Most Common Late Complication After Laparoscopic Repair of Lower Abdominal Incisional Hernia
Adhesions are the most common late complication following laparoscopic repair of a large lower abdominal incisional hernia in a patient with a history of multiple cesarean sections. 1
Pathophysiology and Risk Factors
Adhesions develop as a natural consequence of the healing process after any abdominal surgery, but are particularly common following:
- Multiple previous abdominal surgeries (such as 4 cesarean sections)
- Laparoscopic mesh placement in the intraperitoneal position
- Large incisional hernias requiring extensive dissection
In this patient's case, the combination of multiple cesarean sections and the subsequent laparoscopic hernia repair significantly increases the risk of adhesion formation. According to the World Journal of Emergency Surgery guidelines, adhesions account for 13.7% of late small bowel obstructions after surgical procedures 1.
Clinical Presentation of Adhesion-Related Complications
Patients with adhesion-related complications typically present with:
- Abdominal pain
- Nausea and vomiting
- Abdominal distension
- Signs and symptoms of bowel obstruction
Other Late Complications After Laparoscopic Hernia Repair
While adhesions are the most common late complication, other important late complications include:
Mesh migration - Found in a smaller percentage of cases but can lead to serious complications including erosion into adjacent structures 2
Wound failure/hernia recurrence - Occurs in approximately 3.5% of cases at 41-month follow-up after laparoscopic repair 3
Bowel obstruction - Directly related to adhesion formation, occurs in about 0.6% of laparoscopic repairs requiring reoperation 4
Fistula formation - Less common but serious complication that can occur when mesh erodes into bowel
Comparison of Options in the Question
A. Adhesions - Most common late complication (seen in up to 96% of patients undergoing subsequent laparoscopic procedures after IPOM) 2
B. Fistula - Less common late complication
C. Mesh migration - Occurs in a minority of cases (reported in only 2 out of 29 patients in one study) 2
D. Wound failure - While recurrence does occur (3.5-12% depending on technique), it is less common than adhesion formation 3
Prevention Strategies
To reduce adhesion-related complications:
- Careful surgical technique during the initial repair
- Proper mesh selection and positioning
- Omental interposition between mesh and bowel when possible 5
Management of Adhesion-Related Complications
When adhesion-related complications occur:
- Early diagnostic imaging is essential
- Laparoscopic adhesiolysis may be considered in selected patients
- Conversion to open surgery may be necessary in cases of dense adhesions 1
The high rate of adhesion formation (96% of cases) makes this the correct answer among the options provided, with mesh migration, fistula formation, and wound failure occurring less frequently.