Incisional hernia of the abdominal wall is one of the common complications after abdominal surgery and obstetrics and gynecology, especially lower abdominal surgery. The incidence of incisional hernia can be even higher up to 40% after incisional infection, and surgical treatment is the only cure. Since the second half of 2009, we have performed laparoscopic repair in three patients with huge incisional hernias with success. Combined with the literature review, we will discuss some experiences. 1. Clinical data 1.1 General information All three cases were female patients with an average age of 64.3 years. Two cases were appendectomies (one of them had postoperative incisional infection) and one case was a hysterectomy with a median incision in the lower abdomen. All were classified as giant incisional hernia (maximum distance of hernia ring ≥10 cm) according to the classification criteria of the Hernia and Abdominal Wall Surgery Group of the Chinese Medical Association Surgery Branch. Those with one of the following conditions were excluded from this group: (1) diseases that cannot tolerate general anesthesia and laparoscopic surgery, such as cardiopulmonary insufficiency; (2) particularly huge incisional hernia with insufficient space for laparoscopic operation; (3) extensive dense adhesions in the abdominal cavity that prevent puncture of the trocar and establishment of pneumoperitoneum; (4) other conditions that are not suitable for patch implantation, such as abdominal infection, ascites or acute abdominal disease. 1.2 Surgical procedure After successful anesthesia, the abdominal wall was carefully examined to determine the site, size and shape of the hernia ring and marked, and a suitable patch was selected. A 10-mm Trocar was placed under the glabella as a visual hole, and two other 5-mm Trocars were placed away from the edge of the hernia ring, requiring the Trocar placement point to be as far away as possible from the original incision and hernia ring, and a certain distance between the Trocars to prevent mutual interference between the inserted instruments. The abdominal pneumoperitoneum pressure is 12-14 mm Hg. The large omentum and the intestinal canal are separated from the abdominal wall, and the hernia contents are retracted to reveal the hernia ring. Care was taken not to damage the intestinal canal during the procedure. After separation of the adhesions, the entire abdominal wall is explored to prevent missing the occult hernia. The shape and size of the hernia ring are measured and determined, and a suitable patch is selected. The shape of the hernia ring is drawn on the patch, taking care to ensure that the patch is more than 5 cm beyond the hernia ring. The patch is knotted with a common suture every 1 cm according to the image of the hernia ring, preserving the ends of the sutures; the outer circumference of the patch is knotted with a common suture every 2-3 cm from the edge, preserving the ends of the sutures. The thread end of the retained suture is placed on the same side of the patch, and the thread end is rolled up inside the patch. The rolled-up patch is placed into the abdominal cavity through a 10-mm poke hole and spread over the intra-abdominal organs, with the tip of the thread toward the abdominal wall. The sutures reserved on the patch were drawn out one by one with a crochet hook from the skin of the abdominal wall at 1 cm intervals according to the hernia ring drawn before anesthesia, and tightened; the sutures reserved around the patch were also drawn out with a crochet hook. After completion of the incisional hernia repair of the abdominal wall, the pneumoperitoneum was released and the incision was sutured after checking that there was no bleeding from the puncture hole. The lap band was wrapped with pressure. Routine postoperative treatment. 2. Case 1 was discharged from the hospital on the 9th postoperative day after bed activity on the first day and anal venting on the second day; after discharge, a plasmacytoma appeared at the hernia sac site, which was cured by puncture and fluid extraction three times and lap band compression bandaging. Case 2 had an operation time of 90 minutes, and was given a semi-liquid diet on the second day after surgery, and developed abdominal pain and distention after eating, which improved after fasting, and then developed abdominal pain and distention again after eating, which lasted for about 10 days, and after symptomatic treatment, the symptoms gradually relieved, and was discharged on the 15th day after surgery. He was discharged from the hospital two months later with no discomfort. There were no complications such as hematoma, intestinal tube injury and intestinal fistula. In the postoperative follow-up, the abdominal wall at the site of hernia repair felt constricted within a short period of time, and there was no recurrence. 3. Discussion Surgical treatment is the only way to cure incisional hernia. The traditional surgical methods include resuturing and patch repair. The open suture repair method has a high tension and a recurrence rate of 40% to 50%, and is basically no longer used; while tension-free repairs with a mesh have a low recurrence rate of about 10%, but the large incisional separation surface makes the incision prone to postoperative pain, fluid accumulation and even secondary infection leading to repair failure. Since the introduction of laparoscopic incisional hernia repair by LeBlanc et al. in 1991, laparoscopic incisional hernia repair has become increasingly popular worldwide with its great advantages as an alternative to open tension-free repair with a recurrence rate of only 2%. 3.1 Advantages of laparoscopic incisional hernia repair Bencini et al. compared 42 laparoscopic incisional hernia repairs with 49 open patch incisional hernia repairs and showed that the length of stay, incisional infection rate, postoperative analgesic use and postoperative recurrence rate were lower in the laparoscopic group than in the open group. The advantage of laparoscopic surgery is that a truly tension-free repair is performed beneath the defect, and after inflation, the omental adhesions beneath the original incision are visible. By separating the adherent omentum, the hernia ring is clearly visible, and hidden incisional hernias that are difficult to detect with open surgery can be found for repair. In contrast, dissection requires separation of the gap to accommodate the patch, which requires greater dissection and separation of the abdominal wall tissues, resulting in extensive abdominal wall tissue damage and increased postoperative pain, as well as a higher incidence of postoperative complications such as hematoma, seroma, and incisional infection. By poking holes in the normal abdominal wall away from the original incision, the adherent gastrointestinal tissues are separated from the surrounding area toward the incision site to avoid damage to the gastrointestinal tract, and then the synthetic material (Mesh patch) is reinforced with sutures to repair from the inside, the surgical access is far away from the original incisional hernia, reducing the infection of the implanted material, the abdominal wall tissue does not need to be widely freed, preserving the strength of the abdominal wall, and reducing various incision-related complications. Also, the fixed patch does not require suturing through the abdominal wall, and postoperative pain is greatly reduced. Therefore, laparoscopic repair has a significantly lower postoperative complication rate than conventional open surgery, with the advantages of less trauma, less bleeding, faster postoperative recovery, and lower recurrence rate. 3.2 Disadvantages of laparoscopic incisional hernia repair Tension-free repair of laparoscopic incisional hernia of the abdominal wall is more difficult, requires higher surgical technique, requires a relatively long learning curve, and demands a higher level of operator skill. Laparoscopic patches and fixation devices are more expensive than those used in open incisional disease, where the patch is placed in front of the peritoneum. In addition, laparoscopic surgery is contraindicated in patients with poor general condition, especially in those with cardiopulmonary insufficiency who cannot tolerate pneumoperitoneum; laparoscopic repair is also contraindicated in those with particularly large incisional hernias, where the surrounding abdominal wall tissue is too small for puncture cannulae to be placed. Spiral nails are commonly used to fix the patch during treatment, but they are not only expensive, but also have the potential to cause intestinal adhesions and even intestinal fistulae. The fixed patch often does not match well with the abdominal wall, and after repair, there is often a gap between the patch and the hernia sac, which affects the repair effect and makes it easy to form a plasmacytoma; on the other hand, the hernia defect is somewhat enlarged in the pneumoperitoneum compared with the normal natural condition, so there is a certain amount of folding after the patch is fixed and the pneumoperitoneum is released. The multi-point suspension we use avoids the problems caused by the spiral nail. There exists intestinal tube injury, postoperative intestinal obstruction and postoperative pain due to improper operation. If intraoperative intestinal injury is suspected, a thorough exploration should be performed immediately and the next step should be decided according to the degree of injury. For milder injuries, they can be treated laparoscopically or through an incision of several centimeters in the abdominal wall corresponding to the injury site; for more severe injuries, an open abdomen is necessary. 3.3 Key points of repair 3. 3.1. Location of Trocar and separation of abdominal wall (1) The Trocar should be placed far from the original surgical incision to avoid intra-abdominal adhesions and to facilitate surgical operation, and the Trocar can be placed either by puncture into the abdomen or by incision into the abdomen; (2) Under the laparoscopic view, the intestine and the hernia sac look similar, so special care should be taken to avoid the intestinal canal (3) Separate the tissues around the hernia ring and try to separate all the tissues adhering to the abdominal wall to avoid missing occult or multiple, coexisting hernias or abdominal wall defects. 3. 3.2. Positioning and fixation of the patch The size and fixation position of the patch are determined under pneumoperitoneum-free conditions, and the corresponding markings are made on the patch and abdominal wall. The advantage is that the patch is fixed in its natural state and the patch is well matched to the abdominal wall, achieving a truly tension-free repair. The patch should be fixed densely, with one stitch at 1-1.5 cm of the hernia ring opening and one stitch at 2-3 cm of the patch edge. In addition, the use of a fuse instead of a spiral nail significantly reduces the cost of surgery and avoids the residual metal foreign body and related complications. 3.3.3. Size and material of the patch Laparoscopic incisional hernia repair requires the edge of the patch to be 3-5 cm beyond the hernia ring, and also has strict requirements for the material of the patch. Direct contact between the polypropylene patch and intra-abdominal organs can cause serious tissue inflammation, which has been reported to lead to severe intestinal adhesions and intestinal fistula formation and cannot be used for laparoscopic incisional hernia repair. Laparoscopic incisional hernia repair must use expanded polytetrafluoroethylene (ePTFE) patch, polypropylene mesh combined with absorbable material (PROCEED patch, PCO anti-adhesion patch, etc.), and must be made with the anti-adhesion side facing the abdominal cavity and the mesh side rough and facing the abdominal wall to strengthen the tissue connection, thus achieving a safe and effective abdominal wall repair. 3.4. Postoperative complications Plasmacytoma formation is one of the most common complications after laparoscopic incisional hernia surgery, especially in huge incisional hernia, where foreign body reaction is more likely to occur in the tissue because the hernia sac is not removed and there is a gap between it and the composite patch. Generally, puncture drainage and lap band pressure dressing can be performed to cure it. However, attention should be paid to aseptic operation to prevent infection of the patch due to puncture. There is a high rate of significant postoperative pain. The main manifestation is significant pain in the area of repair, which is worse and longer in those with lower abdominal incisional hernia repair. This is due to the fact that the tissues have not yet grown into the patch in the early stage and intra-abdominal tension is concentrated at the stapling point; and the force on the lower abdomen is significantly higher than that on the upper abdomen, resulting in increased and longer duration of postoperative pain. It usually resolves after 3 to 6 weeks. In our 3 cases, there was no significant pain, but rather a tightness in the lower abdomen (repair patch), which persisted for 1-2 months and gradually resolved. The manifestations of incomplete intestinal obstruction such as abdominal distension and abdominal pain, which mostly occur in patients with larger incisional hernias, are caused by the significant reduction of abdominal volume after repair compared with the preoperative period, as well as the inflammatory response caused by anesthesia and patching and the weakening of intestinal peristalsis due to surgical manipulation, and require only symptomatic treatment, and usually do not require special treatment and can resolve on their own in 1-2 weeks. However, special attention should be paid to distinguish abdominal distension caused by acute gastric dilatation or urinary retention, and gastrointestinal decompression and urinary catheter must be placed promptly. Others, such as intestinal tube injury, bleeding and hematoma, are often related to surgical operation; while urinary retention, intestinal obstruction, infection (material placement can promote infection), perforation hole hernia and recurrence, as well as material displacement and wrinkling, are not universal and may vary depending on the wound healing process and individual response, and need further study.