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This video demonstrates the Laparoscopic Repair of Subcostal Incisional Hernia. The subcostal incisional hernia, though not very common, requires adequate surgical treatment. Its surgical correction involves rebuilding the muscle-aponeurotic defect, supra-aponeurotic fixation of polypropylene _ Polyurathane mesh, with less complexity and lower rates of complications and recurrences. 

Subcostal incisional hernias are a challenging subset of abdominal wall hernias that occur following surgical incisions near the ribcage, commonly after open cholecystectomy, liver surgery, or upper abdominal procedures. These hernias can lead to discomfort, chronic pain, and cosmetic concerns, and in some cases, may cause complications like bowel obstruction. Traditional open repair of subcostal hernias can be difficult due to scar tissue, proximity to ribs, and limited tissue for closure. Laparoscopic repair offers a minimally invasive alternative that reduces morbidity and promotes faster recovery.

Anatomy and Etiology

The subcostal region lies just below the rib margin. Hernias in this area typically occur through previous incisions, especially if the incision was vertical or oblique, poorly closed, or if postoperative complications like infection occurred. Contributing factors include:

Obesity

Chronic cough or straining

Advanced age

Poor wound healing

Understanding the anatomy is crucial, as the hernia defect is often near the costal margin, diaphragm, or upper abdominal musculature, which makes mesh fixation technically demanding.

Indications for Laparoscopic Repair

Laparoscopic repair is preferred in the following scenarios:

Symptomatic hernias causing pain or discomfort

Risk of incarceration or obstruction

Large or recurrent hernias where open repair is challenging

Patients seeking minimally invasive options with faster recovery

Preoperative Assessment

Before surgery, careful evaluation is essential:

Clinical examination: Assessment of hernia size, reducibility, and tenderness

Imaging: CT scan of the abdomen is preferred to delineate the defect size, content, and relation to surrounding structures

Optimization: Control of comorbidities (diabetes, hypertension, obesity) to reduce postoperative complications

Surgical Technique
1. Patient Positioning

The patient is placed in a supine position with a slight reverse Trendelenburg to improve exposure of the upper abdomen.

Arms may be tucked or extended depending on port placement.

2. Port Placement

Typically, three to four laparoscopic ports are used.

Ports are positioned away from the hernia site to avoid prior scar tissue and ensure safe triangulation for mesh placement.

3. Hernia Reduction

Adhesiolysis is performed carefully to release any adhesions between the hernia sac and underlying viscera.

The hernia sac is reduced, and the edges of the defect are clearly defined.

4. Mesh Selection and Placement

A composite or dual-sided mesh is preferred to minimize adhesion to viscera.

The mesh should overlap the defect by at least 5 cm in all directions.

Fixation is achieved using tackers, transfascial sutures, or fibrin glue depending on defect location and proximity to ribs.

5. Closure of Defect (Optional)

In selected cases, primary closure of the defect using intracorporeal suturing can be performed before mesh placement to restore abdominal wall integrity.

6. Final Inspection and Hemostasis

Ensure mesh is properly fixed without folds

Confirm hemostasis and absence of visceral injury

7. Postoperative Care

Early mobilization is encouraged.

Pain is managed with analgesics; minimally invasive approach typically results in less postoperative pain.

Diet is resumed gradually, and patients are advised to avoid heavy lifting for 4–6 weeks.

Advantages of Laparoscopic Repair

Reduced wound complications and infection

Less postoperative pain

Shorter hospital stay

Faster return to normal activities

Better visualization of defect margins and adhesions

Challenges and Considerations

Technical difficulty due to proximity to ribs and diaphragm

Risk of mesh migration if not adequately fixed

Potential injury to diaphragm or liver during adhesiolysis

Need for advanced laparoscopic skills and experience

Conclusion

Laparoscopic repair of subcostal incisional hernias represents a safe, effective, and minimally invasive option for patients with complex hernias in the upper abdomen. Careful patient selection, meticulous preoperative planning, and adherence to surgical principles are key to achieving optimal outcomes. With the advancement of laparoscopic techniques, this approach is increasingly becoming the preferred choice over traditional open repair in suitable cases.