Laparoscopic and percutaneous repair of a large midline incisional hernia extending to the bilateral subcostal region: A case report

INTRODUCTION: Optimal surgery for a midline incisional hernia extending to the subcostal region remains unclear. We report successful hybrid laparoscopic and percutaneous repair for such a complex incisional hernia. PRESENTATION OF CASE: An 85-year-old woman developed a symptomatic incisional hernia after open cholecystectomy. Computed tomography revealed a 14 × 10 cm fascial defect. Four trocars were placed under general anesthesia. Percutaneous defect closure was performed using multiple non-absorbable monofilament threads, i.e., a “square stitch.” Each thread was inserted into the abdominal cavity from the right side of the defect and pulled out to the left side. The right side of the thread was subcutaneously introduced anterior to the hernia sac. The threads were sequentially tied in a cranial to caudal direction. A multifilament polyester mesh with resorbable collagen barrier was selected and fixed using absorbable tacks with additional full-thickness sutures. The cranial-most limit of mesh fixation was at the level of the subcostal margin, and the remaining part was draped over the liver surface. The postoperative course was uneventful, with no seroma, mesh bulge, or hernia recurrence at 1, 3, 6, and 12 months of follow-up. DISCUSSION: The advantages of our technique are the minimal effect on the scar in the midline during defect closure, the minimal damage to the ribs and obtaining more overlap during mesh fixation. The disadvantage is the postoperative pain. CONCLUSION: Our proposed hybrid surgical approach may be considered as the treatment of choice for a large midline incisional hernia extending to the bilateral costal region.