Taking the Road Less Traveled: Emergency Laparoscopic Repair of Incarcerated Ventral Hernia

BACKGROUND So far, the role of laparoscopy for the repair of incarcerated/strangulated ventral hernia remains uncertain. Data from a few case series suggest that, compared to elective laparoscopic repair, a laparoscopic approach to acutely complicated ventral hernias is not associated with an increasing rate of postoperative complications and/or hernia recurrence. In addition, the potential detrimental effect on the laparoscopic procedure given by the concomitant small bowel obstruction (SBO) has not been addressed yet. Finally, laparoscopic emergency hernia repair may represent a tremendous challenge for the surgeon that, in a safe and effective manner, should be able to perform adhesiolysis, to relieve the herniated bowel into the peritoneal cavity and to repair the wall defect in the presence of distended bowel loops. METHODS By a review of an institutional hernia database prospectively maintained since 2015, 32 patients (27 F; 5 M, mean age: 66 yrs, mean BMI: 29.5 Kg/m2) which underwent to laparoscopy surgery for acute complications of ventral hernia were identified and analyzed. All of these were referred for abdominal pain associated with the evidence of an incarcerated anterior abdominal wall hernia. After initial resuscitation, diagnostic imaging studies (including plain X-ray film of the abdomen, abdominal US scan and abdominal CT scan) were obtained. As emergency surgery was warranted, a careful selection of patients suitable for a laparoscopic approach was made. The decision-making process included the degree of the SBO, the size and the location of the hernia defect, the defect/hernia sac ratio, and the on-call surgeon’s laparoscopic skill. Conversion to open surgery, length of the procedure, length of postoperative stay, postoperative morbidity, and hernia recurrence were the main outcome measures of the study. RESULTS At laparoscopy, 15 out 32 patients (47%) had an incarcerated bowel within the defect with signs of SBO. In the remaining 17 cases, the content of the hernia sac was omentum. The procedure was completed laparoscopically in 30 patients (94%). Once the herniated bowel loop/ omentum had been repositioned in the peritoneal cavity, the hernia defect was repaired by the placement of an intra-peritoneal composite mesh. The mean size of the width and the length of defect through which incarceration occurred were respectively 3.2 and 4.6 cm. Before the placement of the mesh, the hernia defect was closed by non-absorbable interrupted sutures in 24 cases (75%). Conversion to open surgery was required in two cases only (6%), and it was due to the need to resect a nonviable bowel loop (one patient) and for dense adhesions (one patient). The mean operative time was 133 min. (range 75-250). Partial thickness small bowel tear occurred in one patient (3%) and it was repaired laparoscopically. In the course, one patient (3%) suffered from a prolonged ileus that was managed conservatively. Mean hospital stay was 2.9 days (range 1-8). After FP2 discharge, 3 patients (9%) developed a clinical seroma that resolved with conservative management. At a mean follow-up of 19 months, there have been no recurrences. CONCLUSIONS Results from this series show that in carefully selected cases a laparoscopic approach to incarcerated ventral hernia is safe and effective. Keeping an uncontaminated abdomen and respecting for the rules of minimally invasive elective repair are the keys for a safe laparoscopic mesh repair and a successful outcome