Difficult Ventral Hernias

Principles of hernia repair:
- Mark grid on skin to keep you honest where pulling out anchor stitch.
- Grid markes 4 corners of defect making sure that they bisect the defect in half.

- Most accurate defect measurement is with abdomen insufflated and form inside. Large BMI makes external measurement more inaccurate.

- Lower risk of infection laparoscopically.

- # of anchoring sutures: 4 corner sutures is sufficient usually. Larger luminous hernias probably need more tacking sutures. They are the only full thickness transabdominal fixation. Make no apologies to pt that it causes pain.

Subxiphoid hernia:
- secondary to cardiac surgical incisions
- difficulty arises in achieving adequate overlap of mesh over defect due to rib cage and diaphragm.
- May need to compromise lateral suture bc limited by costal margin.
- order of placing tacking transabdominal sutures: sup, far lateral, inf, near lateral
- may have difficulty passing superior tacking suture: Gore suture passer can be placed through the xiphoid process.

Suprapubic hernias:
- Trocar placement from above
- 3 way foley to fill and drain bladder. May need to talk to pt about bladder mobilization and injury
- 4 cm over lap below pubis
- Anchor inferior, far lateral, superior then near lateral.
- Cardinal suture into pubis periosteum. Overlap below pubic bone.
- Four bone anchor sutures placed through the pubic rami and tack down around circumference of mesh

- Bone anchor drilled. Same as flank hernia. Permenant bone anchor stitch with #2 polyester u stitch through pubic bone and mesh.

Flank hernias:
- Mobilize retroperitoneal sutures to bring out lumborum suture.
- Bone anchors into iliac crest.
- PTs on immunoauppressants may not hold bone anchor.
- PTs may get neuralgia.

Chronic pain:
Waits 6 weeks before doing anything
Injects marcaine. Usually from a tacking clip they have never had to remove stitch.