Incisional hernia is a common complication following abdominal surgery, occurring in 10–20% of patients after midline laparotomy. Traditional open repair is associated with higher recurrence rates, wound infection, and prolonged recovery. Laparoscopic repair has emerged as a minimally invasive alternative, offering reduced postoperative pain, faster recovery, and lower complication rates.

A critical component of laparoscopic repair is the selection of mesh. Polyurethane-coated mesh has gained popularity due to its biocompatibility, reduced adhesion formation, and strength. This article outlines the principles, techniques, and advantages of laparoscopic incisional hernia repair using polyurethane mesh.

Patient Evaluation and Selection

Preoperative evaluation includes:

Detailed history: previous surgeries, wound infections, comorbidities.

Physical examination: size, location, reducibility of hernia.

Imaging: CT scan is preferred for large or complex hernias to evaluate defect size, loss of domain, and intra-abdominal adhesions.

Laboratory tests: complete blood count, coagulation profile, and biochemical assessment.

Patient selection is essential for success. Laparoscopic repair is particularly advantageous in:

Hernias with defects less than 10 cm in diameter.

Patients without extensive abdominal adhesions.

Those at higher risk of wound infection where open repair may be challenging.

Anesthesia and Positioning

General anesthesia with muscle relaxation is mandatory.

Patient positioned supine, with arms tucked and slight Trendelenburg tilt for lower abdominal hernias.

Surgeon stands on the side of least obstructed access; monitor positioned at the foot of the table.

For large hernias, proper padding and positioning are essential to prevent pressure injuries.

Port Placement

Pneumoperitoneum is established using a Veress needle or open technique at the periumbilical site.

Typical insufflation pressure: 12–14 mmHg.

A 10 mm camera port is placed at a safe distance from the hernia defect.

Two or three 5 mm working ports are inserted under direct vision, triangulated to allow ergonomic instrument manipulation.

Port placement should avoid previous scars or adhesions.

Adhesiolysis and Defect Exposure

Laparoscopic visualization allows safe adhesiolysis of intra-abdominal organs adherent to the anterior abdominal wall.

Sharp and blunt dissection is performed carefully to avoid bowel injury.

The hernia defect is identified and measured; margins are cleared of fat and scar tissue to allow adequate mesh overlap.

Polyurethane Mesh Selection

Polyurethane-coated mesh has a dual-layer structure:

Visceral-facing side: smooth polyurethane prevents adhesions with bowel loops.

Parietal side: rough or porous surface encourages tissue ingrowth, promoting secure fixation.

Mesh size should allow 3–5 cm overlap beyond all defect edges. The choice of mesh thickness and flexibility depends on the size and location of the hernia. Polyurethane mesh is preferred for intraperitoneal placement due to its adhesion-resistant surface.

Mesh Placement and Fixation

Introduction: Mesh is rolled and inserted through a 10 mm port.

Positioning: Unrolled over the defect with the smooth side facing the bowel.

Fixation:

Tackers or transfascial sutures secure the mesh circumferentially.

Ensure mesh lies flat without folding.

Avoid excessive tension to prevent postoperative pain or migration.

Special Considerations:

For large or parastomal defects, additional fixation points may be required.

Fibrin glue can be used selectively to minimize tackers near nerves.

Final Inspection and Closure

Confirm adequate overlap and proper mesh orientation.

Check for hemostasis and absence of bowel entrapment.

Gradually release pneumoperitoneum, ensuring mesh remains in place.

Remove ports and close the 10 mm fascial defects to prevent port-site hernias.

Skin closure with subcuticular sutures or adhesive ensures a cosmetically acceptable outcome.

Postoperative Care

Early ambulation and oral intake are encouraged.

Analgesics: NSAIDs primarily, opioids if needed.

Patients are typically discharged within 24–48 hours, depending on hernia size and complexity.

Avoid heavy lifting or strenuous activity for 4–6 weeks.

Follow-up: monitor for seroma, hematoma, mesh infection, or recurrence.

Advantages of Polyurethane Mesh in Laparoscopic Repair

Reduced adhesions: Smooth visceral surface prevents bowel attachment.

Tissue ingrowth: Promotes secure fixation on the abdominal wall.

Durability: High tensile strength reduces recurrence.

Ease of handling: Flexible and conformable to abdominal contours.

Minimally invasive: Combined with laparoscopic technique, results in faster recovery and better cosmetic outcomes.

Limitations and Considerations

Cost is higher compared to standard polypropylene mesh.

Requires advanced laparoscopic skills for adhesiolysis and mesh placement.

Large or complex hernias may still require open or hybrid techniques.

Rare risk of chronic pain if tacks impinge on nerves.

Conclusion

Laparoscopic incisional hernia repair using polyurethane mesh is a safe, effective, and minimally invasive technique for selected patients. By combining meticulous adhesiolysis, accurate defect measurement, and secure placement of dual-layer mesh, surgeons can achieve low recurrence, minimal adhesions, and rapid postoperative recovery.

With proper patient selection, careful dissection, and precise mesh handling, laparoscopic repair with polyurethane mesh represents a modern standard for managing incisional hernias, offering both functional durability and patient satisfaction.