IEHS Guidelines on Laparoscopic Treatment of Ventral/Incisional Abdominal Hernia
In July 2019, the International Endohernia Society (IEHS) published updated guidelines regarding laparoscopic treatment of ventral and incisional abdominal wall hernias. [50]
Hernia with diastasis recti
Mesh reinforcement of ventral hernia repairs with a concomitant rectus diastasis is recommended.
In laparoscopic intraperitoneal onlay mesh (IPOM) repair of ventral hernia and concurrent rectus diastasis, reconstruction of the linea alba with mesh augmentation should be performed when possible.
Several endoscopic, laparoscopic, and robotic options for extraperitoneal mesh repair of ventral hernia with concomitant rectus diastasis can be offered. Ongoing evaluation is needed.
Patients with significant diastasis and associated functional impairment should be offered surgical repair.
Component separation techniques
Component separation (CS) techniques (CST) should be used to obtain fascial closure in large midline hernias. CST should be used in combination with mesh reinforcement whenever possible. CST should be considered to obtain fascial closure in contaminated fields, when no mesh is used.
With regard to anterior CST preferences, for fascial closure of large midline hernias, surgeons should consider endoscopic anterior CS (EaCS) or minimally invasive anterior CS (MIaCS) as an alternative to open anterior CS (OaCS) in order to reduce postoperative wound morbidity.
For intermediate-to-large defects, surgeons should consider EaCS, MIaCS, or transversus abdominis release (TAR) as an alternative to OaCS in order to reduce postoperative wound morbidity. For lateral defects in need of a large mesh overlap, TAR should be preferred to anterior CST.
Transversus abdominis release
TAR can be applied for abdominal wall reconstruction to achieve restoration of the midline in complex ventral hernias (M1-5, W3); for recurrent hernias following previous anterior CS; and for lateral hernia repair (L1-4).
TAR can be open, laparoscopic, or robotic.
Preoperative adjunct interventions
No recommendations can be made regarding the use of botulinum toxin A, progressive pneumoperitoneum, or tissue expanders as adjuncts in ventral hernia repair.
Robotic ventral/incisional hernia repair
Robotic IPOM (rIPOM) may be considered comparable to standard laparoscopic ventral hernia repair with intraperitoneal mesh (LVHR) in most clinical outcomes, at the expense of increased operating time. Data are insufficient to allow adequate comparison of recurrence risk. Hospital length of stay (LOS) may be reduced with rIPOM. rIPOM improves the ability to close the hernia defect during minimally invasive hernia repair.
Robotic transabdominal preperitoneal repair (rTAPP) is a safe and effective alternative to rIPOM or standard IPOM LVHR for small hernias. rTAPP allows placement of mesh in an extraperitoneal position, which may reduce long-term mesh-related complications.
Significant reduction in LOS is possible with robotic retromuscular ventral hernia repair (rRVHR) or robotic TAR (rTAR) and should be considered in patients with ventral/incisional hernias.
Reduction in surgical-site infection (SSI) may be achieved with rVHR, rTAR, or robotic extended totally extraperitoneal (eTEP) repair; larger studies are necessary for further assessment.
Recurrence rates appear similar to those of open ventral hernia repair (OVHR) and LVHR, but long-term follow-up is lacking.
Robotic eTEP may reduce the need for additional myofascial release as compared with rTAR, thus more closely approximating the stepwise approach to myofascial release performed in OVHR.
Lateral primary or incisional hernia
Open and laparoscopic mesh techniques can be recommended for the treatment of primary and incisional hernias of the lateral abdominal wall.
Large lateral abdominal wall hernias (defect diameter >15 cm) should be treated via an open approach.
Spigelian hernia
For the treatment of spigelian hernias, laparoendoscopic mesh repair should be preferred because of lower postoperative morbidity and reduced hospital LOS.
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Large right inguinal hernia in 3-month-old girl.
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In this baby with gastroschisis, bowel is uncovered and presents to right inferior aspect of cord.
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Hernia of umbilical cord.
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Note translucent sac in baby with large omphalocele. Umbilical vessels attach to sac.
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Hernia content balloons over external ring when reduction is attempted.
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Hernia can be reduced by medial pressure applied first.
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Infant with Silon chimney placed in treatment of gastroschisis.
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Atrophy of right testis after hernia repair. Note adult-type incision.
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Iatrogenic cryptorchid testis in child. Taking care to position testis in scrotum is integral part of completion of hernia repair in boys.
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Erythematous edematous left scrotum in 2-month-old boy with history of irritability and vomiting for 36 hours. Local signs of this magnitude preclude reduction attempts.
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Testis at operation in 2-month-old boy with history of irritability and vomiting for 36 hours. Capsulotomy was performed, but atrophy occurred. Patient also required bowel resection.
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Ventriculoperitoneal shunt, decreased activity, and acute scrotal swelling in 6-month-old boy.
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Ventriculoperitoneal shunt, decreased activity, and acute scrotal swelling in 6-month-old boy. Abdominal radiograph shows incarcerated shunt within communicating hydrocele. Repair of hydrocele relieved increased intracranial pressure.
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Bassini-type repair approximating transversus abdominis aponeurosis and transversalis fascia to iliopubic tract and inguinal ligament.
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Anatomic locations for various hernias.
