Laparoscopic Repair of Suprapubic Ventral Hernias
Alfredo M. Carbonell, DO
T he laparoscopic approach to ventral hernia repair ap-
pears to be superior to the traditional open operation.
The use of laparoscopy is associated with less pain, a better
cosmetic result, a lower incidence of mesh and wound com-
plications, and possibly a lower recurrence rate. As a result of
their low prevalence, hernias located in atypical areas may
not be seen as frequently by surgeons, leading to a relative
inexperience in their repair; and a subsequent higher recur-
rence rate. The suprapubic incisional hernia is one which is
located in close proximity to the pubic bone, arising after
urologic or gynecologic procedures. The repair of these her-
nias can be difficult because of the complexity of dissection
and their anatomic proximity to bony, vascular, and nerve
structures. This technique article gives the operating surgeon
a thorough understanding of the nature of suprapubic her-
nias and an illustrated step by step approach to the laparo-
scopic repair of this difficult problem; particularly the trans-
abdominal suture fixation to the bony and ligamentous
structures of the pelvis. Although technically demanding and
time-consuming, the laparoscopic repair of suprapubic her-
nias yields a durable hernia repair. It is safe, technically fea-
sible, results in a low recurrence rate, and is applicable to
large or multiply recurrent hernias.
Incisional hernias can develop in up to 20% of patients
undergoing laparotomy, and, after a primary repair, these
hernias may recur in up to 63% of patients.1 With the devel-
opment of laparoscopic techniques, the recurrence rate for
ventral hernia repair is frequently reported to be below 4%.2-5
Based on the open, retrorectus, Rives-Stoppa6 repair mandat-
ing wide coverage of the hernia defect, the laparoscopic ap-
proach is associated with few recurrences, rapid hospital dis-
charge, improved cosmesis, a reduced risk of infection, and
possibly less postoperative pain.2-5 Certain critical steps are
required to ensure a reliable laparoscopic ventral hernia re-
pair, such as a minimum of 4 to 5 cm mesh overlap of the
hernia defect, and mesh fixation with both full-thickness
transabdominal sutures and helical tacks.7,8 Although no ran-
domized, prospective studies have been performed, a strong
association has been made in the literature between hernia
recurrences and the lack of mesh fixation with full-thickness
Division of General Surgery, Minimally Invasive Surgery Center, Virginia
Commonwealth University Medical Center, Richmond, VA.
Address reprint requests to Alfredo M. Carbonell, D.O., Division of General
Surgery, Virginia Commonwealth University Medical Center, 1200
East Broad Street, PO Box 980519, Richmond, VA 23298. E-mail:
amcarbonell@vcu.edu
10 1524-153X/06/$-see front matter © 2006 Elsevier Inc. All rights reserved.
doi:10.1053/j.optechgensurg.2006.04.005
transabdominal sutures.2,7,8 Additionally, animal studies
have demonstrated the superior fixation strength of sutures
compared with tacks for mesh fixation.9,10
The terms suprapubic and parapubic are often used inter-
changeably. When used to describe hernias, they refer to
those located just above the symphysis pubis. They may oc-
cur as a result of low mid-line, Pfannenstiel, Maylard, and
Cherney incisions used principally for gynecologic, prostatic,
or rectal procedures.11 These hernias have also been reported
after suprapubic catheterization.12 There is limited experi-
ence with the repair of these difficult hernias using both the
open11,13-15 and laparoscopic approach.16-18
The abdominal oblique aponeurosis, rectus abdominus
musculature, and rectus sheath insert on the symphysis pu-
bis. In the event an incision is placed in proximity to this
musculotendinous insertion, a hernia may develop as a result
of inadequate tissue purchase inferiorly when re-approximat-
ing the fascia. The complexity of dissection and the close
proximity of these hernias to bony, vascular, and nerve struc-
tures make the repair of suprapubic hernias a formidable
operation. We developed a unique technique in the repair of
these hernias, and present our 10-year experience, discussing
in detail the operative approach.
Preoperative Workup
Patient selection for the laparoscopic approach is up to the
individual surgeon. Preoperative workup should include a
thorough history of all past surgeries and review of operative
reports, particularly if a previous hernia repair with mesh was
undertaken. On physical examination the surgeon should
palpate the entire incision both in the supine and upright
position. Provocative maneuvers should be used to accentu-
ate the hernia bulge and attempt to delineate the inferior-
most edge of the defect. For the laparoscopic ventral hernia
repair, a minimum 4 cm overlap of mesh past the edge of the
hernia defect is recommended; as a result, hernias less than 4
cm from the pubic symphysis are defined as suprapubic and
will require this modified approach to repair. Computed to-
mography (CT) is helpful in determining the exact size of the
hernia, its contents, and the relation of the inferior edge to the
pubic symphysis. Although we do not typically have the pa-
tient undergo CT before hernia repair, we will do so if there is
a question regarding proximity of the hernia to the pubic
symphysis or if there has been a previous mesh repair. A
previous repair with mesh may make the laparoscopic ap-
proach difficult, particularly if polypropylene mesh was used
Laparoscopic repair of suprapubic ventral hernias
or a previous laparoscopic repair attempted. This informa-
tion helps plan out the operative approach.
Equipment
Instrumentation for the repair is similar to that of the typical
laparoscopic ventral hernia repair. We use from three to four
trocars for the procedure; at least one being 10 mm in size,
the rest may be 5 mm. Because most of the trocars are 5 mm,
we use a 5 mm, 30-degree angled laparoscope that will allow
the surgeon to change the position of the camera between
multiple ports. The angle allows the surgeon to “look around
corners” during difficult portions of the procedure. A Mary-
land dissector, atraumatic graspers, and laparoscopic shears
are required for the lysis of adhesions. We refrain from the
use of ultrasonic coagulating shears to take down adhesions
because this can result in an unnoticed thermal injury to the
intestine. Sharp division of adhesions is advised. Simple mo-
nopolar cautery attached to the scissors should suffice if nui-
sance bleeding arises. The use of a 5 mm clip applier can
serve as an added measure for hemostasis. For mesh we use
expanded polytetrafluoroethylene (ePTFE, DualMesh Gore-
Tex, WL Gore & Associates, Flagstaff, AZ), however, several
other tissue-separating mesh products are available that are
safe to use in direct contact with the intestine. The four car-
dinal sutures used to initially hold the mesh in place are CV-0
sutures constructed of ePTFE (Gore-Tex, WL Gore & Asso-
ciates). The additional fixation sutures should be size #0 or
#1 polypropylene or polybutester that are both nonabsorb-
able. Our preferred fixation construct device is the ProTack
(United States Surgical, Norwalk, CT) that employs titanium
spiral tacks. Several other fixation construct devices are avail-
able as well. For passing and retrieving the transabdominal
sutures, a Gore Suture Passer (WL Gore & Associates) is
used.
Patient Set-up
After anesthetic induction, a three-way Foley catheter is
placed into the bladder. This is used to instill saline into the
11
bladder as a tumescent to aid in determination of the blad-
der’s location in the preperitoneal space so as to avoid injury
to it during the procedure. Should an injury be suspected,
methylene blue can be instilled in the irrigant to help identify
a cystotomy. The patient is positioned supine with both arms
padded and tucked. This allows the surgeon and the assistant
to work on the same side of the patient without interference
from the patient’s extended arm. With more obese patients,
padding to elevate the tucked arm will ensure there is no
undue traction placed on the brachial plexus. The pubic hair
is shaven to ensure complete access to the area of the pubic
symphysis during the operation. Using a standard iodine skin
prep, the abdomen is prepped up to the nipple line, as far
lateral as the arms allow, and down onto the thighs. An io-
dine-impregnated skin drape is used on the abdomen for an
added antimicrobial barrier.
Trocar Placement
The procedure commences with an open cutdown to enter
the abdomen safely away from any previous incisions and
placement of a 10-mm trocar. The incision can be made in
the midline above the umbilicus, distant to the hernia defect.
Placing the first trocar this far above allows a more expanded
view of the abdomen and ensures the trocar is out of the way
should it be required to place a large piece of mesh. Two
additional 5 mm trocars are placed in a horizontal line.
Lysis of Adhesions
The procedure proceeds with a sharp enterolysis, avoiding
injury to any hollow viscus. Care should be taken in dissect-
ing the inferior-most aspect of the hernia because it often
contains herniated bladder. The herniated contents should
be completely reduced, and no effort made to remove the
hernia sac. At this point, a metric ruler is placed into the
abdomen to determine the proximity of the inferior edge of
the hernia defect to the pubic symphysis. If this measures less
than 4 cm, plans should be made to proceed with this mod-
ified technique.
12 A.M. Carbonell

Operative Technique

Figure 1 After initial access to the abdomen via an open cutdown technique, laparoscopic ports are placed in a
horizontal configuration far above the hernia defect to allow manipulation and placement of a large enough piece of
mesh without interfering with the ports. This picture demonstrates the surgeon working in the pelvis on a suprapubic
hernia associated with a large Pfannenstiel incision. (Color version of figure appears online.)
Laparoscopic repair of suprapubic ventral hernias 13

Figure 2 With suprapubic hernias the inferior edge of the defect may be intimately associated with the superior edge of
the bladder. (A) The intraoperative photo demonstrates the bladder filled with saline and the hernia defect completely
abutting the pubic bone. (B) The CT shows a portion of the bladder herniating into the defect. When the hernia edge
lies within 4 cm of the superior most aspect of the pubic bone the surgeon must create a peritoneal flap to enter the
prevesical space of Retzius so as to identify the proper bony and vascular structures for safe suture mesh fixation. (Color
version of figure appears online.)
14 A.M. Carbonell

Figure 3 If the hernia defect edge is less than 4 cm from the pubis, then a peritoneal flap will need to be created to enter
the space of Retzius and Bogros to expose the posterior aspect of the pubic bone, Cooper’s ligaments, and the inferior
epigastric vessels bilaterally. Identification of these key structures will allow the surgeon to place the transabdominal
sutures and tacks with pinpoint precision, avoiding injury to any of the surrounding neurovascular structures. The
peritoneum is grasped in the midline at the median umbilical ligament at a level immediately below the hernia defect
edge. The surgeon can avoid injury to the bladder at this point by instilling approximately 200 mL of saline through the
three-way Foley catheter, allowing the bladder to become more visible. The peritoneum is sharply incised in a
horizontal fashion toward the epigastric vessels (Lateral umbilical ligaments) on either side. The prevesical space of
Retzius is entered and blunt dissection similar to that used for the laparoscopic, transabdominal, preperitoneal,
inguinal hernia repair is performed. (Color version of figure appears online.)

Figure 4 The flap is raised inferiorly to expose the underlying bony pelvic structures. The dissection proceeds until the
posterior aspect of the pubic bone, Cooper’s ligaments, and the inferior epigastric vessels are identified bilaterally.
(Color version of figure appears online.)
Laparoscopic repair of suprapubic ventral hernias 15

Figure 5 (A) After completely delineating the edges of the hernia, 3.5⬙ long 20 gauge spinal needles are placed at the
extreme edges of the hernia defect. These spinal needles mark the edges of the hernia, helping to measure the exact size
of the hernia using an intracorporeally placed thin, plastic, metric ruler. Once the maximum vertical and horizontal
measurements of the hernia are taken, the overlap superiorly and laterally should be no less than 4 cm. (B) Inferiorly,
the overlap onto the pubic bone is calculated as the distance from the edge of the hernia to the superior most aspect of
the pubic bone plus 1 to 2 cm for overlap below the pubis. (Color version of figure appears online.)
16 A.M. Carbonell

Figure 6 Pretied CV-0 ePTFE sutures are placed with a 1 cm bite, 1 cm in from the mesh edge at the four corners of the
mesh to serve as the initial transabdominal fixation sutures. Because the inferior portion of the mesh will overlap onto
the pubic bone, the inferior suture should be placed 2 cm from the actual mesh edge. (Color version of figure appears
online.)
Laparoscopic repair of suprapubic ventral hernias 17

Figure 7 (A) The mesh is rolled from the top and the bottom concomitantly like a scroll. (B) This allows for the mesh
to be dragged directly into the abdomen. (C) The mesh is then unrolled without having to reorient the mesh once it is
in the abdomen. (Color version of figure appears online.)
18 A.M. Carbonell

Figure 8 After unrolling the mesh, the inferior transabdominal suture needs to be retrieved first to ensure adequate
overlap inferiorly where it is most important. (A,B) The suture passer is advanced into the abdomen, puncturing the
periosteum of the pubic bone and grasping one limb of the inferior suture, a second path through the periosteum grasps
the second limb of the suture and brings the inferior portion of the mesh against the pubic bone. (C) Note, the inferior
suture is not tied down immediately, rather, the suture limbs are held under tension with a hemostat. (Color version of
figure appears online.)
Laparoscopic repair of suprapubic ventral hernias 19

Figure 8 Continued
20 A.M. Carbonell

Figure 9 (A) The superior suture and the two lateral sutures are then retrieved transabdominally ensuring a minimum
of 4 cm mesh-defect overlap. When the mesh lies tight against the anterior abdominal wall, then the superior and lateral
sutures are tied. (B) The superior and lateral portion of the mesh is then fixated to the abdominal wall with spiral tacks
every 1 to 2 cm apart and interrupted #1 permanent suture every 4 to 6 cm. (Color version of figure appears online.)
Laparoscopic repair of suprapubic ventral hernias 21

Figure 10 (A–F) While holding the inferior-most midline suture untied outside the body, a minimum of two additional
#1 polypropylene transabdominal sutures are passed through the periosteum of the pubis approximately 2 cm lateral
to the first inferior midline suture. The suture must be taken in with the suture passer, advanced through the mesh and
a second pass through the mesh retrieves the suture, forming a U-stitch. These sutures are not secured until all of the
inferior sutures are placed. This allows the surgeon to hold the mesh loosely upwards with a grasper to allow direct
visualization of the suture passer safely traversing the abdominal wall and periosteum. A minimum of three sutures are
placed through the periosteum. More may be placed as space allows. After placing all the inferior sutures, they are
individually tied. (Color version of figure appears online.)
22 A.M. Carbonell

Figure 10 Continued
Laparoscopic repair of suprapubic ventral hernias 23

Figure 10 Continued
24 A.M. Carbonell

Figure 11 (A,B) Further mesh fixation is achieved with spiral tacks every 1 cm and transabdominal #1 polypropylene
suture every 4 to 5 cm circumferentially around the mesh, avoiding placement of sutures or tacks below the iliopubic
tract. Although several tacks are placed directly into the posterior pubis and Cooper’s ligament laterally, care should be
taken because of the close proximity to neurovascular structures. It is unnecessary to reconstruct the peritoneal defect.
(Color version of figure appears online.)
Laparoscopic repair of suprapubic ventral hernias
Figure 12 At the conclusion of the procedure the 10 mm trocar site is closed with a permanent suture using a suture
passer. All sutures are tied, skin is closed in the standard fashion, and sterile dressings are applied. Patients are typically
admitted to the hospital and discharged once their pain is controlled and a diet is tolerated. (Color version of figure
appears online.)
Procedure Outcomes
We published our outcomes in 36 patients (26 females and
10 males) with a mean age of 55.9 years (range, 33-76) and a
mean BMI of 31.0 kg/m2 (range, 22-67) underwent LRSPH.19
Twenty-two (61%) of the repairs were for recurrent hernias,
with an average of 2.3 previously failed open repairs each
(range, 1-11). The mean hernia size was 191.4 cm2 (range,
20-768), with an average mesh size of 481.4 cm2 (range,
193-1428). All repairs were performed with ePTFE. Mean
operating room time was 178.7 minutes (range, 95-290),
with a mean blood loss of 40 mL (range, 20-100). One pa-
tient undergoing her fifth repair required conversion because
of adhesions to previously placed polypropylene mesh. Hos-
pital stay averaged 2.4 days (range, 1-7). Mean follow up was
21.1 months (range, 1-70). Complications (16.6%) in-
cluded: deep venous thrombosis,1 prolonged pain greater
than 6 weeks,1 trocar site cellulitis,1 ileus,1 prolonged se-
roma,1 and Clostridium difficile colitis.1 Hernias recurred in
two of our first nine patients, for an overall recurrence rate of
5.5%. Since initiating the technique of applying multiple su-
tures directly to the pubis and Cooper’s ligament (in the
subsequent 19 patients), no recurrences have been docu-
mented.
Discussion
Hermann Johann Pfannenstiel’s first description of his epon-
ymous incision in 51 patients in 1900, reported no incisional
25
hernias after a 2-year follow up.20 Recent authors cite a 0.04%
to 2.1% incisional hernia rate after Pfannenstiel incision.21,22
There is a paucity of literature regarding the technical aspects
of the repair of suprapubic ventral hernias. Bendavid11 re-
ported the Shouldice Clinic experience repairing parapubic
hernias via an open technique in seven patients. All of his
patients presented with a denuded pubis lacking fascia. He
approached the defect preperitoneally through the space of
Retzius, and placed a polypropylene mesh anchored to the
pubis and Cooper’s ligaments inferiorly, and full-thickness
abdominal wall sutures superiorly. Although recurrence was
not reported, his results were favorable after a 5 to 48 month
follow-up with no infections or seromas. Hirasa17 reported
the first laparoscopic experience with the repair of suprapu-
bic hernias. They employed a composite mesh with a 2 to 3
cm overlap, fixated only with spiral tacks and no transab-
dominal sutures in seven patients. After a 4 to 9 month follow
up in six of the patients, one hernia (14.3%) recurred at 8
months as a result of the mesh pulling off of the abdominal
wall.
There is some evidence to support the use of full-thickness
transabdominal sutures to ensure adequate mesh fixation.2,7,8
Another important aspect of ventral hernia repair is an ade-
quate overlap of mesh from the edge of the hernia defect.2,7
Obtaining adequate overlap to provide the necessary surface
area for mesh-host tissue integration is difficult to achieve in
hernias occurring just above the pubic bone. We develop a
peritoneal flap inferiorly similar to the dissection plane for
26
laparoscopic, transabdominal, preperitoneal, inguinal hernia
repair to identify the critical pelvic structures, and allow for
the safe placement of fixation constructs directly to Cooper’s
ligaments and the pubic bone. We believe this represents the
strongest tissue of the pelvis, holding suture well enough to
rely on them almost exclusively for the inferior fixation of the
mesh. The two recurrences reported in our series occurred in
the first nine patients (5.5% overall recurrence rate).19 The
recurrences occurred just above the pubis before we began to
employ full-thickness, transabdominal sutures incorporating
the periosteum of the pubis. After this modification, no re-
currences have been documented. This underscores the im-
portance of adequate mesh fixation with sutures to the strong
bony or ligamentous structures as opposed to the attenuated
muscle at the hernia’s border.
Although technically demanding, the LRSPH is technically
feasible, safe, and results in a low recurrence rate. It can be
performed with low morbidity in very large and recurrent
hernias. Transabdominal suture fixation to the bony and lig-
amentous structures yields a durable hernia repair.
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