonary disease, debilitation from cancer, chemotherapy, the use of steroids,

hypoalbuminemia, and other pre-existing comorbid conditions are patient factors that have been

incriminated. Patients with an aortic aneurysm or a proven defect in collagen metabolism also exhibit

an increased incidence of incisional hernias.117 Read and Yoder in a retrospective review found that 17%

of incisional hernias are incarcerated or strangulated at presentation.118 The consequences of unrepaired

enlarging symptomatic hernias include loss of abdominal domain; significant biomechanical alterations

that affect posture; compromise of activities of daily living, including lifting and straining; and poor

cosmetics. Most of the published literature on treatment options addresses midline defects. The

management of nonmidline incisional hernias (i.e., subcostal, transverse, or gridiron incisions) to some

extent must be extrapolated.119

At least some ventral hernias can be prevented by proper abdominal closure after a laparotomy.

Monofilament slowly absorbable or nonabsorbable sutures should be placed in the aponeurosis only 5 to

8 mm from the wound edge, not to include muscle, 4 to 5 mm apart in a single layer. Studies have

shown that nonabsorbable sutures result in a lower incidence of incisional herniation but at the cost of

increased wound pain and chronic suture sinuses when they become infected.106 These suture sinuses

tend to be multiple and take years to eradicate by probing the sinus tracks and removing deep sutures.

The development of better monofilament absorbable sutures has caused most surgeons to use a slowly

absorbable monofilament suture.107 Using small needles is recommended to avoid including excessive

amounts of tissue. By measuring the suture remnants in relationship to the total length of the suture,

one can calculate a suture length to wound length ratio which should never be less than 4.120

Another common practice after laparotomy is to prescribe abdominal binders. Although most

surgeons prescribe abdominal binders following laparotomy, there is no evidence that these devices

decrease pain; improve respiratory function; or prevent incisional hernias, seroma formation, or wound

complications. The use of a binder may provide some comfort in the immediate postoperative period to

some patients and may be recommended for this purpose only.121,122

Massive Hernia

Although there is no consistent definition as to what constitutes a massive hernia, this term applies to

abdominal wall hernias with a large portion of the abdominal contents situated within the sac and to

hernias that are said to have “loss of domain” because the contents of the hernia exceed the capacity of

the abdominal cavity. Many of these hernias are associated with morbid obesity, skin ulcerations,

enterocutaneous fistulae, diverting stomas, and distortion of the abdominal wall from multiple prior

attempts to repair them. Several physiologic changes such as alteration of ventillatory equilibrium and

impairment of venous return results from long-standing massive hernias. Forced reduction of the hernia

with replacement of contents into the abdominal cavity can increase intra-abdominal pressure

considerably, resulting in respiratory insufficiency and cardiovascular compromise.123 In extreme cases,

it is impossible to return the contents to the abdomen and repair the hernia defect without resection of

intra-abdominal contents, such as colectomy with omentectomy. Repair of massive ventral hernias with

loss of domain is technically challenging and is associated with high morbidity, mortality, and

recurrence rates. A good understanding of the abdominal wall anatomy and the nature of fascial defects

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is essential prior to repairing these ventral hernias. Complications of repair are common and include

respiratory compromise, abdominal compartment syndrome, skin flap necrosis, and wound infection, in

addition to the usual surgical complications. Therefore, repair should not be recommended unless there

are overwhelming indications such as disabling symptoms, bowel obstruction or strangulation, or

extensive skin ulceration caused by the hernia. These patients might best be seen in centers with special

interest in this area where teams have been assembled to treat complex abdominal wall pathologies.124

Preoperative Preparation

The key to successful management of ventral hernia is good preoperative work-up. Many of these

patients have had multiple prior surgeries including previous attempts at hernia repair and it is

important for the surgeon to obtain and review all the previous operative reports and evaluate the

nature of previous surgeries, incision types, and closure techniques. Smoking and obesity are major

contributors to failure of ventral hernia repair. At our institution, we require 4 weeks of smoking

cessation prior to elective ventral hernia repair. Morbidly obese patients are at increased risk for wound

infection and dehiscence and should be managed in a multidisciplinary setting with the bariatric surgery

team, and sometimes a staged approach may be needed with weight loss surgery initially with

temporary repair of ventral hernia followed by definitive repair once the patient achieves maximal

weight loss and has fewer comorbidities. Management of chronic wounds and infections (both local and

distant), smoking cessation, optimization of cardiopulmonary and nutritional status, and control of

blood sugars in diabetic patients is recommended prior to surgery also optimize the chances of a

successful repair. Imaging studies in the form of CT scan of the abdomen and pelvis, although not

routinely indicated, may be helpful for preoperative planning in patients with large or complex ventral

hernias, posttraumatic hernias, morbid obesity, and special cases such as lumbar hernias. Functional cine

MRI is a new technology that can be used to find postoperative adhesions.125 A mechanical bowel

preparation may be used in patients with complex ventral hernias. On the day of surgery, special

attention must be paid to the administration of thromboembolism prophylaxis and preoperative

antibiotics. An iodophor skin barrier may be used to decrease mesh contact with the skin. In the

operating room, sharp debridement of devitalized or infected tissues is recommended and sometimes a

staged approach for hernia repair is necessary. Prior to abdominal wall closure, attention should be paid

to ventilator mechanics as rising peak and plateau pressures can be early signs of abdominal

compartment syndrome.

Progressive Preoperative Pneumoperitoneum

Progressive preoperative pneumoperitoneum (PPP), which was first described for repair of giant

incisional hernias, was described by Goni Moreno in 1940 and is a useful technique in these patients to

expand the abdominal cavity by stretching the abdominal wall and the diaphragm.29,123,126,127 The

maneuver involves injecting room air (or CO2

) via a needle or implantable catheter every 1 to 3 days to

tolerance (development of shoulder pain, difficulty breathing, or subcutaneous emphysema). This can be

performed by patients and families as outpatient, but some surgeons prefer to use pressure monitoring,

keeping it less than 15 mm Hg. Although theoretically attractive, pneumoperitoneum is not always

successful. The injected gas sometimes preferentially enters the hernia sac and distends it with minimal

effect on the abdominal cavity. In addition, pneumoperitoneum has been shown to diminish lower

extremity venous return. This could translate into a higher risk of thromboembolic complications.

PPP has been more commonly applied in Europe and South America with good results for large

ventral hernias. In a recent study, safety and feasibility of this approach were shown in 16 patients.123

Of these 16 patients, 7 still required an additional procedure such as ileocecectomy or lateral relaxing

incision on the rectus sheath to achieve abdominal wall closure. In another small series consisting of 9

patients, PPP was sufficient to reduce the visceral contents, permitting a retrorectus repair in 80% of

these patients.128 Of 9 patients, 1 patient with diabetes mellitus developed an abdominal wall abscess

requiring drainage in the postoperative period. Many surgeons in North America are skeptical about the

approach, questioning how one ensures that the air injected stays in the peritoneal cavity and does not

leak into the hernia sac, enlarging it further. Also of concern is the possibility of infection and the cost,

especially if in-hospital monitoring is needed.

Tissue Expansion

Tissue expanders can also be used when either skin or the myofascial elements of the abdominal wall

are deficient.129 They are implanted subcutaneously or subfascially and are gradually inflated until the

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desired amount of extra tissue is obtained. The limitation of the technique is the delay in definitive

repair while the expansion is going on and the considerable amount of pain that patients complain of.

The intra-abdominal placement of tissue expanders has also been described to address the issue of loss

of domain, but this is primarily confined to the pediatric literature.

Visceral Resection

In certain circumstances, resection of intra-abdominal viscera is necessary to avoid causing increase in

intra-abdominal pressure. Options include total omentectomy, subtotal colectomy, and removal of

retroperitoneal fat.

Algorithm 72-4. Management of incisional hernia.

Treatment of Ventral Hernias

General Principles

8 As described above, the abdominal wall is a complex unit and plays an important role in respiration,

defecation, micturition, movement of the trunk, and protection of intra-abdominal organs (Algorithm

72-4). It has been shown that health-related quality of life improves after ventral incisional hernia

repair, presumably related to improved abdominal wall function.130 Many experts believe that

reapproximation of rectus muscles in the midline restores functional abdominal wall anatomy and is

recommended if it can be performed without excessive tension.

Nonprosthetic Repairs

Traditionally, the repair of an incisional hernia depended on the size of the hernia. If the defect was

solitary and 3 cm or less, primary closure with nonabsorbable suture material was recommended. This

concept is now questioned after the publication of a landmark prospective randomized trial by

Luijendijk and colleagues from the Netherlands in the year 2000 and updated in 2004 comparing a

prosthetic repair versus primary suture.131,132 These investigators found a 50% reduction in the

recurrence rate when a prosthesis was used, and this even applied to small hernias (<10 cm2). For this

reason, a simple, nonprosthetic technique should be reserved for only the smallest hernias in patients

without risk factors for further recurrence.

Component Separation

9 Abdominal wall reconstruction and component separation are useful tools in the armamentarium of

the hernia surgeon. The main types of component separation techniques currently used are described

below.

Anterior Component Separation. A more complex nonprosthetic repair is the component separation

technique popularized in the early 1990s by Ramirez and colleagues which is based on lateral

fasciotomies that allow sliding of the muscular fascia layers toward the midline providing coverage for

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