Tension-Free Repairs

Overlay Hernia Repair

Many hernia surgeons utilize the simple overlay hernia repair as a “tension free” ventral hernia repair. The defect is dissected free from the hernia sack, and the size and shape of the defect is measured.

An identical size and shape of mesh is fitted to this defect and then the mesh is sutured, usually in a running fashion, to the edge of the defect. The adipose and skin is closed over the mesh, occasionally with a closed suction drain. The hernia sack is usually opened and adhesions to bowel freed and the peritoneum reconstructed under the mesh. There are specialized two-sided mesh products that have been created to solve the common problem of inadequate peritoneum for closure; the mesh has a non-adherent side to face the bowel, and a textured side to allow incorporation into the scar that forms with the adipose layer. Another popular method of overlay mesh hernia repair is to place the mesh directly over the fascia after a direct suture repair. The mesh is in direct contact with the external side of the superficial fascia that may or may not be sutured down to that fascia. The adipose and skin are then closed over the mesh.

Prolene Hernia System

The Prolene Hernia System utilizes a specialized double layer of Prolene mesh attached at the center with a short connector. It is supplied in several sizes, related to the size of the “underlay mesh”, and one “extended” size with a 3 inch underlay and a 4 inch overlay mesh.

The mesh is used primarily for inguinal hernias. However it has been successfully adapted to: femoral, umbilical, Spigelian, and small ventral hernia repairs. It has a remarkably low recurrence rate if placed properly; but great care must be taken to assure precise placement of the preperitoneal mesh to achieve these results. If the hernia surgeon has no experience opening the floor of the inguinal canal and dissecting the preperitoneal space, then he/she will require additional training before attempting this popular repair.

Preperitoneal and Intramuscular Hernia Repair

The combination of preperitoneal and intramuscular hernia repairs is utilized most commonly with flank and lateral ventral hernias. The defect is usually irregular in shape, surrounded by extremely weak muscle and thin fascia, and frequently has close proximity to bone.

The result is that simple direct suture hernia repairs will not hold. By adding two layers of mesh, preferably polypropylene that incorporates into the fascia with collagen deposition, a remarkably strong hernia repair is achieved. The hernia sack is dissected free of the surrounding tissues, with great care taken to avoid injury to the sack or its contents. The peritoneum is then carefully dissected free from the underside of the deep fascia for a distance of at least the size of the defect from every edge. It is important to overlap any bony margin as far as possible in this layer; sutures are not used in the periostium since they are very painful and will not support a repair. However, if the mesh overlaps the bone two-three times the size of the defect, the mesh will be incorporated into the fascia at that level adding tremendous strength.

Once the preperitoneal space is widely dissected, then a piece of polypropylene mesh is placed behind the deep fascia.

Care is taken to smooth out the mesh under the fascia with maximal overlap from the defect edge in all directions. The fascial defect edge is then sutured down to the mesh with running monofilament suture. Occasionally the mesh can be entirely covered with the first layer of fascia and muscle, however most of the time the proper tension on this fascia layer requires that a small ellipse of mesh remains exposed. The next layer is variable depending upon the tissue available. Great care should be taken during the dissection to identify the different muscle and fascia layers so that at least two tissue planes can be re-created for mesh reinforcement. This second layer is frequently beneath the external or internal oblique muscles, and a wide tissue plane is common. Another piece of polypropylene mesh is cut to shape, and placed into this wide intramuscular layer. Again the mesh is sutured to the edge of the fascia defect, avoiding placing any sutures through fascia that is not protected by several centimeters of surrounding mesh reinforcement. The adipose and skin are “close” in the routine fashion, trimming redundant or non-viable skin.

1. Not previously in the literature; personal experience by HerniaRegistry.com editor; Bill Welch MD, 2001