Optimized approach to the surgical treatment of patients with large and giant postoperative ventral hernia

OBJECTIVE: To optimize surgical approach in patients with large and giant postoperative ventral hernias through an analysis of early and long-term results of modern techniques of hernia repair. MATERIAL AND METHODS: There were 680 patients with postoperative ventral hernia over a 15-year period who underwent surgery in the Sklifosovsky Research Institute for Emergency Care and Medical Unit of the Ministry of Internal Affairs (445 (65.4%) women, 235 (34.6%) men). Mean age of patients was 63.2±14.2 years. Middle and elderly (employable) age patients (45-74 years) prevailed in the study (n=510, 75%). Hernia repair using «sublay» technique was performed in 490 (72%) patients without severe comorbidities and relative volume of hernial protrusion up to 18%. Submuscular-inlay technique was used in 95 (14%) patients with significant comorbidities and those over 50 years old or with a relative volume of hernial protrusion over 18%. We have applied a modified repair technique for the last 3 years in 5 (0.75%) patients with a giant postoperative ventral hernia and anterior abdominal tissue deficiency (partial or complete absence of some anatomical structures, for example, rectus muscle). A hybrid technology was applied in 12 patients with severe concomitant diseases, hernias W2 according to European qualifications or recurrent hernias, significant adhesions in the abdominal cavity or hernial sac. RESULTS: Early postoperative wound complications occurred in 27 (5.5%) patients including hematoma (n=12, 2.5%), infiltration (n=7, 1.4%), wound suppuration (n=8, 1.6%). Other complications were observed in 6 (1.2%) patients: pneumonia, pulmonary embolism, intestinal obstruction. Lethal outcomes were absent. Recurrences in long-term period were found in 18 (3.7%) patients. Submuscular-inlay technique of hernia repair was followed by early postoperative wound complications in 5 (5.1%) patients including hematoma (n=3, 3.2%), infiltration (n=1, 1%), wound suppuration (n=1, 1%). There was no mortality. No other early postoperative complications were observed. Recurrences were detected in 5 (5.2%) patients. Preoperative intra-abdominal pressure was 7-10 mm Hg in all patients with tissue deficit. This value did not exceed 12 mm Hg after repair due to creation of a «specified diastasis». Lethal outcomes were absent. There were no early and long-term recurrences or wound complications. Analysis of early and long-term results of the modified hybrid repair of the anterior abdominal wall did not reveal recurrences, local and systemic complications. Persistent minor diastasis between rectus muscles reinforced with a mesh implant was observed in 3 (25%) out of 12 patients. CONCLUSION: Thus, optimized and personalized approach in patients with large and giant postoperative ventral hernias considers all intra- and postoperative risk factors.