Incisional/Ventral Hernia
  Laparoscopic Incisional Hernia Repair
   
  “Recurrence rates vary between 10 – 50% and are reduced by more than half with the use of a mesh. The experience with laparoscopic repairs employing mesh has been favourable with recurrence rates as low as 1-10%.”

   
   
Surgical Procedures  >  Hernias  >   Incisional/Ventral Hernia    
 

Incisional hernias occur as a result of excessive tension and/or inadequate healing of a previous incision, which is often associated with surgical site infection.

Signs and Symptoms

  • Bulge in the abdominal wall, usually under or close to the site of the previous incision, the size varies from small to very large defects and bulges. It also enlarges upon increases in the intra-abdominal pressure or standing position.
  • Multiple or single defects and/or bulges can be found.
  • Pain also varies from patient to patient, depends on the size of the defect and the contents of the hernia sac.
  • Abdominal Distension when the contents of the hernia sac involve .intra-abdominal organs, mainly small bowel, this sign/symptom can be present, accompanied by increased pain.
  • When the contents cannot return to the abdominal cavity, it is incarcerated; this may lead to increased pain, bowel obstruction and strangulation, which if its left untreated, can lead to serious complications.
Diagnosis

It is done by a physical examination. Just in difficult cases, imaging studies such as ultrasound or CT Scan, may have a role.

Treatment

For this type of hernia(s) the laparoscopic technique is the preferred option since the advantages of this approach are great, as seen below.

Primary repair (approximation of patient’s own tissues) of incisional hernias can be done when the defect is small in diameter, less than 1 inch (<2.5 cm) and there is viable (strong) surrounding tissue.

Since larger defects, > 1 inch (>2.5cm) have a high recurrence rate if closed primarily (using just sutures to approximate tissues) the use of a prosthetic mesh is mandatory. Recurrence rates vary between 10 – 50% and are reduced by more than half with the use of a mesh. The experience with laparoscopic repairs employing mesh has been favorable with recurrence rates as low as 1-10%.

A variety of meshes are available; the ideal mesh has yet to be defined and finally the one used is decided by Dr. Rosales, depending on what is best for your case.

Regarding the best technique, it is highly desirable to have the mesh placed beneath the fascia, with a wide overlap of mesh and fascia, the forces of the abdominal cavity act to hold the mesh in place. This can be accomplished using the laparoscopic approach for incisional hernia repair, which relies on this principle; that is why it is Dr. Rosales’ preference in the majority of cases.
     
 


Complications

  • Seroma 1-5%
  • Bleeding 1%
  • Hematoma 5%
  • Visceral injury 1%
  • Wound infection 2%
  • Bowel obstruction 0.5%
  • Urinary retention 2%
  • Nausea and vomiting 8%
  • Recurrence 10%
  • Mesh infection
  • Enterocutaneous fistula 1-3%

The incidence of postoperative complications and recurrence are less in hernias repaired laparoscopically; based on comparative trials, laparoscopic incisional hernia repair results in fewer complications, lower infection rate and decreased hernia recurrence. But in order to achieve these results, it has to be done by a surgeon with experience in advanced laparoscopic procedures such as Dr. Rosales. It should, moreover, be remembered that many of these complications are transient and can be addressed easily.

Laparoscopic vs. Open Incisional Hernia Repair
 
     
 
Laparoscopic Groin Hernia Repair   Open Groin Hernia Repair
     
     
  • Very small incisions (3)
  • Fast recovery time (one or two nights hospital stay, depends on the case)
  • Minimal postoperative pain
  • Lower morbidity rate
  • Lower hospital stay
  • Return to normal activity and return to work in shorter period of time (complete recovery in 5 to 7 days)
  • Decreased risk of wound infection and hernia formation
  • Minimal scarring
  • Better visualization, capability of detecting all defects (key advantage)
  • Possibility of adequate overlapping of the mesh in relation to the defect
  • No need of dissection of the abdominal wall fatty tissue to put the mesh in place
  • Possibility of using the abdominal wall’s natural forces to anchor the mesh in place.
Surgical Technique (Simplified)

Under general anesthesia, a 10 mm incision is made in the lateral area of the abdomen at the height of the umbilicus/navel, CO2 is introduced to the cavity, then 2 more incisions are made in the abdomen (both of 5mm) to introduce the rest of the instruments, the hernia sac and its contents are brought back to the abdominal cavity, the whole area is dissected and the mesh is introduced through one of the incisions and placed covering the totality of the defect(s) with an overlap of at least 4 cm, then it is fixed with staples, incisions are closed with suture and the procedure is completed.

**The material Dr. Rosales uses depends on the case and his personal preference.


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