Incisional hernias are a frequent complication of abdominal surgery, particularly after midline laparotomy. When a patient presents with massive intra-abdominal adhesions from previous surgeries, laparoscopic repair becomes technically challenging due to limited workspace, increased risk of bowel injury, and difficulty in mesh placement.

Despite these challenges, laparoscopic repair using a two-port technique has emerged as a feasible minimally invasive option. This approach reduces operative trauma, minimizes port-related complications, and allows precise adhesiolysis and hernia repair even in complex cases.

Patient Evaluation and Preparation

Preoperative assessment is crucial to plan a safe laparoscopic approach in patients with massive adhesions:

History: Document previous surgeries, number of laparotomies, complications, and onset of hernia.

Physical examination: Evaluate size, reducibility, and location of hernia.

Imaging: CT scan is preferred to assess the extent of adhesions, defect size, and organ involvement.

Lab work: Routine blood tests, coagulation profile, and biochemical evaluation.

Patient counseling is important, highlighting:

Possibility of conversion to open surgery.

Use of minimal ports.

Risk of organ injury during adhesiolysis.

Mesh type and fixation strategy.

Anesthesia and Positioning

General anesthesia with muscle relaxation is mandatory for safe laparoscopic maneuvering.

The patient is positioned supine, arms tucked, with a slight Trendelenburg tilt for lower abdominal hernias.

Padding and positioning must prevent pressure injuries, especially in prolonged adhesiolysis cases.

Two-Port Technique: Port Placement

The two-port laparoscopic approach is advantageous in patients with massive adhesions because it:

Reduces additional trauma to the abdominal wall.

Provides adequate visualization for adhesiolysis and mesh placement.

Port placement strategy:

Primary port (10–12 mm): Usually placed remote from previous scars using an open (Hasson) technique to avoid bowel injury.

Secondary port (5 mm): Placed under direct vision to allow instrument triangulation.

This minimal port strategy requires precise handling and excellent ergonomics, as all dissection and mesh manipulation are performed with only one working instrument in addition to the camera.

Adhesiolysis

Massive adhesions are carefully dissected using blunt and sharp techniques.

Energy devices like bipolar cautery or advanced vessel sealing instruments aid in safe dissection.

Adhesiolysis is performed gradually, always under direct vision, to prevent bowel or organ injury.

Reduction of hernia sac contents follows, ensuring bowel, omentum, or other viscera are free and returned into the abdominal cavity.

Tips for safety in two-port adhesiolysis:

Constantly change the angle of the camera for optimal visualization.

Use the working instrument to lift adhesions away from underlying bowel before cutting.

Maintain low insufflation pressure if needed to avoid tension on the abdominal wall.

Defect Preparation

After adhesiolysis, the hernia defect is exposed and cleared of fat and scar tissue.

Precise measurement ensures adequate mesh overlap (3–5 cm beyond the defect).

In massive adhesion cases, it is critical to have a flat, clean surface for mesh fixation to avoid folding or migration.

Mesh Selection and Placement

Mesh considerations:

Composite or dual-layer mesh is preferred for intraperitoneal placement to prevent adhesions.

Mesh size should provide adequate overlap to cover the defect and surrounding weakened fascia.

Placement steps:

Roll the mesh and insert through the 10 mm port.

Unroll carefully, orienting the anti-adhesive side toward the bowel.

Fixation is performed using tackers, transfascial sutures, or fibrin glue, avoiding nerves and major vessels.

Despite only two ports, careful handling allows secure and precise placement of large meshes even in complex adhesions.

Final Inspection and Closure

Confirm mesh lies flat without folds and completely covers the defect.

Check for hemostasis and ensure no bowel entrapment.

Gradually release pneumoperitoneum and observe mesh stability.

Remove ports and close the fascial defect at the 10 mm port.

Skin is closed with subcuticular sutures or adhesive for cosmetic results.

Postoperative Care

Early ambulation and oral intake.

Analgesics (primarily NSAIDs) for pain management.

Discharge is usually 24–48 hours, depending on adhesiolysis complexity.

Avoid heavy lifting for 4–6 weeks.

Monitor for complications: seroma, hematoma, infection, or recurrence.

Advantages of Two-Port Laparoscopic Repair

Minimally invasive even in complex adhesion cases.

Fewer ports reduce risk of port-site complications and additional scarring.

Enhanced visualization allows safer adhesiolysis.

Effective placement of composite mesh ensures low recurrence and reduced adhesions.

Ability to manage massive or recurrent hernias without open conversion in most cases.

Limitations

Technically demanding; requires experienced laparoscopic surgeon.

Limited working space may increase operative time.

In extremely dense adhesions, conversion to open or hybrid repair may be required.

Mesh fixation with only one working instrument may be challenging for large defects.

Conclusion

Two-port laparoscopic repair of incisional hernia with massive adhesions is a feasible and safe technique in skilled hands. Proper preoperative planning, careful adhesiolysis, accurate defect measurement, and meticulous mesh placement are key to success.

This approach combines the benefits of minimally invasive surgery with reduced port trauma, safe adhesiolysis, and reliable mesh reinforcement, making it an effective solution for complex incisional hernias.