Chapter 2 Laparoscopic Ventral Hernia Repair—Standard 
1 Surgical Anatomy
The laparoscopic repair of ventral hernia borrows from the open technique espoused by Rives and Stoppa. It maintains the tenets of large mesh overlap with transabdominal fixation of the prosthetic. In a standard laparoscopic ventral herniorrhaphy, the biomaterial is placed intraabdominally in juxtaposition to the underlying viscera; therefore, a tissue-separating mesh is required. Traditionally, the hernia defect is bridged with mesh; however, some authors have described reapproximating the midline by closing the defect with transabdominal sutures.
In a laparoscopic ventral hernia repair, the mesh is placed in an insufflated abdominal cavity. Ideally, there is a slight degree of tension on the mesh at the completion of the repair. The mesh does not lie flush against the underside of the abdominal wall. Rather, it transects the abdominal space, so that when the abdominal cavity is desufflated, the mesh will not occupy the hernia sac (Fig. 2-1).
There has been a lot of debate in the literature regarding the approach for ventral herniorrhaphy. Length of stay, postoperative pain, and operative times are essentially similar between the open and laparoscopic techniques in experienced hands. However, the laparoscopic technique consistently demonstrates significant reductions in wound and mesh infections. For this reason alone, the laparoscopic repair of ventral hernias should be the preferred approach when applicable.
2 Preoperative Considerations
3 Operative Steps
1 Patient Positioning
For the majority of patients with defects in the midline, supine positioning with the arms tucked works well. The pressure points at the elbow and wrist should be padded (Fig. 2-2). For larger patients, the arm sleds may be required. In patients with defects off the midline or lumbar defects, a bump may be placed under the hip on the side of the hernia, or a true lateral position may be necessary with the aid of a bean bag.
2 Gaining Abdominal Access
Abdominal entry can be the most difficult step in the patient who has undergone multiple abdominal operations. Selecting the location for entry can be challenging because many of these patients have had numerous abdominal incisions. The upper quadrant at the tip of the eleventh rib is generally a safe place to gain access even in such cases. The side of entry should avoid previous incisions. For example, in the patient with an open cholecystectomy incision, the left upper quadrant should be chosen.
Once initial entry into the abdominal cavity is achieved, at least one and preferably two additional trocars are placed laterally on the side of entry. Typically one can be placed above the initial site once pneumoperitoneum has been initiated, and an additional one can be inserted inferiorly with care not to be too close to the iliac crest. Two trocars are placed on the opposite side to provide additional viewing perspective for adhesiolysis and aid in retraction (Fig. 2-3).
