Laparoscopic Retromuscular Repair of Ventral Hernias: eTEP and eTEP-TAR

*Victor G. Radu*

#### **Abstract**

Professors Jean Rives and Rene Stoppa published that the retrorectus space is the best for mesh placement in open ventral hernia repair and their technique has become the gold standard. This chapter presents a new technique in laparoscopic ventral hernia repair (LVHR), which combines the advantages of Rives-Stoppa procedure with the advantages of minimally invasive surgery (MIS)—it is about enhanced-view totally extraperitoneal (eTEP) approach. Restoration of the architecture of the abdominal wall and also of its functionality and the possibility to extend laterally the retromuscular dissection, if it is needed, performing transversus abdominis release (TAR) give laparoscopic retromuscular repair of ventral hernias the chance to become the gold standard in LVHR.

**Keywords:** eTEP, eTEP-TAR, laparoscopic ventral hernia repair, abdominal wall reconstruction, laparoscopic retromuscular repair, laparoscopic rives-Stoppa

#### **1. Introduction**

In 2012 Jorge Daes published the enhanced-view totally extraperitoneal (eTEP) approach in inguinal hernia repair. His procedure inspired Igor Belyansky to extend the retrorectus dissection cranially and cross over the midline, remaining outside of the peritoneal cavity and connecting both the retrorectus spaces. In this way he performed endoscopically the Rives-Stoppa procedure (eRS) and transversus abdominis release (eTEP-TAR), respectively, publishing a novel approach in ventral hernia repair.

#### **1.1 History**

The laparoscopic techniques in ventral hernia repair are improved from the "bridged-IPOM" performed by Leblanc in the 1990s to "IPOM plus"—a concept introduced 20 years later by J.F. Kukleta, who closed the defect and used the mesh for augmentation of the abdominal wall repaired [1, 2].

The evolution did not stop there and conversely still continues by not trying to find the ideal mesh but instead the ideal mesh placement. In 2002 Marc Miserez repaired a ventral hernia placing the mesh pre-peritoneally, and Wolfgang Reinpold placed the mesh under the rectus muscles by trans-hernial access (MILOS technique) [2–4].

In 2016, Igor Belyansky published a new technique combining the eTEP access described by Jorge Daes with the principles of TAR described by Yuri Novitsky [5–8]. The result (eRives/eTEP-TAR) is very promising, and the technique has the potential to become one of the best solutions in laparoscopic ventral hernia repair (LVHR) [6].

#### **2. Ventral hernia classification**

In 2009, a group of international experts from EHS published a new classification of ventral hernias, based on location and dimensions of the hernial defect.

The primary ventral hernias are classified as medial (epigastric and umbilical) and lateral (spigelian and lumbar). In relation with the diameter, these hernias can be small, medium, or large (**Table 1**) [9].

In a similar way, the ventral incisional hernias can be medial or lateral.

The medial incisional hernias are located in the area limited by xiphoid (cranially), pubic symphysis (caudally), and the lateral edge of rectus muscles.

An easily memorable classification from M1 to M5 going from the xiphoid to pubic bone was proposed. Therefore, they define 5 M zones [9]:

Classification of the midline incisional hernias includes five zones, from xiphoid process to pubic symphysis from 3 to 3 cm (**Figure 1**).


The borders of the lateral area are defined as:


In this way, the lateral hernias are classified as follows (**Figure 2**).

**23**

**Figure 1.**

**Table 1.**

*were defined [9].*

many different sizes and shapes.

*Laparoscopic Retromuscular Repair of Ventral Hernias: eTEP and eTEP-TAR*

*The European hernia society classification for primary abdominal wall hernias [9].*

In contrast to the primary abdominal wall hernias, incisional hernias come in

*To classify midline incisional hernias between the two lateral margins of the rectus muscle sheaths, five zones* 

The length of the hernia defect was defined as the greatest vertical distance between the most cranial and the most caudal limit of the hernia defect. In case of multiple hernia defects from one incision, the length is between the cranial margin of the most cranial defect and the caudal margin of the most caudal defect (**Figure 3**). This technique has no contraindications related to the width of the defects. As in open retromuscular surgery, the eTEP approach can be used to repair all varieties of ventral hernias, from small umbilical hernias to large and complex ventral hernias.

*DOI: http://dx.doi.org/10.5772/intechopen.89677*


Measurement of the incisional hernias.

*Laparoscopic Retromuscular Repair of Ventral Hernias: eTEP and eTEP-TAR DOI: http://dx.doi.org/10.5772/intechopen.89677*


#### **Table 1.**

*Techniques and Innovation in Hernia Surgery*

**2. Ventral hernia classification**

be small, medium, or large (**Table 1**) [9].

• M1: subxiphoidal

• M2: epigastric

• M3: umbilical

• M4: infraumbilical

• M5: suprapubic [9]

1.Cranial: the costal margin

2.Caudal: the inguinal region

4.Lateral: the lumbar region

• L1: subcostal

• L2: flank

• L3: iliac

• L4: lumbar

(LVHR) [6].

In 2016, Igor Belyansky published a new technique combining the eTEP access described by Jorge Daes with the principles of TAR described by Yuri Novitsky [5–8]. The result (eRives/eTEP-TAR) is very promising, and the technique has the potential to become one of the best solutions in laparoscopic ventral hernia repair

In 2009, a group of international experts from EHS published a new classification of ventral hernias, based on location and dimensions of the hernial defect. The primary ventral hernias are classified as medial (epigastric and umbilical) and lateral (spigelian and lumbar). In relation with the diameter, these hernias can

The medial incisional hernias are located in the area limited by xiphoid (crani-

An easily memorable classification from M1 to M5 going from the xiphoid to

Classification of the midline incisional hernias includes five zones, from xiphoid

In a similar way, the ventral incisional hernias can be medial or lateral.

ally), pubic symphysis (caudally), and the lateral edge of rectus muscles.

pubic bone was proposed. Therefore, they define 5 M zones [9]:

process to pubic symphysis from 3 to 3 cm (**Figure 1**).

The borders of the lateral area are defined as:

3.Medial: the lateral margin of the rectal sheath

Measurement of the incisional hernias.

In this way, the lateral hernias are classified as follows (**Figure 2**).

**22**

*The European hernia society classification for primary abdominal wall hernias [9].*

#### **Figure 1.**

*To classify midline incisional hernias between the two lateral margins of the rectus muscle sheaths, five zones were defined [9].*

In contrast to the primary abdominal wall hernias, incisional hernias come in many different sizes and shapes.

The length of the hernia defect was defined as the greatest vertical distance between the most cranial and the most caudal limit of the hernia defect. In case of multiple hernia defects from one incision, the length is between the cranial margin of the most cranial defect and the caudal margin of the most caudal defect (**Figure 3**).

This technique has no contraindications related to the width of the defects. As in open retromuscular surgery, the eTEP approach can be used to repair all varieties of ventral hernias, from small umbilical hernias to large and complex ventral hernias.

**25**

**Figure 4.**

*Law of Laplace [12].*

*Laparoscopic Retromuscular Repair of Ventral Hernias: eTEP and eTEP-TAR*

**3. The biomechanics of the abdominal wall and abdominal cavity**

The advantages of the retrorectus dissection are well known. Once the rectus muscles are removed from their encasement in the rectus sheaths, linea alba can be restored, the muscles being able to be translated medially 3 cm, 5 cm, and 3 cm, respectively, in the upper, middle, and lower third of the abdomen, as Ramirez wrote in the paper describing his component separation technique. In this way large

Because of an excellent arterial blood supply, the retrorectus space serves as a well-vascularized position where mesh prostheses become incorporated. This sublay mesh position has benefits at both a molecular level and a pure mechanical level. The perifilamentous collagen deposition on the mesh has a higher type I/III ratio compared with mesh placed onlay. The predominance of mature collagen (type I)

The tone of the abdominal wall muscles induces an intra-abdominal pressure between 5 and 7 mmHg. According to Laplace's law, this pressure acts equally on the abdominal wall, determining a tension in the abdominal wall which is a positive

The restoration of architecture and functionality of the abdominal wall conducts restoration of the physiological tension in the abdominal wall. The focus of these procedures is the reconstruction of the linea alba, the "central tendon" of the

The posterior layer will have the role of barrier between the mesh and the viscera. It is very important to suture the posterior layer totally tension free, to avoid rupture of the suture line. To suture without tension is possible preserving the peritoneal structures (the falciform ligament, the umbilical ligament, or/and the hernia sac) as a bridge between the posterior rectus sheaths. The resistance of the

*DOI: http://dx.doi.org/10.5772/intechopen.89677*

defects up to 10 cm width can be closed.

tension (**Figure 4**) [11].

abdominal wall.

confers a higher tensile strength of the wound [10].

posterior layer will be charged by the mesh.

**Figure 3.** *Definition of the width and the length of incisional hernias [9].*

*Laparoscopic Retromuscular Repair of Ventral Hernias: eTEP and eTEP-TAR DOI: http://dx.doi.org/10.5772/intechopen.89677*

#### **3. The biomechanics of the abdominal wall and abdominal cavity**

The advantages of the retrorectus dissection are well known. Once the rectus muscles are removed from their encasement in the rectus sheaths, linea alba can be restored, the muscles being able to be translated medially 3 cm, 5 cm, and 3 cm, respectively, in the upper, middle, and lower third of the abdomen, as Ramirez wrote in the paper describing his component separation technique. In this way large defects up to 10 cm width can be closed.

Because of an excellent arterial blood supply, the retrorectus space serves as a well-vascularized position where mesh prostheses become incorporated. This sublay mesh position has benefits at both a molecular level and a pure mechanical level. The perifilamentous collagen deposition on the mesh has a higher type I/III ratio compared with mesh placed onlay. The predominance of mature collagen (type I) confers a higher tensile strength of the wound [10].

The tone of the abdominal wall muscles induces an intra-abdominal pressure between 5 and 7 mmHg. According to Laplace's law, this pressure acts equally on the abdominal wall, determining a tension in the abdominal wall which is a positive tension (**Figure 4**) [11].

The restoration of architecture and functionality of the abdominal wall conducts restoration of the physiological tension in the abdominal wall. The focus of these procedures is the reconstruction of the linea alba, the "central tendon" of the abdominal wall.

The posterior layer will have the role of barrier between the mesh and the viscera. It is very important to suture the posterior layer totally tension free, to avoid rupture of the suture line. To suture without tension is possible preserving the peritoneal structures (the falciform ligament, the umbilical ligament, or/and the hernia sac) as a bridge between the posterior rectus sheaths. The resistance of the posterior layer will be charged by the mesh.

*Techniques and Innovation in Hernia Surgery*

**24**

**Figure 3.**

**Figure 2.**

*Definition of the width and the length of incisional hernias [9].*

*To classify lateral incisional hernias, four zones lateral of the rectus muscle sheaths were defined [9].*

#### **Figure 5.** *Carbonell's algorithm: 2xRW:DW ≥ 2:1.*

The preoperative CT scan is very useful. It allows us to locate the defect, measure it, and establish the strategy for the surgery.

Rives-Stoppa technique is sufficient when the sum of bilateral rectus muscle width is at least 2x > maximal defect width (**Figure 5**).

Additional myofascial release (TAR) may be necessary if maximal defect width closely approximates or exceeds 2x rectus width (**Figure 6**). This is Alfredo Carbonell's algorithm, presented at the 9th Annual Abdominal Wall Reconstruction Summit, Montana, USA, 2018.

The principles of the eTEP technique are:


Thinking of the abdomen as a "cylinder" with many layers, the principles mentioned above can be realized, connecting three spaces:


Connection of these spaces can be performed crossing over the midline. If the hernia is located in the upper part of the abdomen, crossover of the midline will be performed below the umbilicus and anterior to the umbilical ligament,

**27**

**Figure 7.**

*Position of the patient.*

**Figure 6.**

*Carbonell's algorithm: 2xRW:DW ≤ 2:1.*

*Laparoscopic Retromuscular Repair of Ventral Hernias: eTEP and eTEP-TAR*

and, conversely, if the hernia is located in the lower part of the abdomen, crossover the midline will be performed from above, anterior to the falciform ligament.

For the median ventral hernias, the patient will be placed in supine position, and the table will be flexed. In this position the distance between costal margins and iliac crests is increased, which allows an optimal port placement, and also the conflict is avoided between the surgeon's hand and the patient's thigh (**Figure 7**). We will place the patient on a lateral decubitus in lateral locations of hernias, especially for lumbar hernia (L4), keeping also the table flexed. The technical

The position of the patient is very important.

aspects in repairing of lumbar hernias will be presented separately.

*DOI: http://dx.doi.org/10.5772/intechopen.89677*

*Laparoscopic Retromuscular Repair of Ventral Hernias: eTEP and eTEP-TAR DOI: http://dx.doi.org/10.5772/intechopen.89677*

**Figure 6.** *Carbonell's algorithm: 2xRW:DW ≤ 2:1.*

*Techniques and Innovation in Hernia Surgery*

it, and establish the strategy for the surgery.

The principles of the eTEP technique are:

Summit, Montana, USA, 2018.

*Carbonell's algorithm: 2xRW:DW ≥ 2:1.*

• Closure of the defect

repair

**Figure 5.**

ment

2.The retrorectus spaces

to the semilunaris lines

width is at least 2x > maximal defect width (**Figure 5**).

The preoperative CT scan is very useful. It allows us to locate the defect, measure

Rives-Stoppa technique is sufficient when the sum of bilateral rectus muscle

• Minimizing fixation of the mesh, without compromising the result of hernia

1.The preperitoneal space, represented in the upper part of the abdomen by the falciform ligament and in the lower part of the abdomen by the umbilical liga-

3.The pretransversalis spaces, by enlarging the retromuscular dissection laterally

Connection of these spaces can be performed crossing over the midline. If the hernia is located in the upper part of the abdomen, crossover of the midline will be performed below the umbilicus and anterior to the umbilical ligament,

Thinking of the abdomen as a "cylinder" with many layers, the principles

Additional myofascial release (TAR) may be necessary if maximal defect width closely approximates or exceeds 2x rectus width (**Figure 6**). This is Alfredo Carbonell's algorithm, presented at the 9th Annual Abdominal Wall Reconstruction

• Use of uncoated mesh, placed outside of the abdominal cavity

mentioned above can be realized, connecting three spaces:

**26**

and, conversely, if the hernia is located in the lower part of the abdomen, crossover the midline will be performed from above, anterior to the falciform ligament.

The position of the patient is very important.

For the median ventral hernias, the patient will be placed in supine position, and the table will be flexed. In this position the distance between costal margins and iliac crests is increased, which allows an optimal port placement, and also the conflict is avoided between the surgeon's hand and the patient's thigh (**Figure 7**).

We will place the patient on a lateral decubitus in lateral locations of hernias, especially for lumbar hernia (L4), keeping also the table flexed. The technical aspects in repairing of lumbar hernias will be presented separately.

**Figure 7.** *Position of the patient.*

#### **Figure 8.** *(a) Port placement, (b) port placement.*

The key stages of this procedure are:

	- 3\* TAR (when needed [6])

The access of the retrorectus space is performed using an optic port placed medially to the semilunaris. The linea semilunaris is the most important landmark for port placement.

**29**

**Figure 9.**

*Development of the retrorectus space.*

*Laparoscopic Retromuscular Repair of Ventral Hernias: eTEP and eTEP-TAR*

under direct vision just medially to the semilunaris line (**Figure 9**).

As a rule, the ports have to be placed in the opposite side of the abdomen related

After the retrorectus space is achieved by CO2 insufflation, the ports are placed

2. It is better to cross over the midline in the virgin part of the wall, on the opposite side to where the defect is located, to minimize the risk of injury of the viscera,

Crossing over the midline to the contralateral retrorectus space is performed anterior to the falciform ligament, when we start from left to right (if the defect is in the lower abdomen) (**Figure 10a**) and, respectively, anterior to the umbilical ligament (if the defect is in the upper abdomen), and dissection starts from the

By dissection of both retrorectus spaces (left and right) and connecting them by incising the posterior sheaths on their medial aspects, we get a common large retromuscular space (the left retrorectus space connected to the right retrorectus space). This space is linked by the preperitoneal bridge represented by the falciform ligament and/or umbilical ligament. The retrorectus dissection is limited laterally by the semilunaris lines, where the neurovascular bundles pass through the poste-

3\*. TAR. When the defect is too large to be closed, the TAR procedure is added. The incorporation of TAR was found beneficial in cases with a wide defect (10 cm), tension on the posterior layer, and narrow retrorectus space (< 5 cm) or when dealing with a poor compliant abdominal wall [6]. Adding the TAR is necessary for closure of the defect and also for placement of a large mesh to obtain a good

As a right-handed surgeon, I perform TAR from the top to bottom on the right

*DOI: http://dx.doi.org/10.5772/intechopen.89677*

to the hernia location (**Figure 8a** and **b**).

which can be adherent to the abdominal wall.

3. Connection of both retrorectus spaces.

rior sheath to the rectus muscles (**Figure 11**).

right to left (**Figure 10b**).

overlapping.

side and bottom-up on the left.

#### *Laparoscopic Retromuscular Repair of Ventral Hernias: eTEP and eTEP-TAR DOI: http://dx.doi.org/10.5772/intechopen.89677*

As a rule, the ports have to be placed in the opposite side of the abdomen related to the hernia location (**Figure 8a** and **b**).

After the retrorectus space is achieved by CO2 insufflation, the ports are placed under direct vision just medially to the semilunaris line (**Figure 9**).

2. It is better to cross over the midline in the virgin part of the wall, on the opposite side to where the defect is located, to minimize the risk of injury of the viscera, which can be adherent to the abdominal wall.

Crossing over the midline to the contralateral retrorectus space is performed anterior to the falciform ligament, when we start from left to right (if the defect is in the lower abdomen) (**Figure 10a**) and, respectively, anterior to the umbilical ligament (if the defect is in the upper abdomen), and dissection starts from the right to left (**Figure 10b**).

3. Connection of both retrorectus spaces.

By dissection of both retrorectus spaces (left and right) and connecting them by incising the posterior sheaths on their medial aspects, we get a common large retromuscular space (the left retrorectus space connected to the right retrorectus space). This space is linked by the preperitoneal bridge represented by the falciform ligament and/or umbilical ligament. The retrorectus dissection is limited laterally by the semilunaris lines, where the neurovascular bundles pass through the posterior sheath to the rectus muscles (**Figure 11**).

3\*. TAR. When the defect is too large to be closed, the TAR procedure is added. The incorporation of TAR was found beneficial in cases with a wide defect (10 cm), tension on the posterior layer, and narrow retrorectus space (< 5 cm) or when dealing with a poor compliant abdominal wall [6]. Adding the TAR is necessary for closure of the defect and also for placement of a large mesh to obtain a good overlapping.

As a right-handed surgeon, I perform TAR from the top to bottom on the right side and bottom-up on the left.

**Figure 9.** *Development of the retrorectus space.*

*Techniques and Innovation in Hernia Surgery*

The key stages of this procedure are:

*(a) Port placement, (b) port placement.*

2.Crossover of the midline preperitoneally

3.Connection of both retrorectus spaces

3\* TAR (when needed [6])

4.Closure of the defect

5.Mesh placement

6.Exsufflation

**Figure 8.**

for port placement.

1.Access of the retrorectus space and port placement

1. Access of the retrorectus space and port placement.

The access of the retrorectus space is performed using an optic port placed medially to the semilunaris. The linea semilunaris is the most important landmark

**28**

**31**

**3.1 Top-bottom TAR**

**Figure 14.**

**Figure 13.**

**3.2 Bottom-up TAR**

line will be placed medially to these structures.

*Laparoscopic Retromuscular Repair of Ventral Hernias: eTEP and eTEP-TAR*

*(a) Posterior component separation. (b) Posterior component separation.*

It is easy to identify the transversus abdominis fibers through transparency of the posterior rectus sheath. Before drawing the TAR cutline, it is necessary to see the neurovascular (NV) bundles and the semilunaris line (**Figure 12a**). The TAR

*(a) Landmark: linea arcuata. (b) TAR bottom-up. (c) TAR after cutting of the posterior lamella of I.O.*

First the posterior lamella of the internal oblique muscle is incised and then transversus abdominis (TA) (**Figure 12b**). The incision must be curved medially to protect the integrity of diaphragm when the dissection is extended cranially.

cranial as possible depending on hernia location (**Figure 13 a** and **b**).

in bottom-up TAR, identification of the arcuate line is necessary (**Figure 14 a**).

After TA is released, of course dissection is extended as lateral as possible and as

In addition to the previous landmarks discussed (linea semilunaris and NV bundles)

*DOI: http://dx.doi.org/10.5772/intechopen.89677*

#### **Figure 10.**

*(a) Crossing over the linea alba above the umbilicus. (b) Crossing over the linea alba below the umbilicus.*

**Figure 11.** *Retromuscular dissection: connecting both retrorectus spaces.*

**Figure 12.** *(a) TAR top-bottom: Landmarks. (b) TAR top-bottom.*

*Laparoscopic Retromuscular Repair of Ventral Hernias: eTEP and eTEP-TAR DOI: http://dx.doi.org/10.5772/intechopen.89677*

**Figure 13.** *(a) Posterior component separation. (b) Posterior component separation.*

**Figure 14.** *(a) Landmark: linea arcuata. (b) TAR bottom-up. (c) TAR after cutting of the posterior lamella of I.O.*

#### **3.1 Top-bottom TAR**

It is easy to identify the transversus abdominis fibers through transparency of the posterior rectus sheath. Before drawing the TAR cutline, it is necessary to see the neurovascular (NV) bundles and the semilunaris line (**Figure 12a**). The TAR line will be placed medially to these structures.

First the posterior lamella of the internal oblique muscle is incised and then transversus abdominis (TA) (**Figure 12b**). The incision must be curved medially to protect the integrity of diaphragm when the dissection is extended cranially.

After TA is released, of course dissection is extended as lateral as possible and as cranial as possible depending on hernia location (**Figure 13 a** and **b**).

#### **3.2 Bottom-up TAR**

In addition to the previous landmarks discussed (linea semilunaris and NV bundles) in bottom-up TAR, identification of the arcuate line is necessary (**Figure 14 a**).

*Techniques and Innovation in Hernia Surgery*

*(a) Crossing over the linea alba above the umbilicus. (b) Crossing over the linea alba below the umbilicus.*

**30**

**Figure 12.**

**Figure 11.**

**Figure 10.**

*(a) TAR top-bottom: Landmarks. (b) TAR top-bottom.*

*Retromuscular dissection: connecting both retrorectus spaces.*

First the Bogros space is dissected, and the preperitoneal dissection is enlarged cranially, behind the posterior sheath. In this way TAR can be performed without cutting the peritoneum (**Figure 14b** and **c**).

Of course, enlarging dissection laterally up to the psoas muscle allows medial mobilization of the posterior rectus sheaths.

In the subxiphoidian hernia (M1), it is very important to extend dissection behind the diaphragm. Keeping the right anatomical plane, dissection can be extended up to the central tendon of diaphragm (**Figure 15**). It is important to mention that in all the cases, there is a landmark of the limit between the transversus abdominis and diaphragm. This limit is represented by a thin fatty tissue—"the yellow line" (**Figure 16**).

In the suprapubic hernia (M5), a large retropubic prevesical dissection is recommended to obtain a good overlap.

#### **Some aspects to keep in mind:**


The defect in the posterior layer has to be closed as barrier between the mesh and the bowel (**Figure 17**).

Restoration of the linea alba is the aim of this technique. This is achieved closing the defect by suturing the anterior rectus sheaths on midline (**Figure 18**).

It is recommended to keep in the suture the peritoneal sac; in this way dead space is avoided, and postoperative seroma occurrence is prevented.

**33**

**Figure 18.**

*Restoration of linea alba.*

**Figure 16.**

**Figure 17.**

*Closure of the posterior layer.*

*Laparoscopic Retromuscular Repair of Ventral Hernias: eTEP and eTEP-TAR*

*"Yellow line": The limit between the transversus abdominis and diaphragm.*

*DOI: http://dx.doi.org/10.5772/intechopen.89677*

**Figure 15.** *Dissection behind the xyphoid process.*

*Laparoscopic Retromuscular Repair of Ventral Hernias: eTEP and eTEP-TAR DOI: http://dx.doi.org/10.5772/intechopen.89677*

**Figure 16.** *"Yellow line": The limit between the transversus abdominis and diaphragm.*

**Figure 17.** *Closure of the posterior layer.*

*Techniques and Innovation in Hernia Surgery*

cutting the peritoneum (**Figure 14b** and **c**).

mobilization of the posterior rectus sheaths.

and protect integrity of the diaphragm.

a thin fat tissue, which is very constant.

4. Closure of the defect and restoration of linea alba

yellow line" (**Figure 16**).

and the bowel (**Figure 17**).

mended to obtain a good overlap. **Some aspects to keep in mind:**

First the Bogros space is dissected, and the preperitoneal dissection is enlarged cranially, behind the posterior sheath. In this way TAR can be performed without

Of course, enlarging dissection laterally up to the psoas muscle allows medial

In the suprapubic hernia (M5), a large retropubic prevesical dissection is recom-

• TAR lines must be curved medially to the top to connect to subxiphoidian space

• The TA and diaphragm are in the same anatomical plane; they are separated by

• In caudal direction, the release of TA must pass the arcuate line to get a large fascial flap, and there is no tension in the suture of the posterior layer.

The defect in the posterior layer has to be closed as barrier between the mesh

It is recommended to keep in the suture the peritoneal sac; in this way dead

the defect by suturing the anterior rectus sheaths on midline (**Figure 18**).

space is avoided, and postoperative seroma occurrence is prevented.

Restoration of the linea alba is the aim of this technique. This is achieved closing

In the subxiphoidian hernia (M1), it is very important to extend dissection behind the diaphragm. Keeping the right anatomical plane, dissection can be extended up to the central tendon of diaphragm (**Figure 15**). It is important to mention that in all the cases, there is a landmark of the limit between the transversus abdominis and diaphragm. This limit is represented by a thin fatty tissue—"the

**32**

**Figure 15.**

*Dissection behind the xyphoid process.*

**Figure 18.** *Restoration of linea alba.*

5. The mesh placement into the retrorectus space will be done after measurement of the entire dissected area which has to be covered by the mesh (**Figure 19**).

Usually I do not fix the mesh. A large dissection and a good overlapping, even posterior to the bones (pubic bones or costal margin) added to a correct closure of the defect, is enough for mesh fixation.

In our practice, after correct dissection and thorough hemostasis, we do not consider drainage necessary.

**Figure 19.** *Mesh placement.*

**35**

the correct position

**Figure 21.**

*Dr. Jorge Daes).*

(**Figure 21a** and **b**).

the ports will be placed laterally to this line.

For that the key stages of the procedure are:

chondrium, to identify the rectus muscle.

*Laparoscopic Retromuscular Repair of Ventral Hernias: eTEP and eTEP-TAR*

6. Slow exsufflation, under direct vision, allows us to ensure the mesh remains in

*Development of the pretransversalis space, laterally to the linea semilunaris and port placement. (Courtesy of* 

The position of the patient is on lateral decubitus, and the table is also flexed to increase the distance between the costal margin and the iliac crest (**Figure 20**). The landmark for port placement is also lateral edge of the rectus muscle, but

The aim is to develop the retromuscular space without penetration into peritoneal cavity, close the defect, and place a mesh outside of the abdominal cavity

1.Insufflation of the peritoneal cavity and placing a port inside, in the hypo-

2.Development of preperitoneal pretransversalis space and port placement.

A different approach is performed for lumbar hernia repair (L4).

*DOI: http://dx.doi.org/10.5772/intechopen.89677*

**Figure 20.** *Position of the patient in sTEP L4 hernia repair.*

*Laparoscopic Retromuscular Repair of Ventral Hernias: eTEP and eTEP-TAR DOI: http://dx.doi.org/10.5772/intechopen.89677*

#### **Figure 21.**

*Techniques and Innovation in Hernia Surgery*

the defect, is enough for mesh fixation.

consider drainage necessary.

5. The mesh placement into the retrorectus space will be done after measurement of the entire dissected area which has to be covered by the mesh (**Figure 19**).

Usually I do not fix the mesh. A large dissection and a good overlapping, even posterior to the bones (pubic bones or costal margin) added to a correct closure of

In our practice, after correct dissection and thorough hemostasis, we do not

**34**

**Figure 20.**

**Figure 19.** *Mesh placement.*

*Position of the patient in sTEP L4 hernia repair.*

*Development of the pretransversalis space, laterally to the linea semilunaris and port placement. (Courtesy of Dr. Jorge Daes).*

6. Slow exsufflation, under direct vision, allows us to ensure the mesh remains in the correct position

A different approach is performed for lumbar hernia repair (L4).

The position of the patient is on lateral decubitus, and the table is also flexed to increase the distance between the costal margin and the iliac crest (**Figure 20**).

The landmark for port placement is also lateral edge of the rectus muscle, but the ports will be placed laterally to this line.

The aim is to develop the retromuscular space without penetration into peritoneal cavity, close the defect, and place a mesh outside of the abdominal cavity (**Figure 21a** and **b**).

For that the key stages of the procedure are:

1.Insufflation of the peritoneal cavity and placing a port inside, in the hypochondrium, to identify the rectus muscle.

2.Development of preperitoneal pretransversalis space and port placement.

#### **Figure 22.**

*Pretransversalis space, laterally to the linea semilunaris.*

#### **Figure 23.**

*(a) Iliohypogastric and ilioinguinal nerves must be protected during dissection in the lumbar region. (b) closure of the defect.*

**Figure 24.** *Mesh placement.*

Under direct vision, a second port is placed laterally to the semilunaris line and preperitoneally, and the gas to this port is connected to develop the preperitoneal space. An optic port is useful at this step.

The third port is placed also under direct vision, laterally to the semilunaris line. Now, keeping the first port site will retract this port from the peritoneal cavity and change its direction laterally, in the preperitoneal space already created (**Figure 22**).

**37**

**Author details**

Victor G. Radu

Life Memorial Hospital, Medlife, Bucharest, Romania

provided the original work is properly cited.

\*Address all correspondence to: dr.victor.radu@gmail.com

*Laparoscopic Retromuscular Repair of Ventral Hernias: eTEP and eTEP-TAR*

3.Dissection and closure of the defect (**Figure 23a** and **b**)

cutaneous nerves will come across and must be protected (**Figure 23**).

It is very important to understand the retroperitoneal lumbar anatomy, because during the retromuscular dissection, the iliohypogastric, ilioinguinal, and femoral-

4.Mesh placement is the last step, respecting the overlap principle. Usually a selfgripping mesh is placed or a polypropylene mesh fixed with glue (**Figure 24**).

5.Slow exsufflation, under direct vision, allows us to ensure the mesh remains in

Soon postoperatively the patients are encouraged for an active mobilization. We do not recommend binders, but if the patients are more comfortable with binders,

Coffee and chewing gum are recommended as soon as possible, and a liquidsemisolid diet is allowed for dinner. The level of pain after this surgery is usually very low. On our first study related to eTEP technique, we mentioned that in mean an eTEP patient gets 2.7 doses of painkiller (NSAI) for every 24 h of hospital stay. The median length of hospitalization was in this study less than 24 hours postoperatively, even for eTEP-TAR cases. Usually the patients are discharged on the

We began to actively asses the quality of life of our patients, and they filled out our questionnaire; in the study we published the results of questionnaires filled out

In conclusion the eTEP techniques in ventral hernia repair (eRS and eTEP-TAR) combine the advantages of open retromuscular technique with the advantages of MIS.

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

*DOI: http://dx.doi.org/10.5772/intechopen.89677*

the correct position.

of course we accept to put it.

following day to their residence.

by 42 from 60 patients which are expressed below:

**3.3 Postoperative care**

*Laparoscopic Retromuscular Repair of Ventral Hernias: eTEP and eTEP-TAR DOI: http://dx.doi.org/10.5772/intechopen.89677*

3.Dissection and closure of the defect (**Figure 23a** and **b**)

It is very important to understand the retroperitoneal lumbar anatomy, because during the retromuscular dissection, the iliohypogastric, ilioinguinal, and femoralcutaneous nerves will come across and must be protected (**Figure 23**).


#### **3.3 Postoperative care**

*Techniques and Innovation in Hernia Surgery*

*Pretransversalis space, laterally to the linea semilunaris.*

**Figure 22.**

**Figure 23.**

*of the defect.*

**36**

**Figure 24.** *Mesh placement.*

space. An optic port is useful at this step.

Under direct vision, a second port is placed laterally to the semilunaris line and preperitoneally, and the gas to this port is connected to develop the preperitoneal

*(a) Iliohypogastric and ilioinguinal nerves must be protected during dissection in the lumbar region. (b) closure* 

The third port is placed also under direct vision, laterally to the semilunaris line. Now, keeping the first port site will retract this port from the peritoneal cavity and change its direction laterally, in the preperitoneal space already created (**Figure 22**).

Soon postoperatively the patients are encouraged for an active mobilization. We do not recommend binders, but if the patients are more comfortable with binders, of course we accept to put it.

Coffee and chewing gum are recommended as soon as possible, and a liquidsemisolid diet is allowed for dinner. The level of pain after this surgery is usually very low. On our first study related to eTEP technique, we mentioned that in mean an eTEP patient gets 2.7 doses of painkiller (NSAI) for every 24 h of hospital stay.

The median length of hospitalization was in this study less than 24 hours postoperatively, even for eTEP-TAR cases. Usually the patients are discharged on the following day to their residence.

We began to actively asses the quality of life of our patients, and they filled out our questionnaire; in the study we published the results of questionnaires filled out by 42 from 60 patients which are expressed below:

In conclusion the eTEP techniques in ventral hernia repair (eRS and eTEP-TAR) combine the advantages of open retromuscular technique with the advantages of MIS.

#### **Author details**

Victor G. Radu Life Memorial Hospital, Medlife, Bucharest, Romania

\*Address all correspondence to: dr.victor.radu@gmail.com

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] LeBlanc K, Allain Brent W. Jr. Laparoscopic Repair of Ventral Wall Abdominal Hernia - 3rd Edition: Prevention and Management [Online]. Available from: http://laparoscopy.blogs.com/ prevention\_management\_3/2010/10/ laparoscopic-repair-of-ventral-wallabdominal-hernia.html. [Accessed: 02 September 2017]

[2] Bittner R et al. Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS)-part 1). Surgical Endoscopy. Jan. 2014;**28**(1):2-29

[3] Miserez M, Penninckx F. Endoscopic totally preperitoneal ventral hernia repair. Surgical Endoscopy. Aug. 2002;**16**(8):1207-1213

[4] Schwarz J, Reinpold W, Bittner R. Endoscopic mini/less open sublay technique (EMILOS)—A new technique for ventral hernia repair. Langenbeck's Archives of Surgery. Feb. 2017;**402**(1):173-180

[5] Belyansky I, Zahiri HR, Park A. Laparoscopic transversus abdominis release, a novel minimally invasive approach to complex abdominal wall reconstruction. Surgical Innovation. Apr. 2016;**23**(2):134-141

[6] Belyansky I et al. A novel approach using the enhanced-view totally extraperitoneal (eTEP) technique for laparoscopic retromuscular hernia repair. Surgical Endoscopy. Sep, 2017;**32**:1531-1532

[7] Daes J. The enhanced view-totally extraperitoneal technique for repair of inguinal hernia. Surgical Endoscopy. Apr. 2012;**26**(4):1187-1189

[8] Novitsky YW. Posterior component separation via transversus abdominis

muscle release: The TAR procedure. In: Hernia Surgery. Cham: Springer International Publishing; 2016. pp. 117-135

[9] Muysoms FE et al. Classification of primary and incisional abdominal wall hernias. Hernia. Aug. 2009;**13**(4):407-414

[10] Novitsky YW, editor. Hernia Surgery. Cham: Springer International Publishing; 2016

[11] De Keulenaer BL, De Waele JJ, Powell B, Malbrain MLNG. What is normal intra-abdominal pressure and how is it affected by positioning, body mass and positive end-expiratory pressure? Intensive Care Medicine. Jun. 2009;**35**(6):969-976

[12] Radu VG, Lica M. The Endoscopic Retromuscular Repair of Ventral Hernia: The eTEP Technique and Early Results. Hernia. 2019. DOI: 10.1007/ s10029-019-01931-x/

**39**

**Chapter 4**

**Abstract**

**1. Introduction**

**2. Surgical anatomy**

Incisional Hernia

*Anil Kumar and Shiv Shankar Paswan*

Incisional hernia is one of the most common postoperative complications after abdominal surgery. Several studies have shown that incisional hernias have different etiologies which are related to the patient, the surgical technique, the suture material and experience of the surgeon. Most patients present with abdominal swelling with some level of discomfort, and in emergency the presentation is usually as bowel obstruction or strangulation which requires urgent exploration. The recurrence rate is almost the same for open as well as for laparoscopic approach. The hernia can be repaired either only by closing the defect with nonabsorbable suture or by applying mesh. The recurrence is very minimal with mesh application as compared to repair done only by suture. The mesh can be placed as onlay, inlay and in sublay positions. The intraperitoneal onlay mesh placement (IPOM) is the widely used laparoscopic method for the incisional hernia repair. The incisional hernia with larger defect usually more than 15 cm requires component separation to reconstruct the abdominal wall by releasing the external oblique or transverse abdominal muscle. The outcome of incisional hernia repair is dependent on the associated comorbid conditions like chronic cough, constipation, stricture of the urethra, benign prostate hyperplasia, ascites and obesity.

**Keywords:** incisional, hernia, mesh, laparotomy, component separation

It is documented that in the first century A.D., a Roman doctor named Aulus Cornelius described the closure of the abdominal wall and elaborated a detailed description of the pre- and postoperative care of the patient [1]. Later on, another famous Roman-Greek physician, Galen, provided a detailed description of the mass closure of the abdominal wall and described the significance of paramedian incision in order to prevent incisional hernia [2]. The advancement of technology like the advent of modern anesthesia and antiseptic and upgradation of skills in the field of surgery in the present era promotes laparotomy. On the other hand, along with increased number of laparotomy, the incidence of incisional hernia also increased consequently. Incisional hernia is a frequent long-term complication of abdominal surgeries with a reported incidence of 2–20% [3–8]. In the USA alone, approximately 348,000 incisional hernia repairs are performed per year with total estimated procedural costs of \$3.2 billion for ventral hernia repair [9–13]. Incisional hernia is more common than primary abdominal wall hernia, and both of these types are included in ventral hernia.

The abdominal wall consists of the skin, fascia (Camper's and Scarpa's fascia), muscles (external oblique, internal oblique, transverse abdominis), rectus sheath,

## **Chapter 4** Incisional Hernia

*Anil Kumar and Shiv Shankar Paswan*

### **Abstract**

Incisional hernia is one of the most common postoperative complications after abdominal surgery. Several studies have shown that incisional hernias have different etiologies which are related to the patient, the surgical technique, the suture material and experience of the surgeon. Most patients present with abdominal swelling with some level of discomfort, and in emergency the presentation is usually as bowel obstruction or strangulation which requires urgent exploration. The recurrence rate is almost the same for open as well as for laparoscopic approach. The hernia can be repaired either only by closing the defect with nonabsorbable suture or by applying mesh. The recurrence is very minimal with mesh application as compared to repair done only by suture. The mesh can be placed as onlay, inlay and in sublay positions. The intraperitoneal onlay mesh placement (IPOM) is the widely used laparoscopic method for the incisional hernia repair. The incisional hernia with larger defect usually more than 15 cm requires component separation to reconstruct the abdominal wall by releasing the external oblique or transverse abdominal muscle. The outcome of incisional hernia repair is dependent on the associated comorbid conditions like chronic cough, constipation, stricture of the urethra, benign prostate hyperplasia, ascites and obesity.

**Keywords:** incisional, hernia, mesh, laparotomy, component separation

#### **1. Introduction**

It is documented that in the first century A.D., a Roman doctor named Aulus Cornelius described the closure of the abdominal wall and elaborated a detailed description of the pre- and postoperative care of the patient [1]. Later on, another famous Roman-Greek physician, Galen, provided a detailed description of the mass closure of the abdominal wall and described the significance of paramedian incision in order to prevent incisional hernia [2]. The advancement of technology like the advent of modern anesthesia and antiseptic and upgradation of skills in the field of surgery in the present era promotes laparotomy. On the other hand, along with increased number of laparotomy, the incidence of incisional hernia also increased consequently. Incisional hernia is a frequent long-term complication of abdominal surgeries with a reported incidence of 2–20% [3–8]. In the USA alone, approximately 348,000 incisional hernia repairs are performed per year with total estimated procedural costs of \$3.2 billion for ventral hernia repair [9–13]. Incisional hernia is more common than primary abdominal wall hernia, and both of these types are included in ventral hernia.

#### **2. Surgical anatomy**

The abdominal wall consists of the skin, fascia (Camper's and Scarpa's fascia), muscles (external oblique, internal oblique, transverse abdominis), rectus sheath,

**38**

*Techniques and Innovation in Hernia Surgery*

[1] LeBlanc K, Allain Brent W. Jr. Laparoscopic Repair of Ventral Wall Abdominal Hernia - 3rd Edition: Prevention and Management [Online]. Available from: http://laparoscopy.blogs.com/ prevention\_management\_3/2010/10/ laparoscopic-repair-of-ventral-wallabdominal-hernia.html. [Accessed:

muscle release: The TAR procedure. In: Hernia Surgery. Cham: Springer International Publishing; 2016.

[9] Muysoms FE et al. Classification of primary and incisional abdominal

[10] Novitsky YW, editor. Hernia Surgery. Cham: Springer International

[11] De Keulenaer BL, De Waele JJ, Powell B, Malbrain MLNG. What is normal intra-abdominal pressure and how is it affected by positioning, body mass and positive end-expiratory pressure? Intensive Care Medicine. Jun.

[12] Radu VG, Lica M. The Endoscopic Retromuscular Repair of Ventral Hernia: The eTEP Technique and Early Results. Hernia. 2019. DOI: 10.1007/

wall hernias. Hernia. Aug. 2009;**13**(4):407-414

Publishing; 2016

2009;**35**(6):969-976

s10029-019-01931-x/

pp. 117-135

[2] Bittner R et al. Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS)-part 1). Surgical Endoscopy. Jan.

[3] Miserez M, Penninckx F. Endoscopic totally preperitoneal ventral hernia repair. Surgical Endoscopy. Aug.

Bittner R. Endoscopic mini/less open sublay technique (EMILOS)—A new technique for ventral hernia repair. Langenbeck's Archives of Surgery. Feb.

02 September 2017]

**References**

2014;**28**(1):2-29

2002;**16**(8):1207-1213

2017;**402**(1):173-180

2017;**32**:1531-1532

Apr. 2012;**26**(4):1187-1189

[4] Schwarz J, Reinpold W,

[5] Belyansky I, Zahiri HR, Park A. Laparoscopic transversus abdominis release, a novel minimally

invasive approach to complex

abdominal wall reconstruction. Surgical Innovation. Apr. 2016;**23**(2):134-141

[6] Belyansky I et al. A novel approach using the enhanced-view totally extraperitoneal (eTEP) technique for laparoscopic retromuscular hernia repair. Surgical Endoscopy. Sep,

[7] Daes J. The enhanced view-totally extraperitoneal technique for repair of inguinal hernia. Surgical Endoscopy.

[8] Novitsky YW. Posterior component separation via transversus abdominis

**Figure 1.** *Rectus sheath formation.*

aponeurosis, linea alba, ligaments, openings, rings, blood vessels and nerves. **Figure 1** showed the formation of rectus sheath at three different levels on the abdominal wall. Above the costal margins, only the external oblique muscle with its aponeurosis forms the rectus sheath. In between xiphisternum and umbilicus, the external oblique remains in front, but the internal oblique splits to enclose the rectus muscles. The transverse abdominis is behind the internal oblique (**Figure 1**). All these muscles fuse to form the linea alba in the midline. The rectus abdominis muscles run vertically on either side of the linea alba. This area between the xiphisternum and umbilicus is the strongest area as compared to above the costal margin or below the semilunar line. Below the semilunar line, all the three aponeurosis are anterior to the rectus muscle and fuse in the midline to form the linea alba. So posterior rectus sheath is absent below the semilunar line, and that is why incisional hernias are more common below the umbilicus. On the other hand, the linea alba is the strongest layer of abdominal wall and less likely to develop incisional hernia if it has repaired properly with good bites through the linea alba.

The umbilicus is usually situated in the midline at the level of the superior iliac spine or at the level between the third and fourth lumbar vertebrae. The umbilicus is a strong fibrous ring. Hernia through the umbilicus may occur in children, obese patient and in multiparous women due to childhood umbilical infection, weak muscles and stretching of muscles due to repeated pregnancies, respectively.

#### **3. Risk factors of incisional hernia**

The development of incisional hernia is multifactorial. It may be related to the patient, surgical technique and experience of the surgeon, type of disease for which the incision was given or biological factors. **Table 1** summarized the various risk factors for the development of incisional hernia.

#### **3.1 Patient-related factors**

The incisional hernias are more common in the elderly age group because of multifactorial reasons including weak abdominal muscles, occurrence of comorbidity

**41**

*Incisional Hernia*

Smoking

incision

**Patient-related factors:** Age more than 60 years

Obesity: (BMI >25 kg/m2

**Disease-related factors:** Emergency operations

Damaged control surgery in trauma

Collagen and metalloproteinase synthesis

Re-laparotomy Wound infection Long operating time Increased blood loss

**Biological factors:** Nutritional deficiencies

*Risk factors of incisional hernia.*

**Table 1.**

*DOI: http://dx.doi.org/10.5772/intechopen.88919*

) **Technical factors related to the surgical technique:**

Wound has not been approximated appropriately Low surgical skill to close the abdomen

Strength and length of suture used is not appropriate

Gender: female after cesarean section

Socioeconomic condition: low profile Occupation: lifting heavy weight

like DM, malignancies and poor immunity. A BMI > 24.5 kg/m2

important risk factor for the development of incisional hernia [14–21]. The patient with low socioeconomic profile is more prone to develop incisional hernia because of malnourishment and being bound to lift heavy weight. Comorbidities like diabetes mellitus, malignancies, chronic lung diseases, benign hypertrophy of the prostate, chronic constipation as well as heavy weight lifting are well-known risk factors for hernia development by increasing the intra-abdominal pressure and delaying the wound healing. The use of immunosuppressant and steroids in organ transplant and other chronic disease patients increases the rate of wound infection, wound dehiscence and incisional hernia [22–27]. Smoking increases the risk of the development of incisional hernia by decreasing the blood flow and tissue oxygenation as well as collagen deposition in the surgical wound, and all these increase the infection rate and synergistically the incisional hernia as well [28, 29]. Abstinence from smoking 30 days preoperatively reduces the adverse effects of smoking on wound healing significantly. This empha-

Comorbidities: diabetes mellitus, chronic cough, benign hypertrophy of the prostate, stricture of the urethra, chronic constipation, ascites, obstructive jaundice, chronic renal failure and certain connective tissue

Wrongly placed incision: lumbar incision, subcostal incision, lower midline incision and large transverse

Type of surgery: bowel surgery, abdominal aortic aneurism, stoma closure, operations for peritonitis

Open abdomen: in the case of severe septicaemia, chance of abdominal compartment syndrome

diseases (Marfan's syndrome, osteogenesis imperfecta and Ehlers-Danlos syndrome) Post-organ transplant patient on immunosuppressive agents/corticosteroids

sized the contributing role of smoking in causing incisional hernia [30, 31].

Despite advancements in techniques for abdominal wall closure, the incisional hernia rate following laparotomy is as high 15–20% [32]. Poor surgical technique may result in wound dehiscence and delay the wound healing. During closure of fascial edges, if it is not approximated properly, not using the suture with appropriate length and strength, then definitely in the postoperative period, there is a chance of wound dehiscence and development of incisional hernia especially if

**3.2 Technical factors related to the surgical technique**

is considered as an

#### **Table 1.**

*Techniques and Innovation in Hernia Surgery*

aponeurosis, linea alba, ligaments, openings, rings, blood vessels and nerves. **Figure 1** showed the formation of rectus sheath at three different levels on the abdominal wall. Above the costal margins, only the external oblique muscle with its aponeurosis forms the rectus sheath. In between xiphisternum and umbilicus, the external oblique remains in front, but the internal oblique splits to enclose the rectus muscles. The transverse abdominis is behind the internal oblique (**Figure 1**). All these muscles fuse to form the linea alba in the midline. The rectus abdominis muscles run vertically on either side of the linea alba. This area between the xiphisternum and umbilicus is the strongest area as compared to above the costal margin or below the semilunar line. Below the semilunar line, all the three aponeurosis are anterior to the rectus muscle and fuse in the midline to form the linea alba. So posterior rectus sheath is absent below the semilunar line, and that is why incisional hernias are more common below the umbilicus. On the other hand, the linea alba is the strongest layer of abdominal wall and less likely to develop incisional hernia if it

The umbilicus is usually situated in the midline at the level of the superior iliac spine or at the level between the third and fourth lumbar vertebrae. The umbilicus is a strong fibrous ring. Hernia through the umbilicus may occur in children, obese patient and in multiparous women due to childhood umbilical infection, weak muscles and stretching of muscles due to repeated pregnancies, respectively.

The development of incisional hernia is multifactorial. It may be related to the patient, surgical technique and experience of the surgeon, type of disease for which the incision was given or biological factors. **Table 1** summarized the various risk

The incisional hernias are more common in the elderly age group because of multifactorial reasons including weak abdominal muscles, occurrence of comorbidity

has repaired properly with good bites through the linea alba.

**3. Risk factors of incisional hernia**

**3.1 Patient-related factors**

factors for the development of incisional hernia.

**40**

**Figure 1.**

*Rectus sheath formation.*

*Risk factors of incisional hernia.*

like DM, malignancies and poor immunity. A BMI > 24.5 kg/m2 is considered as an important risk factor for the development of incisional hernia [14–21]. The patient with low socioeconomic profile is more prone to develop incisional hernia because of malnourishment and being bound to lift heavy weight. Comorbidities like diabetes mellitus, malignancies, chronic lung diseases, benign hypertrophy of the prostate, chronic constipation as well as heavy weight lifting are well-known risk factors for hernia development by increasing the intra-abdominal pressure and delaying the wound healing. The use of immunosuppressant and steroids in organ transplant and other chronic disease patients increases the rate of wound infection, wound dehiscence and incisional hernia [22–27]. Smoking increases the risk of the development of incisional hernia by decreasing the blood flow and tissue oxygenation as well as collagen deposition in the surgical wound, and all these increase the infection rate and synergistically the incisional hernia as well [28, 29]. Abstinence from smoking 30 days preoperatively reduces the adverse effects of smoking on wound healing significantly. This emphasized the contributing role of smoking in causing incisional hernia [30, 31].

#### **3.2 Technical factors related to the surgical technique**

Despite advancements in techniques for abdominal wall closure, the incisional hernia rate following laparotomy is as high 15–20% [32]. Poor surgical technique may result in wound dehiscence and delay the wound healing. During closure of fascial edges, if it is not approximated properly, not using the suture with appropriate length and strength, then definitely in the postoperative period, there is a chance of wound dehiscence and development of incisional hernia especially if

other predisposing factors are also present [33–35]. The preferably paramedian, oblique and transverse incisions are better than midline, large transverse, subcostal and lumbar incisions to prevent the occurrence of incisional hernia [36–39].

#### **3.3 Disease-related factors**

Wound infection and wound dehiscence are the major risk factors for the development of incisional hernia [18, 29, 35–37, 40–45]. Cases operated for infected intra-abdominal conditions like perforation peritonitis, gangrene of the intestine, severe necrotizing pancreatitis, etc. usually develop incisional hernia. The incidence of infection is less in a diabetic patient if their perioperative glycaemic control is adequate [46]. Furthermore, chance of infection in diabetic patient is higher than nondiabetic patient even after controlling for hyperglycaemia [47]. Re-laparotomy is a strong risk factor for IH [29]. Incidence of incisional hernias in open abdomen for severe septicaemia or for damaged control surgery ranged from 21% at 21 months to 54% after 5 years of follow-up [48–50]. Burst abdomen and open abdomen after the damage control surgery are the most important factors for the occurrence of incisional hernia. In the case of long operative time and where blood loss is more, the chance of IH development is also more. Incisional hernia has been also reported after traumatic abdominal injury [51]. Emergency surgeries are also associated with a higher incidence of incisional hernia development.

#### **3.4 Biological factors**

Apart from obesity, malnourishment is also the contributing factor for the development of incisional hernia by causing delayed wound healing and wound dehiscence [52–54]. Defective collagen metabolism with reduced ratio of collagen I-collagen III as well as a reduced ratio of matrix metalloproteinase 1 (MMP1)-MMP2 plays an important role in the development of IH [55]. Micronutrients like copper and zinc are required for the synthesis of the enzyme lysyl oxidase, and this enzyme is very important for the integrity of collagen molecule. So deficiency of these elements may cause the incisional hernia to occur. The plasminogen activator inhibitor, urokinase plasminogen activator inhibitor, in the scar tissue may contribute in the development of IH [56–58].

#### **4. Classification**

Various classifications for ventral hernia are available in literature, but unfortunately none of them have been widely accepted. Various classification systems are proposed by Chevrel and Rath, Korenkov et al., Schumpelick et al., Dietz et al., Ammaturo and Bassi and Miserez et al. [59–64]. They all have used variables like size and number of hernia defects, size of hernia sac and its ratio with anterior abdominal wall, primary or incisional hernia, recurrent hernia, location of hernia, and other symptoms and risk factors, in various combinations. To make it standardized, European Hernia Society (EHS) has divided the abdominal wall hernia as "Primary abdominal wall hernia" which is also called as ventral hernia and other "Incisional hernia" rather than either term. Recurrent hernia after treatment for primary abdominal wall hernia would fall in the group of incisional hernia. According to this system, classification of incisional hernias uses localisation and size of hernia as the two variables, as shown in **Table 2**. To avoid confusion with primary abdominal wall hernias (small, medium and large), a coded taxonomy was chosen (W1 < 4 cm; W2 ≥ 4–10 cm; W3 ≥ 10 cm) instead of a nominative one, and yes or no is used for the recurrent incisional hernia in EHS **Table 2**.

**43**

*Incisional Hernia*

*DOI: http://dx.doi.org/10.5772/intechopen.88919*

**Midline** Subxiphoidal M1

**Lateral** Subcostal L1

Epigastric M2 Umbilical M3 Infraumbilical M4 Suprapubic M 5

Flank L2 Iliac L3 Lumbar L4 **Recurrent Incisional Hernia? Yes No**

**Width** W1 < 4 cm W2 ≥

**Length** Cm **Width** Cm

**cm** 0 0 0

4–10 cm

W3 ≥ 10 cm

**EHS Incisional hernia classification**

Here the abdomen was divided into a midline zone and a lateral zone.

Thus, all incisional hernias between the lateral margins of both rectus muscle sheaths are classified as midline hernias. A simple and easily memorable classification from M1 to M5 going from the xiphoid to the pubic bone is summarized in

2.M2: epigastric (from 3 cm below the xiphoid till 3 cm above the umbilicus)

4.M4: infraumbilical (from 3 cm below the umbilicus till 3 cm above the pubis)

Lateral hernias: The borders of the lateral area are defined as in **Figure 2b**:

The borders of the midline area are defined as follows:

3.Lateral: the lateral margin of the rectal sheath

**Figure 2a**. Therefore, we define 5 M zones as follows:

1.M1: subxiphoidal (from the xiphoid till 3 cm caudally)

3.M3: umbilical (from 3 cm above till 3 cm below the umbilicus)

5.M5: suprapubic (from the pubic bone till 3 cm cranially).

3.Medially: the lateral margin of the rectal sheath

1.Cranial: the xiphoid

**Table 2.**

2.Caudal: the pubic bone

*Showing EHS classification of incisional hernia.*

1.Cranial: the costal margin

2.Caudal: the inguinal region


#### *Incisional Hernia DOI: http://dx.doi.org/10.5772/intechopen.88919*

**Table 2.**

*Techniques and Innovation in Hernia Surgery*

**3.3 Disease-related factors**

**3.4 Biological factors**

**4. Classification**

other predisposing factors are also present [33–35]. The preferably paramedian, oblique and transverse incisions are better than midline, large transverse, subcostal

Wound infection and wound dehiscence are the major risk factors for the development of incisional hernia [18, 29, 35–37, 40–45]. Cases operated for infected intra-abdominal conditions like perforation peritonitis, gangrene of the intestine, severe necrotizing pancreatitis, etc. usually develop incisional hernia. The incidence of infection is less in a diabetic patient if their perioperative glycaemic control is adequate [46]. Furthermore, chance of infection in diabetic patient is higher than nondiabetic patient even after controlling for hyperglycaemia [47]. Re-laparotomy is a strong risk factor for IH [29]. Incidence of incisional hernias in open abdomen for severe septicaemia or for damaged control surgery ranged from 21% at 21 months to 54% after 5 years of follow-up [48–50]. Burst abdomen and open abdomen after the damage control surgery are the most important factors for the occurrence of incisional hernia. In the case of long operative time and where blood loss is more, the chance of IH development is also more. Incisional hernia has been also reported after traumatic abdominal injury [51]. Emergency surgeries are also

associated with a higher incidence of incisional hernia development.

inhibitor, in the scar tissue may contribute in the development of IH [56–58].

yes or no is used for the recurrent incisional hernia in EHS **Table 2**.

Various classifications for ventral hernia are available in literature, but unfortunately none of them have been widely accepted. Various classification systems are proposed by Chevrel and Rath, Korenkov et al., Schumpelick et al., Dietz et al., Ammaturo and Bassi and Miserez et al. [59–64]. They all have used variables like size and number of hernia defects, size of hernia sac and its ratio with anterior abdominal wall, primary or incisional hernia, recurrent hernia, location of hernia, and other symptoms and risk factors, in various combinations. To make it standardized, European Hernia Society (EHS) has divided the abdominal wall hernia as "Primary abdominal wall hernia" which is also called as ventral hernia and other "Incisional hernia" rather than either term. Recurrent hernia after treatment for primary abdominal wall hernia would fall in the group of incisional hernia. According to this system, classification of incisional hernias uses localisation and size of hernia as the two variables, as shown in **Table 2**. To avoid confusion with primary abdominal wall hernias (small, medium and large), a coded taxonomy was chosen (W1 < 4 cm; W2 ≥ 4–10 cm; W3 ≥ 10 cm) instead of a nominative one, and

Apart from obesity, malnourishment is also the contributing factor for the development of incisional hernia by causing delayed wound healing and wound dehiscence [52–54]. Defective collagen metabolism with reduced ratio of collagen I-collagen III as well as a reduced ratio of matrix metalloproteinase 1 (MMP1)-MMP2 plays an important role in the development of IH [55]. Micronutrients like copper and zinc are required for the synthesis of the enzyme lysyl oxidase, and this enzyme is very important for the integrity of collagen molecule. So deficiency of these elements may cause the incisional hernia to occur. The plasminogen activator inhibitor, urokinase plasminogen activator

and lumbar incisions to prevent the occurrence of incisional hernia [36–39].

**42**

*Showing EHS classification of incisional hernia.*

Here the abdomen was divided into a midline zone and a lateral zone. The borders of the midline area are defined as follows:


Thus, all incisional hernias between the lateral margins of both rectus muscle sheaths are classified as midline hernias. A simple and easily memorable classification from M1 to M5 going from the xiphoid to the pubic bone is summarized in **Figure 2a**. Therefore, we define 5 M zones as follows:

1.M1: subxiphoidal (from the xiphoid till 3 cm caudally)

2.M2: epigastric (from 3 cm below the xiphoid till 3 cm above the umbilicus)


5.M5: suprapubic (from the pubic bone till 3 cm cranially).

Lateral hernias: The borders of the lateral area are defined as in **Figure 2b**:


#### **Figure 2.**

*(a) 5M zone of incisional hernia. (b) 4L zone of incisional hernia.*

4.Laterally: the lumbar region

Thus, 4L zones on each side are defined as follows:


#### **5. Clinical features**


**45**

*Incisional Hernia*

**Figure 3.**

**Figure 4.**

*Complex Hernia with visible bulge.*

*DOI: http://dx.doi.org/10.5772/intechopen.88919*

• The scar is thin and evidence of secondary changes like ulceration or skin color

• Intraoperatively during creation of pneumoperitoneum, the bulge/swelling

• After reduction of the contents, a defect can be palpated through the scar. Defect depends upon the number of stiches that have given away.

• Expansile impulse on cough and reducibility may be present.

through the scar becomes more obvious (**Figure 6**).

changes may be present (**Figure 5**).

*Burst abdomen prone to develop incisional hernia.*

• There is bulge or swelling around the scar (**Figure 4**).

*Techniques and Innovation in Hernia Surgery*

4.Laterally: the lumbar region

umbilicus)

**Figure 2.**

umbilicus)

**5. Clinical features**

(**Figure 3**).

• History of surgery in the past.

tion, etc. is usually present.

region)

Thus, 4L zones on each side are defined as follows:

*(a) 5M zone of incisional hernia. (b) 4L zone of incisional hernia.*

4.L4: lumbar (latero-dorsal of the anterior axillary line)

Such cases later develop an incisional hernia.

• There is bulge or swelling around the scar (**Figure 4**).

1.L1: subcostal (between the costal margin and a horizontal line 3 cm above the

3.L3: iliac (between a horizontal line 3 cm below the umbilicus and the inguinal

• History of infection during the first surgery, postoperative cough, constipa-

• Serosanguinous discharge on the fourth postoperative day through the main suture line is a signal of the development of partial or total wound dehiscence.

• Burst abdomen and open abdomen are more likely to develop incisional hernia

2.L2: flank (lateral to the rectal sheath in the area 3 cm above and below the

**44**

**Figure 3.** *Burst abdomen prone to develop incisional hernia.*

**Figure 4.** *Complex Hernia with visible bulge.*


**Figure 5.** *Lower abdominal wall hernia hanging up to the scrotum with secondary changes.*

**Figure 6.** *Prominent hernial defect after pneumoperitoneum.*


#### **5.1 Abdominal palpation**

In most of the cases, hernial content can be palpated. In few cases even the edges of hernial defect can be appreciated, and the size can be measured. Except in obstructed and strangulated hernia, impulse on coughing and reducibility are present.

**47**

*Incisional Hernia*

**5.2 Percussion**

liquid or gas.

**5.3 Auscultation**

**6. Evaluation**

**7. Management**

obesity (BMI ≥ 50 kg/m2

**7.1 Preoperative management**

).

required to bring the BMI < 30–40 Kg/m<sup>2</sup>

**7.2 Indication of surgery in incisional hernia**

1.To get the relief from symptoms

3.To improve the quality of life

strangulation

*DOI: http://dx.doi.org/10.5772/intechopen.88919*

and confirm the content of sac as bowel loop.

Percussion guides us to assess whether the content of the hernia sac is solid,

If the content of the sac is bowel loop, a peristaltic bowel sound may be heard

Although most cases of an incisional hernia are diagnosed with a history and physical examination, imaging is sometimes indicated in early stages, obese patients, or complex cases especially to outline the extent of defect and plan the surgical procedure. The first imaging modality in case of incisional hernia is ultrasonography, but the computed tomography scan (CT) is the most commonly used method for the diagnosis as well as for planning of operative management especially for complex cases [65, 66]. CT scan evaluates the incisional hernia by confirming its diagnosis, sizing the defect, identifying the hernia content and assessing the abdominal cavity to plan the surgical treatment. Magnetic resonance imaging (MRI) can also be used to assess abdominal wall hernias but are less commonly used for academic purpose only.

The management of incisional hernia includes nonoperative and operative management. Nonoperative management is indicated in patients who are not fit for surgery, those who require preoperative optimization or those who have highly complex hernia like loss of abdominal wall domain, patient with diagnosis of metastatic cancer, advanced cirrhosis, severe cardiopulmonary disease and super

1.Weight reduction is very important before operating for incisional hernia. It is

2.Control of COPD, definitive treatment of benign prostatic hyperplasia, stricture of the urethra and all other conditions who may increase the intra-abdom-

2.Prevention of complication like pain, incarceration, bowel obstruction and

inal pressure in postoperative period in view to avoid the recurrence.

3.Cessation of smoking is very helpful for good outcome.

.

#### **5.2 Percussion**

*Techniques and Innovation in Hernia Surgery*

• In case of obstructed or impacted content in the defect, the patient may

• In most people, hernias limit patients' physical activities either due to the

In most of the cases, hernial content can be palpated. In few cases even the edges of hernial defect can be appreciated, and the size can be measured. Except in obstructed and strangulated hernia, impulse on coughing and reducibility are

associated symptoms or as a precaution to avoid worsening.

*Lower abdominal wall hernia hanging up to the scrotum with secondary changes.*

• Features of bowel obstruction or strangulation may be found in complicated cases.

complain of pain in that area.

*Prominent hernial defect after pneumoperitoneum.*

**5.1 Abdominal palpation**

**46**

present.

**Figure 6.**

**Figure 5.**

Percussion guides us to assess whether the content of the hernia sac is solid, liquid or gas.

#### **5.3 Auscultation**

If the content of the sac is bowel loop, a peristaltic bowel sound may be heard and confirm the content of sac as bowel loop.

## **6. Evaluation**

Although most cases of an incisional hernia are diagnosed with a history and physical examination, imaging is sometimes indicated in early stages, obese patients, or complex cases especially to outline the extent of defect and plan the surgical procedure. The first imaging modality in case of incisional hernia is ultrasonography, but the computed tomography scan (CT) is the most commonly used method for the diagnosis as well as for planning of operative management especially for complex cases [65, 66]. CT scan evaluates the incisional hernia by confirming its diagnosis, sizing the defect, identifying the hernia content and assessing the abdominal cavity to plan the surgical treatment. Magnetic resonance imaging (MRI) can also be used to assess abdominal wall hernias but are less commonly used for academic purpose only.

#### **7. Management**

The management of incisional hernia includes nonoperative and operative management. Nonoperative management is indicated in patients who are not fit for surgery, those who require preoperative optimization or those who have highly complex hernia like loss of abdominal wall domain, patient with diagnosis of metastatic cancer, advanced cirrhosis, severe cardiopulmonary disease and super obesity (BMI ≥ 50 kg/m2 ).

#### **7.1 Preoperative management**


#### **7.2 Indication of surgery in incisional hernia**


There are various operations for the treatment of incisional hernia depending upon the size of the defect, location of the hernia, patient choice as per their economical conditions as laparoscopic repair may be costly and surgeon expertise. **Table 3** summarized the different surgical options for incisional hernia.

#### **7.3 Open hernia repair**

Although minimal invasive surgery is widely acceptable and treatment of choice in present era, but open surgery still plays a very important role in incisional hernia repair especially in conditions contraindicated for laparoscopic surgery like very large, non-reducible hernia and strangulated hernia. Besides these contraindicated cases, for small umbilical hernias, open repair is preferred choice. Open repair can be done either by suture repair or by applying mesh. Recurrence rate after suture repair is 42% and after mesh repair only 24%. Ideally if the defect size is more than 4 cm, mesh placement should be the preferred approach, but even for the smaller defect which is less than 2 cm in size, the recurrence rate is 5.6% with suture method as compared to mesh where only 2.2% recurrence rate occurs. Three main positions of the mesh placement for incisional hernia are onlay, inlay and sublay positions (**Figure 3**).

Onlay mesh is placed over the anterior fascia and under the subcutaneous tissue. Inlay mesh is placed to the margin of the aponeurosis. In this case the mesh acts as bridge between the two fascial edges. Sublay mesh is placed retro muscularly and preperitoneally. The sublay mesh placement has been reported to be the best regarding recurrence and skin and soft tissue infection but is associated with higher risk of chronic pain. The main principle to place the mesh is that the mesh should be overlapped at least 5 cm all around the defect. Otherwise, the plane is created between the posterior rectus sheath and rectus muscle, and the mesh is placed in that location, and the anterior rectus sheath is sutured. This is called retro muscular sublay mesh repair. Before placing the mesh, the sac is opened, the greater omentum is excised, and the content is reduced followed by closure of the peritoneum. A mesh is kept in place. In all these repairs, tensionless, nonabsorbable suture repairs are done. Seroma formation is a common complication in open mesh repair which can be overcome by placing drain before closing the wound.

**49**

**Table 4.**

*Incisional Hernia*

*DOI: http://dx.doi.org/10.5772/intechopen.88919*

**7.4 Laparoscopic incisional hernia repair**

laparoscopic and open hernia repair.

pneumoperitoneum is created.

overlap, thereby preventing recurrence.

8.Fixation of mesh is usually done by tacker or suture.

postoperative shrinkage of mesh.

true size of the hernia defect.

The larger defect is usually more than of 10–15 cm

*Contraindications of laparoscopic incisional hernia repair.*

Prior multiple open surgeries Ascites with child class C cirrhosis Inability to create a working space

abdominal surgeries.

cavity.

**7.5 Contraindications of laparoscopic incisional hernia repair**

for other laparoscopic surgeries which are summarized in **Table 4**.

**7.6 Operative steps of laparoscopic incisional hernia repair**

First time in 1993, LeBlanc and Booth introduced the laparoscopic method for incisional hernia repair [67], and since then various studies and approach have been published in literature [68]. Laparoscopic repair of incisional hernia is a very safe procedure and having all the advantages of minimal access surgery like earlier recovery, decreased hospital stay and less wound infections. It has been reported to have a low conversion rate of 2.4%, an enterotomy rate of 1.8% and recurrence rate of 4.2%; however recent randomized trials have shown a similar recurrence in

Contraindications to laparoscopic incisional hernia repair are almost the same as

1.Complete all the preanaesthetic checkup and preoperative order like Nil per orally 12 hours prior to surgery and securing IV line for fluid administration,

2.Take the patient on the table in supine position, and after general anesthesia,

3.Three working ports are placed as far as possible from the scar of the previous

4.Start the adhesiolysis if indicated and repose the sac content into the peritoneal

5.Primary fascial closure may be done to restore the normal anatomy. The technique for this primary fascial closure may be intracorporeal closure, extracorporeal closure or with the help of suture passing needle. This step prevents the postoperative bulge and seroma formation. It also allows wider lateral mesh

6.Overlap of mesh should be ideally 5 cm in all directions because of significant

7.Before fixing the mesh, the intra-abdominal pressure should reduce to 5–8 mmHg, so that the abdominal wall is minimally stretched revealing the

antibiotic test dose and shifting the patient to the operation room.

**Open hernia repair** Suture repair Mesh repair **Laparoscopic incisional hernia repair** Primary fascial closure Different mesh fixation techniques **Abdominal wall reconstruction technique** Bridge repair Anterior component separation (ACS) Perforator-sparing ACS Endoscopic ACS Posterior component separation **Preoperative tissue expansion** Tissue expanders Progressive pneumoperitoneum **Flap and tissue transfer**

#### **Table 3.** *Surgical options for incisional hernia repair.*

*Techniques and Innovation in Hernia Surgery*

hernia.

(**Figure 3**).

closing the wound.

**Open hernia repair** Suture repair Mesh repair

Primary fascial closure

Perforator-sparing ACS Endoscopic ACS

Tissue expanders

Bridge repair

**Laparoscopic incisional hernia repair**

Anterior component separation (ACS)

Posterior component separation **Preoperative tissue expansion**

Progressive pneumoperitoneum **Flap and tissue transfer**

*Surgical options for incisional hernia repair.*

Different mesh fixation techniques **Abdominal wall reconstruction technique**

**7.3 Open hernia repair**

There are various operations for the treatment of incisional hernia depending upon the size of the defect, location of the hernia, patient choice as per their economical conditions as laparoscopic repair may be costly and surgeon expertise. **Table 3** summarized the different surgical options for incisional

Although minimal invasive surgery is widely acceptable and treatment of choice in present era, but open surgery still plays a very important role in incisional hernia repair especially in conditions contraindicated for laparoscopic surgery like very large, non-reducible hernia and strangulated hernia. Besides these contraindicated cases, for small umbilical hernias, open repair is preferred choice. Open repair can be done either by suture repair or by applying mesh. Recurrence rate after suture repair is 42% and after mesh repair only 24%. Ideally if the defect size is more than 4 cm, mesh placement should be the preferred approach, but even for the smaller defect which is less than 2 cm in size, the recurrence rate is 5.6% with suture method as compared to mesh where only 2.2% recurrence rate occurs. Three main positions of the mesh placement for incisional hernia are onlay, inlay and sublay positions

Onlay mesh is placed over the anterior fascia and under the subcutaneous tissue. Inlay mesh is placed to the margin of the aponeurosis. In this case the mesh acts as bridge between the two fascial edges. Sublay mesh is placed retro muscularly and preperitoneally. The sublay mesh placement has been reported to be the best regarding recurrence and skin and soft tissue infection but is associated with higher risk of chronic pain. The main principle to place the mesh is that the mesh should be overlapped at least 5 cm all around the defect. Otherwise, the plane is created between the posterior rectus sheath and rectus muscle, and the mesh is placed in that location, and the anterior rectus sheath is sutured. This is called retro muscular sublay mesh repair. Before placing the mesh, the sac is opened, the greater omentum is excised, and the content is reduced followed by closure of the peritoneum. A mesh is kept in place. In all these repairs, tensionless, nonabsorbable suture repairs are done. Seroma formation is a common complication in open mesh repair which can be overcome by placing drain before

**48**

**Table 3.**

#### **7.4 Laparoscopic incisional hernia repair**

First time in 1993, LeBlanc and Booth introduced the laparoscopic method for incisional hernia repair [67], and since then various studies and approach have been published in literature [68]. Laparoscopic repair of incisional hernia is a very safe procedure and having all the advantages of minimal access surgery like earlier recovery, decreased hospital stay and less wound infections. It has been reported to have a low conversion rate of 2.4%, an enterotomy rate of 1.8% and recurrence rate of 4.2%; however recent randomized trials have shown a similar recurrence in laparoscopic and open hernia repair.

#### **7.5 Contraindications of laparoscopic incisional hernia repair**

Contraindications to laparoscopic incisional hernia repair are almost the same as for other laparoscopic surgeries which are summarized in **Table 4**.

#### **7.6 Operative steps of laparoscopic incisional hernia repair**


#### **Table 4.** *Contraindications of laparoscopic incisional hernia repair.*

The larger defect is usually more than of 10–15 cm Prior multiple open surgeries Ascites with child class C cirrhosis Inability to create a working space

#### **8. Abdominal wall reconstruction**

The open and the laparoscopic techniques are used for small- and medium-sized defects but are not sufficient for very large defects which are too large to allow the fascial to be approximated. In such large size defect, a novel method of abdominal component separation was being developed. According to the EHS, large ventral hernia is defined as a hernia with defect greater than 10 cm and loss of domain defined by more than 50% of visceral contents lying chronically beyond the bounds of the abdomen. In such defect repair by open or laparoscopic method is usually not possible and component separation is required which was first introduced by Ramirez and colleagues in 1990 [69]. Component separation may be anterior, posterior, perforator-sparing ACS or endoscopic ACS.

#### **8.1 Component separation**

The component separation technique was first described by Ramirez in 1990. It is very effective for reconstructing large or complex midline abdominal wall defects, and it has the advantage of restoring the innervated dynamic abdominal wall integrity without producing undue tension on the repair. It is a myofascial release that separates the components of the abdominal wall allowing their mobilization into adjacent tissue defects. Classic CST involves releasing the rectus muscle from its posterior sheath and releasing the aponeurosis of the external oblique muscle along the lateral side of the rectus, allowing the rectus muscle to slide towards the midline with its attached internal oblique and anterior rectus fascia. In fact this is called anterior component separation. Fascial defects up to 10 cm wide at the upper abdomen, 20 cm at the waistline and 6 cm at the suprapubic region may be closed using this method.

#### *8.1.1 Steps of anterior component separation*


**51**

**9. Preoperative tissue expansion**

*Incisional Hernia*

*8.2.1 Steps of PCS*

*8.1.2 Complications of ACS*

component separation techniques.

**8.2 Posterior component separation**

creation of huge space for the mesh placement.

*DOI: http://dx.doi.org/10.5772/intechopen.88919*

The surgical site infection (SSI), site dehiscence, seroma, hematoma, site necrosis and recurrences have been reported to be highest with ACS compared to other

In order to gain further mobility of the rectus sheath, Crbonell et al. introduced the concept of posterior component separation (PCS) which involved extending the retro muscular plane laterally between the internal oblique and transverse abdominis. Further modification of the technique was done by Novinsky et al. with the release of transverse abdominis muscle and entry into the retro rectus space, and dissection is carried till lateral of psoas muscle, avoiding skin flap necrosis. A mesh is placed in sublay position after closing the posterior rectus sheath in the midline. PCS is the CS procedure of choice to obtain medial fascial advancement and the

An incision is made in the posterior rectus sheath within 0.5 cm of its medial border. This incision is extended superiorly and inferiorly along the entire length of the rectus muscle. Dissection is continued medial to lateral as blunt or sharp preventing injury to the epigastric vessels as it lies within the muscles. The lateral limit of this dissection in PCS is the linea semilunaris up to the lateral border of the rectus muscle, the area of fusion of the anterior and posterior rectus sheaths. It is important to identify and preserve intercostal neurovascular structures entering the posterior aspect of the rectus muscle. Superiorly, this plane extends to the retroxiphoid/ retrosternal space and inferiorly into the space of Retzius. In many circumstances, dissection in the retrorectus space up to the linea semilunaris is insufficient to permit adequate abdominal wall reconstruction, and there is also insufficient retrorectus space to permit adequate prosthetic reinforcement for hernia. In order to extend the retrorectus dissection lateral to the linea semilunaris, intramuscular dissection is possible by diving the internal oblique muscle; further dissection is performed within the preperitoneal plane or with transverse abdominis release (TAR). Incision is made approximately 0.5 cm medial to the linea semilunaris in the posterior sheath to expose the transverse muscle. It is easy in the upper half of the abdomen where the muscle belly is well developed. With electrocautery, transection of the transverse abdominis muscle is done to prevent injury to the transversalis fascia or peritoneum. This plane may extend superiorly beyond the costal margin to the diaphragm, inferiorly to the myopectineal orifice and laterally to the psoas muscle. Similarly, TAR is completed on the contralateral side. This is followed by reconstruction of the posterior layer with re-approximation of the posterior rectus sheath in midline using running suture. A large mesh is used to cover the space created at the retro muscular space up to the lateral border of dissection. The anterior rectus sheath is approximated in the midline.

In situations where fascial closure cannot be achieved even after CS, several other options have been described, each with its own advantages and disadvantages.

#### *Incisional Hernia DOI: http://dx.doi.org/10.5772/intechopen.88919*

#### *8.1.2 Complications of ACS*

*Techniques and Innovation in Hernia Surgery*

**8. Abdominal wall reconstruction**

rior, perforator-sparing ACS or endoscopic ACS.

**8.1 Component separation**

be closed using this method.

skin grafting.

*8.1.1 Steps of anterior component separation*

to the mid to posterior axillary line.

The open and the laparoscopic techniques are used for small- and medium-sized defects but are not sufficient for very large defects which are too large to allow the fascial to be approximated. In such large size defect, a novel method of abdominal component separation was being developed. According to the EHS, large ventral hernia is defined as a hernia with defect greater than 10 cm and loss of domain defined by more than 50% of visceral contents lying chronically beyond the bounds of the abdomen. In such defect repair by open or laparoscopic method is usually not possible and component separation is required which was first introduced by Ramirez and colleagues in 1990 [69]. Component separation may be anterior, poste-

The component separation technique was first described by Ramirez in 1990. It is very effective for reconstructing large or complex midline abdominal wall defects, and it has the advantage of restoring the innervated dynamic abdominal wall integrity without producing undue tension on the repair. It is a myofascial release that separates the components of the abdominal wall allowing their mobilization into adjacent tissue defects. Classic CST involves releasing the rectus muscle from its posterior sheath and releasing the aponeurosis of the external oblique muscle along the lateral side of the rectus, allowing the rectus muscle to slide towards the midline with its attached internal oblique and anterior rectus fascia. In fact this is called anterior component separation. Fascial defects up to 10 cm wide at the upper abdomen, 20 cm at the waistline and 6 cm at the suprapubic region may

1.Through a laparotomy incision, the posterior rectus sheath is cleared bilaterally of any attachments to the viscera through careful lysis of adhesions.

2.The rectus muscle is loosely attached to its posterior sheath and can be freed from the posterior sheath at this point, as Ramirez did. Freeing the rectus muscle from its posterior sheath allows advancement of this muscle by 3 cm in

the upper third, 5 cm in the middle third and 3 cm in the lower third.

3.Separate the skin and subcutaneous tissues from the anterior rectus sheath using electrocautery. Develop this plane until about 2 cm beyond the lateral edge of the rectus sheath. Further lateral dissection in patients with limited subcutaneous tissue may place the resulting skin flaps at risk for ischemia and failure resulting in a large soft tissue defect that will require split-thickness

4.Carefully incise the external oblique aponeurosis 2 cm lateral to the lateral edge of the rectus sheath. Extend this incision parallel to the rectus muscle, superiorly advancing at least 5–7 cm above the costal margin and inferiorly down to the suprapubic region. The plane between the external and internal oblique aponeuroses is relatively avascular and should be bluntly dissected free down

**50**

The surgical site infection (SSI), site dehiscence, seroma, hematoma, site necrosis and recurrences have been reported to be highest with ACS compared to other component separation techniques.

#### **8.2 Posterior component separation**

In order to gain further mobility of the rectus sheath, Crbonell et al. introduced the concept of posterior component separation (PCS) which involved extending the retro muscular plane laterally between the internal oblique and transverse abdominis. Further modification of the technique was done by Novinsky et al. with the release of transverse abdominis muscle and entry into the retro rectus space, and dissection is carried till lateral of psoas muscle, avoiding skin flap necrosis. A mesh is placed in sublay position after closing the posterior rectus sheath in the midline. PCS is the CS procedure of choice to obtain medial fascial advancement and the creation of huge space for the mesh placement.

#### *8.2.1 Steps of PCS*

An incision is made in the posterior rectus sheath within 0.5 cm of its medial border. This incision is extended superiorly and inferiorly along the entire length of the rectus muscle. Dissection is continued medial to lateral as blunt or sharp preventing injury to the epigastric vessels as it lies within the muscles. The lateral limit of this dissection in PCS is the linea semilunaris up to the lateral border of the rectus muscle, the area of fusion of the anterior and posterior rectus sheaths. It is important to identify and preserve intercostal neurovascular structures entering the posterior aspect of the rectus muscle. Superiorly, this plane extends to the retroxiphoid/ retrosternal space and inferiorly into the space of Retzius. In many circumstances, dissection in the retrorectus space up to the linea semilunaris is insufficient to permit adequate abdominal wall reconstruction, and there is also insufficient retrorectus space to permit adequate prosthetic reinforcement for hernia. In order to extend the retrorectus dissection lateral to the linea semilunaris, intramuscular dissection is possible by diving the internal oblique muscle; further dissection is performed within the preperitoneal plane or with transverse abdominis release (TAR). Incision is made approximately 0.5 cm medial to the linea semilunaris in the posterior sheath to expose the transverse muscle. It is easy in the upper half of the abdomen where the muscle belly is well developed. With electrocautery, transection of the transverse abdominis muscle is done to prevent injury to the transversalis fascia or peritoneum. This plane may extend superiorly beyond the costal margin to the diaphragm, inferiorly to the myopectineal orifice and laterally to the psoas muscle. Similarly, TAR is completed on the contralateral side. This is followed by reconstruction of the posterior layer with re-approximation of the posterior rectus sheath in midline using running suture. A large mesh is used to cover the space created at the retro muscular space up to the lateral border of dissection. The anterior rectus sheath is approximated in the midline.

#### **9. Preoperative tissue expansion**

In situations where fascial closure cannot be achieved even after CS, several other options have been described, each with its own advantages and disadvantages. Hybrid Operation have been described where fascia is partially closed & reminder is bridge with an absorbable mesh in underlay or sublay position. Addition of vacuum-assisted closure to reduce the SSO and SSI in hybrid procedures has also been described. An alternative to these procedures is preoperative tissue expansion or flap and tissue transfer.

#### **10. Tissue expanders**

Tissue expanders are used to provide soft tissue coverage and restore abdominal domain by increasing both the size and the vascularity of the donor tissue by producing a strong, vascularized capsule around the expanders. Various sites of placing tissue expanders have been described like in the subcutaneous space, abdominal wall intramuscular spaces (between the internal oblique and transverse abdominis muscles), intermuscular sites (between the external and internal oblique muscles) and finally intra-abdominally. The expanders can be insufflated over various weeks depending on patient tolerance. Before starting filling of the expander, a period of wound healing is usually awaited for 3 weeks to prevent expander exclusion. Expanded skin retracts after removal of expanders, hence overexpansion is necessary. Complications like expulsion, exposure or infection of implants can occur in about 15% cases.

#### **11. Progressive pneumoperitoneum**

Reduction of contents of giant hernias may result in abdominal compartment syndrome. Progressive pneumoperitoneum technique is used to stretch the abdominal wall muscles before repair. Progressive pneumoperitoneum (PPP) increases the capacity of the retracted abdominal cavity, performs a pneumatic lysis of intestinal adhesions, allows the reduction of the hernia contents and improves diaphragmatic function. Air, CO2 or NO is insufflated over a period of a few weeks every couple of days to about a total of 15–20 L depending on patient tolerability monitored by the development of scapular pain, dyspnoea or subcutaneous emphysema. Once tissue expansion is obtained, hernia repair is attempted.

#### **12. Flap and tissue transfer**

An alternative to tissue expansion is the use of plastic surgery procedures of flap and tissue transfer like latissimus dorsi, tensor fascia lata or rectus femoris flaps, but they are more complex and result in donor site defects and functional limitations.

**53**

**Author details**

\* and Shiv Shankar Paswan<sup>2</sup>

1 All India Institute of Medical Sciences, Patna, India

\*Address all correspondence to: dranil4@gmail.com

provided the original work is properly cited.

2 All India Institute of Medical Sciences, Bhubaneswar, India

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Anil Kumar1

*Incisional Hernia*

*DOI: http://dx.doi.org/10.5772/intechopen.88919*

*Incisional Hernia DOI: http://dx.doi.org/10.5772/intechopen.88919*

*Techniques and Innovation in Hernia Surgery*

or flap and tissue transfer.

**10. Tissue expanders**

about 15% cases.

**11. Progressive pneumoperitoneum**

expansion is obtained, hernia repair is attempted.

**12. Flap and tissue transfer**

Hybrid Operation have been described where fascia is partially closed & reminder is bridge with an absorbable mesh in underlay or sublay position. Addition of vacuum-assisted closure to reduce the SSO and SSI in hybrid procedures has also been described. An alternative to these procedures is preoperative tissue expansion

Tissue expanders are used to provide soft tissue coverage and restore abdominal domain by increasing both the size and the vascularity of the donor tissue by producing a strong, vascularized capsule around the expanders. Various sites of placing tissue expanders have been described like in the subcutaneous space, abdominal wall intramuscular spaces (between the internal oblique and transverse abdominis muscles), intermuscular sites (between the external and internal oblique muscles) and finally intra-abdominally. The expanders can be insufflated over various weeks depending on patient tolerance. Before starting filling of the expander, a period of wound healing is usually awaited for 3 weeks to prevent expander exclusion. Expanded skin retracts after removal of expanders, hence overexpansion is necessary. Complications like expulsion, exposure or infection of implants can occur in

Reduction of contents of giant hernias may result in abdominal compartment syndrome. Progressive pneumoperitoneum technique is used to stretch the abdominal wall muscles before repair. Progressive pneumoperitoneum (PPP) increases the capacity of the retracted abdominal cavity, performs a pneumatic lysis of intestinal adhesions, allows the reduction of the hernia contents and improves diaphragmatic function. Air, CO2 or NO is insufflated over a period of a few weeks every couple of days to about a total of 15–20 L depending on patient tolerability monitored by the development of scapular pain, dyspnoea or subcutaneous emphysema. Once tissue

An alternative to tissue expansion is the use of plastic surgery procedures of flap and tissue transfer like latissimus dorsi, tensor fascia lata or rectus femoris flaps, but they are more complex and result in donor site defects and functional limitations.

**52**

#### **Author details**

Anil Kumar1 \* and Shiv Shankar Paswan<sup>2</sup>


\*Address all correspondence to: dranil4@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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**54**

*Techniques and Innovation in Hernia Surgery*

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[11] Rutkow IM. Demographic and socioeconomic aspects of hernia repair in the United States in 2003. The Surgical Clinics of North America.

[12] Flum DR, Horvath K, Koepsell T. Have outcomes of incisional hernia repair improved with time? A population-based analysis. Annals of

[13] Poulose BK, Shelton J, Phillips S, Moore D, Nealon W, Penson D, et al. Epidemiology and cost of ventral hernia repair: Making the case for hernia research. Hernia. 2012;**16**:179-183

[14] Llaguna OH, Avgerinos DV, Lugo JZ, Matatov T, Abbadessa B, Martz JE, et al. Incidence and risk factors for the development of incisional hernia following elective laparoscopic versus open colon resections. American Journal of Surgery.

2003;**5**:1045-1051

2010;**200**:265-269

1991;**157**:29-31

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of Surgery. 1996;**171**:80-84

[17] Veljkovic R, Protic M,

2010;**210**:210-219

Gluhovic A, Potic Z, Milosevic Z, Stojadinovic A. Prospective clinical trial of factors predicting the early development of incisional hernia after midline laparotomy. Journal of the American College of Surgeons.

polypropylene mesh. American Journal

Surgery. 2003;**237**:129-135

[2] Sanders DL, Kingsnorth AN. From ancient to contemporary times: A concise history of incisional hernia

[4] Eisner L, Harder F. Incisional hernias.

[5] Klinge U, Prescher A, Klosterhalfen B, Schumpelick V. Development and pathophysiology of abdominal wall defects. Der Chirurg. 1997;**68**(4):293-303

[6] Mudge M, Hughes LE. Incisional hernia: A 10-year prospective study of incidence and attitudes. The British Journal of Surgery. 1985;**72**(1):70-71

[7] Santora TA, Roslyn JJ. Incisional hernia. The Surgical Clinics of North

Welty G. Meshes within the abdominal wall. Der Chirurg. 1999;**70**(8):876-887

[9] National Center for Health Statistics. Combined Surgery Data (NHDS and NSAS) Data Highlights. 1996. Available from: http://www.cdc.gov/nchs/about/

Nguyen K, Wang X, Ko F, Wright TE, et al. Transforming growth factor beta (2) lowers the incidence of incisional hernias. The Journal of Surgical Research. 2001;**97**(2):109-116

America. 1993;**73**(3):557-570

[8] Schumpelick V, Klinge U,

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[10] Franz MG, Kuhn MA,

2005;**10**:1343-1347

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[51] Yagnik VD, Joshipura V. Nonincisional traumatic lateral abdominal wall hernia. ANZ Journal of Surgery. 2017;**87**(11):952-953. IH after traumatic

[52] Daley J, Khuri SF, Henderson W, Hur K, Gibbs JO, Barbour G, et al. Risk adjustment of the postoperative morbidity rate for the comparative assessment of the quality of surgical care: Results of the National Veterans Affairs Surgical Risk Study. Journal of the American College of Surgeons.

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laparotomy for ovarian cancer. Obstetrics

& Gynecology. 2015;**125**:407-413

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s00423-014-1240-4

abdominal injury

1997;**185**:328-340

2012;**28**:1022-1027

2008;**83**:3-7

#### *Incisional Hernia DOI: http://dx.doi.org/10.5772/intechopen.88919*

*Techniques and Innovation in Hernia Surgery*

and sinus/fistula: A network metaanalysis. Annals of the Royal College of Surgeons of England. 2019

negative pressure and delayed primary fascia closure. Hernia. 2014;**18**:105-111

[42] Song IH, Ha HK, Choi SG, Jeon BG, Kim MJ, Park KJ. Analysis of risk factors for the development of incisional and parastomal hernias in patients after colorectal surgery. Journal of the Korean Society of Coloproctology.

[43] Gislason H, Viste A. Closure of burst abdomen after major

[44] Lamont PM, Ellis H. Incisional hernia in re-opened abdominal incisions: An overlooked risk factor. The British Journal of Surgery.

Sarfeh IJ, Juler GL, Shimoda KJ. Repair

[46] Dronge AS, Perkal MF, Kancir S, Concato J, Aslan M, Rosenthal RA. Long-term glycemic control and postoperative infectious complications. Archives of Surgery. 2006;**141**:375-380

[47] Martin ET, Kaye KS, Knott C, Nguyen H, Santarossa M, Evans R, et al. Diabetes and risk of surgical site infection: A systemic review and metaanalysis. Infection Control and Hospital

Epidemiology. 2015;**37**:88-99

[49] Petersson U, Acosta S,

Google Scholar

[48] Bjørsum-Meyer T, Skarbye M, Jensen KH. Vacuum with mesh is a feasible temporary closure device after fascial dehiscence. Danish Medical Journal. 2013;**60**(11):A4719. PubMed,

Björck M. Vacuum-assisted wound

gastrointestinal operations–Comparison of different surgical techniques and later development of incisional hernia. The European Journal of Surgery.

2012;**28**:299-303

1999;**165**:958-961

1988;**75**:374-376

397-399

[45] Houck JP, Rypins EB,

of incisional hernia. Surgery, Gynecology & Obstetrics. 1989;**169**:

[35] Müller-Riemenschneider F, Roll S, Friedrich M, Zieren J,

Reinhold T, von der Schulenburg JM, et al. Medical effectiveness and safety of conventional compared to laparoscopic incisional hernia repair: A systematic review. Surgical Endoscopy.

[36] Beltrán MA, Cruces KS. Incisional hernia after McBurney incision:

Retrospective case-control study of risk factors and surgical treatment. World Journal of Surgery. 2008;**32**:596-601

[37] Le Huu NR, Mege D, Ouaïssi M, Sielezneff I, Sastre B. Incidence and prevention of ventral incisional hernia. Journal of Visceral Surgery. 2012;**149**

[38] Bucknall TE, Cox PJ, Ellis H. Burst abdomen and incisional hernia: A prospective study of 1129 major laparotomies. British Medical Journal (Clinical Research Edition).

[39] Bickenbach KA, Karanicolas PJ, Ammori JB, Jayaraman S, Winter JM, Fields RC, et al. Up and down or side to side? A systemic review and metaanalysis examining the impact of incision on outcomes after abdominal surgery. American Journal of Surgery.

[40] Sanchez VM, Abi-Haidar YE, Itani KM. Mesh infection in ventral incisional hernia repair: Incidence, contributing factors, and treatment. Sugical Infections (Larchmt).

Perathoner A, Zitt M, Pratschke J, Kafka-Ritsch R. Incisional hernia rate after open abdomen treatment with

Mar;**101**(3):150-161

2007;**21**:2127-2136

(5 Suppl):e3-e14

1982;**284**:931-933

2013;**206**:400-409

2011;**12**:205-210

[41] Brandl A, Laimer E,

**56**

closure and mesh-mediated fascial traction—A novel technique for late closure of the open abdomen. World Journal of Surgery. 2007;**31**(11):2133- 2137. DOI: 10.1007/s00268-007-9222-0. PubMed, CrossRef, Google Scholar

[50] Willms A, Güsgen C, Schaaf S, Bieler D, von Websky M, Schwab R. Management of the open abdomen using vacuum-assisted wound closure and mesh-mediated fascial traction. Langenbeck's Archives of Surgery. 2015;**400**(1):91-99. DOI: 10.1007/ s00423-014-1240-4

[51] Yagnik VD, Joshipura V. Nonincisional traumatic lateral abdominal wall hernia. ANZ Journal of Surgery. 2017;**87**(11):952-953. IH after traumatic abdominal injury

[52] Daley J, Khuri SF, Henderson W, Hur K, Gibbs JO, Barbour G, et al. Risk adjustment of the postoperative morbidity rate for the comparative assessment of the quality of surgical care: Results of the National Veterans Affairs Surgical Risk Study. Journal of the American College of Surgeons. 1997;**185**:328-340

[53] Spencer RJ, Hayes KD, Rose S, Zhao Q, Rathouz PJ, Rice LW, et al. Risk factors for early-occurring and late-occurring incisional hernias after primary laparotomy for ovarian cancer. Obstetrics & Gynecology. 2015;**125**:407-413

[54] Jie B, Jiang ZM, Nolan MT, Zhu SN, Yu K, Kondrup J. Impact of preoperative nutritional support on clinical outcome in abdominal surgical patients at nutritional risk. Nutrition. 2012;**28**:1022-1027

[55] Bellón JM, Durán HJ. Biological factors involved in the genesis of incisional hernia. Cirugía Española. 2008;**83**:3-7

[56] Ozdemir S, Ozis ES, Gulpinar K, Aydin SM, Eren AA, Demirtas S, et al. The value of copper and zinc levels in hernia formation. European Journal of Clinical Investigation. 2011;**41**:285-290

[57] Salameh JR, Talbott LM, May W, Gosheh B, Vig PJ, McDaniel DO. Role of biomarkers in incisional hernias. The American Surgeon. 2007;**73**:561-567

[58] Rosch R, Binnebösel M, Junge K, Lynen-Jansen P, Mertens PR, Klinge U, et al. Analysis of c-myc, PAI-1 and uPAR in patients with incisional hernias. Hernia. 2008;**12**:285-288

[59] Chevrel JP, Rath AM. Classification of incisional hernias of the abdominal wall. Hernia. 2000;**4**:7-11

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**59**

**Chapter 5**

**Abstract**

necrosis and seroma.

**1. Introduction**

Refinements and Advancements in

Anterior Component Separation

This chapter will explore the newest innovations for performing anterior component separation (CS). It will include open CS, perforator sparing CS and minimally invasive component separation (MICS). It will also address the use of various meshes and their plane of inset. It will cover soft tissue management including panniculectomy, quilting sutures and drains. Fascial closure techniques will also be included. The highlight of this chapter will be the description of tips and tricks of performing MICS. We will also touch upon preoperative preparation such as body mass index (BMI) optimization and smoking cessation as well as management of postoperative complications including surgical site infections, skin

Abdominal wall domain and function is maintained by balancing the centripetal forces exerted on the abdominal wall by the internal organs with the centrifugal forces exerted by the combined action of the musculofascial abdominal wall. This musculoaponeurotic girdle consisting of a layered muscle arrangement coalescing into a static ligamentous supports can be broadly subdivided into the ventral abdominal wall and the lateral abdominal wall. The ventral abdominal wall comprises of longitudinally oriented rectus abdominis muscles encased in the anterior and posterior rectus sheath bounded centrally by the linea alba. It extends from the xiphoid process to the pubic symphysis. The lateral abdominal wall consists of a layered arrangement the external oblique, internal oblique, transversus abdominis and transversalis fascia. It extends from the costal margins superiorly to the iliac crest inferiorly and the linea semilunaris anteriorly to the thoracolumbar fascia posteriorly. The linea alba, linea semilunaris, and thoracolumbar fascia serve as a static attachment points for these muscles and translate their circumferentially and longitudinally oriented force vectors to generate centrifugal forces necessary to

The incidence of ventral or incisional hernia following laparotomy ranges from 1 to 20% [1–3], while the recurrence rates can range from 20 to 48% [4]. Once the linea alba has been incised via midline laparotomy, the healed scar tissue that results is much weaker than the uninjured fascia and can attenuate over time leading to bulge or hernia formation. The main objective of treating ventral hernias is to achieve primary fascial closure, reduce tension acting along the midline scar and

**Keywords:** hernia, mesh, component separation, abdominal wall

contain the internal organs and maintain abdominal wall domain.

*Sahil K. Kapur and Charles E. Butler*

#### **Chapter 5**

*Techniques and Innovation in Hernia Surgery*

Laparoendoscopic Surgeons. 2017;**21**(4).

[66] Holihan JL, Karanjawala B, Ko A, Askenasy EP, Matta EJ, Gharbaoui L, et al. Use of computed tomography in diagnosing ventral hernia recurrence: A blinded, prospective, multispecialty

[68] Franklin ME, Gonzalez JJ, Glass JL, Manjarrez A. Laparoscopic ventral and incisional hernia repair: An 11-year experience. Hernia. 2004;**8**:23-27

[69] Ramirez OM, Ruas E, Dellon AL. "Components separation" method for closure of abdominal-wall defects: An anatomic and clinical study. Plastic and Reconstructive Surgery.

1990;**86**(3):519-526

PMC free article. PubMed

evaluation. JAMA Surgery. 2016;**151**(1):7-13. PubMed

[67] LeBlanc KA, Booth WV, Whitaker JM, Bellanger DE. Laparoscopic incisional and ventral herniorrhaphy: Our initial 100 patients. Hernia. 2001;**5**:41-45. PubMed. Google

Scholar

**58**
