1. Ventral hernia more than 3cm in size.

2. Obesity and recurrent incisional hernia even with small size.

3. Swiss cheese type hernia (because clearer laparoscopically).

1. Multiple scars on the abdominal wall, which make intra-peritoneal access difficult3.

2. Large defect where 3 to 5 cm meshes overlap is not possible intra-abdominally2.

3. Patient with large amount of redundant skin and fat on the abdominal wall are better suited for abdominoplasty procedures3.

4. Infection and peritonitis.

5. Acute and subacute intestinal obstruction.

6. Severe cardiopulmonary disease.

7. Portal hypertension.

Morbid obesity, prostatism, chronic cough, wound infection, large incision, and malnutrition are considered as risk factors for ventral hernia and incisional hernia⁶.

Laparoscopic repair of ventral hernias was done at a time when laparoscopic appendectomy and cholecystectomy had shown definite benefit over open procedures. Although technically demanding and time-consuming⁹, it is safe and feasible. With introduction of different prosthetic meshes and great improvement in the laparoscopic techniques, it is hoped that an improvement in the complication rate would be realized⁸. Increasing application of laparoscopic surgery all over the world indicates that these goals might indeed be achieved. There are many controversies but laparoscopic surgery continues to evolve with regard to laparoscopic repair of ventral hernias and there is more data in the literatures available as compared to the past due to the increased popularity of this procedures⁵.

In our study, 25 patients underwent open repair and 25 patients underwent laparoscopic repair of ventral hernia.

Open surgical technique was popularized by Rives, Stoppa and Wantz³. After taking patients to operation theater and under general anesthesia, endotracheal intubation and close monitoring, the operation started. Foleys catheter was put for patients with lower abdominal ventral hernia repair and nasogastric tube for upper abdominal hernia repair with perioperative single-dose antibiotic in form of cefotaxime. Then, after proper cleaning, painting and draping of the abdomen, the skin incision was made according to site and size of defect, a subcutaneous flap was raised up to 3 to 5cm around the defect and after the hernia sac was found, the contents were reduced. Then posterior rectus sheath and muscle were dissected, and rectus muscle and peritoneum in the lower abdomen. The posterior rectus sheath and peritoneum were closed primarily with 2:0 absorbable suture, then polypropylene meshes of suitable size with a minimum of 3cm overlap beyond the margin of the defect were placed over posterior rectus sheath/peritoneum and rectus muscle and fixed in four corners with 2:0 polypropylene sutures taken out through abdominal muscle on the anterior rectus sheath. The anterior rectus sheath was closed over the mesh with a loop of polypropylene or nylon without tension. Then the skin was closed over the drain depending upon size and extension of the wound.

Almost all types of ventral hernia can be repaired by minimal access surgical techniques and it should be clear to the patient that laparoscopic repair will not help cosmetically if the skin is lax, hanging loosely in large hernias. In laparoscopic repair of ventral hernia, evacuation of the urinary bladder in lower abdominal surgery and nasogastric tube in upper abdominal surgery is a must, because in most cases the access is through Palmer’s point, 2 to 3cm below the left costal margin in the mid-clavicle line. Bowel should be prepared to make more room in the abdominal cavity.

Laparoscopic repair of ventral hernia can be done with intraperitonial meshplasty.⁷

General anesthesia with endotracheal intubation, close monitoring, I.V. cannula and proper fluid and electrolyte balance

Supine position without any tilt, so that the bowel is distributed evenly

The surgeon stands left to the patient with the camera man on his left or right depending upon the location of the ventral hernia. If the hernia is below the umbilicus the camera operator stands right to the surgeon and if the defect is above the umbilicus, the camera operator should stand left to the surgeon. The monitor should be placed opposite to the surgeon and the instrument trolley should be towards the leg of the patient.³

Figure 1

Port position

The patient should be cleaned, painted and draped with checking light cable, insufflation tube, electro-surgical cautery wires and suction/irrigation tube. A 10mm-trochar is inserted in the epigastrium with open method and the pneumoperitoneum is created. Once the pneumoperitoneum is created, a 5-mm port and another 10mm-port are put under vision according to the Baseball diamond concept, after diagnostic laparoscopy.

If there is any adhesion, careful adhesiolysis is performed and the content of the hernia sac which is either omentum or bowel is returned as shown below.

Figure 2

Fig. 1: Contents in the sac separated

Then the extent of the defect is assessed thoroughly. The measurement of the defect is drawn on the external surface of the anterior abdominal wall and a mesh of adequate size that covers the whole defect overlapping up to 3 to 5cm from the edge is selected. All the necessary precautions are to be taken to avoid contamination of the mesh with skin pathogens. Then the mesh is rolled and inserted in a port of adequate caliber to the abdominal cavity, the mesh is unrolled and fixed by stitches to the abdominal wall without dissecting peritoneum. This is called onlay technique.

Figure 3

Fig. 2: Mesh fixation

.Finally the omentum is laid over the underlying bowel loops to prevent direct contact with the mesh. After completing the procedure the ports are withdrawn under vision and the telescope port is the last to be removed with keeping some instrument or the telescope itself inside to prevent traction of any part of omentum or bowel. The insertion sites of the 10mm-ports are better repaired because of the chances of incisional hernia. A sterile dressing is applied.

Figure 4

Fig. 3: Post-operative scars after laparoscpic ventral hernia repair

Meshes for laparoscopic hernia repair have undergone many changes over the last several years. In general, the ideal mesh is characterized by economic aspects, functionality and operative handling, sterility or even anti-infectivity and optimized biocompatibility⁸, and all seek to achieve two goals:

1. Rapid and permanent ingrowth into the prosthesis

2. Diminution of the risk of intestinal adhesion

There are two types of mesh: synthetic and collagen-based ePTFE⁸ (expanded

polytetrafluroethylene) were used with polypropylene. Because of a low affinity for adhesion, the PTFE mesh is probably the first choice for an intraperitoneal position of the prosthesis. In summary, the use of a mesh can reduce the recurrence rate from 40-50% to about 10% only.²

The most frequent content of the hernia sac was omentum, there were no intraoperative complications such as bowel or vascular injury requiring conversion to open technique and, significantly, there was not much blood loss, no patient required blood transfusion. A closed suction tube was put more often for open procedures. The majority of incisional hernias in the lower abdomen were due to gynecological operations and primary ventral hernias were located at or around umbilicus.

1. Wound infection

Wound-related infection was less frequent in laparoscopic repair and few of the patients required drainage and antibiotic cover in comparison with open cases.

2. Mesh infection

Mesh infection was very rare when compared to the open technique; skin pathogens were responsible for most of the infections. Infections with polypropylene mesh can be managed locally but infections with ePTFE meshes need removal of the mesh.

3. Seroma formation

Seromas develop above the mesh and within a retained hernia sac; the mean incidence is at 4 to 8 weeks (11.4%). They rarely result in long-term problems, only aspiration may be recommended for those who enlarge or persist before they reach a large size.

4. Recurrence

The incidence of recurrence of ventral hernia described in the literature is decreasing depending upon treatment of infection, adequate mesh fixation, adequate overlap and diagnosing missed hernias laparoscopically; however, few cases of re-recurrence were reported in some articles.

5. Chronic pain

After laparoscopic repair of ventral hernia, chronic pain at suture sites is not uncommon. A possible explanation may be due to trans-abdominal sutures entrapping intercostals nerves as they course through abdominal muscles, and local ischemia of the port is another possibility. Treatment is by NSAIDs and local anesthetic injection.

6. Postoperative morbidity

Postoperative morbidity may be due to unrecognized enterotomy, wound infection, intraperitoneal abscess or respiratory failure. Such complications increase the duration of hospital stay and costs.