Ventral abdominal wall hernias are a common problem encountered by general surgeons. Despite the large volume of hernia repairs performed there remains no one best technique. Over the last decade, the laparoscopic repair of ventral and incisional hernias has been used with increasing frequency. It is based on the principles of the Rives–Stoppa repair in which the mesh is placed deep to the hernia defect and fixed with wide mesh coverage to healthy abdominal wall fascia using point fixation and full-thickness permanent sutures. The laparoscopic repair differs in that the mesh is placed inside the peritoneal cavity rather than the retrorectus position, a technique made possible by the advent of new bilayered biosynthetic materials that promote tissue ingrowth on one side and prevent tissue ingrowth on the other. Laparoscopic ventral hernia repairs allows for clear visualization of the abdominal wall, wide mesh coverage beyond the defect, and secure fixation to abdominal wall fascia.

For patients with hernias not requiring an urgent operative repair, our hernia program has begun to function in a patient-centered, team approach. In this new model for patient care, the option to have a ventral hernia repair and the technique opted for is now the choice of the patient. After appropriate information is given to the patient, a discussion between members of the hernia team (including the surgeon) and the patient and their family creates a shared decision-making process. The patient is not required to make a decision at any specific time and the issues discussed include the patient’s quality of life while living with a hernia and the realistic expected outcomes (risks and benefits) of the various choices for operative repair and nonoperative management.

If the patient does decide to have a laparoscopic ventral hernia repair, it is appropriate to review the realistic expectations of the procedure. It is normal to have pain at incision sites and mesh suture fixation sites after surgery. In most cases this will necessitate hospital admission for adequate control of pain. In select patients, particularly those at high risk for conversion to open and for large defects, preoperative placement of an epidural catheter for pain can be helpful. For larger hernia repairs, repair of incarcerated hernias, or those requiring extensive intra-abdominal adhesiolysis and bowel manipulation, prolonged hospital admission should be anticipated for adequate pain control and while awaiting resolution of postoperative paralytic ileus.

One very important risk to discuss with the patient is the potential for bowel injury and the management of an injury should it occur. The possibility should be emphasized for patient with large hernia defects, multiple comorbidities, multiple previous abdominal surgeries, multiple previous abdominal wall hernia repairs, and previous placement of mesh. The patient and family should be prepared for the possibility of delayed mesh placement and a second surgery with prolonged inpatient hospitalization if that is one of the options that the surgeon would potentially utilize.

All patients with morbid obesity are counseled regarding the increased risk for hernia recurrence and are sent for bariatric evaluation prior to hernia repair. Patients who smoke are referred for cessation therapy and their hernia repair is ideally not performed until smoking cessation is successful.

One important consideration in performing a laparoscopic ventral hernia repair is the choice of prosthetic material to be used in the repair. There is no ideal mesh; however, for intra-abdominal placement a mesh should be designed so the peritoneal side will minimize adherence to the visceral organs and prevent ingrowth of tissues. At this point in our understanding, macro-porous mesh placed in an intraperitoneal position should be avoided because of the risk of bowel erosion, fistula formation, and small bowel obstruction. There are several mesh products available that are appropriate for intra-abdominal placement (Table 1). Most mesh selection is based on a surgeon’s education and experience, anecdotal evidence, hospital contracts, and various relationships between surgeons and other surgeons as well as sales representatives. In the future, we will be including the patient and family in the process of mesh choice. Also, through a mesh explants clinical quality improvement study, we hope to gain information about what types of mesh perform better and/or worse in different patient groups.

Other types of equipment include standard laparoscopic trocars and instruments, such as atraumatic graspers. Some equipment has been developed primarily for laparoscopic hernia repair. Suture passers, point fixation devices and mesh deployment and manipulation devices have evolved in an attempt to make the procedure more efficient and to allow for a better outcome. Through clinical quality improvement projects, it is likely that these devices can be improved and other new device ideas can be invented to continue to improve the efficiency and quality of outcomes for laparoscopic ventral hernia repair.

After induction of general anesthesia the patient is typically positioned supine on the operating room table with arms tucked at the sides. Prophylactic antibiotics against skin flora are routinely given. An orogastric tube is placed for gastric decompression and a Foley catheter is placed for decompression of the bladder. Sequential compression devices and subcutaneous heparin are utilized for deep venous thrombosis prophylaxis based on individual patient risk factors. Monitors are placed on either side of the patient with one additional monitor at the feet if necessary depending on the location and extent of the hernia defect. The patient is shaved, prepped, and draped widely to allow for the lateral placement of ports, usually at about the anterior axillary line. An Ioban drape is used routinely to help avoid mesh to skin contact.

There are several methods of gaining safe entrance into the peritoneal cavity including the open Hassan technique, Veress needle, and direct laparoscopic guidance using a dilating, optical port, among others. We routinely use blunt digital dissection through a 12-mm skin incision at either the left or right costal margin at the tip of the 11th rib, which usually corresponds to the anterior axillary line. A 10-mm balloon-tip port (Covidien, Norwalk, CT) is then used for secure port placement. This method,
when performed well, provides a safe and effective means of gaining entrance into the peritoneal space regardless of the presence or type of intra-abdominal adhesions.

We routinely place two to three additional 5-mm ports, depending on the size and position of the ventral hernia. Ports are placed in the lateral abdominal wall, far enough from the edge of the hernia defect such that the mesh being used in the repair does not overlap them. Lateral abdominal wall adhesions are taken down prior to port placement to avoid inadvertent injuries.

Adhesions to the abdominal wall are lysed using blunt and sharp dissection. Electrocautery is used sparingly to avoid inadvertent thermal injury to visceral organs. Bleeding may be controlled with pressure, hemoclips, or electrocautery after all nearby visceral organs have been safely identified. Typically, a plane is developed between the abdominal wall and the adherent abdominal contents, which allows for safe and gentle dissection. In the situation where there is no discernible plane, the abdominal wall is cut and left on the adherent tissue in an attempt to protect the bowel. This dissection is performed with care in an attempt to avoid causing, and, more importantly, missing, an injury to the bowel. If an enterotomy does occur, the injury is repaired either laparoscopically or through an open incision. Then, the adhesiolysis may be completed with the surgeon using their best judgment to determine the appropriate timing of mesh placement. Although there are reports of placing mesh after bowel injury, we often plan to delay mesh placement. Our current practice is to admit these patients and place them on intravenous antibiotics for several days. If they do not show signs of sepsis and they are recovering well, we would offer the patient a return to the operating room for delayed mesh placement. Typically, when the reoperation occurs within 3 to 7 days the reformation of adhesions is minimal and repeat adhesiolysis adds little time or morbidity to the operation.

After adhesiolysis the boundaries of the fascial defect are identified and the hernia contents are reduced. This can be done with gentle traction using atraumatic laparoscopic graspers and external manual compression on the hernia. If omentum is incarcerated within the hernia then the major risk associated with reduction is bleeding. This can be managed with pressure, hemoclips, endoloops, or electrocautery. If the bowel is incarcerated in the hernia or densely adhered to the hernia sac then excess tension should be avoided to minimize a traction injury to the bowel. Sharp dissection may be necessary to dissect the bowel off of the hernia sac. In some cases it may be necessary to extend the fascial defect by cutting into the fascial edge with scissors in order to adequately reduce the hernia contents. The viability of incarcerated bowel is assessed and necrotic or nonviable bowel is resected.

For many hernias, additional dissection and exposure of the abdominal wall surrounding the fascial defect is necessary prior to mesh placement. This may involve division of the falciform ligament and/or median umbilical ligament, mobilization of the bladder to exposure of the pubic symphysis and Cooper’s ligaments, and/or dissection of the white line to mobilize retroperitoneal organs. For division of ligaments, electrocautery or ultrasonic dissection is used due to the vasculature running within these ligaments.

At this point, with the hernia contents reduced, the fascial edges of the hernia defect identified circumferentially, and the posterior abdominal wall exposed allowing for wide mesh coverage, the defect is measured. A spinal needle placed perpendicularly through the abdominal wall is used to mark the fascial edges. The pneumoperitoneum is evacuated and the defect measured. Alternatively, the hernia can also be measured intracorporeally using a sterile plastic ruler. If there are multiple hernias present, the maximal distance between all defects is measured.

A mesh designed for intra-abdominal placement is then selected to overlap all fascial defect margins by at least 5 cm. It is trimmed as necessary and then marked for orientation and placement of sutures. The four cardinal permanent sutures are then placed equidistant around the mesh, usually at the superior, inferior, and bilateral side positions. Markings on the Ioban drape help to plan the site of externalization of the cardinal stay sutures. The mesh is then rolled like a scroll along its long axis with the sutures tucked in the middle. A 5-mm grasper is inserted through a port opposite the 10-mm balloon port and brought through the abdominal wall at the balloon port site. The port is removed, the mesh placed in the grasper, and the grasper brought through into the abdomen with the mesh. An external clamp can help push the mesh through the 10-mm incision site. A 5-mm laparoscope may also be used to visualize mesh insertion. The balloon-tip port is then reinserted and the mesh unfurled and oriented inside the abdomen. There are a variety of mesh deployment devices under development to assist with this step of the procedure.