This video demonstrates the Laparoscopic Management of Suprapubic Incisional Hernia by Dr. R K Mishra at World Laparoscopy Hospital. The suprapubic hernia is the term to describe ventral hernias located less than 4 cm above the pubic arch in the midline. Hernias with an upper margin above the arcuate line encounter technical difficulties, and the differences in repair methods forced us to define them as large suprapubic hernias. Laparoscopic repair of large suprapubic hernias can be considered as the first option in treatment. The low recurrence rates reported in the literature and the lack of recurrence, as observed in our video.

Suprapubic incisional hernia is a challenging type of ventral hernia that develops following lower abdominal or pelvic surgeries such as cesarean section, hysterectomy, prostatectomy, or bladder surgery. Due to its proximity to critical anatomical structures like the urinary bladder, pubic symphysis, and major neurovascular bundles, surgical repair of suprapubic incisional hernia requires advanced expertise. In recent years, laparoscopic management has emerged as a safe, effective, and minimally invasive option offering excellent outcomes.

Anatomical Challenges

The suprapubic region lies below the arcuate line, where the posterior rectus sheath is absent. This results in reduced tissue support and makes mesh fixation difficult. Additionally, the presence of the urinary bladder and iliac vessels increases the risk of intraoperative injury. Proper understanding of preperitoneal anatomy and meticulous surgical technique are essential for successful repair.

Indications for Laparoscopic Repair

Laparoscopic repair is indicated in:

Symptomatic suprapubic incisional hernia

Recurrent hernia after open repair

Defects larger than 3 cm

Patients seeking faster recovery and better cosmetic results

Contraindications may include uncorrected coagulopathy, extensive intra-abdominal adhesions, or inability to tolerate pneumoperitoneum.

Surgical Technique
Patient Positioning and Port Placement

The patient is placed in a supine position with slight Trendelenburg tilt to allow bowel displacement. Ports are usually placed higher in the abdomen to provide adequate working space. A standard three-port technique is commonly used.

Adhesiolysis

Careful adhesiolysis is performed to free the hernia sac contents while avoiding injury to the bowel or bladder. Sharp dissection with energy devices is preferred for precision.

Hernia Defect Assessment

The hernia defect is clearly delineated, and its size is measured. Adequate overlap (at least 5 cm beyond the defect margins) is planned for mesh placement.

Mesh Placement and Fixation

A composite mesh suitable for intraperitoneal onlay mesh (IPOM) repair is used. The mesh is placed to cover the defect with sufficient overlap, extending below the pubic symphysis when necessary. Fixation is achieved using a combination of transfascial sutures and absorbable or non-absorbable tackers. Special care is taken during fixation near the pubic bone to avoid nerve and vascular injury.

Bladder Protection

Preoperative bladder catheterization is essential. In selected cases, partial bladder dissection may be required to ensure adequate mesh placement without injury.

Advantages of Laparoscopic Repair

Reduced postoperative pain

Lower wound infection rates

Shorter hospital stay

Faster return to normal activities

Better visualization of anatomy

Lower recurrence rates when performed correctly

Complications

Although laparoscopic repair is generally safe, potential complications include:

Seroma formation

Mesh infection

Chronic groin or suprapubic pain

Bladder injury (rare)

Hernia recurrence

Most complications can be minimized with proper patient selection and surgical expertise.

Postoperative Care

Patients are encouraged early ambulation. Oral intake is resumed as tolerated. Abdominal binders may be advised for additional support. Heavy lifting is restricted for at least 4–6 weeks.

Conclusion

Laparoscopic management of suprapubic incisional hernia is a technically demanding but highly rewarding procedure. With a thorough understanding of anatomy, careful dissection, and appropriate mesh selection and fixation, laparoscopic repair offers excellent clinical outcomes with minimal morbidity. It has become the preferred approach in experienced hands for managing this complex hernia type.