An incisional hernia is a common complication that can develop after abdominal surgery. It occurs when abdominal contents protrude through a weakness at the site of a previous surgical incision. Depending on the size of the defect, an incisional hernia may cause mild discomfort, significant pain, or even dangerous complications like obstruction or strangulation.

Over the past two decades, laparoscopic repair of incisional hernia has revolutionized hernia management. With smaller incisions, better visualization, and stronger mesh reinforcement, it offers distinct advantages over conventional open surgery.

Understanding Incisional Hernia
Causes and Risk Factors

An incisional hernia forms when a surgical wound fails to heal properly or when the abdominal wall is weakened. Contributing factors include:

Previous abdominal surgery (midline and large incisions are more prone)

Postoperative wound infection

Obesity and increased intra-abdominal pressure

Multiple pregnancies

Chronic coughing, constipation, or straining

Smoking, diabetes, or poor nutrition that delay wound healing

Symptoms

A visible bulge or swelling at or near a surgical scar

Pain or discomfort, especially when standing, lifting, or coughing

A dragging or heavy sensation in the abdomen

In complicated cases: nausea, vomiting, bowel obstruction, or strangulation of herniated contents

Why Surgery is Needed

A lumbar incisional hernia is an uncommon but challenging type of hernia that develops in the flank or lumbar region of the abdominal wall, typically following previous surgeries such as nephrectomy, retroperitoneal procedures, or trauma-related operations. Because of its location and the difficulty of securing strong tissue planes for repair, this condition presents a significant surgical challenge. Fortunately, with advancements in minimally invasive techniques, laparoscopic repair of lumbar incisional hernia has emerged as a safe and effective approach.

Understanding Lumbar Incisional Hernia

The lumbar region is the area between the lower ribs and the iliac crest. Hernias in this zone are relatively rare compared to umbilical or midline incisional hernias. They often occur after retroperitoneal or flank incisions that weaken the abdominal wall.

Causes and Risk Factors

Previous flank or lumbar surgery (e.g., kidney surgery, adrenalectomy)

Postoperative wound infection

Trauma to the flank region

Obesity and increased intra-abdominal pressure

Chronic cough or constipation

Poor nutritional status or systemic illness impairing wound healing

Symptoms

A bulge or swelling in the flank or lumbar region

Pain or discomfort, especially when standing or bending

Asymmetry of the abdominal wall

Rarely, bowel obstruction or incarceration if the hernia sac contains intestine

Challenges in Treating Lumbar Hernias

Repairing lumbar incisional hernias is difficult due to:

The anatomical complexity of the flank area

Limited availability of strong fascial tissue for closure

Proximity to bones (ribs, iliac crest) and nerves

Higher recurrence rates with traditional open repair

These challenges have made laparoscopic repair the preferred approach in modern surgical practice, as it provides magnified visualization, access to the retroperitoneal region, and the ability to fix large meshes securely.

Laparoscopic Repair: Step-by-Step
Anesthesia and Positioning

The procedure is performed under general anesthesia. The patient is placed in a lateral or modified supine position depending on the hernia’s location.

Port Placement

A 10 mm camera port is inserted at a site away from the hernia defect.

Two or three 5 mm working ports are placed strategically to allow safe triangulation.
This arrangement ensures good access to the lumbar defect.

Adhesiolysis and Dissection

Adhesions between the hernia sac, bowel, and retroperitoneal structures are carefully dissected. Because the hernia often contains fat or bowel loops, meticulous technique is required to prevent injury.

Reduction of Hernia Contents

The herniated structures are returned to the abdominal cavity. Complete reduction of the hernia sac is essential for durable repair.

Defect Measurement

The defect is measured to determine the size of mesh required. Lumbar hernias often have irregular margins, so the mesh should overlap the defect by at least 4–5 cm in all directions.

Mesh Placement

A large composite mesh is introduced laparoscopically. This type of mesh is designed for intraperitoneal use and minimizes adhesion formation. The mesh is spread across the defect to ensure complete coverage.

Mesh Fixation

Fixation is critical in lumbar hernias due to the absence of broad fascial planes. Techniques include:

Transfascial sutures placed through the abdominal wall and tied externally

Tackers or absorbable fixation devices placed circumferentially

Anchoring to strong structures like the iliac crest, ribs, or psoas fascia when necessary

Closure

Ports are removed, and incisions are closed with sutures. The abdominal wall is inspected for hemostasis.

Advantages of Laparoscopic Repair

Minimally invasive: Small incisions reduce trauma and scarring

Enhanced visualization: The laparoscope provides magnified views of the complex lumbar anatomy

Secure mesh placement: Large overlap reduces the chance of recurrence

Less postoperative pain: Compared to open flank incisions

Faster recovery: Patients often return to daily activity within a week

Lower wound infection rates: Especially important in previously scarred areas

Risks and Challenges

While effective, laparoscopic repair carries certain risks:

Injury to bowel or retroperitoneal structures during dissection

Difficulty in mesh fixation due to proximity to bony landmarks

Postoperative seroma formation

Rare mesh-related complications such as infection

Recurrence if mesh overlap is inadequate

These risks are minimized when performed by surgeons experienced in advanced laparoscopic hernia repair.

Postoperative Care

Early mobilization is encouraged to reduce complications

Pain is controlled with oral medications

A gradual return to oral diet is allowed within 24 hours

Heavy lifting and strenuous activity should be avoided for at least 4–6 weeks

Long-term measures include weight management, smoking cessation, and treating chronic cough or constipation to reduce recurrence risk

Outcomes and Success Rates

Clinical studies and surgical experience have shown that laparoscopic lumbar incisional hernia repair achieves success rates of over 90%. Patients benefit from reduced pain, quicker recovery, and lower recurrence rates compared to traditional open repair.

Conclusion

Laparoscopic repair of lumbar incisional hernia is a technically demanding yet highly effective procedure. It addresses the unique anatomical challenges of the lumbar region with the advantages of minimally invasive surgery. By ensuring secure mesh placement and minimizing surgical trauma, this approach offers durable results, faster recovery, and improved quality of life for patients.

For individuals suffering from the discomfort and risks of lumbar hernia, laparoscopic repair stands as the modern gold standard for treatment.