Clinical Pearls in Hernia Repair: Avoiding Errors

By CHASE DOYLE

Hernia repairs can be a challenging surgical problem, even for experienced surgeons. During MedStar Georgetown University Hospital’s Abdominal Wall Reconstruction 2021 Conference, Jeffrey A. Blatnik, MD, noted several tips and tricks for avoiding errors when performing these complex procedures.

According to Dr. Blatnik, an associate professor of surgery at Washington University in St. Louis, the most important step is to understand the limits of the hernia, the patient and the hospital, respectively, before the procedure. This means considering the patient’s age, medical conditions, the size of the hernia, complications from prior operations and several other factors.

“Having these limitations in the back of your mind when you start to evaluate complex hernia patients can help you avoid making the first error of operating on somebody that you or your facility lack the resources to take care of,” Dr. Blatnik said.

Dr. Blatnik shared the following clinical pearls:

Getting Access

Surgeons should develop a plan to get into the abdomen by studying the CT scan and abdomen. Previous repairs and the presence of old mesh are complicating factors for hernia repair.

“I try to get into the abdomen away from previous surgery,” said Dr. Blatnik, who noted that this is primarily done via sharp dissection. “I use a scalpel to feel the fibers of the old mesh as I divide them, and I like to open the entire midline before dissecting out laterally.”

With respect to lysis of adhesions, Dr. Blatnik recommended “finding a plane out lateral and circling back.” He also advised “staying on the bowel side of things” to avoid inadvertently mobilizing the colon or injuring the peritoneum.

Dealing With Old Mesh

Old hernia mesh is not only incredibly painful for patients but is the greatest predictive factor of challenges. Dr. Blatnik recommended dividing the mesh down the middle while opening the abdomen and then freeing underlying adhesions first.

“When removing old mesh, the lateral edge of old mesh is key,” he said. “If the mesh ends medial to linea semilunaris, you can usually salvage the posterior sheath. If it ends lateral to the linea semilunaris, however, you’re going to lose some peritoneum.”

Dr. Blatnik advised leaving old mesh in position while doing a release and removing it at the end. He also suggested using landmarks, such as tacks or sutures, when working around old mesh to mark borders.

Transversus Abdominis Release

There are several places to start, including mid-rectus, over the transversus abdominis, below the arcuate line and the falciform ligament. Choosing the right place depends on the patient’s history and the part of the peritoneum or posterior sheath that is most preserved.

“Medial tension is key,” Dr. Blatnik said. “I do this with three clamps, evenly spaced, with cautery along the way.”

Dr. Blatnik encouraged surgeons to gain experience differentiating the peritoneum from the transversalis fascia, a thin aponeurotic membrane that lies between the inner surface of the transverse abdominis and the parietal peritoneum. This is an important distinction, especially in the subcostal region where the peritoneum can be very thin, he said.

When doing a release, Dr. Blatnik underscored going laterally around thin or challenging areas before working back. If a difficult closure is anticipated, use the hernia sac as part of posterior closure, he said.

Closing the Posterior Sheath

For patients with a straightforward midline hernia without a hernia repair history, closing the posterior sheath can be a straightforward process. For many patients, however, this part of the surgery may require creativity. For a posterior sheath that won’t close, Dr. Blatnik advised getting lateral and saving the part with the greatest tension for last. By removing the safety towel at that point, some of the tension can be relieved. “It’s also important not to rely on suture to pull the edges together, and if it still won’t close, then patch,” he said.

Dr. Blatnik also recommended using omentum for small holes and absorbable mesh for larger holes. Lateral holes in the posterior sheath should be closed transversely to avoid additional midline tension.

Closing the Fascia

Run primarily with long-term absorbable suture. As the tension increases, however, surgeons should transition to figure 8 sutures, and if there is a big lateral defect from a transverse incision, a barbed suture is recommended. Dr. Blatnik also advised keeping an eye on airway pressures as the fascia is closed.

“Ultimately, do everything you can to preserve the peritoneum,” Dr. Blatnik concluded. “And when the going gets tough, get lateral and work your way back to the midline.” ■

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‘Mesh is not always a nice flat piece that can easily peel away. I will not compromise the abdominal wall to remove every centimeter, especially if I’m not there for infection. Take care of unnecessary damage to the abdominal wall.’ —Jeffrey A. Blatnik, MD