Overview
Definition:
Abdominal wall reconstruction with mesh, particularly using the retrorectus approach, involves placing a synthetic or biologic mesh in the space between the posterior rectus sheath and the peritoneum to reinforce weakened or defected abdominal wall areas, typically for large ventral or incisional hernias
This method aims to restore abdominal wall integrity, reduce recurrence rates, and improve functional outcomes.
Epidemiology:
Ventral and incisional hernias are common, occurring in up to 20% of patients following abdominal surgery
Large or recurrent hernias, complex abdominal wall defects, and patient factors like obesity or previous failed repairs increase the incidence of requiring mesh reconstruction
The retrorectus approach is favored for certain defect sizes and locations, reducing intra-abdominal complications compared to preperitoneal placement.
Clinical Significance:
Effective abdominal wall reconstruction is crucial for preventing complications such as bowel incarceration, strangulation, chronic pain, and body image distortion
The retrorectus technique offers a robust solution for challenging hernias, restoring fascial continuity and improving abdominal wall mechanics
Understanding this approach is vital for surgical residents preparing for DNB and NEET SS examinations, as it represents a cornerstone in managing complex abdominal wall pathologies.
Indications
Indications For Mesh Reconstruction:
Recurrent ventral hernias
Large ventral or incisional hernias (>10 cm)
Defects with significant fascial laxity
Patients with comorbidities that increase recurrence risk
Failed previous hernia repairs
Complex hernias with tissue loss or contamination.
Indications For Retrorectus Approach:
Large primary or recurrent ventral hernias
Hernias with a significant defect in the posterior rectus sheath
Cases where component separation techniques are also employed
Hernias extending into the flank or supraumbilical region
When a wide mesh coverage with minimal protrusion into the peritoneal cavity is desired.
Contraindications:
Active infection at the surgical site
Uncontrolled sepsis
Severe malnutrition or coagulopathy
Patient factors making surgery prohibitive
Significant intra-abdominal adhesions requiring extensive lysis that may compromise mesh placement
Inability to achieve adequate fascial closure over the mesh.
Diagnostic Approach
History Taking:
Detailed history of previous surgeries and hernia repairs
Onset and progression of hernia symptoms
Palpable bulge characteristics
Any history of incarceration or strangulation
Associated symptoms like pain, nausea, vomiting, or bowel changes
Comorbidities such as obesity, diabetes, COPD, smoking, immunosuppression
Previous mesh complications or infections.
Physical Examination:
Careful palpation of the hernia defect size and borders
Assessment of fascial laxity and integrity
Presence of any skin changes or previous surgical scars
Evaluation for associated masses or tenderness
Complete abdominal examination to rule out intra-abdominal pathology
Assessment of respiratory status and mobility.
Investigations:
Ultrasound: Useful for initial assessment of hernia contents and defect size, especially in obese patients
CT scan (Axial, Coronal, Sagittal views): Essential for precise measurement of hernia defect dimensions, assessing fascial planes, identifying anatomical landmarks, evaluating the extent of fascial laxity, and planning mesh size and placement
MRI: May be used in specific cases to evaluate soft tissues and complex anatomy
Laboratory tests: Complete blood count, coagulation profile, electrolytes, renal and liver function tests as per standard surgical protocol.
Differential Diagnosis:
Lipoma
Desmoid tumor
Sarcoma
Abscess
Hematoma
Lymphadenopathy
Rectus sheath hematoma
Adnexal masses (in females).
Management
Preoperative Preparation:
Optimization of comorbidities: weight reduction, smoking cessation, glycemic control
Nutritional assessment and support
Prophylactic antibiotics (cefazolin)
Bowel preparation if indicated
Mechanical bowel preparation or oral antibiotics for elective cases, especially with mesh
Preoperative marking of defect and midline
Patient counseling regarding risks, benefits, and alternatives.
Retrorectus Mesh Technique:
Surgical incision over the hernia sac or a wider approach for component separation
Dissection to identify the posterior rectus sheath
Incision of the posterior rectus sheath lateral to the rectus muscle
Creation of a retrorectus pocket extending superiorly and inferiorly to accommodate the mesh
Careful dissection to mobilize the rectus muscles and create adequate space
Meticulous hemostasis
Placement of the mesh (e.g., polypropylene, ePTFE, biologic) in the retrorectus space, ensuring adequate overlap with healthy tissue
Securement of the mesh if necessary (e.g., sutures, tacks, fibrin glue), though often secured by fascial tension
Primary closure of the posterior rectus sheath if possible, or closure of anterior rectus sheath and overlying tissues
Component separation techniques (e.g., transversus abdominis release) may be combined for larger defects.
Postoperative Care:
Pain management: adequate analgesia (epidural, PCA, multimodal)
Early mobilization
Incentive spirometry
Monitoring for signs of infection, bleeding, or seroma formation
Drain management if placed
Gradual reintroduction of diet
Ambulation and physical therapy
Wound care and monitoring
DVT prophylaxis with subcutaneous heparin or LMWH and compression stockings
Patient education on activity restrictions and warning signs.
Complications
Early Complications:
Wound infection
Seroma formation
Hematoma
Mesh infection
Mesh extrusion or dehiscence
Ileus
Urinary retention
Pneumonia
DVT/PE
Acute kidney injury.
Late Complications:
Chronic mesh infection
Mesh migration or erosion into adjacent organs (bowel, bladder)
Chronic pain
Recurrence of hernia
Bowel obstruction due to adhesions
Fibrous adhesions formation
Cosmetic deformity.
Prevention Strategies:
Meticulous surgical technique and hemostasis
Use of appropriate mesh material
Adequate mesh overlap
Proper placement in the retrorectus space
Minimizing dead space to reduce seroma/hematoma
Judicious use of drains
Early mobilization
Strict wound care
Prophylactic antibiotics
Adequate nutritional support
Patient education on activity and warning signs
Component separation for tension-free closure
Careful selection of patients for mesh repair.
Prognosis
Factors Affecting Prognosis:
Size and complexity of hernia defect
Patient comorbidities (obesity, diabetes, smoking)
Previous surgical history and complications
Type of mesh used
Surgical technique and experience
Postoperative wound healing and complication management.
Outcomes:
Successful reconstruction with a retrorectus mesh technique generally leads to low recurrence rates (typically <5-10% for large defects) and improved functional outcomes
Patient satisfaction is usually high when pain and cosmetic concerns are addressed
Long-term outcomes are significantly influenced by adherence to postoperative care and management of any complications
Recurrence remains a possibility, especially in patients with high-risk factors.
Follow Up:
Regular follow-up appointments are essential, typically at 1 week, 1 month, 3 months, 6 months, and 1 year postoperatively
Subsequent follow-up may be annual or as needed
Patients are instructed to report any new swelling, pain, redness, fever, or wound drainage immediately
Imaging may be considered if recurrence or complications are suspected.
Key Points
Exam Focus:
The retrorectus approach is preferred for large ventral/incisional hernias to minimize intra-abdominal mesh contact and reduce bowel complications
Key steps include dissecting the retrorectus space, placing the mesh, and ensuring adequate fascial closure
Complications like mesh infection and recurrence are critical exam topics
Differentiate between preperitoneal and retrorectus placement
Component separation may be used adjunctively.
Clinical Pearls:
For large defects, consider placing the mesh inferiorly and superiorly to the defect to ensure adequate overlap
Always assess the integrity of the posterior rectus sheath before placing the mesh retrorectally
Meticulous hemostasis is paramount to prevent hematoma formation, a nidus for infection
If tension is too high for posterior sheath closure, consider transversus abdominis release.
Common Mistakes:
Inadequate mesh overlap leading to recurrence
Placing mesh too anteriorly or posteriorly, causing bowel entrapment or limited coverage
Insufficient dissection of the retrorectus space, leading to tension
Neglecting to address comorbidities that increase recurrence risk
Failure to recognize and manage early signs of mesh infection or seroma
Aggressive mobilization of rectus muscles without adequate closure.