Overview
Definition:
Abdominal wall reconstruction with mesh in the preperitoneal space involves placing a synthetic or biological mesh between the posterior rectus sheath (or transversalis fascia) and the peritoneum to reinforce a weakened abdominal wall, most commonly for large incisional or ventral hernias
This technique aims to restore structural integrity and prevent recurrence by allowing tissue ingrowth into the mesh, creating a strong, tension-free repair.
Epidemiology:
Incisional hernias occur in 10-20% of patients after abdominal surgery, with higher rates after emergency procedures or midline incisions
Large or recurrent ventral hernias present significant reconstruction challenges
The preperitoneal approach is particularly favored for hernias exceeding 10 cm in diameter and those involving significant fascial defect.
Clinical Significance:
Effective abdominal wall reconstruction is critical for patient quality of life, preventing complications like bowel obstruction or incarceration, and reducing chronic pain
The preperitoneal mesh technique offers a tension-free repair with lower recurrence rates compared to some other methods, especially for complex defects
Understanding this approach is vital for surgical residents preparing for DNB and NEET SS examinations, as it is a common and important procedure.
Indications
Primary Indications:
Recurrent incisional hernias
Large (>10 cm) primary incisional or ventral hernias
Defects with tissue loss or significant fascial retraction
Hernias associated with enterocutaneous fistulas (in selected cases)
Cases requiring wide mesh coverage.
Contraindications:
Active infection at the surgical site or systemic sepsis
Uncontrolled coagulopathy
Severe malnutrition or cachexia
Patient refusal or inability to tolerate surgery
Certain extensive abdominal wall tumors requiring radical resection.
Relative Contraindications:
Previous mesh infection
Significant abdominal contamination
Patient with poor wound healing potential.
Preoperative Preparation
Patient Assessment:
Thorough history and physical examination to assess hernia size, location, and associated comorbidities
Nutritional assessment and optimization
Smoking cessation counseling
Optimization of comorbidities like diabetes or hypertension.
Imaging Studies:
Ultrasound or CT scan of the abdomen to precisely delineate hernia anatomy, defect size, fascial planes, and identify any intra-abdominal adhesions or pathology
MRI may be useful in select cases for better soft tissue visualization.
Surgical Planning:
Decision between open versus laparoscopic approach based on defect size, patient factors, and surgeon expertise
Choice of mesh material (synthetic polypropylene, ePTFE, or biological grafts) considering factors like infection risk and mesh cost
Preoperative antibiotic prophylaxis.
Surgical Management
Open Preperitoneal Technique:
A curvilinear or transverse incision is made above or below the hernia defect, creating a plane between the posterior rectus sheath and the peritoneum
The peritoneum is dissected away from the posterior rectus sheath to create adequate space for mesh placement
The mesh is then secured using sutures, tacks, or fibrin glue, overlapping the defect margins by at least 5-10 cm
The rectus muscles are then approximated, and the anterior fascia and skin are closed.
Laparoscopic Preperitoneal Technique:
Performed laparoscopically, typically using the Trans-Abdominal Pre-Peritoneal (TAPP) or Extraperitoneal (IPOM – Inlay Onlay Mesh) approach
For TAPP, ports are placed, and the peritoneum is incised and dissected to create a preperitoneal space
For IPOM, dissection is performed directly in the preperitoneal space without entering the peritoneal cavity
Mesh is introduced and secured with tacks or sutures
The peritoneal flap is then closed if necessary (TAPP).
Mesh Selection:
Synthetic meshes (e.g., polypropylene, ePTFE) are durable and cost-effective but have a higher risk of infection
Biological meshes offer better tissue integration and reduced infection risk but are more expensive and can retract or lose strength over time
Combination meshes may be used in contaminated fields
The choice depends on hernia complexity, patient factors, and surgeon preference.
Fixation Methods:
Sutures for secure fixation, especially in open procedures
Tacks (e.g., spinal needles, spiral tacks) for laparoscopic procedures to minimize tissue trauma
Fibrin glue can be used as an adjunct or primary fixation in select cases
The goal is to ensure adequate mesh coverage and prevent migration.
Postoperative Care
Pain Management:
Adequate analgesia is crucial, often involving multimodal approaches including parenteral opioids, NSAIDs, and patient-controlled analgesia (PCA)
Epidural anesthesia can be considered for open procedures
Regional blocks may also be beneficial.
Monitoring:
Close monitoring for signs of infection (fever, wound redness, discharge), hematoma formation, seroma, or mesh-related complications
Vital signs monitoring
Assessment for bowel function recovery.
Mobility And Activity:
Early ambulation is encouraged to prevent deep vein thrombosis (DVT) and pulmonary complications
Restrictions on heavy lifting and strenuous activity are typically advised for 6-8 weeks, with gradual return to normal activities as tolerated
Graduated exercise programs may be recommended.
Wound Care:
Standard wound care, including keeping the incision clean and dry
Dressing changes as per protocol
Monitoring for wound dehiscence or signs of infection
Follow-up appointments to assess wound healing and patient recovery.
Complications
Early Complications:
Wound infection
Hematoma or seroma formation
Mesh infection
Urinary retention
Ileus
Pneumonia
Deep vein thrombosis (DVT) or pulmonary embolism (PE).
Late Complications:
Chronic pain (neuropathic or mesh-related)
Mesh migration or shrinkage
Bowel obstruction due to adhesions
Enterocutaneous fistula (rare with preperitoneal placement)
Recurrence of hernia
Persistent seroma.
Prevention Strategies:
Meticulous surgical technique to minimize tissue trauma and ensure proper mesh placement
Use of prophylactic antibiotics
Appropriate mesh selection for the defect
Adequate wound closure and drainage if necessary
Patient education on activity restrictions
Optimization of patient comorbidities.
Prognosis
Factors Affecting Prognosis:
Hernia size and complexity
Patient comorbidities
Surgeon's experience
Mesh type and fixation
Presence of infection
Adherence to postoperative instructions.
Outcomes:
Successful abdominal wall reconstruction with preperitoneal mesh typically leads to a significant reduction in hernia recurrence rates and improvement in quality of life
Long-term success rates are generally high, especially with large mesh overlap and secure fixation.
Follow Up:
Regular follow-up appointments are essential for at least 1-2 years postoperatively to monitor for recurrence, assess wound healing, and manage any long-term complications
Patient education on recognizing signs of recurrence is crucial.
Key Points
Exam Focus:
Preperitoneal mesh placement provides a tension-free repair for large ventral and incisional hernias
Key advantage: reduced recurrence compared to purely intraperitoneal or underlay repairs
Differentiate between open and laparoscopic approaches (TAPP vs
IPOM)
Understand mesh types and fixation methods and their implications for complications like infection and migration.
Clinical Pearls:
Ensure adequate mesh overlap (at least 5-10 cm) in all dimensions for optimal results
Careful dissection in the preperitoneal plane is crucial to avoid injury to the peritoneum, bowel, or bladder
Consider biologic mesh in contaminated fields or in patients with high infection risk
Postoperative pain control is paramount for early mobilization and recovery.
Common Mistakes:
Inadequate mesh overlap
Incomplete dissection of the preperitoneal space
Poor fixation leading to mesh migration
Ignoring patient comorbidities that can impair wound healing
Premature return to strenuous activity
Failure to recognize and manage early signs of infection or seroma.