Guidelines for Laparoscopic Ventral Hernia Repair

This statement was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) on Aug 2014.

David Earle, MD1, Scott Roth, MD2, Alan Saber, MD3, Steve Haggerty, MD4, Joel F. Bradley III, MD5, Robert Fanelli, MD6, Raymond Price, MD7, William S. Richardson, MD8, Dimitrios Stefanidis, MD, PhD9. SAGES Guidelines Committee

Corresponding author:

William S. Richardson, MD
Ochsner Clinic
1514 Jefferson Highway
New Orleans, LA 70121
wrichardson@ochsner.org

1 Baystate Medical Center, Tufts University School of Medicine, Springfield, MA
2 University of Kentucky College of Medicine, Lexington, KY
3 Weill Cornell Medical College, New York, NY
4 NorthShore University HealthSystem, Evanston, IL
5 Premier Surgical Associates, Knoxville, TN
6 The Guthrie Clinic, Sayre, PA
7 Intermountain Healthcare, University of Utah, Salt Lake City, UT
8 Ochsner Clinic, New Orleans, LA
9 Carolinas HealthCare System, Charlotte, NC

Preamble

The goals of ventral hernia repair are relief of patient symptoms and/or cure of the hernia with minimization of recurrence rates. While laparoscopic ventral hernia repair (LVHR) has gained popularity in recent years, there is still significant controversy about the optimal approach to ventral hernia repair. This document has been written to assist surgeons utilizing a laparoscopic approach to ventral hernia repair in terms of patient selection, operative technique, and postoperative care. It is not intended to debate the merits of prosthetic use or specific types of prosthetics.

Disclaimer

Guidelines for clinical practice are intended to indicate preferable approaches to medical problems, as established by experts in the field. These recommendations have been made based on existing data or a consensus of expert opinion when little or no data are available. Guidelines are applicable to all physicians, without regard to specialty training or interests, who address these clinical problems and are intended to indicate the preferable, but not necessarily the only, acceptable approaches. Guidelines are intended to be flexible. Given the wide range of specifics in any health care case, the surgeon must always choose the course best suited to the individual patient and the variables in existence at the moment of decision.

Guidelines are developed under the auspices of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and its various committees and approved by the Board of Governors. Each clinical practice guideline has been systematically researched, reviewed, and revised by the guidelines committee and reviewed by an appropriate multidisciplinary team. These guidelines were available for public comment for a period of 1 month prior to its finalization. The recommendations are therefore considered valid at the time of their production, based on the data available. Each guideline is scheduled for periodic review to allow incorporation of pertinent new developments in medical research, knowledge, and practice.

Methodology

A systematic literature search was performed on MEDLINE in March 2012 and was updated in October 2014. The search strategy included the following terms: Hernia, Ventral/su [Surgery] + Laparoscopy + English + Human.

The abstracts were reviewed by the assigned working group members of the SAGES guidelines committee. Duplicates, letters to the editor, and articles not involving ventral, incisional or Spigelian hernias were not generally included unless there was a direct correlation with the specific subject. Studies that compared different types of mesh were beyond the scope of this guideline and were not included.

The reviewers graded the level of evidence using the GRADE recommendations (Table 1)[1] and searched the bibliography of each article for additional articles that may have been missed during the original search. Additional relevant articles were obtained and included in the review for grading. To facilitate the review by multiple reviewers, the guideline was divided into the following topics:

  1. Laparoscopic vs. Open Repair
  2. Preoperative Considerations
  3. Operative Technique
  4. Postoperative Management: Avoiding and Treating Problems

Additional articles pertaining to specific subsections of the above topics were reviewed and graded, providing the evidence used to formulate the recommendations included in these guidelines.

I. Laparoscopic versus Open Repair

Guideline 1:

Laparoscopic ventral hernia repair, compared to open repair, has a lower rate of wound infections. Recurrence rates and postoperative pain are similar between the two techniques, during mid-term follow-up. The advantages offered by LVHR over open hernia repair in terms of decreased wound complication rates should be taken into consideration by surgeons and disclosed to patients during consultation and discussion of surgical options. (++++, strong recommendation)

Four meta-analyses [2-5], including a Cochrane systematic review [5], have assessed the comparative effectiveness of the laparoscopic and open ventral hernia repair. These studies have examined data from available comparative randomized controlled trials (RCTs) and concluded that there was no difference in recurrence rates or postoperative pain between the techniques, but significantly fewer wound infections occurred after laparoscopic hernia repair. Since the publication of this level I evidence, 3 more RCTs have been published [6-8]. The findings of these new RCTs are congruent with the results of the meta-analyses: compared to open repair, laparoscopic repair resulted in fewer surgical-site infections (SSI) and similar recurrence rates. In regards to postoperative complications, one RCT found lower rates after laparoscopic repair [6] and one found lower rates after open repair [8], and one found no difference [7]. One RCT reported less postoperative pain a year after surgery for laparoscopic repair, compared to open repair, but another reported no difference (this study noted better physical functioning after laparoscopic repair) [7]. One RCT also demonstrated a 5-day quicker return to work following laparoscopic repair [6]. The largest prospective, but not randomized, study to date (n=710) comparing quality of life after laparoscopic and open ventral hernia repair demonstrated a decrease in quality of life at 1 month after laparoscopic repair but no difference beyond 6 months [9].

Meta-analyses of available studies may be difficult to interpret because techniques, mesh types, mesh position, and fixation methods vary widely in the published literature, all of which make valid comparisons challenging. Further, while no level I evidence study to date has demonstrated any differences in recurrence rates between the two techniques, the longest average follow-up duration reported has been 35 months [8], and therefore further long-term studies are needed.{Forbes, 2009 #46}{Forbes, 2009 #46}

II. Preoperative Considerations

A. Indications and Patient Selection

Guideline 2:

Surgeons should base their decision to perform LVHR on the anticipated complexity of the operation, the resources available at their institutions, and their experience and training with this operation. Prior hernia repairs, large defect sizes, and incarcerated hernias increase the difficulty and duration of the procedure and should be taken into consideration by surgeons (++, weak recommendation)

Indications to repair a ventral hernia are symptom relief, cosmesis, and prevention of future problems related to the hernia such as pain, acute incarceration, enlargement, and skin problems [5, 10, 11]. For all hernia repairs it is important to define and align patient and surgeon goals for the operation preoperatively.

It is important to consider the size of the hernia defect when contemplating a laparoscopic approach, as larger defects generally increase the difficulty of the procedure [12]. A recently published guideline by an Italian Consensus Conference recommended caution for defects greater than 10cm but did not consider such defects as absolute contraindication [13]. On the other hand, the same group recommended that hernias with a defect size <3cm should not be approached laparoscopically [13]. This recommendation was based on expert opinion and a survey showing that less than 10% of surgeons used prosthetics in defects less than 3cm; it was, therefore, deemed “an indirect indication of a minimum size limit for laparoscopy.”[13] The present MEDLINE search of the literature did not reveal any evidence in support of this recommendation. Therefore, additional evidence is needed before a minimum size for laparoscopic repair can be defined. Reported conversion rates in the literature range between 1-14% in series with over 50 patients [11, 14-29]. Possible reasons for a higher conversion rate may include poor patient selection, severe adhesions, incarcerated hernia content impossible to reduce and/or inadequate training and expertise on the part of the surgeon [19].

Given the variation of technical ability and institutional capability, along with the gradual acquisition of experience, surgeons must use their judgment when determining whether to perform a laparoscopic or open VHR. When considering a laparoscopic approach and selecting patients, the surgeon should consider his or her own experience. There is limited evidence to indicate how expertise with laparoscopic VHR is developed; however, it appears prudent to recommend that less experienced surgeons should start with less complex cases. A study analyzing 180 cases of a prospectively collected database found a number of clinical factors that significantly increased operative time (which was used as a surrogate for laparoscopic repair complexity) [12] such as adhesiolysis and prior ventral hernia repair(s) [30]. Other factors reported in the literature that increase the complexity of LVHR include large defects (>10cm diameter), hernias in unusual locations (subxiphoid, suprapubic, flank, etc.), incarcerated hernia, hernias with small defect size but large hernia sac, obesity, bowel distention, pregnancy, and presence of ascites [10-13, 19, 31].

The aforementioned factors, which are known to increase the technical difficulty of the operation, should help guide the surgeon in selecting the appropriate patients for LVHR. The decision of whether or not to perform a LVHR should weigh the surgeon’s training and experience, as well as the institution’s capability to provide the proper equipment and supplies. As training and experience is gained, gradually more complex laparoscopic VHRs may be appropriately undertaken.

B. Special Considerations

Guideline 3:

Special situations such as loss of domain, presence of abdominal skin grafts or active enterocutaneous fistulas, the need to remove previously placed prosthetic mesh, or large abdominal wall defects may represent contraindications to laparoscopic repair. (++, weak recommendation)

In the following situations the laparoscopic approach to VHR may be problematic and associated with higher conversion rates and potentially suboptimal outcomes:

1. Working room

Sufficient working room in the abdomen must exist to perform an adequate laparoscopic repair. When a large portion of the abdominal contents is outside of the abdomen and cannot be reduced, this makes it difficult to have enough room to repair the hernia laparoscopically [32, 33].

2. Abdominal skin grafts

An abdominal skin graft overlying the hernia defect makes a proper adhesiolysis between the viscera and the posterior aspect of the graft challenging and may result in graft ischemia and necrosis, thus exposing the prosthetic, which would risk infection and the need for removal. An open approach may be therefore preferable.

3. Small defect but large hernia sac

This situation represents a scenario that may be difficult to address laparoscopically, especially if there are adhesions between the viscera and the hernia sac. The adhesions may be difficult to visualize or reach with laparoscopic instruments due to the narrow defect size or angulation required to visualize the hernia sac content through the hernia defect. Pulling on the viscera with great force can also result in inadvertent visceral injury. On the other hand, external pressure on the abdominal wall in the area of the hernia may help reduce the sac contents intra-abdominally or make them more easily visible for safe dissection and should be employed when this situation is encountered. A laparoscopic approach may be associated with a higher probability of conversion to an open approach under these circumstances.

4. Incarcerated hernia

The scenario is often present with the small defect and large sac scenario as described above. Trying to reduce acutely or chronically incarcerated viscera can result in inadvertent visceral injury. Surgeons might be able to reduce an incarcerated hernia laparoscopically by incising the neck of the hernia with a laparoscopic scissor without diathermy (expert opinion). Further, external pressure may prove very valuable. A laparoscopic approach may be attempted but will have a higher probability of being converted to an open or laparoscopic-assisted approach [34].

5. Active enterocutaneous fistula

Active enterocutaneous fistulas are generally considered a contraindication for laparoscopic hernia repair, as the current laparoscopic techniques include prosthetic mesh placement and are therefore reserved for clean and clean-contaminated cases [26, 34, 35].

C. Diagnosis

Guideline 4:

While most ventral hernias are easily diagnosed based on clinical exam, a preoperative abdominal CT scan or ultrasound may be considered for select patients with suspected ventral hernias to confirm the diagnosis or to aid the surgeon with preoperative planning. (++, weak recommendation)

Diagnosis of a ventral hernia is typically made during the history and physical examination. Imaging studies including ultrasound, computed tomography (CT) with and/or without Valsalva, and magnetic resonance imaging (MRI) can also be used for diagnosis. Imaging studies may be helpful to assess the anatomic details of a ventral hernia, augmenting the physical examination, especially when a hernia cannot be reduced, and therefore the defect cannot be palpated and measured. These situations commonly arise with small defects, obese patients, or incarceration (either acute or chronic). CT has been found to be useful in diagnosing occult hernias, multiple defects, abscess, and hematoma, as well as in differentiating incarcerated hernias from abdominal wall neoplasms [36, 37]. In a retrospective review of 146 consecutive LVHRs, 48% of patients had occult defects not detected on preoperative physical exam [38].

In one study, diagnosis of hernia recurrence after mesh repair was correct 88% of the time on physical exam and 98% of the time on CT [39]. Another study that evaluated the comparative effectiveness of dynamic abdominal sonography versus CT for the diagnosis of ventral hernias demonstrated a sensitivity of 98% and specificity of 88%, with PPV 91% and NPV 97% for the dynamic sonography, which identified hernias in a few more patients than did CT imaging [40].

Preoperative CT is also helpful in defining the abdominal wall anatomy in non-midline hernias such as those on the flanks, suprapubic or subxiphoid regions, and identifying posterior abdominal wall defects. CT scans accurately assess the relationship of the hernia to structures such as the bladder, pubic symphysis, anterior superior iliac spine, and the ribs, in addition to defining the integrity and nature of the muscles of the abdominal wall and the size of the defect. This information is useful for the surgeon when deciding on the safest point of access and where or how to anchor the mesh. Imaging data may also allow the surgeon to determine that an open or laparoscopic-assisted approach may be more appropriate [33]. CT scanning is not useful in determining the presence and character of intra-abdominal adhesions, a known factor that increases complexity of LVHR. Finally, CT cannot determine compliance of the abdominal wall or the feasibility of closing the defect and replacing all the viscera within the peritoneal cavity.

D. Bowel Preparation

Guideline 5:

Mechanical bowel preparation prior to LVHR may be useful in select cases, but additional evidence on its risks/benefits is needed before a recommendation can be provided.

Prior to LVHR, some surgeons prefer bowel preparation either routinely or selectively. Reported advantages of bowel preparation include dealing with a clean bowel in case there is an enterotomy, decompressing the GI tract to avoid bowel distension (especially if colon was contained in the hernia sac), improving the safety of intraoperative bowel handling and adhesiolysis, and avoiding a full colon in the event of a postoperative ileus (which has been reported to range between 0.8% and 20%) [11, 14, 16, 19, 23, 25, 26, 41-47]. Most authors report using mechanical preoperative bowel preparation without antibiotics. While the available evidence on the benefits and risks of bowel prep before LVHR is lacking, a recent study on pigs by Vlot et al. demonstrated increased working space after bowel preparation [48].

E. Patient Position

Guideline 6:

Patient positioning should use all appropriate precautions to prevent patient injury while enabling access to the needed abdominal wall and allow for adequate-size mesh placement and fixation. Supine position with the arms tucked will offer the most versatile position when performing LVHR. Hernias requiring lateral or posterior access should be performed with the patient in a full or partial lateral position. (++, strong recommendation)

The patient should be placed during LVHR in a safe and stable position to assure access to the hernia through operative exposure and an ergonomic working position for the surgeon and operating team. A supine position with the arms tucked at the patient’s side is the standard position for patients with midline hernias, while hernias of the flanks or posterior abdominal wall require a lateral decubitus or modified lateral decubitus position. Careful patient positioning ensures adequate working space to perform adhesiolysis and handling and fixation of the mesh.

Frequent tilting of the OR bed, Trendelenburg, and/or reverse Trendelenburg position may be need to optimize operative exposure by passively retracting the viscera out of the way, especially for large hernias or hernias located off the midline or in the subxiphoid/suprapubic location. The need for frequent position changes during LVHR makes the secure attachment, with appropriate padding of pressure points, of the patient to the OR bed imperative [11, 14, 16, 19, 23, 25, 26, 41-47].

F. Urinary Bladder Catheter

Guideline 7:

Placement of a urinary bladder catheter during LVHR should be determined based on the anticipated duration of the procedure and the location of the hernia. For LVHR near the symphysis that requires dissection and prosthetic fixation to the pubic bone, the placement of a 3-way catheter should be considered to allow drainage and easy instillation of sterile saline solution to distend the bladder, which may help in recognizing and avoiding bladder injuries. (+, weak recommendation)

Placement of a urinary bladder catheter during LVHR should be determined based on the anticipated duration of the procedure and the location of the hernia. Incisional hernias from previous lower midline incisions, particularly if the defect is near the symphysis, generally require fixation to the inferior pubic ramus. In order to properly fix the prosthetic to these structures, extraperitoneal dissection and mobilization of the bladder (similar to exposure in laparoscopic inguinal hernia repair) is necessary. Placement of a urinary bladder catheter before prepping and draping the patient allows for continuous drainage and monitoring of urine output. An empty bladder also gives additional space in the abdominal cavity, which might be essential in reducing larger hernias [16, 31, 49].If a 3-way catheter is used, the bladder can be filled with sterile saline solution while clamping the outflow temporarily, which may facilitate easier identification of the urinary bladder during dissection and may help prevent injury to the bladder. In the event of a urinary bladder injury, a distended bladder may further aid in the detection and repair of the injury.

G. Prophylactic Antibiotics

Guideline 8:

A single dose, first-generation cephalosporin (cefazolin) should be given preoperatively for LVHR. Vancomycin should be added in patients colonized with MRSA. Vancomycin or Clindamycin should be given to patients allergic to cephalosporins. (+++, strong recommendation)

The guidelines recently published jointly by the American Society of Health-System Pharmacists (ASHP), the Infectious Diseases Society of America (IDSA), the Surgical Infection Society (SIS), and the Society for Healthcare Epidemiology of American (SHEA) recommend that a single dose of a first-generation cephalosporin (cefazolin) be administered within 60 minutes prior to incisional hernia repair with a prosthetic [50]. For patients known to be colonized with MRSA, a single preoperative dose of vancomycin should be added and administered within 120 minutes prior to surgery. For b-lactam-allergic patients, clindamycin or vancomycin should be given. These recommendations are based on category A evidence [50]. Even though these guidelines were developed from the evidence included in the inguinal hernia literature, they also apply to incisional hernias, where the risk for infection seems to be higher than in inguinal hernias. Evidence exists in the open ventral hernia literature that preoperative antibiotics significantly reduce wound infection rates [51, 52]. However, data from open repair may not translate from open to laparoscopic repair, since there is a significantly lower infection rate after laparoscopic repair [2]. The large case series’ that we reviewed all used antibiotic prophylaxis [14, 18-20, 23, 25, 28, 32, 33, 42-44, 53, 54].

The most common microorganisms isolated from SSI after hernia repair are aerobic gram-positive organisms, typically Staphylococcus species, but aerobic streptococci and Enterococcus species have also been reported. MRSA is commonly found in prosthetic mesh infections [55, 56].

H. Plastic Adhesive Drape

Guideline 9:

Antimicrobial-impregnated plastic adhesive drapes are often used during LVHR, but the current literature neither supports nor discourages their use, as no evidence exists that they decrease surgical-site infection or increase complications. (+, weak recommendation)

Plastic adhesive drapes are commonly used during LVHR [28, 39, 43, 54, 57-61]. The only study examining the use of this practice for ventral hernia repair was a retrospective review of 506 laparoscopic and open ventral hernia repairs at a single institution that reported plastic adhesive drapes were used in 59.1% of the cases, mostly by the highest volume laparoscopic surgeons [60]. Proposed benefits of utilizing these types of drapes are (1) reducing contact between the prosthetic and skin and (2) securing the drapes to the patient to avoid breaks in the sterile field. Because the drapes are placed so laterally, unless they are adherent to the skin, they are at risk of lifting off the skin and exposing un-prepped portions of the abdominal wall or the operating table itself. While this study noted a perceived benefit among surgeons in terms of improving surgical draping, it failed to demonstrate a benefit in terms of infection reduction.

The use of an iodophor-impregnated plastic incise drape in abdominal surgery has been shown to lower the incidence of wound contamination but not SSI rates, and a meta-analysis in 2007 of a variety of studies and case types revealed there was no evidence that plastic adhesive drapes reduced surgical-site infection rates and some evidence that they may actually increase these rates, if the drapes were non-iodinated [62].

During LVHR, some surgeons place the prosthetic on the abdominal wall to assess prosthetic and suture anchor location. The prosthetic therefore will potentially be exposed to skin flora, the most common bacteria associated with prosthetic infection, and this practice has largely driven the concept of utilizing a plastic adhesive drape for LVHR. Prosthetic infection may be related to enterotomy, infectious disease-related medical history of the patient (particularly history of wound or prosthetic infection), existing infectious disease-related issues (eg, occult infection), wound classification (based on concomitant GI procedures, skin infection, etc.), use of prophylactic antibiotics, abdominal wall preparation, prosthetic choice, and prosthetic handling. Further complicating the issue is the fact that most reports don’t include microbiological date related to prosthetic infection, and many prosthetic infections occur after 30 days, often up to one year postoperatively.

In summary, while plastic adhesive drapes impregnated with iodine reduce wound bacterial inoculum, they have not been proven to reduce clinical infection rates. Plastic drapes incur a small additional cost and may reduce breaks in sterile technique due to the wide draping requirements of LVHR. Potential, but rare, side effects of the adhesive drape include mild skin irritation and adverse wound healing [28, 39, 43, 54, 57-61].

III. Operative Technique

A. Abdominal Access and Trocar Placement

Guideline 10:

The location of initial abdominal access (primary port placement) for LVHR should not be immediately over the hernia and should be as far from the prior incision as possible. The ideal location for the port may be the left or right upper quadrant, but location should be modified according to the patient’s surgical history and anatomy. (++, strong recommendation)

Guideline 11:

A Veress needle, open Hasson technique, and/or optical trocar entry may all safely be used for primary port placement during LVHR.  The specific technique and location used should be primarily based on the surgeon’s experience and outcomes with the technique and take into consideration the patient’s surgical history and anatomy. (++, weak recommendation)

Guideline 12:

Secondary port placement should be performed under direct vision and working ports placed as lateral from the hernia defect as possible to allow the surgeon to work in an ergonomically favorable position for adhesiolysis and placement/fixation of the prosthetic. (++, strong recommendation)

The principles of safe abdominal access for laparoscopic surgery apply to LVHR, and technical details about establishment of pneumoperitoneum can be found in the SAGES Fundamentals of Laparoscopic Surgery (FLS) program [63]. There have been no comparative data regarding techniques for establishing pneumoperitoneum specifically for LVHR, although a variety of techniques have been described in the published literature, all with low rates of complications and successful establishment of pneumoperitoneum [63-68]. Current options most commonly used for initial peritoneal access for LVHR include direct trocar insertion with an optical trocar (with or without a pneumoperitoneum with the use of the Veress needle), or an open Hasson technique. Multiple meta-analyses and randomized controlled trials with a variety of general surgical and gynecological laparoscopic procedures reveal no difference in major complication rates with direct trocar insertion without pneumoperitoneum compared to establishment of pneumoperitoneum with Veress needle prior to initial trocar insertion. Regardless of the technique, the surgeon should have adequate training and/or experience with it in similar clinical situations. Additionally, since many LVHRs are performed for midline hernias, it is recommended to access the abdomen off the midline, to avoid areas with potential adhesions of bowel. The techniques reported in the literature for LVHR are listed in Table 2.

Regarding placement location, it is desirable to have the working ports as far lateral as possible to expose midline hernias and to be able place a large piece of mesh without interference. The operation is usually accomplished using 3-5 ports. A larger port (10-12mm) is typically utilized for the insertion of the prosthetic mesh.  This port is sometimes the initial port placed with an open technique, and placed just lateral to the rectus muscle for primary midline hernias, used mostly for mesh placement, and is eventually covered by the mesh used for the repair. There are usually 3 ports placed on one side of the abdominal wall and 1-2 ports placed on the other.  Many authors report their entry techniques; however, none directly compare the techniques.  One of the largest retrospective series described placement of a Veress needle at least 10 cm away from the prior scar, preferentially 2 cm below the left costal margin in the mid clavicular line (Palmer’s point) [69]. The left upper quadrant (LUQ) is the most commonly reported initial entry site with all techniques (Table 2).

While port placement will affect ergonomics, instrument length, patient position, surgeon position, and instrument grasping will also have an effect. Since LVHR frequently has an operative field that encompasses both the upper and lower abdomen, it should be recognized that ports placed too close to the pelvis and legs may negatively impact instrument manipulation while operating in the upper abdomen [63].

B. Adhesiolysis

Guideline 13:

Adhesiolysis should be performed carefully with sharp and/or blunt dissection and sparing use of energy for hemostasis to avoid inadvertent delayed enterotomy. Clips, sutures and hemostatic agents are preferable to energy application to achieve hemostasis near the bowel. (+, strong recommendation)

Guideline 14:

The adhesiolysis should include the entire old incision. Dependent on the hernia location, the falciform and umbilical ligaments may need to be taken down and the space of Retzius dissected to identify occult hernia defects and allow adequate exposure of the abdominal wall for placement of an appropriately sized prosthetic. (++, weak recommendation)

Guideline 15:

The surgeon should inspect the bowel after adhesions are taken down as the adhesiolysis progresses and/or at the conclusion of the entire adhesiolysis to rule out any inadvertent enterotomies. (+, weak recommendation)

Safe adhesiolysis is the most challenging step of LVHR [12, 14, 24, 35, 59]. Although preoperative adhesion detection with ultrasound and cine-MRI has been shown to be accurate in 76-92% of cases, it is not used clinically with significant frequency in the United States for the purpose of estimating the quantity and/or quality of adhesions preoperatively [70, 71]. Review of the operative records can give a reasonable sense of the difficulty level of previous abdominal operations related to adhesions. Adhesions between bowel or omentum and the abdominal wall should be taken down to allow complete visualization of the defect and the abdominal wall, as well as provide an adequate area for placement of the appropriate-sized prosthetic [19]. Exposure of the entire old incision should be pursued, even if the symptomatic or palpable defect is only a small portion of the old incision, as long as the enterotomy risk of continued adhesiolysis is not high [26, 38, 59]. This might expose occult fascial defects, which occur in almost half of cases, thus allowing adequate mesh coverage of all defects and the entire old incision [38].

Enterotomy during LVHR has been reported between 1-6% and usually occurs during adhesiolysis [6, 11, 16, 19, 24, 35, 41, 59, 72]. Several maneuvers facilitate safe adhesiolysis [6, 14-16, 19, 25, 33, 35, 44, 59, 73], including the following:

  • Traction/counter-traction technique
  • Use of angled or flexible laparoscope
  • Moving the scope among ports
  • Improved exposure utilizing outside pressure on the abdominal wall, particularly for adhesions within a hernia sac
  • Meticulous sharp dissection under direct vision close to the anterior abdominal wall
  • Limited use of an energy source, particularly near the hollow viscera
  • Working in a good ergonomic position
  • Repositioning/adding ports as needed to maintain appropriate ergonomic position and access to the operative field
  • Use of instruments with appropriate length (may need longer instruments to maintain the fulcrum near the middle of the instrument shaft)
  • Avoiding too much torque on access ports during critical aspects of the adhesiolysis
  • Maintaining a clear camera image
  • Maintaining a conscious vigilance for the mucosa of the GI tract, as an enterotomy may only be visible for a fleeting moment
  • Final Inspection of the bowel to identify enterotomies

Use of an energy source for hemostasis should be kept to a minimum to avoid bowel injury [74]. It is important to recognize that as the adhesiolysis progresses, vigilance regarding the proximity of the hollow viscera, particularly in the GI tract, must be in the forefront of the surgeon’s mind. In general, bleeding near the bowel should be controlled with sutures, clips or a topical hemostatic agent rather than an energy source [74].

At the conclusion of the adhesiolysis, it is prudent to inspect the areas of the hollow viscera involved for evidence of partial thickness, full thickness, or thermal injury [6, 72, 74]. This can be accomplished for each area separately as the adhesiolysis progresses, and/or at the conclusion of the adhesiolysis.

“Anatomic adhesions” such as the falciform and umbilical ligaments may also need to be taken down to adequately expose the abdominal wall for abdominal wall exploration and/or prosthetic placement. Mobilization of the urinary bladder may also be necessary to expose the symphysis pubis and ramus pubis for mesh fixation, particularly for lower midline defects [12, 44]. This may be done with more judicious use of an energy source, compared to adhesions between the abdominal wall and the GI tract, but care must be taken to avoid injury to the urinary bladder [12]. Mobilization of the colon may be necessary for hernia defects in the lateral abdominal wall. The reader is also referred to the Fundamental Use of Safe Energy (FUSE) program developed by SAGES for additional recommendations on safe energy use during laparoscopy [74].

C. Measuring the Hernia Defect

Guideline 16:

Surgeons should measure and document the size of the hernia defect they are repairing. The total area encompassing all the defects should be measured, and surgeons should be familiar with internal and external measurement techniques for all hernia locations, as well as how to avoid common measurement errors. (++, strong recommendation)

Accurate measurement of the defect is a key to ensuring adequate mesh coverage and minimizing recurrence. There are two main approaches to measuring the defect – externally on the abdominal wall and internally within the peritoneal cavity [6, 16, 26, 44, 57]. This will in turn allow for selection of the most appropriately sized prosthetic, which should reduce the chance for a hernia recurrence [38]. If there are multiple defects, it is important to measure the total area between the rectus muscles (for midline defects) that contain the multiple defects to determine which sized prosthetic is appropriate. The craniocaudal extent of the measurement will be the distance between the most superior defect and the most inferior defect. Measurement of each defect is not necessary and may lead to underestimating the defect and prosthetic size, thus leading to increased risk of recurrence.

External Measurements

These are typically accomplished using a (spinal) needle placed through the skin, hernia sac, and/or abdominal wall near the edges of the defect and observing the needle laparoscopically to make sure the needle tip is at or adjacent to the edge of the defect [12, 75, 76]. The borders of the defect are then marked on the abdominal wall using a sterile marking pen. A sterile ruler is then used to measure the dimensions on the abdominal wall. Because the circumference of the abdominal wall is larger on the outside compared to the inside, this technique will typically overestimate the size of the defect. It is important to note that the thicker the abdominal wall, the larger the difference will be between measured and actual size of defect. Factors increasing this discrepancy include a fully insufflated abdomen, obesity, and a large hernia sac. In the setting of obesity and a large sac, the discrepancy will be greatest. Pitfalls of performing the external measurements include (1) angling the needed (either towards or away from the defect) through the abdominal wall rather than removing and re-inserting the needle when identifying the borders of the defect, and (2) performing the measurements with a fully insufflated abdomen, particularly if there is a large hernia sac. It is important to note that reducing the insufflation pressure may reduce but won’t eliminate the overestimation of defect size [44, 45].

Internal Measurements

These are accomplished laparoscopically. A variety of techniques have been employed, but the most common utilize an umbilical tape or sterile ruler [69, 73, 77-79]. The measurement tool is placed on opposite sides of the defect in two dimensions, and the size is recorded. Regardless of what is used to measure the distance, it is important to measure the distance at the proper angles to accurately determine defect size. To minimize the problem of obtaining the proper angles for measurement, two spinal needles (or spinal needle trocars) can be used by placing them through the skin, hernia sac, and/or abdominal wall, similar to the external measurement technique but placing them on opposite sides of the defect and viewing the tips at the opposite edges of the defect laparoscopically [12]. The measurement tool can then be placed adjacent to the needle tip, thus ensuring the defect is being measured at a proper angle.

Alternatively, the instrument tip (with or without the jaws open) can be useful for measuring the defect, especially when the defects are small, since the stainless steel portion of the jaws of the instrument tip usually has a known length and width. For defects larger than 4-5 cm in diameter, however, this technique may be less accurate. Additionally, because there is a fixed fulcrum, and the instrument is often approaching the defect from an angle, this method is more error prone, especially as the defect becomes larger and more elliptical in shape.

Overestimating the defect size will result in the choice of a larger prosthetic size, which may be more difficult to handle and may have more laxity, allowing it to bulge into the defect more than it would if it were placed taut [44]. The difficulty in prosthetic handling may also lead to errors in fixation, and the prosthetic can more easily sway between fixation points, due to the larger dimensions. On the other hand, a larger prosthetic is generally associated with a lower chance for hernia recurrence. Underestimating the defect size may lead to choosing a prosthetic that is too small, thus increasing the risk of hernia recurrence. While none of the current techniques are highly precise, knowledge of the inherent flaws in the measurement processes will allow surgeons to choose as appropriately sized prosthetics as possible to minimize recurrence rates and maximize ease of the operation.

D. Closing the Hernia Defect

Guideline 17:

Closure of hernia defect should be undertaken at the surgeon’s discretion, as theoretical advantages exist but have not been proven definitively by good quality comparative studies. Further evidence is needed. (++, weak recommendation)

Reasons to close the defect during LVHR prior to mesh insertion include the possibility of reduced serosa rate reduced recurrence rate, improved “abdominal wall function,” and improved abdominal wall contour postoperatively [11, 80-82]. Indeed, the international Endohernia Society guidelines for laparoscopic hernia repair recommend primary closure of the fascial defect with mesh underlay for defects of limited size [83]. In our opinion, none of these outcomes have been rigorously studied, and there is no general agreement on the definition of the term “abdominal wall function.”

Techniques of defect closure are highly variable and include a variety of suture passer techniques through a series of mini incisions through the hernia sac and/or old scar, laparoscopic techniques utilizing both intra- and extra-corporeal knot tying techniques, the use of barbed suture material, and the use of endoscopic “component separation” to assist defect closure [11, 80-82, 84-87]. When LVHR is combined with component separation, care should be taken with regards to lateral port placement after component separation, as there is an increased risk of port site hernia if ports are placed through only two layers of muscle (internal oblique and transversus abdominus) [47, 84, 85].

Palanivelu et al. reported laparoscopic, sutured closure of midline defect with mesh reinforcement of incisional hernias in 721 midline incisional hernias [11]. Mean defect size was 96cm2. Recurrence rate was 0.55% with a mean follow-up of 4.2 years. Several techniques of fascial closure have been reported including laparoscopic, open, and transfascial. Agarwal et al. reported on 29 patients with primary fascial closure using an overlapping repair with transfascial vertical mattress sutures [87]. Orenstein et al. reported a “shoelacing” technique of sequential transfascial figure of eight sutures [81].

In summary, favorable outcomes have been reported utilizing a variety of closure techniques; however, prospective and comparative data are lacking.

E. Prosthetic Choice, Overlap and Fixation

Guideline 18:

The prosthetic used during LVHR should be designed to bridge a defect in the abdominal wall and sized with appropriate overlap for the size and location of the defect (++, strong recommendation)

Guideline 19:

Fixation type and amount should be appropriate for the size, shape and location of the defect. Increased fixation strength is required as the defect becomes larger and the prosthetic/defect ratio decreases. (++, strong recommendation)

Guideline 20:

Fixation to the bony/ligamentous portions of the pelvis should be used for defects near the symphysis pubis. (+, weak recommendation)

Guideline 21:

Fixation into the rectus muscle and lateral/posterior abdominal wall should be used with caution to avoid injury to the epigastric vessels, peripheral nerves, ureters, and retroperitoneal vascular structures. (++, strong recommendation)

Guideline 22:

Fixation above the costal margin should be used with caution to prevent cardiac and lung injuries (++, strong recommendation)

Modern LVHR is generally performed by placing a prosthetic in an intra-peritoneal position [2]. Therefore, the prosthetic will contact the abdominal viscera on one side and abdominal wall on the other side. This concept has launched a large amount of ongoing research by clinicians and industry to develop a variety of absorbable and non-absorbable prosthetics for use with LVHR. It is beyond the scope of this guideline to catalog the available prosthetic choices along with all of their associated features, raw materials, and design characteristics. Rather, this guideline will focus on some general prosthetic characteristics, as well as sizing and overlap issues.

Traditionally, the LVHR technique did not include defect closure, and the prosthetic bridged the gap [34, 42, 43, 49, 88-93]. Even in cases where the defect is closed, as suggested by recent publications [11], the rate of it reopening is poorly studied, and the prosthetic may be bridging a gap at some point after repair. In almost all instances, bridging a gap with a hernia prosthetic will have the best results in terms of hernia recurrence with a permanent prosthetic [80, 81]. Therefore, for LVHR, a permanent prosthetic should generally be used [2, 6, 11-14, 16, 18, 26, 31-33, 35-39, 42, 43, 45, 47, 49, 52-54, 58, 65, 67, 68, 72, 75-79, 84, 86, 88, 89, 91-128]. There may be unique circumstances such as contaminated cases that bring the surgeon and patient to the decision to utilize an absorbable (biologic or synthetic) prosthetic to bridge a gap [56, 99, 129, 130]. Currently there are no commercially available biologic meshes on the market specifically made for the laparoscopic approach.

The optimal amount of prosthetic overlap over the defect has been poorly studied and is not known [111]. This is recognized by the Italian Laparoscopic Ventral Incisional Hernia Guidelines, which recommend a minimum of 3cm overlap but note a trend to extend to at least 5 cm overlap, especially in larger defects [13, 119, 131]. Generally, larger defects apply more stress on the fixation points of the prosthetic [13]. The more points of fixation there are, the more the tension will be distributed among them, hence the lower the tension on each individual fixation point. Additionally, as the size of the prosthetic increases, the prosthetic-area : defect-area ratio will increase, and the tension on the prosthetic fixation sites will decrease. Since all defects vary in terms of size, shape, and location, it is important that surgeons consider the total area encompassed by all defects and not base their prosthetic calculations on the largest or dominant defects [19]. In patients with an incisional hernia from a previous midline incision with multiple hernia defects, it is more useful for choosing the right-sized prosthetic to refer to the entire area as a single defect, encompassing the entire gap between the rectus muscles.

Table 3 summarizes factors that are associated with choice of prosthetic when considering recurrence as the primary outcome measure. Since there are few data available directly comparing the long-term outcomes of different prosthetics in humans, no recommendation can be made about a specific prosthetic. Selection of the prosthetic is typically based on surgeon’s experience, intra-operative handling characteristics, and the purported features associated with the prosthetic. Post-market, continuous evaluation in terms of patient-centered outcomes of all prosthetics is needed. It is technically easier to achieve the parameters listed in Table 3 to reduce recurrence rates for smaller defects, and it is relatively less important to achieve these for smaller defects. As the defect becomes larger in size, these parameters will be more important in determining recurrence rates.

Fixation of the Mesh

Fixation of a hernia prosthetic to the abdominal wall is required as part of LVHR. Controversy exists regarding the amount, strength, and type (absorbable or permanent) of fixation required [19, 41, 92, 107, 109, 127].

Currently, there are two main categories of fixation method available for use in the operating room – tacks and sutures, both of which are available in absorbable or permanent varieties. Sutures are commonly anchored to the mesh with conventional instruments in combination with a suture-passing device [19, 34, 49, 61, 92, 107, 109, 127]. Tacks are usually deployed via a mechanical device typically referred to as a “tacker” (deploys a variety of anchoring devices collectively known as “tacks”) [92, 107, 109, 112, 123]. There are human and laboratory reports utilizing fibrin-based sealant for fixation during LVHR, but the available evidence is limited. Proponents of tacks-only fixation have cited the shorter operating time, fewer skin incisions, improved cosmesis, and less acute and chronic pain as the main advantages of this approach [92, 123]. Proponents of suture-only fixation cite as advantages the lower cost and stronger attachment of the prosthetic to the abdominal wall, which may minimize recurrences. Proponents of a combination of tack and suture fixation argue that the combination method affords the advantage of maximum fixation strength and reduced operative time compared to suture or tack fixation only. In a recent prospective, randomized study that compared tack versus suture fixation of prosthetic during LVHR, suture fixation was found to be more cost-effective with less early postoperative pain and quicker return to activity than tacker fixation in patients with small-to-medium-sized defects. This study demonstrated that the two procedures were equally effective regarding recurrence rates, complications, hospital stay, chronic pain, quality of life, and patient satisfaction [123]. On the other hand, another RCT demonstrated that double-crown fixation of intra-peritoneal mesh during laparoscopic ventral hernia repair was quicker, was less painful immediately post-operative and after 3 months, and did not increase the recurrence rate at 24 months compared with sutures and one row of spiral tackers. [132]

A systematic review of 25 series that assessed the impact of mesh fixation on hernia repair outcomes did not find any differences in recurrence rates with an overall recurrence rate of 2.7 % (95 % CI [1.9–3.4 %]). This review that included thirteen trials that used both tacks and sutures, ten that used only tacks, and two that used only sutures, also failed to document a difference in abdominal wall pain experienced by patients after surgery [133]. Another review that assessed longer term outcomes (mean follow up time was 30 months) of transfascial suture versus tack fixation in over 8,000 patients found no significant difference in rates of hernia recurrence, mesh removal, or prolonged postoperative pain but noted a significantly higher rate of surgical site infection in the suture group.[112]. It should also be noted that a study that compared absorbable versus non absorbable tack fixation in 816 patients undergoing LVHR found that absorbable tack fixation of the mesh was associated with a higher risk of recurrence than non-absorbable tacks for laparoscopic mesh repair of incisional hernia with no difference in chronic pain. [134]

The location of fixation also determines the strength of attachment of the prosthetic to the abdominal wall independent of the fixation method used. Fixation into bony and ligamentous structures such as the symphysis pubis, Cooper’s ligaments, ribs, and the iliac crest are generally considered to be stronger than fixation to the muscular abdominal wall anteriorly, which in turn is stronger than fixation to the musculature of the posterior abdominal wall [127]. Further, taking down the preperitoneal fat and/or falciform ligament allows the prosthetic to oppose directly to the fascia and may provide stronger attachment as compared to fixating it to undissected preperitoneal fat or the falciform ligament.

Regardless of the method of fixation to the anterior abdominal wall, and considering midline defects only, fixing the prosthetic lateral to the rectus muscles may result in a better mechanical advantage, compared to fixation in the middle of the rectus muscle. Another advantage of fixation lateral to the rectus muscles is reducing the risk of epigastric vessel injury that can result in hemorrhage and/or hematoma, both a potential etiology for re-operation, postoperative pain, and hernia recurrence due to prosthetic displacement.

Challenges of Anatomic Location of the Hernia

Fixation above the costal margins should not be accomplished with sutures placed between the ribs. Further, while fixation with tacks may be feasible, it should generally be avoided to prevent lung or cardiac injury or injuries to the neurovascular bundles running along the inferior surface of each rib [135]. There are multiple known cases of cardiac tamponade after ventral and hiatal hernia repair, mostly from tacking devices but also from sutures near the pericardium. The majority of these cases resulted in mortality. If fixation is deemed necessary near the pericardium, the diaphragm should be grasped and tented away from the pericardium, and a superficial suture, rather than a tack should be carefully placed. An alternative and safer option to prosthetic fixation above the costal margin during LVHR is to allow the prosthetic to drape over the diaphragm superiorly without fixation, and add full thickness fixation to the edge of the costal margin and xiphoid process away from the edge of the prosthetic. There is almost always a small rim of either abdominal wall or scar tissue that will accommodate sutures. Even in the absence of this rim of tissue, full thickness fixation could be placed at the closest area near the defect, and circumferentially around the defect, in addition to increasing the prosthetic:defect size ratio.

Defects near the symphysis pubis should be fixed to the public bone, pubic ramus, and Cooper’s ligaments. Whether or not this is performed with permanent or absorbable fixation will depend on how close the defect is the pubic symphysis, the size of the defect, and the body mass index (BMI). Increased fixation strength is required for larger BMI, larger defects, and defects closer to the symphysis [31, 77]. Permanent fixation can be placed with a tacking device, bone anchor, or suture material utilizing intra-or extra-corporeal knotting techniques with anticipated equal effectiveness, although there is no data comparing these methods.

Fixation to the lateral and posterior abdominal wall should avoid injury to retroperitoneal structures such as peripheral nerves, major vascular structures, and the ureters. As with inguinal hernia repair, avoiding fixation inferior to the iliopubic tract will help avoid injury to the lateral femoral cutaneous nerve, genitofemoral nerve, and the external iliac vessels. Likewise, placing deep fixation superior to the iliopubic tract puts the ilioinguinal and iliohypogastric nerves at risk for injury. Proper exposure of these areas often requires lateral patient position that requires proper planning during the prepping and draping process.

Increasing fixation strength and amount and prosthetic size (particularly as it relates to the defect size) will likely lower recurrence rates. In summary, method of fixation depends on the size, shape, and location of the hernia defect, as well as patient-related factors such as previous known response to a particular prosthetic, collagen disorders, and body habitus to name a few. Increased fixation strength occurs with increasing the prosthetic:defect size ration, depth of fixation, and fixation into bony/ligamentous structures Increased fixation strength is generally required for larger defects.

IV. Postoperative Management: Avoiding and Treating Problems

A. Pain Management

Guideline 23:

Persistent pain following laparoscopic ventral hernia repair should be treated with analgesics, anti-inflammatory medications, steroids, trigger point injection or nerve block. (+, weak recommendation)

There is a high degree of patient variability regarding postoperative pain, and clinical experience has shown that acute postoperative pain is more than expected for other laparoscopic procedures [5, 13, 42, 126, 136-139], but should be resolved by 4-6 weeks. The incidence of protracted pain ranges from 1.6-28% [5, 6, 11, 14, 16, 19, 25, 26, 31, 32, 41, 43, 49, 53, 69, 73, 75, 77, 78, 90, 93, 97, 103, 113, 121, 128, 140-142]. Non-steroidal anti-inflammatory medications have been utilized with success in the management of persistent postoperative pain. Elastomeric pumps, continuously delivering bupivacaine in the hernia sac above the mesh, have been shown to reduce pain scores after LVHR, but the clinical significance of this is uncertain. Successful relief of protracted pain has also been demonstrated with injections of either a local anesthetic or a combination of local anesthetic and steroid. Intercostal nerve blocks have also been successfully employed in the treatment of chronic postoperative pain. Excision of sutures or tacks has been reported to result in pain resolution in some circumstances [5, 11, 16, 25, 26, 33, 43, 53, 61, 69, 75, 76, 78, 93, 140-144].

B. Seroma Management

Guideline 24:

Seroma following laparoscopic ventral hernia repair should be expected. There are no measures proven to reduce this occurrence. Most seromas spontaneously resolve. (+, weak recommendation)

Guideline 25:

Treatment of seroma for symptoms may be necessary and if aspiration is not helpful excision of the sac surrounding the seroma may be necessary. (+, weak recommendation).

Seroma formation following laparoscopic hernia repair should be considered an expected outcome, rather than a complication.[145] Seromas that are persistent for prolonged periods of time or those that are symptomatic may require treatment. Clinically detectable seromas in the early postoperative period have been reported to occur in the majority of patients. Seromas resolve spontaneously in most cases but can be persistent at least 2.6% of the time.[19]

Aspiration of a postoperative seroma carries a potential risk of bacterial inoculation. However, retrospective studies have shown up to 29% symptomatic necessity to aspirate seromas with low risk.[146] Similarly, conservative seroma management is not associated with an increased risk of infectious complications. Chronic seromas that fail to respond to aspiration and/or drainage have been reported to be successfully treated with removal of the sac surrounding the seroma.[147]

Techniques for prevention of seromas may be employed to minimize the likelihood of developing this persistent problem but results of these techniques are mixed. There are few studies showing that cauterization of the hernia sac may decrease seroma formation.[29] The use of abdominal pressure dressings and abdominal binders may improve pain but may not reduce seroma occurance. [148, 149]. Laparoscopic defect closure at the time of laparoscopic ventral hernia repair have been suggested to help restore the contour of the abdominal wall, reduce abdominal bulging as well as reduce seroma formation. Reports of this technique have demonstrated a mixed benefit upon seroma formation with a low or absent incidence of clinically significant seromas,[150-152] however abdominal wall contouring may be a benefit.

C. Postoperative Ileus

Guideline 26:

Patients developing a postoperative ileus should be initially treated non-operatively with fluid administration, bowel rest, and/or gastric decompression.  (+, Weak recommendation)

There is no uniformly accepted definition of prolonged ileus following laparoscopic ventral hernia repair, but “ileus” or “prolonged ileus” is reported to be between 0% and 20%, with the average incidence 4.0%. [13, 15, 19, 26, 27, 31, 32, 42, 43, 49, 69, 75, 77, 100, 113, 126, 153-157]. Only 4 articles reported an incidence greater than 5%. The study that reported a 20% incidence, defined it as “ileus >24 hours”, but given the short time duration may have included patients with postoperative nausea and vomiting due to general anesthesia. In addition, this study had very few patients (n=29) and it was reflective of the early learning curve of the authors with the procedure [155] One study reported a 10.7% incidence, but this was only for cases where there was a recognized intraoperative enterotomy.[153] This same study also reported an incidence of 100% for patients reoperated on with unrecognized enterotomy that also had a 40% mortality rate. The unrecognized enterotomy patients were not included in the overall group determining incidence ileus.[153] The article with a 9.5% incidence only had 21 patients in the series, making it difficult to extrapolate to a larger group of patients. [154]

The cause of postoperative ileus after LVHR has been speculated to be due to suture site pain, adhesiolysis, duration of procedure, or bowel manipulation.[158-160] Additionally, it has been noted that ileus may be a sign of something more serious that requires operative intervention, such as a mechanical small bowel obstruction or unrecognized/delayed enterotomy. CT scan is useful to distinguish among these diagnoses. [13, 15] The incidence of mechanical bowel obstruction after LVHR is reported to be 0.5-3%. [13, 15]

All of the articles reporting on postoperative ileus either did not mention the treatment, or stated that all patients resolved their ileus with non-operative management, such as limiting oral intake, intravenous fluids, and/or nasogastric decompression. Of all the articles reviewed, there was only a single case reported for operative therapy of what was described as “an ileus due to a volvulus”, that had resolved at re-laparoscopy where an adhesiolysis among bowel loops resulted in enterotomy, laparotomy, and infected mesh requiring explantation 6 months postoperatively. [136]

D. Management of Enterotomies

1. Recognized Intraoperative Enterotomy

Guideline 27:

The laparoscopic repair of a hernia with a permanent synthetic mesh immediately following an enterotomy should be carefully considered in light of a paucity of evidence and the potential for infectious complications. A tailored approach may include open or laparoscopic techniques and should be based upon operative findings, degree of contamination, surgeon experience, and patient best interest. The possibility of enterotomy and management options should be discussed with the patient preoperatively. (+, weak recommendation)

Adhesiolysis involving the GI tract is frequently required during hernia repair. Although enterotomies occur infrequently, immediate recognition and treatment is essential to successful outcomes. The incidence of enterotomy during hernia repair has been reported to be 12.8% in a prospective study [161]. A review of enterotomies occurring LVHR reported a ≤ 2% incidence [35] and was corroborated by the findings of another series reporting on >2000 patients [153]. Other systematic reviews of the available literature, however, suggest that the risk of enterotomy is higher after laparoscopic repair than it is after open [162]. Injuries to the small intestine occur much more commonly than injuries to the colon [35] Recognized intestinal injuries may be approached by any of several methods under two main categories: 1) enterotomy repair with hernia repair (lap or open, with or without permanent mesh) and 2) enterotomy repair with delayed hernia repair (lap or open, short or long delay, permanent mesh) [118, 163]. When delayed hernia repair is chosen, it is usually accomplished either before or after the proliferative wound healing phase (ie, within the first week) [118, 163] or after 6-8 weeks postoperatively, respectively.

Successful outcomes have been reported following enterotomy repair and concomitant implantation of a permanent synthetic mesh. This practice is further corroborated by animal and human studies documenting the safety and efficacy of placing permanent synthetic mesh at the time of other clean-contaminated procedures such as colectomy, creation of a stoma, and gastric bypass [164-176]. Some of these studies were prospective randomized trials that resulted in lower hernia rates without mesh-related complications, but most represent small case series. Successful outcomes have also been reported following laparoscopic or open repair of the visceral injury followed by primary closure of the hernia defect. This approach will obviously eliminate the risk for mesh-related complications but carries a high risk for hernia recurrence.

Other published studies argue against the use of prosthetic mesh in a contaminated field [177-181]. Choi and colleagues analyzed 33,832 patients of the NSQIP database and compared postoperative occurrences following VHRs using mesh in clean-contaminated and contaminated wounds. They found that the odds of having one or more postoperative occurrences were significantly greater in clean-contaminated and contaminated cases using mesh when compared with clean cases, with odds ratios of 3.56 (3.25-3.89) and 5.05 (1.78-12.41), respectively. There was a significantly increased risk of superficial SSI (2.53), deep SSI (3.09) and organ/space SSI (6.16), wound disruption (4.41), pneumonia (4.43), and sepsis (4.90) for clean-contaminated cases. Both clean-contaminated and contaminated cases had an increased risk of septic shock (5.82 and 26.74, respectively). In addition, they found a significantly increased odds ratio of complications in patients who underwent VHR with mesh (3.56) or without mesh (2.52) in clean-contaminated cases and recommended avoidance of the use of mesh at any level of contamination. Nevertheless, this study included mainly open repairs, did not report the rate of mesh infection or need for mesh removal, and did not specify how many enterotomies with limited contamination occurred. In another series of 1071 open and laparoscopic VHRs with concomitant intra-abdominal procedures using a variety of prosthetics and techniques, factors associated with the need for mesh explantation were analyzed [180]. The authors found that 4.6% (4/88) of VLHR cases with polytetrafluoroethylene (PTFE) prosthetics had to be removed a median of one year postoperatively, two of which were for infection, and two of which were not defined. The authors concluded permanent prosthetic mesh should be used with caution when incisional hernia repair is performed with concomitant intra-abdominal procedures. In a retrospective study of 1124 elective incisional hernia repairs utilizing a variety of techniques and prosthetics, unplanned enterotomy or bowel resection due to incarceration or other factors during ventral hernia repair (for LVHR it was 7.9%) was found to increase postoperative complications, return to the operating room, risk of enterocutaneous fistula, length of hospitalization, and operative time [181]. This study, however, did not analyze the impact of prosthetic usage in this setting.

One of the primary concerns during LVHR is what to do when a small enterotomy occurs during adhesiolysis with limited contamination of the operating field. There has been no study to date that has directly addressed this concern. There is a moderate amount of anecdotal and retrospective evidence and clinical experience with a variety of management strategies, all of which can be safe and effective, but the evidence suggests that caution should be exercised when permanent mesh is used in contaminated fields.

2. Delayed Enterotomy

Guideline 28:

Patients with a delayed intestinal injury following laparoscopic hernia repair should be returned to the operating room for bowel repair, resection, and/or GI tract diversion. Consideration should be given to mesh removal at the time of re-operation. (+, strong recommendation)

A delayed or missed enterotomy is considered an enterotomy that manifests clinically during the early postoperative period and was either unrecognized or not present during the operation. This group would include intraoperative enterotomies that were unrecognized, thermal injuries that were not full thickness at the time of occurrence, and enterotomies that occurred in the postoperative period due to fixation devices such as mechanical tacks. Intestinal injuries occurring following LVHR represent one of the most serious complications reported and result in significantly poor patient outcomes [35, 153]. The management of these injuries should include abdominal exploration with intestinal repair, control of contamination, and mesh removal (expert opinion). Anecdotal reports of intestinal injury repair without the removal of the mesh exist but this practice cannot be recommended in the absence of convincing evidence. Management should be guided by sound surgical judgment. The decision to remove mesh should serve the patient’s best interest and be guided by the patient’s physiologic status, extent of contamination, and type of mesh.

3. Surgical-Site Infections

Guideline 29:

Laparoscopic ventral hernia repair leads to fewer surgical-site infections compared to open repair and should therefore be considered in patients with higher risk for infection. (+++, strong recommendation)

Compared with open ventral hernia repair, LVHR has been reported to lead to fewer superficial and deep SSI in several randomized clinical trials. In a recent multicenter randomized trial of laparoscopic versus open ventral incisional hernia repair in 162 patients, SSI were significantly fewer in the laparoscopic group (2.8% versus 21.9%; OR, 10.5;95% CI, 2.3-48.2;p=0.003) [7]. A meta-analysis of eight randomized trials comparing laparoscopic and open incisional or ventral hernia repair with mesh revealed that laparoscopic hernia repair was associated with decreased surgical-site infection rates (relative risk, 0.22;95% CI, 0.09-0.54) and a trend toward fewer infections requiring mesh removal [2].

4. Cellulitis

Guideline 30:

Postoperative cellulitis following laparoscopic ventral hernia repair may be treated with a short course of antibiotics. (+, weak recommendation)

Cellulitis following LVHR occurs infrequently, in 2-4% of patients [89]. The etiology of cellulitis overlying the surgical mesh has been postulated to occur as a result of either infection or an inflammatory response related to the prosthetic mesh.

Successful resolution of cellulitis with administration of antibiotics has been demonstrated in retrospective studies. Fever of unknown origin has been reported following LVHR in 5-60% of patients, all of who responded to antibiotics without sequelae [34]. The etiology of these postoperative febrile events is not clear.

Prophylactic antibiotics are administered prior to laparoscopic hernia repair to reduce the risk of wound and mesh infections [182]. A single retrospective study demonstrated a reduction in abdominal wall cellulitis overlying the postoperative seroma in patients who were administered postoperative antibiotics for seven days following laparoscopic hernia repair [58]. There was no difference in mesh infections between those patients receiving preoperative antibiotics and those receiving a longer duration of antibiotics.

5. Mesh Infection

Guideline 31:

Infected prosthetic mesh salvage may be successful with a combination of antibiotics, percutaneous drainage, and/or wound debridement with negative pressure wound therapy placement. When this approach fails (or in septic patients), mesh excision should be undertaken. (+, weak recommendation)

Prosthetic mesh infections following laparoscopic hernia repair represent a significant source of morbidity. Numerous strategies for dealing with mesh infection have been reported. Successful management strategies include antibiotics, local wound care with mesh salvage, and mesh removal with or without concomitant hernia repair [56, 183, 184]. Successful laparoscopic removal of the infected mesh and placement of a biologic mesh has been described, but long-term outcomes were not reported [184]. The strategy minimizes the risk of bowel incarceration into the hernia defect and allows for a temporary hernia repair. Numerous retrospective case series have described the successful treatment of mesh infections after laparoscopic hernia repair with open mesh excision. In the largest series of laparoscopic hernia repairs, the incidence of mesh infection was less than 1% [19]. One patient was successfully treated with mesh salvage utilizing a strategy including antibiotics and percutaneous drainage. This patient remained free of hernia recurrence and infection 2 years following treatment.

There are no prospective trials specifically evaluating the management of patients with infected mesh following laparoscopic incisional hernia repair. The decision to attempt mesh salvage should be based on the incorporation of the mesh and the patient’s clinical condition. Expert opinion suggests that meshes that incorporate with encapsulation are less likely to be successfully treated with conservative measures and typically require removal. Further, septic patients require immediate removal of the infected prosthetic. The single-stage management of patients with infected mesh has been described utilizing techniques of component separation with the adjunctive use of biologic mesh materials. Further, mesh salvage has been successful in a small case series with wound debridement and the use of a negative pressure wound therapy (VAC).

Summary of Recommendations

Guideline 1:

Laparoscopic ventral hernia repair, compared to open repair, has a lower rate of wound infections. Recurrence rates and postoperative pain are similar between the two techniques, during mid-term follow-up. The advantages offered by LVHR over open hernia repair in terms of decreased wound complication rates should be taken into consideration by surgeons and disclosed to patients during consultation and discussion of surgical options. (++++, strong recommendation)

Guideline 2:

Surgeons should base their decision to perform LVHR on the anticipated complexity of the operation, the resources available at their institutions, and their experience and training with this operation. Prior hernia repairs, large defect sizes, and incarcerated hernias increase the difficulty and duration of the procedure and should be taken into consideration by surgeons (++, weak recommendation)

Guideline 3:

Special situations such as loss of domain, presence of abdominal skin grafts or active enterocutaneous fistulas, the need to remove previously placed prosthetic mesh, or large abdominal wall defects may represent contraindications to laparoscopic repair. (++, weak recommendation)

Guideline 4:

While most ventral hernias are easily diagnosed based on clinical exam, a preoperative abdominal CT scan or ultrasound may be considered for select patients with suspected ventral hernias to confirm the diagnosis or to aid the surgeon with preoperative planning. (++, weak recommendation)

Guideline 5:

Mechanical bowel preparation prior to LVHR may be useful in select cases, but additional evidence on its risks/benefits is needed before a recommendation can be provided.

Guideline 6:

Patient positioning should use all appropriate precautions to prevent patient injury while enabling access to the needed abdominal wall and allow for adequate-size mesh placement and fixation. Supine position with the arms tucked will offer the most versatile position when performing LVHR. Hernias requiring lateral or posterior access should be performed with the patient in a full or partial lateral position. (++, strong recommendation)

Guideline 7:

Placement of a urinary bladder catheter during LVHR should be determined based on the anticipated duration of the procedure and the location of the hernia. For LVHR near the symphysis that requires dissection and prosthetic fixation to the pubic bone, the placement of a 3-way catheter should be considered to allow drainage and easy instillation of sterile saline solution to distend the bladder, which may help in recognizing and avoiding bladder injuries. (+, weak recommendation)

Guideline 8:

A single dose, first-generation cephalosporin (cefazolin) should be given preoperatively for LVHR. Vancomycin should be added in patients colonized with MRSA. Vancomycin or Clindamycin should be given to patients allergic to cephalosporins. (+++, strong recommendation)

Guideline 9:

Antimicrobial-impregnated plastic adhesive drapes are often used during LVHR, but the current literature neither supports nor discourages their use, as no evidence exists that they decrease surgical-site infection or increase complications. (+, weak recommendation)

Guideline 10:

The location of initial abdominal access (primary port placement) for LVHR should not be immediately over the hernia and should be as far from the prior incision as possible. The ideal location for the port may be the left or right upper quadrant, but location should be modified according to the patient’s surgical history and anatomy. (++, strong recommendation)

Guideline 11:

A Veress needle, open Hasson technique, and/or optical trocar entry may all safely be used for primary port placement during LVHR.  The specific technique and location used should be primarily based on the surgeon’s experience and outcomes with the technique and take into consideration the patient’s surgical history and anatomy. (++, weak recommendation)

Guideline 12:

Secondary port placement should be performed under direct vision and working ports placed as lateral from the hernia defect as possible to allow the surgeon to work in an ergonomically favorable position for adhesiolysis and placement/fixation of the prosthetic. (++, strong recommendation)

Guideline 13:

Adhesiolysis should be performed carefully with sharp and/or blunt dissection and sparing use of energy for hemostasis to avoid inadvertent delayed enterotomy. Clips, sutures and hemostatic agents are preferable to energy application to achieve hemostasis near the bowel. (+, strong recommendation)

Guideline 14:

The adhesiolysis should include the entire old incision. Dependent on the hernia location, the falciform and umbilical ligaments may need to be taken down and the space of Retzius dissected to identify occult hernia defects and allow adequate exposure of the abdominal wall for placement of an appropriately sized prosthetic. (++, weak recommendation)

Guideline 15:

The surgeon should inspect the bowel after adhesions are taken down as the adhesiolysis progresses and/or at the conclusion of the entire adhesiolysis to rule out any inadvertent enterotomies. (+, weak recommendation)

Guideline 16:

Surgeons should measure and document the size of the hernia defect they are repairing. The total area encompassing all the defects should be measured, and surgeons should be familiar with internal and external measurement techniques for all hernia locations, as well as how to avoid common measurement errors. (++, strong recommendation)

Guideline 17:

Closure of hernia defect should be undertaken at the surgeon’s discretion, as theoretical advantages exist but have not been proven definitively by good quality comparative studies. Further evidence is needed. (++, weak recommendation)

Guideline 18:

The prosthetic used during LVHR should be designed to bridge a defect in the abdominal wall and sized with appropriate overlap for the size and location of the defect (++, strong recommendation)

Guideline 19:

Fixation type and amount should be appropriate for the size, shape and location of the defect. Increased fixation strength is required as the defect becomes larger and the prosthetic/defect ratio decreases. (++, strong recommendation)

Guideline 20:

Fixation to the bony/ligamentous portions of the pelvis should be used for defects near the symphysis pubis. (+, weak recommendation)

Guideline 21:

Fixation into the rectus muscle and lateral/posterior abdominal wall should be used with caution to avoid injury to the epigastric vessels, peripheral nerves, ureters, and retroperitoneal vascular structures. (++, strong recommendation)

Guideline 22:

Fixation above the costal margin should be used with caution to prevent cardiac and lung injuries (++, strong recommendation)

Guideline 23:

Persistent pain following laparoscopic ventral hernia repair should be treated with analgesics, anti-inflammatory medications, steroids, trigger point injection or nerve block. (+, weak recommendation)

Guideline 24:

Seroma following laparoscopic ventral hernia repair should be expected. There are no measures proven to reduce this occurrence. Most seromas spontaneously resolve. (+, weak recommendation)

Guideline 25:

Treatment of seroma for symptoms may be necessary and if aspiration is not helpful excision of the sac surrounding the seroma may be necessary. (+, weak recommendation).

Guideline 26:

Patients developing a postoperative ileus should be initially treated non-operatively with fluid administration, bowel rest, and/or gastric decompression.  (+, Weak recommendation)

Guideline 27:

The laparoscopic repair of a hernia with a permanent synthetic mesh immediately following an enterotomy should be carefully considered in light of a paucity of evidence and the potential for infectious complications. A tailored approach may include open or laparoscopic techniques and should be based upon operative findings, degree of contamination, surgeon experience, and patient best interest. The possibility of enterotomy and management options should be discussed with the patient preoperatively. (+, weak recommendation)

Guideline 28:

Patients with a delayed intestinal injury following laparoscopic hernia repair should be returned to the operating room for bowel repair, resection, and/or GI tract diversion. Consideration should be given to mesh removal at the time of re-operation. (+, strong recommendation)

Guideline 29:

Laparoscopic ventral hernia repair leads to fewer surgical-site infections compared to open repair and should therefore be considered in patients with higher risk for infection. (+++, strong recommendation)

Guideline 30:

Postoperative cellulitis following laparoscopic ventral hernia repair may be treated with a short course of antibiotics. (+, weak recommendation)

Guideline 31:

Infected prosthetic mesh salvage may be successful with a combination of antibiotics, percutaneous drainage, and/or wound debridement with negative pressure wound therapy placement. When this approach fails (or in septic patients), mesh excision should be undertaken. (+, weak recommendation)

Table 1: GRADE system for rating the quality of evidence for SAGES guidelines

Quality of Evidence

Definition

Symbol Used

High qualityFurther research is very unlikely to alter confidence in the estimate of impact

++++

Moderate qualityFurther research is likely to alter confidence in the estimate of impact and may change the estimate

+++

Low qualityFurther research is very likely to alter confidence in the estimate of impact and is likely to change the estimate

++

Very low qualityAny estimate of impact is uncertain

+

GRADE recommendations based on the quality of evidence for SAGES guidelines
StrongIt is very certain that benefit exceeds risk for the option considered
WeakRisk and benefit well balanced, patients and providers faced with differing clinical situations likely would make different choices, or benefits available but not certain regarding the option considered

Adapted from Guyatt et al[1]

Table 2. Methods for establishing pneumoperitoneum and port placement

First authorYearnAccess TechniqueLocation of initial entry siteTotal number and location of ports
Bageacu[54]

2002

159

Veress needle“…as far as possible from the hernia (typically on the left anterior axillary line in the case of a midline hernia.”3-4, location not mentioned
Ben-Haim[15]

2002

100

Open technique“…as laterally from the hernia site as possible.”No number mentioned. Location “according to hernia site”
Berger[136]

2002

150

Open technique“as far from the hernia as possible and mainly in the subcostal area.”5-7; location “laterally on both sides”
Chowbey[42]

2000

200

Veress, open technique“…unless contraindicated, the Veress needle is inserted in the left subcostal region…” If Veress insertion unsuccessful, open technique used.3; left abdominal wall laterally
Franklin[26]

2004

384

Veress, “very rarely” open technique“…usually from a nonmidline location…”3-4; “lateral to rectus muscles”
Frantzides[100]

2004

208

Optical viewing trocar“…as far as possible from the hernia defect…”Number “depended on the difficulty of the subsequent adhesiolysis”. Location not mentioned
Gillian[44]

2002

100

Optical viewing trocarLeft subcostal3-4; left abdomen, right side as needed
Heniford[19]

2003

850

Open Hassan 650, Veress 200“usually just inferior to the tip of the eleventh rib.”Number “as needed”; location lateral abdominal wall for midline defects, dependent of defect location for non-midline defects
LeBlanc[32]

2000

100

Open Hassan, Veress, Optical viewingNot mentionedNo number; Location “…as far laterally as possible…”; scope port should be on same side as surgeon.
Mizrahi[185]

2003

231

VeressLeft subcostal3; :location “along an imaginary semilunar line connecting the epigastrium with the left lower quadrant”
Morales-Conde[33]

2004

140

Subcostal veress, Optical viewingLeft subcostalNumber and location  of secondary ports not mentioned
Moreno Egea[102]

2004

90

VeressNot mentioned“The position of the trocars depended on the size, location, and number of abdominal wall defects, usually three in a line along the left flank.”
Palanivelu[11]

2007

721

Not mentionedNot mentioned3; epigastric port for scope, two lateral ports for working instruments; occasionally 3 ports on all one side laterally
Perrone[16]

2005

116

Veress 88%, Open technique 12% (only when Veress needle failed)“…well away from the hernia, typically in either subcostal area or the lateral abdomen lateral to the rectus sheath.”No number mentioned; Additional ports placed …”as far from the hernia defect and as lateral as possible.”
Rosen[27]

2003

100

Veress, open technique, or optical trocar“…far from the defect…”3-5; “…as far laterally as possible.”
Saber[142]

2008

174

Open techniqueRight or left upper quadrant and “away from the hernia”2-3; “…away from the hernia defects to allow adequate surgical manipulations.”
Sharma[69]

2011

1,242

Veress“…at least 10cm away from the hernia/previous scar. The most preferred site … was Palmer’s point – a point 2cm below the left costal margin in the midclavicular line.”3, more for larger hernias; “Ports were placed in the form of an arc around the hernial defect…”
Toy[28]

1998

144

Veress, Open“…away from the hernia defect and any abdominal incisions…”“…number and position are individualized.” All placed “…as far laterally as possible.”
Ujiki[23]

2004

100

Veress – primary herniaOpen – previous abdominal surgeryLateral, “on the side of the abdomen farthest from the hernia defect”No number mentioned; Lateral, “on the side of the abdomen farthest from the hernia defect”
Yavuz[25]

2005

150

Veress – primary and trocar site herniasOpen – all other incisional herniasLeft hypochondrium3, with more “as necessary”; “…as laterally as possible…”, usually all on the left side

Table 3 Factors associated with higher vs. lower recurrence rates. Prosthetic: defect size ratio refers to a continuum dependent on the size of the hernia.

Recurrence rate higherRecurrence Rate lower
Low Prosthetic:Defect size ratioLarge Prosthetic:Defect size ratio
Prosthetic does not reach lateral to rectus musclesProsthetic reaches lateral to rectus muscles
Overlap from defect edges <3cm [13]Overlap from defect edges >5cm

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This document was prepared and revised by The SAGES Guidelines Committee.

  • David Earle, MD. Baystate Medical Center, Tufts University School of Medicine, Springfield, MA
  • Scott Roth, MD, University of Kentucky College of Medicine, Lexington, KY
  • Alan Saber, MD, Weill Cornell Medical College, New York, NY
  • Steve Haggerty, MD. NorthShore University HealthSystem, Evanston, IL
  • Joel F. Bradley III, MD. Premier Surgical Associates, Knoxville, TN
  • Robert Fanelli, MD. The Guthrie Clinic, Sayre, PA
  • Raymond Price, MD. Intermountain Healthcare, University of Utah, Salt Lake City, UT
  • William S. Richardson, MD. Ochsner Clinic, New Orleans, LA
  • Dimitrios Stefanidis, MD, PhD. Carolinas HealthCare System, Charlotte, NC

This statement was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) on Aug 2014.

SAGES publication #VHERNIA

For more information please contact:

SOCIETY OF AMERICAN GASTROINTESTINAL ENDOSCOPIC SURGEONS (SAGES)
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Los Angeles, CA 90064
Tel:
(310) 437-0544
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(310) 437-0585
Email:
publications@sages.org

Guidelines for clinical practice are intended to indicate preferable approaches to medical problems as established by experts in the field. These recommendations will be based on existing data or a consensus of expert opinion when little or no data are available. Guidelines are applicable to all physicians who address the clinical problem(s) without regard to specialty training or interests, and are intended to indicate the preferable, but not necessarily the only acceptable approaches due to the complexity of the healthcare environment. Guidelines are intended to be flexible. Given the wide range of specifics in any health care problem, the surgeon must always choose the course best suited to the individual patient and the variables in existence at the moment of decision.

Guidelines are developed under the auspices of the Society of American Gastrointestinal and Endoscopic Surgeons and its various committees, and approved by the Board of Governors. Each clinical practice guideline has been systematically researched, reviewed and revised by the guidelines committee, and reviewed by an appropriate multidisciplinary team. The recommendations are therefore considered valid at the time of its production based on the data available. Each guideline is scheduled for periodic review to allow incorporation of pertinent new developments in medical research knowledge, and practice.