**1. Introduction**

180 Updated Topics in Minimally Invasive Abdominal Surgery

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An incisional hernia (Fig 1.) is defined as any abdominal wall gap with or without a bulge in the area of a postoperative scar perceptible or palpable by clinical examination or imaging [1]. Incisional hernia is a common long-term complication following abdominal surgery and is estimated to occur in 11-23% [2, 3]. Risk factors for incisional hernia are male gender, body mass index, cancer, and previous laparotomy [4, 5].

Fig. 1. Clinical presentation of a patient with a large incisional hernia

Conventional hernia repair with tissue approximation was associated with a recurrence rate of 60%. Theodore Billroths vision was the source of changes in hernia repair. Billroth told to his pupil Cerny: "If we could artificially produce tissues of the density and toughness of fascia and tendon the secret of the radical cure of hernia would be discovered". This statement appeard in the classic Beiträge zur Chirurgie in 1987. Francic C. Usher introduced 1957 a polypropylene based prosthesis to bridge the hernia defect and to reinforce the abdominal wall without tension [6]. With the implantation of prosthesis the recurrence rate in hernia repair was downsized [7].

Laparoscopic Incisional Hernia Repair 183

A swelling or protrusion with or without abdominal pain can be observed in a patient with an incisional hernia when the patient sits up or coughs. In large incisional hernia peristaltic bowel movements can be observed through a thin skin, sometimes already accompanied with signs of a skin infection. Incisional hernias may occur along the full length of the incision with one or multiple hernial orifices. Incarceration is the main complication of an incisional hernia [10] and occurs in 1-3% of all hernias. Signs of incarceration are acute pain and vomiting. Clinically there is a tense, tender irreducible hernia. In these cases an emergency hernia repair is mandatory. Emergency hernia repair can also be performed by

Incisional hernia can be diagnosed by physical examination. Additional ultrasound or CT-

Fig. 2. CT-Scan of a patient with a large incisional hernia. The hernia contains small and

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

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

laparoscopy with an additional mini-laparotomy if bowel resection is necessary.

scan examination are recommended in cases of uncertainty (Fig 2).

**3. Symptoms** 

large bowel.

Incisional hernia can be repaired by open or by laparoscopic approach and prosthetic meshes are nowadays implanted in most procedures. The use of laparoscopy for the treatment of incisional hernia was first reported in 1993 by LeBlanc and Booth [8]. With the introduction of modern two-layered mesh, laparoscopic incisional hernia repair has become an accepted therapeutic option. Feasibility and safety of laparoscopic incisional hernia repair has been shown in various randomized controlled trials.
