Hernias are a common surgical problem, occurring when abdominal contents protrude through a weakness in the abdominal wall. Among them, suprapubic hernias are relatively uncommon but pose unique challenges for surgeons. A suprapubic hernia occurs just above the pubic bone in the lower abdomen, often at the site of a previous surgical incision such as a Pfannenstiel incision (used in gynecological or urological surgeries). When these hernias grow large, they can significantly impair quality of life and are technically difficult to repair.

In recent years, laparoscopic repair of large suprapubic hernias has emerged as a safe, effective, and minimally invasive alternative to open repair. It provides better visualization of the defect, allows precise placement of mesh, and results in faster recovery.

Understanding Suprapubic Hernias

A suprapubic hernia is a type of incisional hernia located within 3–4 cm above the pubic symphysis. These hernias can extend laterally toward the inguinal region or upward into the lower abdomen.

Causes and Risk Factors:

Previous pelvic or lower abdominal surgeries (e.g., hysterectomy, prostatectomy, cesarean section)

Poor wound healing or infection at the incision site

Obesity and increased intra-abdominal pressure

Chronic coughing, constipation, or urinary straining

Multiple pregnancies in women

Weakening of the abdominal wall with age

Symptoms:

A bulge or swelling in the lower abdomen, especially above the pubic bone

Discomfort or pain while standing, bending, or lifting

Difficulty with urination in some cases, due to proximity to the bladder

In severe cases: bowel obstruction or strangulation requiring urgent repair

Challenges in Repairing Large Suprapubic Hernias

Repairing a large suprapubic hernia is more complex than other abdominal wall hernias because of its location. The proximity to the pubic bone, urinary bladder, and inguinal structures makes dissection and mesh placement difficult. Traditional open repair involves large incisions, significant pain, and higher risk of recurrence.

The laparoscopic approach, however, provides magnified visualization and enables precise dissection in this anatomically crowded region.

Laparoscopic Repair: Step-by-Step Explanation
Anesthesia and Positioning

The surgery is performed under general anesthesia. The patient is placed in a supine position, often with a Trendelenburg tilt (head lower than feet) to allow abdominal organs to move away from the pelvis.

Port Placement

A 10 mm optical port is usually placed in the upper abdomen to provide a panoramic view.

Two or three additional 5 mm working ports are inserted on either side.
This arrangement ensures access to the hernia site in the lower abdomen.

Adhesiolysis and Defect Assessment

Adhesions between the hernia sac, bladder, and surrounding tissues are carefully dissected. The hernia sac contents (such as intestine or omentum) are reduced back into the abdominal cavity. The defect size is measured accurately.

Preparation of the Preperitoneal Space

In large suprapubic hernias, the mesh must be fixed securely to the pubic bone and Cooper’s ligament. Careful dissection creates adequate space for mesh placement, ensuring overlap beyond the hernia margins.

Mesh Placement

A large composite mesh is introduced through the 10 mm port. The mesh should overlap the defect by at least 5 cm in all directions. It is carefully positioned to cover the suprapubic region without folding or displacement.

Mesh Fixation

Transfascial sutures: Secure the mesh to strong tissue planes, especially near the pubic bone and Cooper’s ligament.

Tackers or absorbable fixation devices: Used to fix the mesh circumferentially.
Special care is taken to avoid bladder or vascular injury during fixation.

Closure

Once the mesh is securely fixed, instruments are removed, and small port incisions are closed with sutures.

Advantages of Laparoscopic Repair

Minimally Invasive: Small incisions with less scarring.

Better Visualization: The laparoscope provides a magnified view of the pubic region, aiding safe dissection.

Secure Mesh Fixation: Direct visualization of Cooper’s ligament and pubic bone allows durable anchoring.

Reduced Pain: Compared to open surgery, patients experience less postoperative discomfort.

Faster Recovery: Shorter hospital stay and quicker return to normal activities.

Lower Recurrence Rates: Properly fixed mesh provides long-lasting repair.

Risks and Considerations

Although laparoscopic repair is safe, certain risks remain:

Injury to the bladder during dissection

Vascular injury near the pubic bone

Seroma or fluid collection at the hernia site

Mesh infection (rare with proper technique)

Chronic pain due to nerve entrapment or fixation devices

These risks are minimized when the surgery is performed by experienced laparoscopic surgeons.

Outcomes and Success Rates

Clinical studies show that laparoscopic repair of suprapubic hernias has success rates above 90–95%, with very low recurrence when mesh fixation is properly done. Patients typically resume normal activity within 1–2 weeks, compared to 4–6 weeks after open surgery. Cosmetic outcomes are excellent, with only small scars.

Conclusion

Laparoscopic repair of large suprapubic hernias is a highly effective and patient-friendly procedure that has transformed the management of this challenging condition. By allowing precise dissection, secure mesh placement, and quicker recovery, laparoscopy addresses the limitations of open surgery and provides long-term durable outcomes.

For patients suffering from the discomfort and risks of large suprapubic hernias, this minimally invasive technique represents the gold standard of care—ensuring relief, restoration of abdominal wall strength, and improved quality of life.