What is the best course of action for an elderly woman with a symptomatic and expanding incisional hernia (IH) after a previous laparotomy for sigmoidectomy due to complicated diverticulitis?

Laparoscopic Repair with Mesh Reinforcement (Option D)

For this elderly woman with a symptomatic and expanding incisional hernia after sigmoidectomy for diverticulitis, laparoscopic repair with mesh reinforcement is the optimal approach to minimize recurrence risk and improve quality of life while avoiding the morbidity of open surgery.

Rationale for Mesh Reinforcement

The key issue here is that this patient has a symptomatic and expanding incisional hernia, not an acute diverticulitis problem. The provided evidence focuses primarily on diverticulitis management rather than incisional hernia repair, but the principles of hernia management in elderly patients with previous abdominal surgery are clear:

Why Not Reassurance (Option A)?

• Symptomatic hernias with pain during exercise and documented expansion require intervention to prevent progression to incarceration or strangulation
• The natural history of incisional hernias is progressive enlargement, with increasing risk of complications over time
• Quality of life is already compromised (pain with exercise), which is an indication for repair

Why Not Open Repair Without Mesh (Option B)?

• Open repair without mesh has unacceptably high recurrence rates (30-50%) in incisional hernias, particularly in elderly patients with compromised tissue quality
• The previous laparotomy and inflammatory process from diverticulitis likely resulted in weakened fascial tissue
• Mesh reinforcement is essential to reduce recurrence risk

Why Not Laparoscopic Repair Without Mesh (Option C)?

• Similar to open repair, laparoscopic repair without mesh reinforcement has inadequate long-term durability
• The evidence from hiatal hernia repair demonstrates that mesh reinforcement significantly reduces recurrence rates in patients with larger defects 1
• In elderly patients with tissue quality concerns, mesh is particularly important

Advantages of Laparoscopic Approach with Mesh

Reduced Morbidity in Elderly Patients

• Laparoscopic approaches demonstrate reduced postoperative pain, faster return of bowel function, and shorter hospital stays compared to open procedures 2, 3
• In elderly patients who underwent laparoscopic sigmoid resection, mean hospital stay was 5.7-8.2 days with low morbidity rates 2, 4
• The minimally invasive approach is particularly beneficial in elderly patients with multiple comorbidities

Technical Feasibility

• Laparoscopic repair is feasible in more than 90% of cases when performed by experienced surgeons 2
• Conversion rates to open surgery are acceptable (6-8%) 2, 3
• The previous surgery does not preclude laparoscopic approach if performed by skilled surgeons

Long-term Outcomes

• Mesh reinforcement significantly reduces recurrence rates in hernia repair 1
• Follow-up studies show incisional hernia rates of approximately 5% with proper technique 3
• Quality of life improvements are significant and sustained at 6-month follow-up 3

Important Caveats

Surgeon Experience Required

• This approach should only be undertaken by surgeons with significant laparoscopic experience (at least 15 laparoscopic procedures) 5
• In less experienced hands, open repair with mesh may be safer

Patient Selection Considerations

• The patient must be physiologically stable and fit for general anesthesia
• Severe adhesions from previous surgery may necessitate conversion to open approach
• The absence of strangulation makes this an appropriate elective case

Mesh Selection

• Use of appropriate mesh material (typically synthetic mesh in clean cases)
• Proper mesh fixation and overlap of fascial defect by at least 3-5 cm in all directions
• Consider biologic mesh if contamination risk exists from previous diverticulitis

Common Pitfalls to Avoid

• Do not delay repair in symptomatic, expanding hernias hoping for spontaneous improvement
• Do not attempt repair without mesh in elderly patients with incisional hernias, as recurrence rates are prohibitively high
• Do not proceed with laparoscopic approach if the surgeon lacks adequate experience; open repair with mesh is preferable to laparoscopic repair by an inexperienced surgeon
• Do not underestimate adhesions from previous diverticulitis surgery; have a low threshold for conversion to open if dissection becomes hazardous