Abdominal Wall

Question 1

Steps: Open Lichtenstein Tension-free Herniorrhaphy

Answer 1

1. An oblique skin incision is made 2 fingerbreadths superior to the inguinal ligament and carried through the subcutaneous tissues
2. The external oblique is cut in the direction of its muscle fibers
3. The cord structures are dissected free from the hernia sac
4. The hernia sac and its contents are returned to the abdomen
5. Polypropylene mesh is secured to the pubic tubercle medially, the inguinal ligament inferiorly, and the rectus sheath and internal oblique muscle superiorly
6. The external oblique is reapproximated and the skin closed

Question 2

Potential Pitfall: Open Lichtenstein Tension-free Herniorrhaphy

Answer 2

• The pubic tubercle must be completely covered by the mesh well secured to avoid recurrence
• All 3 nerves (ilioinguinal, iliohypgastric, and genital branch of GF) must be identified and protected throughout case
• Mesh fixation must be tension free
• Avoid injury to the cord structures, and return them to their proper position at the end of case

Question 3

Steps: Component Seperation

Answer 3

1. Remove all prosthetic material and address any bowel issues as necessary
2. Perform complete adhesiolysis of the entire anterior abdominal wall to the paracolic gutters to allow muscular components to slide to the midline during reconstruction
3. Elevate lipocutaneous flaps 2 cm lateral to the linea semilunaris, edge of the rectus muscle
4. Incise the external oblique fascia and seperate the external and internal oblique muscles in avascular plane
5. Continue the dissection 3-4 cm above the costal margin and inferiorly to the inguinal ligament
6. Release the posterior rectus sheath by making an incision 1 cm to the linea alba
7. Develop the retromuscular plane out to the linea semilunaris while preserving the neurovascular bundles to the rectus muscle
8. Place an appropriately sized biologic graft as an underlay, redistributing tension across the graft to help medialize the rectus complex
9. Drains placed over the mesh
10. Midline fascia reapproximated with interrupted Fo8 sutures
11. Remove excess devascularized skin and close over multiple drains

Question 4

Pitfalls: Component Seperation

Answer 4

• Not dissecting the adhesions free from the undersurface of the abdominal wall, which prevents the muscular blocks from medializing after release
• Inadvertent injury to the linea semilunaris, which results in full thickness defect in the lateral abdominal wall and a diff. hernia repair
• Skin flap necrosis from excessive undermining and division of the medial row (periumbilical) perforators

Question 5

Steps: Enterocutaneous Fistula

Answer 5

1. Elliptical incision to encompass the ECF and any inflamed tissue
2. Careful entry into the abdomen in the area with intact fascia, either superior or inferior to ECF
3. Thorough abdominal exploration with complete lysis of adhesions and circumferential dissection of the fistulized segment
4. Resect ECF and any involved abdominal wall, include any foreign body material while preserving as much normal intestine as possible
5. Drainage of any intra-abdominal abscess
6. Restoration of GI continuity by side-side or end-end anastomosis
7. Abdominal wall closure

Question 6

Pitfalls: Enterocutaneous Fistula

Answer 6

• Inadvertent enterotomies or serosal tears during enterolysis
• Uncertainty about the integrity of the SB anastomosis due to significant peritoneal contamination either 2/2 unaddressed abscesses or spillage at the time of fistula takedown, necessitating protective loop enterostomy
• Inability to primarily close fascia at the end of case

Question 7

Steps: Infected Ventral Hernia Mesh

Answer 7

1. Laparotomy in the area of infected mesh
2. Complete LOA and evaluation of bowel and surrounding structures
3. Repair any GI issues as appropriate
4. Excision of all prosthetic mesh taking care to preserve abdominal wall muscles
5. Utilize landmarks such as transfascial sutures or tacks to identify periphery of mesh
6. Repair the resulting hernia defect with primary closure vs. resorbable mesh

Question 8

Pitfalls: Infected Ventral Hernia Mesh

Answer 8

• Underlying GI fistula to mesh
• Unable to remove all prosthetic material due to concern of significant damage to abdominal wall
• Insufficient soft tissue or skin coverage

Question 9

Steps: Postoperative Dehiscence

Answer 9

1. Debride all non-viable fascia
2. Reinforce wound with an absorbable or biologic meshif necessary to achieve tension-free closure
3. Consider temporary abdominal closure for patients at risk of abdominal compartment syndrome

Question 10

Pitfalls: Postoperative Dehiscence

Answer 10

• Inadequate wound debridement due to a concern of not being able to primarily close the wound
• Excessive tension on the wound as this promotes fascial necrosis