**3.2.2 Recurrence after laparoscopic repair**

Luijendijk (2000) and Burger (2004) stressed the importance of mesh reinforcement for incisional hernia repair, with long-term recurrence rates of 60% in the suture repair group and 32% in the mesh group. Recurrence rates following laparoscopic and open ventral hernia repair with prosthetic reinforcement are comparable (Bingener et al., 2007; Goodney et al., 2002; Sajid et al., 2009). Wound infection is one of the main contributors to the recurrence rate after laparoscopic ventral hernia repair, but surgical-technical failure is underestimated. Technical failure (i.e. inadequate mesh fixation, mesh overlap and lateral detachment) accounts for approximately 50% of the recurrences and infection for an additional 25% (Awad et al., 2005). This explains the major decrease of recurrences in experienced hands, compared to non-experts. By laparoscopic ventral hernia repair the intraperitoneally placed mesh is pushed outward and held in place by the natural intraabdominal pressure. Another benefit of the laparoscopic approach is identifying small

Around 40% of incisional hernias are symptomatic and approximately 1 out of every 3 incisional hernias is repaired in an elective or emergency setting. In the United States, approximately 4 to 5 million laparotomies are performed annually, leading to 400,000 to 500,000 incisional hernias, of which approximately 200,000 repairs are performed (Burger et

Different classification systems for incisional hernias are available. The European Hernia Society developed a classification for incisional hernias which takes in account the location, size and possible recurrence of the incisional hernia (Muysoms et al., 2009). This classification allows comparison of publications and future studies on treatment and

Midline: M1 (subxiphoidal), M2 (epigastric), M3 (umbilical), M4 (infraumbilical)

The Ventral Hernia Working Group (USA) developed a hernia grading system based on the characteristics of the patient and the wound (Ventral Hernia Working et al., 2010). Using this system a surgeon can assess the risk for surgical-site occurrences (infection, seroma, wound dehiscence, and the formation of enterocutaneous fistulae) for individual patients and thereby select the appropriate surgical technique, repair material, and overall clinical approach for the patient. The grading system with assessment of risk for surgical site

Grade 1, Low risk: patients without a history of wound infection and a low risk of

Grade 2, Co-morbid: patients with one or more co-morbidities of smoking, obesity,

Grade 3, Potentially contaminated: patients with a previous wound infection, stoma

Luijendijk (2000) and Burger (2004) stressed the importance of mesh reinforcement for incisional hernia repair, with long-term recurrence rates of 60% in the suture repair group and 32% in the mesh group. Recurrence rates following laparoscopic and open ventral hernia repair with prosthetic reinforcement are comparable (Bingener et al., 2007; Goodney et al., 2002; Sajid et al., 2009). Wound infection is one of the main contributors to the recurrence rate after laparoscopic ventral hernia repair, but surgical-technical failure is underestimated. Technical failure (i.e. inadequate mesh fixation, mesh overlap and lateral detachment) accounts for approximately 50% of the recurrences and infection for an additional 25% (Awad et al., 2005). This explains the major decrease of recurrences in experienced hands, compared to non-experts. By laparoscopic ventral hernia repair the intraperitoneally placed mesh is pushed outward and held in place by the natural intraabdominal pressure. Another benefit of the laparoscopic approach is identifying small

outcome of incisional hernia repair. Incisional hernias are classified by:

 Lateral: L1 (subcostal), L2 (flank), L3 (iliac) and L4 (lumbar) Width: W1 (smaller than 4 cm), W2 (4 to 10 cm), W3 (10 cm or more)

diabetes mellitus, COPD, immunosuppression.

**3.2.2 Recurrence after laparoscopic repair** 

present or operation with violation of the gastrointestinal tract. Grade 4, Infected: patients with an infected mesh or septic dehiscence.

al., 2004).

**3.2.1 Classification** 

Location:

occurrences:

complications

and M5 (suprapubic)

Recurrence: yes or no

fascial defects, known as ''Swiss cheese'' defects, which may be missed during open repair. These small fascial defects are thought to be the major source of incisional hernia recurrence and therefore identification is important for a successful hernia repair.

#### **3.3 Trocar site heria**

Trocar site hernias (TSH) have an overall low incidence of less than 1% in adults. The incidence of TSH increases with the size of the used trocar. Almost all TSH develop from trocars of 10 mm or above. Most TSH are located at the umbilical port site, where the largest trocars are used and the fascia is expanded to remove surgical specimen. To prevent TSH the fascia of trocar sites of 10 mm or above should be sutured with a non-absorbable or slowly-absorbable suture, especially in the umbilical area. Co-morbidities as diabetes, smoking and obesity might be risk factors for TSH (Helgstrand et al., 2010). The use of a Veress Needle (instead of an open introduction technique) and a sharp trocar (compared to a conical shaped trocar) are associated with a higher incidence of TSH. In young children the reported incidence of TSH is higher than in adults (5% vs 1%). Herniation of the small sized bowels through trocar ports of 3-5 mm is described, which shows the importance of closing all trocar port fascias in paediatric patients.

## **3.4 Umbilical hernia**

A congenital umbilical hernia develops when the umbilical scar fails to heal at birth. The incidence of congenital umbilical hernia is 10-30%, with a higher incidence in African American children than in Caucasian children. During the first 1.5 year of life most umbilical hernias close and at the age of 5 almost all children have complete closure of the umbilical ring. Repair should not be considered before an age of 3 years and only in children with large hernias that do not decrease in size or are symptomatic. In the rare case of incarceration, repair is necessary to avoid strangulation (Katz, 2001). Umbilical hernias in adults are an acquired defect in over 90% and are three times more frequently seen in women than in men. The development of an umbilical hernia is associated with obesity, abdominal distension, ascites and pregnancy. In females umbilical hernias are more frequent among multipara and are often easily reducible. Men often present with an incarcerated umbilical hernia, most often containing herniated omentum or preperitoneal fat. Laparoscopic umbilical hernia repair with an onlay patch is a safe and efficacious technique, and compared to open repair has the advantages of a lower rate of wound complications, reduced postoperative pain, shorter hospital stay and a diminished morbidity rate (Lau & Patil, 2003; Toy et al., 1998). Hernia repair in the presence of ascites due to cirrhosis should be considered elective, since emergency repair has an associated morbidity of 70% and mortality of 5% (Telem et al., 2010). Even in patients with mild to moderate cirrhosis correction can be safely performed (Heniford et al., 2000).

### **3.5 Epigastric hernia**

An epigastric hernia is a defect in the linea alba located between the xyphoid process and umbilicus. Epigastric hernias are comparable to umbilical hernias, but smaller in size, often less than 1 cm (Lang et al., 2002). Epigastric hernias are acquired defects with an incidence of 3-5%, three times more frequent in men than in women and mostly diagnosed between 40- 60 years. Associated factors for the development of epigastric hernias are increased intraabdominal pressure and muscle or linea alba weakness. During laparoscopy an epigastric

Laparoscopic Hernia Repair 173

elastic and permits movement during swallowing and breathing. The extrinsic component of the anti-reflux mechanism is the pinching action of the right crus of the diaphragm. The right crus narrows the hiatus and increases the angle between the ventrally bended distal esophagus and the cardia. The LES and crus normally supplement each other in preventing acid reflux during swallowing or acute increased intra-abdominal pressure (Lange &

A diaphragmatic or hiatal hernia occurs after enlargement of the hiatus and is a common disorder of the digestive tract. Cranial movement of the esophagus with protrusion of abdominal content (stomach in general) into the thoracic cavity can occur through the widened hiatus. This natural antireflux function is often disrupted by the presence of a hiatal hernia and is strongly associated with gastro-esophageal reflux disease (GERD). Hiatal hernias larger than 3 cm are a risk factor for erosive GERD and Barrett's esophagus.

 Type 1: Sliding hernia. The gastroesophageal junction migrates into the thoracic cavity. Type 2: Paraesophageal hernia. Herniation of the gastric fundus anterior to a normally

 Type 4: Herniation of additional organs. The whole stomach and sometimes additional visceral organs (i.e. colon, omentum or spleen) migrate into the thoracic cavity. This can

Up to 95% of all hiatal hernias can be classified as a type 1, sliding hernia. Type 3 and type 4 hiatal hernias tend to be large or giant hernias. Large or giant hernias are defined as at least 30%-50% of the stomach herniating into the thoracic cavity. Patients with hiatal hernia can experience symptoms of GERD, as epigastric pain, dysphagia, heartburn, but in more severe cases gastric hemorrhaging, vomiting and cardiopulmonary problems with dyspnea. Paraesophageal hernias account for less than 5% of all hiatal hernias but can have potentially life-threatening complications, such as obstruction, dilatation, necrosis with

Patients with sliding hernias and GERD should be considered for elective surgical repair. The objectives of hiatal hernia surgery for GERD are repair of the intrinsic component of the anti-reflux mechanism by bringing back LES into the hiatal tunnel and repair of the extrinsic component of the anti-reflux mechanism by narrowing the hiatus. Paraesophageal hernias (type 2, 3 and 4) should be repaired when symptomatic, due to the associated possible lifethreatening complications. The laparoscopic approach to hiatal hernia repair has the benefit of easy exposure of the hiatus area and a good vision into the mediastinum. To restore the intrinsic component of anti-reflux mechanism a laparoscopic fundoplication is performed. The laparoscopic Nissen fundoplication (360° wrap) is the most frequently applied procedure. Other possible fundoplications are the posterior Toupet (270° wrap) and anterior Dor (180° wrap). The laparoscopic Nissen fundoplication is equally effective in patients with GERD or with paraesophageal hernia and is the preferred fundoplication procedure. The failure rate of a Nissen fundoplication for GERD is between 2-30%, depending whether failure is defined as resumption of conservative treatment or failure requiring reoperation.

Kleinrensink, Surgical Anatomy of the Abdomen, Elsevier gezondheidszorg, 2002).

Anatomically four different types of hiatal hernias can be recognised:

positioned gastroesophageal junction.

perforation or bleeding of the stomach.

**4.2 Laparoscopic repair** 

Type 3: Mixed sliding and paraesophageal hernia.

result in a stomach in upside-down position.

**4.1 Classification** 

hernia can be difficult to visualize due to lack of peritoneal involvement through the hernia defect. Frequently epigastric hernias present incarcerated and in general only contain omentum or preperitoneal fat. Because of the small defect the hernia defect mostly need to be enlarged to reduce the hernial sac and its content.
