DIAGNOSIS

It is performed by physical examination. Only in difficult cases, imaging studies, such as ultrasound or computed tomography, may play a role.

TREATMENT

For this type of hernia, the laparoscopic technique is the preferred option, since the advantages of this approach are many, as will be seen below.

La reparación primaria (aproximación de los tejidos propios del paciente) de las hernias incisionales se puede realizar cuando el defecto es de diámetro pequeño, mide menos de <2,5 cm (1 pulgada) y hay tejido circundante viable (fuerte).

Since larger defects > 2.5 cm (> 1 inch) have a high recurrence rate if closed primary (using only sutures to approximate tissues), the use of a prosthetic mesh is mandatory. Recurrence rates range from 10-50% and are reduced by more than half with the use of mesh. Experience with laparoscopic repairs using mesh has been favorable with recurrence rates as low as 1-10%.

A wide variety of meshes are available; the ideal mesh has not yet been defined and Dr. Rosales will decide which one to use, depending on what is best for your case.

Regarding the best technique, it is highly desirable to place the mesh under the fascia (the strongest layer of the abdominal wall), with a wide overlap of mesh and fascia, the forces of the abdominal cavity acting to hold the mesh in place. This can be accomplished using the laparoscopic approach to incisional hernia repair, which is based on this principle, which is why it is Dr. Rosales’ preference in most cases.

Image of the ventral / incisional defect «seen» with the camera from inside the abdomen and being covered with the mesh.

COMPLICATIONS OF VENTRAL HERNIA SURGERY

• Seroma 1-5%.
• Bleeding 1% Bleeding
• Hematoma 5%.
• Visceral lesion 1%.
• Wound infection 2%.
• Intestinal obstruction 0.5%.
• Urinary retention 2%.
• Nausea and vomiting 8%.
• Recurrence 10%.
• Mesh infection 1- 8%
• Enterocutaneous fistula 1-3%.

The incidence of postoperative complications and recurrence are lower in laparoscopically repaired hernias; according to comparative trials, laparoscopic incisional hernia repair results in fewer complications, a lower infection rate and lower hernia recurrence. But to achieve these results, it must be performed by a surgeon experienced in advanced laparoscopic procedures. In addition, it should be remembered that many of these complications are transient and can be easily addressed.

ADVANTAGES OF LAPAROSCOPIC INCISIONAL HERNIA REPAIR

• Very small incisions (3)
• Rapid recovery time (one or two night hospital stay, depending on the case)
• Minimal postoperative pain.
• Lower morbidity rate
• Shorter hospital stay
• Return to normal activity and work in a shorter period of time (full recovery in 5 to 7 days).
• Decreased risk of wound infection and new hernia formation.
• Minimal scarring
• Better visualization, ability to detect all defects (key advantage)
• Possibility of adequate overlapping of the mesh in relation to the defect.
• It is not necessary to dissect the fatty tissue of the abdominal wall to put the mesh in place.
• Ability to use the natural forces of the abdominal wall to anchor the mesh in place.

SURGICAL TECHNIQUE (SIMPLIFIED EXPLANATION)

Under general anesthesia, a 10 mm incision is made in the lateral area of the abdomen at the level of the umbilicus, CO2 is introduced into the cavity, then 2 more incisions are made in the abdomen (both 5 mm) to introduce the instruments, the hernia sac and its contents are returned to the abdominal cavity, the entire area is dissected and the mesh is introduced through one of the incisions and placed covering the entire defect(s) with an overlap of at least 4 cm, then fixed with staples, the incisions are closed with sutures and the procedure is completed.

** The material Dr. Rosales uses depends on the case and his preference based on experience.

Incisions for laparoscopic incisional hernia repair