The macquarie system for comprehensive management of complex ventral hernia.

BACKGROUND: Despite recent advances in the operative management of complex ventral hernia (CVH), significant challenges remain. Closure of large defects can have serious pathophysiological consequences due to chronic contraction and retraction of the lateral abdominal wall muscles. Certain features of CVH make repair technically demanding and time consuming, such as massive fascial defects, unusual hernia locations, involvement of other abdominal wall structures and previous tissue trauma.

METHODS: Preoperative assessment with three-dimensional volume rendered CT (3DVR-CT) imaging and an illustrative series of clinical cases is introduced for repair of CVH using laparoscopic approach.

RESULTS: CVH presented here include traumatic hernias involving extensive tissue trauma, massive ventral hernias with defects > 20 cm in width, hernias requiring additional procedures such as wiring of ribs, and hernias in difficult locations such as suprapubic and flank hernias. Specific techniques such as individually tailoring mesh and size, transfascial mesh straps fixation and transcutaneous defect closure will be discussed. All hernias in this series have been repaired laparoscopically (Lap) or laparoscopic-open-laparoscopic (LOL) technique with transcutaneous fascial closure. After hernia closure the mesh is placed in either an intra-peritoneal onlay mesh (IPOM) placement or modified Rives-Stoppa technique with pre-peritoneal mesh placement.

CONCLUSION: CVH repair requires multidisciplinary planning with management tailored to each patient's clinical and surgical requirements. The surgeon must have a variety of surgical skills and strategies to address the multiple and/or atypical defects that affect these patients.