Overview
Definition:
Preperitoneal mesh repair for umbilical hernia is a surgical technique where a synthetic mesh is placed in the preperitoneal space (between the transversalis fascia and the peritoneum) to reinforce the abdominal wall defect, preventing recurrence
This approach is widely adopted for both open and laparoscopic procedures.
Epidemiology:
Umbilical hernias are common, particularly in infants and the elderly
In adults, they are often associated with increased intra-abdominal pressure, obesity, and multiparity
Surgical repair is indicated for symptomatic hernias or those with a large defect.
Clinical Significance:
Effective repair of umbilical hernias is crucial to relieve patient symptoms, prevent complications such as incarceration and strangulation, and improve quality of life
Preperitoneal mesh repair offers durable results with a low recurrence rate, making it a cornerstone of surgical management.
Indications
Surgical Indications:
Symptomatic umbilical hernias (pain, discomfort)
Hernias with a defect greater than 1-2 cm in diameter
Irreducible or incarcerated hernias
Cosmetic concerns in selected patients
Patient preference for definitive repair to prevent recurrence.
Contraindications:
Absolute contraindications are rare but include severe coagulopathy or active infection at the surgical site
Relative contraindications may include uncontrolled systemic disease, morbid obesity, or a history of multiple abdominal surgeries that may complicate dissection.
Preoperative Preparation
Patient Evaluation:
Thorough history and physical examination
Assessment of comorbidities (diabetes, hypertension, cardiovascular disease)
Evaluation of nutritional status and smoking history
Review of previous abdominal surgeries.
Imaging Studies:
Ultrasound is often used to confirm the diagnosis and assess defect size, especially in obese patients or when diagnosis is uncertain
CT scan may be useful for complex cases or to rule out other intra-abdominal pathology.
Anesthesia Considerations:
General anesthesia is typically required for laparoscopic repair
Local anesthesia with sedation may be an option for selected small open repairs
Optimization of cardiopulmonary status is essential.
Informed Consent:
Discussion with the patient regarding the procedure, potential risks (infection, bleeding, mesh-related complications, recurrence), benefits, alternatives, and expected recovery period.
Surgical Management
Open Preperitoneal Repair:
Incision made circumferentially around the umbilicus or a curvilinear incision superior or inferior to it
Dissection carried down to the preperitoneal space
Hernia sac dissected and reduced
Mesh (e.g., polypropylene, composite) is trimmed to size and secured in the preperitoneal space using sutures or tacks
Fascia is then approximated anterior to the mesh.
Laparoscopic Preperitoneal Repair Tepp:
Small infraumbilical or supraumbilical ports are inserted
CO2 insufflation creates a pneumoperitoneum
Dissection plane between the peritoneum and transversalis fascia is developed using laparoscopic instruments
The peritoneal sac is reduced, and a pre-cut mesh is introduced and placed over the defect
The mesh is secured using tacks or fibrin glue, or it may be fixed by the pneumoperitoneum itself (e.g., dual mesh).
Mesh Selection:
Choice of mesh depends on surgeon preference and whether the repair is open or laparoscopic
Non-absorbable synthetic meshes like polypropylene are common
Composite meshes with a visceral barrier are used to reduce bowel adhesion risk in laparoscopic repairs.
Closure And Drainage:
The anterior fascia is often not directly closed over the mesh in laparoscopic TEPP, relying on anatomical planes
In open repairs, anterior fascial closure is performed
Drains are generally not required unless significant dissection or contamination is present.
Postoperative Care
Pain Management:
Adequate analgesia is provided, often with a multimodal approach including NSAIDs and opioids
Epidural or regional blocks may be considered for open repairs.
Activity Restrictions:
Patients are encouraged to ambulate early
Strenuous activity and heavy lifting are typically restricted for 4-6 weeks, depending on the extent of repair and patient recovery.
Wound Care:
Routine wound care is advised
Patients are instructed on signs of infection and when to seek medical attention
Antibiotics are generally not routinely prescribed postoperatively unless there is a specific indication.
Dietary Recommendations:
A regular diet is usually resumed as tolerated
Adequate hydration is encouraged to prevent constipation.
Complications
Early Complications:
Wound infection
Hematoma formation
Seroma
Urinary retention
Pain
Ischemia of the umbilical skin flap in open repairs
Trocar site pain or bleeding in laparoscopic repairs.
Late Complications:
Mesh infection (rare but serious)
Mesh migration or erosion
Chronic pain syndrome
Recurrence of the hernia
Bowel obstruction due to adhesions (more common with intraperitoneal placement).
Prevention Strategies:
Strict aseptic technique
Meticulous hemostasis
Appropriate mesh selection and fixation
Careful dissection to avoid injury to surrounding structures
Antibiotic prophylaxis in selected cases
Patient education on activity restrictions.
Prognosis
Factors Affecting Prognosis:
Size of the hernia defect
Patient's BMI and comorbidities
Surgeon's experience
Choice of surgical technique
Adherence to postoperative instructions.
Outcomes:
Preperitoneal mesh repair, both open and laparoscopic, offers excellent outcomes with high success rates and low recurrence rates, typically exceeding 95% at long-term follow-up.
Follow Up:
Routine follow-up is usually scheduled at 2-4 weeks postoperatively to assess healing and patient recovery
Further follow-up may be based on clinical assessment or patient symptoms.
Key Points
Exam Focus:
Understand the rationale for preperitoneal placement (tension-free repair)
Differentiate between open and laparoscopic techniques (TEPP, TAPP-like access)
Know common mesh materials and fixation methods
Recognize key complications like mesh infection and recurrence.
Clinical Pearls:
For laparoscopic TEPP, maintaining the preperitoneal plane is critical
In open repair, ensure adequate mesh coverage of the defect
Always consider the patient's BMI and comorbidities in surgical planning
Reinforce the importance of postoperative activity restrictions to prevent early recurrence.
Common Mistakes:
Inadequate dissection creating a confined space for the mesh
Over-reliance on tacks without adequate mesh overlap
Ignoring patient comorbidities
Premature return to strenuous activity by the patient
Incomplete reduction of the hernia sac.