Incisional hernias are an all too frequent complication of laparotomies and surgeons spend a significant part of their practice repairing such defects. Leblanc and Booth published the first report of laparoscopic incisional hernia repair in 1993.1 Over the course of time, this approach has gained popularity with patients who seek a “minimally invasive” solution to their hernia problem and with surgeons who believe that the laparoscopic approach offers advantages over traditional repairs.
After nearly two decades of experience with laparoscopic incisional hernia repair, there is a surprising paucity of good data clearly proving the benefits of this technique over standard open surgery. In this chapter, we will review the published experience, technical factors needed for successful laparoscopic repairs, the costs, and long-term results of laparoscopic ventral hernia repair (LVH). Since most ventral hernias are small and easy to repair primarily, we will focus on incisional hernias and use the term LVH to cover both types of defect.
Although the pioneers of LVH felt that this approach would be less invasive and therefore less painful than traditional surgery, many other advantages became apparent as the procedure was developed. Traditional incisional hernia repairs—even when performed with mesh—have a relatively high failure rate. Some of the failures are due to patient-related factors such as obesity, steroid use, tobacco abuse, or abdominal stressors such as chronic cough. However, one of the most common technical causes of failure is failure to identify all fascial defects. Many incisional hernias have multiple components, some of which are not apparent on physical examination. If a surgeon fails to repair all the defects, failure (occasionally described as a new hernia defect in proximity to the prior repair) is almost certain to occur. LVH offers a superior view of the fascial defect and hence reduces the likelihood that a surgeon will fail to identify the extent of the problem that needs to be fixed. This is particularly helpful when the fascia is attenuated. An additional advantage is gained in patients who have undergone surgery for abdominal neoplasms in that peritoneoscopy may occasionally discover signs of recurrent disease. Finally, in patients whose incisions are deeply scarred, approaching the defect transperitoneally can avoid a tedious dissection of the subcutaneous layers. Likewise, if a patient has had a prior wound infection, the transperitoneal approach delivers the mesh prosthesis through a clean field and may reduce the risk of recurrent infection.
There are disadvantages of LVH that need to be considered when recommending treatment to a patient. Since very little is done to the subcutaneous tissue, LVH often leaves a large dead space that can result in a seroma. Even if seroma formation is prevented, excess skin and fat can lead to a poor cosmetic outcome following repair of large defects. Some patients in whom LVH is attempted may have severe adhesions necessitating a tedious and occasionally hazardous adhesiolysis. Inadvertent bowel injury is probably the leading cause of mesh infection in ...