S. Gananadha FRACS; J. S. Samra D Phil, FRACS; G. S. Smith MS, FRACS; R. C. Smith MD, FRACS; S. Leibman FRACS; T. J. Hugh MD, FRACS.
Dr Thomas J. Hugh, Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St Leonards, Sydney, NSW 2065, Australia. Email: email@example.com
Incisional hernia is a relatively frequent complication of abdominal surgery. The use of mesh to repair incisional and ventral hernias results in lower recurrence rates compared with primary suture techniques. The laparoscopic approach may be associated with lower postoperative morbidity compared with open procedures. Long-term recurrence rates after laparoscopic ventral and incisional hernias are not well defined. A prospective study of the initial experience of a standardized technique of laparoscopic incisional and ventral hernia repair carried out in a tertiary referral hospital was undertaken between January 2003 and February 2007. Laparoscopic hernia repair was attempted in 71 patients and was successful in 68 (conversion rate 4%). The mean age of the patients identified was 63.1 years (39 men and 31 women). Multiple hernial defects were identified in 38 patients (56%), and the mean overall size of the fascial defects was 166 cm2. The mean mesh size used was 403 cm2. The mean operative time was 121 minutes. There were six (9%) major complications in this series, but there were no deaths. Hernia recurrence was noted in four patients (6%) at a mean follow up of 20 months. Our preliminary experience indicates that laparoscopic incisional and ventral hernia repair is technically feasible and has acceptable postoperative morbidity and low early recurrence rates.
Incisional hernia is a major complication after abdominal surgery with a reported incidence of 2–20%.1–3 The treatment of both incisional and ventral hernias has evolved over the past few decades. Primary suture repair was once widely practised, but more recently, mesh repair has become the preferred technique because it is followed by lower long-term recurrence rates. Data from one multicentre trial showed that the 10-year cumulative recurrence rate after suture repair was 60% compared with 32% for mesh repair.4 Laparoscopic placement of the mesh is attractive because it avoids a large incision and the need for extensive tissue dissection. In a recent meta-analysis of studies comparing open and laparoscopic ventral hernia repair, the laparoscopic approach led to less postoperative morbidity and a shorter recovery time compared with an open mesh repair.5 This study reports our early experience with laparoscopic repair of incisional and ventral hernias.
Data were prospectively collected on a consecutive series of patients undergoing laparoscopic ventral or incisional hernia repair in a tertiary referral institution between January 2003 and February 2007. Demographic information, operative findings, postoperative outcomes, and follow-up data were recorded. A total of 71 patients were included in the study.
The procedure was carried out in the supine position under general anaesthesia. All patients received prophylactic intravenous antibiotics at induction of anaesthesia. A large adhesive sterile drape was placed on the abdomen to decrease the risk of skin flora contamination when shaping the mesh. Port placements varied with the site of the hernia. Generally, hernias were approached from the side furthest from the main palpable defect. All ports were placed as far lateral as possible so that the working instruments could approach the hernial defect. In the majority of cases, the abdominal cavity was accessed through the left lateral abdominal wall using an 11-mm plastic-tipped optical port. A 30° laparoscope was inserted and two 5-mm trocars were then placed under direct vision. Laparoscopic evaluation of the extent and morphology of any intra-abdominal adhesions was carried out at the beginning of the procedure and reassessed at the end of the dissection. Adhesions were stratified according to a classification that was modified from several previously described systems.6–8 A grading system was developed that incorporated the morphology and extent of adhesions as well as the degree of difficulty of dissection (Table 1). Adhesions were divided by sharp scissor dissection, hook diathermy on a low-power setting, or by the Ligasure electrocautery device (Autosuture; US Surgical, Norwalk, CT, USA). In the presence of dense intra-abdominal adhesions, an initial limited adhesiolysis of the lateral abdominal wall was undertaken to place the working ports under direct vision. Occasionally, an additional port was placed on the contralateral side through which the laparoscope was passed in order to assist with complete dissection of the adhesions.
Table 1. Grading system for the degree of adhesions to the abdominal wall (n = 68)
Minimal, filmy adhesions covering <25%. Easy to divide by blunt or sharp dissection
Moderately dense adhesions covering up to 50%. Sharp dissection required
Severely dense adhesions covering >50% or adherent small or large bowel. Sharp dissection required
Incarcerated bowel within the hernia sac or bowel adherent to previously placed mesh. Sharp dissection required
The technique of incisional hernia repair used in this study has been described previously by Heniford et al.9 All hernial defects were identified, and the contents reduced and the fascial margins cleared. The hernial sac was not routinely dissected free other than to assist in the definition of the fascial margins. Expanded polytetrafluoroethylene (ePTFE) mesh (WL Gore & Associates, Flagstaff, AZ, USA) was used in all cases. In the latter half of the study period, Gore-Tex DualMesh plus (WL Gore & Associates), an ePTFE mesh impregnated with silver carbonate and chlorhexidine diacetate, was used in the repair.
The edge of the defect and a surrounding area 3–4 cm wide was accurately marked on the skin, and a single piece of mesh was then cut to size. In giant hernias the pneumoperitoneum was partially evacuated when sizing the mesh to avoid mesh redundancy. Before insertion of the mesh, 2/0 prolene sutures (Ethicon, Somerville, NJ, USA) were placed at the superior, inferior and lateral edges of the mesh. Additional sutures were placed between the principal fixation points when the mesh size was very large.
The mesh and attached fixation sutures were then tightly rolled and introduced into the peritoneal cavity through the lateral 11-mm port (Figs 1,2). In some cases, two or more pieces of mesh were sutured together to cover extremely large or multifocal defects. After correct orientation, the attached sutures were passed outwards through the abdominal wall through stab incisions using an Endo Close device (Tyco Healthcare, Norwalk, CT, USA) and then tied in the subcutaneous tissue. The remainder of the mesh was secured around the periphery by multiple laparoscopic firings of the ProTack 5-mm spiral tacker (Autosuture; US Surgical) (Fig. 3). These tacks were placed accurately 1 cm apart around the periphery so as to avoid rolling of the edges that expose the adherent side of the ePTFE mesh. The spiral tacks were fully deployed into the abdominal wall against counter pressure with a hand externally on the abdominal wall.
Before commencing this technique, all the surgeons in our unit attended at least one instructional course on laparoscopic incisional and ventral hernia repair. To minimize complications, we focused on four key technical aspects: safe establishment of the pneumoperitoneum, careful dissection of intra-abdominal adhesions, accurate measurement of the defect and mesh size, and secure fixation of the mesh with a combination of transfascial sutures and multiple firings of the spiral tacker.
A normal diet was allowed on the first postoperative day in most cases. Follow up was by way of clinical review at 3–6 weeks postoperatively and then at 3–6 monthly intervals thereafter. Clinical suspicion of a hernia recurrence was assessed either by ultrasound examination or by computed tomography (CT) scanning.
Laparoscopic hernia repair was attempted in 71 patients and was ultimately successful in 68 patients. The laparoscopic approach was abandoned in three patients (4%) for the following reasons: extremely dense adhesions that precluded a pneumoperitoneum (1), an enterotomy during dissection of grade 4 adhesions (1), and clinically unsuspected portal hypertension and ascites (1).
There were 39 men and 32 women with a mean age of 63.1 years. The various types of hernia are listed in Table 2. Seventy-five per cent of patients had grade 2 or greater adhesions, and in most cases, they required moderate to extensive adhesiolysis (Fig. 4a–d). A single hernial defect was identified in 30 patients (44%); multiple defects were found in the remaining 38 patients (56%). The mean size of the hernial defects (including multifocal hernias) was 166 cm2 (2–975 cm2), and the mean mesh size used was 403 cm2 (90–1276 cm2). The mean operative time in this series was 121 minutes (50–360 minutes).
Table 2. Hernia classification (n = 71)
Type of hernia
Previous open mesh repair
Abdominal aortic aneurysm repair
Coronary artery bypass
The median hospital stay was 3 days (range 1–32 days), and 87% of the patients were discharged by the 5th postoperative day.
There were no postoperative deaths in this series. There were six (9%) major complications as outlined in Table 3. The most serious intraoperative complication involved an inadvertent but recognized small bowel injury during dissection of grade 4 adhesions. This injury was repaired laparoscopically, and the patient had a delayed open mesh repair.
Table 3. Complications after laparoscopic hernia repair (n = 68)
Suture fixation pain
Urinary tract infection
Two patients (3%) were classified as having mesh infection. Both these patients had giant multifocal incisional hernias that were repaired early in our experience using Goretex DualMesh (WL Gore & Associates). The first patient presented 4 weeks postoperatively with abdominal pain, mild dysuria and signs of systemic sepsis. A CT scan showed a large fluid collection on the peritoneal side of the mesh. Percutaneous aspiration showed purulent material containing gram-negative rods. Urinary culture was negative. The patient returned to the operating room for removal of the mesh and all the spiral tacks through a laparotomy. There was no obvious visceral injury at that time, although it was presumed that the inferior fixation suture had injured his bladder and that this was the source of the infection. Twelve months later, he had an uneventful repeat laparoscopic repair using Goretex DualMesh plus (WL Gore & Associates). In one other patient who, subsequent to our mesh repair, underwent a laparotomy in another hospital for an unrelated reason, the Goretex DualMesh plus was found to be intact but had a fibrinous layer on the peritoneal side with several small bowel loops adherent to the spiral tacks. Although this patient was not septic at the time, the mesh was removed on the suspicion that it was infected. However, cultures of the mesh were negative.
One patient with a large epigastric poststernotomy hernia had a small asymptomatic pneumothorax secondary to pleural puncture from one of the fixation sutures. This was recognized on the first postoperative day and was managed expectantly with complete resolution after 5 days. Two patients had delayed hospital stays because of postoperative ileus after extensive adhesiolysis. Both patients recovered fully with conservative management.
In this series, there were 20 (29%) minor complications as outlined in Table 3. Six patients had a prolonged hospital stay because of fever or erythematous changes in the abdominal wall. One of these patients was readmitted and had a long hospital stay (32 days) because of extensive and persistent abdominal wall erythema and oedema after repair of a giant multifocal incisional hernia using Goretex DualMesh plus. His symptoms eventually settled after intravenous antibiotic treatment, although positive bacterial cultures were never obtained despite repeated percutaneous needling. The patient remains well 11 months after his surgery.
Follow-up interview and physical examination was complete for all patients, with a median follow-up period of 19 months (1–46 months). Additional radiological imaging was undertaken in seven patients because of suspicion of hernia recurrence.
Four (6%) patients developed a recurrent hernia during the observation period, all within 6 months of the laparoscopic repair. All four have been successfully re-repaired: three laparoscopically and one as an open sandwich mesh repair. Although quality of life and cosmetic appearance were not specifically measured, all patients expressed satisfaction with the outcome of their laparoscopic surgery.
This study describes our initial experience with laparoscopic incisional and ventral hernia repair. Although open mesh procedures are effective, particularly if the mesh is placed in a retromuscular position or if a sandwich mesh technique is used,4,10,11 this often requires large incisions to identify and include all hernial defects, as well as extensive mobilization of healthy fascia. This increases the morbidity of the procedure, particularly wound-related complications.12 Laparoscopic repair is appealing because of the smaller incisions, the opportunity to readily identify all hernial defects, minimal mobilization of fascial edges, and the ability to place the mesh deep to the fascial layer, with a consequent mechanical advantage. In the present series, 56% of patients had multifocal defects, many of which were clinically not obvious and therefore might have been missed at open operation.
In our hands laparoscopic incisional and ventral hernia repair was relatively easy to perform and we were satisfied that it produced a technically sound repair with few postoperative problems. We were particularly impressed with the minimal postoperative morbidity and the rapid recovery after repair of giant multifocal hernias (Fig. 5). Numerous other studies have shown similar satisfactory early experience with laparoscopic incisional and ventral hernia repair.13–16
The major difficulty of this procedure relates to the type and density of intra-abdominal adhesions. Currently, there is no universally accepted classification or grading of abdominal wall adhesions. In this study, we describe a new grading system that incorporates the morphology and extent of adhesions together with the degree of difficulty of the laparoscopic dissection (Table 1). This is helpful in allowing uniformity of reporting and offering a guide as to the likely safety of the dissection. In our patients, the majority of incisional hernias were associated with moderately dense adhesions to the abdominal wall (grades 2–4).
In an attempt to minimize hernia recurrence, Heniford et al. emphasized the importance of fixing the mesh with both transfascial sutures and spiral tacks.9,17 In contrast, Morales-Conde et al. avoided using sutures and instead placed a double crown of spiral tacks only. Using this technique, they achieved a recurrence rate of 2% at a mean follow up of 40 months.18 In our series, we used at least four nonabsorbable transfascial fixation sutures and a ring of spiral tacks around the periphery of the mesh. In the latter half of the study, we increased the number of sutures, especially for large hernial defects in obese patients.
Sutures that are fixed too tightly may result in early postoperative pain at the fixation sites.9,19 This complication occurred in four (6%) of our patients. In one case, the symptoms settled spontaneously, whereas in the other three patients, this pain disappeared after percutaneous injection of a small volume of lignocaine and dexamethasone into the affected area. Our impression was that postoperative abdominal pain was reduced by using a large number of sutures to fix the mesh possibly as a result of distributing tension more evenly across the abdominal wall. None of our patients have had long-term abdominal pain.
In all four patients who had a second laparoscopic repair for a recurrent hernia, we observed that the previously placed spiral tacks were well peritonealized and that there was no adherent small or large bowel overlying them. Incompletely deployed or loose spiral tacks are likely to increase the risk of bowel perforation. Biological glues might be used as an alternative so as to avoid this potential problem. One study of ventral hernias in a rat model suggested that a fibrin sealant might be as effective as tacks for short-term fixation of onlay mesh.20 Further human studies are required to determine the safest and most effective fixation method.
The potential for visceral or vascular injuries when establishing the pneumoperitoneum, or during dissection of adhesions, is greater with this technique compared with an open, extraperitoneal repair. Having said that, in the largest laparoscopic series published to date, only 14 of 850 patients (1.7%) sustained a bowel or bladder injury during attempted ventral hernia repair.9 In our own series, only one patient (1%) had an inadvertent enterotomy, and this occurred during dissection of a loop of small bowel firmly adherent to previously placed polypropylene mesh (grade 4 adhesions). This was recognized at the time, and the enterotomy closed laparoscopically. Although this patient had a successful open repair several weeks later, in retrospect, a wiser approach might have been to avoid a bowel injury by early conversion to an open operation. In this regard, Lederman and Ramshaw recommend abandoning the operation when there is a suspicious or recognized visceral injury during laparoscopic hernia repair, in favour of a short delay of 2–6 days with antibiotic cover before definitive laparoscopic placement of the mesh.21
We chose to use an ePTFE mesh because it is a durable, noncomposite material that can easily be manipulated and fixed to the abdominal wall. The smooth, nonadherent side has small interstices (3 μm) that minimize bowel adhesions, whereas the adherent side has large interstices (22 μm) that facilitate collagen ingrowth.22 In a rat model, ePTFE impregnated with silver carbonate and chlorhexidine diacetate (Goretex DualMesh plus) had the least susceptibility to infection compared with all other currently available prosthetic materials.23 Since changing to the Goretex DualMesh plus®, we have not had any further mesh infections.
Erythematous changes in the abdominal wall developed in the early post operative period in three of our patients. Three others had significant postoperative fevers without an obvious infective source. These six patients had a prolonged hospital stay because of treatment with intravenous antibiotics, although, fortunately, none developed mesh sepsis. This raises the possibility that these clinical signs may not have been caused by infection. In relation to this, Cobb et al. showed that noninfectious postoperative fever occurs in up to 40% of patients who undergo laparoscopic ventral repair using ePTFE impregnated with silver/chlorhexidine.24 They postulated that an increased systemic inflammatory response, or possibly even an allergy to the chlorhexidine, may be responsible for the fever. This is important when the alternative diagnosis of a major visceral injury or an early mesh infection causes such anxiety for both the surgeon and the patient. Appropriate inflammatory markers that could identify this problem might be helpful in order to avoid unnecessary and costly investigations looking for an infective source.
Seroma formation is the most commonly reported complication after laparoscopic ventral or incisional hernia repair.9,13 In our series, eight patients (16%) developed a seroma, but all these resolved without the need for intervention. Most commonly, these fluid collections lay between the mesh and the skin, sometimes mimicking an early recurrence of the hernia (Fig. 6). In our experience, CT scanning was useful in reassuring both the surgeon and the patient. The majority of these seromas completely disappeared within 6 months without the need for intervention. In two patients who had CT scans because of low-grade abdominal discomfort, large fluid collections were found on the peritoneal side of the mesh. These collections were aspirated through the mesh using 23G needle, and on both occasions, only sterile serous fluid was found. Videos of the original procedures were reviewed to confirm the correct placement of the mesh. Symptoms completely resolved in both patients after the needle aspiration. We accepted the small risk of infection inherent in percutaneous abdominal aspiration to exclude deep mesh infection. Unlike polypropylene, infected ePTFE mesh should be removed when infection occurs.
The median postoperative hospital stay of 3 days in our series is similar to that reported in most other studies of laparoscopic ventral and incisional hernia repair.9,13–16 The majority of our patients did not require narcotic analgesia postoperatively and were ambulatory on the first postoperative day. We did not prospectively evaluate postoperative pain scores or resumption of normal activities in this study, but we are planning to assess long-term quality of life and the cosmetic outcome in this group of patients.
In this series, four (6%) patients developed a recurrent hernia during the median follow-up period of 19 months. All these recurrences occurred within the first 6 postoperative months, which suggests that technical factors might be responsible. These patients were operated on early in our experience when we were only using four fixation sutures. One patient was morbidly obese and at re-laparoscopy was found to have a recurrence at the superior edge presumably because of inadequate fixation. This was repaired laparoscopically with an additional piece of ePTFE mesh. In another patient with a large suprapubic incisional hernia, the recurrence at the inferior edge was because of insufficient fixation over the bladder. In regard to this, Carbonell et al. noted that this type of hernia can be difficult to treat laparoscopically because of the peritoneal fold over the bladder.25 These authors stressed the importance of using multiple sutures to fix the mesh to the pubis and to Cooper’s ligament to decrease the risk of recurrence.25
In one of our patients with a large Spigelian hernia, recurrence occurred at the inferior edge where transfascial sutures had not been used because of concern about possible nerve entrapment. He underwent further laparoscopic surgery 6 months later, and the residual defect was covered with an additional piece of mesh. All recurrences occurred early in our experience, and this suggests that experience with the technique reduces the recurrence rate. Technical factors, such as insufficient mesh overlap or inadequate suture fixation, are likely to be the cause of most recurrent hernias that develop within the first 18 months after laparoscopic surgery.26
The median follow-up period of 19 months (1–46 months) in this study is relatively short. However, several recent studies, including a large meta-analysis, suggest that the long-term results after laparoscopic repair are at least equivalent to, and may be better than, open mesh repair.5,27–31 Overall recurrence rates in these reported series range from 1 to 16%, with mean follow ups ranging from 6 to 49 months,13,5 In the present series, we followed up 100% of our patients by interview and physical examination. Studies that report incomplete follow up and that do not include physical examination as a part of the evaluation should be interpreted with caution.
To date, there have only been two prospective randomized studies published in the English literature comparing open and laparoscopic mesh repair of ventral hernias.32,33 Although these studies involved relatively small numbers of patients (<30 in each group), both concluded that laparoscopic repair led to a shorter hospital stay and less wound complications compared with open mesh techniques.32,33 One other study published in 2004 reported the design of a multicentre randomized study comparing laparoscopic and open mesh repair.34 This study aims to recruit >300 patients over a 32-month period. These results are likely to provide valuable information to guide surgeons and patients in the choice of surgical techniques for the repair of these hernias.
The current series represents our early experience with laparoscopic incisional and ventral hernia repair. We are satisfied with the short- and medium-term outcomes and will continue to follow up all the patients to document long-term complications or recurrence. As a result of our experience, we conclude that this technique is safe and feasible and that it may be the operation of choice particularly for large, multifocal ventral or incisional hernias.