Mission: Incision — Open Retromuscular Repair of a Ventral Incisional Hernia

by Yiu Luke, Medical Communications, Digital Surgery

A surgeon knows too well that surgeries don’t always end “happily ever after”. Sometimes, a surgical incision becomes a weak point after healing. The weak point can be made worse by strenuous activity or weight gain, allowing internal tissue to protrude. This is called a ventral incisional hernia. Ventral incisional hernias are fairly common, developing after 15% to 20% of laparotomies.1

Ventral incisional hernias may start as a painless, reducible abdominal bulge. They always require surgery to treat definitively. If left untreated, the hernia may grow larger, and may lead to bowel incarceration, obstruction or strangulation. If these complications happen, the patient would have symptoms like pain, nausea, vomiting or constipation. Emergency surgery would be needed in these cases, so it’s better to repair the hernia earlier with elective surgery.2

Touch Surgery’s™ new simulation, Open Retromuscular Repair of a Ventral Incisional Hernia, demonstrates how to perform an open surgery to repair a ventral incisional hernia using Medtronic’s ProGrip™ self-gripping polyester mesh. This simulation shows the procedure on a midline incisional hernia, which is more common than non-midline incisional hernias. The retromuscular approach is used, where the mesh goes between the posterior rectus sheath and the rectus muscle.3,4

Open Retromuscular Repair of a Ventral Incisional Hernia is a virtual simulation designed for core program surgical trainees, or more senior trainees interested in learning a new procedure.

Dissecting the hernia sac from the surrounding subcutaneous tissues.

Developing the retromuscular plane

Developing the retromuscular plane for mesh placement with a Force TriVerse™ electrosurgical device.

Key Steps

An open retromuscular repair of a ventral incisional hernia generally goes through the following sequence of six key objectives:

  1. Preparing the patient. The surgical team completes the appropriate preoperative procedures, including positioning and draping the patient, and marking the surgical site.
  2. Exposing the hernia sac. The surgeon cuts through the skin and subcutaneous tissues to find and free the sac containing the herniated abdominal contents. The old incision can be used as the means of access.
  3. Reducing the hernia sac. If needed, the surgeon may open the hernia sac, free the abdominal contents, and push them back through the gap.
  4. Readying the retromuscular plane. The surgeon prepares the area for the mesh by opening the rectus sheath, then developing a plane between it and the rectus muscle. If the hernia is above the arcuate line, the posterior rectus fascia must be closed, as is the case in our simulation.
  5. Inserting the mesh. The mesh can then be placed in the retromuscular space, remembering to allow at least 5 cm overlap, depending on the size of the gap. Slowly absorbable 2-0 Maxon monofilament is used to close the anterior rectus fascia over the mesh.
  6. Closing the incision. The surgeon closes the subcutaneous tissues and skin. In some cases, a closed-suction drain may be placed over the mesh, or in the subcutaneous plane.

That’s just the short version! Interested in knowing more about open retromuscular repair for ventral incisional hernias? Get the full simulation on the Touch Surgery™ app.

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References

1. Hope WW, Tuma F. Incisional Hernia. https://www.ncbi.nlm.nih.gov/books/NBK435995/. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan. Updated 26 Jun. 2020. Accessed 19 Jan. 2021.

2. Emile SH, Elgendy H, Sakr A, et al. Outcomes following repair of incarcerated and strangulated ventral hernias with or without synthetic mesh. World J Emerg Surg. 2017;12:31.

3. Hopson S, Miller L. Open ventral hernia repair using ProGrip™ self-gripping mesh. Int J Surg. 2015;23:137-140.

4. Demetrashvili Z, Pipia I, Loladze D, et al. Open retromuscular mesh repair versus onlay technique of incisional hernia: A randomized controlled trial. Int J Surg. 2017;37:65-70.