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16.10.2020 | original article Open Access

Hybrid approach to ventral wall hernia repair: a single-institution cohort study

European Surgery
MRCS, BSc Sara Jamel, MSC, MD, FRCS Sherif Mohamad Hakky, MBBS Karina Tukanova, MRCS, PhD Sarah Huf, MRCS, PhD, PhD, MA, MSc Sheraz Markar, FRCS, MD Sanjay Purkayastha
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The online version of this article contains a video. The article and the video are online available (https://​doi.​org/​10.​1007/​s10353-020-00671-y). The video can be found in the article back matter as “Electronic Supplementary Material”.

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Ventral hernias pose a substantial challenge for surgeons. Even though minimally invasive surgery and hernia repair have evolved rapidly, there is no standardised method that has been widely accepted as standard of practice. Hybrid ventral hernia repair (HVR) is an alternative surgical approach, which has not been adopted widely to date. It combines laparoscopic mesh insertion with closure of the hernia defect. The aim of this retrospective cohort study is to evaluate short- and long-term outcomes in patients undergoing HVR.


Between October 2012 and June 2016, 56 HVRs were performed at St Mary’s Hospital, Imperial College London. The medical records of these patients were reviewed retrospectively for demographics, comorbidities, previous surgeries, operative technique, complications and recurrences over a 3-year follow-up.


HVRs were performed by four surgeons. Mean age was 48 years with a mean body mass index (BMI) of 32.8 kg/m2. 71.4% had incisional hernias and 28.6% had primary hernias. The number of hernia defects ranged from 1 to 4, with average defect size 42.9 cm2 (range 8–200 cm2). Adhesiolysis was performed in 66.1% of patients. Recurrence occurred in 2 patients (3.6%), 16.1% of patients developed postoperative seroma, 0.3% had respiratory complications, 0.3% had paralytic ileus and 0.2% had urinary retention. Only 2 patients required epidural postoperatively, both had a defect size of 150.0 cm2. There were no reoperations within 90 days. Mean length of hospital stay was 2 days (1–10 days). Over the follow-up period, 2 patients (3.6%) developed chronic pain.


The hybrid technique is safe and feasible, and has important benefits including low rates of seroma formation, chronic pain and hernia recurrence. Future investigations may include randomised controlled trials to evaluate the benefits of VHR, with careful assessment of patient-reported outcome measures including quality of life and postoperative pain.

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The video highlights the main steps of the surgical approach. The abdominal cavity was entered laparoscopically utilising an optical entry technique 12mm port, which was inserted in the left upper quadrant at Palmer’s point. Two further laparoscopic ports were inserted under vision. First, all hernia defects were identified laparoscopically, with adhesiolysis in this case. This was followed by reduction of the hernia sac content into the abdominal cavity and the sac content was freed of adhesions. Subsequently, Conversion to an open approach was then made over the hernia defect using the previous incision. The sac was then excised and hernia edges were cleared. Extracorporeal trans-facial closure of the hernia defect was performed. Subsequently returning to laparoscopy to allow mesh insertion.
The video highlights the surgical approach of visiport entry, subsequent post placements and the extent of adehesiolysis with hernia reduction laparoscopically. The next step is converting to open to allow sac excision and closure of facial layers. Finally retiring to laparoscopy for mesh placement to the anterior abdominal wall utilising double crown configuration technique.
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