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Abdominal Wall Reconstruction and Hernia Repair

Reconstruction of the abdominal wall refers to the reconstruction of the fascia of the abdomen, which is the strength layer of the abdominal wall that normally acts to keep the abdominal contents inside.  Following complications of abdominal surgery or trauma, a patient may be left with a “hole” in the fascia known as a hernia that allows the abdominal contents to protrude thru into the soft tissue of the abdomen.  The herniation of abdominal fat or bowel can be vary in size, and larger defects can cause discomfort, difficulty with mobility or the fit of clothing, and patient dissatisfaction with the aesthetic appearance of their abdomen.


Abdominals

The goals for abdominal wall reconstruction are to re-approximate the native abdominal fascia whenever possible with a long-lasting repair that doesn’t compromise patient function.  While small defects may be successfully closed primarily or repaired with synthetic mesh alone, moderate to large defects of the abdominal wall should be considered for other methods of reconstruction.  The most appropriate method of reconstruction for a patient depends on the size and location of the hernia/defect, as well as patient factors such as previous hernia repair attempts or intra-abdominal surgeries, nutrition status, obesity, overall patient functional status, and smoking status.  It is vital to see an experienced surgeon to help develop an abdominal wall reconstruction plan that is tailored to your problem and medical/surgical history.  Here we will discuss some of the general principles that you may hear about at your consultation.

The technique of “bridging” an abdominal wall defect with mesh is the most common technique of abdominal wall repair and involves simply sewing in a piece of synthetic/biologic material as a large patch to reconstruct the fascia, rather than actually re-approximating the fascial edges. While a mesh-only bridge repair may be appropriate in some cases, for larger hernias this technique yields a high rate of recurrence in which the material used in the repair stretches and becomes part of the hernia. Our preferred method for reconstruction of moderate to large abdominal wall hernias involves a technique known as component separation. The abdominal wall fascia is made up of three layers which envelope the rectus muscles anteriorly (the rectus muscles are the pair of muscles running vertically down the center of the abdomen that create “six-pack abs” when people are very fit). Component separation involves dissecting and separating these layers, which lengthens the fascia and allows the edges of the defect to be pulled together and closed with significantly less tension.  We close the abdominal wall in several separate layers, with synthetic or biologic mesh often being placed under the rectus muscles over the closed abdominal layer suture line, the anterior layer of fascia is the closed over top of the mesh. This creates a “sandwich” of closed abdominal layers with mesh buried in the center to reinforce the repair and a better chance for a long-lasting repair.

Abdominal Wall Layers

Some potential complications with any abdominal wall reconstruction include recurrence of the hernia, wound breakdown or infection, fluid collections within the layers of the repair, and bowel injury.