Laparoscopic Incisional and Ventral Hernia Repair

The repair of incisional and ventral hernias by the laparoscopic method is now ten years old. The value of this technique has been proven by numerous published reports. The cumulative recurrence rate of this repair is averages 3.3%. This is a significant improvement considering the 10-24% recurrence rate of the open prosthetic repair of these hernias. There has been a steady increase in the adoption of this technique in the United States and around the world such that approximately 30-35% of these hernias are repaired this way in 2001.

There are several significant technical aspects of this herniorraphy that provide for this level of success. The information that has been gleaned from the literature and from my own personal contacts reveals a few critical details. It is imperative that a minimum overlap of three cms. beyond the fascial edges of the hernia orifice is provided by the prosthetic biomaterial. In most instances, this is easy to achieve and, in fact, there is more than this amount of overlap.

Fixation of the prosthesis is the second critical component of this herniorraphy. Most of the recurrences that have been reported in the literature have concluded that inadequate fixation was all or part of the problem. The majority of the "experts" believe that secure attachment of the prosthesis can only be achieved with the combination of transfascial permanent sutures and the helical tacks. These sutures should be no further than five cm. apart along the periphery of the patch. These represent the most important aspect of fixation. The tacks are placed between these sutures at intervals of 1-1½ cm. These function to provide close approximation of the prosthetic/tissue interface so that tissue ingrowth will be assured and that no intra-abdominal contents will interdigitate between the sutures.

An important consideration in this operation is the prosthetic material itself as this represents a most critical element. Only a few centers will utilize a polypropylene material for this repair. The vast majority will use a biomaterial that is designed to provide tissue ingrowth and maintain an anti-adhesive surface. The most popular products utilize ePTFE as reported in the literature. Newer products are in development or have been recently released. The surgeon should review the literature when making this critical choice. The ease of handling of the product, the tissue ingrowth, the anti-adhesive properties and long-term results should guide the surgeon. This should be approached in a scientific manner as we do all of the new methodologies that are released with increasing frequency.

The complication rates of the LIVH are generally less than that of the open repair and are usually 10-15%. The most significant complication is either infection or a missed enterotomy. The infection usually results in removal of the patch. The enterotomy that is missed can result in the death of the patient. The surgeon must be vigilant during the operative procedure so that this does not occur.

Despite thoughts to the contrary, this laparoscopic technique is less expensive than the open method regardless of the prosthesis chosen. This has been shown to be because of the decrease in the length of hospitalization of these patients. In our experience, the average is 1.2 days (including the very large incarcerated patients).

In summary, the LIVH has been proven to be an effective operation that has improved complication rates, lessened hospital stays, a more effective cost/benefit ratio and decreased rates of recurrence when compared to the open method. These facts have resulted the increasing popularity of this herniorraphy.

- Karl A. LeBlanc, M.D., M.B.A., FACS