**5.2 Large incisional hernia**

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].

Laparoscopic Incisional Hernia Repair 187

space SSIs are defined as infections in any organ or space. In laparoscopic incisional hernia repair the incidence of SSI is low. In a meta-analysis of 8 randomized controlled trials Forbes et al. showed a significant reduced risk of surgical site infections in laparoscopic incisional hernia repair compared to open surgery [18]. The extensive tissue dissection which is associated with the open approach explains the significant higher infection rate in open surgery. Mostly SSIs in laparoscopic surgery are superficial and can be treated

In general the mortality rate of laparoscopic incisional hernia repair is low with 0.05% [8]. The most serious complication during laparoscopic incisional hernia repair is enterotomy [8]. Enterotomy occurs during adhesiolysis or as a burning lesion with the electorcauter. Therefore we avoid electrocauterisation during adhesiolysis to prevent bowel lesions and perforation. The incidence of intraoperative bowel injuries has been reported to be 1.78% [20] A recognized enterotomy during the operation is associated with a mortality rate of 1.7% [20]. However, if the enterotomy is not recognized during the operation the mortality rate is increased up to 7.7% [20]. Enterotomy can be repaired by laparoscopic or open

Enterocutaneous fistula after intraperitoneal non-resorbable mesh implantation was first reported in by Kaufman et al. in 1981 [21]. An overview of the current literature shows that enterocutaneous fistula after incisional hernia repair is a rare complication and occurs in up to 1% [22]. There was no association of enterocutaneous fistula if the omentum was placed between the mesh and bowel or not. In cases of enterocutaneous fistula the mesh has to be resected partially around the fistula. Complete mesh removal is very rare and depends on

Lomanto et al. showed that there is no difference in the amount of pain comparing laparoscopic and open hernia repair at 24 and 48 hours postoperatively [24]. However, patients undergoing laparoscopic repair had significantly less pain at 72 hours compared to

The threshold for chronic pain is set at three months postoperatively according to the International Association for the Study of Pain [25]. There is no meta-analysis investigating chronic pain after laparoscopic incisional hernia repair. Postoperative pain after mesh fixation with transfascial sutures is likely due to nerve irritation or entrapmen [26]. There is a randomized controlled trial investigating pain comparing two different techniques of mesh fixation [26]. Postoperative pain following suture fixation was significantly higher at 6 weeks postoperatively and two patients suffered from nerve irritation at sites of sutures. However, after 6 months, no difference was seen between the two groups. Pain after mesh fixation with transfascial sutures is likely due to nerve irritation or entrapment and the relatively small distance between individual sutures used in this study. The significant reduction of pain between 6 weeks and 6 months post operation in these patients could be in response to desensitisation of entrapped nerve fibres or in response to resolution of local

open surgery allowing earlier discharge and return to work [24].

conservatively. Mesh removal due to an surgical site infection is very rare [19].

**6.4 Enterotomy** 

approach with similar outcome result [20].

**6.5 Enterocutaneous fistula** 

the surgeons experience [23]

**6.6 Pain** 


Values in parentheses are percentages unless indicated otherwise. \* Values are median (range).

Table 2. Results of outcome parameters of large incisional hernia repair
