What is the best approach for managing a symptomatic painful incisional hernia in an elderly woman with a history of laparotomy (surgical incision in the abdominal wall) for sigmoidectomy (removal of the sigmoid colon) after complicated diverticulitis?

Management of Symptomatic Incisional Hernia in Elderly Woman After Sigmoidectomy

Laparoscopic repair with mesh reinforcement is the optimal approach for this patient, offering superior outcomes in recurrence rates, hospital stay, and perioperative complications compared to open repair or reassurance alone.

Why Surgical Repair is Mandatory

• Reassurance is not an option for a symptomatic painful incisional hernia, as the pain indicates compromised quality of life requiring intervention 1
• Incisional hernias after laparotomy for sigmoid resection carry a 4.6% repair rate within 5 years, with colon and rectum surgery sites having a hazard ratio of 1.2 for hernia development 2
• The burden of untreated symptomatic hernias includes progressive pain, risk of incarceration, and deteriorating quality of life 2

Laparoscopic Mesh Repair: The Evidence-Based Choice

Current evidence strongly supports laparoscopic incisional hernia repair with mesh as the optimal surgical treatment, demonstrating:

• Shorter hospital stays compared to open repair 1
• Decreased perioperative complication rates 1
• Lower recurrence rates than open techniques 1
• Acceptable outcomes even in potentially contaminated fields when appropriate technique is used 3

Why Open Repair Without Mesh is Inferior

• Open repair without mesh has historically been associated with higher recurrence rates compared to mesh-reinforced repairs 1
• Mesh reinforcement is essential regardless of approach (open or laparoscopic) to minimize recurrence risk 1, 3
• The mean hospital cost per hernia repair is €4,153, representing significant healthcare burden that can be minimized with optimal technique 2

Special Considerations for This Patient Population

History of Complicated Diverticulitis

• This patient's history of sigmoidectomy for complicated diverticulitis does not contraindicate mesh use 3
• Prosthetic repair can be safely performed even in potentially contaminated fields with appropriate technique, showing acceptable rates of infectious complications (wound infection requiring mesh removal occurred in only 2/19 patients in one series) 3
• Recurrence rates remain acceptable (15.78% in one series) even when mesh is used in patients with previous complicated diverticulitis 3

Elderly Patient Factors

• Age ≥40 years increases risk of incisional hernia development, making definitive repair with mesh even more critical 2
• The laparoscopic approach offers particular advantages in elderly patients through reduced physiological stress and faster recovery 1

Technical Approach

The laparoscopic technique should include:

• Adequate mesh overlap beyond the hernia defect margins
• Secure mesh fixation to prevent migration (critical given case reports of mesh plug migration causing bowel complications) 4
• Four or five cannula approach as standard 5

Common Pitfalls to Avoid

• Never perform open repair without mesh - this significantly increases recurrence risk 1
• Do not underestimate the importance of mesh fixation - inadequate fixation can lead to buttonhole hernia development or mesh migration 3, 4
• Avoid dismissing symptoms as minor - symptomatic hernias compromise quality of life and warrant definitive repair 1
• Be aware that mesh-related complications, while rare, can include late-onset issues such as mesh migration or adhesion to bowel 4

Expected Outcomes

• Mean follow-up data shows acceptable long-term results with mesh repair 3
• Recurrence requiring reoperation occurs in approximately 0.7% of patients within 5 years when optimal technique is used 2
• The laparoscopic approach provides superior recovery metrics including faster return to normal activities 1, 5