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Purpose In this study, a three-step novel surgical technique was developed for incisional hernia, in which a laparoscopic procedure with a mini-laparotomy is combined: so-called ‘three-step incisional hybrid repair’. The aim of this study was to reduce the risk of intestinal lacerations during adhesiolysis and recurrence rate by better symmetrical overlap placement of the mesh. Objectives To evaluate first perioperative outcomes with this technique. Methods From 2016 to 2020, 70 patients (65.7% females) with an incisional hernia of > 2 and ≤ 10 cm underwent a elective three-step incisional hybrid repair in two non-academic hospitals performed by two surgeons specialised in abdominal wall surgery. Intra- and postoperative complications, operation time, hospitalisation time and hernia recurrence were assessed. Results Mean operation time was 100 min. Mean hernia size was 4.8 cm; 45 patients (64.3%) had a hernia of 1–5 cm, 25 patients (35.7%) of 6–10 cm. Eight patients had a grade 1 complication (11.4%), five patients a grade 2 (7.1%), two patients (2.8%) a grade 4 complication and one patient (1.4%) a grade 5 complication. Five patients had an intraoperative complication (7.0%), two enterotomies, one serosa injury, one omentum bleeding and one laceration of an epigastric vessel. Mean length of stay was 3.3 days. Four patients (5.6%) developed a hernia recurrence during a mean follow-up of 19.5 weeks. Conclusion A three-step hybrid incisional hernia repair is a safe alternative for incisional hernia repair. Intraoperative complications rate was low.

An enterocutaneous fistula (ECF) with an associated large hernia defect poses a significant challenge for the reconstructive surgeon. We aim to describe operative details and 30-day outcomes of elective hernia repair with an ECF when performed by surgeons participating in the Abdominal Core Health Quality Collaborative (ACHQC). Patients undergoing concomitant hernia and ECF elective repair were identified within the ACHQC. Outcomes of interest were operative details and 30-day rates of surgical site infections (SSI), surgical site occurrences requiring procedural intervention (SSOPI), medical complications, and mortality. 170 patients were identified (mean age 60 years, 52.4% females, mean BMI 32.3 kg/m2). 106 patients (62%) had small-bowel ECFs, mostly managed with resection without diversion. 30 patients (18%) had colonic ECFs, which were managed with resection without diversion (14%) or resection with diversion (6%). 100 (59%) had a prior mesh in place, which was removed in 90% of patients. Hernias measured 14 cm ± 7 in width, and 68 (40%) had a myofascial release performed (41 TARs). Mesh was placed in 115 cases (68%), 72% as a sublay, and more frequently of biologic (44%) or permanent synthetic (34%) material. 30-day SSI was 18% (37% superficial, 40% deep), and 30-day SSOPI was 21%. 19 patients (11%) were re-operated: 8 (8%) due to a wound complication and 4 (2%) due to a missed enterotomy. Two infected meshes were removed, one biologic and one synthetic. Surgeons participating in the ACHQC predominantly resect ECFs and repair the associated hernias with sublay mesh with or without a myofascial release. Morbidity remains high, most closely related to wound complications, as such, concomitant definitive repairs should be entertained with caution.

To present a novel technique for the repair of parastomal hernias. A total of 15 patients underwent parastomal hernia repair. A robotic Sugarbaker technique was utilized for repair. The fascial defect was closed prior to robotic intraperitoneal placement of the mesh. Baseline demographics of the patients were obtained, and intra-operative and post-operative outcomes were tracked. The etiology of the ostomies was oncologic in all but three patients. Five of the stomas were urostomies (33.3%). Patient characteristics were as follows: age 64.9.1 ± 9.3 years, BMI 30.1 ± 4.7 kg/m2, smoking history 60.0%, and diabetes 6.7%. The mean size of the hernia defect was 46.0 ± 40.1 cm2 with a mesh size of 372.0 ± 101.2 cm2. The mean operative time was 182.0 ± 51.9 min. In seven patients, an inferolateral preperitoneal flap was created for mesh placement. Intraoperatively, only one enterotomy was made during dissection, which was repaired without complication. The mean length of stay was 4.2 ± 1.9 days. There was only one hernia recurrence (6.7%). There were no wound complications, surgical site infections, or mesh infections. A mean follow-up time of 14.2 ± 9.4 months was achieved. Robotic Sugarbaker parastomal hernia repair is a safe and effective technique. The results demonstrate the feasibility of fascial closure with this technique and a low recurrence rate. The authors propose this technique should be widely considered for parastomal hernia repair.

The purpose of this study was to evaluate a novel hernia repair glue fixation device (LiquibandFix8™) in laparoscopic IPOM repair for incisional hernias. All ventral incisional hernia patients requiring laparoscopic IPOM repair were included in the study. A retrospective review of the data was performed. 137 patients underwent 138 laparoscopic IPOM repairs for incisional hernias using n-butyl-2-cyanoacrylate (LiquibandFix8™) for mesh fixation over a 40-month period by a single experienced laparoscopic surgeon. There were 70 males and 67 females, median age 54 years (range 23–80 years). Defects were predominantly midline n = 123/138 (89%) and were closed by transfascial sutures in 126/138 (91%) prior to IPOM repair (IPOM plus). Mesh fixation was successful in all 138 repairs. Synthetic meshes (Symbotex™ [polyester/collagen composite, Medtronic] n = 80, and Dynamesh® [polypropylene/PVDF composite, FEG Textiltechnik mbH] n = 5) and biologic meshes (Surgimend® [bovine collagen dermal matrix, Integra] n = 53) were used. Median follow-up was 32 months (range 12–48 months). There were 16 adverse events in 12 patients (9%): conversion to open surgery (inadvertent enterotomy) 2 (1.5%), bladder perforation 1, intraperitoneal bleeding 2, port-site haematoma 2, port site wound infection 1, post-op ileus 2, chest infection 1, seroma 1 (1%), hernia recurrence 3 (2%) and chronic pain 2 (1.5%). This retrospective study shows that mesh fixation in laparoscopic IPOM using cyanoacrylate glue with the Liquiband Fix8™ device is feasible, safe, easy to learn, and is associated with a low risk of seroma, hernia recurrence and chronic pain with short-medium term follow-up.

Though perineal hernias remain rare, the incidence is reportedly rising. Secondary to the historical rarity, optimal method of repair and outcomes after repair remain poorly understood. Therefore, we reviewed the past 25 years of our institutional experience with perineal hernia repair. A retrospective review of an institution-maintained database was conducted from January 1, 1994 to January 31, 2018 for patients undergoing perineal hernia repair. Data were collected on patient characteristics, operative technique, and post-operative outcomes. Twenty-one patients (n = 12 male) underwent perineal hernia repair in the study period with two-thirds of the operations occurring in the most recent 7 years (since January 1, 2011). The median time to repair was 13 months (range 2–127) after index operation. The approach was transabdominal in nine, perineal in nine, and combined in three. Mesh, a tissue flap, or a combination of these was used in 19 of the cases and 6 additional abdominal wall hernias were repaired concurrently. Post-operative complications consisted of superficial surgical-site infection (n = 2), infected seroma (n = 1), and a missed enterotomy (n = 1). Follow-up ranged from 0 to 112 months (median 2 months) and only one recurrence was noted. Presentation for repair of perineal hernia has increased at our instituion over the past 2 decades. Outcomes did not differ between the three repair approaches and the choice of mesh or tissue-based repair. Surgeons should base these decisions on hernia complexity and local tissue conditions.

Iatrogenic enterotomy (IE) during laparoscopic ventral/incisional hernia repair (LIVHR) is reported to be associated with poorer surgical outcomes. We report our experience with diagnosis, management and complications in patients who had IE during LIVHR at our tertiary referral institute between 1994 and 2011. We retrospectively reviewed prospectively collected data of 2,346 patients who underwent LIVHR from 1994 to 2011. We identified 33 patients who had IE during LIVHR. All surgical procedures were performed by five consultants and fellows under supervision who followed a standardized operative protocol. Patients were followed up for 6 months to evaluate morbidity, mortality, additional surgical procedures, unplanned readmissions and hospital stay. Mortality occurred in 2 patients (6 %). Complications occurred in 16 patients (48.5 %). Median hospital stay was 3 days (2–36). Unplanned readmission was required in 6 patients (18 %). In 18 patients, (55 %) additional surgical procedures were required within 6 months of LIVHR. In 5 patients, the enterotomy was recognized postoperatively. These patients had worst outcomes [mortality 40 %, additional surgical procedures were required in all patients (100 %) and median hospital stay was 12 days (range 7–36)]. Iatrogenic enterotomy is a serious complication during LIVHR. IE is associated with mortality, morbidity, additional surgical procedures, unplanned readmissions and prolonged hospital stay. In patients where IE was recognized postoperatively, the prognosis was worst.

The role of laparoscopy in the management of incarcerated (irreducible) ventral hernia remains to be elucidated. We present our experience of the laparoscopic repair of incarcerated primary ventral and incisional hernias over an 8-year period. A retrospective review of the records of 112 patients undergoing laparoscopic repair for incarcerated primary ventral and incisional hernias from January 1998 to February 2006 was performed. The patient demographics, perioperative data, and postoperative complications were assessed. The procedure was completed entirely laparoscopically in 103 patients (91.9%) with the placement of intraperitoneal mesh. A sutured tissue repair (without mesh) was performed in seven patients and hernia repair was abandoned after laparoscopy in two patients. Five patients required limited conversion by a targeted skin incision for the resection of nonviable bowel (three patients) and to complete adhesiolysis within multiloculated hernial sacs (two patients). The contents of the hernial sacs were incarcerated omentum (42 patients), small bowel (28 patients), large bowel (six patients), and omentum and small bowel (34 patients). Of these, seven patients presented with signs of acute small-bowel obstruction. The mean size of the largest defect through which incarceration occurred was 3.5 ± 1.6 cm (range 1.5–7.5 cm) and the mean size of the mesh used was 379 ± 210 cm2 (range 225–780 cm2). The mean operative time was 96 ± 40.8 min (range 50–170 min). Inadvertent enterotomy occurred in four patients during bowel reduction and adhesiolysis. In two patients, the enterotomy was repaired by total laparoscopy followed by mesh placement, and two patients required conversion to formal laparotomy due to long-segment tears and peritoneal contamination. The average postoperative hospital stay was 2.8 ± 1.5 days (range 1–6.5 days). Postoperative complications occurred in 20.5% patients. There was no mortality. Hernia recurred in three patients at a mean follow-up of 48 ± 28.3 months (range 1–84 months). Laparoscopic ventral abdominal wall hernia repair can be safely performed with a low complication rate, even in incarcerated hernias. Careful bowel reduction with adhesiolysis and mesh repair in an uncontaminated abdomen with a 5-cm mesh overlap remain key factors for a successful outcome.

During laparoscopic ventral/incisional hernia repair (LVIHR), conversion to conventional (open) technique is required when safe adhesiolysis is not possible, incarcerated bowel in hernial sac cannot be reduced or for repair of iatrogenic enterotomies. A formal laparotomy in these circumstances entails significant morbidity due to factors such as wound infection, prolonged immobility, and longer hospital stay. During a period between 1994 and 2007, 1,503 LVIHRs were performed at our centre following a standardized protocol by five consultants and fellows. Out of these, 6 patients had a formal laparotomy in the initial part of our experience and 26 patients had a limited conversion to facilitate completion of LVIHR. We have devised the term “limited conversion” for the procedure wherein bowel reduction/adhesiolysis/enterotomy repair was performed through a small targeted skin incision. This was followed by laparoscopic placement of intraperitoneal mesh. Conversion to an open procedure was required in 32 (2.1%) out of 1,503 LVIHR procedures. Twenty-six patients underwent a limited conversion and completion of the repair by laparoscopy. All but one of these patients had intraperitoneal placement of mesh by laparoscopic route. The wound complication rate was 3.8% (one patient), the mean hospital stay was 2.1 days, and mean operative time was 124 min. Limited conversion offers a safe alternative to a formal laparotomy in patients with bowel incarcerated in hernial sacs or in patients requiring extensive bowel adhesiolysis. Patient morbidity is reduced due to the targeted skin incision whilst retaining several advantages of a minimal access approach viz. laparoscopic evaluation of the entire abdominal wall and placement of a large intraperitoneal prosthesis.

Repair of parastomal represents a significant challenge for the hernia surgeon. Repair of these hernias is indicated because of an ill-fitting appliance, cosmetic deformity, inability to maintain proper hygiene and complications from the hernia itself such as incarceration or strangulation. Recent reports in the literature have shown that primary fascial repair can occur in 46% of patients and relocation of the stoma is associated with a 40% recurrence rate. For this reason, the use of polypropylene mesh has been applied to this repair. The recurrence rate with this open technique will still incur a failure rate of 20-29%. Additionally there are other complications such as obstruction, fistulization or mesh erosion with this biomaterial. The laparoscopic approach to this hernia may offer a new choice for this difficult problem. We have used ePTFE to repair 12 parastomal hernias with three different approaches. There have been eight colostomy, two ileostomy and two urostomy hernias. Follow-up ranges from 3-39 months (average 20 months). There has been one recurrence that required two repairs (8%). Other complications included enterotomy (one patient), ileus (one), seroma (one), and death from postoperative aspiration (one). The laparoscopic repair of parastomal hernias appears to be a promising technique for this complex dilemma.

Complications will occur with any operative procedure. The possibility of this must be considered for laparoscopic incisional and ventral hernia repair (LIVH) as well. The most commonly reported of these include: intraoperative intestinal injury (1-3.5%), infection involving the prosthetic biomaterial (0.7-1.4%), (2.6-100%), postoperative ileus seromas (1-8%), and persistent postoperative pain (1-2%). The incidence of enterotomy can be reduced by careful dissection and judicious use of any energy source. Infection can be minimized by the use of perioperative antibiotics, an antimicrobially impregnated biomaterial, and careful manipulation of the prosthesis during the procedure. Seromas are so common that they should be expected but can be decreased by the use of a postoperative abdominal binder. Aspiration will be necessary in a few instances. Similarly, ileus is expected when there is significant bowel dissection and bleeding. Early ambulation and standard use of postoperative bowel care will aid in the treatment of this problem. Persistent pain will generally occur at the site of a transfascial suture. It cannot be predicted or prevented with certainty. When it occurs, local injection with bupivacaine, steroids, or non-steroidal agents will help, but occasionally, removal of the offending suture(s) will be required. The average recurrence rate for LIVH is approximately 5.6% in the literature. Rates as high as 15.7%, however, have been reported. Recurrence will be increased by inadequate prosthetic overlap of the fascial defect, infection that involves the biomaterial, which then requires its removal, and lack of the use of transfascial sutures. To prevent these risks, the surgeon must assure that there is at least a 3-cm overlap of all portions of the hernia defect and insist that sutures are used at 5-cm intervals to fix the biomaterial. Infection that requires explantation of the patch will generally result in recurrence, as this must be repaired primarily. Alternatively, the use of a collagen prosthesis may allow immediate repair, but this is associated with a high failure rate. A staged repair will be necessary in the future in most patients.

Our first 100 patients and our second 100 patients who underwent a laparoscopic repair of incisional and ventral hernias were compared and evaluated. This analysis revealed that the second group was approximately 9 years older with more comorbid medical conditions. In all, 15% were incarcerated hernias, and 21% were recurrent. Seven operations were converted to the open repair because of adhesions in five patients and either a small or large bowel injury in two patients. There were no complications related to enterotomy. Older and more infirm patients in the second group did not significantly affect outcomes. The average size of the hernia defects was 111 cm2. The average size of the prosthesis was 257.5 cm2. Larger prostheses were used in the second group. With more experience, the recurrence rates have declined from 9% to 4%. The etiology of these recurrences differed in these two groups of patients. Removal of the prosthetic due to infection was a predictable recurrence in two patients. A new hernia below the original hernia has caused us to repair the entire incision that had the initial hernia. Only one technical failure was noted, due to fracture of the suture during transfascial placement and clamping of the suture. It is not recommended to grasp any suture that remains in the patient during this hernioplasty. Recurrences were reduced because of the use of an increased overlap of the biomaterial and the use of dual methods of fixation (tacks and transfascial sutures).

Large series of laparoscopic ventral hernia repair have shown excellent results. However, published comparative studies have had conflicting outcomes. We retrospectively reviewed the first 29 laparoscopic ventral hernia repairs performed at a VA Medical Center from January 2000 to June 2001. The outcome was compared to that of open repairs performed during the same time period. Outcomes between the groups were similar in all respects, except for the length of stay. The conversion rate for the laparoscopic approach was 13.8%. There was one death in the laparoscopic group due to an unrecognized enterotomy. There were three recurrences in the open group and one in the laparoscopic group with a mean follow up of 13 months. In our series, laparoscopic hernia repair resulted in a shorter hospital stay but no other significant benefits, along with a risk of missed enterotomy. The risk-benefit ratio for this procedure may be high during the learning curve.

Conventional repairs of incisional hernia are plagued with frequent complications and recurrences. Laparoscopic incision/ventral herniorrhaphy (LIVH) has been reported to be a safe and feasible technique with low morbidity and low early rates of recurrence. In this study, we review our experience with LIVH. All cases of LIVH performed consecutively at St. Joseph's Hospital, Hamilton, Ontario and University of Kentucky Medical Center between November 93 and January 1999 being followed prospectively were reviewed. Seventy-five hernias were repaired in 73 patients (38F, 35M) ranging from 25 to 84 years (mean 57) with a mean American Society of Anesthesiologists (ASA) score of 2.1. Postoperative complications occurred in 14 patients (19%) including seroma (3), wound infection (1), patch infection (2), bowel injury (2), ileus (3), pain (1), atelectasis (1), and congestive heart failure (1). One case was converted to an open procedure and in one case a prosthesis was not placed due to an enterotomy repaired laparoscopically. Postoperative recurrences occurred in 7 (9%) of patients, within two to twelve months. Three of these were repaired laparoscopically. Over the five-year experience, the number of recurrent hernias repaired has increased, operative times have increased, and hospital length of stay has decreased. During that same interval the incidence of recurrence and complications has not changed. In conclusion, LIVH is a safe and feasible technique, applicable to all patient populations including the obese and multi-operated abdomen. Recurrence is low, and may be repaired laparoscopically.