Hybrid ventral hernia repair: technique and results

Open and laparoscopic approaches to ventral hernia repair are generally exclusive of each other. However, select patients with difficult hernias may benefit from combined open/laparoscopic hybrid techniques to avoid dissection of large subcutaneous flaps. Seven patients underwent combined laparoscopic and open approaches for ventral hernia repair. Records were reviewed for technical details, demographics, hernia and mesh characteristics, and postoperative outcomes. Two hybrid techniques were used: (1) initial laparoscopic approach converted to open adhesiolysis followed by totally laparoscopic mesh fixation and (2) open repair and adhesiolysis with laparoscopic-assisted mesh fixation. In the first approach, after conversion to open adhesiolysis, mesh with four quadrant sutures was placed intraabdominally. Pneumoperitoneum was re-established, and the mesh was fixed laparoscopically with sutures and tacks in standard fashion. For the second hybrid approach, after hernia reduction and adhesiolysis, mesh was anchored with sutures placed at 3-4 cm intervals with a Reverdin needle and further secured posteriorly with a hernia tacker over 180A degrees circumference. Prior to tying the contralateral transfascial sutures, two 5-mm laparoscopic ports were placed lateral to the mesh under direct vision on the opposite side. Once the facial sutures were tied, pneumoperitoneum was established, and the contralateral side of mesh was tacked laparoscopically. Mean patient age was 65 years and BMI 38. Mean defect size was 10.6 cm x 8.3 cm and mean mesh size was 25 cm x 19 cm. Operative time was 318 min (210-405 min). Hospital stay was 5 days (4-7 days). Morbidity was 57 % including one deep wound infection and a chronic sinus requiring reoperation. There were no hernia recurrences with average follow-up of 15 months (3-63 months). Hybrid laparoscopic and open techniques may be used in obese patients with difficult incisional hernias requiring open adhesiolysis. Further studies need to be done to better delineate hernia characteristics of patients that may benefit from this approach.