ORIGINAL ARTICLE
Incisional Hernia: Laparoscopic or Open Repair? Francesco Stipa, MD, PhD, FACS, Valentina Giaccaglia, MD, Antonio Burza, MD, Ettore Santini, MD, Bruno Bascone, MD, and Marcello Picchio, MD
Purpose: To compare laparoscopic and open repair of incisional hernia in terms of complications and failure rates. Methods: Between June 2005 and April 2012, 252 patients underwent incisional hernia repair. Of these, 126 underwent laparoscopic and 126 open repair. The median follow-up was 38.7 months. Results: Baseline characteristics [age, body mass index, American Society of Anesthesiologists (ASA) score, comorbidities, hernia size, and follow-up] did not differ significantly. Mean operative time was similar (72 vs. 83 min). Laparoscopic repair was associated with less postoperative pain, less postoperative complications (3.9% vs. 13.4%, P = 0.012), and shorter hospital stay (3.5 vs. 4.3, P = 0.002). Recurrence occurred in 6 patients of group 1 and in 7 patients of group 2 (4.7% vs. 5.5%, P = not significant). Conclusions: In this study, the trend in favor of laparoscopic treatment for incisional hernias is remarkable. Fewer postoperative complications and shorter hospital stay with similar operative time may balance the higher costs associated with the technique. Key Words: incisional hernia, open repair, laparoscopic repair
(Surg Laparosc Endosc Percutan Tech 2013;23:419–422)
I
ncisional hernia is a protrusion bulging out near or along a prior abdominal surgical incision and represents a rather common complication of a laparotomy. Large hernias may cause a systemic syndrome with respiratory, vascular, and intestinal distress. The incidence of incisional hernias after laparotomy ranges between 10% and 30% and rises up to 30% to 50% in case of postoperative wound infection,1 without substantial improvements overtime.2 In most patients (75%), incisional hernia develops within 1 year after abdominal surgery and in 50% of cases within 6 months. Because of its frequency, incisional hernia has major social and economic implications. Risk factors for incisional hernia can be local or systemic. Local factors are site, type, and length of laparotomy, with transverse incision causing fewer hernia and skin incision wider than 5 cm, excessive tension on the suture, and infection of the abdominal wall causing more complications. Diabetes, chronic use of corticosteroids, connective tissue and respiratory chronic diseases, laxity of the abdominal wall with age, obesity, and malnutrition are recognized as considerable systemic risk factors.2 Recurrence rates range from 25% up to 52% in case of hernia Received for publication May 21, 2012; accepted January 27, 2013. From the Department of Surgery, San Giovanni Hospital, Roma, Italy. Presented in part at the 32nd International Congress of European Hernia Society (EHS), Istanbul, Turkey, October 6 to 9, 2010. The authors declare no conflicts of interest. Reprints: Francesco Stipa, MD, PhD, FACS, Department of Surgery, San Giovanni Hospital, Via dell’Amba Aradam 8, 00186 Roma, Italy (e-mail:
[email protected]). Copyright r 2013 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
repair by direct suture,3 compared with 2% to 36% in case of mesh placement.4–8 In 1993 Le Blanc and Booth9 reported the laparoscopic approach for incisional hernia repair, by applying an intraperitoneal polytetrafluoroethylene (PTFE) mesh overlapping the defect. The laparoscopic repair seems promising with lower rates of complications, but relapses may be similar.10,11 The aim of this study was to compare laparoscopic and open approach of incisional hernia repair in terms of complication and recurrence rates.
MATERIALS AND METHODS Patients Between June 2005 and April 2012, 252 patients with incisional hernia were operated in our Department by 3 experienced surgeons. Of these, 126 patients (group 1) underwent laparoscopic positioning of an intraperitoneal PTFE mesh. A total of 126 patients (group 2) underwent open repair: 42 received intraperitoneal PTFE mesh and 84 polypropylene mesh according to Rives technique. Table 1 shows patients characteristics. Patients presented with abdominal bulging (98%), local pain (66%), severe constipation (30%), and respiratory distress (55%). The site of incisional hernia was median in 89 patients of group 1 and 92 patients of group 2. The mean size of incisional hernia was similar in both groups (10.5 vs. 11.5 cm). Preoperatively, all patients underwent ultrasonography or computed tomography scan in order to assess the site and size of incisional hernia. In case of obesity, pulmonary distress, or huge parietal defects, spirometry was added. Exclusion criteria were American Society of Anesthesiologists (ASA) score IV and urgent operation.
Surgical Technique In both groups, no bowel preparation was used, antithrombotic prophylaxis was administered, and firstgeneration cephalosporin was given 30 minutes before surgery. General anesthesia was used in all cases. Nasogastric tube and bladder catheterization were used just for the duration of the operation in a few selected cases (ie, very large defects or hernia located in the lowed quadrant). In the laparoscopic group, after the induction of pneumoperitoneum with a Veress needle in the left upper quadrant, the first 12-mm trocar was inserted on the left side as far laterally as possible from the parietal defect. A 30-degree laparoscope was used to explore the whole abdominal cavity and the inner face of the anterior wall. Two additional 5-mm trocars were placed under vision forming a triangle. Adhesiolysis and peritoneal sac reduction were performed with blade scissors, coagulation hook, or 5-mm ultrasonic scalpel in case of severe adhesions. After hernia reduction in the abdominal cavity, the size of parietal defect was measured by applying needles for spinal
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TABLE 1. Patients Characteristics
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TABLE 2. Results
Laparoscopy (126)
Open (126)
P
63/63 65 (30-90) 30 (24-35) 99/27 10.5 (5-24)
66/60 62 (29-90) 28 (24-34) 102/24 11.5 (5-22)
— NS NS — NS
Sex (M/F) Median age (y) Median BMI (kg/m2) Site (median/lateral) Size (cm)
BMI indicates body mass index; NS, not significant.
Operative time (min) (± SD) Hospital stay (d, range) Complications (%) Recurrences (%) Median follow-up (mo)
Laparoscopy (76)
Open (76)
P
72 ± 29.2
83 ± 35.2
NS
3.5 (1-14) 5 (3.9%) 6 (4.7%) 38.6
4.3 (2-12) 0.002 17 (13.4%) 0.012 7 (5.5%) NS 38.8 NS
NS indicates not significant.
anesthesia at the 4 cardinal points of the mesh. The mesh (Dual Mesh; Gore) was therefore shaped, marked to facilitate intra-abdominal orientation, rolled, and introduced through the 12-mm trocar. It was applied over the hernia with 4 transparietal stitches so that it overlapped the defect by at least 3 cm in all directions with a Berci needle. Finally, the mesh was fixed by a single ring made of 5-mm spiral titanium tacks distanced 1 cm one from the other (ProTack; Covidien, Mansfield, MA). In the open procedure (group 2), a polypropylene mesh (Surgimesh) was applied under the rectus abdominis muscle according to the Rives-Stoppa technique. This is an open procedure in which the prosthesis is positioned extraperitoneally as a sublay with wide overlapping coverage of the fascial defect to achieve a tension-free closure that also maximizes the surface area for tissue ingrowth through the mesh. In the original description of the Stoppa repair, the prosthesis placement is in the intraparietal plane, deep to the transversalis fascia, and superficial to the peritoneum.4,6 A later modification for ventral hernias placed the prosthesis anterior to the posterior rectus sheath and posterior to the rectus abdominis muscles.12 This technique allows extensive overlap between the prosthesis and the fascial edges with a tension-free closure, as well as a large surface area for tissue incorporation. In some patients of group 2, especially in those with a very large defect (xifo-pubic incisional hernia), there was a lack of the posterior sheath of the rectus and/or the peritoneal layer and a PTFE mesh was used. In all patients, we routinely applied a compression dressing for 2 days, followed by abdominal binder for 4 weeks.
Data Collected intraoperative data included: mean operative time, size of the parietal defect, complications such as intestinal injury or bleeding. Postoperative data concerned mean hospitalization, complications (pain, hematoma, seroma, granuloma, wound, or mesh infection), recurrences, and deaths. A visual analog scale (VAS) was used for pain measuring: from 0, no pain, to 10, worse imaginable pain.13 Follow-up evaluation consisted of physical examination 1 week, 1 to 6, and 12 months after surgery. Ultrasonography was used only in case of suspected complication. Clinical control after 12 months was completed in 102 patients of both groups.
Statistical Analysis Data were expressed as mean for absolute numbers and percentage. Statistical analysis was done using the Student t test to assess differences between the 2 study
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groups. A P value 10 cm), with VAS at 24 hours in the laparoscopic and open groups of 5 versus 8, respectively (Table 3). Table 4 shows postoperative complications occurring in 5 patients of group 1 (3.9%) and 17 of group 2 (13.4%), P = 0.012. In group 1, 3 patients developed hematoma, 1 granuloma ultrasonographically detected and medically treated, and 1 patient complained of local chronic pain at 1 month and successfully treated with conservative therapy. In group 2, complications consisted of 1 hemorrhage requiring blood transfusions the first postoperative day, 3 hematomas (of whom 1 was treated with blood transfusion), 7 seromas (of whom 2 treated with evacuation in the outpatient clinic), 4 wound infections, and 1 mesh infection requiring its removal. All 4 cases of wound
TABLE 3. Pain Evaluation According to Visual Analog Score (VAS) Laparoscopy Defect >10 cm Open Defect >10 cm
At 24 h
At 48 h
At 72 h
P
4 5 7 8
3 3 6 7
2 2 4 4
NS
NS indicates not significant.
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TABLE 4. Intraoperative and Postoperative Complications
Laparoscopy (126) Intestinal injury Hemorrhage Hematoma Seroma Chronic local pain Granuloma Wound infection Mesh infection Mortality Total (%)
3 1 1
5
0 0 (2.3%) 0 (0.7%) (0.7%) 0 0 0 (3.9%)
Open (126) 1 1 3 7
(0.7%) (0.7%) (2.3%) (5.5%) 0 0 4 (3.1%) 1 (0.7%) 0 17 (13.4%)
P NS NS NS NS NS NS NS NS NS 0.012
NS indicates not significant.
infections were registered in obese patients (BMI > 30) undergoing repair of big defects (>10 cm). Relapse occurred in 6 patients (4.7%) of the laparoscopic group (of whom 1 at the site of trocar insertion) and in 7 patients (5.5%) of the open group. Between these 13 cases with relapses, more than half (8 patients) were recurrent incisional hernias, 10 patients were obese, and all of them had a huge parietal defect (> 18 cm). In conclusion, there were no major complications, except for 1 postoperative hemorrhage requiring blood transfusion.
DISCUSSION Incisional hernia is a common complication of abdominal surgery, and the optimal surgical treatment is still under debate. Few studies comparing laparoscopic and open surgical repair are available in the literature. The majority are retrospective and the few randomized generally provide short-term follow-up evaluation on small cohorts of patients.14,15 Sajid et al16 in 2009 published a meta-analysis of 5 randomized controlled trials with a total of 366 patients. They conclude that laparoscopic repair is a safe and effective alternative to open techniques and is associated with shorter operative time and hospitalization and lower incidence of perioperative complications. However, there were no differences between the 2 techniques in terms of recurrence rates and postoperative wound pain. In our series, the baseline characteristics (mean age, BMI, symptoms, and hernia size) in the 2 groups of patients were comparable. Despite learning curve, mean operative time was slightly shorter in the laparoscopic group, although the difference with the open group was not statistically significant. Postoperative pain, measured with VAS scale, was higher in group 2, even though the difference between the 2 groups was not statistically significant. In particular, the difference was more remarkable in patients with huge parietal defect (>10 cm), probably due to large skin incision and extensive tissue dissection in the open group (Table 3). In our series, the most frequent complications in the open group were seroma and hematoma (5.5% and 2.3%, respectively). These percentages are higher than those reported in the literature, for instance Heniford et al17 enrolled 850 patients with only 0.4% of hematomas. In the laparoscopic approach, the sac is not resected, creating an r
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Incisional Hernia: Laparoscopic or Open Repair?
empty space between the prosthesis and the abdominal wall, with possible seroma formation. In our study, 7 patients of the open group and none of the laparoscopic group developed postoperative seroma and of these only 2 required ambulatory aspiration. Most surgeons, including us, drain only persistent or symptomatic seromas. As reported by Rives and Stoppa, the high wound infection rate associated with open anterior repair (12% to 20%) seems to be due to extensive tissue dissection and drainage placement.4–6,12 Laparoscopic repair is likely to be a better approach avoiding direct contact of the mesh with the skin and not requiring wide lateral dissection and postoperative drainage. In our series, among the 4 patients in the open group with wound infection, only 1 required reintervention for the prosthesis removal. All patients with wound infection were obese. Recurrence rates in the laparoscopic approach are reported to be lower than the open one, in the range of 0% to 11%.17–19 In our experience, there were 7 relapses in the open group (5.5%) and 6 in the laparoscopic group (4.7%). According to Heniford et al,17 prior unsuccessful open repair attempt, large parietal defect, and postoperative complications represent the most important risk factors for the development of recurrences. In fact, in our experience, between these 13 cases with relapses, more than half were recurrent hernias, 10 were obese, and all of them had a huge parietal defect (> 18 cm). In agreement with Perrone et al,20 we believe that the negative outcome of incisional hernia repair may be attributed to the use of small mesh, inadequate mesh fixation and, above all, the lack of experience in the surgeon. Interestingly, among the several techniques of mesh fixation, the application of both single-crown and doublecrown spiral tacks distanced 0.5 to 1 to 2 cm one from the other is universally accepted by surgeons, whereas transfascial suture is used in the range of 26% to 97% of investigators,21 despite its possible role in avoiding mesh shrinkage or migration. We use single-crown titanium tacks and at least 4 transabdominal nonabsorbable stitches at the cardinal points of the mesh applied with the aid of a suture passer (Berci needle). We believe that the combined use of single-crown tacks and transabdominal stitches may respectively reduce postoperative pain and relapses. Recently, the introduction of a new absorbable clip applicator seems to be promising in the reduction of postoperative pain and visceral adhesions formation. Concerning mesh fixation, a recent randomized trial comparing transfascial sutures with metal taks, reported more pain within the first 6 postoperative weeks but less mesh shrinkage after 6 months in the transfascial sutures group.22 Single-port access ventral hernia repair has been proposed.23 The single-access incision should not be larger than a conventional laparoscopic port. The advantages in terms of reduced parietal trauma, postoperative pain, and cosmesis are under evaluation.24,25 This study was not randomized and follow-up was shorter than 3 years. In fact, a follow-up of at least 3 years has been shown to be important to correctly assess the recurrence rate.26 In conclusion, laparoscopic repair of incisional hernia is a safe, feasible, and effective alternative to traditional open techniques, especially in obese patients, multiple parietal defects, and recurrent incisional hernia. Open approach is indicated when the size of the weakened area is smaller than 4 cm or wider than 12 cm. In this study, the www.surgical-laparoscopy.com |
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trend in favor of laparoscopic treatment for incisional hernias is remarkable. Fewer postoperative complications with similar operative time and hospital stay may balance the higher costs associated with the technique. Further investigation with a larger patient sample and a careful monitoring of longer follow-up are needed to confirm these preliminary results. REFERENCES 1. Pham CT, Perera CL, Watkin DS, et al. Laparoscopic ventral hernia repair: a systematic review. Surg Endosc. 2009;23:4–15. 2. Rudmik LR, Schieman C, Dixon E, et al. Laparoscopic incisional hernia repair. Hernia. 2006;10:110–119. 3. Hesselink VJ, Luijendijk RW, de Wilt JH, et al. An evaluation of risk factors in incisional hernia recurrence. Surg Gynaecol Obstet. 1993;176:228–234. 4. Stoppa R, Henry X, Verhaeghe P, et al. Trends in the surgical treatment of chronic dehiscences of the abdominal walls. Bull Acad Natl Med. 1981;165:493–501. 5. Stoppa R, Louis D, Henry X, et al. Postoperative eventrations: apropos of a series of 247 surgically treated patients. Chirurgie. 1985;111:303–305. 6. Stoppa RE. The treatment of complicated groin and incisional hernia. World J Surg. 1989;13:545–554. 7. Van der Linden FT, van Vroonhoven TJ. Long term results after surgical correction of incisional hernia. Neth J Surg. 1988;40:127–129. 8. Toniato A, Pagetta C, Bernante P, et al. Incisional hernia treatment with progressive pneumoperitoneum and retromuscular prosthetic herniplast. Lagenbecks Arch Surg. 2002;387:246–248. 9. Le Blanc KA, Booth WV. Laparoscopic repair of incisional abdominal hernias using expanded polytetrafluoroethylene: preliminary findings. Surg Laparosc Endosc. 1993;3:39–41. 10. Le Blanc KA, Booth WV, Whitaker JM, et al. Laparoscopic incisional and ventral herniorrhaphy: our initial 100 patients. Hernia. 2001;5:41–45. 11. Chowbey PK, Sharma A, Khullar R, et al. Laparoscopic ventral hernia repair. J Laparoendosc Adv Surg Tech. 2000;10: 79–84. 12. Rives J, Pire JC, Flament JB, et al. Treatment of large eventrations: new therapeutic indications apropos of 322 cases. Chirurgie. 1985;111:215–225.
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13. Anonymous. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms— prepared by the International Association for the Study of Pain, Subcommitee on Taxonomy. Pain Suppl. 1986;3: S1–S226. 14. Olmi S, Scaini A, Cesana GC, et al. Laparoscopic versus open incisional hernia repair. Surg Endosc. 2007;21:555–559. 15. Asencio F, Aguilo J, Peiro S, et al. Open randomized clinical trial of laparoscopic versus open incisional hernia repair. Surg Endosc. 2009;23:1441–1448. 16. Sajid MS, Bokhari SA, Mallick AS, et al. Laparoscopic versus open repair of incisional ventral hernia: a meta-analysis. Am J Surg. 2009;197:64–72. 17. Heniford BT, Park A, Ramshaw BJ, et al. Laparoscopic repair of ventral hernias: nine years’ experience with 850 consecutive hernias. Ann Surg. 2003;238:391–399. 18. Carbajo MA, Martyn del Olmo JC, Blanco JI, et al. Laparoscopic treatment vs open surgery in the solution of major incisional and abdominal wall hernias with mesh. Surg Endosc. 1999;13:250–252. 19. Ramshaw BJ, Esartia P, Schawb J, et al. Comparison laparoscopic and open ventral herniorrhaphy. Am Surg. 1999;65:827–831. 20. Perrone JM, Soper NJ, Eagon C, et al. Perioperative outcomes and complications of laparoscopic ventral hernia repair. Surgery. 2005;138:708–716. 21. Park A, Birch DW, Lovrics P. Laparoscopic and open incisional hernia repair: a comparison study. Surgery. 1998; 124:816–822. 22. Beldi G, Wagner M, Bruegger LE, et al. Mesh shrinkage and pain in laparoscopic ventral hernia repair: a randomized clinical trial comparing suture versus tack mesh fixation. Surg Endosc. 2011;25:749–755. 23. MacDonald E, Pringle K, Ahmed I. Single port laparoscopic repair of incarcerated ventral hernia. Hernia. 2009;13:339. 24. Podolsky ER, Mouhlas A, As Wu, et al. Single-port access (SPA) laparoscopic ventral hernia repair: initial report of 30 cases. Surg Endosc. 2010;24:1557–1561. 25. Bucher P, Pugin F, Morel P. Single-port access prosthetic repair for primary and incisional ventral hernia: toward less parietal trauma. Surg Endosc. 2011;25:1921–1925. 26. Anthony T, Bergen PC, Kim LT, et al. Factors affecting recurrence following incisional herniorrhaphy. World J Surg. 2000;24:95–100.
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