Ventral hernia repair is unique from other surgeries we approach laparoscopically in two very particular aspects. First, unlike most other laparoscopic procedures, we approach ventral hernias from the opposite direction, and oftentimes in apposition to our field of view. We find ourselves looking “up” instead of down, and “at” ourselves instead of “ahead” of ourselves. Thus, we may need to manipulate mesh and tackers in reverse when the camera is coming from the contralateral side. Aside from the difficulties of adhesiolysis being performed laparoscopically, these two factors alone can be challenging to most surgeons who may otherwise be very adept at other laparoscopic procedures.

In addition, when we repair a ventral hernia, we are exposing the patient to the very same problem we are addressing. Each incision or port site is a nidus for recurrence of the disease.

Further, the application of the reduced port techniques and single port access surgery should be applied with the same thought process as multiport laparoscopy. The additional loss of the “triangulated” view for an inline view can be a difficult transition as well.

When undertaking the practice of laparoscopic ventral hernia repair, these factors play an important role in moving forward. Both as hurdles we must overcome, as well as potential learning points from which we can improve the technique and outcomes when positioned correctly.

Attention to a new approach as well as the potential for subsequent hernia formation at the port site must remain in the forefront.

The indications for these are now proving themselves to be all levels of ventral hernias. Simple primary ventral hernias are the easiest with which to begin. Any hernia less
than 2 cm can generally be repaired without the application of mesh and an open technique would be in order. However, if a laparoscopic repair is going to proceed, then the single port access technique is a viable alternative.

All patients for ventral hernia repair can be considered to have the procedure performed laparoscopically, but both science and common sense will dictate which patients are appropriate candidates for this approach. Oftentimes, patients will be prepared for a laparoscopic approach and repair, but intraoperative findings or conditions may dictate an open procedure needs to be performed. In this light, a surgeon performing laparoscopic hernia surgery should also be well versed in all open repair techniques, meshes, and reconstructive procedures.

Single port access ventral hernia repair is a new technique. The most important contraindication would be lack of familiarity with single port access surgery. Clearly you have to decide at what level of skill you can proceed with the hernia repair through decreasing number of port sites. In the past, the author’s developed a simplified approach to laparoscopic ventral hernia repair with a “two-port, single-stitch” technique. This allowed us to repair small hernias and ultimately we graduated to much larger hernia repairs. However, as you move forward with single port access, the most important contraindication will be your level of skill with this new procedure. As you develop your technical skills, single port access ventral hernia repair can be offered to the patients with small and large hernias as well as multiple or complex defects. Again, the most important aspect is safety and it should always be remembered to add another port site or trocar whenever necessary to maintain a safe operative procedure.

The simplest of ventral hernias are not only the obvious clear indicators for the laparoscopic approach, but also the best hernias to begin a surgeon’s development of the laparoscopic hernia repair practice. Each of these hernias can be repaired easily and oftentimes with success, serving as a bridge to larger and more complex hernias.

One should master multiport ventral hernia repair before moving onto reduced port repairs. Just as is taught with single port access cholecystectomy and colectomy surgery, the “step-down” approach is a gradual transition from multiport to single port surgery. In fact, as the developers of single port access surgery, the author began the road to reduced port surgery with the introduction of the “two-port, one-stitch” technique for ventral hernia repair. The surgeon should begin by eliminating one of the port sites at a time. Only add one extra instrument to a port site at a time. Not only does it make for an easier transition, but it also allows for a better chance at success at each level, encouraging the surgeon to move to the next level.

In our experience, as reported initially in our first series, we have repaired not only primary defects but also recurrent hernias. We had been able to apply this technique to multiple defects as well as small to large defects. In addition, we have been able to apply the repairs with prior mesh repairs that need a new sublay mesh.

Once mastered, moving to more complex repairs becomes easier and manageable.

The contraindications for single port ventral hernia repair are the same as for multiport ventral hernia repair. Any medical contraindication that would disallow the application of carbon dioxide or the implantation of mesh would also be a contraindication in these patients.

Other preoperative considerations would be the following:

Intraoperative considerations/concerns would be the following:

As we approach the patient with a ventral hernia, the need to reduce the trauma we incur on the patient must also decrease in order to ultimately defeat this process. We need to plan the surgery before we arrive in the operating room, so we are ready to handle all possibilities. Conversion from single port access to reduced port surgery to multiport laparoscopy to open surgery is not a complication, but rather a natural progression in the “safe” approach to ventral hernia repair.

Over the next several pages, we will demonstrate to you a technique that offers the ability to approach ventral hernia repair through a single port site, thus not only minimizing the patient’s discomfort and recovery periods, but also offer the least possibility of recurrence of this disease process through our treatment site.

The planning for these patients is somewhat different. With most laparoscopies we can generally enter through the umbilicus. However, most patients generally have a midline scar through which the hernia has occurred. We need to decide based on the patient’s anatomy and abdominal wall examination where we want to place our first and sometimes only trocar. Obviously, you need to plan this based on the patient’s prior surgeries. A surgical procedure in a particular quadrant of the abdomen would make that a quadrant we would want to avoid. In some instances, the initial port site may need to be just to the left of the xyphoid process. It can be very difficult to manipulate and tack the mesh from this point, so we will have to prepare the patient for at least a second site of entry.