incisional hernia is a common long - term complication of abdominal surgery and is estimated to occur in 3% to 13% of laparotomy incisions .
however , its incidence is greater than 23% in patients who have developed an infection in the laparotomy wound .
approximately 50% of incisional hernias develop within the first 2 years after the primary operation , and 74% develop after 3 years .
approximately more than 100,000 men , women , and children in the usa undergo surgery for ventral hernia repair each year .
the recurrence rate of incisional hernia , after primary closure is high , ranging between 10% and 50% , and has been reduced to 3% to 18% after the introduction of prosthetic materials ( meshes ) in hernia repair .
nevertheless , open hernia repair can be a major operation with considerable morbidity due to mesh - related infections .
an increasing interest in laparoscopic surgery and the availability of new materials have encouraged the adoption of laparoscopic techniques in ventral hernia repair .
laparoscopic ventral hernia repair ( lvhr ) was introduced into surgical practice by leblanc and booth in 1991 .
it is based on the same physical and surgical principles as the open underlay procedure described by stoppa , rives , and wantz .
surgeons and patients have rapidly accepted laparoscopic repair for incisional and primary ventral hernia over the past decade .
lvhr is now being used with increasing frequency even for the management of patients with complex incisional hernias . with the use of the laparoscopic approach , large incisions and drain placement
can be avoided , which leads to a reduction in postoperative wound - related problems .
recent reports on this topic have supported minimal postoperative morbidity , a shorter convalescence period , and an acceptable recurrence rate . limiting factors in most studies include technical variations , limited sample size , and restricted follow - up . to date , more than 100 studies on lvhr have been published , although most of them are case series lacking control groups . recently , several studies based on large numbers of patients have been accumulated due to increasing experience .
herein , we analyze the existing literature on lvhr , in an effort to examine the optimal surgical technique , complications , and long - term results in comparison with the open ventral hernia repair ( ovhr ) .
early postoperative development of incisional hernia implies an important role of perioperative factors , such as type of incision , suture technique , wound infection , or wound dehiscence .
it is hypothesized that incisional hernias are caused by acute subclinical fascial separations in the early postoperative period .
several studies have compared different suture material , and it has been recommended that an absorbable suture be used for fascial closure , as it decreases the likelihood of infection and eventually dissolves , preventing a  saw - like  effect on the fascia , which may predispose to fascial disruption . however , more recently , 2 meta - analyses identified more incisional hernias after closure with absorbable sutures than with nonabsorbable sutures . another meta - analysis performed by van't
riet et al found no difference in incisional hernia development between slowly absorbable materials , such as pds , and nonabsorbable sutures , such as nylon .
in addition , nonabsorbable sutures were found to be associated with an increased incidence of prolonged wound pain and suture sinus formation ; therefore , the use of slowly absorbable sutures should be considered in abdominal wound closure .
late development of an incisional hernia implicates other mechanisms , such as advanced age , diabetes , malignancy , and connective tissue disorders .
however , there is evidence that the abdominal wound can weaken over the course of years and give rise to an incisional hernia . wound healing depends on a variety of cellular and molecular factors capable of inducing hemostasis , angiogenesis , inflammation , fibroplasias , and wound remodeling .
one of the major extracellular proteins involved in wound healing is collagen , with 2 main types : type i and type iii collagen .
type i collagen is found in fascia , bone , and skin , and has a high tensile strength .
type iii collagen has a lower tensile strength but increased flexibility and is found in blood vessels , smooth muscle , and organ parenchyma .
early aponeurotic wound healing is based mainly on type iii collagen , which provides the wound with little tensile strength .
therefore in the early phase , closure and healing of the aponeurosis depends largely on technical closure .
however , fascial strength increases later as type i collagen increases and forms tight intermolecular links .
it is believed that abnormalities in collagen synthesis may predispose to weak healing of the aponeurosis and progression to development of an incisional hernia . in an experimental study by dubay et al , , a fibrablast growth factor (
bfgf)-releasing rod was placed into the fascial wound and as a result a significant increase in type i collagen staining around the bfgf treated fascia was noted .
this contributed to a considerable increase in the fascia - breaking strength , and as a consequence a significant reduction in primary and recurrent incisional hernia formation rate was observed .
advances in analyzing the cellular and molecular mechanisms of the pathogenesis of incisional hernia will help in applying therapeutic agents to strengthen wound healing and prevent incisional hernia formation .
traditional primary open repair is based on suture approximation of aponeurosis on each side of the hernia defect . however , recurrence rates after this procedure range from 41% to 52% in the long term .
the introduction of prosthetic meshes in hernia repair has substantially helped in the reduction of recurrence rates .
indeed , luijendijk et al demonstrated a significant reduction in recurrence rates between primary suture repair compared with mesh repair , 43% to 24% , respectively , for first - time incisional hernia repairs .
however , the mesh repairs still require wide dissection of soft tissue , which contributes to an increased incidence of wound - related complications ( more than 12% ) . among the open repairs ,
this technique is easy , convenient , but it has a considerable morbidity rate and recurrence rate ( 8% to 27% ) . another repair option is the inlay technique , such that the mesh is sutured to the aponeurotic edges .
this technique has been used to cover large aponeurotic gaps , and it carries extremely high recurrence rates . in the extra - peritoneal underlay technique , widely known as the rives - stoppa repair , the mesh is placed retromuscularly and anterior to the posterior rectus sheath , followed by primary closure of the anterior fascia .
this technique requires limited soft tissue dissection ; therefore , it carries acceptable morbidity and recurrence rates . because there is no direct contact of mesh with the abdominal viscera ,
moreover , problems resulting from placement of the prosthesis in the subcutaneous space , such as seroma formation and wound infection , are also avoided .
the intraperitoneal underlay technique was first described by mccarthy et al in 1981 . at the beginning , they used polypropylene mesh , which was sutured to the peritoneal edge of the hernia sac .
polypropylene was gradually abandoned for intraperitoneal mesh fixation due to its trend to cause adhesions to bowel loops and was replaced by the polytetraflouoroethylene ( eptfe ) mesh or bilayer polytetrafluoroethylene and polypropylene mesh in the more recent series .
a recent study by millikan et al with this technique using full - thickness transfascial sutures in 102 patients showed a 0% recurrence rate in a median follow - up of 28 months .
nevertheless , in the majority of studies analyzing the intraperitoneal underlay technique , the recurrence rate did not surpass 10% .
although the onlay technique seems to be the most popular due to its simplicity , it carries a higher morbidity rate than the other 3 techniques .
in addition , rudmik et al performed an extensive review of the articles referring to the main techniques used in open ventral hernia repair and calculated an overall 4.5% , 8% , 14% , and 48% recurrence rate for the intraperitoneal underlay repair , the extraperitoneal underlay repair , onlay repair , and inlay repair , respectively .
the relatively high morbidity and recurrence rates of the open repair techniques prompted the development of the laparoscopic approach in an effort to improve the clinical outcome .
since the introduction of the laparoscopic approach in ventral hernia repair by leblanc and booth , the laparoscopic technique has gradually become increasingly popular worldwide , as it offers early recovery , decreased hospital stay , minimal morbidity , and low recurrence rates .
the laparoscopic technique has numerous variations of the methodology used by surgeons , although several common steps are followed by all .
the procedure starts with entering the peritoneal cavity by using a veress needle , an open hasson method , or an optical trocar allowing view of the abdominal wall layers during penetration .
three trocars are used , one 10-mm trocar and two 5-mm , which are placed as laterally as possible on the abdominal wall , so they are at an adequate distance from the hernia orifice ( figure 1 ) .
perforation of the intestine is the most serious injury associated with laparoscopic ventral hernia repair .
schematic presentation of a midline hernia defect , trocar sites , suture fixation of the mesh , and tack application points .
after adhesiolysis , the sac contents are gently reduced into the peritoneal cavity , while the peritoneal sac is left in situ .
closure of large hernia defects is recommended by franklin et al with nonabsorbable sutures , even if only a limited closure is possible .
the periphery of the hernia defect is evaluated by direct vision and palpation and is marked on the abdominal wall skin with a marker .
the carbon dioxide should be released prior to measurement , revealing the true size of the hernia defect .
the craniocaudal and lateral measurements are taken to define the size of the prosthetic mesh .
the surgeon should add 6 cm to these measurements in both directions , which provides a 3-cm overlap of the aponeurotic edges of the hernia by the mesh .
some surgeons suggest a 4-cm to 5-cm overlap , especially if the patient is morbidly obese , or if the hernia is recurrent or of large size .
the size of mesh that most closely approaches this measurement is selected for the repair .
four main types of mesh have been used : polypropylene ( prolene , ethicon , sommerville , nj , usa ) , expanded polytetrafluoroethylene ( dual mesh , gore - tex , gore medical , flagstaff , az , usa ) , composite polypropylene+polytetrafluoroethylene ( composix , cr bard , cranston , nj , usa ) , or composite polypropylene+collagen ( parietene , sofradim , trevoux , france ) . polypropylene prosthesis has been abandoned in the laparoscopic approach , because it may create adhesions with bowel loops .
it has been replaced by proceed ( ethicon ) , which is composed of polypropylene covered with oxidized regenerated cellulose ( orc ) ( table 1 ) .
the most popular prosthetic biomaterials available for incisional hernia repair eptfe = expanded polytetrafluoroethylene , ppm = polypropylene , pol = polyester , ha = hyalouronic acid , pds = polydioxanone , orc = oxidized regenerated cellulose , cmc = carboxymethyl cellulose .
gore - tex ( eptfe ) mesh has been widely used worldwide , but composix has become more popular in the last few years .
all collagen meshes have been treated to eliminate all cells and proteins other than collagen , which may evoke adverse reactions to the host .
the most popular of these meshes is surgisis ( surgisis gold , cook surgical , bloomington , il , usa ) , made of porcine small intestinal mucosa .
these meshes are mainly used to reconstruct the abdominal wall in an infected field , but they are of limited use in laparoscopic ventral hernia repair .
after selection of the appropriate - sized mesh , 4 to 6 sutures are placed on the edges of the prosthetic mesh .
the suture sites are numbered with a marker to allow easier orientation of the prosthetic mesh in the abdominal cavity .
the tailored prosthetic mesh is rolled tightly and inserted in the peritoneal cavity through the 10-mm to 11-mm trocar .
two - mm skin incisions are made in the marked points on the abdominal wall . with the help of a berci fascial closure instrument
( karl storz gmbh & co. kg , tuttlingen , germany ) or the endoclose ( autosuture ) inserted through each skin incision into the peritoneal cavity , the 2 ends of each suture are grasped and drawn outside through the skin incisions by separate passages and at different angles .
the mesh is further secured with 5-mm titanium tacks using protack ( autosuture , norwalk , ct , usa ) , the ems stapler ( ethicon ) , or the reusable salute ( cr bard ) .
lvhr achieves adequate closure of the hernia defect by using intraperitoneal mesh fixation with minimal soft - tissue dissection .
the technique has all the advantages of the laparoscopic approach , such as less postoperative pain , earlier recovery , and a shorter convalescence period than the ovhr .
moreover , the patients feel more comfortable and tolerate oral intake earlier than after the open procedure . for patients undergoing laparoscopic repair of a primary ventral hernia
however , for patients undergoing laparoscopic repair of an incisional hernia , the benefit in terms of body image is limited .
lvhr also has significant technical advantages . with this approach , minimal fascial defects , known as 
swiss cheese  defects , which may be missed during the open repair , can be identified and closed with one mesh .
in addition , by placing the mesh intraperitoneally , the intraabdominal pressure pushes upwards and holds the mesh into position .
the major debate for this type of repair is which mesh fixation technique should be used , tacks plus transfascial sutures or tacks alone .
a variety of reports are available on this type of mesh fixation , which represents the traditional technique in lvhr .
heniford et al , in a large series of 850 consecutive hernias , used an eptfe mesh that was fixed on the abdominal wall with tacks and tranfascial eptfe stitches in 97% of cases .
tacks alone were used to secure the mesh in several cases at the beginning of the study , but later this practice was discontinued . during a mean follow - up of 20.2 months ,
leblanc et al have also suggested the importance of suture anchorage at 4-cm to 5-cm anchorage intervals around the perimeter of the mesh to minimize the risk for mesh migration . in another study ,
leblanc 's group retrospectively compared 2 patient groups , one early and one late lvhr group , of 100 patients each . in a median follow - up of 36 months ,
the recurrence rate droped from 9% to 4% , which was attributed to the use of transfascial sutures and the increased mesh overlap in the more recent group .
franklin et al published their 11-year experience in 384 patients who underwent lvhr using transfascial sutures . in a median follow - up of 47.1 months ,
perrone et al recently reported their results in a group of 116 patients who had lvhr . in a median follow - up of 22 months ,
the majority of cases were performed with transfascial sutures ; however , 35% of cases were performed with tacks alone .
the 2 groups , ie , the transfascial suture group and the tack alone group , had similar recurrence rates , 9.2% and 8.5% , respectively .
in a recent large review in lvhr by cobb et al , a 3.8% overall recurrence rate was found , when transfascial sutures and tacks were used , compared with a 5.6% recurrence rate , when tacks only were used .
frantzides et al followed up 208 patients for a median period of 24 months and reported a very low 1.4% recurrence rate .
bageacu et al studied a similar group of 159 patients for a median follow - up of 49 months .
the recurrence rate was very high , 15.7% , and this was attributed by the authors to the learning curve effect : their recurrence rate decreased from 20% to 10% between the early ( 1993 to 1995 ) and the late period ( 1996 to 1998 ) of the study .
the largest study was performed by carbajo et al who followed up 270 patients for a median period of 44 months . in this study ,
et al review of the related literature , the calculated recurrence rates after the suture and tack fixation technique and the tack fixation technique were approximately equal , 4.5% and 4.4% .
therefore , it seems that the fixation technique does not really affect the final outcome in lvhr , and that the laparoscopic repair yields very low recurrence rates .
however , there is a general idea that tacks do not have the same holding strength as full - thickness abdominal sutures , and this is further supported by experimental evidence .
up to the present , no randomized prospective trial has compared the 2 fixation techniques , and therefore we can not draw any safe conclusion in this matter .
the laparoscopic approach in ventral hernia repair carries the risk of intestinal or bladder injury intraoperatively .
adhesions to the abdominal scar represent a significant problem during lvhr , with the risk of bowel injury around the neck of the hernia during dissection .
rudmik et al , in their review , calculated an overall risk of enterotomy of 2.1% .
injury of a hollow organ is a very serious event and should be recognized and treated immediately .
this should be managed with endoscopic suturing if it is limited , whereas the procedure should be converted to open in case a more extensive laceration occurs of the small bowel or the colon , or if spillage of bowel contents occurs in the abdominal cavity . in the latter case ,
if the enterotomy remains unnoticed , it may result in an acute abdominal condition and sepsis within a few hours after surgery .
the main disadvantage of the laparoscopic approach is that the hernia sac is usually retained in place , which predisposes to postoperative seroma formation .
the latter is a fluid collection inside the hernia sac , which develops in most cases . actually , in a series , systematic ultrasound examinations detected seromas in 93% of patients postoperatively .
many of these cases are not noticed by the patient , and the majority resolve without intervention .
however , some seromas persist for more than 8 weeks or cause symptoms requiring intervention , which is usually a sterile aspiration .
the incidence of symptomatic seromas according to various reports ranges from 1% to 24% . according to the carolina medical center 's experience
, only 2.6% of a large group of 860 patients with lvhr had seromas that persisted for more than 8 weeks or caused symptoms requiring intervention .
long - term complications , such as infection , do not usually develop from these fluid collections , regardless of whether they are aspirated early or allowed to persist for 8 weeks or longer .
seroma formation is a common problem after lvhr ; however , its incidence is similar to that after ovhr . despite the fact that no specific measures are available to prevent this complication , leblanc et al showed that applying a postoperative compressive bandage or wearing an abdominal binder for a couple of months after surgery may decrease clinically significant seroma formation . in lvhr ,
the mesh comes into minimal contact with the patient 's dermal flora while it is introduced intraperitone - ally .
minimal tissue dissection in the laparoscopic approach further reduces the risk of infection . despite the potential benefit of a reduction in infectious complications from lvhr , still
a percentage of patients , ranging from 0.7% to 5% in different series , may acquire infection related to the hernia repair .
the overall calculated incidence of mesh infection is 0.6% , whereas the incidence of fistula formation is 0.1% .
any associated abscesses should be drained percutaneously under computed tomography guidance , and the patient should receive systemic antimicrobial therapy .
prophylactic measures to reduce the risk of infection include efforts to minimize skin contamination at surgery , elimination of any potential sources of infection before surgery , limit the contact of mesh with the skin , and the use of antibiotic prophylaxis perioperatively . protracted pain ( more than 12 weeks ) at the sites of the transfixing sutures on the abdominal wall is not uncommon ( 1.3% to 3.3% ) .
patients with prolonged pain are initially treated with anti - iflammatory medications , or injections of local anesthetics . in case of persisitent pain , removal of the anchoring suture
however , there may be neuroma formation , which does not resolve after suture removal .
prolonged ileus may develop in a minority of patients ( 3% ) and should be treated expectantly , in - hospital , until patients can tolerate oral intake . in some patients , adhesions may form between the omentum or the intestines and the mesh at the tack sites , and this may predispose to intestinal obstruction .
exacerbation of chronic obstructive pulmonary disease may occur after the laparoscopic procedure , as a result of pneumoperitoneum .
cardiac complications may also occur in patients with preexisting cardiac disease , such as congestive cardiac failure , coronary artery disease , and other such things .
heniford et al found significant associations between recurrence and larger hernias , longer operative times , previous hernia repairs , morbid obesity , and higher complication rates .
sains et al performed an excellent meta - analysis of recent high - quality studies comparing lvhr with ovhr and they noted a trend towards lower hernia recurrence rates following the laparoscopic approach , though not achieving statistical significance . pierce et al have presented a pooled data analysis of 45 published series in lvhr , representing 5340 patients ( 4582 lvhr , 758 ovhr ) .
they demonstrated a significantly lower recurrence rate with lvhr for both the pooled ( 4.3% ) and the paired ( 3.1% ) study cohorts ( studies comparing patients who had undergone lvhr or ovhr within a given institution ) , compared with ovhr series ( 12.1% , p<0.0001 ) .
although recurrence still remains an important problem after lvhr , it does not surpass 5% to 10% in most series .
the laparoscopic technique has numerous variations of the methodology used by surgeons , although several common steps are followed by all .
the procedure starts with entering the peritoneal cavity by using a veress needle , an open hasson method , or an optical trocar allowing view of the abdominal wall layers during penetration .
three trocars are used , one 10-mm trocar and two 5-mm , which are placed as laterally as possible on the abdominal wall , so they are at an adequate distance from the hernia orifice ( figure 1 ) .
perforation of the intestine is the most serious injury associated with laparoscopic ventral hernia repair .
schematic presentation of a midline hernia defect , trocar sites , suture fixation of the mesh , and tack application points .
after adhesiolysis , the sac contents are gently reduced into the peritoneal cavity , while the peritoneal sac is left in situ .
closure of large hernia defects is recommended by franklin et al with nonabsorbable sutures , even if only a limited closure is possible .
the periphery of the hernia defect is evaluated by direct vision and palpation and is marked on the abdominal wall skin with a marker .
the carbon dioxide should be released prior to measurement , revealing the true size of the hernia defect .
the craniocaudal and lateral measurements are taken to define the size of the prosthetic mesh .
the surgeon should add 6 cm to these measurements in both directions , which provides a 3-cm overlap of the aponeurotic edges of the hernia by the mesh .
some surgeons suggest a 4-cm to 5-cm overlap , especially if the patient is morbidly obese , or if the hernia is recurrent or of large size .
the size of mesh that most closely approaches this measurement is selected for the repair .
four main types of mesh have been used : polypropylene ( prolene , ethicon , sommerville , nj , usa ) , expanded polytetrafluoroethylene ( dual mesh , gore - tex , gore medical , flagstaff , az , usa ) , composite polypropylene+polytetrafluoroethylene ( composix , cr bard , cranston , nj , usa ) , or composite polypropylene+collagen ( parietene , sofradim , trevoux , france ) . polypropylene prosthesis has been abandoned in the laparoscopic approach , because it may create adhesions with bowel loops .
it has been replaced by proceed ( ethicon ) , which is composed of polypropylene covered with oxidized regenerated cellulose ( orc ) ( table 1 ) .
the most popular prosthetic biomaterials available for incisional hernia repair eptfe = expanded polytetrafluoroethylene , ppm = polypropylene , pol = polyester , ha = hyalouronic acid , pds = polydioxanone , orc = oxidized regenerated cellulose , cmc = carboxymethyl cellulose . the clinical experience with all these types of mesh varies from country to country .
gore - tex ( eptfe ) mesh has been widely used worldwide , but composix has become more popular in the last few years .
all collagen meshes have been treated to eliminate all cells and proteins other than collagen , which may evoke adverse reactions to the host .
the most popular of these meshes is surgisis ( surgisis gold , cook surgical , bloomington , il , usa ) , made of porcine small intestinal mucosa .
these meshes are mainly used to reconstruct the abdominal wall in an infected field , but they are of limited use in laparoscopic ventral hernia repair .
after selection of the appropriate - sized mesh , 4 to 6 sutures are placed on the edges of the prosthetic mesh .
the suture sites are numbered with a marker to allow easier orientation of the prosthetic mesh in the abdominal cavity .
the tailored prosthetic mesh is rolled tightly and inserted in the peritoneal cavity through the 10-mm to 11-mm trocar .
two - mm skin incisions are made in the marked points on the abdominal wall . with the help of a berci fascial closure instrument
( karl storz gmbh & co. kg , tuttlingen , germany ) or the endoclose ( autosuture ) inserted through each skin incision into the peritoneal cavity , the 2 ends of each suture are grasped and drawn outside through the skin incisions by separate passages and at different angles .
the mesh is further secured with 5-mm titanium tacks using protack ( autosuture , norwalk , ct , usa ) , the ems stapler ( ethicon ) , or the reusable salute ( cr bard ) .
lvhr achieves adequate closure of the hernia defect by using intraperitoneal mesh fixation with minimal soft - tissue dissection .
the technique has all the advantages of the laparoscopic approach , such as less postoperative pain , earlier recovery , and a shorter convalescence period than the ovhr .
moreover , the patients feel more comfortable and tolerate oral intake earlier than after the open procedure . for patients undergoing laparoscopic repair of a primary ventral hernia
however , for patients undergoing laparoscopic repair of an incisional hernia , the benefit in terms of body image is limited .
lvhr also has significant technical advantages . with this approach , minimal fascial defects , known as 
defects , which may be missed during the open repair , can be identified and closed with one mesh .
in addition , by placing the mesh intraperitoneally , the intraabdominal pressure pushes upwards and holds the mesh into position .
the major debate for this type of repair is which mesh fixation technique should be used , tacks plus transfascial sutures or tacks alone .
a variety of reports are available on this type of mesh fixation , which represents the traditional technique in lvhr .
heniford et al , in a large series of 850 consecutive hernias , used an eptfe mesh that was fixed on the abdominal wall with tacks and tranfascial eptfe stitches in 97% of cases .
tacks alone were used to secure the mesh in several cases at the beginning of the study , but later this practice was discontinued . during a mean follow - up of 20.2 months ,
leblanc et al have also suggested the importance of suture anchorage at 4-cm to 5-cm anchorage intervals around the perimeter of the mesh to minimize the risk for mesh migration . in another study ,
leblanc 's group retrospectively compared 2 patient groups , one early and one late lvhr group , of 100 patients each . in a median follow - up of 36 months ,
the recurrence rate droped from 9% to 4% , which was attributed to the use of transfascial sutures and the increased mesh overlap in the more recent group .
franklin et al published their 11-year experience in 384 patients who underwent lvhr using transfascial sutures . in a median follow - up of 47.1 months ,
perrone et al recently reported their results in a group of 116 patients who had lvhr . in a median follow - up of 22 months , the recurrence rate was 9.3% .
the majority of cases were performed with transfascial sutures ; however , 35% of cases were performed with tacks alone .
the 2 groups , ie , the transfascial suture group and the tack alone group , had similar recurrence rates , 9.2% and 8.5% , respectively .
in a recent large review in lvhr by cobb et al , a 3.8% overall recurrence rate was found , when transfascial sutures and tacks were used , compared with a 5.6% recurrence rate , when tacks only were used .
frantzides et al followed up 208 patients for a median period of 24 months and reported a very low 1.4% recurrence rate .
bageacu et al studied a similar group of 159 patients for a median follow - up of 49 months .
the recurrence rate was very high , 15.7% , and this was attributed by the authors to the learning curve effect : their recurrence rate decreased from 20% to 10% between the early ( 1993 to 1995 ) and the late period ( 1996 to 1998 ) of the study .
the largest study was performed by carbajo et al who followed up 270 patients for a median period of 44 months . in this study ,
et al review of the related literature , the calculated recurrence rates after the suture and tack fixation technique and the tack fixation technique were approximately equal , 4.5% and 4.4% .
therefore , it seems that the fixation technique does not really affect the final outcome in lvhr , and that the laparoscopic repair yields very low recurrence rates .
however , there is a general idea that tacks do not have the same holding strength as full - thickness abdominal sutures , and this is further supported by experimental evidence . up to the present , no randomized prospective trial has compared the 2 fixation techniques , and therefore we can not draw any safe conclusion in this matter .
the laparoscopic approach in ventral hernia repair carries the risk of intestinal or bladder injury intraoperatively .
adhesions to the abdominal scar represent a significant problem during lvhr , with the risk of bowel injury around the neck of the hernia during dissection .
rudmik et al , in their review , calculated an overall risk of enterotomy of 2.1% .
injury of a hollow organ is a very serious event and should be recognized and treated immediately .
this should be managed with endoscopic suturing if it is limited , whereas the procedure should be converted to open in case a more extensive laceration occurs of the small bowel or the colon , or if spillage of bowel contents occurs in the abdominal cavity . in the latter case , mesh repair of the ventral hernia should be postponed for a second stage .
if the enterotomy remains unnoticed , it may result in an acute abdominal condition and sepsis within a few hours after surgery .
the main disadvantage of the laparoscopic approach is that the hernia sac is usually retained in place , which predisposes to postoperative seroma formation .
the latter is a fluid collection inside the hernia sac , which develops in most cases . actually , in a series , systematic ultrasound examinations detected seromas in 93% of patients postoperatively .
many of these cases are not noticed by the patient , and the majority resolve without intervention .
however , some seromas persist for more than 8 weeks or cause symptoms requiring intervention , which is usually a sterile aspiration .
the incidence of symptomatic seromas according to various reports ranges from 1% to 24% . according to the carolina medical center 's experience ,
only 2.6% of a large group of 860 patients with lvhr had seromas that persisted for more than 8 weeks or caused symptoms requiring intervention .
long - term complications , such as infection , do not usually develop from these fluid collections , regardless of whether they are aspirated early or allowed to persist for 8 weeks or longer .
seroma formation is a common problem after lvhr ; however , its incidence is similar to that after ovhr .
despite the fact that no specific measures are available to prevent this complication , leblanc et al showed that applying a postoperative compressive bandage or wearing an abdominal binder for a couple of months after surgery may decrease clinically significant seroma formation . in lvhr ,
the mesh comes into minimal contact with the patient 's dermal flora while it is introduced intraperitone - ally .
minimal tissue dissection in the laparoscopic approach further reduces the risk of infection . despite the potential benefit of a reduction in infectious complications from lvhr
, still a percentage of patients , ranging from 0.7% to 5% in different series , may acquire infection related to the hernia repair .
the overall calculated incidence of mesh infection is 0.6% , whereas the incidence of fistula formation is 0.1% .
any associated abscesses should be drained percutaneously under computed tomography guidance , and the patient should receive systemic antimicrobial therapy .
prophylactic measures to reduce the risk of infection include efforts to minimize skin contamination at surgery , elimination of any potential sources of infection before surgery , limit the contact of mesh with the skin , and the use of antibiotic prophylaxis perioperatively . protracted pain ( more than 12 weeks ) at the sites of the transfixing sutures on the abdominal wall is not uncommon ( 1.3% to 3.3% ) .
patients with prolonged pain are initially treated with anti - iflammatory medications , or injections of local anesthetics . in case of persisitent pain , removal of the anchoring suture
, however , there may be neuroma formation , which does not resolve after suture removal .
prolonged ileus may develop in a minority of patients ( 3% ) and should be treated expectantly , in - hospital , until patients can tolerate oral intake . in some patients , adhesions may form between the omentum or the intestines and the mesh at the tack sites , and this may predispose to intestinal obstruction .
exacerbation of chronic obstructive pulmonary disease may occur after the laparoscopic procedure , as a result of pneumoperitoneum .
cardiac complications may also occur in patients with preexisting cardiac disease , such as congestive cardiac failure , coronary artery disease , and other such things .
heniford et al found significant associations between recurrence and larger hernias , longer operative times , previous hernia repairs , morbid obesity , and higher complication rates .
sains et al performed an excellent meta - analysis of recent high - quality studies comparing lvhr with ovhr and they noted a trend towards lower hernia recurrence rates following the laparoscopic approach , though not achieving statistical significance .
pierce et al have presented a pooled data analysis of 45 published series in lvhr , representing 5340 patients ( 4582 lvhr , 758 ovhr ) . they demonstrated a significantly lower recurrence rate with lvhr for both the pooled ( 4.3% ) and the paired ( 3.1% ) study cohorts ( studies comparing patients who had undergone lvhr or ovhr within a given institution ) , compared with ovhr series ( 12.1% , p<0.0001 ) .
although recurrence still remains an important problem after lvhr , it does not surpass 5% to 10% in most series .
our review indicates that lvhr is a safe and effective approach to abdominal wall hernias .
the technique offers the advantages of the laparoscopic approach , ie , a short hospital stay , less postoperative pain , and early convalescence .
the procedure carries an acceptable risk of complications , a low risk of recurrence , and an excellent cosmetic result .
however , larger , long - term multicenter studies comparing the laparoscopic with the open technique are needed to establish its efficacy . for the time being , it is considered a good alternative to its open counterpart , at least in experienced hands .
 background : the purpose of this study was to analyse the surgical techniques , perioperative complications , and recurrence rate of laparocopic ventral hernia repair ( lvhr ) , in comparison with the open ventral hernia repair ( ovhr ) , based on the international literature.methods:a medline search of the english literature was performed using the term  laparoscopic ventral hernia repair .  
 further articles were found by cross - referencing the references of each main article.results:current literature on the topic suggests that lvhr is a safe alternative to the open method with the main advantages being minimal postoperative pain , a shorter convalescence period , and better cosmetic results . 
 main complications after the laparoscopic approach , such as incidental enterotomy , protracted pain , postoperative seroma , or mesh infection occur at an acceptable rate . 
 furthermore , most articles favor lvhr versus ovhr in terms of recurrence rate.conclusions:although further randomized studies are needed to draw safe conclusions in terms of complications and recurrence , lvhr is fast becoming the standard approach in the repair of abdominal wall hernias . 