JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES Volume 19, Number 2, 2009 © Mary Ann Liebert, Inc. DOI: 10.1089/lap.2008.0244 Laparoscopic Incisional and Ventral Hernia Repair Without Sutures: A Single-Center Experience with 200 Cases Paolo Baccari, MD, Jacopo Nifosi, MD, Luca Ghirardelli, MD, and Carlo Staudacher, MD, FACS Abstract Background: Laparoscopic incisional and ventral herniorraphy (LIVH), using a mesh, has gained recognition as an effective method and is associated with lower complication and recurrence. Controversies in the opera- tive technique still exist about biomaterial, method of fixation, and overlap of the mesh over the defect. The aim of this study was to evaluate the outcomes achieved with LIVH in 200 consecutive patients treated in a single hospital, using fixation of the mesh with only tacks. Results of the first 100 (group A) and the last 100 (group B) operations were also compared. Methods: From 2003 through 2007, 200 patients underwent LIVH. Overlap of the mesh was 3–5 cm. The mesh was secured with tacks alone, with the “double crown” technique. In group B, adhesiolysis was performed, avoiding high energies. Results: Mean ventral defect was 107.5 ( 95.4) cm 2 . The recurrent ventral hernia rate was 20%, and the con- version rate was 2.5%. Mean operative time was 77.5 ( 33.9) minutes. Mean mesh dimension was 326.4 ( 166.8) cm 2 . The overall morbidity rate was 10.5%. Bowel injuries were 5 (2.5 %). Minor complications were 8.0%. Median postoperative hospital stay was 3 days. Recurrence rate was 3.5%, with a mean follow-up of 22.5 months. Chronic pain was 1%. No difference was seen between groups A and B regarding minor complications, whereas a significant difference was found regarding enterotomies (5 vs. 0; P = 0.024) and recurrences (6 vs. 1; P = 0.056). Conclusions: Fixation of the mesh with the sole use of tacks was demonstrated to be safe and effective. Avoid- ing high energies, no case of enterotomy occurred. 175 Introduction I NCISIONAL HERNIAS STILL HAVE a high incidence, up to 20% after abdominal surgery. 1 The traditional open surgery used to treat these conditions is associated with an unac- ceptable recurrence rate as high as 54% with the direct su- ture of the defect. 2,3 Using a mesh for the repair, the inci- dence of relapse was reported as ranging from 10 to 24%, but the extensive soft-tissue dissection required to implant prosthetic meshes leads to high rates of wound-related com- plications. 4–7 The availability of new materials and meshes for implantation within the abdomen by laparoscopic sur- gery, a technique that adheres to the principles of tension- free repair, further reduced the recurrence rate. Laparoscopic treatment of incisional and ventral hernias was first reported in 1993 by LeBlanc and Booth. 8 Since that time, laparoscopic incisional and ventral herniorraphy (LIVH) has gained a growing acceptance and popularity between surgeons. Orig- inal papers based on large series of patients reported after LIVH a low rate of conversion to open surgery, moderate in- cidence of complications and recurrence, shorter hospital stay, and improved outcomes 9,10 for patients. Randomized trials comparing laparoscopic versus open incisional hernia repair confirmed the advantages of LIVH. 11–14 Many of the technical aspects of laparoscopic repair are currently standardized between the surgeons, but contro- versies still exist regarding biomaterial, the overlap of the mesh beyond the margins of the fascial defect, and the method of fixation of the prostheses. Inadequate overlap of the mesh on the defect and failure of tacks or transfascial su- tures could be the cause of hernia recurrence. There is sig- nificant variability in the use of fixation devices by re- searchers. Some use only sutures, others sutures and tacks, and still another group of surgeons fix the mesh with the sole use of tacks. The use of transfascial sutures is not stan- dardized: the number of sutures, the distance they are placed Department of General Surgery, Division of Gastrointestinal Surgery, Scientific Institute San Raffaele University Hospital, Milan, Italy.