Abdominal Wall Reconstruction & Open Repair

What is an incisional (ventral) hernia?

A hernia in the muscles of your abdominal wall happens when tissue from inside the abdomen pushes through a weak spot in the muscle layer, creating a visible bulge that can cause discomfort, pain, or limit your activity. It can start as a hernia that simply enlarges over time, or it can develop at a prior surgical incision, or both.

About 2 out of every 10 people who have had a midline abdominal incision later develop a hernia there. Your risk is higher if you have diabetes, smoke, are overweight, needed emergency surgery, or had a wound infection after a prior abdominal operation.

Why repair it?

Repair is recommended once a hernia causes symptoms, keeps enlarging, or interferes with daily activities. The goal is to restore strength to the abdominal wall and lower your risk of future complications.

What is open abdominal wall reconstruction?

Open abdominal wall reconstruction rebuilds the abdominal wall through a single incision, usually along your prior surgical scar. It's the traditional approach for larger or more complex hernias, and it gives the surgeon direct hands-on access to every part of the repair.

The repair is built in the retro-rectus space (the layer just behind the abdominal muscles) whenever possible, which keeps the mesh away from the intestines.

Goals of the surgery

• Find and repair every hernia defect, not just the obvious one
• Restore your normal abdominal wall anatomy
• Rebuild the center line of your abdomen (linea alba) without tension
• Reinforce the repair with mesh

How open repair works

The incision is made directly over the hernia, typically reopening the prior scar. The abdominal muscles are carefully freed from the surrounding scar tissue and from each other, using your CT scan as a roadmap to find every defect. Once all defects are identified and repaired, the muscles from both sides are brought together at the midline with heavy suture, and mesh is measured, cut to fit, and placed flat in the retro-rectus space, sometimes stretching from the bottom of the breastbone to the pelvis.

When is a "TAR" needed?

If the muscles can't be brought together without too much tension, Dr. Rodriguez may perform a transversus abdominis release (TAR), releasing one specific muscle layer to allow more give when rebuilding the midline. Larger or more complex hernias sometimes need this on both sides.

Special situations: contaminated fields and combined procedures

Some operations involve more than a routine hernia repair. If a bowel procedure needs to happen in the same operation, or if there's an infection or prior mesh that has to be removed, the surgical field is considered "contaminated" or "clean-contaminated." In these cases, a different type of mesh (often a biologic mesh that the body can incorporate) is sometimes used instead of permanent synthetic mesh, to lower the risk of mesh infection. If a large amount of loose, overhanging skin is present, a panniculectomy (removal of that excess skin) may be combined with the repair to improve the final result and reduce wound complications. A wound vacuum (wound VAC) is sometimes used after surgery to support healing of larger or higher-risk incisions.

Advantages of the open approach

• Direct access to the entire abdominal wall, which is valuable for very large or complex hernias
• Wide mesh coverage for a more durable repair
• Mesh stays outside the main abdominal cavity, lowering the risk it sticks to the bowel
• Restores normal anatomy and function
• Allows combined procedures (such as bowel surgery or panniculectomy) in a single operation when needed

Risks to know about

• Bleeding or infection
• Injury to the bowel, other organs, or blood vessels (uncommon)
• Nerve injury or chronic pain
• Fluid or blood collection (seroma or hematoma)
• Hernia recurrence, despite mesh reinforcement
• Temporary breathing or pressure-related symptoms after large repairs
• Wound healing problems, especially with larger incisions or contaminated fields
• Extra skin or a midline ridge, which usually improves over time

Hospital stay and early recovery

• Hospital stay is typically longer than with a minimally invasive approach, often several days, depending on the size and complexity of the repair.
• A urinary catheter placed during surgery is removed once you're up and moving well, usually within a day or two.
• An abdominal binder is optional. Some patients find it helpful, others don't.
• Home medications usually restart on day 1; blood thinners typically resume on day 2, depending on coordination with your other doctors.
• Early fullness or some difficulty taking deep breaths is common and temporary. Walking, sitting upright, and breathing exercises (incentive spirometry) help.
• If drains are placed, they're removed once drainage drops below about 2 tablespoons in 24 hours.

Before going home, you'll need to: have pain controlled with pills, eat and drink adequately, urinate on your own after the catheter is removed, and walk safely (physical therapy may help assess this).

Pain control

An abdominal wall nerve block before surgery can last up to 72 hours. For the first 3 days: scheduled Tylenol (acetaminophen), Celebrex (celecoxib), and Robaxin (methocarbamol), with narcotics available only for breakthrough pain. A bowel regimen is provided too, since constipation is common after surgery and narcotics.

Wound care & activity limits

• Incisions are closed with dissolvable stitches and a purple waterproof glue (Dermabond). You can shower the day of surgery; let water run over the incisions and pat dry. Do not submerge incisions in a pool, tub, or other body of water for at least 4 weeks.
• If present, remove the umbilical dressing the Sunday after surgery.
• Avoid sun exposure on incisions for 6 months to prevent permanent discoloration.
• Walking is encouraged starting the day of surgery.
• Avoid pushing, pulling, or lifting more than 10 pounds, and avoid core exercise, for 4 weeks.
• You can resume driving when no longer taking narcotic / sedating medications and you can quickly go from gas to brake pedal without pain inhibiting your movement.

Recovery is gradual over several weeks. Some temporary swelling, firmness, or change in your abdominal shape is normal and improves with time.