Controversies in laparoscopic repair of incisional hernia

• Main Author: Sarela Abeezar
• Format: Article
• Language: English
• Published: Wolters Kluwer Medknow Publications 2006-01-01
• Series: Journal of Minimal Access Surgery
• Subjects: Intra-peritoneal onlay mesh; ventral hernia repair; composite mesh; dual-sided mesh.
• Online Access: http://www.journalofmas.com/article.asp?issn=0972-9941;year=2006;volume=2;issue=1;spage=7;epage=11;aulast=Sarela

<b>Background: </b> Incisional hernias can be a significant problem after open abdominal surgery. Laparoscopic incisional hernia repair (LIHR) is conceptually appealing: a large, abdominal wall re-incision with potential wound-related ill effects is avoided and an intra-peritoneal onlay mesh is expected to provide security that is equivalent to open, retro-muscular mesh repair. As such, LIHR has gained substantial popularity despite sparse, randomised clinical data to compare with conventional, open repair. <b> Aim: </b> To enumerate and discuss important, controversial issues in patient-selection, technique and early post-operative care for LIHR. <b> Materials and Methods: </b> Pragmatic summary of comprehensive review of English language literature, discussion with experts and personal experience. <b> Outcomes:</b> Six important areas of some dispute were identified: 1. Size of abdominal-wall defect that is suitable for LIHR: Generally, defect-diameter &gt; 10 cm is better served by open retromuscular repair with tension-free re-approximation of the edges of the defect. 2. Extent of adhesiolysis: Complete division of adhesions to the anterior abdominal wall may identify sub-clinical "Swiss-cheese" defects but incurs some risk of additional complications. 3. Intra-operative recognition of enterotomy: Possible options are either laparoscopic suture of bowel injury and simultaneous completion of LIHR, or staged LIHR or conversion to open suture-repair. 4. Choice of mesh: "Composite" meshes are regarded as the current standard of care but there is paucity of data regarding potential dangers of intra-peritoneal polypropylene mesh. 5. Technique of mesh-fixation: Trans-parietal sutures are more secure than tacks, with limited data to correlate with post-operative pain. 6. Alarm over post-operative pain: Unlike other advanced laparoscopic operations, the specificity of pain as a marker of intra-abdominal sepsis after LIHR remains unclear. <b> Conclusion</b> : Recognition of and attention to controversial issues will promote increased success of LIHR.