**5. Postoperative complications**

of the operation is adhesiolysis. The adhesions in the abdomen are lysed using an electrocautery, an ultrasonic scalpel, or scissors. No cauterization should be done that may injure the bowel wall. Perforation of the intestine is the most serious injury associated with laparoscopic ventral hernia repair [12]. Thus, in selected cases, if extensive adhesiolysis is deemed to be particularly hazardous for enterotomy, the conversion should be done and division of omental and bowel adhesions to the anterior abdominal wall is performed through laparotomy. Other causes of conversion are bigger size of the fascial defect than it was primary expected but which was impossible to repair during laparoscopic procedure only, lack of progression of operation, and intraoperative bleeding. The authors analyzed the causes of conversion based on 237 patients primarily qualified to hernia repair with the IPOM procedure in our department between 2008 and 2016. In case of 27 patients (11.4%) from a group of 237 patients, it was necessary to change surgical approach from laparoscopic to open surgical

**Causes of conversion n-237 (%)** Massive adhesions 4.6 Injury of small bowel during adhesiolysis 3 Injury of small bowel during trocar placement 1.3 Size of defect (too large to repair during laparoscopy) 1.3 Lack of progression of operation 0.9 Intraoperative bleeding 0.4

Performance of open, safe adhesiolysis or repair of injuries is essential for graduating to another step of the procedure. Placement of the mesh into the abdominal cavity, closing the fascial defect and laparoscopic fixation of the mesh, should progress the same as in case of

There are no objectively defined selection criteria of treatment of incisional hernias, but we

In our concept, hybrid surgical approach can be dedicated to patients with large, difficult incisional hernias, where extensive, dense adhesions are expected (e.g., patients with two or more recurrences of hernia, patients with history of successful treatment of gastrointestinalcutaneous fistulas, patients after many laparotomies—three or more). Moreover, it may be prudent to offer hybrid repair for particularly large incisional hernias, where transverse sepa-

selected some rules which may find helpful in making treatment decisions.

approach. Respective causes of conversion are presented in **Table 1**.

**Table 1.** Causes of conversion during IPOM procedure based on 237 cases.

66 Hernia Surgery and Recent Developments

standard combined laparoscopic technique.

ration of the fascial edges is >8–10 cm.

**3. Indications for the hybrid technique**

Complications after hybrid approaches to incisional hernia repair span a wide range of severities. To do it more comprehensibly, they were divided into early and long-term complications.

### **5.1. Early postoperative complications**

Early postoperative complications are revealed during the operation or not longer than 30 days after the operation. Some of postoperative complications are composed of those common to all general surgery, for example, thromboembolism and superficial surgical site infection, and are typically managed no differently [16]. Unique to recovery from hernia surgery however can be increased pain after mesh placement, seroma related to large dissection planes, infections of the mesh, as well as pulmonary insufficiency due to changes or loss in abdominal domain.

An inadvertent enterotomy is a serious complication of adhesiolysis. Adhesions to the abdominal scar represent a significant problem during hybrid repair, with the risk of bowel injury around the neck of the hernia during dissection. Rudmik et al. [17] in their review calculated an overall risk of enterotomy of 2.1% when the laparoscopic approach is the first step of hybrid repair. Injury of a hollow organ is a very serious event and should be recognized and treated immediately. An incidental enterotomy may occur during initial trocar placement or may result from adhesiolysis. Two strategies are available to deal with such a situation. One option, which is particularly attractive when there is no enteric spillage, is to suture the perforation and proceed with hybrid repair, in conjunction with copious saline lavage of the peritoneal cavity and intravenous antibiotics. The second option is to complete adhesiolysis and repair the bowel injury but to delay mesh placement (i.e., perform a "staged repair," within a fairly short interval), in order to optimize bacterial clearance and minimize the risk of infection [18]. Colonic injury is a more serious concern; there is no substantial evidence base to guide decision-making. The optimal strategy in case of enteric injury needs to be decided on a case-by-case basis. A safe option, particularly if laparotomy has been undertaken because of the bowel injury, is to perform simply a suture repair of the hernia and accept that the risk of mesh infection has been exchanged for a higher risk of hernia recurrence. If the enterotomy remains unnoticed, it may result in an acute abdominal condition and sepsis within a few hours after surgery.

into the muscle. This theory explains why acute postoperative pain is the most frequently observed in young, slim females. Furthermore, some studies show that the use of multiple transparietal sutures is largely related to a perceived association with increased postoperative

Hybrid Technique for Incisional Hernias http://dx.doi.org/10.5772/intechopen.76941 69

Patients with acute pain are initially treated with anti-inflammatory medications and continu-

Long-term complications are revealed more than 30 days after the operation and include chronic pain, chronic mesh infections, and enterocutaneous fistula involving mesh and her-

Chronic pain is defined as pain lasting more than 3 months. Evidence reveals that chronic pain is most likely multifactorial with an incidence ranging from 1 to 7% [20]. Major factors that have been identified as possible etiologies include the technique of mesh fixation. The authors' group noted severe postoperative pain with the use of a large number of tacks. Initial nonoperative management of chronic pain with oral analgesics and anti-inflammatory medications is the most conservative approach, but local injection of anesthetic and even mesh

Patients with complications carry a higher risk of developing a hernia recurrence. Most recurrences occur after mesh removal for postoperative infection. Some researchers found significant associations between recurrence and larger hernias, longer operative times, previous hernia repairs, morbid obesity, and higher complication rates [21]. Several studies compare open and laparoscopic approach in incisional hernia repair. These studies have not shown significant differences in recurrence rates for laparoscopic and open incisional hernia repair. Contrary to previous studies that reported recurrence rates up to 20% with mesh repair, there are some studies showing exceptionally low recurrence rates varying between 0 and 5% [22–24]. Only singlecenter reports show results of hybrid technique of incisional hernia repair based on a small group of patients and with a short follow-up periods (from 12 to 63 months). During these follow-up periods, no hernia recurrences occurred [25, 26]. Our results, although from a single institution, are based on average follow-up period of 27 months (3–96 months). Recurrence

revealed in four patients including one case after biologic mesh implantation.

**Long-term complications Group 1 (n = 34) Group 2 (n = 27)**

Hernia recurrence 2 2 Chronic pain 2 4 Total 4 6

**Table 3.** Long-term complications in both groups.

Long-term postoperative complications in authors' studied groups are shown in **Table 3**.

pain, perhaps due to muscular ischemia or entrapment neuropathy [19].

ous infusion of opioids during 24–48 h after hernia repair.

**5.2. Long-term postoperative complications**

nia recurrence.

excision may be required.

Authors have experiences based on 61 patients who underwent hybrid hernia repair in our department between 2008 and 2016. They were divided into two groups. Group 1 (n = 34) identifies patients operated with standard combined laparoscopic technique, whereas group 2 (n = 27) labels combined technique with early conversion. Both groups were compared in terms of early complications and shown in **Table 2**.

Serious complications include mesh infections and enterocutaneous fistula involving mesh, as well as the rare, but highly morbid mesh. Complications such as these likely require revisional surgery for resolution. Then, in our opinion, complete removal of the mesh is required, as well as drainage of subcutaneous surface and intravenous antibiotics.

Early postoperative abdominal pain is a fairly regular feature of the hybrid repair. In our concept, it is usual to anticipate a comfortable patient at 24–72 h after operation and remain within 6–7 on the Visual Analogue Scale. Mesh fixation with titanium tacks plays a key role in the development of acute postoperative pain. Conceptually, a 4-mm-long tack would be expected to penetrate only 2 mm into the abdominal wall, after allowing 1 mm for the thickness of the mesh and another 1 mm for the tack profile that projects on the surface of the mesh. Thus, in obese patients, the tack may be restricted to the extraperitoneal fat without purchase


**Table 2.** Postoperative early complications in both groups.

into the muscle. This theory explains why acute postoperative pain is the most frequently observed in young, slim females. Furthermore, some studies show that the use of multiple transparietal sutures is largely related to a perceived association with increased postoperative pain, perhaps due to muscular ischemia or entrapment neuropathy [19].

Patients with acute pain are initially treated with anti-inflammatory medications and continuous infusion of opioids during 24–48 h after hernia repair.

### **5.2. Long-term postoperative complications**

injury but to delay mesh placement (i.e., perform a "staged repair," within a fairly short interval), in order to optimize bacterial clearance and minimize the risk of infection [18]. Colonic injury is a more serious concern; there is no substantial evidence base to guide decision-making. The optimal strategy in case of enteric injury needs to be decided on a case-by-case basis. A safe option, particularly if laparotomy has been undertaken because of the bowel injury, is to perform simply a suture repair of the hernia and accept that the risk of mesh infection has been exchanged for a higher risk of hernia recurrence. If the enterotomy remains unnoticed, it may

Authors have experiences based on 61 patients who underwent hybrid hernia repair in our department between 2008 and 2016. They were divided into two groups. Group 1 (n = 34) identifies patients operated with standard combined laparoscopic technique, whereas group 2 (n = 27) labels combined technique with early conversion. Both groups were compared in

Serious complications include mesh infections and enterocutaneous fistula involving mesh, as well as the rare, but highly morbid mesh. Complications such as these likely require revisional surgery for resolution. Then, in our opinion, complete removal of the mesh is required,

Early postoperative abdominal pain is a fairly regular feature of the hybrid repair. In our concept, it is usual to anticipate a comfortable patient at 24–72 h after operation and remain within 6–7 on the Visual Analogue Scale. Mesh fixation with titanium tacks plays a key role in the development of acute postoperative pain. Conceptually, a 4-mm-long tack would be expected to penetrate only 2 mm into the abdominal wall, after allowing 1 mm for the thickness of the mesh and another 1 mm for the tack profile that projects on the surface of the mesh. Thus, in obese patients, the tack may be restricted to the extraperitoneal fat without purchase

**Postoperative early complications Group 1 (n = 34) Group 2 (n = 27)**

Enterotomy during initial trocar or Veress needle placement 0 3 Enterotomy during laparotomy 1 1 Enterotomy during adhesiolysis 5 7 Injury of the bladder 1 0 Acute postoperative pain 6 8 Surgical site infection 6 8 Enterocutaneous fistula 2 0 Mesh infection 2 1 Small bowel tied up into 12 mm trocar defect 1 0 Left part of mesh fixing system 1 0 Total 25 28

result in an acute abdominal condition and sepsis within a few hours after surgery.

as well as drainage of subcutaneous surface and intravenous antibiotics.

terms of early complications and shown in **Table 2**.

68 Hernia Surgery and Recent Developments

**Table 2.** Postoperative early complications in both groups.

Long-term complications are revealed more than 30 days after the operation and include chronic pain, chronic mesh infections, and enterocutaneous fistula involving mesh and hernia recurrence.

Chronic pain is defined as pain lasting more than 3 months. Evidence reveals that chronic pain is most likely multifactorial with an incidence ranging from 1 to 7% [20]. Major factors that have been identified as possible etiologies include the technique of mesh fixation. The authors' group noted severe postoperative pain with the use of a large number of tacks. Initial nonoperative management of chronic pain with oral analgesics and anti-inflammatory medications is the most conservative approach, but local injection of anesthetic and even mesh excision may be required.

Patients with complications carry a higher risk of developing a hernia recurrence. Most recurrences occur after mesh removal for postoperative infection. Some researchers found significant associations between recurrence and larger hernias, longer operative times, previous hernia repairs, morbid obesity, and higher complication rates [21]. Several studies compare open and laparoscopic approach in incisional hernia repair. These studies have not shown significant differences in recurrence rates for laparoscopic and open incisional hernia repair. Contrary to previous studies that reported recurrence rates up to 20% with mesh repair, there are some studies showing exceptionally low recurrence rates varying between 0 and 5% [22–24]. Only singlecenter reports show results of hybrid technique of incisional hernia repair based on a small group of patients and with a short follow-up periods (from 12 to 63 months). During these follow-up periods, no hernia recurrences occurred [25, 26]. Our results, although from a single institution, are based on average follow-up period of 27 months (3–96 months). Recurrence revealed in four patients including one case after biologic mesh implantation.


Long-term postoperative complications in authors' studied groups are shown in **Table 3**.

**Table 3.** Long-term complications in both groups.

The surgical treatment of incisional hernia has changed rapidly during the last decade with the increasing use of mesh technique and the introduction of laparoscopy. However, many questions concerning mesh type, mesh positioning, fixation method, and operation type still remain unanswered. Patients with incisional hernia are a heterogeneous population with patient-specific comorbidity and innate differences (e.g., collagen formation quality). This makes the choice of the technique most suitable for each patient even if it is more difficult.

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[13] Azar FK, Crawford TC, Poruk KE, et al. Ventral hernia repair in patients with abdominal loss of domain: An observational study of one institution's experience. Hernia.

[14] Tanaka EY, JH Y, Rodrigues AJ Jr, et al. A computerized tomography scan method for calculating the hernia sac and abdominal cavity volume in complex large incisional her-

[16] Bleier JIS, Resnick AR. Complications of incisional hernia repair. Seminars in Colon and

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[18] Sarela A. Controversies in laparoscopic repair of incisional hernia. Journal of Minimal

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[20] Snyder CW, Graham LA, Vick CC, et al. Patient satisfaction, chronic pain, and quality of life after elective incisional hernia repair: Effects of recurrence and repair technique.

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1713-1716

The authors' retrospective study including 61 patients with large incisional hernias treated with hybrid technique has shown that the hybrid technique is an effective method confirmed by a low rate of recurrence. However, the hybrid technique is a complicated surgical method. Perfect knowledge of anatomy of the abdominal wall is required from a surgeon as well as expertly employed of open and laparoscopic surgical approach. Moreover, long-term multicenter studies comparing the results of hybrid technique are needed to establish its efficacy. For the time being, it is considered a good alternative to its open-only counterpart, at least in experienced hands.
