**2.1. Standard combined laparoscopic technique**

Fascial defect is exposed via incision over the previous surgical scar and hernia sac incised to access into the abdomen (**Figures 1** and **2**). Afterward during the next step of laparotomy, extensive and safe adhesiolysis can be ensured; reduction of the hernia sac (**Figure 3**) and proper placement of the laparoscopic trocars under direct vision are the other steps. Finally, the mesh can be laid into the peritoneal cavity (under the fascia defect) (**Figure 4**). Some researchers use Prolene sutures to fixate the mesh [10]. Then, mesh material is left in the abdomen, and fascial defect was primarily closed.

**Figure 1.** Recurrent hernia with thin overlying skin after laparotomy and the primary suture repair complicated by wound infection.

**Figure 2.** Removal of surgical scar.

operation and technical progress, associated with innovations in synthetic materials which are covered by anti-adhesive substance of the ventral side, lead to the development of laparoscopic surgery [5, 6]. This method offers many advantages: minimal pain, shorter stay in the hospital, quicker return to activities, and the ability to identify additional defects in abdominal wall [7, 8]. However, the problem of recurrence after incisional hernia repair still exists,

As the hernias have become more complex, the management strategy has evolved as well. In some difficult cases, defects are very large, and then even after laparoscopic repair, patients are unhappy because of cosmetic appearance of their wound. Moreover, sometimes miniinvasive repair of complicated postoperative hernia is not so easy to perform due to massive adhesions after the primary operations which are especially dangerous during placing laparoscopic tools into abdominal cavity. Some surgeons are convinced that it is worth to combine

Fascial defect is exposed via incision over the previous surgical scar and hernia sac incised to access into the abdomen (**Figures 1** and **2**). Afterward during the next step of laparotomy, extensive and safe adhesiolysis can be ensured; reduction of the hernia sac (**Figure 3**) and proper placement of the laparoscopic trocars under direct vision are the other steps. Finally, the mesh can be laid into the peritoneal cavity (under the fascia defect) (**Figure 4**). Some researchers use Prolene sutures to fixate the mesh [10]. Then, mesh material is left in the abdo-

**Figure 1.** Recurrent hernia with thin overlying skin after laparotomy and the primary suture repair complicated by

the two techniques, open and laparoscopic, to maximize benefits of both methods.

and its incidence rate ranges between 1.8 and 10% [9].

Hybrid incisional repair can be performed by two techniques.

**2.1. Standard combined laparoscopic technique**

men, and fascial defect was primarily closed.

**2. Surgical technique**

62 Hernia Surgery and Recent Developments

wound infection.

**Figure 3.** Prepared hernia sac.

**Figure 4.** The mesh placed into abdominal cavity.

The next step is the laparoscopic part of the procedure, intraperitoneal placement of the mesh after the reduction of the intraperitoneal pressure to 7–8 mm Hg. The mesh should have appropriate size, covering the actual hernia size edges for at least 5–7 cm, and then it is laparoscopically fixed with transfascial stay stitches (Protac, AbsorbaTack, or CapSure) (**Figure 5**). Desufflation and skin sutures finish the procedure (**Figure 6**).

In case of large incisional hernia where primary closure of fascial defect is impossible, authors enlarge the abdominal wall surface by modified component separation technique. The dissection of adhesions between the peritoneum and small bowels is needed until rectus muscles are entirely exposed. The skin is elevated and dissected from the anterior surface of the rectus sheath to the exposure of external abdominal oblique muscles by 5 cm (**Figure 7**). At 2 cm, lateral from rectus sheath, the aponeurosis of the external abdominal oblique muscle is longitudinally

transected (**Figure 8**), superiorly to the level of costal margin and inferiorly to the symphysis pubis. By releasing bilateral external abdominal oblique muscle attachment, a gap of 7–10 cm between rectus abdominis muscles could be bridged at the waistline [11]. Closure of abdominal wall defect can be achieved using continuous running sutures. Suction drains placed at the subcutaneous space are necessary. The laparoscopic part is the same as mentioned above.

Hybrid Technique for Incisional Hernias http://dx.doi.org/10.5772/intechopen.76941 65

The procedure starts with entering the peritoneal cavity by using a Veress needle, an open Hasson method, or an optical trocar allowing the view of the abdominal wall layers during penetration. The authors prefer the Veress needle entered under the left costal margin—the left upper quadrant as space where the least adhesions are expected. Three trocars are used, one 10 mm trocar and two 5 mm trocars, which are placed as laterally as possible on the abdominal wall, so they are at an adequate distance from the hernia orifice. The next step

**2.2. Combined technique with early conversion**

**Figure 8.** The transection of the aponeurosis of external abdominal oblique muscle.

**Figure 7.** Dissection of the skin from anterior surface of rectus sheath.

**Figure 5.** The mesh fixated laparoscopically.

**Figure 6.** Early postoperative view.

**Figure 7.** Dissection of the skin from anterior surface of rectus sheath.

The next step is the laparoscopic part of the procedure, intraperitoneal placement of the mesh after the reduction of the intraperitoneal pressure to 7–8 mm Hg. The mesh should have appropriate size, covering the actual hernia size edges for at least 5–7 cm, and then it is laparoscopically fixed with transfascial stay stitches (Protac, AbsorbaTack, or CapSure) (**Figure 5**).

In case of large incisional hernia where primary closure of fascial defect is impossible, authors enlarge the abdominal wall surface by modified component separation technique. The dissection of adhesions between the peritoneum and small bowels is needed until rectus muscles are entirely exposed. The skin is elevated and dissected from the anterior surface of the rectus sheath to the exposure of external abdominal oblique muscles by 5 cm (**Figure 7**). At 2 cm, lateral from rectus sheath, the aponeurosis of the external abdominal oblique muscle is longitudinally

Desufflation and skin sutures finish the procedure (**Figure 6**).

**Figure 6.** Early postoperative view.

**Figure 5.** The mesh fixated laparoscopically.

64 Hernia Surgery and Recent Developments

transected (**Figure 8**), superiorly to the level of costal margin and inferiorly to the symphysis pubis. By releasing bilateral external abdominal oblique muscle attachment, a gap of 7–10 cm between rectus abdominis muscles could be bridged at the waistline [11]. Closure of abdominal wall defect can be achieved using continuous running sutures. Suction drains placed at the subcutaneous space are necessary. The laparoscopic part is the same as mentioned above.
