Following trocar placement , adhesiolysis is performed sharply with limited use of electrosur­gery or ultrasonic coagulators. This is another critical step for a safe LVHR. Inadvertent and unrecognized bowel injuries can cause signifi ­cant morbidity and even mortality. Missed enter­otomy during LVHR remains the most common reason for malpractice litigation. Reduction of the hernia contents is performed using blunt graspers and sharp dissection from the inside and

any persistent cellulitis and/or persistent fl uid col­lection around the intra- peritoneal mesh should be a point of concern for acute or chronic prosthetic infection, especially if ePTFE-based mesh was used. Open exploration, mesh removal, primary hernia repair, and delayed formal reconstruction are the best and safest ways to approach infected mesh after LVHR.

Intra-operative complications such as bleeding or injury to surrounding intra-abdominal structures are rare. Nonetheless, an enterotomy or missed enterotomy will signifi cantly impact the outcome of surgery. An enterotomy identifi ed during surgery with spillage of enteric content within the abdomen should cause the surgeon to re-evaluate the opera­tive plan. The enterotomy can be repaired laparo­scopically if it is well visualized and ports are optimally placed. If there is any question about the integrity of laparoscopic repair of the enterotomy, conversion to a laparotomy is mandatory. With gross spillage of enteric content, a formal hernia repair should be delayed. Missed enterotomy or a delayed bowel injury from electrocautery resulting in intra- abdominal sepsis and mesh infection would require laparotomy, repair of the bowel injury, and complete excision of the mesh. Failure to com­pletely remove the mesh would almost certainly lead to persistent intra-abdominal infection.