Laparoscopic Incisional Hernia Repair 

Updated: Jul 23, 2019
Author: Juan Luis Calisto, MD; Chief Editor: Vikram Kate, MBBS, MS, PhD, FRCS, FACS, FACG, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS 

Overview

Background

A hernia is the protrusion of tissue or part of an organ through the bone, muscular tissue, or the membrane by which it is normally contained. Hernias can be classified as internal or external and as abdominal or thoracic.

Abdominal wall hernias can occur spontaneously (presumably from congenital defects) or after surgery. When they occur after surgery, they are called incisional hernias, which can range from small defects to extremely large ones. Some defects are so large that contents are irreducible owing to an abdominal wall that is chronically injured and reduced. This is referred to as “loss of domain."

Incisional hernias are very common. They are the second most common type of hernia after inguinal hernias. Approximately 4 million laparotomies are performed in the United States annually, 2-30% of them resulting in incisional hernia.[1] Between 100,000 and 150,000 ventral incisional hernia repairs are performed annually in the United States.[2]

Incisional hernias after laparotomy are mostly related to failure of the fascia to heal and involve technical and biological factors.[3] Approximately 50% of all incisional hernias develop or present within the first 2 years following surgery, and 74% occur within 3 years.[4, 5, 6]

Depending on size, the repair of an incisional hernia varies from simple suturing to major reconstruction of the abdominal wall with creation of muscle flaps and the use of large pieces of mesh. This can be done with an open approach or laparoscopy.

In 1993, LeBlanc reported the first case of laparoscopic incisional hernia repair with the use of synthetic mesh.[7]  The procedure involves the placement of a mesh inside the abdomen without abdominal wall reconstruction. The mesh is fixed with sutures, staples, or tacks. The recurrence rate of laparoscopic repair is reported as equal to or less than that of open repair. Incisional hernia repair is considered a challenging procedure, especially with recurrent hernias, in which the chances of failure increase with each surgical attempt.[8, 9]

Guidelines regarding laparoscopic treatment of incisional hernias have been published by the International Endohernia Society (IEHS).[10, 11]

Risk factors for hernia formation

A 0.1% rate of acute laparotomy wound failure has been reported in the literature.[12] The true rate of laparotomy failure is about 11%; of these patients, 94% present with recurrence in the first 3 years after the operation.[3] The real laparotomy wound failure rate is therefore 100 times greater than previously thought. The early mechanical failure, therefore, occurs early in the course of the disease, and the healing skin conceals a myofascial defect that enlarges or appears later.

Perioperative shock is a recognized risk factor for incisional hernia formation.[13]

Upper midline incisions have a higher incidence of hernia formation than other types of incision do.[14, 15]

Technique is a factor as well. The configuration of the collagen bundles of the abdominal wall are oriented transversely; therefore, a transverse suture line is mechanically more stable, as it encircles the fibers rather than splitting them.[16]

Indications

The hernia may be asymptomatic, but usually, it is easily palpated and the defect can be delineated. In obese patients, the authors recommend computed tomography (CT) of the abdomen with contrast to better outline the anatomy.

Indications for performing a hernia repair are as follows:

  • Symptoms such as pain and abdominal enlargement
  • Risk of incarceration, especially hernia sacs with a small neck that contain bowel
  • Suitable size - The best candidates are small to moderate-sized hernias in which the contents can be easily reduced and port-site hernias

Laparoscopic incisional repair compares favorably with open repair in terms of shorter operating time, reduced length of stay, and lower costs.[17]

Contraindications

Patients with major comorbidities, such as congestive heart failure (CHF) or severe chronic obstructive pulmonary disease (COPD), may be at a higher risk of complications when undergoing general anesthesia and may not benefit from hernia repair, especially if mild symptoms are the indication. Risks and benefits must be evaluated on an individual basis.

Contraindications for laparoscopic ventral hernia repair are the same as those for any major laparoscopic operation and include the following:

  • Inability to create a working space
  • Acute or emergency procedure (ie, bowel obstruction)
  • Prior multiple surgeries with open repair and mesh placement
  • Infection of skin or surrounding structures overlying the repair (all infection must be treated and cured before the procedure)
  • Ascites with Child class C cirrhosis

Obesity is not considered a contraindication, though obese patients should be counseled regarding the increased risk for hernia recurrence. Therefore, prior to the hernia repair, a bariatric evaluation is recommended. Patients are encouraged to lose weight preoperatively, if possible.

Hernias away from the midline can represent difficult cases and may be more amenable to open repair. This happens especially when bone fixation will be required—as, for example, with posterolateral hernias close to the flank and lumbar areas and with very high or low hernias in which the ribs, pubis, or xiphoid process may be used to fixed the mesh.

Technical Considerations

Anatomy

The abdominal wall is situated between the xiphoid process cephalad and the pubic bone caudally. Laterally, it extends from one side of the lumbar spine circumferentially to the other side, having the rib cage and the iliac crest as limits.

The structures or different components of the abdominal wall include, medially, the rectus abdominis and, laterally, the external oblique, internal oblique, and transversus abdominis and their respective fascias. These structures provide the support that maintains the integrity and limits of the abdominal cavity. The muscular and aponeurotic layers are covered by subcutaneous tissue and the skin. These last two structures have no specific role in the pathophysiology of incisional hernia.

Although obesity is related to an increase in subcutaneous fat, it is the increased intra-abdominal pressure that overcomes the firm containment of the muscular and aponeurotic components and places obese patients at risk for incisional hernias.

For surgeons, the anterior abdominal wall is of special interest regarding incisional hernias. The following discussion focuses mainly on this structure.

The multiple components that make up the anterior abdominal wall, from outside to inside, are as follows:

  • Skin
  • Subcutaneous tissue (Camper and Scarpa fascias)
  • Anterior aponeurosis
  • Muscle (rectus abdominis, external oblique, internal oblique, and transversus abdominis)
  • Posterior aponeurosis
  • Transversalis fascia
  • Peritoneum

Already identified weakened areas are prone to incisional hernias. These present a change in the configuration of the layers and include the following:

  • Midline - The center of the abdominal rectus has the joining of the anterior and posterior aponeuroses of the rectus abdominis; most incisions are created in the midline, usually for exploratory laparotomies in order to gain better exposure of the abdominal cavity; the midline also has the highest amount of pressure, which makes it prone to incisional hernia
  • Arcuate line - The posterior aponeurotic sheath of the rectus abdominis becomes anterior two fingerbreadths below the umbilicus
  • Semilunaris line - This extends laterally along the edges of the abdominal rectus; it is the joining of the rectus and the internal oblique and transversus abdominis aponeuroses

Procedural planning

The difference between the open and laparoscopic approaches consists of the access to and exposure of the defect. In the open procedure, the abdominal wall is incised over the defect. The disruption of surrounding tissue can lead to devascularization. When large incisions are employed, a higher incidence of seromas, hematomas, and wound infections has been reported.

Although technically challenging, laparoscopy can be used to evaluate other defects or even synchronous inguinal hernias. However, the laparoscopic approach has been criticized for not resecting the hernia sac and not restoring the anatomy, thereby allowing the persistence of abdominal bulging and an abdominal wall that is mechanically unstable and has uncoordinated muscles. In addition, placement of a mesh over the defect leads to seroma formation in a large number of patients.

Complication prevention

Seromas may be caused when a hernia sac is left. The use of abdominal binders may prevent their development. Some authors cauterize the hernia sac or even dissect it, but this is technically challenging.

The authors do not routinely place drains.

To prevent enterotomies, take extreme caution when using energy devices inside the abdomen. Dissection must be with blunt technique as much as possible. Careful identification of the structures and inspection of the abdominal cavity for intestinal injuries must be done if these are suspected. The major problem with enterotomies is failure to recognize them intraoperatively.

To minimize the risk of hemorrhage, antiplatelet drugs and warfarin should be stopped preoperatively. Inability to withhold these drugs should be considered a strong contraindication to elective hernia repair. Careful hemostasis should be achieved. In some patients, prophylactic anticoagulation may be delayed in order to decrease postoperative bleeding.

Smoking places patients at an increased risk of wound infection and, therefore, of incisional hernia. Patients should be counseled about the importance of quitting smoking for at least 2 weeks (preferably, 8 weeks) perioperatively.

Outcomes

A meta-analysis of 880 patients who underwent laparoscopic versus open primary repair showed benefits of the laparoscopic approach, such as decreased wound infections, hospital stay, hematomas, and pain. Laparoscopic repair has the disadvantage of increasing the risk of enterotomies.[18]

In an incarcerated hernia, dissection of the sac contents may be easier with the open approach. With laparoscopy, it is difficult to estimate the amount of bowel or omentum involved, especially when dense adhesions are present.

Other authors have described the same advantages and properties of the laparoscopic approach as compared with the open approach.[19]

The conversion rate of these procedures is an impressive 2.4%, with an enterotomy rate of 1.8%, confirming the low risk of this technique. The recurrence rate of 4.2% is low and underscores the effectiveness of the laparoscopic approach. This procedure may become the standard of care in the near future.[20]

The practicability of laparoscopic incisional hernia repair is evidence-based, with large series of patients and high-quality long-term follow-up.[21, 22, 23]

In a systematic review and meta-analysis of of randomized controlled trials comparing laparoscopic with open incisional hernia repair, Al Chalabi et al concluded that the short- and long-term outcomes of the two approaches (with particular regard to hernia recurrence) were highly comparable.[24]

 

Periprocedural Care

Patient Education and Consent

Patient education is paramount and centers on dietary modification and avoidance of increased intra-abdominal pressures, avoidance of constipation, smoking cessation, and weight loss. Patients are also taught to recognize the signs and symptoms of wound infection in order to avoid further complications involving recurrence of hernia and other conditions that compromise the patient’s health.

Preprocedural Planning

Prophylactic antibiotic therapy is mandatory. The authors use a first-generation cephalosporin to cover skin bacteria, given 30-60 minutes prior to incision.

The authors routinely use standard deep venous thrombosis prophylaxis according to the indications for each patient, such as compressive stockings or sequential compression devices in the operating room, and continue those until the patient is ambulatory. Prophylactic anticoagulation is initiated within 24 hours unless there is an increased risk of bleeding. The administration of an intravenous proton pump inhibitor is maintained while the patients continue to receive nothing orally.

Equipment

The following equipment is used in laparoscopic incisional hernia repair:

  • Laparoscope - A 0° degree scope can be used for the insertion of the first trocar; 30° and 45° scopes are used during the remainder of the procedure
  • Blunt graspers (2)
  • Hook electrocautery
  • Tacking device
  • Laparoscopic clip applier and suction irrigator should always be available
  • Foley catheter - Recommended as a routine; it is also useful to decompress the bladder in cases of low hernias (ie, Pfannenstiel hernias)
  • Trocars - 10 mm (1), 5 mm (3)
  • Suture passer (eg, Carter Thomason CloseSure System)
  • Laparoscopic scissors with monopolar coagulation
  • Mesh - This must be a permanent material large enough to produce a wide (3- to 5-cm) overlap beyond the defect’s edges
  • Synthetic mesh - Nonabsorbable (polypropylene, nylon, polytetrafluoroethylene [PTFE], polyester) and absorbable (polyglactin)
  • Biologic mesh (porcine dermis, porcine intestinal submucosa, bovine dermis, bovine pericardium, cadaveric dermis)

Patient Preparation

Laparoscopy requires general endotracheal anesthesia with paralytics to relax the abdominal wall musculature. As the repair is performed under no tension, the use of postoperative mechanical ventilation is very rare, as can be seen in the open repair, when fascia closure might produce respiratory compromise.

The patient is placed in a supine position for almost all hernia repairs. If the hernia is an epigastric defect, the lithotomy position with stirrups is also used. Arms are tucked to the sides. If the defect is not midline, the surgeon should stand on the opposite site of the hernia.

Monitoring & Follow-up

Patients are usually released on postoperative day 2 or 3. Patients follow up in the clinic in 2 weeks. If the patient is discharged home with drains, he or she should follow up in one week with strict recording of drain output.

Healing of the repair takes 3-4 months, and the mesh surface can reduce up to 50%, thus bringing the edges of the muscles together. Patients are counseled that the risk of recurrence is approximately 30% and that they should follow up with their surgeon with any concerns for healing or recurrence.

 

Technique

Approach Considerations

Basic surgical principles of laparoscopic hernia repair include the following:

  • No tension
  • Appropriate trocar placement
  • Use of mesh

The abdominal wall defect remains, and the mesh is placed without any tension so as to prevent herniation of the abdominal cavity content.

The number of trocars used and their placement are related to the location of the hernia in the abdominal wall and its size. The most important consideration is to be able to maintain the surgical principles during the hernia repair. Good exposure, triangulation, traction, and countertraction must never be compromised in an attempt to use fewer trocars.

When mesh is not used, the recurrence of incisional hernias may be as high as 63% after 10 years, compared with 32% when mesh is used.[25, 26, 27, 28]

Robotic-assisted laparoscopic approaches have also been described. In a multicenter case series (N=368), Gonzalez et al reported short-term perioperative outcomes for robotic-assisted repairs that were comparable to those cited in published studies of laparoscopic and open ventral hernia repairs.[29]  Compared with standard laparoscopic repairs, robotic-assisted repairs appear to be associated with a longer operating time but a shorter length of stay.[30, 31]

Guidelines regarding laparoscopic treatment of incisional hernias have been published by the International Endohernia Society (IEHS).[10, 11]

Laparoscopic Repair of Incisional Hernia

Trocar placement and creation of pneumoperitoneum

The procedure starts by gaining access to the abdominal cavity. Pneumoperitoneum must be established. A 5-mm or 10-mm trocar can be used with an open or a needle technique. The authors prefer to place a 10-mm optical port and two 5-mm ports, with an additional 5-mm port contralateral to the optical port to deploy additional fixation tacks (see the image below).

Ideal port placement. 1. Optical trocar 2,3,4. Wor Ideal port placement. 1. Optical trocar 2,3,4. Working trocars.

The placement and number of trocars is related to the location of the hernia in the abdominal wall and its size. The most important considerations are to be able to maintain the surgical principles during the hernia repair. Good exposure, triangulation, traction, and countertraction must never be compromised in an attempt to use fewer trocars. Once pneumoperitoneum is created, a pressure of 12 mm Hg is maintained throughout the case.

Lysis of adhesions and sac reduction

Intra-abdominal adhesions are often present. These are usually omental and located inside the hernia sac. Safely lysing these adhesions is an important step, and enterotomies can occur if too much force is used or if electrosurgical instruments are used without caution. The authors advocate blunt dissection, use of sharp scissors, and minimal use of electrocautery to avoid electrical injury. If there is no clear plane between intra-abdominal viscera and the abdominal wall, the authors resect abdominal wall tissue to preserve bowel integrity.

The sac is reduced into the abdominal cavity. At this point, bleeding can occur and should be controlled mechanically with clips, sutures, or endoscopic loops rather than with energy so as to prevent inadvertent injury to the viscera.

Sac management

The authors routinely refrain from excising the hernia sac unless it is small; this avoids prolonged operating times and excessive bleeding.

Mesh placement

The mesh is introduced through the 10-mm trocar. A swatch that overlaps at least 5 cm from the hernia edges should be used. The authors use a dual-surface mesh that has a textured surface to maximize tissue incorporation to the abdominal wall and a smooth surface to minimize intra-abdominal adhesions to the underlying omentum and bowel. Another option is to use a polytetrafluoroethylene (PTFE) mesh.

The mesh is oriented with the textured surface into the hernia and the smooth layer facing inward. A fixation device may be used in the form of a tacker that places absorbable or nonabsorbable tacks; one study suggested that the former may be associated with a higher recurrence rate.[32] The authors use two lines of tacks, creating a double-circle configuration, with the outer line located close to the edge to prevent the mesh from folding on itself.

The authors strongly advocate placement of transfascial sutures to prevent migration of the mesh, especially in obese patients. A Carter-Thomason suture passer is a good option for performing this step. At least four of these anchoring sutures are placed (see the image below).

Mesh fixation using transfascial sutures. Mesh fixation using transfascial sutures.

The mesh is inspected for adequate coverage and absence of tension, and hemostasis is ensured. Following this, pneumoperitoneum is released, and the trocars are removed under direct visualization. The 10-mm port is closed with figure-eight 0 absorbable suture. The skin is closed with a 4-0 absorbable suture.

Postoperative Care

Ambulatory or outpatient is considered for cases of small incisional hernias. Patients may be released after voiding and postanesthesia routine care, usually after 4 hours.

Pain is controlled with intravenous opioids given as patient-controlled analgesia (PCA). Muscle relaxants such as methocarbamol or cyclobenzaprine are routinely used.

Patients are started on a clear liquid diet and advanced as tolerated. Activity is ad libitum.

The authors routinely use abdominal binders, which may help prevent seroma formation and provide a sense of support to the patient.

Complications

Approximately 3% of patients who undergo laparoscopic incisional hernia repair develop prolonged ileus, which is usually managed with gastric decompression and, in some cases, parenteral nutrition and observation.

As many as 2% of patients may experience prolonged pain after the procedure.

A literature review of 3925 patients who underwent laparoscopic ventral hernia repair showed an overall enterotomy rate of 1.78%. About 97% of enterotomies are recognized intraoperatively and can be repaired. Missed enterotomies are associated with increased mortality.[33]  A retrospective sudy comparing complication rates between open and laproscopic incisional hernia repair found that although the latter had a low incidence of complications overall, it was associated with a higher risk of undetected enterotomy.[34]

Although most patients develop seromas after laparoscopic repair, persistent seromas occur in as many as 3% of patients.

Port-site hernia is an uncommon complciation. A 2010 study found the incidence to be 1.7%.[35]  A 2017 study that included both primary and incisional ventral hernias found the incidence of this complication to be only 0.02%.[36]

Mesh infection is a serious complication, and although its incidence is very low, its consequences are severe. Most infections are caused by skin pathogens. Infected mesh is treated with drainage and removal of unincorporated pieces of mesh. In most cases, removal of the entire synthetic material is required. The reported incidence in 3276 patients was 0.6%.[37]