Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

Thoracic Region
Midline posterior thoracic wounds after spine surgery can be treated with a variety of flaps. Bilateral
paraspinous muscle advancement flaps are most commonly employed and should be considered a first-
line option. However, there are situations in which the paraspinous muscles may be unavailable or
inadequate for the obliteration of dead space and hardware protection. This could occur in patients who
have had multiple previous spine surgeries, in patients whose paraspinous muscles have been resected in
cases of spinal malignancy, or in patients who have been previously treated with radiation therapy,
leaving the adjacent paraspinous musculature fibrotic and of poor quality. In these scenarios, the
latissimus dorsi muscle can reach the superior midline thoracic back as an advancement flap. If the defect
is along the inferior thoracic back or has a significant volumetric component, then a reverse latissimus
dorsi flap—based on the thoracic and lumbar perforating vessels—may be a better option. 59 Yet another
option, the omentum flap can be tunneled through the retroperitoneum to fill dead space along the
thoracic spine. 60
Locally advanced lung cancers and some primary bone tumors of the vertebra may necessitate a
composite resection of the chest wall and thoracic spine. In this scenario, both anatomic areas will require
soft tissue reconstruction. If a partial or total vertebrectomy has been performed and the pleural space has
been entered, then the spinal cord and chest cavity are in continuity. The natural anatomic separation of
the spinal cord, vertebral hardware, and chest cavity must be re-established by the interposition of
healthy well-vascularized soft tissue. 61 This is usually achieved with a latissimus or trapezius muscle flap
(Figure 94.11). The thoracic spinal cord and hardware are typically protected by the imbrication of
paraspinous muscle flaps. Despite the addition of a spine wound component to the defect, the standard
parameters for skeletal chest wall reconstruction should be sufficient in restoring a normal chest wall
contour and preventing paradoxical ventilation.
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FIGURE 94.11 Posterior spine defect after partial vertebrectomy and composite chest wall resection for sarcoma. A. Defect
with exposed spinal cord at base, posterior instrumentation, and exposed pleural cavity. B. Pleural cavity separated from spinal
cord with a trapezius muscle flap. C. Right latissimus flap for coverage of spinal cord and instrumentation.
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Lumbar and Lumbosacral Region
The paraspinous muscles are the largest and most mobile in the lumbar spine, making them ideally
suited for reconstructions in this area. A second-line option for this area is the reverse latissimus dorsi
muscle or myocutaneous flap, based on the lumbar perforating vessels. If additional dead space
obliteration is needed, a lumbar perforator propeller flap can be dropped into the defect and de-
epithelialized. Lumbar region reconstructions tend to have a higher rate of minor wound healing
complications (seroma, skin edge separation, etc), owing to the more dependent location and lordotic
spinal curvature, which may allow for seroma accumulation. 55 The liberal use of closed suction drains is
encouraged to mitigate seromas.
Reconstructions of the sacral and lumbosacral spine are usually associated with a partial or total
sacrectomy defect. These defects typically require obliteration of dead space for seroma and abscess
prevention and to reduce the chance of a developing perineal hernia. 52 Some plastic surgeons prefer to
place a bridging bioprosthetic mesh in the sacral defect to minimize perineal bulge development;
however, this practice is controversial and has been associated with a higher complication rate. 62 Partial
sacrectomies that are inferior to the sacroiliac joint are technically simpler from a reconstruction
perspective because the entire resection and reconstruction can be performed from a prone, transperineal
approach; these sacrectomies, in general, are at the S3 level or more inferior. Provided that the superior
gluteal vessels are preserved, these defects are reliably reconstructed with either V-Y or rotational
fasciocutaneous advancement flaps or a superior gluteal perforator flap, depending on the mobility of the
soft tissues and cutaneous requirement of the defect (Figure 94.12). A sacrectomy that includes the
sacroiliac joint and/or the S1 or S2 level is much more complex. These resections require both a supine,
trans-abdominal approach as well as a prone, transperineal approach. Moreover, if one or both of the S2
nerve roots are resected, then incontinence is likely. Because of the laparotomy requirement, trans-
abdominal flaps based on the deep inferior epigastric vessels, such as a VRAM, are a good option to
obliterate dead space and resurface the sacrum. Total sacrectomies and partial sacrectomies that include
complete resection of one or both of the sacroiliac joints result in sacropelvic discontinuity. In this
scenario, many surgeons believe that the longevity of the hardware construct may be improved with the
addition of a vascularized bone flap. 52 The free fibula flap is the flap of choice and a variety of branches
from the internal iliac artery and vein are often available for recipient sites. 51 The fibula flap may be used
for large segmental defects, double barreled for added integrity, and as an A-frame strut with loss of the
spinopelvic junction. Free fibula flaps will usually demonstrate radiographic signs of ossification at
6 weeks whereas fibula bone grafts may require 12 months or more for bony union.
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FIGURE 94.12 Posterior defect after partial sacrectomy for sarcoma. A. Defect with exposed spinal cord at base and exposed
viscera of the peritoneal cavity. B. Bilateral gluteal advancement flaps for coverage of defect.
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Outcomes, Complications, and Management
Hardware Exposure
Acute hardware exposure is defined as occurring within 6 months of placement whereas a chronic
exposure occurs more than 6 months after. In general, an acute exposure can be treated with aggressive
debridement, irrigation, muscle flap closure, and culture-directed antibiotics. A chronic exposure is more
difficult and requires removal of the exposed/involved hardware due to the likely presence of a bacterial
biofilm. In chronic infections, all hardware bathed in purulent fluid should be removed; hardware
encased in bone can be left in place. A muscle flap wound closure with numerous drains should be
performed.
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Cerebrospinal Fluid Leak
A CSF leak may become evident after persistent serous drain output from an epidural drain in
combination with the subjective patient complaint of a postural headache. Drainage can be sent to the lab
to test for beta-transferrin, the presence of which is indicative of a CSF leak. Most CSF leaks resolve with
conservative management, such as restricting the patient to the supine or prone position and avoiding
straining. If the leak persists, a lumbar drain or external ventricular drain can be placed to offload
pressure on the leak site with the intention of promoting spontaneous healing. Occasionally, a chronic
occult CSF leak will form a pseudomeningocele, which most often requires operative repair. The dura is
either repaired primarily or with a patch; the 
 repair site can then be reinforced with a muscle flap to
help seal the leak.
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Hematoma
When reconstructing any midline spine wound, drains should be placed deep to the muscle flaps in the
epidural space as well as more superficially, between the skin and muscle closure. When laminectomies
or vertebrectomies have been performed, the epidural drains are especially important because they help
to drain away the excess serosanguinous fluid that, if allowed to accumulate, could cause a certain degree
of cord compression. If a hematoma is suspected in the epidural space, deep to the muscle flap closure,
the patient must be immediately returned to the operating room for evacuation and hemostasis; the
pressure from an unaddressed expanding hematoma could easily injure the cord. 
 Small superficial
hematomas can be left to spontaneously resorb; however, if there is evidence of skin compromise, it must
be drained.
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Conclusion
Large defects of the chest, sternum, and back can result in significant functional impairment and present
major challenges to the reconstructive surgeon. A cohesive multidisciplinary approach with preoperative
communication facilitates and is essential for surgical planning and patient optimization. Adequate
debridement, nutrition, rigid/semirigid stabilization of large defects, and soft tissue coverage are
fundamental principles of this anatomy. A thorough knowledge of local pedicled and free flaps such as
workhorses like the pectoralis major, paraspinous, and latissimus dorsi myocutaneous flap is critical for
sternal and anterior chest wall reconstruction. Prophylactic reconstruction should be considered in high-
risk situations, such as large resections/instrumentations, multiple previous surgeries, significant
devascularization, and extensive patient comorbidities so as to avoid complications before they occur.
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Questions
1. A 62-year-old woman with a history of disseminated breast cancer and spinal metastasis for which
she received an external beam radiation therapy to her spine presents to the emergency room with a
pathologic fracture of T8, and received an emergent titanium rod posterior stabilization by
neurosurgery. Her postoperative course was complicated by incisional dehiscence with purulent
drainage from her wound. Optimal initial management includes:
a. Infectious disease consultation and intravenous broad-spectrum antibiotics for 48 to 72 hours.
b. A bone scan with fluorescence-based leukocyte labeling to determine the extent of infection
and presence of osteomyelitis
c. Operative debridement, irrigation, paraspinous muscle flap coverage of hardware, and wound
specimens to allow for culture-directed antibiotic coverage
d. Neurosurgery consultation for removal of hardware
e. Application of vacuum-assisted closure with antibiotic instillation until demonstration of
healthy granulation tissue and clearance of infection.
2. A 50-year-old woman is diagnosed with a 6 cm, fungating, locally advanced intraductal carcinoma
of the right breast with direct invasion into the pectoralis major and intercostal muscles. A modified
radical mastectomy is planned with resection of the underlying chest wall. The diameter of the
musculoskeletal chest wall defect is 5 cm in diameter. What is the most appropriate reconstructive
strategy?
a. Two-stage breast reconstruction with tissue-expansion, followed by exchange for a permanent
breast implant
b. Polyethylene mesh—methylmethacrylate construct for reconstruction of the skeletal chest
wall followed by free deep inferior epigastric artery perforator flap for breast reconstruction.
c. Pedicled latissimus dorsi muscle flap followed by a split thickness skin graft
d. Bioprosthetic mesh for reconstruction of the skeletal chest wall followed by free anterolateral
thigh flap for chest wall coverage.
3. A 75-year-old male patient requires a coronary artery bypass graft operation in which the left
internal mammary artery and saphenous vein grafts were used. The operation is successful, however
at his 3-week follow up appointment, the cardiac surgeon notes erythema overlying the sternum and
purulent drainage from the incision. You are consulted for recommendations regarding treatment of
this patient’s wound. Optimal initial management includes:
a. Infectious disease consultation and intravenous broad-spectrum antibiotics for 48 to 72 hours.
b. A bone scan with fluorescence-based leukocyte labeling to determine the extent of infection
and presence of osteomyelitis
c. Application of vacuum-assisted closure with antibiotic instillation until demonstration of
healthy granulation tissue and clearance of infection
d. Operative debridement, irrigation, removal of all foreign bodies, followed by eventual
reconstruction with bilateral pectoralis major advancement flaps.
4. A 33-year-old homeless woman is diagnosed with tuberculosis after having an episode of massive
hemoptysis. The thoracic surgeon evaluates her and determines she will require an urgent
pneumonectomy, as the disease is extensive and in danger of eroding into her hilum. A preoperative
work up reveals severe protein malnutrition. You are consulted for immediate reconstruction. What
is the most appropriate reconstructive option?
a. Immediate thoracoplasty after removal of the lung to reduce the size of the pleural cavity and
encourage healing.
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b. Latissimus-sparing thoracotomy followed by intrathoracic transposition of the latissimus
dorsi muscle for reinforcement of the bronchial stump and filling the pleural cavity.
c. Trans-diaphragmatic transposition of a pedicled omental flap for reinforcement of the
bronchial stump and filling the pleural cavity.
d. Respectfully explain to the thoracic surgeon that you do not believe that an immediate wound
reconstruction is necessary.
e. Intrathoracic transposition of the pectoralis major muscle for reinforcement of the bronchial
stump and filling the pleural cavity.
5. A patient undergoes a right partial sacrectomy at the S3 level for resection of a chordoma. What is
the most appropriate reconstructive approach?
a. Elevation of a vertical rectus abdominis myocutaneous flap during the supine-positioned first
stage followed by inset of the flap in the defect during the second prone-positioned stage
b. Right superior gluteal artery perforator flap
c. Left superior gluteal artery perforator flap
d. Bilateral paraspinous muscle flaps.
1. Answer: c. Surgical site infections are common after chest and spinal hardware procedures. The
U.S. Centers for Disease Control and Prevention (CDC) recommends that surgical site infections be
specified as superficial, deep, or organ space infections. The most common organism infecting is S.
aureus, seen in up to 81% of cases; this suggests skin flora contamination during hardware
implantation. In general, hardware removal is not possible after immediate placement to stabilize a
compression fracture. Treatment proceeds with wide operative debridement followed by elevation of
paraspinous muscle flaps for hardware coverage. Wound specimens are taken to allow for culture
directed antibiotic coverage; however, antibiotic treatment alone is insufficient to treat these complex
wounds.
2. Answer: d. Because this chest wall defect is located on the anterior surface and is 5 cm in diameter,
the patient will benefit from reconstruction to minimize paradoxical respiration and maintain a
normal chest wall contour. The fungating nature of this patient’s tumor qualifies her surgical wound
as clean-contaminated according to the Centers for Disease Control. Because of this, she is at a higher
risk for developing a postsurgical wound infection and so synthetic materials should be avoided; a
bioprosthetic mesh is a good option in this situation. The size and locally advanced nature of her
tumor will necessitate post-mastectomy radiation therapy, and so a tissue expander reconstruction
would be inappropriate. Similarly, immediate reconstruction with an autologous abdominal flap
should be reserved for after radiation and complete treatment of her malignancy.
3. Answer: d. Surgical site infections are a known complication after median sternotomy. Certain risk
factors include diabetes, reoperative surgery, diabetes, obesity, and off-midline sternotomy.
Treatment proceeds with wide operative debridement and irritation and removal of all sternal wires
or plates. Wound specimens are taken for culture directed antibiotic coverage; however, antibiotic
treatment alone is insufficient to treat these complex wounds. Once the wound has been adequately
debrided—which may require multiple operations—it is reconstructed with well-vascularized soft
tissue. Although the pectoralis turnover flap nicely fills the wound dead space, a left pectoralis major
turnover flap is not possible in this patient because his left internal mammary artery has been used
for coronary revascularization.
4. Answer: b. This patient is at high risk for developing a bronchopleural fistula after her
pneumonectomy, considering her protein malnutrition, clean-contaminated wound classification,
and severe disease. Therefore, immediate muscle flap reconstruction of the intrathoracic space is
indicated for reinforcing the bronchial stump and filling the non-collapsible pleural cavity with well-
vascularized tissue. The latissimus dorsi muscle provides the most bulk and is therefore the first
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choice, as long as it is preserved by the thoracotomy. Other options include the serratus anterior,
rectus abdominis, pectoralis major, and omental flap.
5. Answer: c. A partial sacrectomy at the S3 level can be performed in a single stage, all from the
prone position. Sacrectomies requiring resection at the S1 or S2 level will require an initial anterior,
supine-positioned approach, making the VRAM flap a better option in that scenario. The superior
gluteal vessels are often ligated on the side of the sacrectomy, therefore a right SGAP flap is not
appropriate. The paraspinous muscles terminate at L5 and are not appropriate for sacral
reconstruction.
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References
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titanium MatrixRIB (Synthes) system. J Thorac Cardiovasc Surg. 2013;146:e37-e40.
Ng, CS, Ho, AM, Lau, RW, Wong, RH. Chest wall reconstruction with MatrixRib system: avoiding pitfalls. Interact Cardiovasc Thorac Surg.
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article with the largest series to date on chest wall reconstruction, spanning a period of 18 years. The authors describe various techniques for skeletal
and soft tissue chest wall reconstruction.
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Arya, R, Chow, WT, Rozen, WM, et al. Microsurgical reconstruction of large oncologic chest wall defects for locally advanced breast cancer
or osteoradionecrosis: a retrospective review of 26 cases over a 5-year period. J Reconstr Microsurg. 2016;3:121-127.
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dorsi myocutaneous flap. Am Surg. 1983;49:608-611.
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Prevosti, LG, Subramainian, VA, Rothaus, KO, et al. A comparison of the open and closed methods in the initial treatment of sternal wound
infections. J Cardiovasc Surg. 1989;30:757-763.
Pairolero, PC, Arnold, PG. Management of infected median sternotomy wounds. Ann Thorac Surg. 1986;42:1-2.Seminal article describing the
three types of infected median sternotomy wounds and the associated management strategies for each.
Song, DH, Wu, LC, Lohman, RF, et al. Vacuum assisted closure for the treatment of sternal wounds: the bridge between debridement and
definitive closure. Plast Reconstr Surg. 2003;111:92-97.
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2004;26:367-372.
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Butterworth, JA, Garvey, PB, Baumann, DP, et al. Optimizing reconstruction of oncologic sternectomy defects based on surgical outcomes. J
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Abolhoda, A, Bui, TD, Milliken, JC, Wirth, GA. Pedicled latissimus dorsi muscle flap: routine use in high-risk thoracic surgery. Tex Heart Inst
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1990;211:656-660.
Garvey, PB, Rhines, LD, Dong, W, Chang, DW. Immediate soft-tissue reconstruction for complex defects of the spine following surgery for
spinal neoplasms. Plast Reconstr Surg. 2010;125:1460-1466.This article demonstrates that complex wounds of the spine benefit from immediate soft
tissue reconstruction. Despite 65% of patients having had previous radiation, there was only a 12% rate of major wound complications and no wounds
required hardware removal.
Chang, DW, Friel, MT, Youssef, AA. Reconstructive strategies in soft tissue reconstruction after resection of spinal neoplasms. Spine (Phila Pa
1976). 2007;32:1101-1106.
Dumanian, GA, Ondra, SL, Liu, J, et al. Muscle flap salvage of spine wounds with soft tissue defects or infection. Spine (Phila Pa 1976).
2003;28:1203-1211.
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instrumentation for thoracic/thoracolumbar kyphosis. Spine (Phila Pa 1976). 2005;30:1594-1601.
Clemens, MD, Chang, EI, Lewis, V, Chang, D. Composite extremity and trunk reconstruction with vascularized fibula flap in post-oncologic
bone defects: a 10 year experience. Plast Reconstr Surg. 2012;129:170-178.
Houdek, MT, Rose, PS, Bakri, K, et al. Outcomes and complications of reconstruction with use of free vascularized fibular graft for spinal and
pelvic defects following resection of a malignant tumor. J Bone Joint Surg Am. 2017;99A:e69.
Moran, SL, Bakri, K, Mardini, S, et al. The use of vascularized fibular grafts for the reconstruction of spinal and sacral defects. Microsurgery.
2009;29:393-400.
Mericli, AF, Tarola, NA, Moore, JH Jr, et al. Paraspinous muscle flap reconstruction of complex midline back wounds: risk factors and
postreconstruction complications. Ann Plast Surg. 2010;65:219-224.Largest series to-date on paraspinous muscle flaps for spinal wound
reconstruction. This article identifies several risk factors for wound healing complications after reconstruction, including a history of multiple previous
spine surgeries, hardware removal, and lumbar location.
Mericli, AF, Moore, JH Jr, Copit, SE, et al. Technical changes in paraspinous muscle flap surgery have increased salvage rates of infected
spinal wounds. Eplasty. 2008;8:e50.
Mericli, AF, Mirzabeigi, MN, Moore, JH Jr, et al. Reconstruction of complex posterior cervical spine wounds using the paraspinous muscle
flap. Plast Reconstr Surg. 2011;128:148-153.Article demonstrating the efficacy of paraspinous muscle flaps for reconstruction of posterior cervical
wounds. The authors introduce their technique and report an acceptable complication rate.
Disa, JJ, Smith, AW, Bilsky, MH. Management of radiated reoperative wounds of the cervicothoracic spine: the role of the trapezius turnover
flap. Ann Plast Surg. 2001;47:394-397.
Sadigh, PL, Chang, LR, Hsieh, CH, et al. The trapezius perforator flap: an underused but versatile option in the reconstruction of local and
distant soft-tissue defects. Plast Reconstr Surg. 2014;134:449e-456e.
McGeorge, DD, Stilwell, JH. The use of the reverse latissimus dorsi flap in the closure of lower spinal defects. Z Kinderchir. 1988;43(suppl
2):30-32.
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Pa 1976). 2007;32:3074-3080.
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Atkin, G, Mathur, P, Harrison, R . Mesh repair of sacral hernia following sacrectomy. J R Soc Med. 2003;96(1):28-30.
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C H A P T E R 9 5
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Abdominal Wall Reconstruction
Brett T. Phillips and Howard Levinson
Key Points
By addressing patient modifiable risk factors, such as hemoglobin A1C, obesity, nutrition, and
tobacco preoperatively, postoperative outcomes are likely to be optimized.
Hernia mesh reduces hernia recurrence by about 50%.
Mesh and graft selection is a continuously evolving field with great controversy, but, in general,
lightweight meshes and microporous meshes have lost favor because of their adverse effects.
Surgical techniques vary widely, and with the exception of a few specific approaches, such as small
bites 5 mm apart, 5 mm from the fascia edge to close laparotomy wounds, there are many reasonably
good options for reconstructing the abdominal wall.
Prophylactic hernia mesh or graft is an emerging field that will likely become a part of abdominal
wall reconstruction.
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Definition of Hernia, Bulge, and Diastasis Recti
An abdominal wall hernia is defined as a defect in the abdominal wall fascia or musculature through
which intra-abdominal contents protrude. In general, the goal of hernia surgery is to restore normal
muscle anatomy and maintain the muscles in normal alignment. Common examples of hernia include
ventral, inguinal, lumbar, Spigellan, umbilical, paraesophageal, diaphragmatic, and femoral (Table 95.1).
Ventral hernia in adults is the most common hernia a plastic surgeon will typically manage, so it will be
the focus of this chapter. An abdominal wall bulge is a weakness in the abdominal wall musculature
where abdominal wall anatomy is normal but the muscles are denervated. Bulges typically form from
previous surgery causing nerve injury or from an inability to restore normal muscle anatomy but may
also be caused by neuromuscular disease. Diastasis recti is a widening of the linea alba fascia with
lateralization of the rectus abdominis muscles but no fascial defect. Hernia, bulge, and diastasis recti are
often differentiated by a combination of history, physical exam, and sometimes imaging.
TABLE 95.1
Abdominal Wall and Trunk Hernias
Hernia
Definition/Anatomic Location
Direct inguinal
Inguinal canal through direct fascial defect, medial to epigastric vessels
Indirect inguinal
Inguinal canal through deep inguinal ring, lateral to epigastric vessels
Femoral
Femoral canal, deep to inguinal ligament, medial to femoral vein
Umbilical
Fascial defect at umbilical stalk
Epigastric
General term for fascial defect in superomedial abdominal wall
Incisional
Fascial defect as a result of previous surgery
Ventral
General term for fascial defect of the abdominal wall
Parastomal
Enlarged fascial defect surrounding an ostomy site
Hiatal
Paraesophageal diaphragmatic defect or weakness
Reducible
Hernia defect in which contents can be manually relocated into the organ space
Nonreducible
Hernia defect in which contents are fixed and cannot be manually relocated into the organ space
Incarcerated
Nonreducible hernia that may cause pain and bowel obstruction
Strangulated
Incarcerated hernia with compromised blood supply
Sliding
Hernia defect in which a portion of the hernia sac is formed by another viscus (i.e., colon, stomach)
Littre
Hernia that contains a Meckel’s diverticulum, omphalomesenteric duct hernia
Amyand
Hernia that contains the appendix
Obturator
Pelvic floor hernia defect through the obturator foramen
Petit
Posterior lateral inferior lumbar triangle hernia; borders are external oblique, iliac crest, latissimus dorsi
Grynfeltt
Posterior lateral superior lumbar triangle hernia; borders are internal oblique, quadratus lumborum, 12th rib
Cooper
Femoral hernia with two sacs, one protruding through the superficial fascia
Pantaloon
Combined indirect and direct inguinal hernia; two sacs
Spigelian
Hernia defect along semilunar line, at the lateral border of the rectus muscle
Richter
Hernia defect that contains only the antimesenteric border of bowel
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Epidemiology
Approximately two million laparotomies are performed annually in the United States, with ventral
hernia being a frequent complication in 10% to 30% of patients. 1–5 The timing of hernia recurrence is not
well understood and there is likely a range of months to years from when they may recur. 6 The 10-year
ventral hernia recurrence rate ranges from 63% without mesh to 32% when a mesh is added to a repair. 7–9
Approximately 350,000 ventral hernia repairs are performed each year in the United States and
practically all include the use of a hernia mesh. 10 Given the above complication rate, incidence of ventral
hernia repair, and average cost/patient for each hernia operation in the United States (in 2006, this
amount was ∼$15,899), an estimated $3 to $6 billion is spent annually on these operations. 10 However,
these numbers underestimate recurrence rates in the rapidly growing morbidly obese population in the
United States. 11,12 With significant increases in the morbidly obese population, ventral hernia formation is
expected to significantly increase as well. 13 In fact, this industry is on the cusp of a giant boom as several
publications, including a recent landmark paper in the Lancet, support the use of hernia mesh
prophylactically in high risk undergoing laparotomy to prevent hernia occurrence. 14
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Anatomy
Muscle/Fascia Anatomy
The abdominal wall is a multilayered structure composed of skin, subcutaneous fat, muscle, nerves,
blood vessels, and fascia (Figure 95.1). Its function is to provide structural support and mobility of the
trunk and to protect underlying abdominal organs. 15 In terms of musculofascial anatomy, the linea alba is
central fascia between the paired recti and the semilunar line is the lateral border of the recti. The recti
originate from the symphysis pubis and the pubic crest and insert onto the fifth, sixth, and seventh costal
cartilages and the xiphoid process. They are encased in an anterior and a posterior rectus sheath. The
arcuate line is a horizontal line below the umbilicus that demarcates the lower limit of the posterior rectus
sheath, and it is also where the inferior epigastric vessels perforate the rectus abdominis. The anterior
rectus sheath is composed of two overlapping fascia layers that are continuations of the external oblique
aponeurosis and internal oblique aponeurosis, respectively. The posterior rectus sheath, cephalad to the
arcuate line, is also composed of two overlapping fascia layers that are continuations of the internal
oblique aponeurosis (the internal oblique aponeurosis splits into an anterior and a posterior layer at the
semilunar line to envelope the recti) and the transversalis fascia. The muscular/fascial layers lateral to the
semilunar line (from superficial to deep) include the external oblique aponeurosis, external oblique
musculature, internal oblique aponeurosis internal oblique musculature, transversalis fascia, and
transversus abdominis. External oblique flaps can be raised between the internal and external oblique
muscles. Posterior to the transversalis fascia is the parietal peritoneum.
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FIGURE 95.1 Abdominal wall anatomy and innervation.
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Nerve Anatomy
Understanding the path of nerves and preserving them during surgery is critically important to prevent
postoperative denervation and bulges. If nerves are injured, bulges will occur and bulges are difficult to
manage because adynamic fabric or scar underperforms innervated muscle. The rectus muscle is
innervated by the lower intercostal and lumbar neurovascular bundles traveling between the internal
oblique and transversus abdominis muscles and is a target for regional nerve blocks. They enter the
rectus sheath laterally and pierce and innervate the rectus muscle and can be injured during dissection
leading to bulges.
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Vascular Anatomy
Blood supply of the abdominal wall comes from the distal internal mammary vessels and multiple
perforating vessels from the iliac and femoral vessels. Understanding the blood supply of the abdominal
wall and the superior thigh is important because it is the basis of local flap reconstruction. The deep
inferior epigastric vessels are critical for blood supply of the abdominal wall and are often the donor
vessel for abdominal autologous tissue reconstruction. The superior epigastric artery is the inferior
extension of the internal mammary artery and is critical for superior-based rectus pedicle flap that can be
used for superior abdominal, back, and chest wall reconstruction. The superior artery runs the length of
the rectus muscle and joins the deep inferior epigastric artery that originates from the external iliac artery
superior to the inguinal ligament. Inferiorly based abdominal wall flaps can be used for breast (i.e., free
transverse rectus abdominis myocutaneous), groin, thigh, and abdominal wall reconstruction. Branches
of the common, superficial and profundal femoral arteries will supply options for superior thigh flaps
that can be rotated superiorly to assist with middle and lower abdominal wall reconstruction.
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Pathophysiology
There are multiple risk factors that affect outcomes of ventral hernia repair, and these factors should be
considered for each patient before surgery. Some of these risk factors are modifiable, in which case
surgery may be delayed until after the risks have been managed. In many cases, the risks cannot be
reduced but recognition of risk factors nonetheless helps predict outcomes and enhances informed
consent. Below, risk factors are classified according to three areas: intrinsic factors, extrinsic factors, and
technical factors.
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Intrinsic Factors
Intrinsic factors are biologic factors specific to the patient such as collagen disorders; Ehlers Danlos and
Marfan syndrome and neurologic diseases such as amyotrophic lateral sclerosis or shingles may weaken
the abdominal wall musculature. 16 Although intrinsic factors are not necessarily modifiable, awareness
may help with the decision to proceed to surgery. Some surgeons may use additional fixation techniques
during repair to enhance outcomes.
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Extrinsic Factors
Extrinsic factors are comorbid conditions and medications that adversely affect wound healing. These
include but are not limited to tobacco (modifiable), corticosteroids (potentially modifiable), abdominal
aortic aneurysm, surgical site infection, chronic obstructive pulmonary disease, multiple surgeries,
chemotherapy agents (potentially modifiable), immunodeficiency, radiation, uncontrolled diabetes
(potentially modifiable), morbid obesity (potentially modifiable), parastomal hernias, and nutritional
status (potentially modifiable). 17 The reader is referred to the literature for a deeper understanding of
each factor because space is limited here.
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Technical Factors
Technical factors are surgical performance, hernia mesh (graft or textile) selection, and anchoring
techniques. Many of these technical factors are widely debated; yet, there are a few agreed upon
principles listed below. In terms of surgical performance, a recent prospective, multicenter, double-blind,
randomized controlled trial demonstrated that small tissue bites of 5 mm every 5 mm with 2-0 absorbable
suture lead to fewer hernias (13%) versus large tissue bites of 1 cm every 1 cm (21%). 18–20 In terms of mesh
selection, lightweight meshes have been associated with ventral hernia recurrence because of mesh
tearing, 21 whereas moderate-weight and heavy-weight meshes do not appear to be at risk of tearing.
Degradable meshes are significantly more expensive than nondegradable meshes but purportedly safer
for use in clean-contaminated and contaminated cases, but these benefits are questionable, 22–24
particularly in bridging (rectus muscle cannot be reapproximated in the midline) repair. Mesh fixation
technique is also critically important in preventing recurrence. An increased number of fixation points do
not necessarily distribute tension across the abdominal wall. One study revealed that more than three
fixation points along a 7-cm region does not increase bursting strength. 25 Therefore, sutures should be
placed approximately 1 to 2 cm apart circumferentially around the mesh. A final point to consider is that,
even with modification of technical factors, ∼>20% of ventral hernia repairs recur and this is most often
due to failure at the mesh, suture, and tissue interface from suture cheese wiring through the tissue or
through the mesh. 26,27
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Diagnosis
History
A thorough history and physical exam is helpful in diagnosing ventral hernias. The most common
predictor of ventral hernia is previous abdominal surgery. Patients with signs and symptoms of a ventral
hernia may present for elective or emergent repair. In general, surgery is indicated for all ventral hernias
but not all patients are good candidates for surgery. 28 A special note is made for postpartum women who
develop new onset abdominal bulges. These bulges are typically not hernias but rather diastasis recti
from pregnancy. Although diastasis recti condition is an anatomic abnormality, there is no hernia so the
disease is classified as cosmetic rather than reconstructive. Care should also be taken in the patient with a
history of a pelvic malignancy because the patient may have received radiation through the abdominal
wall—a fact can be overlooked in the history. Operating on an irradiated abdominal wall can lead to
challenging complications.
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Physical Exam
Abdominal Wall
Examination of the abdomen for surgical scars and obvious bulges is done during the initial evaluation.
Common physical exam findings, which are typically best done with the patient lying flat yet flexing
their abdominal wall muscles by raising their shoulders from midline hernia or twisting for flank hernias,
are a separation of muscle edges and pain on palpation. Performing a Valsalva maneuver may also
elucidate an incidental hernia. Of course, hernias may be difficult to ascertain in the morbidly obese
patient whose occult hernias may surprisingly be encountered at the time of panniculectomy if imaging
has not been completed.
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Laboratory Assessment
Depending on a patient’s medical and surgical history, additional testing may be required. In a diabetic
patient, hemoglobin A1C should be obtained to ascertain proper glycemic control. If nutrition is a
concern, a nutrition evaluation can be obtained before elective surgery. Patients with respiratory disease
may need pulmonary function tests to assess lung capacities. Patients with a history of tobacco use may
be tested for cessation by assessing urine cotinine.
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Imaging
Routine imaging surveillance, including CT scan, MRI, or ultrasound may identify asymptomatic ventral
hernias or recurrences from previous abdominal surgery. Imaging is more reliable at diagnosing
incisional hernias than physical exam. The caveat is that asymptomatic hernias not found on clinical exam
require treatment. 19 The disadvantage to utilize CT scans is increased cost and radiation exposure.
Ultrasound is user dependent but is more accessible and cheaper than CT and there is no radiation.
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Emergency Versus Elective Surgery
Emergent need for ventral hernia repair is most commonly found in the setting of bowel obstruction or
following abdominal trauma. Patients with bowel obstruction may complain of distension, abdominal
pain, nausea, vomiting, absent flatus, or absent bowel movements. Abdominal findings include
tenderness, distension, obvious mass or bulge, tympany, or overlying skin changes. Hernia contents can
be reduced back through the fascial defect are considered reducible. An incarcerated hernia is a
nonreducible hernia that may contain bowel but has no findings of vascular compromise. A strangulated
hernia is a nonreducible hernia in which the blood supply to the hernia contents is obstructed and will
result in necrosis if not repaired. Depending on the clinical situation, hernia repair may be performed
during the initial surgery or in a delayed fashion. Obviously, trauma patients with an open, distended
abdominal will have their hernia repaired in a delayed fashion, and these cases are typically complicated.
Elective ventral hernia repair is performed to relieve symptoms, improve abdominal wall appearance,
prevent need for emergent surgical intervention, and improve quality of life. Hernia repair is often
performed as a combined procedure with other surgical services, or it may be scheduled in a delayed
fashion if the abdomen cannot be closed from the initial operation because of abdominal compartment
syndrome, need for second look operation, or transplant mismatches, for example.
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Patient-centered Outcome Tools
Over the past decade, there have emerged several patient-centered areas of investigation and tool
development to measure and improve surgical outcomes, including quality-of-life scales, patient
registries, and preoperative risk assessment tools. These areas continually mature and rapidly evolve.
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Quality of Life Scales
There are a number of validated scales to measure patient-related outcomes following ventral hernia
repair, these include but are not limited to generic Short Form-36 (SF-36), and disease specific hernia-

related quality-of-life assessment tool (HerQLes), and Carolinas Comfort Scale. 29 The generic SF-36 is
useful to compare outcomes across different populations and interventions for cost-effectiveness studies,
but it is less effective at assessing disease specific concerns. The Carolinas comfort scale is designed to
measure quality of life after mesh implantation during hernia repair, so it cannot measure longitudinal
outcomes because patients do not have mesh before surgery, whereas the HerQLes scale is meant to
measure abdominal wall function pre- and postoperatively. The two scales complement each other. 29
This 12-question tool with questions related to activities of daily living found improvement in quality of
life from preoperative to postoperative patients in as short as 4 weeks postoperatively.
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Registries
The two best-known national registries are the National Surgical Quality Improvement Program from the
American College of Surgeons, American Hernia Society Quality Collaborative from the American
Hernia Society. These two widely used databases collect data from across the United States and the
databases are available for inquiry. Each database has led to a number of publications, and this number is
likely to increase exponentially over the years and big data systematically grows. Peer-reviewed studies
have shown that both registries are effective in improving the quality of surgical care.
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Risk Analysis
Risk analysis tools are intended to be used by patients and physicians preoperatively to inform both
about predicted outcomes. Each of these tools calculates clinical outcomes from a database and the
fidelity of the tools will obviously increase as the databases grow. From the Americas Hernia Society
Quality Collaborative (AHSQC) registries come the outcomes reporting app for clinician and patient
engagement (ORACLE). The AHSQC ORACLE uses preoperative and intraoperative information to
estimate important 30-day and 1-year outcomes following elective ventral hernia repair using mesh. From
the Charlotte Carolina group comes the Carolinas Equation for Quality of Life (CeQOL). The CeQOL
predicts the chances of having chronic pain after inguinal hernia repair. The same group has also created
the Carolinas Equation for Determining Associated Risks (CeDAR). This free app predicts a patient’s risk
for wound-related problems and associated costs following ventral hernia repair.
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Use of Mesh in Hernia Repairs
Mesh and Graft Selection
There are a wide variety of hernia meshes or grafts that one can choose from for repair. They can be
classified according to material (e.g., polypropylene, polyester, poly-4-hydroxybutyrate, poly-l-lactic acid,
expanded polytetrafluoroethylene, or animal tissue), manufacturing approach (e.g., knitting or weaving
of textiles versus tissue processing (allografts and xenografts)), presence of antiadhesive coating, physical
characteristics (e.g., for textiles this includes pore size, filament diameter, thickness, areal density (this
parameter differentiates light-weight, moderate-weight, and heavy-weight meshes)), and permanence
(nondegradable versus degradable). For any given knitted or woven textile, the fabrics physical
characteristics will vary according to the diameter of filament used to create the textile (typical filament
diameters range between 100 and 150 µm) and the knit or weave structure. Physical characteristics,
material selection, and manufacturing approach together affect the textiles mechanical performance (e.g.,
ball burst, suture retention strength, tear resistance, and stress strain). Current thinking on the clinical
relevance of physical characteristics, material selection, manufacturing approach, and mechanical
performance is briefly described later, with the understanding that the field is constantly advancing and
concepts will become outdated.
The first consideration in choosing a product is whether to choose a textile or a graft. All hernia grafts
degrade whereas many synthetic hernia textiles do not. Although each specific graft has its differentiating
factors, it is difficult to state that any one graft has a clear competitive advantage over another graft.
Hernia grafts were popularized in the 1990s as a means to overcome mesh infection because there was a
belief that these were either resistant to infection or would degrade during an infection so there would
not be a need to remove these at a second operation. 30 There was also a belief that grafts led to a more
durable repair than a textile. These topics are still hotly debated. In 2010, a Ventral Hernia Working
Group published consensus guidelines concluding that hernia grafts are appropriate for use in patients at
high risk for a surgical site occurrence (e.g., clean-contaminated or contaminated cases) and most
surgeons would probably agree with this approach. 31 The main disadvantages to using a hernia graft are
that they are orders of magnitude more expensive than synthetic meshes and they lose their mechanical
properties as they degrade. In general, the purpose of a synthetic degradable textile is to replace the use
of grafts with a less-expensive textile.
The second consideration is whether to use a textile with an antiadhesive coating. Currently, mesh
labeling contains warnings that meshes should not be placed in direct contact with the viscera because
they may cause erosion, adhesion, fistula formation, or lead to sepsis. This labeling creates a surgical
conundrum because meshes are often needed to treat bridging hernias defects. The purpose of an
antiadhesive coating is to prevent viscera from adhering to mesh, so most surgeons would use a textile
with an antiadhesive coating when bridging a fascia defect or when placing the mesh in a location where
it could contact viscera.
Finally, when it comes to choosing a specific mesh for ventral hernia repair, all FDA cleared meshes have
met mechanical performance metrics and these metrics appear to meet all clinical needs. There have been
a few case reports of lightweight mesh tearing. So, many surgeons prefer moderate-to-heavy weight
meshes. 32 In terms of which moderate- or heavy-weight mesh to choose, each mesh will have its specific
advantages but it is difficult to state that any mesh is superior to another. In general, there is a belief that
it is advantageous to choose a mesh with the largest pores because large-pore meshes have less material,
which clinically related to less chance of infection and less pain because of reduced inflammation. 33
Oftentimes, mesh availability and surgeon preference lead to device selection. Perhaps, the greatest
deficiency in mesh today is not which mesh to use but rather how to anchor mesh to tissue. 34 Many
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surgeons use suture, glue, tacks, or screws to anchor meshes; yet, despite these various approaches failure
at the anchor point is common and ventral hernias recur in ∼20% of patients. Some groups have
invented novel sutures, meshes, and adjuncts in an attempt to overcome this problem, but these products
are still under development. 27,35,36 Care should be taken in using permanent mesh in patients who grow
show as children or women of child-bearing age.
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Anatomic Mesh Placement
The most common locations for mesh placement are as follows 37 (Figure 95.2):
Onlay: anterior to the anterior rectus sheath
Retrorectus: between the recti and posterior rectus sheath
Preperitoneal: posterior to the posterior rectus sheath but anterior to the peritoneum
Intraperitoneal: within the abdomen
FIGURE 95.2 Anatomic mesh placement.
Care should be taken when placing a mesh intraperitoneally, because the bowel may come into contact
with the mesh, leading to adhesions, erosions, sepsis, and fistula.
In almost all instances, the goal is to restore the recti to their normal anatomic position and to add mesh
to bolster the repair, whichever tissue plane is chosen. In select patients, the rectus muscles may not be
able to be reapproximated in the midline at the time of hernia repair, in which case a mesh or graft would
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bridge the defect. In a bridged repair, the mesh serves as surrogate abdominal wall to prevent
evisceration. Because the mesh or graft is adynamic, it is inferior to an anatomic repair. Use of a
degradable mesh in bridge repair has a high incidence of hernia recurrence. 38
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Mesh Controversies
Mesh type and location continue to be controversial to this day. Literature supports and contradicts itself
and varies among geographic locations and patient populations. Because of this ongoing debate, specific
recommendations for the location of mesh placement and in what clinical situations should specific mesh
types be placed, continue to be based on personal experience and interpretation of the literature. The
Ventral Hernia Working Group classified patients into four groups—clean, clean-contaminated,
contaminated, dirty—based on contamination, complication risk, and mesh recommendations. They
recommend the use of prosthetic mesh in all cases of incisional hernia repair except in situations of gross
contamination. Bioprosthetic mesh was recommended in patients with medical comorbidities or any
gross contamination. 31,39 Another recent multicentered retrospective review actually found that synthetic
mesh when placed in a sublay position had decreased surgical site occurrences and decreased hernia
recurrence rates compared with biologic mesh. High-level evidence with randomized prospective
multicenter trials is needed to solve this ongoing debate. 22
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Hernia Repair Technique
Hernia repair techniques vary widely and there are oftentimes more opinions than surgeons. A few of the
more commonly debated topics are listed below with evidence where applicable.
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Suturing Techniques in Laparotomy Closure
A slowly absorbable or permanent monofilament running suture in small bite increments is
recommended for primary fascial closure. Smaller bites that are <10 mm from the wound edge are
obtained by using a smaller needle at smaller 5 mm intervals. Increased smaller bites and avoiding
excessive suture tension will improve the suture length to wound length ratio to above 4. 20,40
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Mesh and Suture
Mesh placement is generally secured where the mesh overlaps the fascia by 3 to 5 cm in all directions. Of
course, some studies suggest much wider overlap. There are a variety of techniques used to anchor the
mesh including, glue, tacks, screws, and suture. Whichever technique is chosen, the surgeon should keep
in mind that a durable repair is paramount. There are insufficient data to suggest that one type of suture
is superior to another.
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Component Separation
Ramirez described component separation in 1990 with the purpose of realigning the recti in the midline
without the use of mesh or local flaps. 41,42 The rationale to the component separation is to release the
lateral pulling or retracted oblique muscles, allowing the recti to centralize, without damaging the recti
nerves or destabilizing the abdominal wall. The original paper describes relaxing incisions that are made
2 cm lateral to the rectus sheath through the external oblique fascia. The incision is made from costal
margin to inguinal ligament. An avascular plane is developed between the external and internal oblique
muscles. The posterior rectus sheath is released from the rectus muscles to obtain medialization of the
recti 5 cm in epigastrium, 10 cm at the umbilicus, and 3 cm at the suprapubic region. Since the original
publication in 1990, component separation has gained traction in the field and the addition of mesh
further enhances the repair. 43 Previous stoma or surgery through the rectus muscle is not an absolute
contraindication to component separation. 44
Multiple adaptations of the original component separation have taken place since its original description,
including general surgery laparoscopic and plastic surgery limited open approaches. The goal of these
adaptations is to provide the same release while limiting dissection to reduce seroma formation and skin
necrosis. Umbilical perforator sparing endoscopic techniques, creation of lateral tunnel incisions to
provide external oblique aponeurosis release, and the laparoscopic transversus abdominis muscle release
are a few examples of these approaches. 37,45
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Laparoscopic/Open Incisional Hernia Repair
Laparoscopic hernia repair with mesh was first reported in 1993 by Leblanc and colleagues. 46 A recent
meta-analysis of several randomized controlled trials found that laparoscopic and open incisional hernia
repairs with mesh had comparable outcomes including recurrence rates less than 10%. 47
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Local/Regional Flaps
Local and regional flaps for abdominal wall reconstruction are a special class of hernia cases that, in the
adult, often occur following trauma or tumor resection. Fasciocutaneous, myocutaneous, and muscle
flaps derive from the abdomen, back, and thighs. The most common flaps are listed in Table 95.2, where
they have been categorized according to upper third, middle third, and lower third reconstruction. In
general, lower and middle defects have thigh-based flaps available for reconstruction whereas the upper
abdomen is limited to local tissue and the latissimus muscle. Defects of the epigastric and xiphoid regions
pose the greatest challenges. In general, tissue expansion does not work well for abdominal wall
reconstruction unless expanders are placed above a stable bone platform like ribs or pelvis.
TABLE 95.2
Pedicle Flaps for Abdominal Wall Reconstruction 37,39
Location and Pedicle
Flap
Blood Supply
Flap Characteristics
Upper Third
Rectus abdominis
Superior epigastric
Inferior or superiorly based flap to cover wounds from chest wall,
abdomen, groin, and perineum
Vertical, horizontal, or oblique skin paddle orientations
External oblique
Lateral intercostal perforators
Ideal for lower chest wall and upper third abdominal defects due to arc of
rotation
Latissimus dorsi
Thoracodorsal
Muscle or myocutaneous flap with large arc of rotation to reach
superolateral abdominal wall defects
Omentum
Right gastroepiploic
May not be available in patients with previous intra-abdominal surgery or
pathology
Requires persistent abdominal wall defect to pedicle the flap
Can provide soft tissue coverage for various abdominal wall defects, cover
with skin graft
Middle Third
Rectus abdominis
Superior or deep inferior
epigastric
Inferior or superiorly based flap to cover wounds from chest wall,
abdomen, groin, and perineum
Vertical, horizontal, or oblique skin paddle orientations
External oblique
Lateral branches of posterior
intercostal perforators
Ideal for lower chest wall and upper third abdominal defects due to arc of
rotation
Medial flap advancement for medial abdominal wall wounds
Tensor fasciae latae
Ascending branch of lateral
circumflex femoral
Large skin paddle, distal flap prone to necrosis, fascial use for abdominal
wall support
Anterior lateral
thigh/vastus lateralis
Descending branch of lateral
circumflex femoral
Large flap that usually reaches to umbilicus without difficulty, minimal
donor-site morbidity
Fascia can be used for abdominal wall fascial reconstruction
Anterior medial
thigh/rectus femoris
Descending branch of lateral
circumflex femoral
Muscle or myocutaneous flap that can be used alone or combined with
anterolateral thigh flap or vastus lateralis
Lower Third
Rectus abdominis
Deep inferior epigastric
Inferior or superiorly based flap to cover wounds from chest wall,
abdomen, groin, and perineum
Vertical, horizontal, or oblique skin paddle orientations
Internal oblique
Deep circumflex iliac
Limited arc of rotation, myocutaneous flap
Tensor fasciae latae
Ascending branch of lateral
circumflex femoral
Large skin paddle, distal flap prone to necrosis, fascial use for abdominal
wall support
Anterior lateral
thigh/vastus lateralis
Descending branch of lateral
circumflex femoral
Large flap that usually reaches to umbilicus without difficulty, minimal
donor-site morbidity
Fascia can be used for abdominal wall fascial reconstruction
Anterior medial
thigh/rectus femoris
Descending branch of lateral
circumflex femoral
Muscle or myocutaneous flap that can be used alone or combined with
anterolateral thigh flap or vastus lateralis
Gracilis
Medial circumflex femoral
Small muscle or myocutaneous flap that could be used for inferior
abdominal wall, groin, or perineal wounds
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Free Flaps
The same flaps that are listed as local rotational flaps can also be used as free tissue transfer. Typically,
free flaps are indicated for very large epigastric defects that are difficult to cover with pedicled flaps.
Recipient vessels could include superior and inferior epigastric vessels, and superficial or deep circumflex
iliac vessels. If these vessels are not available, then vein grafts could be used to gain access to internal
mammary recipient vessels. Intra-abdominal gastroepiploic vessels have also been used as recipient
vessels when other vessels are not available. Functional free tissue transfer can also be done with an
innervated chimeric anterolateral thigh, rectus femoris, and tensor fascia lata (TFL) flaps, but the long-
term results of these approaches are unknown. 39
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Abdominal Wall Transplant
A special consideration in abdominal wall reconstruction is patients with massive abdominal wall defects
who have lost most of their muscle. These patients may be considered candidates for composite tissue
allotransplantation. To be a candidate for allotransplantation, the patient should be actively taking
immunosuppressive
therapy
for
other
transplanted
organs.
The
reason
for
this
is
that
immunosuppression has been associated with de novo cancer formation and death. Abdominal wall
transplantation is still considered experimental with less than 25 cases performed worldwide since 1994
and should only be performed in centers that have the necessary multidisciplinary teams in place. 39
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Prophylactic Hernia Prevention
Recent studies suggest that there is a role for application of mesh or graft at the time of laparotomy
closure in high-risk patients to prevent hernia formation. This is a relatively new concept that is gaining
traction with a number of quality clinical trials. In a couple of meta-analyses of clinical trials of elective
primary midline laparotomy patients, onlay mesh placement was found to have the least hernia
occurrence rates compared to primary suture repair and sublay mesh placement. Onlay mesh repair was
found to have higher seroma rates due to the increased subcutaneous tissue elevation. 14,48–50
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