Overview
Definition:
Hybrid ventral hernia repair, also known as lap-open or laparoscopically-assisted open repair, is a surgical technique combining laparoscopic visualization and dissection with an open approach for mesh placement
It is typically employed for complex or recurrent ventral hernias where traditional open repair carries significant morbidity, or where pure laparoscopy is challenging.
Epidemiology:
Ventral hernias, including incisional and umbilical hernias, are common, with an incidence of up to 20% after abdominal surgery
Recurrence rates vary widely based on repair technique, mesh type, and patient factors, often necessitating complex reconstructions like hybrid approaches.
Clinical Significance:
Hybrid ventral hernia repair offers potential advantages by leveraging the benefits of laparoscopy (e.g., better visualization of the defect and posterior sheath, reduced fascial dissection) while mitigating the challenges of pure laparoscopic mesh fixation in complex cases, aiming to reduce recurrence and complication rates for patients.
Indications
Primary Indications:
Large or complex ventral/incisional hernias
Recurrent hernias after previous repairs
Hernias with significant fascial defects or loss of domain
Patients where pure laparoscopic repair is deemed technically difficult or unsafe.
Contraindications:
Absolute contraindications are rare but include severe uncorrectable coagulopathy, active infection at the surgical site, or inability to tolerate pneumoperitoneum
Relative contraindications may include extensive adhesions making laparoscopic dissection perilous.
Patient Selection:
Careful patient selection based on hernia characteristics, comorbidities, and surgeon expertise is crucial
A multidisciplinary approach may be considered for very complex cases involving abdominal wall reconstruction.
Preoperative Preparation
Assessment:
Thorough patient history, physical examination, and review of previous surgical records are essential
Imaging studies, such as CT or MRI, are critical for defining hernia dimensions, sac contents, and the integrity of the abdominal wall musculature.
Imaging:
CT scan with intravenous contrast is the gold standard for assessing hernia morphology, identifying potential incarcerated contents, and evaluating the width of the defect
MRI may be useful for assessing fascial integrity and rectus muscle atrophy.
Optimization:
Nutritional optimization, smoking cessation, and aggressive management of comorbidities like diabetes and obesity are paramount
Preoperative antibiotic prophylaxis is standard
Bowel preparation may be considered for cases with potential bowel involvement.
Procedure Steps
Laparoscopic Phase:
Creation of pneumoperitoneum
Insertion of trocars at strategic locations
Mobilization of the hernia sac and dissection of the abdominal contents from the posterior sheath and mesh bed
Identification and mobilization of the edges of the defect
If necessary, lysis of adhesions and reduction of contents.
Transition To Open:
After adequate laparoscopic dissection and preparation of the defect, a limited open incision is made, typically overlying the hernia defect, to facilitate mesh placement and fixation
The size of the open incision is minimized.
Mesh Placement And Fixation:
Placement of a large, appropriately sized prosthetic mesh (e.g., dual-mesh or component separation with mesh) is performed via the open incision
The mesh should cover the defect with adequate overlap onto the healthy fascia
Fixation can be achieved using sutures, tacks, or fibrin glue, depending on the mesh type and surgeon preference
The posterior sheath may be repaired laparoscopically prior to mesh placement.
Closure:
The abdominal wall layers are closed meticulously
If component separation was performed, the anterior fascia is closed
The skin is closed in layers
Drains are typically not used.
Postoperative Care
Pain Management:
Multimodal pain management is crucial, involving oral analgesics, and potentially regional anesthesia or patient-controlled analgesia (PCA) in the immediate postoperative period
Early mobilization is encouraged.
Monitoring:
Close monitoring for signs of infection, seroma, hematoma, mesh-related complications, and bowel obstruction
Vital signs, fluid balance, and pain levels should be assessed regularly.
Activity Restrictions:
Patients are advised to avoid heavy lifting and strenuous activity for typically 6-8 weeks
Gradual return to normal activities is guided by pain and recovery progress
The type of mesh used may influence the duration of restrictions.
Complications
Early Complications:
Seroma formation
Hematoma
Wound infection
Mesh infection
Injury to intra-abdominal organs (bowel, bladder)
Pneumothorax or subcutaneous emphysema from trocar insertion.
Late Complications:
Chronic pain
Mesh migration or shrinkage
Hernia recurrence
Fistula formation
Adhesions leading to bowel obstruction
Granulomatous reactions to mesh.
Prevention Strategies:
Meticulous surgical technique to minimize tissue trauma and bleeding
Appropriate mesh selection and fixation
Prophylactic antibiotics
Close postoperative monitoring and prompt management of any suspected complications
Adequate mesh overlap
Consideration of component separation for large defects.
Prognosis
Factors Affecting Prognosis:
Recurrence rates are influenced by hernia size, patient comorbidities (obesity, diabetes), prior surgical history, mesh type, and fixation technique
Successful hybrid repair generally leads to good long-term outcomes with low recurrence rates.
Outcomes:
The hybrid approach aims to achieve durable hernia repair with reduced morbidity compared to pure open techniques and potentially better mesh fixation than pure laparoscopic techniques in select cases.
Follow Up:
Routine follow-up is recommended at 2-4 weeks postoperatively, and then at 3-6 months, and annually thereafter, to monitor for recurrence and complications
Patients should be educated on self-examination for potential recurrence.
Key Points
Exam Focus:
Understand the rationale behind choosing a hybrid approach over pure open or laparoscopic methods
Differentiate indications and contraindications
Key steps include laparoscopic mobilization and open mesh placement
Complications are similar to both open and laparoscopic mesh repairs.
Clinical Pearls:
A limited open incision is key
it should not be a full open laparotomy
Meticulous dissection in the laparoscopic phase is crucial for a clean mesh bed
Ensure adequate mesh overlap onto healthy fascia for optimal recurrence prevention.
Common Mistakes:
Making the open incision too large, negating the benefits of laparoscopy
Inadequate laparoscopic dissection leading to poor mesh coverage or mesh fixation issues
Underestimating the complexity of large or recurrent hernias, leading to inappropriate technique selection.