VENTRAL HERNIA REPAIR BY THE LAPAROSCOPIC APPROACH

Ventral hernias include incisional hernias and primary defects in the abdominal fascia, which can cause umbilical, epigastric, or spigelian hernias. In adults, incisional hernias account for 80% or more of the ventral hernias that surgeons repair. The prevalence of incisional hernia after laparotomy is 2% to 11% and increases substantially when certain risk factors for postoperative incisional hernia, such as a wound infection or obesity, are present. 7,11,14 The principles of ventral hernia repair are well established. 7,11 The wound closure should be free of excessive tension, the sutures should be placed in healthy tissue, and strong suture material should be used to support the wound through the critical period of healing. If a prosthetic mesh is used in the repair, it should be well tolerated by the patient, durable, and should not increase the risk for wound healing complications. An effective ventral hernia repair, with low perioperative morbidity and recurrence rates, should be performed. Several surgical techniques have been described to meet these goals, including relaxing incisions, internal retention suture technique, and muscle-flap rotation. 3,14 The use of prosthetic mesh has resulted in a lower recurrence rate compared with a primary repair, but for mesh placement, a more extensive dissection is necessary but slightly increases the risk for wound healing complications. 3,10 In the past 4 decades, the surgical techniques for ventral hernioplasty have gone through three stages. Before 1960, most incisional hernias were repaired primarily, that is, by direct suture technique. This was probably adequate for small, uncomplicated hernias, but the overall experience with the repair of ventral and incisional hernias was unsatisfactory, and the recurrence rate ranged from 30% to 50%. 11,15 This was true even though modifications such as relaxing incisions in the fascia and the use of internal retention sutures, fascia lata grafts, or muscle flaps were often part of the procedure. The next era, the era of the mesh prosthesis, for hernia repair began in the early 1960s, when Usher 16,17 first demonstrated the clinical usefulness of a knitted polypropylene mesh for use in the repair of complex hernias. Today hernia repair with a prosthetic mesh is commonplace for groin hernias and anterior abdominal wall hernias. The addition of prosthetic mesh has been beneficial to patients and has improved outcome. With mesh repairs, the recurrence rate for incisional hernia has decreased to 10% to 20%, and difficult surgeries have been simplified by the availability of this technique. 10,14 In the 1990s, a third approach to incisional hernia repair was introduced: the minimally invasive approach with laparoscopy. For surgeons who use laparoscopic repair, the expectation is that the laparoscopic approach equals the results of open hernia repair and presents a decreased risk for infection, fewer postoperative complications, and a more rapid recovery. The early experience seems to support these projections, but relatively few comparative studies of open versus laparoscopic repair have been performed, the follow-up is still short, and the author is aware of only one published, prospective randomized study. 2 This article reviews the indications and patient selection for laparoscopic ventral hernia repair and looks at the short-term and long-term results in the overall context of the experience for open ventral hernia repair.