Incisional Hernia: The Open Approach, Introducing MILA Technique (Minimally Invasive Laparotomy Approach)

Before the advent of minimally invasive techniques for ventral hernia surgery, optimal access for an open retromuscular repair (Rives-Stoppa-Wantz technique) could only be achieved at the expense of large high morbidity incisions [1]. It should be the aim of the surgeon to employ the type of incision considered to be the most suitable for that particular hernia repair to be performed. In doing so, three essentials should be achieved: accessibility, extensibility, and security [1]. The incision must not only give ready access to the abdominal wall anatomy to be investigated but also provide sufficient room for the operation to be performed [2]. The incision should be extensible in a direction that allow for any probable enlargement of the scope of the operation, but it should interfere as little as possible with functions of the abdominal wall surgery. The surgical incision and the resultant wound represent a major part of the morbidity of the abdominal wall surgery. The incision must be tailored to the patients need but is strongly influenced by the surgeon’s preference and experience. For any open incisional hernia repair, the best is to go through the previous laparotomy incision, because this minimizes further loss of tensile strength of the abdominal wall by avoiding the creation of additional fascial defects [3]. Care must be taken to avoid “tramline” or “acute angle” incisions, which could lead to devascularization of tissues. Cosmetic end results of any incision in the body are most important from patient’s point of view. Consideration should be given wherever possible, to siting the incisions in natural skin creases or along Langer’s lines. Good cosmesis helps patient morale. Much of the decision about the direction and the length of the incision depends on the type of hernia defect and the previous scar position but also on the shape of the abdominal wall. Traditionally, for an open retromuscular ventral hernia repair, a generous midline laparotomy is required, but there are some cases in which it is possible to adopt our MILA (minimally invasive laparotomy approach) technique with the same excellent results. Elliptical incisions can be used to incorporate previous scars, skin ulcerations, and/or defects. For most, and especially morbidity obese, patients with large midline hernias, an excision of the umbilicus to minimize postoperative wound morbidity is possible.