Laparoscopic Repair of Incisional and Other Complex Abdominal Wall Hernias

Laparoscopic Repair of Incisional and Other Complex Abdominal Wall Hernias


Randall O Craft, MD; Kristi L Harold, MD

 

Summer 2009 - Volume 13 Number 3

https://doi.org/10.7812/TPP/09-001

Abstract

Incisional hernia is one of the most common complications of abdominal surgery, with a reported occurrence rate of up to 20% after laparotomy. The high incidence of hernia formation significantly contributes to both patient morbidity and health care costs. Although a variety of approaches have been described to repair these defects, historically the results have been disappointing. Recurrence rates after primary repair have been reported to range from 24% to 54%. The recent advent of laparoscopic ventral hernia repair (LVHR) has offered promising outcomes by combining tension-free repair using a prosthesis with minimally invasive techniques, lowering reported recurrence rates to <10%. This review discusses standardized, well-researched techniques that have contributed to the success of LVHR. We also discuss how these techniques have been modified for laparoscopic repair of suprapubic lumbar hernias, hernias near the iliac crest, and parastomal hernias. In addition, we review our own experience with LVHR in the context of the principles discussed.

Incisional hernia is one of the most common complications of abdominal surgery, with a reported occurrence rate of up to 20% after laparotomy.1 The high incidence of hernia formation significantly contributes to both patient morbidity and health care costs.2 Although a variety of approaches have been described to repair these defects, the results have been historically disappointing. Recurrence rates after primary repair have been reported to range from 24% to 54%.1,3–5 Risk factors for recurrence include suture repair, infection, prostatism, and previous surgery for an abdominal aortic aneurysm.3 The incorporation of prosthetic mesh improved the durability of the repair regardless of the size of the hernia but surgery still resulted in recurrence rates of up to 34%.3,5,6 Repair of a recurrent incisional hernia has been associated with recurrence rates of up to 48%.7 The recent advent of laparoscopic ventral hernia repair (LVHR) has offered promising outcomes by combining tension-free repair using a prosthesis with minimally invasive techniques, lowering reported recurrence rates to <10%.8–11

Pooled analysis of LVHR compared with open ventral hernia repair (OVHR) encompassing 5340 patients in a 14-year period revealed that LVHR was associated with significantly fewer wound complications (3.8% vs 16.8%; p < 0.0001), fewer total complications (22.7% vs 41.7%; p < 0.0001), fewer hernia recurrences (4.3% vs 12.1%; p < 0.0001), and a shorter length of stay (2.4 vs 4.3 days; p = 0.0004). No differences in cardiac, neurologic, septic, genitourinary, or thromboembolic complications were found. The mortality rate was 0.13% for LVHR and 0.26% for OVHR (p = NS).12

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