Concomitant sublay mesh repair of umbilical hernia and abdominoplasty

Abstract

U mbilical hernias are occasionally present in patients desiring abdominoplasty. Current data strongly support the use of synthetic mesh when repairing ventral hernias >3 cm in diameter. Longterm data demonstrate improved recurrence rates with mesh, even for smaller umbilical defects (1,2). With simultaneous abdominoplasty, an open approach to umbilical herniorrhaphy is preferred due to the improved exposure; however, dissection of an umbilical hernia at the fascial level can damage the umbilical perforating vessels, resulting in necrosis and loss. During abdominoplasty, circumferential skin incision around the umbilicus divides the subdermal vessels, making it dependent on the deep inferior epigastric supply. This blood supply originates from the deep inferior epigastric artery, traverses the rectus abdominus muscle and continues through the anterior rectus fascia. Traditional hernia repair, as an onlay or subfascial mesh placement, risks deep umbilical blood flow. Unilateral approach with dissection in the preperitoneal plane enables preservation of unilateral and, potentially, bilateral deep perfusion because the dissection plane is deep to the posterior rectus sheath.We present a patient with a defect 3 cm in size at the umbilicus hernia and diastasis presenting for simultaneous open mesh umbilical hernia repair and abdominoplasty (Figure 1). Umbilical perfusion was maintained during open repair with preservation of unilateral deep perforating vessels and placement of mesh in a plane consisting of both the preperitoneal and retrorectus space. Surgical TechniqueThe patient was marked preoperatively for lower abdominal incision. The skin was incised and dissection was taken through Scarpa's fascia to the deep fascia of the abdominal wall. The umbilicus was incised circumferentially through the skin. The cutaneous flap was raised to the umbilical incision and the flap was split and subcutaneous dissection bevelled away from the umbilicus to the fascia and preserved periumbilical perfusion. The adipocutaneous flap was elevated to the xiphoid and medial costal margins. The anterior rectus sheath was incised over the right rectus muscle. Dissection was carried through the medial posterior rectus sheath to the preperitoneal plane adjacent to the hernia. Contents of the hernia were reduced. The contralateral rectus preperitoneal plane was dissected for placement of mesh with peripheral fascial overlap. The umbilical stalk and perforating vessels were preserved on the contralateral side. The peritoneum was reapproximated in the midline to 'close off' the abdominal cavity. This manoeuvre created a pocket deep to the fascia to lay mesh (Figure 2). A lightweight polypropylene mesh was used in this retrorectus position in the preperitoneal space to reinforce the midline closure (Figure 3). The mesh was secured with transabdominal wall monofilament permanent sutures. The linea alba was recreated with long-acting absorbable sutures. Midline plicating sutures were placed above and below the umbilicus. The cutaneous flap was...

Outcome of Combining Ventral Hernia Repair with Abdominoplasty or Mesh-abdominoplasty in Multiparous Women

“…It is noteworthy that the high recurrence rate, reaching 10%-50% [15], reported in the literature for ventral hernias with defects of <4 cm was noted when reinforcement with midline aponeurotic plication was not performed. Other authors [17,18], reported even a higher hernia recurrence of 67% with primary closure alone in large defects of >10 cm, and with such large defects, they recommended reinforcement with a prosthetic mesh.…”

“…However, given predisposing factors for recurrence, such as obesity, smoking, steroid usage, or advanced age, the use of a prosthetic material has been recommended even in smaller fascial defects [16]. If defects are >4 cm, they should be repaired with a prosthesis, unless an associated infection or other source of contamination is present [17,18]. In addition, similar to our strategy, Cheesborough et al [7], who studied the outcome of simultaneous meshabdominoplasty for large ventral hernia and severe rectus diastasis repairs, reported no hernia or bulge recurrences with a mean follow-up of 16 months.…”

“…When dissecting the abdominal flap in standard abdominoplasty, the umbilical stalk is detached from the skin flap leaving vascularization of the umbilicus to be provided only by vessels entering its base from the musculo-aponeurotic layer. At the same time, ventral hernia repair via direct closure or mesh may require incision at the umbilical stalk base, which may jeopardize the umbilical perforating vessels and result in partial or full umbilical necrosis with possible infection of the prosthesis [17]. In order to minimize the risk of potential devascularization of the umbilical stalk several approaches have been proposed for simultaneous abdominoplasty and ventral hernia repair via the open approach with or without mesh.…”

“…In order to minimize the risk of potential devascularization of the umbilical stalk several approaches have been proposed for simultaneous abdominoplasty and ventral hernia repair via the open approach with or without mesh. McKnight et al [17], reported on the "right lateral" approach in which they preserve the rectus muscle sheet completely on one side. A similar approach was reported by Bruner et al [19], but via an inferior midline incision in 17 patients without umbilical necrosis.…”

Does Abdominoplasty Add Morbidity to Incisional Hernia Repair? A Randomized Controlled Trial

“…[4][5][6] The aim of this study is to find if an incisional hernia repair associated with a tummy tuck is a cause of high morbidity for patients, or if they could be safely combined using its potential aesthetic and functional advantages, without changes in morbidity.…”