Incisional hernia occurs after laparotomy in 2–20% of patients, generally within three years after surgery, more frequently after long median abdominal incisions were created for aortic aneurysm and peritonitis [1–7]. Incisional hernias have been classified by Chevrel as small (<5 cm), medium (5–10 cm), large (>10 cm), and giant or very large (>20 cm), based on the diameter of the wall defect [8, 9]. Many authors still repair fascial defects larger than 15 cm only by the conventional approach [10–13]. The surgical management of incisional hernias before the use of prosthetic meshes had a 12–54% rate of recurrence, but in the last two decades the use of meshes has dramatically reduced the recurrence rate [2, 6, 14]. Adversely, serious complications, before unknown, have been noted with the new techniques, such as migration of meshes into the urinary bladder or other hollow viscus, peritoneal adhesions, intestinal obstruction, and persistent pain for 6–8 weeks [3, 4, 7, 15–18]. The introduction of minimally invasive techniques has changed the approach to surgical management of incisional hernia. Although no randomized study has been conducted yet, the published data suggest that minimal access surgery results in lower morbidity and a shorter hospital stay than open surgery [3–5, 7, 8, 11, 14, 17, 19–23]. Indications for laparoscopic surgery for the so-called giant or complex or multiorificial hernias are controversial, as well as indications for fascial defects >10 cm and in obese patients, while a unanimous definition of giant incisional hernia is still lacking [8, 13, 19, 20, 24, 25]. The aim of this study is to analyze the outcomes of the laparoscopic incisional hernia repair (LIHR) and in particular for fascial defects larger than 15 cm.

Material and methods

From April 2002 through April 2007 a total of 100 patients underwent LIHR in our institution. There were 44 men and 56 women of mean age of 64 years (range = 23–85). The diameters of hernias as reported in Table 1 were measured during laparoscopy from within the peritoneal cavity. The measurement between two points on the surface of the abdominal wall led to an overestimation in diameter of 2.5 cm only for large fascial defects. The mean diameter of hernias was 11.49 cm (range = 4–22) and their mean area was 79.23 cm2 (range = 9–219 cm2). The hernia was recurrent in 19 patients: 13 had undergone previous repair with mesh and 6 without mesh. Before coming under our observation, each patient had undergone 1.75 laparotomies on average (range = 0–5), apart from one incisional hernia on port site.

Table 1 Classification of wall defects according to Chevrel [9]. Data related to site, BMI of patients and recurrences after LIHR
Full size table

Twenty-five patients, 16 men and 9 women of mean age of 66 years (range = 42–85), had wall defects larger than 15 cm, 6 of which were 20 cm or larger (see Table 2 for patient characteristics). The mean diameter of defects larger than 15 cm was 17.8 cm (range = 16–22) and their mean area was 155 cm2 (range = 100,48–219 cm2). In 75 cases the hernia was located on the median line and in 25 it was located laterally. As many as 12 fascial defects of the median line were multiorificial or complex, located along a unique scar. This series included also three patients with double wall defect, i.e., two separate orifices and two scars, in median and lateral sites. The data of the wall defects are given in Table 1. With respect to the three patients with double wall defect, Table 1 refers to the diameter of the larger one. A 64-year-old woman had a peristomal defect that occurred three years after laparoscopic Miles’ operation.

Table 2 Characteristics and operative and postoperative data of 25 patients with hernia larger than 15 cm
Full size table

Comorbidities affected most patients in this study and included hypertension (n = 41), insulin-independent diabetes mellitus (n = 16), chronic cardiac disease (n = 15), and chronic bronchopneumopathy (n = 9). As many as 38 patients in this series were obese (38%). Their mean body mass index (BMI) was 29.36 kg/m2 (range = 19–45) and obesity is defined as a BMI > 30 kg/m2. The mean BMI of patients with hernias larger than 15 cm was 28.5 kg/m2 (range = 22–33). The general conditions were classified according to the criteria of the American Society of Anaesthesiology (ASA) and the ASA score was 2.1 for patients in this series, including 7 patients with ASA I, 72 with ASA II, and 21 with ASA III. All patients were asked for consent before minimal access surgical repair and all were treated by the same surgeon.

Preparation of patients

A short-term antibioprophylaxis was administered to all patients consisting of intravenous cephazoline 2 g the day of surgery and nadroparine 0.3 ml subcutaneously the night before surgery. Obese patients were stockinged as an antithrombothic prophylaxis. An enema was administered the night before surgery. A nasogastric tube and a urinary catheter are inserted in the operating theatre for decompression whenever required.

Study design

This retrospective study was undertaken to analyze the outcomes of laparoscopic management of incisional hernias in 100 patients; in particular, focusing on feasibility of laparoscopic repair of hernias larger than 15 cm. Fascial defects were classified according to their diameter and area measured intraoperatively. The parameters considered were intraoperative complications, conversion rate, duration of surgery, postoperative early morbidity and mortality (within 30 days from surgery), time to oral feeding and to ambulation, hospital stay, and late morbidity. All patients were controlled by clinical examination 10, 30, 60, 90, 180, and 360 days after surgery. Echography with a 7.5-MHz probe was performed after 10, 30, and 60 days. Successively they were followed-up by clinical examination or telephone call. The mean follow-up span was 24 months (range = 2–58).

Statistical analysis

The data of this study were collected retrospectively from the database of 100 patients according to the diameter of wall defects. Analysis of the data was done using the SPSS 11.0 statistical analysis software package(SPSS Inc., Chicago, IL). For continuous variables Student’s t test was used and the χ2 test was used for discrete variables. p < 0.05 was considered statistically significant.

Surgical technique of incisional hernia repair

A Verhess needle is inserted in the left subcostal space and the pneumoperiteoneum is instituted with intra-abdominal pressure of 12–13 mmHg. Through a 10–12-mm trocar, generally at the left flank of the patient, a 0° optic view is inserted. Two more operative trocars are inserted into the peritoneal cavity, depending on the site of the wall defect, and exploration of the cavity is performed. In recurrent hernias, trocars are inserted in the intact areas of the abdominal wall to minimize the risk of intestinal injury. The adhesions are divided by ultrasound scalpel (Ultracision®, Ethicon ,Cincinnati, OH) or by scissors near the intestinal loops. The abdominal wall is prepared and freed of fat tissue all around the borders of fascial defect. To measure the defect’s diameter, first the abdominal pressure is lowered to 6 mmHg. Next, four spinal needles of 22 gauge are inserted through the wall on either side of the defect so that the external distance of the needles corresponds exactly to the diameter of wall defect. Then, the pressure is raised again to 12 mmHg to allow insertion of a ePTFE prothesis (Gore Dual Mesh® Plus Biomaterial,Gore & Associates, Flagstaff, AZ) with a minimal overlap of 3–4 cm. One side of the mesh is secured by one coil of the Pro-Tack device of 5 mm (Auto Suture, US Surgical Corp., Norwalk, CT). The endoabdominal pressure is lowered once again to 6 mmHg and the mesh is fully secured to the abdominal wall by a double crown of titanium tacks, with the inner crown at a distance of 2 cm from the outer one. In the subxyphoid area the falciform ligament is divided and the mesh is secured by tacks to subcostal regions. Sometimes in large subxyphoid or subcostal fascial defects the mesh is secured also by extracorporeal skipknots. In the suprapubic area the bladder is dissected and the mesh is secured by tacks to the pubis. When dealing with a very large piece of mesh (18 cm × 24 cm or larger), the prosthetic material is suspended on the wall by four suture-pass transparietal threads. The peritoneal lining of the sac is never treated. No drainage is placed in either the abdominal cavity or the subcutaneous layer. The port sites larger than 1 cm are closed. All patients use an abdominal compressive packing for 4–5 days after surgery.

Surgical technique of peristomal incisional hernia repair

The pneumoperitomeum is instituted at 12 mmHg through a Veress needle in the hypocondrium. Three trocars are inserted on the side opposite the side of the colostomy: one in the hypocondrium for the optic view (12 mm), the second at the right flank, and the third in the iliac fossa. The first step consists of division of adhesions between the sac and the colonic loop to expose the peristomal wall defect. Dissection is conducted by monopolar scissors and, next to the intestinal loops, by bipolar forceps. Once the colonic loop is completely freed of adhesions, the hernia repair is performed. To avoid twisting, a tube may be inserted in the colonic loop from outside. The dimension of the mesh is derived from the colonic circumference, measured by a rubber band passed around the loop. Two spinal needles are inserted through the abdominal wall 5 cm from the margin of the wall defect and the pneumoperitoneum is lowered to 7 mmHg to obtain a correct measurement of the fascial defect. The prosthetic material is an oval piece of ePTFE Dual Mesh (Gore Dual Mesh® Plus). The mesh is cut to fashion a central opening and the prosthetic margins are fashioned all around in several flaps so as to attach to the colon. The needles are removed and the pneumoperitoneum is raised again to 12 mmHg. The mesh is inserted into the peritoneal cavity and placed all around the loop. Then it is fixed to the fascia by Pro-Tack coils with a 5 cm overlap. The last step includes suturing flaps to the colonic serosa by intracorporeal nonabsorbable PTFE stitches.

Results

A total of 100 patients underwent LIHR, 25 of which had hernias larger than 15 cm in diameter. A mean number of three trocars were used, with a mean number of 66 titanium tacks per patient (range = 30–110) disposed in double crown. Overall, the mean duration of surgery was 152 ± 25 min (range = 45–275) and 205 ± 101 min (range = 85–540) for defects larger than 15 cm. Other laparoscopic procedures were performed in 13 patients, including cholecystectomy (n = 6), radiofrequency of hepatic metastasis (n = 1), groin hernioplasty (n = 4), umbilical hernioplasty(n = 1), Nissen antireflux fundoplication (n = 1), and adrenalectomy (n = 1). The duration of the these procedures was not included in the operating time. On the whole, the estimated mean blood loss in totally laparoscopic repairs was 65 ± 55 ml (range = 10–145) and 74 ± 78 ml (range = 10–230) for defects larger than 15 cm (p > 0.05). There were three intraoperative complications: one omental bleeding and two intestinal injuries (2%). Two were managed successfully by laparoscopy, while one needed conversion to open surgery because of massive adhesions. Conversion was needed also in another patient with massive adhesions; the overall conversion rate was 2%. Overall morbidity rate was 23% because of general complications in 50% of the cases and because of local complications in 10% of cases (Table 3). No wall hematoma was observed. No leaks were observed, neither cutaneous nor intestinal. No prosthetic migration was observed in this study. The postoperative course for giant hernias 20 cm or larger was uneventful. Morbidity was 24% after repair of defects larger than 15 cm and 22% for defects smaller than 15 cm (Table 4), but this difference was not statistically relevant (p > 0.05). There was 1 post-operative death for massive pulmonary embolism 4 days after surgery (1%) occurring in an obese patient with small wall defect.

Table 3 Early and late surgical morbidity with general complications of 99 patients
Full size table
Table 4 Early and late surgical morbidity with general complications of 25 patients with incisional hernia larger than 15 cm
Full size table

Morbidity in the other 37 obese patients (19%) and in 62 nonobese patients (26%) showed no statistically relevant difference with the χ2 test (p > 0.05). With respect to early morbidity, at the outset of our experience seromas were drained percutaneously under ultrasound control. A seroma was present in all patients who underwent echography within 15 days after surgery, but the echographic controls at 30 days generally showed a decrease in the seroma with complete disappearance within 60 days. Hence, we now consider treating only a seroma that persists without modification 8 weeks after surgery, is infected, or is causing symptoms. The postoperative course of the peristomal hernia was uneventful and the patient showed no recurrence 18 months after repair. There was 1 (1%) postoperative death from a massive pulmonary embolism 4 days after surgery; it occurred in an obese patient with a small wall defect. Reuptake of oral feeding and ambulation started between the first and the second postoperative day for 95% of patients. For fascial defects larger than 15 cm, oral intake started 1.3 days and ambulation 1.1 days after surgery. The mean hospital stay was 4.69 ± 3 days (range = 1–18) and 5 ± 2.6 days (range = 2–14) for patients with wall defects larger than 15 cm (p > 0.05). The hospital stay was longer than 10 days for two patients who had total laparoscopic repair because of oral anticoagulant therapy reassessment and adjustment. The differences between outcomes after repair of fascial defects that are smaller or larger than 15 cm were not statistically relevant (p > 0.05). The longest operative time (540 min), the greater blood loss (325 ml), the latest start of oral intake (after 6 days), and latest start of ambulation (after 5 days), and the longest hospital stay (14 days) were all associated with one patient after conversion to open surgery for intraoperative intestinal injury requiring ileal resection. Obese patients had the same mean hospital stay as nonobese patients. One obese woman stayed in the intensive care unit for 24 h because of her cardiopulmonary and metabolic comorbidities. No significant difference in short-term results was observed between obese and nonobese patients (p > 0.05). As to late morbidity, one infection of the mesh was observed 8 months after percutaneous aspiration of seroma; the mesh was removed and the 7-cm wall defect was repaired by conventional suture. Chronic pain lasted longer than 6 months in three patients (just one treated for a defect larger than 15 cm). Recurrent hernia was observed within 6 months of surgery in three patients (all treated for defects smaller than 15 cm) who were reoperated on by the minimally invasive approach (see Table 1). Incisional hernia on the port site occurred 6 months after surgery in two patients (treated for defects larger than 15 cm) who were not reoperated on because of the very small size of the hernias (<2 cm). Intestinal obstruction was observed as a late complication in one patient 15 months after repair of a defect smaller than 15 cm; it was cured laparoscopically by separating the adhesions from the titanium tacks.

Discussion

The management of incisional hernias using the minimal access approach is still controversial, and the diameter of the wall defect seems to be the main limitation preventing this procedure from gaining wider acceptance [6]. Obesity does not represent a contraindication for laparoscopic approach for treating fascial defects [20, 25], and in our series 38 patients were obese. The overall mean duration of surgery in this study was 152 min, comparable with the 50-149 min reported in other studies that included hernias of smaller mean size [20, 22, 26–28]. Laparoscopic division of adhesions represents a very important step in incisional hernia repair. Intestinal injury during adhesiolysis ranges from 0% to 6% and such a complication is more frequent during the learning phase and can jeopardize the procedure when not recognized intraoperatively [4, 28]. We currently use laparoscopic scissors and avoid coagulation by both ultrasonic scalpel and bipolar forceps close to the intestinal loops. Despite this careful technique, in our study intestinal injury occurred in two patients (2%); however, in both cases it was recognized intraoperatively and required conversion to laparotomy in one because of the great extent of peritoneal adhesions. The mean hospital stay was consistent with the stays from 0 to 64 days reported in the literature [4, 6, 20, 22, 26]. In the literature the rate of local complications after laparoscopic repair is equal to that of open surgery [6] or lower [29, 30], and morbidity seems to be higher for large defects [23]. In our series 10% of patients experienced local complications, but patients with defects larger than 15 cm showed no significant difference in outcomes compared with those with smaller defects. The occurrence of seroma after open repair depends on extended dissection with sac removal. On the other hand, in laparoscopic surgery the whole sac is left in place, but a seroma may occurr after coagulation of the sac by argon beam [23]. There is no agreement in the literature about the need for draining a seroma. It certainly needs to be drained in case of infection or symptoms or if it still present after 6–8 weeks [4, 31]. Mortality after repair of the 25 defects that were larger than 15 cm was nil and late morbidity was quite acceptable, represented by chronic pain in one patient, two port-site hernias of very small size not requiring reoperation, and, above all, no hernia recurrence. Recurrent hernia is a local complication attributable to technical errors or infection [23]. Surprisingly, it occurred in only three patients in our study who were treated for defects smaller than 15 cm. To summarize, although some authors have used the term “giant” for wall defects larger than 15 cm [10, 19], the exact definition of giant hernia is not clear yet, since Chevrel defined as “ giant” only hernias larger than 20 cm [29]. However, to date giant incisional hernias are considered a contraindication to laparoscopic surgery [19], but in this study wall defects larger than 15 cm, including giant defects 20 cm or larger, were successfully repaired by laparoscopy with noticeable short- and long-term results.

Conclusions

Laparoscopic repair of incisional hernias is feasible and safe. Surgical repair by minimal access of fascial defects larger than 15 cm in diameter seems to be promising and should have the same outcomes as that of laparoscopic repair of smaller defects.