Can't Do Plication with Ventral Hernia Repair?

Question

I have a ventral hernia, very wide diastasis recti, and extra skin due to pregnancies (one large baby then large twins). The general surgeon recommended having a plastic surgeon do a tummy tuck to remove extra skin during the procedure. I met with the plastic surgeon, and he told me that the general surgeon doesn't like to have any plication done during the hernia repair. Does this sound correct? I would really like to have plication done as well during this surgery, if possible.

Chad Deal, MD · Answer

While different surgeons may have different opinions, I have to strongly disagree with the one that you’ve been given. If you truly have a central ventral hernia, then when you repair the diastasis it will also fix the ventral hernia with it. Further, the better news is that it usually can be fixed without mesh and has a much less likelihood of recurrence.

J. Jason Wendel, MD, FACS · Answer

Tummy tuck with plication, muscle repair and tightening can be performed at the same time as a hernia repair. It is the best time to do it all at once.

Ricardo A. Meade, MD · Answer

Great Q BonneV, if all hyou have is a diastasis then you absolutely need a plication of your rectus muscles, that is how you fix it. That's in fact the problem! Sometimes hernia repair needs mesh, if that's the case, it means you have much more than just a diastasis and a TT is not the best option at the same time because it can . This one needs to be done on a case by case basis. You should consider coming in for a free conslutation since we're in the same city, I'd be glad to give you my 2 cents worth!

Jonathan Saunders, MD · Answer

perhaps your surgeons misunderstood you, i work with general surgeons frequently and plications are routinely performed. actually i think it can give an extra layer of strength to your hernia repair. maybe a second opinion is in order.

Gary M. Horndeski, MD · Answer

My background, as with most plastic surgeons, is in general surgery. And as such, I routinely repair ventral hernias while performing abdominoplasties. Plication does not interfere with hernia repair when it is being done simultaneously. It only becomes an issue if the hernia repair is done at a later time by laparascopy. If your PS does not have a background in general surgery or does not feel comfortable doing the repair; look for one that does. Having the hernia repaired at the same time as your TT can save time and money (not to mention great exposure of your hernia defect!) Best wishes, Dr. H

Jeffrey M. Darrow, MD · Answer

Having your TT done at the same time as the hernia repair is a good idea as it lets you recover from both at the same time. If your hernia is small and right in the midline where your diastasis is, the hernia repair can then be incorporated into the plication and makes the repair stronger. If the hernia is large and requires a mesh to closed the hole, the plication is still possible. Get a second opinion to clarify where these can be combined in your case safely.

Stephen M. Chen, MD · Answer

Great question BonneV. Abdominoplasty and ventral hernia repair with or without plication can be performed together to rejuvenate your midsection and correct the functional deficit. The technical portion of hernia repair may or may not involve plication depending on the technique of the surgeon. Hernia repair and diastasis repair are similar in that both try to relocate the rectus muscles into their appropriate midline location. Hernias can repaired primarily (sewing one edge of the defect to the other edge) or with mesh (overlay reinforcement where hernia is repaired and then reinforced with mesh on top, underlay reinforcement where hernia is repaired and then reinforced with mesh underneath to act as a patch, inline where hernia defect is too wide to close and mesh is sewn as a bridge or in combination with flap procedures. Given your case of pregnancies, I need to know what your weight is. If you are close to normal weight and your fascia is really just stretched out, Primary repair with reinforcement is most likely what will be performed. It gets more complicated if you are obese or if you have had any previous loss of abdominal wall from cancer or infections.

Steven Turkeltaub, MD · Answer

As evidence by the strong consensus on the issue, plication can and should be performed if needed during a tummy tuck when a ventral hernia is performed at the same time. There is no rational or medical reason not to.

Jay Burns, MD · Answer

There is no reason why a hernia repair can not be done with muscle plication. 

	A hernia is an actual defect in the abdominal wall in which internal bowel contents can protrude. This can be dangerous if the bowel becomes trapped as it can die and cause serious issues. Such a hernia can be painful as well. Therefore a hernia needs to be repaired. 

	Diastasis recti is a thinning of the abdominal wall with stretching and actual separation of the muscles but no actual defect in the abdominal wall. Diastasis causes a lax abdomen with a bulging belly and is primarily cosmetic in nature. (Some literature would state that tightening of the abdominal wall actually improves core stability and therefore also improves back pain). 

	An abdominal wall hernia could be repaired  and yet the abdominal wall could still be lax from a cosmetic standpoint if muscle separation after pregnancy was still present. Further tightening of the abdominal wall, after hernia repair has no deleterious defect on the hernia repair and produces a better cosmetic appearance. Usually such tightening only reinforces the hernia repair. 

	It actually makes sense to combine the procedures to minimize future surgeries. It should all be done at one time in my opinion.

Peter A. Aldea, MD · Answer

A few comments to clear things up
	- The vast majority of Board-certified Plastic surgeons have fully trained in and are board certified in Surgery prior to training in Plastic Surgery.
	- a wide separation of the rectus muscles = a diastasis which is NOT necessarily a hernia.
	- There is NO reason why the muscle separation could not be repaired duting a Tummy Tuck.

	If you have a ventral hernia repair which was previously not been operated, the vast majority of such cases CAN be operated by a well trained Plastic surgeon either with muscle plication, or if needed, by a Component Separation technique (described by Oscar Ramirez, a Plastic surgeon now practicing in Florida).

	I suspect you are dealing with reluctance of one surgeon to interfere with another's turf or livelihood.

Can't Do Plication with Ventral Hernia Repair?

Answers (18)

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