Incisional hernia is one of the most common complications following abdominal surgeries, resulting from a weakness or defect in the abdominal wall at the site of a previous surgical incision. Patients often present with swelling, pain, or discomfort at the site, and in severe cases, the hernia can lead to complications such as bowel obstruction or strangulation. With advancements in minimally invasive surgery, laparoscopic repair has become the preferred method due to its reduced morbidity, shorter hospital stay, and better cosmetic outcomes. Traditionally, laparoscopic incisional hernia repair is performed using three or more ports, but recent innovations have shown that it can be safely and effectively performed using only two ports, thus further minimizing surgical trauma.

Understanding the Two-Port Technique

The two-port laparoscopic repair is an advanced minimally invasive approach designed to reduce the number of incisions required. Typically, one port is used for the laparoscope (camera) to provide visualization of the hernia defect and surrounding structures, while the second port is used for the working instrument to perform adhesiolysis, defect closure, and mesh placement.

By reducing the number of ports, surgeons can minimize postoperative pain, lower the risk of port-site complications such as infection or herniation, and improve cosmetic outcomes. Moreover, with the growing expertise in laparoscopic surgery and availability of advanced energy devices, the two-port approach is gaining acceptance as a safe and efficient alternative.

Surgical Technique

Patient Positioning and Anesthesia
The patient is placed in a supine position under general anesthesia. Prophylactic antibiotics are administered, and a nasogastric tube may be inserted if required.

Port Placement

The first port (usually 10 mm) is inserted away from the hernia defect using an open or Veress needle technique, and the laparoscope is introduced.

The second port (typically 5 or 10 mm) is strategically placed to allow adequate triangulation for working instruments.

Proper placement of ports is crucial to ensure good ergonomics and safe access to the hernia site.

Adhesiolysis
Dense adhesions between the bowel, omentum, and hernia sac are carefully dissected using energy devices or blunt dissection. The goal is to create a clear plane for mesh placement without injuring the underlying viscera.

Defect Closure (Optional)
In some cases, the hernia defect may be closed intracorporeally using sutures passed through the working port. Alternatively, closure can be achieved with specialized suturing devices.

Mesh Placement
A suitable prosthetic mesh, often a dual-layer composite to prevent adhesions, is introduced through the 10 mm port. The mesh is spread out and positioned to cover the defect with an adequate overlap (usually 3–5 cm). Fixation can be achieved with tacks, transfascial sutures, or self-gripping meshes depending on the surgeon’s preference and case requirement.

Closure and Recovery
Ports are removed, and the skin is closed with absorbable sutures. Patients are usually mobilized within hours of surgery and discharged within 24–48 hours, depending on recovery.

Advantages of Two-Port Laparoscopic Repair

Reduced Surgical Trauma: With fewer incisions, the overall trauma to the abdominal wall is minimized.

Less Postoperative Pain: Patients often experience reduced pain compared to multi-port approaches.

Lower Risk of Port-Site Complications: Fewer ports mean a reduced chance of port-site hernia, infection, or bleeding.

Improved Cosmesis: Only two small incisions result in superior cosmetic results.

Shorter Recovery Time: Most patients return to normal activities sooner.

Limitations and Challenges

While promising, the two-port approach comes with certain limitations:

Technical Demands: Surgeons need advanced laparoscopic skills since triangulation and instrument handling are more restricted.

Limited Working Space: With fewer instruments in use, tasks like adhesiolysis or mesh fixation can be more challenging.

Case Selection: The technique is best suited for small to medium-sized incisional hernias. Very large or complex defects may still require a conventional three-port approach.

Outcomes and Success Rates

Studies and clinical experiences have demonstrated that two-port laparoscopic incisional hernia repair has comparable outcomes to the conventional multi-port method in terms of recurrence rates, complication rates, and long-term durability. Patient satisfaction, particularly regarding postoperative pain and cosmetic appearance, is often higher with the two-port approach.

Conclusion

Laparoscopic repair of incisional hernia by two ports is an evolving technique that offers a balance between effective hernia repair and minimal invasiveness. By reducing the number of access points, it enhances patient comfort, improves cosmesis, and minimizes complications without compromising surgical outcomes. While it requires a skilled surgeon and is not suitable for all types of hernias, in selected cases, the two-port approach represents a significant step forward in the minimally invasive management of incisional hernias.