Most Common Late Complication Following Laparoscopic Repair of Large 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 multiple cesarean sections.
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) 1
- Laparoscopic mesh placement for hernia repair 2
- Large incisional hernias requiring extensive dissection 3
The patient's history of multiple cesarean sections significantly increases her baseline risk for adhesion formation. When combined with the laparoscopic hernia repair using intraperitoneal mesh, this creates an ideal environment for adhesion development.
Evidence Supporting Adhesions as the Most Common Late Complication
According to Praxis Medical Insights, adhesions account for 13.7% of late small bowel obstructions after surgical procedures, with adhesions being the third most common cause of late small bowel obstruction in a large study of 2325 patients 1.
A 2019 study by Chirurgia found that adherences to the mesh were present in 96% of patients who underwent subsequent laparoscopic procedures after intraperitoneal onlay mesh (IPOM) ventral hernia repair 2. This demonstrates the near-universal nature of adhesion formation following this procedure.
Clinical Presentation of Adhesion-Related Complications
Patients with adhesion-related complications typically present with:
- Intermittent abdominal pain
- Symptoms of partial bowel obstruction
- Nausea and vomiting
- Abdominal distension 1
Other Potential Late Complications (Less Common)
Mesh Migration (Option C)
While mesh migration can occur as a late complication, it is less common than adhesions. The 2019 Chirurgia study found mesh migration in only 2 out of 29 patients who underwent subsequent laparoscopic procedures after IPOM repair 2.
Wound Failure/Recurrence (Option D)
Recurrence rates following laparoscopic incisional hernia repair are relatively low. A 2021 study in BJS Open reported significantly lower recurrence rates for laparoscopic repair compared to open repair, particularly for defects between 2-6 cm 4. Recurrence rates were reported at only 3.5% at 41-month follow-up in another study 5.
Fistula Formation (Option B)
Fistula formation is a rare but serious complication. The risk is minimized with proper surgical technique and appropriate mesh selection. The 2008 study by the Journal of the American College of Surgeons reported no fistula formation in their series of patients undergoing laparoscopic adhesiolysis and mesh repair for recurrent incisional hernias 5.
Prevention Strategies
To reduce the risk of adhesion formation:
- Careful surgical technique with minimal tissue trauma
- Proper mesh positioning
- Omental interposition between mesh and bowel when possible 6
- Consideration of adhesion barriers in high-risk patients
Conclusion
Based on the available evidence, adhesions (Option A) represent the most common late complication following laparoscopic repair of large lower abdominal incisional hernia in a patient with multiple cesarean sections.