Overview
Definition:
Recurrent ventral hernia refers to the reappearance of a ventral hernia (a protrusion of abdominal contents through a defect in the anterior abdominal wall) at a previously operated site
This is a common and challenging problem in general surgery, often associated with a higher risk of complications and recurrence compared to primary hernias.
Epidemiology:
Recurrence rates after ventral hernia repair vary widely, with some studies reporting up to 20-30% recurrence rates after open repairs and lower rates with laparoscopic techniques
Factors influencing recurrence include patient comorbidities, wound healing, mesh type and fixation, and surgical technique
The incidence of recurrent hernias increases with each subsequent repair attempt.
Clinical Significance:
Recurrent ventral hernias pose significant challenges for both patient and surgeon
They can lead to chronic pain, bowel obstruction, strangulation, and cosmetic deformity
Understanding optimal repair strategies is crucial for minimizing recurrence, improving patient quality of life, and reducing the burden of repeated surgical interventions
This topic is highly relevant for DNB and NEET SS surgical examinations.
Indications For Repair
Symptomatic Hernias:
Hernias causing pain, discomfort, or functional limitations
Bulging that causes significant cosmetic or psychological distress.
Asymptomatic Hernias:
While historically debated, many guidelines now recommend repair of asymptomatic hernias larger than 2 cm or those with risk factors for incarceration or strangulation, due to the potential for serious complications.
Incarcerated Or Strangulated Hernias:
These are surgical emergencies requiring prompt intervention to relieve obstruction and restore blood flow to compromised bowel.
Risk Factors For Recurrence:
Patients with multiple previous repairs, comorbidities like obesity, diabetes, smoking, or immunosuppression may require more robust repair techniques and optimized perioperative care.
Diagnostic Approach
History Taking:
Detailed history of previous surgeries, including the type of repair and any complications
Characterization of current symptoms: pain, bulge size and reducibility, bowel symptoms
Assessment of patient comorbidities: smoking, diabetes, obesity, steroid use, connective tissue disorders
Review of previous operative reports if available.
Physical Examination:
Careful palpation of the abdominal wall to delineate the hernia defect, assess its size, and check for reducibility
Evaluation of surrounding tissue quality and presence of scars
Assessment for ascites or diastasis recti
Comprehensive examination of the cardiopulmonary and vascular systems.
Imaging Modalities:
Ultrasound is useful for initial assessment of fascial defects and contents, especially in obese patients
CT scan with thin slices in both axial and coronal planes is the gold standard for defining the defect size, assessing fascial planes, identifying incarcerated contents, and evaluating the extent of fascial damage
MRI can be used in specific cases, particularly to assess soft tissues.
Differential Diagnosis:
Lipoma, desmoid tumor, abdominal wall abscess, rectus sheath hematoma, sarcomas, and other soft tissue masses
These can often be distinguished by imaging characteristics and clinical history.
Surgical Management Strategies
Preoperative Optimization:
Weight management, smoking cessation, glycemic control, and nutritional support are critical
Antibiotic prophylaxis should be administered
Mechanical bowel preparation may be considered in cases of suspected bowel involvement.
Open Vs Laparoscopic Approach:
Open repair offers direct visualization and tactile feedback, often preferred for very large defects or contaminated fields
Laparoscopic repair allows for a tension-free mesh placement, reduced incisional complications, and potentially faster recovery, especially for recurrent hernias where scar tissue may be extensive.
Mesh Selection And Placement:
Synthetic meshes (polypropylene, ePTFE) are commonly used
Biological meshes may be considered in contaminated fields but have higher recurrence rates
Placement can be preperitoneal (IPOM - Intraperitoneal Onlay Mesh, Retromuscular) or intraperitoneal
IPOM is a popular laparoscopic technique.
Component Separation Techniques:
For very large defects where primary fascial closure is not feasible or would create excessive tension, component separation techniques (e.g., transverse abdominis release - TAR) can mobilize fascial flaps to achieve tension-free closure
This is often combined with mesh reinforcement.
Abdominal Wall Reconstruction Principles:
Tension-free repair is paramount
Minimizing dead space, ensuring adequate mesh overlap, and secure mesh fixation are essential
Consideration for biologic mesh in contaminated cases, though with increased recurrence risk
Achieving stable abdominal wall integrity to prevent further recurrence and optimize respiratory mechanics.
Complications And Prevention
Early Complications:
Wound infection (superficial or deep), seroma, hematoma, mesh infection, skin necrosis, ileus, pneumonia, urinary retention
Prevention involves meticulous surgical technique, appropriate antibiotic prophylaxis, wound care, early mobilization, and pain management.
Late Complications:
Hernia recurrence, chronic pain, meshoma, enterocutaneous fistula, bowel obstruction due to adhesions or mesh migration, mesh extrusion
Prevention involves careful mesh selection, secure fixation, appropriate technique for the defect size, and patient selection.
Risk Factors For Recurrence Post Repair:
Poor wound healing, obesity, smoking, diabetes, suboptimal mesh choice or fixation, infection, high intra-abdominal pressure, and technical errors during repair
Addressing these factors preoperatively and intraoperatively is key to reducing recurrence.
Prognosis And Follow Up
Factors Affecting Prognosis:
The prognosis depends on the extent of the defect, comorbidities, the chosen surgical technique, and the surgeon's experience
Recurrence rates are generally higher after multiple previous repairs and with larger defects.
Outcomes With Modern Techniques:
Laparoscopic and open repairs with mesh, especially IPOM and TAR, have demonstrated improved outcomes and lower recurrence rates compared to historical methods
Component separation techniques significantly improve the ability to achieve tension-free closure.
Long Term Follow Up:
Regular follow-up is essential to monitor for signs of recurrence, chronic pain, or other complications
Follow-up intervals are typically at 1, 6, and 12 months postoperatively, and then annually
Patients should be educated to report any new bulges or symptoms promptly.
Key Points
Exam Focus:
Understanding the indications for different mesh types (synthetic vs
biologic), placement strategies (onlay, inlay, IPOM, retromuscular), and component separation techniques (TAR)
Differentiating between open and laparoscopic approaches for recurrent hernias and their respective advantages/disadvantages
Recognizing common complications and their management.
Clinical Pearls:
Thorough preoperative optimization is non-negotiable for recurrent hernias
Always consider the quality of the patient's abdominal wall tissue
For large defects, component separation may be necessary even in open repair
Thorough understanding of mesh fixation techniques and their implications for recurrence and pain.
Common Mistakes:
Attempting primary closure of large fascial defects without considering component separation, leading to tension and recurrence
Inadequate mesh overlap or fixation
Ignoring patient comorbidities that impair healing
Incorrect placement of mesh (e.g., too anteriorly, leading to pain or fistula)
Failure to recognize and manage mesh infection early.