Limited-conversion technique: a safe and viable alternative to conversion in laparoscopic ventral/incisional hernia repair

Abstract

Background: During laparoscopic ventral/incisional hernia repair (LVIHR), conversion to conventional (open) technique is required when safe adhesiolysis is not possible, incarcerated bowel in hernial sac cannot be reduced or for repair of iatrogenic enterotomies. A formal laparotomy in these circumstances entails significant morbidity due to factors such as wound infection, prolonged immobility, and longer hospital stay.

Materials and methods: During a period between 1994 and 2007, 1,503 LVIHRs were performed at our centre following a standardized protocol by five consultants and fellows. Out of these, 6 patients had a formal laparotomy in the initial part of our experience and 26 patients had a limited conversion to facilitate completion of LVIHR. We have devised the term "limited conversion" for the procedure wherein bowel reduction/adhesiolysis/enterotomy repair was performed through a small targeted skin incision. This was followed by laparoscopic placement of intraperitoneal mesh.

Results: Conversion to an open procedure was required in 32 (2.1%) out of 1,503 LVIHR procedures. Twenty-six patients underwent a limited conversion and completion of the repair by laparoscopy. All but one of these patients had intraperitoneal placement of mesh by laparoscopic route. The wound complication rate was 3.8% (one patient), the mean hospital stay was 2.1 days, and mean operative time was 124 min.

Conclusion: Limited conversion offers a safe alternative to a formal laparotomy in patients with bowel incarcerated in hernial sacs or in patients requiring extensive bowel adhesiolysis. Patient morbidity is reduced due to the targeted skin incision whilst retaining several advantages of a minimal access approach viz. laparoscopic evaluation of the entire abdominal wall and placement of a large intraperitoneal prosthesis.