**4. Surgical technique of laparoscopic hernia repair**

We routinely use a 30° camera. Scissors and two graspers have to be prepared for laparoscopic hernia repair. The screen is placed at the opposite of the surgeon. The patient is placed in a supine position with both arms unabducted under general anesthesia. A single shot of antibiotics is given preoperatively. The site of trocar placing depends on the localization of the hernia. If the hernia is localized in the right hemiabdomen, the trocars should be placed on the left side. Using a limited open technique the pneumoperitoneum is established and the optical trocar is inserted, and under direct vision, a minimum of two additional trocars at a suitable distance from the hernial orifice are inserted. Alternatively the pneumoperitoneum can be established using a Verres-Needle. After establishing the pneumoperitoneum at 12mmHg a diagnostic laparoscopy is performed. Adhesions between the omentum or intestine with the anterior wall surrounding the hernial orifice are divided, and the content of the hernia is reduced completely (Fig. 3). Adhesiolysis has to be

Laparoscopic Incisional Hernia Repair 185

overlap the hernia margins by at least 5 cm on each side. In addition, the mesh should overlap the full length of the incision of the primary operation. Non absorbable monofilament sutures are placed in 2-3 cm intervals along the mesh margin. The mesh is

Then the mesh is rolled up and introduced into the abdominal cavity. After the mesh is positioned correctly in the abdominal cavity, the suture ties are pulled through the abdominal wall with a suture passer and the threats are knotted smoothly with the knots buried in the subcutaneous tissue after reduction of the intraabdominal pressure to 8mmHg. We use titanium tackers that are applied between the sutures every 1 to 2 cm between the sutures and around the hernial orifice (Fig 5). If the skin is necrotic or to enhance cosmetic results in large incisional hernia an additional open cutaneous excision is recommended.

rolled up and inserted into the abdomen through a 12mm trocar.

Fig. 5. Intraoperative laparoscopic view after Mesh implantation.

In general we plan the laparoscopic approach for all patients with incisional hernia. Contraindications for laparoscopic hernia repair are the presence of anesthetic (severe pulmonary disease) or technical contraindications (eviscerated organs) or patients unwilling

In our institution we prospectively evaluated 125 with a hernia diameter ≥5cm among 428 patients undergoing incisional hernia repair. We demonstrated that laparoscopic repair of large incisional hernias is technical feasible and associated with less SSI and shorter hospital

stay but a comparable recurrence rate as open hernia repair (Table 2) [11].

**5. Patient selection** 

**5.1 General considerations** 

to undergo laparoscopic surgery.

**5.2 Large incisional hernia** 

performed with scissors and without electocoagulation under direct vision to avoid bowel lesions. In cases of incarceration the necrotic tissue has to be resected. If there is not enough working space or the trocars are not correctly placed an additional trocar can be helpful.

Fig. 3. Intraoperative laparoscopic view of the hernial orifice

In general, the hernial sac is left in situ. After completion of adhesiolysis, the pneumoperitoneum is released, the maximal longitudinal and horizontal hernia diameter is measured and marked on the skin (Fig. 4). An appropriate sized mesh is tailored in order to

Fig. 4. Patient with an incisional hernia in the upper part of the scar. The hernia and the size of the mesh is marked on the patients skin.

performed with scissors and without electocoagulation under direct vision to avoid bowel lesions. In cases of incarceration the necrotic tissue has to be resected. If there is not enough working space or the trocars are not correctly placed an additional trocar can be helpful.

In general, the hernial sac is left in situ. After completion of adhesiolysis, the pneumoperitoneum is released, the maximal longitudinal and horizontal hernia diameter is measured and marked on the skin (Fig. 4). An appropriate sized mesh is tailored in order to

Fig. 4. Patient with an incisional hernia in the upper part of the scar. The hernia and the size

Fig. 3. Intraoperative laparoscopic view of the hernial orifice

of the mesh is marked on the patients skin.

overlap the hernia margins by at least 5 cm on each side. In addition, the mesh should overlap the full length of the incision of the primary operation. Non absorbable monofilament sutures are placed in 2-3 cm intervals along the mesh margin. The mesh is rolled up and inserted into the abdomen through a 12mm trocar.

Then the mesh is rolled up and introduced into the abdominal cavity. After the mesh is positioned correctly in the abdominal cavity, the suture ties are pulled through the abdominal wall with a suture passer and the threats are knotted smoothly with the knots buried in the subcutaneous tissue after reduction of the intraabdominal pressure to 8mmHg. We use titanium tackers that are applied between the sutures every 1 to 2 cm between the sutures and around the hernial orifice (Fig 5). If the skin is necrotic or to enhance cosmetic results in large incisional hernia an additional open cutaneous excision is recommended.

Fig. 5. Intraoperative laparoscopic view after Mesh implantation.
