ABSTRACT
Although the principles of abdominal wall repair are well established and the complication rate has decreased significantly over the past decade, the complication and recurrence rates for open incisional hernia repair are far from ideal. A prospective, randomized, multicenter study recently reported a 46 per cent recurrence rate after primary open repair of ventral hernias when a prosthetic material was not employed.1 Others have reported recurrence rates of 25 per cent and 52 per cent for fascial defects smaller and larger than 4 cm, respectively.2-4 Recurrences are also associated with the number of repairs performed, with 18-43 per cent after initial repair and over 50 per cent after recurrent repair.1,3
It is common to perform a primary repair for ventral hernias smaller than 4 cm in diameter. For larger defects, the use of a prosthetic material is recommended to allow for a tension-free repair. The use of a variety of mesh materials for open hernia repairs has resulted in a lower recurrence rate compared with primary repairs,1,5 but they have been associated with other types of complications, including wound infection, seromas, mesh extrusion, fistula formation, and adhesions.5-7 Infections can occur in up to 15 to 45 per cent of open mesh repairs and may also correlate with recurrence rates.1,8 This high infection rate is thought to be secondary to the large incision with which the mesh is in contact and the wide dissection necessary for adequate mesh placement. The laparoscopic technique involves access to the abdominal cavity away from the defect, avoiding placement of the mesh through a large incision, thereby reducing the probability of contamination and infection.9 It also allows
fixation of a large mesh without subcutaneous tissue dissection in patients with large hernia defects.10-12
Laparoscopic ventral hernia repair is based on the method described by Stoppa for open incisional hernia repair,4 reported to have the lowest recurrence rate. It involves posterior reinforcement of the abdominal wall with a large piece of prosthetic material based on Laplace’s law. The large surface area of the mesh allows substantial ingrowth of tissue for permanent mesh fixation, and the intra-abdominal pressure tends to hold the mesh in apposition to the posterior abdominal wall over a wide surface area.13,14
Since the first report of laparoscopic ventral hernia repair,15 numerous series have been published supporting the use of this technique. Table 21.1 summarizes the results of 2002 laparoscopic ventral hernia repairs published in the literature. We have tabulated these data and will discuss the averages from this information. Demographic data show a slightly higher predominance of females (56 per cent), with a mean age of 55 years. Fifty-six per cent of the patients were obese, with a mean body mass index (BMI) of 34 kg/m2. Consistent with previous literature, the prevalence of incisional hernias (89 per cent) is higher than for primary hernias (11 per cent).
