Overview of Operative Approaches and Staging Systems for Ventral/Incisional Hernia Repairs
Creating a common language for surgeons to discuss ventral hernias, including the techniques for repair and outcomes, can enhance overall knowledge of the disease process and improve care for patients. Many attempts have been made at defining a classifica
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David M. Krpata and Michael J. Rosen
28.1 Introduction With the multitude of operative approaches and variability amongst patients and hernias, defining a single, ideal operative approach is challenging and possibly unrealistic for ventral hernia repair. Additionally, surgeon preference and technical ability probably play the largest roles in determining an appropriate operative approach for patients undergoing ventral hernia repair. Some surgeons have been trained in minimally invasive surgery and prefer laparoscopic ventral hernia repairs over open ventral hernia repair, while others are more comfortable with open approaches. Further complicating decision making is identifying the location for mesh placement as a sublay, onlay, underlay, or bridge? It remains controversial as to whether a component separation should be performed and if fascial releases are contemplated the reconstructive surgeon has a multitude of layers of the abdominal wall to release. While previous chapters in this text focused on important concepts in ventral hernia repair, such as anatomy and preoperative optimization, and subsequent chapters will focus on specific techniques for the various approaches to ventral hernia repair, this chapter tries and defines the decision making behind choosing the ideal/appropriate operative technique based on the hernia and patient characteristics. In order to facilitate that conversation, we also think it is important to provide the structure of a classification system to enable all surgeons to appropriately classify hernias to help guide the technical discussions.
D.M. Krpata, M.D. (*) • M.J. Rosen, M.D. Department of General Surgery, Cleveland Clinic, 9500 Euclid Ave, A100, Cleveland, OH 44195, USA e-mail: [email protected]; [email protected]
28.2 C lassification Systems for Ventral Hernias In a field where standardization of techniques and operative approaches is sparse, the need for a classification system is only more greatly highlighted. Classification systems have many benefits, but most importantly they provide a common language which allows for comparison of surgical techniques and approaches within the literature and between surgeons on a case-by-case basis. If you search the term “ventral hernia” on pubmed.gov over 9000 articles describing studies regarding ventral hernias appear. It can safely be assumed that there is no standard method for characterizing ventral hernia defects throughout these 9000 manuscripts. This makes it difficult to compare studies and can at times only confuse the literature. Further complicating the creation of a ventral hernia staging system is identifying the most appropriate outcome measure to stratify risk. In the authors’ opinion the two most relevant hernia outcome measures include surgical site infection and hernia recurrence rate. It is important to understand the historical efforts to define a hernia classification system and their advantages and disadvantages. In 2000, the earliest attempts at unifying discussions of ventral hernia repair and creating ventr
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