Chapter 54 Laparoscopic Incisional Hernia Repair
INTRODUCTION
Incisional hernia formation after laparotomy is a complication that occurs in approximately 20% of patients.1 Several open hernia repair methods have been developed, but they are associated with significant recurrence rates and wound-related complications secondary to extensive tissue dissection.2,3 The application of minimally invasive surgery techniques has led to the development of laparoscopic methods for repairing incisional hernias. Several comparative studies now demonstrate the high rate of success and low associated morbidity compared with those of the open approach.4–7
Since they were first reported in the literature in 1992, the number of laparoscopic ventral hernia repairs (LVHR) performed has significantly grown as excellent outcomes have been published. Although complications have been reported to occur less frequently when compared with those of the open approach, they continue to remain an issue, especially in less experienced hands. Heniford and coworkers8 reported an overall complication rate of 13.2% in a series of 850 patients.
OPERATIVE STEPS
Although the technical aspects of LVHR vary, the operation involves a series of well-defined steps.
OPERATIVE PROCEDURE
Abdominal Access and Trocar Placement
Trocar Insertion Injuries
An open or closed technique may be used for access to the peritoneal cavity. A number of complications can occur while gaining access to the peritoneal cavity because a significant number of these patients may have had multiple abdominal procedures. The total number of trocars placed is dependent on several factors, including the extent of adhesions and the size and location of the hernias. Trocars should be placed at least 5 cm away from the fascial defect to allow mesh placement with appropriate fascial overlap (Fig. 54-1).
Complications of trocar insertion are discussed in Section I, Chapter 7, Laparoscopic Surgery.
Lysis of Adhesions
Intestinal Injury
Adhesiolysis can be the most difficult and technically challenging portion of the operation. This is especially evident in patients with multiple previous surgeries and/or previously placed mesh. Soper and associates9 reported their results of 121 consecutive patients that showed an enterotomy rate of 11.4% in patients with prior hernia repairs compared with 0% in patients undergoing a first-time repair.9
• Consequence
• Repair
• Prevention
Hemorrhage
• Consequence
• Prevention
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