Another double-mesh modality has been proposed by Carbonell-Tatay. It differs from the previous one on the fact that the second mesh adapts to the hernia defect. The incision is performed removing the old scar and the subcutaneous tis­sue is cleared to expose the aponeurosis on about 10 cm around the hernia defect. We discover the edges of the defect and the preperitoneal level, using blunt or electrocautery dis­section. The first prosthesis is placed on the preperitoneal level, with a size bigger than the defect on at least 5 c. and is fixated with transmuscular stitches (PPL 2/0) in U. The stitches are knotted in the end with a soft traction to achieve the complete expansion of the mesh. On this level, we can apply adhesive tissue to minimize the dead space. The sec­ond mesh is adjusted to the edges of the defect and is fixated with continuous suture. On this second mesh, we can pulver­ize the rest of the adhesive. The hemostasis must be rigorous and we must leave two vacuum drainages, like Redon with heavy gauge. We finish by closing the subcutaneous cell tis­sue and the skin. What this options intends is to obtain a solid healing, without tension that restores the biomechanics of the abdominal wall as much as possible (Fig. 17.5) [2, 3].

The supraumbilical optical and the lateral working trocars are placed and the hernia defect is identified. Approximately 4 cm above the defect the peritoneum is opened through the Told fascia to enter into the preperi­toneum. We lower the sheet of peritoneum from the urachus triangular ligament to the iliac crest, widely sur­passing the defect. That way, we reduce the content of the hernia, leaving the posterior abdominal wall free and without interfering with the sigmoid colon or the intesti­nal loop. We identify the bones structures (pubis, Cooper, and iliac crest), the neuro-vascular structures (epigastric

The position of the patient depends on the side of the hernia. The trocars are placed away from the target. The dissection is entirely intra-abdominal. We perform a full adhesiolysis and we can mobilize the liver to increase the cranial overlap. The reconstruction with mesh is sim­ilar to that used on any other medial defect. The exten­sion of the mesh is usually simple on these defects. The fixation must be safe, we advise a double crown and also an adhesive to the rest of the surface of the mesh in con­tact with the posterior abdominal wall (Fig. 17.6E). We must inspect the abdominal cavity and the trocars must

be removed under direct vision. We empty the pneumo­peritoneum slowly and finish the procedure. In our expe­rience, the laparoscopy allows an outpatient treatment of lateral hernia in more than 30% of the cases. Complications are rare and local, seroma or hematoma. Severe complications are exceptional, unlike what hap­pens with medial hernias repair. The hematoma is more frequent on iliac hernias and the seromas on subcostal ones. Pain is more frequent on lumbar hernias treatments. The recurrence rate is at 8.2%, more frequent on subcostal hernias (25%) [9]. The esthetic result is better and there is no associated muscular atrophy. The outcomes of laparo­scopic approach depend on (1) size >15 cm; (2) obesity BMI >30 kg/m2; and (3) the type of subcostal hernia. On these three groups, the laparoscopic approach should be limited. The open approach must be chosen on these three groups of patients and on the cases where muscular atro­phy is associated, previous meshes or damage on the skin. The double- mesh technique is the one that obtains better results on complex lateral hernias (more security and strength). Since lateral hernias are very different (etiology, size, location, evolution of the hernia, muscular atrophy, associated diseases, type of surgeon, experience, etc.) it is not possible to standardize the approach, and thus individ­ual approach is advised. As stated elsewhere, these patients should be managed in experience and specialized centers [8–11, 14, 15].