Incisional hernias are a well-known complication of abdominal surgery, even after small incisions such as a McBurney’s incision commonly used for appendectomy. Although the McBurney’s incision is oblique and relatively small, it can weaken the abdominal wall, predisposing to herniation over time. Repairing incisional hernias in this region can be challenging due to scar tissue, adhesions, and altered anatomy.

Laparoscopic repair offers a minimally invasive, safe, and effective alternative to open repair, even in patients with prior surgical scars. Advantages include reduced postoperative pain, faster recovery, lower wound infection rates, and the ability to evaluate the entire abdominal wall for occult hernias.

Patient Evaluation

Preoperative assessment is essential to plan a safe laparoscopic repair:

History:

Previous appendectomy via McBurney’s incision.

Onset of hernia symptoms: bulge, pain, or obstruction.

Comorbidities such as diabetes, obesity, or smoking status.

Physical Examination:

Assess the size, reducibility, and location of the hernia.

Palpate for fascial defects and tenderness.

Imaging:

Ultrasound is useful for small hernias and evaluating sac contents.

CT scan provides precise information on defect size, adhesions, and intra-abdominal organ involvement, which is particularly important in recurrent or complex cases.

Laboratory Tests:

Routine blood work, including CBC and coagulation profile.

Preoperative assessment for anesthesia.

Patient Preparation and Anesthesia

Procedure is performed under general anesthesia with endotracheal intubation.

Supine position with arms tucked.

Trendelenburg tilt of 15–20 degrees allows bowel loops to move away from the lower right quadrant.

Foley catheter may be inserted to decompress the bladder if hernia is close to the pelvic brim.

Preoperative prophylactic antibiotics are administered to prevent infection.

Port Placement

Careful port placement is crucial to avoid injury to adhesed bowel or organs near the old McBurney’s incision.

Primary camera port: Placed away from previous scar, often at the umbilicus or opposite side of the abdomen using open (Hasson) technique to minimize risk of injury.

Working ports: Two 5 mm ports are placed under direct vision to triangulate the hernia defect.

Optional port: In select cases, a 3rd working port may be inserted to facilitate adhesiolysis or mesh placement.

Adhesiolysis

Adhesions from previous surgery are common, especially in the right lower quadrant.

Blunt and sharp dissection is performed carefully under direct laparoscopic vision.

Advanced energy devices such as bipolar cautery or ultrasonic scalpels may be used to minimize bleeding and reduce thermal injury.

Hernia sac contents, typically omentum or small bowel, are gently reduced back into the peritoneal cavity.

Defect Assessment and Preparation

The fascial defect is measured precisely using laparoscopic rulers or markings.

Surrounding scar tissue and preperitoneal fat are cleared to ensure proper mesh placement.

Creating a flat, clean surface ensures secure fixation and prevents mesh folding.

Mesh Selection and Placement

Composite or dual-layer mesh is preferred for intraperitoneal placement, preventing adhesions to bowel.

Mesh should overlap the defect by at least 3–5 cm in all directions.

Mesh is introduced through the 10 mm port and unrolled over the defect with the anti-adhesive side facing viscera.

Fixation can be achieved using tackers, transfascial sutures, or fibrin glue, taking care to avoid nerves and major vessels.

Closure and Final Inspection

Ensure mesh lies flat without folds and fully covers the defect.

Hemostasis is confirmed; bowel entrapment is ruled out.

Pneumoperitoneum is gradually released to confirm mesh stability.

Ports are removed, and the 10 mm fascial port is closed to prevent port-site hernia.

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

Postoperative Care

Early ambulation and resumption of oral intake are encouraged.

Pain is managed primarily with NSAIDs.

Patients are typically discharged within 24–48 hours, depending on adhesiolysis complexity.

Avoid heavy lifting for 4–6 weeks.

Follow-up is necessary to monitor for complications such as seroma, hematoma, infection, or recurrence.

Advantages of Laparoscopic Repair After McBurney’s Incision

Minimally invasive with small incisions and better cosmesis.

Enhanced visualization allows identification and reduction of adhesed structures.

Tension-free mesh repair reduces recurrence risk.

Ability to detect occult hernias elsewhere in the abdominal wall.

Faster recovery and reduced postoperative pain compared to open repair.

Special Considerations

Previous McBurney’s incision increases the risk of adhesions; meticulous dissection is mandatory.

Avoid blind trocar insertion near the scar to prevent bowel injury.

Mesh choice and fixation should accommodate the irregular contour of scar tissue.

Patient counseling is important regarding possible conversion to open surgery if adhesions are extensive.

Conclusion

Laparoscopic incisional hernia repair after a previous McBurney’s incision is a safe and effective approach for patients with localized abdominal wall weakness. With careful preoperative assessment, meticulous adhesiolysis, precise mesh placement, and proper fixation, surgeons can achieve excellent outcomes, low recurrence, minimal postoperative pain, and superior cosmetic results.

This approach demonstrates that even in patients with prior appendectomy scars, laparoscopic techniques offer a minimally invasive solution with enhanced safety and durability.