Incisional hernias are a common complication of midline laparotomies, with a reported incidence of 9% to 20%.¹ Over 100,000 incisional hernia repairs are performed annually in the United States alone.² Since the introduction of laparoscopic incisional hernia repair (LIHR) by LeBlanc in 1993, the approach has gained popularity with general surgeons as a preferred technique for selected incisional hernia repairs.³

As LIHR becomes more common in the armamentarium of general surgeons, more information has become available regarding the benefits of laparoscopic hernia repair. However, only a small number of randomized trials exist comparing open hernia repair to laparoscopic repair. These studies have mixed results, with no clear consensus proving that one should replace the other as a standard approach to incisional hernias. Thus, it is important for general surgeons to be familiar with both techniques of hernia repair, as well as risks and benefits of both. This chapter will focus on the advantages and disadvantages of LIHR, discuss technical considerations, and review the literature on outcomes.

Early studies demonstrated a decrease in wound complications, hospital stay, operative times, and recurrence rates with LIHR compared to open primary repair.^4,5 However, more recent studies have found decreased wound complications and length of hospital stay with LIHR, with no difference in recurrence rates.^6-8 The smaller incisions used for the laparoscopic approach are thought to be the major factor leading to decreased wound complications. Studies have demonstrated a decreased rate of surgical site infection in laparoscopic versus open incisional hernia repair (2.3% vs 9.2%, respectively),⁹ including superficial and deep surgical site infections as well as wound disruption.¹⁰ Large tissue flaps are not raised during LIHR, thereby obviating the need for postoperative surgical drains and further decreasing the risk of wound complications. In contrast to the known benefits of laparoscopic approach for other surgeries, it was thought that the smaller incisions used in LIHR would result in less postoperative pain than open repair. However, recent studies demonstrate either an increase or no difference in early postoperative pain compared to open procedures.⁷

One of the most feared complications of LIHR is an intestinal injury. Enterotomies can occur during initial trocar placement, lysis of adhesions, and intestinal manipulation. Laparoscopic adhesiolysis has been associated with an increased risk of unrecognized bowel injuries compared to open techniques.^6,11 The incidence of enterotomy has been reported as 7.9% for laparoscopic repair compared to 7.3% for open repair.¹² Injuries most commonly occur in the small intestine. A missed intestinal injury can have harmful effects, including mesh infection, sepsis, and even death. The mortality of an unrecognized injury is 7.7%, compared to 1.7% for an injury recognized intraoperatively.¹¹ If recognized at the time of surgery, it is at the discretion of the surgeon to attempt laparoscopic repair or convert to an open procedure. If recognized in the postoperative period, operative management with intestinal repair, source control, and removal of the mesh is typically mandated.

Most hernia defects are not reapproximated with the laparoscopic technique, causing patients to potentially have a persistent bulge after laparoscopic repair. Often, this is confused with a recurrent hernia, and patients should be counseled appropriately. It also leaves a dead space, which can increase the risk of developing a postoperative seroma. Most seromas can be observed without intervention; however, symptomatic ones may require percutaneous drainage. Again, patients should be advised that they may have a persistent mass following laparoscopic repair that decreases in size and usually disappears over time. The risk of seroma formation can be decreased by placement of a compressive abdominal binder.

Identifying appropriate patients for the laparoscopic approach includes determining the size of the defect, the ability to get lateral to the defect, adequate tissue for mesh fixation, extent of prior surgical procedures, and experience of the surgeon. Novice surgeons should select low-risk hernias for their initial procedures. These would include small, uncomplicated, reducible, midline, periumbilical hernias with healthy overlying skin and no prior history of peritonitis. With increased experience, surgeons can extend the laparoscopic approach to more complicated presentations, but even the most experienced surgeons would not choose a laparoscopic approach for patients with open skin lesions, fistulas, or massive loss of domain.