Incisional hernia is one of the most common complications following abdominal surgery, where the abdominal contents protrude through a weakness in the surgical scar. Among the different types, subcostal incisional hernia presents unique challenges due to its location beneath the rib margin. Repairing this type of hernia is particularly demanding because of the proximity to bony structures, the diaphragm, and vital organs such as the liver. In recent decades, laparoscopic surgery has emerged as a highly effective method for repairing subcostal incisional hernias, offering patients better outcomes compared to traditional open repair.

Understanding Subcostal Incisional Hernia

A subcostal incision is commonly used in surgeries involving the gallbladder, liver, or bile ducts. While this incision provides excellent surgical exposure, it carries a significant risk of hernia formation later. A subcostal incisional hernia typically develops at or near the surgical scar under the rib cage, where the abdominal wall is weakened.

Causes and Risk Factors

Previous Subcostal Surgery: Procedures such as cholecystectomy or liver resections.

Poor Wound Healing: Infection, malnutrition, or systemic illnesses.

Excessive Strain: Chronic cough, obesity, or heavy lifting.

Technical Factors: Improper closure of the abdominal wall during the initial surgery.

Patients often present with a noticeable bulge under the rib cage, discomfort, pain during exertion, and sometimes digestive disturbances. In severe cases, the hernia may lead to obstruction or strangulation, requiring urgent intervention.

Limitations of Open Repair

Traditionally, subcostal incisional hernias were repaired by open surgery. However, this method has several drawbacks:

Large incisions leading to greater post-operative pain.

Longer hospital stay and recovery time.

Higher chances of wound infections and recurrence.

Technical difficulty in placing mesh under the rib cage through an open approach.

These limitations paved the way for minimally invasive techniques like laparoscopic repair, which provide superior outcomes in both functional and cosmetic terms.

Laparoscopic Repair: A Modern Solution

The laparoscopic approach is now widely accepted as the gold standard for many incisional hernias, including subcostal types. It involves the use of small incisions through which a camera and specialized instruments are inserted to repair the defect.

Key Steps in Laparoscopic Subcostal Hernia Repair

Patient Positioning
The patient is usually placed in a supine position, sometimes with a slight tilt to facilitate access to the upper abdomen.

Port Placement

A 10 mm port is typically placed away from the hernia defect for the laparoscope.

Two or more additional 5 mm working ports are placed under direct vision.
Port placement requires careful planning due to the proximity of the ribs and diaphragm.

Adhesiolysis
Adhesions from previous surgeries are carefully dissected to free the hernia sac and reduce its contents back into the abdominal cavity. This is often the most time-consuming step, particularly in recurrent hernias.

Defect Assessment
The hernia defect is measured accurately. Subcostal defects can be irregular in shape and close to the rib margin, making closure challenging.

Mesh Placement
A composite mesh designed for intra-abdominal use is introduced. The mesh must cover the defect with at least a 3–5 cm overlap on all sides to minimize recurrence.

Mesh Fixation
Fixation is done using a combination of transfascial sutures and absorbable or non-absorbable tacks. In subcostal hernias, fixation near the rib margin requires particular care to avoid injury to intercostal vessels or nerves.

Closure
After ensuring proper fixation, the ports are removed and the incisions closed with minimal scarring.

Advantages of Laparoscopic Repair

Minimally Invasive: Smaller incisions lead to less pain and better cosmetic results.

Reduced Risk of Infection: Compared to open repair, the risk of wound infection is significantly lower.

Enhanced Visualization: The laparoscope provides magnified views of the defect, enabling precise dissection and mesh placement.

Faster Recovery: Patients often return to normal activity within a shorter period.

Lower Recurrence Rates: With proper mesh placement and fixation, the risk of recurrence is reduced.

Challenges in Subcostal Hernia Repair

While laparoscopic repair offers many benefits, subcostal hernias remain technically demanding. Challenges include:

Limited Space for Mesh Fixation due to the rib margin.

Risk of Diaphragm Injury during dissection and suturing.

Difficulty in Achieving Adequate Overlap because of anatomical constraints.

Chronic Pain Risk if intercostal nerves are inadvertently damaged during fixation.

Surgeons with advanced laparoscopic expertise are best suited to perform this complex procedure.

Clinical Outcomes

Studies have shown that laparoscopic repair of subcostal incisional hernias results in high patient satisfaction, low recurrence rates, and fewer complications compared to open techniques. The use of advanced meshes and fixation devices has further improved long-term outcomes.

Conclusion

Laparoscopic repair of subcostal incisional hernia is a safe, effective, and patient-friendly technique that addresses the limitations of open surgery. Despite the challenges posed by its anatomical location, careful dissection, precise mesh placement, and secure fixation allow for excellent outcomes. With advances in minimally invasive surgery, patients suffering from subcostal hernias can expect faster recovery, reduced pain, and a significantly improved quality of life.

This procedure demonstrates how modern surgical innovation continues to transform complex hernia management, offering hope and relief to patients worldwide.