Laparoscopic ventral hernia repair

INTRODUCTION — One-third (by physical examination) to one-half (by radiographic imaging) of all individuals have a ventral hernia. Nearly one-third of patients develop an incisional hernia after abdominal operations, and as many as 43 percent develop a recurrent hernia three years post-ventral incisional hernia repair [1,2].

The treatment of ventral hernias (primary and incisional) represents an underappreciated challenge for surgeons. Over 600,000 ventral hernia repairs are performed yearly in the United States at an estimated cost of ten billion dollars by 2021 estimates [3]. Recurrences, emergency repair, and implementation of new technology all contribute to increased cost [4]. Thus, thoughtful perioperative decision making in regards to patient optimization, surgical technique, and choice of mesh has the potential to save millions of dollars in health care expenditures [1,2,4].

The classification, clinical features, and diagnosis of ventral hernias are discussed in another topic. (See "Overview of abdominal wall hernias in adults".)

Many, but not all, ventral hernias can be repaired with either open or minimally invasive approaches (laparoscopic or robotic). In this topic, we discuss the patient selection, techniques, and controversies of laparoscopic ventral hernia repair. The process of choosing an approach and the techniques of open ventral hernia repair are discussed in another topic. (See "Management of ventral hernias".)

Other topics on or related to abdominal wall hernias include:

●(See "Robotic ventral hernia repair".)

●(See "Overview of component separation".)

●(See "Wound infection following repair of abdominal wall hernia".)

●(See "Rectus abdominis diastasis".)

PREOPERATIVE PREPARATION

Patient — Acutely incarcerated or strangulated ventral hernias require urgent repair. Chronic symptomatic ventral hernias may be repaired electively assuming there are no medical contraindications (eg, active smoking, body mass index exceeding 40 kg/m², or poorly controlled diabetes with HbA1c exceeding 8 percent) [5]. Chronic ventral hernias with minimal or no symptoms may be watched if the patient wishes to avoid surgical repair. (See "Management of ventral hernias", section on 'Acutely incarcerated or strangulated ventral hernias' and "Management of ventral hernias", section on 'Reducible or chronically incarcerated ventral hernias'.)

In the elective setting, laparoscopic ventral hernia repair should not be performed in patients with active skin or soft tissue infections; active infections should be treated with antibiotics and/or incision and drainage prior to hernia surgery.

Procedure — Most, but not all, ventral hernias can be repaired with open or minimally invasive approaches. The choice largely depends on surgeon training, expertise, and preference, except for the following.

Absolute contraindications to laparoscopic ventral hernia repair are the same as those to laparoscopy, including inability to tolerate pneumoperitoneum or inability to safely access the peritoneal cavity. The latter may be due to a "hostile abdomen," such as those rendered by a history of extensive or multiple abdominal operations (especially with placement of intraperitoneal meshes), an open abdomen, severe abdominal injuries, or the presence of enterocutaneous fistulas [6].

Relative contraindications to laparoscopic ventral hernia repair are largely dependent on surgeon skill and resources but may include:

●Large ventral hernias with a defect width >8 to 10 cm or with greater than one-half of the abdominal viscera being outside of the boundary of the abdomen (ie, loss of domain) are difficult to repair without using advanced techniques such as component separation. An open approach is preferred unless the surgeon is facile with minimally invasive component separation techniques (see 'Role of minimally invasive component separation' below). Although there are randomized trials comparing laparoscopic versus open ventral/incisional hernia repair in defects up to 15 cm in size, most prior trials did not perform fascial defect closure [7]. Increased defect size is associated with inability to achieve fascial defect closure, eventration/bulging, and hernia recurrence.

●Ventral hernias with an associated acute moderate- to high-grade gastrointestinal tract obstruction can be difficult to repair with minimally invasive techniques. Distended bowel can easily be injured with trocar placement or manipulation with laparoscopic instruments, which could further complicate the repair if mesh is used. Certain clinical situations that may be amenable to laparoscopy include proximal obstruction, patients without a significant surgical history, and when the clinical situation allows for a short period of nasogastric decompression prior to surgery.

●In general, gastrointestinal tract perforation should be considered a contraindication for intraperitoneal mesh placement. Depending on surgeon experience, skill, and comfort in approaching this setting, options include laparoscopic bowel resection and suture repair of the ventral/incisional hernia only, retromuscular/preperitoneal mesh placement, and fascial defect closure with reinforcement with mesh of low infectious complication risk in certain cases [8]. (See "Hernia mesh", section on 'Wound classifications'.)

●Definitive treatment of ventral hernias in patients with an infected mesh and associated complications, such as enteric fistulas, often requires abdominal wall reconstruction with component separation techniques and sublay mesh placement. Intraperitoneal permanent mesh placement is generally not recommended in infected or contaminated fields, and intraperitoneal placement of biologic or bioabsorbable meshes may be associated with significantly increased rates of complications and recurrences [9-11]. Thus, an open approach is preferred unless the surgeon can perform minimally invasive mesh explantation, component separation, and sublay placement of mesh.

For the rest of this topic, it is assumed that the patient has been determined to be a suitable candidate for and offered laparoscopic repair.

SURGICAL TECHNIQUES — The techniques described in this section reflect the authors' preference and should not be regarded as the only approach to laparoscopic ventral hernia repairs. Alternative techniques are discussed in the next section. (See 'Controversial issues' below.)

Preoperative antibiotics — Preoperative antibiotics should be administered within one hour of the incision per standard protocols (table 1). Cefazolin (2 to 3 grams) is the drug of choice for many surgeons. Alternatives include vancomycin (15 mg/kg) or clindamycin (900 mg). (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults", section on 'General approach'.)

Venous thromboembolism prophylaxis — Our practice for perioperative venous thromboembolism (VTE) prophylaxis is based on recommendations from the American College of Chest Physicians [12]. Unless contraindicated, all patients receive sequential compression devices perioperatively as well as early postoperative ambulation. Patients at moderate-to-high risk for VTE events receive pharmacologic perioperative prophylaxis (unfractionated heparin or low-molecular-weight heparin) in addition to serial compression devices. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)

Premedication — A multimodal drug regimen, including nonsteroidal anti-inflammatory drugs (eg, ibuprofen), acetaminophen, and gabapentin or pregabalin, can be administered preoperatively to minimize postoperative pain and narcotic use. Perioperative use of regional anesthesia, including transversus abdominis plane blocks, has also been demonstrated to decrease early postoperative narcotic use [13]. (See "Approach to the management of acute pain in adults", section on 'Preventive analgesia for postoperative pain'.)

Additionally, in our practice, patients at high risk for urinary retention (including older men, men with a history of benign prostatic hyperplasia, and patients undergoing repair of suprapubic ventral/incisional hernias) are generally given tamsulosin (or a similar medication) preoperatively. Perioperative tamsulosin has been shown in some studies to reduce the risk of postoperative urinary retention in patients undergoing inguinal hernia repair [14,15], but not others [16].

Equipment — The following equipment should be available for a standard laparoscopic ventral hernia repair:

●5 mm, 30 or 45 degree standard operating laparoscope.

●Two to three 5 mm laparoscopic trocars.

●One 10 to 12 mm laparoscopic trocar (for insertion of mesh, depending on size of ventral hernia defect and size of mesh utilized).

●Energy device (hook dissector with monopolar cautery, ultrasonic or bipolar dissector per surgeon's choice).

●Monopolar shears (if adhesiolysis is required).

●Mesh (macroporous, medium-density polypropylene or polyester mesh with antiadhesive coating appropriate for intraperitoneal placement). (See 'Mesh material' below.)

●Slowly absorbable sutures (eg, 0 polydioxanone) for fascial defect closure and transfascial suture placement. Although there have been no studies that compared permanent with slowly absorbable sutures in ventral hernia repair, we prefer slowly absorbable sutures because they have been associated with a lower risk of suture-related complications such as stitch abscess but not a higher hernia recurrence rate in laparotomy closure studies [17,18]. Permanent sutures may also be utilized per surgeon preference.

●Transfascial suture passer.

●Laparoscopic mesh tacking (fixation) device. (See 'Mesh fixation' below.)

Patient positioning — In general, both arms should be tucked with all pressure points padded. Patients should be secured to the bed with straps to allow the bed to be steeply tilted into reverse Trendelenburg or Trendelenburg positions when necessary, depending on the location of the hernia. A "bump" (wedge) placed under the site of planned trocar placement may facilitate lateral trocar placement, especially in smaller patients.

Tubes — A urinary catheter should be placed in patients with a history of urinary retention, when operative time is expected to exceed two to three hours, or when repairing a lower midline or suprapubic hernia. An orogastric tube should be placed to decompress the stomach if the peritoneal cavity is to be entered via the left upper quadrant; the stomach is often distended during preoxygenation and induction of general anesthesia.

Abdominal entry and port placement — Because there is no evidence that any specific technique is better than others in preventing entry-related major visceral or vascular complications [19], the peritoneal cavity should be entered initially using a technique that the surgeon is most experienced with [20]. We generally enter with a 5 mm optical trocar in the left subcostal location, lateral to the midclavicular line (Palmer's point). We prefer blunt tip trocars due to decreased risk of port-site bleeding [21]. In the reoperative abdomen, the initial entry should be performed away from any previous incisions and surgical field. (See "Abdominal access techniques used in laparoscopic surgery", section on 'Initial port placement'.)

For primary ventral hernia repair, one to two additional 5 mm blunt tip trocars are placed in the left abdomen to facilitate safe adhesiolysis (if required) and mesh fixation. For the complex reoperative abdomen, more than two 5 mm blunt tip trocars may be required. However, we avoid placing trocars larger than 5 mm laterally to minimize the risk of trocar site hernia. If larger trocars are necessary for mesh insertion, they should be placed through the hernia defect, which will eventually be covered by the mesh [22]. (See 'Fascial defect closure (with video)' below.)

Lysis of adhesion — For most ventral incisional hernia repairs, adhesiolysis is required to make room for subsequent mesh insertion, manipulation, and fixation. Careful attention should be paid to avoid bowel injury [21]. Sharp dissection (without energy) is a safe approach to take down bowel adhesions while avoiding thermal injury.

Preperitoneal dissection (with video) — When repairing hernias with incarcerated preperitoneal fat (typically primary ventral hernias such as umbilical and epigastric hernias), it is essential that all preperitoneal contents are reduced. Using the surgeon's choice of energy device, the peritoneum is incised around the hernia fascial defect and the preperitoneal plane is entered. The preperitoneal fat is generally reduced en bloc with the associated hernia sac (movie 1). With hernias that are at or above the level of the umbilicus, the falciform ligament should be taken down with the energy device to completely expose the fascial edges of the hernia and permit wide mesh apposition to the abdominal wall.

Fascial defect closure (with video) — In general, mesh reinforcement should be utilized in all patients undergoing elective laparoscopic ventral hernia repair. If it is to be inserted in the intraperitoneal position, the mesh chosen should overlap the hernia defect for at least 5 cm in all directions, as measured prior to fascial defect closure [23-26]. The 2019 International Endohernia Society (IEHS) consensus statements suggest that the area of the mesh should be four times the area of the fascial defect being addressed [21,27]. It is important to note that this recommendation is based on level 3 data and considered a grade C recommendation.

A 10 to 12 mm trocar is then placed through the fascial defect, through which the mesh is introduced. In general, we place four 0-polydioxanone sutures at the four corners prior to introducing the mesh into the peritoneal cavity. The sutures will serve as transfascial sutures. Alternatively, if the surgeon does not wish to use transfascial sutures, a single stay stitch can be placed in the center of the mesh to help position the mesh. Additionally, surgeons may consider the use of self-positioning systems that are available commercially with certain mesh products (eg, balloon or nitinol frame). If there are any pathologic specimens, such as excised chronically incarcerated preperitoneal fat or a hernia sac, they can be removed through the 10 to 12 mm trocar/fascial defect at this time.

The fascial defect is then closed with 0-polydioxanone sutures using a transcutaneous suture passing device (movie 2). Fascial defects are generally closed longitudinally, but for small defects, transverse closure may be appropriate. Among the reported randomized controlled trials, sutures are placed 1 cm apart (with 0.5 to 1 cm fascial bites) [28]. Small stab incisions are made along the long axis of the hernia defect. A suture passer is used to place 0-polydioxanone sutures every 1 cm, and the abdomen is desufflated prior to tying the sutures after every four sutures have been placed [29]. In our experience, fascial defects as large as 10 to 12 cm in width can be closed using this approach.

Depending on the location of the fascial defect as well as the skill of the surgeon, some fascial defects can also be closed intracorporeally using barbed sutures [29]. Alternatively, a hybrid technique may be used in selected cases, where a small incision directly over the fascial defect permits hernia sac and content reduction/excision, mesh introduction, and fascial defect closure; this is followed by laparoscopic mesh fixation.

Although results of several randomized trials support fascial defect closure [28-32], its necessity during laparoscopic ventral hernia continues to be debated. (See 'Fascial defect closure' below.)

Mesh fixation (with video) — Meshes can be fixated to the anterior abdominal wall with transfascial sutures, tacks, or a combination of the two. If no transfascial sutures are placed, two rows of permanent tacks should be used to fixate the mesh; if transfascial sutures are used, one or two rows of either absorbable or permanent tacks may be placed at the surgeon's discretion.

●To place transfascial sutures, multiple small "stab" incisions are made in the skin at locations that correspond to those of the previously placed sutures on the mesh. A transcutaneous laparoscopic suture passing device is advanced through the stab wound into the peritoneum. The assistant uses a laparoscopic grasper to feed each end of the sutures into the jaws of the awaiting suture passing device, which, when closed, brings the suture through the abdominal wall. For larger meshes, some surgeons place additional transfascial sutures to ensure ≤5 cm intervals in between [33]. Once all the sutures are brought through the abdominal wall, the peritoneal cavity is desufflated and the sutures are tied. The peritoneal cavity is then reinsufflated to a lower pressure (5 to 10 mmHg), and the mesh is examined laparoscopically to ensure appropriate coverage of fascial defect as well as appropriate apposition to the abdominal wall.

The mesh is then additionally fixated utilizing single or double rows (crowns) of absorbable or permanent tacks, per surgeon preference (movie 3). The tacks are placed circumferentially at the margins of the mesh at 1 cm intervals to prevent the bowel from becoming trapped between the mesh and the abdominal wall (single-crown technique). A second row of tacks may be placed at approximately 2 cm intervals and 2 cm from the hernia edge to provide a more robust mesh fixation to the peritoneal surface (double-crown technique) [34].

●If transfascial sutures are not utilized, the stay stitch on the mesh is generally brought through the abdominal wall at the center of the hernia fascial defect to facilitate mesh fixation with a double crown of permanent tacks (movie 4). Other commercially available mesh positioning devices are available but may be difficult to place (require large trocars, which may increase the risk of port site hernia), difficult to remove, or costly, and no studies have associated their use with improved clinical outcomes.

Mesh fixation methods are directly related to important patient outcomes such as postoperative pain and hernia recurrence. The optimal technique of mesh fixation is controversial; evidence for and against various mesh fixation methods is presented below. (See 'Mesh fixation' below.)

Closure — After mesh fixation, the operative field is examined for hemostasis and exclusion of any injury to underlying viscera. The peritoneal cavity is desufflated, trocars are removed, and the skin incisions are closed per the surgeon's preference. In general, we do not place drains for laparoscopic ventral hernia repair.

Postoperative care — With enhanced recovery protocols, which employ multimodal pain regimens and regional anesthesia (eg, transversus abdominis plane block), the majority of patients can be discharged the same day following elective laparoscopic ventral hernia repair. It is important to counsel patients regarding how much pain is expected after surgery and strategies for managing pain. (See 'Premedication' above.)

Patients should be seen in clinic within two to four weeks to evaluate for postoperative issues and complications. As an example, seromas and postoperative swelling may be encountered with larger hernias. Fevers, other signs of infection (eg, erythema and/or drainage at incisions), inability to tolerate oral intake, and worsening abdominal pain should prompt immediate reevaluation. Early ambulation should be encouraged. Patients should not drive while taking narcotic pain medications. Return to work and activity restrictions should be individualized based on the level of postoperative pain. (See 'Complications' below.)

CONTROVERSIAL ISSUES — The techniques described in the above section reflect the authors' practice. Controversial areas in laparoscopic ventral hernia repair are discussed in this section, followed by data where available.

Fascial defect closure — In most cases of open ventral hernia repair, the fascia is closed by the end of the procedure. However, the necessity of fascial defect closure in laparoscopic ventral hernia was debated without any high-quality data to guide practice [35] until the publication of several randomized trials [28-32]. While each study has its strengths and weaknesses, as a whole, trials support the use of fascial defect closure [28-32]. We suggest closing the fascial defect for all laparoscopic ventral hernia repairs. (See 'Fascial defect closure (with video)' above.)

●In a trial of 193 patients undergoing laparoscopic ventral hernia repair, bridged repair resulted in more bulging (49 versus 31 percent, p = 0.022) and seromas (67 versus 45 percent, p = 0.004), while fascial defect closure (with the hybrid technique) resulted in higher early postoperative pain scores (5.2 versus 4.3/10, p = 0.019) at one month. At one year, there were no differences in recurrence rates or pain and quality-of-life scores [31,32].

●In another trial of 129 patients undergoing laparoscopic ventral hernia repair, fascial defect closure resulted in greater improvement in patient quality-of-life scores than bridged repairs at two years (change in quality of life 41.3 versus 28.7/100, p = 0.047). The minimally clinically important difference was 7 (minor change) to 14 (major change). There were no differences in any secondary outcomes, including surgical site infection, seroma, eventration, or hernia recurrence [28].

●In another trial of 80 patients undergoing laparoscopic umbilical hernia repair, closure of the fascial defect reduced 30 day seroma formation rate (35 versus 58 percent, p = 0.043) and two-year hernia recurrence rate (7 versus 19 percent, p = 0.047) without increasing early or late pain [30]. The results of this trial are globally worse than those of the other two trials, possibly due to different hernia types (umbilical versus ventral [36]) or the mesh material used [37-39].

Role of minimally invasive component separation — It is often difficult to achieve fascial defect closure in patients with large fascial defects (width >8 to 12 cm) without a relaxing incision. In open ventral hernia repair, component separation is the most commonly used technique to achieve midline fascial closure. The details of open anterior and posterior component separation techniques are discussed elsewhere. (See "Overview of component separation".)

Laparoscopic, endoscopic, and robotic-assisted component separation techniques have been described [40-43], which can be used to facilitate fascial defect closure in laparoscopic ventral hernia repair. The increasing popularity of minimally invasive techniques, particularly robotic techniques, for abdominal wall reconstruction has led to increased use of robotic posterior component separation techniques [44]. (See "Robotic ventral hernia repair", section on 'Retrorectus with transversus abdominis release'.)

The complication rates of minimally invasive component separation techniques are thought to be lower than those of traditional open component separation techniques; however, no randomized trials exist to validate these assumptions. It is unknown whether minimally invasive component separation techniques lead to improved outcomes in laparoscopic ventral hernia repair.

Potential advantages of these advanced techniques may be outweighed by significant technical complications when performed improperly (such as disruption of the linea semilunaris) as well as complications related to the technique (ie, posterior rectus sheath disruption). These potential complications may outweigh any potential benefits, in particular for smaller fascial defects. Newer techniques for minimally invasive approaches to the retrorectus space, such as enhanced-view totally extraperitoneal (eTEP) based approaches, should be considered experimental given the lack of long-term outcomes data [45,46].

Mesh fixation — The mesh fixation method needs to be durable enough to prevent mesh migration yet gentle enough to minimize injury to the abdominal wall and postoperative pain. (See "Hernia mesh", section on 'Ventral hernia repair'.)

Popular methods of mesh fixation include absorbable or permanent tacks, transfascial sutures, and a combination of sutures and tacks. Fibrin glue has been used, but less frequently. Because of a higher-than-expected recurrence rate at one year (26 percent fibrin sealant versus 6 percent tacks) in a trial of umbilical hernia repairs, this technique should be avoided until further studies demonstrate safety and efficacy [33,47,48].

Studies have associated lower hernia recurrence rates with high (versus low) mesh-to-defect-size ratio, mesh reaching (versus not reaching) lateral to the rectus muscles, and mesh overlap from defect edges of >5 cm (versus <3 cm) [23]. However, the evidence supporting most of this discussion is at high risk for bias, with heterogenous hernias and populations, and only demonstrates association, not causation. Compared with larger defects, small defects can be repaired with greater mesh overlap, fewer points of fixation, and a lower risk for recurrence.

Fixation methods — To date, no single mesh fixation method used for laparoscopic ventral hernia repair has been found to be superior to others. However, several conclusions can be drawn from the studies:

●Meshes can be fixated with two rows of permanent tacks only or transfascial sutures only. Although these two techniques have been compared in multiple studies (including randomized trials), data do not conclusively show one technique to be superior to the other. In a 2018 systematic review and meta-analysis of three trials that directly compared the two techniques, suture fixation was associated with a lower recurrence rate, but the difference was not statistically significant (recurrence rate 7.2 versus 1.7 percent; relative risk [RR] 3.07, 95% CI 0.71-13.33) [33]. In individual trials, suture fixation was equal to tacks [49-51] in terms of hernia recurrence and superior [51,52], inferior [50], or equal to tacks [49] in terms of postoperative pain.

●Meshes can be fixated with a combination of transfascial sutures and either a single or double row of tacks. In a trial comparing mesh fixation with double rows of permanent tacks and transfascial sutures plus a single row of tacks, transfascial sutures caused more postoperative pain at three months; however, the recurrence rate was not statistically different at two years (11.1 percent tacks versus 3.7 percent suture plus tacks, p = 0.381) [53]. We prefer to use permanent tacks with transfascial sutures. Although absorbable tacks are safe, they are associated with increased costs and no apparent clinical benefit (eg, pain, patient satisfaction) [54].

●Meshes should not be fixated with absorbable tacks alone, because of increased recurrence rate compared with permanent tacks. In a nationwide cohort study of 880 patients from the Danish Ventral Hernia Database who underwent fixation with two rows of permanent or absorbable tacks (double-crown technique) only, recurrence-free survival was significantly lower in the absorbable tack group compared with the permanent tack group (71.5 versus 82 percent; p = 0.007). This is despite shorter follow-up in the absorbable fixation group (34 versus 44 months) and larger hernia size in the permanent fixation group (9 versus 7 cm largest median diameter). No differences were seen in chronic pain rates [55]. In a 2018 network analysis of six studies, absorbable tack fixation was the only method found to be statistically inferior to permanent tack fixation in terms of hernia recurrence (RR 1.37, 95% CI 1.03-1.81) [33].

Fixation locations — The location of fixation also determines the strength of attachment of the mesh to the abdominal wall independently of the fixation method used [23]. Some surgeons believe that fixation to bony or ligamentous structures such as the pubic symphysis, Cooper's ligament, ribs, and iliac crest is stronger than fixation to anterior abdominal wall muscles, which is in turn stronger than fixation to posterior abdominal wall muscles. However, no clinical trials substantiate this belief, and one must carefully balance this purported benefit against the potential increased risk of chronic pain or other complications.

Peripherally located hernias pose unique challenges to mesh fixation; wide dissection and exposure along with wide mesh overlap may help overcome the barriers for circumferential fixation at these locations [23]:

●Superior hernias close to the costal margin are best managed by leaving an overhang of mesh draped over the diaphragm without fixation. Fixation with tacks to the diaphragm should be avoided as it has been associated with serious complications such as lung and cardiac injuries (tamponade). Fixation above the costal margin should not be accomplished with sutures placed between ribs either, which may injure neurovascular bundles running along the inferior surface of each rib or cause a pneumothorax.

●Inferior hernias near the pubic symphysis should be fixed to the pubic bone, pubic ramus, or Cooper's ligament. Fixation inferior to the iliopubic tract should be avoided because of a risk of groin nerve injury, as in laparoscopic inguinal hernia repairs.

●For lateral hernias, fixation to the lateral and posterior abdominal wall should avoid injury to retroperitoneal structures such as nerves, blood vessels, and the ureters.

Lateral abdominal wall hernia repair is discussed in detail separately. (See "Lateral abdominal wall hernia repair".)

Mesh location — During ventral hernia repair, the mesh can be placed above the fascia (onlay), between the rectus muscles and peritoneum/posterior rectus sheath (retrorectus), below the peritoneum (intraperitoneal), or in between fascial edges (inlay), among other abdominal wall planes (figure 1) [56]. (See "Hernia mesh", section on 'Mesh location'.)

While retrorectus mesh placement is preferred in open repair due to lower recurrence and surgical site infection rates [57,58], it is technically challenging during laparoscopic repair. Instead, the intraperitoneal technique, pioneered by LeBlanc [59], is most widely used in laparoscopic repairs. Although the intraperitoneal technique has been associated with postoperative complications related to the presence of intraperitoneal mesh, they are rare and the majority have only been reported in case reports or cases in series [60].

There is a paucity of randomized trials designed to directly compare alternate mesh positions during laparoscopic repair. However, a network meta-analysis of 19 randomized trials on ventral hernia repair evaluating optimal location of mesh placement (sublay [retromuscular, preperitoneal, and transversalis fascial], onlay, or underlay [intraperitoneal]) demonstrated that laparoscopic ventral hernia repair with intraperitoneal mesh placement had the highest probability of having the lowest rate of surgical site infections (odds ratio [OR] 0.63, 95% CI 0.01-7.69, probability of being the best 47.1 percent) [57].

There has been increasing interest in transabdominal preperitoneal (TAPP) as well as enhanced-view total extraperitoneal (eTEP) approaches to minimally invasive ventral hernia repair [60,61].

●TAPP – A systematic review and meta-analysis of nine studies (1429 patients) comparing the TAPP approach with other minimally invasive hernia repair techniques demonstrated reduced pain, cost, and surgical site infections as opposed to intraperitoneal mesh placement; TAPP repair was also associated with shorter operative time and hospital length of stay than eTEP techniques [62]. Additionally, small studies suggest that the learning curve of minimally invasive TAPP ventral hernia repair as it relates to consistent operative times and quality of the preperitoneal flap is approximately 40 to 60 procedures [63].

●Enhanced-view TEP – Enhanced-view TEP (eTEP) approaches for laparoscopic repairs of incisional and ventral hernias are increasingly being described. Purported advantages include the ability to place wide pieces of mesh in the retrorectus/retromuscular spaces. It may also help facilitate minimally invasive fascial defect closure in the case of large fascial defects requiring posterior (transversus abdominis) component release techniques [45].

•A randomized trial of 100 patients comparing robotic eTEP to robotic intraperitoneal techniques in patients with hernias with fascial defects <7 cm revealed no differences in pain between the two techniques at 30 days follow-up. Surgeon workload, operative times, and surgical site occurrences favored the intraperitoneal technique [64].

•A second randomized trial of 60 patients evaluating the same two techniques performed in patients with hernias 2 to 5 cm in size revealed outcomes favoring eTEP (postoperative pain up to six weeks, seroma, and cost effectiveness). Some of the improvement in pain scores may have been secondary to lack of transfascial suture and tack fixation in the eTEP group (a potential advantage of the extraperitoneal approach). All procedures in this study were performed laparoscopically [65].

•A systematic review and pooled meta-analysis of 13 studies (918 patients) evaluating the eTEP technique reported promising short-term (median follow up of 6.6 months, range 1 to 24 months) outcomes as it related to surgical site infections, seromas, intraoperative complications, conversion rates, hospital length of stay, and major (Clavien-Dindo III-IV) complications [66]. Short-term data suggest that this approach is safe. The potential outcome advantages are unknown. Further study to define the role of eTEP in ventral and incisional hernia repair is needed.

The eTEP technique of ventral hernia repair is described elsewhere. (See "Robotic component separation techniques", section on 'eTEP approach'.)

TAPP and eTEP techniques of laparoscopic ventral hernia repair appear to show safety in short-term outcomes; however, they require continued further study to attest to effectiveness, potential clinical benefits [67], and generalizability [21]. For now, they are considered experimental techniques, the misuse of which may lead to severe complications. (See 'Role of minimally invasive component separation' above.)

Mesh material — The three general categories of meshes used in the repair of ventral hernias are synthetic mesh, biologic/bioabsorbable mesh, and biosynthetic mesh. There are increasing high-quality data supporting the use of synthetic mesh as opposed to biologic mesh in both clean and contaminated fields [8,68-70], however, this issue remains controversial and is further discussed in another topic. (See "Hernia mesh", section on 'Mesh material'.)

A national cohort study from the Danish Ventral Hernia Database compared the reoperation rate after laparoscopic ventral hernia repairs performed with one type of the following hernia meshes [71].

●For primary ventral hernia (2874 patients), ultra-low-density mesh (hazard ratio [HR] 3.45, 95% CI 2.16-5.51) and low-density mesh (HR 2.53, 95% CI 1.35-4.75) were associated with higher risk of reoperation for recurrence compared with mid-density or high-density meshes.

●For incisional hernias (2726 patients), ultra-low-density mesh (HR 3.90, 95% CI 1.80-8.46), high-density polypropylene mesh (HR 2.99, 95% CI 1.13-7.93), high-density polyester mesh (HR 2.55, 95% CI 1.17–5.55), and low-density polypropylene mesh (HR 2.63, 95% CI 1.11-6.20) were associated with a higher risk of reoperation for recurrence compared with mid-density polypropylene mesh.

These data are far from definitive as the meshes were not randomly chosen. Other studies may show different recurrence rates for these meshes. Of note, some brands of ultra-low-density mesh have been voluntarily taken off the market.

COMPLICATIONS — A large cohort study reported that 15 percent of patients undergoing ventral incisional hernia repair had one or more complications. Wound complications accounted for 51 percent of all complications, followed by medical complications (42 percent) and surgical complications (29 percent) [72]. The same patient may have had complications in more than one category.

The surgical complications that most commonly occur after laparoscopic ventral hernia repair include:

Pain — Postoperative pain after laparoscopic ventral hernia repair is common but mostly resolves by four to six weeks. The incidence of persistent pain beyond six weeks ranges from 1.6 to 28 percent.

Prolonged intractable pain may be due to nerve entrapment by a suture or tack and can be treated with analgesics, nonsteroidal anti-inflammatory medications, steroids, trigger point injection, nerve block, or excision of sutures or tacks [23].

It is debated whether transfascial sutures or tacks cause more postoperative pain. Absorbable tacks have not been shown to cause any less pain than permanent tacks. (See 'Mesh fixation' above.)

Wound complications — Compared with open ventral hernia repair, laparoscopic repair causes fewer surgical site infections, both superficial and deep. (See "Management of ventral hernias", section on 'Open versus laparoscopic repair'.)

Two to 4 percent of patients develop abdominal wall cellulitis after laparoscopic ventral hernia repair as a result of either infection or inflammatory response to the prosthetic mesh. Postoperative cellulitis can be treated with antibiotics [23].

Fewer than 1 percent of patients develop mesh infection following laparoscopic ventral hernia repair. Except in septic patients, attempts should be made to salvage an infected prosthetic mesh with a combination of antibiotics, percutaneous drainage, and/or wound debridement (eg, with negative pressure wound therapy). However, mesh excision may be required if salvage effects fail.

Seromas can be detected radiographically in almost all patients and clinically in approximately one-third of the patients in the early postoperative period after a laparoscopic ventral hernia repair [23]. It is widely regarded as an expected outcome, rather than a complication of the surgery. Asymptomatic seromas are commonly observed, and only 3 to 4 percent do not resolve spontaneously. Persistent or symptomatic seromas may be aspirated under sterile conditions, but there is a small but real risk of infection. Seromas that recur after aspiration may require surgical drainage with excision of the seroma lining or, rarely, mesh excision.

Intraoperative maneuvers such as cauterization of the hernia sac, suture closure of the hernia defect (see 'Fascial defect closure (with video)' above), and the use of pressure dressings (eg, abdominal binder) may reduce the incidence of postoperative seroma formation, but no high-quality data exist to support these assumptions.

Enterotomy — Iatrogenic enterotomy occurs in 0 to 14 percent of patients undergoing laparoscopic ventral hernia repair [73]. It is the most common intraoperative complication of laparoscopic ventral hernia repair, half of which occur during adhesiolysis [20]. The risk of iatrogenic enterotomy should be discussed with all patients prior to surgery.

When an enterotomy is recognized intraoperatively, it must be immediately repaired or resected. Subsequent management (of the hernia) varies; options include aborting the ventral hernia repair; converting to open hernia repair using a synthetic, biologic, or bioabsorbable mesh in the sublay position; and completing laparoscopic ventral hernia repair either using a mesh at low risk of infectious complications intraperitoneally [8] or synthetic mesh in a preperitoneal or retrorectus/retromuscular location [23]. There is a moderate amount of anecdotal and retrospective evidence and clinical experience in support of each option, but no study has directly addressed the clinical scenario of a small enterotomy that occurs during adhesiolysis with limited contamination, making the operation a clean-contaminated case. However, although placement of intraperitoneal synthetic mesh following a repaired enterotomy was not recommended given increased risks of mesh infection, high-quality data from several randomized trials demonstrate the superiority of synthetic mesh over biologic mesh in infected fields, including in the intraperitoneal location [8,68-70]. Further supportive data and continued evaluation of long-term outcomes are likely required before this practice becomes the standard of care [73,74].

Eighteen percent of enterotomies are not recognized until after surgery [73,74]. They can be caused by an intraoperative intestinal injury that is not recognized, a thermal injury that progresses from partial to full thickness postoperatively, or enterotomies caused by mesh fixation devices such as tacks. Management involves reexploration with intestinal repair/resection and, in most cases, mesh removal. These delayed enterotomies are the most serious complications, with a mortality of 40 percent and morbidity of 100 percent [74]. Because of this, when there is concern for potential bowel injury, the surgeon should carefully examine the intestine and repair any potential injuries.

Prolonged ileus — Laparoscopic ventral hernia repair is associated with a low incidence of postoperative ileus, with few patients with no return of bowel activity after five days. Patients who require extensive adhesiolysis and/or manipulation of the intestine, large prosthetic mesh implantation, or heavy postoperative narcotic use are at higher risk of developing ileus. Initial treatment is nonoperative and includes bowel rest, minimizing narcotic use, intravenous fluid, and gastric decompression. (See "Postoperative ileus", section on 'Management'.)

Hernia recurrence — Laparoscopic ventral hernia repairs are typically performed with mesh. The recurrence rate of all ventral incisional hernias and most primary ventral hernias is lower after mesh repair compared with suture repair. (See "Management of ventral hernias", section on 'Ventral hernias between 1 and 10 cm'.)

In a 2014 systematic review of laparoscopic ventral hernia repair that included 25 series, the overall recurrence rate was 2.7 percent (95% CI 1.9 to 3.4 percent) [75]. None of the mesh fixation techniques were superior in preventing hernia recurrence compared with others.

In a 2018 systematic review and network meta-analysis of methods of mesh fixation, crude recurrence rates varied from 1.5 percent (with sutures only) to 17.5 percent (with absorbable tacks only) [33]. Other fixation methods were associated with intermediate recurrence rates of 6 percent (with permanent tacks plus sutures), 7.7 percent (with permanent sutures only), and 0.7 percent (with absorbable tacks plus sutures; this group had fewer patients and a shorter follow-up than the others).

Mesh fixation methods and their contributions to hernia recurrence have been discussed in detail above. (See 'Mesh fixation' above.)

Mesh bulging — Not every bulge in the area of a previous ventral hernia repair is an anatomic recurrent hernia. In some patients, mesh that remains anchored to the abdominal wall peripherally can protrude centrally through the hernia opening into the hernia sac to cause bulging. Such cases of mesh bulging (also referred to as eventration) cannot be distinguished from true hernia recurrences very easily without imaging. Mesh bulging is observed in 1.6 to 17.4 percent of patients, mostly after undergoing laparoscopic repair of large ventral hernias [24].

Bulging can be caused by expansion of the mesh [76] or narrowing of the hernia defect [77]. Because bridging of the hernia defect as performed with the standard intraperitoneal technique does not fully restore the abdominal wall function, it can cause more frequent recurrence and bulging [78]. For that reason, fascial defect closure has been suggested to reduce the risk of mesh bulging [79]. However, a trial demonstrated no statistically significant differences in mesh eventration/bulging at two years following fascial defect closure versus bridged repair [28]. Continued study is warranted. (See 'Fascial defect closure' above.)

For symptomatic patients, treatment can be reapproximating the fascia alone or a new mesh repair (ie, old mesh explantation, fascial closure, placement of new mesh). In asymptomatic patients, "watchful waiting" is a reasonable option. Once "bulging" occurs, it neither has the tendency for further enlargement nor seems to lead to the development of recurrences [77].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Ventral hernia" and "Society guideline links: Laparoscopic and robotic surgery".)

SUMMARY AND RECOMMENDATIONS

●Patient selection – Most, but not all, ventral hernias can be repaired both open and laparoscopically. The choice largely depends on surgeon training, expertise, and preference, except that (see 'Preoperative preparation' above):

•Absolute contraindications to laparoscopic ventral hernia repair include inability to tolerate pneumoperitoneum and inability to safely access the peritoneal cavity (typically due to a "hostile abdomen").

•Relative contraindications to laparoscopic ventral hernia repair are dependent on surgeon skill and resources and may include very large hernia defects (width >8 to 10 cm or loss of domain), hernias with associated acute bowel obstruction or perforation, and infected meshes or associated complications (eg, enteric fistulas).

●Mesh size/overlap – In general, mesh reinforcement should be used in all patients undergoing elective laparoscopic ventral hernia repair. The fascial defect should be measured and mesh chosen to allow for at least 5 cm of overlap in all directions if the mesh is to be inserted in the intraperitoneal position, or the area of the mesh should be at least four times the area of the preclosure fascial defect. (See 'Fascial defect closure (with video)' above.)

●Fascial closure – For laparoscopic ventral hernia repairs, we suggest closing the fascial defect rather than a bridged repair (Grade 2B). Fascial defect closure has been associated with lower rates of seroma, hernia recurrence, or bulging in some studies. (See 'Fascial defect closure' above.)

●Mesh fixation – Multiple acceptable methods for mesh fixation exist, including with transfascial sutures only, with transfascial sutures plus one or two crowns (rows) of tacks, or with tacks only. When transfascial sutures are omitted, we suggest mesh fixation with a double crown of permanent, rather than absorbable, tacks (Grade 2C). (See 'Mesh fixation (with video)' above and 'Mesh fixation' above.)

●Mesh location – There are multiple options for mesh location in ventral hernia repair, including intraperitoneal (underlay) placement, preperitoneal placement, and retromuscular/retrorectus (sublay) placement. Intraperitoneal (underlay) mesh placement is most commonly performed in laparoscopic repair. (See 'Mesh location' above.)

●Mesh material – Intraperitoneal placement of synthetic meshes following a repaired enterotomy was historically avoided because of a high risk of mesh infection; however, there is increasing, high-quality evidence that the use of synthetic mesh in contaminated fields is safe and may be associated with better long-term outcomes than biologic mesh. Further study is required. (See 'Enterotomy' above and "Hernia mesh", section on 'Mesh material'.)