Controversies in Laparoscopic Repair of Incisional Hernia

J Minim Access Surg. 2006 Mar;2(1):7-11. doi: 10.4103/0972-9941.25670.

Abstract

Background: Incisional hernias can be a significant problem after open abdominal surgery. Laparoscopic incisional hernia repair (LIHR) is conceptually appealing: a large, abdominal wall re-incision with potential wound-related ill effects is avoided and an intra-peritoneal onlay mesh is expected to provide security that is equivalent to open, retro-muscular mesh repair. As such, LIHR has gained substantial popularity despite sparse, randomised clinical data to compare with conventional, open repair.

Aim: To enumerate and discuss important, controversial issues in patient-selection, technique and early post-operative care for LIHR.

Materials and methods: Pragmatic summary of comprehensive review of English language literature, discussion with experts and personal experience.

Outcomes: SIX IMPORTANT AREAS OF SOME DISPUTE WERE IDENTIFIED: 1. Size of abdominal-wall defect that is suitable for LIHR: Generally, defect-diameter > 10 cm is better served by open retromuscular repair with tension-free re-approximation of the edges of the defect. 2. Extent of adhesiolysis: Complete division of adhesions to the anterior abdominal wall may identify sub-clinical "Swiss-cheese" defects but incurs some risk of additional complications. 3. Intra-operative recognition of enterotomy: Possible options are either laparoscopic suture of bowel injury and simultaneous completion of LIHR, or staged LIHR or conversion to open suture-repair. 4. Choice of mesh: "Composite" meshes are regarded as the current standard of care but there is paucity of data regarding potential dangers of intra-peritoneal polypropylene mesh. 5. Technique of mesh-fixation: Trans-parietal sutures are more secure than tacks, with limited data to correlate with post-operative pain. 6. Alarm over post-operative pain: Unlike other advanced laparoscopic operations, the specificity of pain as a marker of intra-abdominal sepsis after LIHR remains unclear.

Conclusion: Recognition of and attention to controversial issues will promote increased success of LIHR.

Keywords: Intra-peritoneal onlay mesh; composite mesh; dual-sided mesh; ventral hernia repair.