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Page 6 of 9 Jani. Mini-invasive Surg 2018;2:14 I http://dx.doi.org/10.20517/2574-1225.2018.08

Table 3. Outcomes of follow-up
Outcomes Data, n (%)
Overall morbidity 22 (7.9%)
Seroma 13 (4.7%)
Chronic pain 5 (1.8%)
Recurrence 2 (0.72%)
Mesh bulge/eventration 1
Mesh infection/rejection Nil

and take interrupted stitches . This may increase the risk of suture granuloma, infection or cosmetic
[16]
dissatisfaction . We prefer to suture the defect intracorporeally with the knots placed extracorporeally at
[17]
the two ends.

Measuring the defect preoperatively in the resting supine position allows us to select an adequately sized
mesh for placement, allowing a minimum of 5 cm overlap of the edges of defect. Literature on the subject
reveals that different centers select the mesh size depending on the original defect or the closed defect .
[16]
However the consensus is that whichever way the defect is measured, there should be an overlap over the
fascial edges of the defect of at least 5 cm in all directions.

Smoking was observed in almost a fifth of our patients while co-morbidities like diabetes mellitus (DM) and
chronic obstructive pulmonary disease (COPD) were seen in less than 10%. COPD is a relative contra-indication
for laparoscopic repair due to the possibility of retention of carbon dioxide during surgery. However, all our
patients were well controlled with pre-operative bronchodilators and nebulization to minimize the risks during
the immediate post-operative period. Smoking, DM and COPD are also considered as risk factors for post-
operative infection and recurrence [18-20] . However, other authors do not consider them as contributory factors in
recurrence after umbilical hernia repair . The average BMI in our series was 27 kg/m , indicating that we had a
2
[21]
larger proportion of obese patients. Obesity is a risk factor for the occurrence of incisional hernia as well as
[22]
recurrence after laparoscopic repair [23,24] . We reported operating times separately for para-umbilical hernias
and incisional hernias as the fascial defect sizes would be different for both of these ventral midline hernias
and hence, time taken for closure of defects would also be different. Our reported timings are in accordance
with what is reported in literature [15,25] .

Intra-operative bowel injury occurred in five of our patients. This is in keeping with the rates reported in
literature [6,26] . All the patients were being operated for incisional hernia, the bowel injured was small intestine
and all the injuries occurred during sharp adhesiolysis. In 4 of the patients, the injuries were seromuscular
in nature while 1 was a full thickness enterotomy. All the injuries were repaired intracorporeally with 3-0
polyglactin 910 and the surgery was completed as planned. The practice of proceeding with the IPOM
repair in presence of small bowel enterotomy without gross peritoneal contamination is also reported by
other authors . In around 13% of our patients with incisional hernias, the fascia was thinned out or there
[5]
were multiple “Swiss-cheese” type of defects where the fascial sutures would not hold. Though the defect
sizes would vary, we considered the hernia to be of the size of the original scar and the mesh was selected
accordingly. Hence, if even a part of the original scar was intact with multiple “Swiss cheese” defects in
the remaining, the entire scar was reinforced with a mesh. In these cases, we opted for a bridging repair
without closure of the fascia, a practice supported by literature [27,28] . Such bridging repairs are known to give
rise to post-operative bulging of the mesh, even eventration of the mesh into the defect, as seen in 1 of our
patients [15,29] .

Average hospital stay in our series was around 2 days. In general, laparoscopic repair is associated with a
shorter hospital stay than open repairs of ventral hernias . Seroma formation was seen in around 5% of
[26]