Ventral / Incisional Hernia Repair
What the Examiner Expects
Repair of hernias through the anterior abdominal wall at or near a previous surgical incision. These are the most common hernias encountered by general surgeons. The examiner expects you to assess the hernia (size of defect, loss of domain, skin quality, presence of mesh from prior repair, patient comorbidities), optimize the patient preoperatively (weight loss, smoking cessation, glycemic control), and choose the appropriate repair technique. The retrorectus (Rives-Stoppa/sublay) mesh position provides the strongest repair with the lowest recurrence rate. For large defects where fascial closure is not possible, component separation techniques (anterior — external oblique release, or posterior — transversus abdominis release/TAR) are used to advance the fascia medially.
Key Examiner Focus Points
- Mesh reinforcement reduces recurrence from ~50% (suture) to ~10–15%
- Sublay (retrorectus/Rives-Stoppa) position has the lowest recurrence rate
- Laparoscopic IPOM (intraperitoneal onlay mesh) requires barrier-coated mesh to prevent adhesions
- Component separation (anterior or posterior) for large defects to achieve fascial closure
- Risk factors for recurrence: obesity, smoking, wound infection, tension on repair
Common Curveballs
The hernia defect is 15 cm wide and you cannot close the fascia without excessive tension
Perform a posterior component separation (transversus abdominis release — TAR) to gain additional medial advancement of the posterior rectus sheath. This can gain 8–10 cm of advancement bilaterally. Place retrorectus/preperitoneal mesh after achieving fascial closure. Do not force primary fascial closure under tension.
The patient has a contaminated field from concurrent bowel resection
Avoid permanent synthetic mesh in a contaminated field (high infection and mesh explantation rate). Options: biologic mesh reinforcement (accepts contamination better but higher recurrence), delayed mesh repair at a later date, or staged approach with temporary closure and delayed definitive hernia repair.
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