Laparoscopic 

Incisional Hernia 
 
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Definition 
 Protrusion of an organ through 
the wall that normally contains it.  Ventral 
hernia occurs in the 
abdominal wall.  Incisional hernia occurs in 
the 
area of an old surgical scar. 
 
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Anatomy of the Abdominal 

Wall 
Superior to the arcuate line 
Inferior to the arcuate line 
 
General 4 
Information: 
 100.000 per year. 
 3-20% laparotomy incisional; 10-15% all hernia 
repairs. 
 > 50% occur within the first two years after 
primary operation.  Symptoms developed for 
33-78% of patients 
 5-15% need surgical repair due to acute 
complication 
(incarceration/strangulation) 
 Mortality 0,3%. 
 Elective repair 1,1%.  Emergency repair ? 
Surg Endosc (2014) 28 : 2-29 
 
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Etiology 
➢ Mechanical Factors – Intraabdominal 
pressure 
overwhelming a weakness in the abdominal 
wall. 
➢ Pathologic changes in collagen that adversely 
affect 
wound healing. 
• Type I collagen is dominant in a mature scar. 
• Type III collagen dominates in the early stages 
of wound healing. 
 
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Risk Factors 
 Age Above 65 or 70  Male Gender  
Malnutrition  Sepsis  Anemia  Uremia  
Ascites / Liver Failure  Diabetes  Pulmonary 
Disease  Smoking 
 Abdominal Distension  BMI > 30  Coughing 
/ Retching  Urinary Retention  Post-op Ileus  
Peritoneal Dialysis  Wound Infection  
Corticosteroids  Chemotherapy  
Immunosuppression 
 
Surgical Risk Factors 
 Surgical risk factors: midline incision  Suture 
materials: slowly absorbable and 
non-absorbable suture 
materials. 
➢ Non- absorbable suture materials, associated 
with 
increased wound pain and sinus formation.  
Suture Technique Ideally, tensile strength 
should be maintained 
during the healing process of the wound.  
Mass closure vs layered Closure. 
➢ Layered closure results higher hernia and 
dehiscence 
rates.  Continuous vs. Interrupted Sutures. 
➢ Continuous suture: faster, easier, and can, 
thus, save 
operating time. 
 
SMALL BITES VS LARGE BITES 
TECHNIQUES 
Hernia surgery, current principle; 2016 
 
 Suture 2.0, HR 36 
5 mm 
5 mm 
Fascia 
Fascia edge 
Intraabdomen 

Suture technic 
Simple  rule,  the  length  between  stitches  must  not 
exceed  the  distance  between  the  fascia  edge  and  the 
stitch. 
Hernia surgery, current principle; 2016 
 
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Clinical Presentation 
 A diffuse bulge directly under or adjacent to a 
previous incision.  Increased protrusion with 
Valsalva or standing.  Cosmetic concerns or 
interference with work 
or activity are common complaints.  Pain is 
unusual as a presenting symptom unless there 
are incarcerated or strangulated structures.  The 
natural history of an incisional hernia is to 
enlarge and become symptomatic. 
 
Clinical 11 
Presentation and Workup 
 Physical exam may not be 
adequate in obese patients.  CT should be 
used to find a recurrence or associated 
pathologies  MRI can be used to find 
postoperative adhesions 
Surg Endosc (2014) 28 : 2-29 
 
Repair Hernia: Open vs Lap. 12 
Principes of success 
Patient Technique Prostetic 
 
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Open repair: 
 Extensive soft-tissue 
dissection.  Limited to visualize of the 
abdominal wall.  Difficult to obese patients. 
 Recurrence rate.  LOS.  Pain.  Wound 
complication. 
Laparoscopic repair: 
 Minimization of soft-tissue 
dissection.  To visualize much of the 
abdominal wall leads to fewer missed hernias.  
In obese patients.  Recurrent hernia.  Wound 
complication.  Recurrence rate.  LOS.  Pain. 
 
With 14 
mesh vs without mesh 
Primary repair without mesh  For defect < 20 
mm  Recurrence rate: 54-63% 
Primary repair with mesh  For defect >= 20 cm 
 Recurrence rate: 32%.  Iatrogenic enterotomy 
: 1.2%  Mesh infection : 1%  Seroma complete 
formation resolution : 100% after (30% 90 days) 
become symptomatic, 
Surg Endosc (2014) 28 : 2-29 
 
Prostetic 15 
Prostetic (Mesh) (Mesh) 
  IPOM  :  only  materials  approved  for  use  in  the 
abdominal  cavity  should  be  used  (PTFE,  PVDF, 
composite  meshes  with  absorbable  barrier  coated  and 
composite meshes with permanent barrier coated) 
 Because the biologic interaction between mesh material 
and patient could 
not be predicted, all patients should be informed about the 
risk of potential interactions and complications. 
 Laparoscopic IPOM (sizes from 880 up to 1.250 cm2) is 
feasible for : 
▪ Obese patients (BMI > 30) 
▪ Defects larger than 15 cm 
Characteristics of ideal mesh : 
•Minimal adhesion formation 
•Excellent tissue ingrowth 
•Minimal shrinkage 
•No infection or fistula formation 
•Minimal pain 
•Minimal seroma formation 
•No change in abdominal wall compliance 
•Low price 
•Easy to manipulate 
Surg Endosc (2014) 28 : 2-29 
 
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 Laparoscopic transperitoneal and total 
extraperitoneal 
preperitoneal / sublay repair are surgical options 
for the cure of small- and medium-sized ventral 
and incisional hernias.  For lower abdomen, 
both techniques require more experiences  ECS 
(Endoscopic component separation) technique, 
Rosen 
2007, combined with both techniques, could be 
done for very large incisional hernia. 
Laparoscopic Technique 
 
Set 17 
Up and Trocar Sites 
 Left or right upper quadrant subcostally 
is recommended for 1st access port.  Use 
30° laparoscope  The trocar entry points should 
be as far 
as possible from the adhesion site/defect 
location (approx. 16-18 cm), and should be 
placed to achieve triangulation of the hernia site. 
 Visually guided entry of trocars is 
recommended because these decrease the size of 
the wound 
Surg Endosc (2014) 28 : 2-29 
 
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Adhesiolysis Adhesiolysis 
  Adhesiolysis offers no additional benefit in itself, should 
be  limited  to  freeing  the  abdominal  wall  to  enable 
adequate overlapping of the defect by the mesh. 
 Cold and sharp adhesiolysis is preferred to 
ultrasonic dissection. 
 Bipolar coagulation is allowed, but 
monopolar should be avoided. 
  Adhesiolysis  should  be  performed  near  the  abdominal 
wall away from the adherent bowel. 
Surg Endosc (2014) 28 : 2-29 
 
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Mesh Attachment 
 The margins of the defect 
may be marked on the skin.  The patch is 
measured and 
trimmed to fit.  Overlapping 3-4 cm.  4-6 
large fixation sutures are placed around the 
patch and tied. 
 
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Currently : Currently : 
 Karl LeBlanc (1993) : bridging repair (classic 
IPOM : metallic tack + 
mesh-fixing sutures) decreased recurrence 
rate from 9% to 4%.  Bridging repair may 
causes functional problem in larger hernias.  
Augmentation repair (IPOM-Plus : transfascial 
closure of defect + IPOM) reduces the 
recurrence rate, seroma formation, and 
incidence of chronic pain.  Mesh overlapping 5 
infraumbilical defect and 8 cm with 
augmentation repair. 
Surg Endosc (2014) 28 : 2-29 
 
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Mesh Insertion 
 
Mesh Fixation 22 
 
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Mesh fixation 
 Method used for fixation : sutures and/or 
tacks.  Suture fixation : longer operation time.  
Tacks : higher rate of mesh shrinkage.  
Additional glue may increases the efficacy of 
fixation 
and postoperative pain. 
 
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Contraindications to Lap. Repair 

 Major loss of abdominal domain.  Severe 
debilitation.  Fewer than 5 years life 
expectancy.  Respiratory distress.  Pregnancy. 
 Portal hypertension.  Renal failure with 
presence of peritoneal dialysis 
catheter. 
 
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Tips and Pitfall 

➢ Risk factor investigation. ➢ 
Ventral/incisional hernia commonly in large 
size so right position 
may help to expose whole defect in a good 
view. ➢ Appropriate trocar site. ➢ Be careful 
to use energy device for adhesiolysis. ➢ Choose 
the good prosthetic/IPOM ((PTFE, PVDF, 
composite meshes with absorbable barrier 
coated and composite meshes with permanent 
barrier coated) ➢ Large defect need to 
augmentation repair (IPOM plus). ➢ Adequate 
overlapping to minimised recurrence. ➢ 
Adequate mesh fixation. 
 
Conclusion 27 
 Ventral hernia is protrusion of an organ 
through the abdominal 
wall.  Incisional hernia occurs in the area of 
an old surgical scar.  If diagnosed, operation 
should always be advised.  Principles of 
success: patient, technique, and prosthetic.  
These can be repaired by laparoscopic IPOM 
that superior 
than open method. 
 
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