Laparoscopic Ventral Hernia Repair
Publication Date: June 1, 2016
Last Updated: March 14, 2022
Recommendations
Laparoscopic versus Open Repair
Laparoscopic ventral hernia repair has a lower rate of wound infections compared to open repair. Recurrence rates and post-operative 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 when they counsel them about surgical options. (High, Strong)
317067
Preoperative Considerations
Indications and Patient Selection
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. (Moderate, Strong)
317067
Special Considerations
Special situations such as loss of domain, presence of abdominal skin grafts or of an active enterocutaneous fistula, the need to remove previously placed prosthetic mesh, or large abdominal wall defects may represent contraindications to laparoscopic repair. (Moderate, Strong)
317067
Diagnosis
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. (Moderate, Strong)
317067
Bowel Preparation
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. (Low)
317067
Patient Position
Patient positioning should use all appropriate precautions to prevent patient injury while enabling access to the needed abdominal wall to 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. (Low, Strong)
317067
Urinary Bladder Catheter
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. (Low, Weak)
317067
Prophylactic Antibiotics
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. (Moderate, Strong)
317067
Plastic Adhesive Drape
Antimicrobial-impregnated plastic adhesive drapes are often used during LVHR, but the current literature does not support their use, as no evidence exists that they decrease surgical-site infections. (Low, Weak)
317067
Operative Technique
Abdominal Access and Trocar Placement
The location of initial abdominal access (primary port placement) for LVHR should be as far from the hernia defect and prior laparotomy incisions as possible. The ideal location for this port may be the left or right upper quadrant, but location should be modified according to the patient’s surgical history and anatomy. (Moderate, Strong)
317067
A Veress needle, open Hasson technique, or optical trocar entry may all safely be used for primary port placement during LVHR. The specific technique 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. (Moderate, Strong)
317067
Secondary port placement should be performed under direct vision and 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. (Moderate, Strong)
317067
Adhesiolysis
Adhesiolysis should be performed carefully with sharp and/or blunt dissection and sparing use of energy for hemostasis to avoid inadvertent delayed enterotomy. Use of sutures and hemostatic agents is preferable to energy application to achieve hemostasis near the bowel. (Low, Strong)
317067
The adhesiolysis should include the entire old incision. Dependent on the hernia location, the falciform and umbilical ligaments should 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. (Low, Strong)
317067
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. (Low, Strong)
317067
Measuring the Hernia Defect
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. (Moderate, Strong)
317067
Closing the Hernia Defect
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. (Low, Weak)
317067
Prosthetic Choice, Overlap and Fixation
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, considering clinical factors such as previous recurrences and obesity. (Moderate, Strong)
317067
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. (Moderate, Strong)
317067
Fixation to the bony/ligamentous portions of the pelvis should be used for defects near the symphysis. (Moderate, Strong)
317067
Fixation into the rectus muscles and lateral/posterior abdominal wall should be used with caution to avoid injury to the epigastric vessels, peripheral nerves, ureters, and retroperitoneal vascular structures. (Low, Strong)
317067
Fixation above the costal margin should be used with caution to prevent cardiac and lung injuries. (Moderate, Strong)
317067
Postoperative Management: Avoiding and Treating Problems
Pain Management
Persistent pain following laparoscopic ventral hernia repair should be treated with analgesics, anti-inflammatory medications, steroids, trigger point injection or nerve block. (Low, Strong)
317067
Seroma Management
Postoperative seroma following laparoscopic ventral hernia repair is common and should be anticipated. Asymptomatic seromas should be observed. Persistent symptomatic seromas may be aspirated under sterile conditions with a low risk of complications. Recurrent seromas after aspiration that are symptomatic should be treated with surgical drainage and excision of the seroma lining if possible. (Low, Strong)
317067
Cauterization of the hernia sac, the use of pressure dressings (such as abdominal binders), or suture closure of the hernia defect may be utilized to reduce the incidence of postoperative seroma. (Low, Weak)
317067
Postoperative Ileus
Laparoscopic ventral hernia repair is associated with a low incidence of postoperative ileus. Patients developing a postoperative ileus should be initially treated non-operatively with fluid administration, bowel rest, and/or gastric decompression. (Low, Weak)
317067
Management of Enterotomies
RECOGNIZED INTRAOPERATIVE ENTEROTOMY
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 interests. The possibility of enterotomy and management options should be discussed with the patient preoperatively. (Low, Weak)
317067
DELAYED ENTEROTOMY
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. (Low, Weak)
317067
SURGICAL-SITE INFECTIONS
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. (High, Strong)
317067
Cellulitis
Postoperative cellulitis following laparoscopic ventral hernia repair may be treated with a short course of antibiotics. (Low, Weak)
317067
MESH INFECTION
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. (Low, Strong)
317067
Recommendation Grading
Overview
Title
Laparoscopic Ventral Hernia Repair
Authoring Organization
Society of American Gastrointestinal and Endoscopic Surgeons
Publication Month/Year
June 1, 2016
Last Updated Month/Year
April 13, 2023
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
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.
Target Patient Population
Patients with ventral hernia
Inclusion Criteria
Female, Male, Adolescent, Adult, Older adult
Health Care Settings
Ambulatory, Hospital, Operating and recovery room, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Management, Treatment
Diseases/Conditions (MeSH)
D006547 - Hernia, D010535 - Laparoscopy, D006555 - Hernia, Ventral
Keywords
hernia, laparoscopy, ventral hernia