Why is wound failure not the most common late complication following laparoscopic repair of a large lower abdominal incisional hernia?

Incisional Hernia is Not the Most Common Late Complication Following Laparoscopic Repair

Trocar-site hernia, not wound failure, is the most common late complication following laparoscopic repair of large lower abdominal incisional hernias. 1

Understanding Complications in Laparoscopic Incisional Hernia Repair

Laparoscopic repair of incisional hernias has become increasingly popular due to several advantages over open repair, including:

• Lower readmission rates (16.2% vs 19.3%) 2
• Fewer reoperations for complications (7.0% vs 12.5%) 2
• Decreased length of hospital stay 3
• Less postoperative pain 3
• Lower recurrence rates for defects between 2-6 cm 2

Why Wound Failure is Not the Primary Late Complication

While wound failure is a significant mechanism for incisional hernia formation after open surgery 4, it is not the predominant late complication following laparoscopic repair of large lower abdominal incisional hernias. Instead, trocar-site hernia (TSH) emerges as the most common late complication in the laparoscopic approach.

Trocar-Site Hernia: The Primary Late Complication

The World Society of Emergency Surgery (WSES) guidelines specifically identify trocar-site hernia as a significant complication of laparoscopic surgery with an incidence of 0.1-1.0% 1. This complication occurs at the sites where trocars were placed during the laparoscopic procedure.

Risk factors for trocar-site hernia include:

• Use of trocars 10 mm or larger in size 1
• Midline placement of trocars 1
• Single incision laparoscopic surgery (SILS) technique 1

Other Potential Complications After Laparoscopic Repair

While trocar-site hernia is the most common late complication, other complications may occur:

1. Bowel obstruction: Occurs at twice the rate in laparoscopic repair (0.6%) compared to open repair (0.3%) 2
2. Mesh-related complications: Including adhesions, erosion, or infection 1
3. Recurrence: Though less common than with open repair, still occurs in 0-9% of laparoscopic repairs 5
4. Surgical site infections: These typically occur earlier (median 23 days) but can present up to 90 days post-surgery 6

Prevention of Trocar-Site Hernias

The WSES guidelines provide specific recommendations to prevent trocar-site hernias:

1. Use smaller trocars when possible: "We recommend using the smaller trocar size appropriate for the procedure" 1
2. Place trocars off-midline: "We recommend using an off-midline location when possible" 1
3. Close fascial defects: "We suggest closing the fascial defect caused by the trocar placement when trocars of 10 mm or of larger sizes are used" 1
4. Avoid SILS when possible: "We recommend conventional laparoscopic procedures over single incision laparoscopic surgery (SILS) due to a higher risk of incisional hernia with the SILS technique" 1

Clinical Implications

Understanding that trocar-site hernia, rather than wound failure, is the most common late complication has important implications for surgical technique and patient follow-up:

• Surgeons should pay particular attention to trocar placement and closure
• Follow-up should extend to at least 90 days to adequately detect wound-related complications 6
• Patients should be educated about the signs of trocar-site hernia development

Conclusion

When performing laparoscopic repair of large lower abdominal incisional hernias, surgeons should be most vigilant about preventing trocar-site hernias through proper technique, appropriate trocar size selection, and meticulous fascial closure at trocar sites ≥10 mm.