Abdominoplasty with Mesh Reinforcement Ventral Herniorrhaphy

Sir: Ventral hernias occur postoperatively in 10 to 20 percent of laparotomies from failed healing or develop spontaneously from architectural deterioration of the abdominal wall.1 Hernias unload the muscle-aponeurosis, allowing it to retract, atrophy, and scar beyond the defect. Occluding only the fascial defect has proven insufficient, and herniorrhaphy has evolved from suture plication to mesh repair. As a result, the reoccurrence rate has been reduced to 12.1 percent in open ventral herniorrhaphy2 and 4.3 percent in laparoscopic ventral herniorrhaphy. An alternate open technique uses an abdominoplasty incision remote from the hernia site. After the flap is elevated, a thorough evaluation of the entire abdominal wall is performed. All hernias are identified, but local suture plication is not required. Instead, the linea alba is plicated uniformly from the sternum to the pubic symphysis, preserving the umbilicus whenever possible. Large mesh is cut into a pentagon shape and sutured under tension to the fascia overlying the anterior superior iliac spine, pubic symphysis, and in the midline cephalad to the umbilicus (Fig. 1). Running sutures attach the mesh inferiorly along the inguinal ligament, transversely along the cephalad edge, and lateral to a vertical line through the anterior superior iliac spine.Fig. 1.: Static mesh lies within the rigid triangle defined by the anterior superior iliac spine (ASIS) bilaterally and the pubic symphysis (PS). Dynamic mesh is powered by the transversalis muscle.A retrospective review of ventral herniorrhaphies in 14 women over 8 years was performed by the authors. There were no reoccurrences, new hernias, or enterotomies. The complications were transient dyspnea in two women and seroma in two others. Weight loss after abdominoplasty with mesh has been reported previously,3 and in this study, 93 percent of patients lost weight postoperatively. Abdominoplasty with mesh reinforcement ventral herniorrhaphy has advantages compared with laparoscopic ventral herniorrhaphy or open ventral herniorrhaphy. Laparoscopic ventral herniorrhaphy requires laparoscopy with possible intraabdominal organ injury, wall injury, adhesions, and mesh erosions. The mesh in abdominoplasty with mesh reinforcement ventral herniorrhaphy increases passive wall tension directly and active wall tension indirectly (Starling's law) over the entire lower abdominal wall, which is subjected to the greatest pressure. Abdominoplasty with mesh reinforcement ventral herniorrhaphy restores lost muscle-aponeurosis function by a dynamic in situ transversalis–to-mesh transfer placed under tension (Fig. 1). The tension in the mesh generates a perpendicular pressure vector directed inward overlying the hernia by the law of Laplace (p = T/r). The mesh in laparoscopic ventral herniorrhaphy or open ventral herniorrhaphy is not placed under muscle tension4 and deforms with loading, which creates shearing at the mesh wall junction and possible recurrence (Fig. 2). The large mesh in abdominoplasty with mesh reinforcement ventral herniorrhaphy treats the hernia abnormality extending beyond the fascial defect and decreases the shearing vector. Ventral hernias are biomechanically analogous to chronic flexor tendon rupture in the hand. Both require interposition grafting under muscle-generated tension to restore function.Fig. 2.: The pressure vectors Pw generated by the wall and Pm generated by the mesh have bisecting (b) and shearing (s) components. Pwb and Pmb are in the same direction and add to opposed intraabdominal pressure. Pms pulls the mesh away from the wall and Pws pulls the wall away from the mesh, causing shearing and possible hernia recurrence. Large mesh, sutured farther from the fascial defect and under tension, increases angle θ. As θ approaches 180 degrees, the shearing vectors Pms and Pws approach 0.Obesity is believed to be a cause of ventral hernia and a risk factor for recurrence.5 An alternate to the cause-and-effect theory postulates that hernias and obesity are two clinical presentations of a single pathologic condition. Hernias are localized, complete wall failure with secondary changes. Obesity may result from generalized wall weakness.3 The authors recommend abdominoplasty with mesh reinforcement for biomechanical failure presenting as hernia or obesity. Gary Horndeski, M.D. Elisa Gonzalez, P.A.-C. Mainland Medical Center Texas City, Texas