**2.2. Combined technique with early conversion**

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

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


**4. Contraindications for the hybrid technique**

) should be primarily qualified to laparoscopic hernia

Hybrid Technique for Incisional Hernias http://dx.doi.org/10.5772/intechopen.76941 67

repair which gives them more benefits than the hybrid technique (e.g., less infection compli-

Patients with giant incisional hernia with loss of abdominal domain are the most challenging ones and require an individual preoperative treatment. Loss of domain (LOD) occurs when an abdominal wall defect progresses to a size at which it may no longer accommodate the viscera, leading to protrusion outside of the abdominal wall and into the hernia sac [13]. Hernia defect area can be calculated from cross-sectional imaging using computed tomography (CT), and hernia sac volume (HSV) and peritoneal cavity volume (CV) are obtained from preoperative CT measurements. If the calculated volume ratio (VR = HSV/CV) is larger than 25%, loss of domain is observed [14]. In these cases the individual preoperative treatment includes pulmonary training, an installation of a pneumoperitoneum, or an implantation of an expander

system to achieve a relaxation and stretching of the skin and muscles as well [15].

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.

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

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

Obese patients (with BMI > 35 kg/m2

**5. Postoperative complications**

**5.1. Early postoperative complications**

abdominal domain.

cations, earlier recovery).

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

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

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 standard combined laparoscopic technique.
