|Year : 2019 | Volume
| Issue : 2 | Page : 517-521
Comparative study of laparoscopic versus open repair of incisional hernia
Mohammed Leithy, Ashraf A Elhady, Asem Fayed, Ahmed Elghazaly
Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||05-Dec-2017|
|Date of Acceptance||09-Jan-2018|
|Date of Web Publication||25-Jun-2019|
Source of Support: None, Conflict of Interest: None
The aim was to compare between laparoscopic and open repair of incisional hernia regarding the technique and outcome.
One of the most common complications of laparotomy is incisional hernia, with an estimated incidence of 3–20% after laparotomy.
Materials and methods
This clinical trial was conducted on 100 patients presented with ventral incisional hernia to Menoufia University Hospital, General Surgery Department, during the period from June 2015 to August 2017. They were randomly distributed into two groups: 50 cases had open repair and 50 cases had laparoscopic repair. Operative and postoperative details were recorded and compared. Follow-up was conducted for 1 year after surgery.
The mean postoperative hospital stay was longer in the open group than laparoscopic group (2.72 ± 0.68 vs. 1.92 ± 0.69 days, P < 0.001). The total postoperative complications were more in the open group than laparoscopic group (23 vs. 13, P = 0.03). The mean operative time of laparoscopic repair was significant statistically longer than the open repair (151.9 ± 20.07 vs. 106.6 ± 13.77 min, P < 0.001). Short-term postoperative pain was more intense in the open repair group than the laparoscopic group (4.72 ± 1.10 vs. 3.78 ± 1.30, P < 0.001).
Laparoscopic incisional hernia repair is a safe alternative to open incisional hernia repair. We recommend increased application of laparoscopic repair of incisional hernia and a large multicenter randomized trial with long follow-up to measure the long-term results.
Keywords: hernia, incisional, laparoscopy
|How to cite this article:|
Leithy M, Elhady AA, Fayed A, Elghazaly A. Comparative study of laparoscopic versus open repair of incisional hernia. Menoufia Med J 2019;32:517-21
|How to cite this URL:|
Leithy M, Elhady AA, Fayed A, Elghazaly A. Comparative study of laparoscopic versus open repair of incisional hernia. Menoufia Med J [serial online] 2019 [cited 2019 Sep 17];32:517-21. Available from: http://www.mmj.eg.net/text.asp?2019/32/2/517/260927
| Introduction|| |
Incisional hernia is a common complication of gastrointestinal surgery. The incidence varies from 2 to 20%. Abdominal wound dehiscence and incisional hernia can both be thought as forms of wound failure, which may be defined as the failure of the incision to heal and to maintain the normal anatomy of the abdominal wall. The goals of incisional hernia repair, regardless of the etiology of the defect, are to re-establish the integrity of the myofascial layer and provide durable cutaneous coverage while minimizing the risk of hernia recurrence. Incisional hernia repair is strongly associated with recurrence, leading to further morbidity and patient dissatisfaction, together with the associated health care and economic costs. There are three major indications to repair an incisional hernia: if the hernia is symptomatic, causing pain or alterations in the bowel habits; when the hernia results in a significant protrusion that affects the patient's quality of life; and when the hernia poses a significant risk of bowel obstruction (such as a large hernia with a narrow neck). During the past 50 years, incisional hernia repair surgery has evolved from direct suture repair to the use of synthetic mesh to obtain a tension-free repair. Finally, the tension-free concepts have been applied to laparoscopic surgery. Primary suture repair of hernias with a large diameter is considered to be inadequate owing to unacceptable high recurrence rates after suture repair. Closure of the hernia defect by re-approximating the fascia in the midline is a real advantage of the open repair. By closing the fascia in the midline with mesh, the patient should have reinforced repair, which has advantages from a functional point of view and from a mesh incorporation aspect. The laparoscopic approach takes advantage of the wide exposure and accessibility for prosthetic mesh placement and avoiding the large incision, extensive subcutaneous dissection and tissue flaps, and the need for drains, and consequently leading to lowering the rate of wound complications. The short-term postoperative pain can be assessed by the well-known visual analog scale and numeric rating scale for assessment of pain intensity, and both scales are equally sensitive in assessing short-term pain after surgery. The aim of the study was to compare between laparoscopic and open repair of incisional hernia regarding the technique and outcome.
| Materials and Methods|| |
This clinical trial included 100 patients who were diagnosed to have ventral incisional hernia. The patients presented to Menoufia University Hospital, General Surgery Department, during the period from June 2015 to August 2017. Patients were randomly divided into two groups: group I included 50 patients who were operated by open repair and group II included 50 patients who were operated by laparoscopic repair. Inclusion criteria were adult patient 18–80 years old or more who had ventral incisional hernia. Exclusion criteria were patients with recurrent incisional hernia; patients with complicated hernia, for example, intestinal obstruction; incarceration; those with morbid obesity; and those with huge organomegaly. The approval to conduct the study was obtained from our institutional ethical committee before commencing the enrollment of patients. Written and informed consent was obtained from all the patients who participated in the study. All cases were operated under general anesthesia. In the open repair group, subcutaneous flaps were raised for 5 cm around the defect. The defect was closed when possible by prolene 0 sutures. Light-weight prolene mesh was used in onlay position [Figure 1] and fixed by prolene 2-0 sutures over distance of 5 cm around the defect. Skin closure was done over suction drain. On the contrary, in the laparoscopic repair group, creation of pneurnoperitoneurn was done by Veress needle, open technique (Hasson), or using the 10 mm optical port away from the lesion. A 30° telescope was introduced away from the margin of the defect. Two additional 5 mm ports were added, and extra ports were used according to the need. Omental and bowel adhesions were dissected. The defect was identified and additional defects carefully looked for. The hernial defect was closed in most cases using V lock sutures or polydioxanone suture (PDS) [Figure 2] whether bridging technique was used. A composite mesh of appropriate size was used to overlap all the defects, on the peritoneal surface, with a margin of at least 4–5 cm. Mesh fixation was done with transfascial sutures and 5 mm absorbable tacks [Figure 3]. The pressure was reduced to 6–8 mmHg during mesh fixation. An intraperitoneal drain was inserted in case of dissection of extensive adhesions. Postoperative care: patients were made ambulatory on the next day in case of open repair and on the same day of operation, at evening, in case of laparoscopic repair. For the immediate postoperative pain relief, injectable diclofenac sodium 50 mg intramuscular was used. Later oral diclofenac 50 mg tablet was used. Pain assessment was done on the first postoperative day according to numeric rating scale where 0 means no pain and 10 means maximum imaginable pain. Orals were usually started on the first postoperative day in laparoscopic repair group and on first to second day in open repair group. Food intolerance was considered as ileus. After discharge from hospital, patients were called for follow-up at 1 week, 4 weeks, 12 weeks, 6 months, and 1 year thereafter. The following complications during the postoperative period were looked for: wound complications, seroma, hematoma, ileus, and recurrence. Statistical analysis was done. A clinical trial study was used. Sample size was calculated using the following formula where From Z tables at type I error of 5%, ZB= 0.842 (from Z tables of 80% power). P1–P2= difference in proportion of events in the two groups (0.25–0.05 = 0.20). As the research hypothesis depends on the reduction of postoperative complication from 25% by open repair to 5% by laparoscopic repair. P = pooled in each group, with a total of 100 participants. Data were collected and analyzed. SPSS statistics, Version 16, was used for statistical analysis (SPSS; International Business Machines Corporation (IBM), Armonk, New York, USA). The groups were compared using the χ2-test or Fisher's exact test for the categorical variables and the t-test for the continuous variables. A P value less than 0.05 was considered significant.
| Results|| |
Regarding age, the mean age for open repair group was 49.1 ± 10.90 years, whereas it was 49.84 ± 8.72 years for the laparoscopic group. There was no significant difference between both groups, as P = 0.7 [Table 1]. Regarding sex, the study included 48 male participants, 23 in the first group and 25 in the second one, and 52 female participants, 27 in the first group and 25 in the second one. The P value was 0.1, showing no statistical significant difference between the two groups [Table 1]. Regarding the operative time, the mean operative time of laparoscopic repair was significant statistically longer than the open repair (151.9 ± 20.07 vs. 106.6 ± 13.77 min, P < 0.001) [Table 2]. No conversion of laparoscopic repair was recorded. As for postoperative hospital stay, the mean postoperative hospital stay was longer in the open group than laparoscopic group (2.72 ± 0.68 vs. 1.92 ± 0.69 days, P < 0.001), which shows significant statistical difference [Table 2]. Regarding short-term postoperative pain, the mean scale for pain intensity was 4.72 ± 1.10 for the first group, and 3.78 ± 1.30 for the second group. There was a significant statistical difference, as P value was less than 0.001, denoting less pain intensity in the laparoscopic group [Table 2]. Postoperative complications were more in the open group than laparoscopic (23 vs. 13), with P = 0.03. The most significant is the superficial wound infection rate where it was significantly more in the first group, with P value of 0.05 [Table 3].
|Table 2: Duration of postoperative hospital stay, short-term postoperative pain, and operative time among the studied groups|
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|Table 3: Operative and postoperative complications among the studied groups|
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| Discussion|| |
Incisional hernia repair is one of the most common operations performed in everyday clinical practice. Incisional hernia is a common long-term complication of abdominal surgery and is estimated to occur in 11–20% of laparotomy incisions. The widespread concept of tension-free repair of incisional hernia with mesh has resulted in a reduced recurrence rate compared with direct suture approximation. The next significant change has been the minimally invasive laparoscopic approach. In our study, the mean operative time for laparoscopic repair (151.9 min) was longer than open repair (106.6 min), and this agrees with the results of Eker et al., with 100 min for laparoscopic repair and 76 min for open repair, and Walter et al., with 105 min for laparoscopic repair and 83 min for open repair. However, this was against the study of Asti et al. where the laparoscopic repair was shorter (90 min) than open repair (140 min). On the contrary, in Rogmark et al. and Barakaat et al., there was no statistical difference between operative times for open or laparoscopic repair. In our study, we had three cases of serosal intestinal tear in the laparoscopic group, which were treated with repair and no conversion was done. We had also one case of serosal tear in the open group and was treated with repair. This agrees with Rogmark et al. where cases of serosal tear in laparoscopic group were repaired without conversion. In our study, no perforation of hollow viscus was reported, and this agreed with other studies like Misra et al.. However, in Eker et al., intestinal perforation and urinary bladder perforation were reported in the laparoscopic group. Moreover, in Itani et al., bowel perforation occurred in three cases, representing 4% of the laparoscopic group during dissection, and they were recognized intraoperatively, and conversion to open repair was done. Postoperative hospital stay in our study was shorter for laparoscopic group than open group, with an average of 1.92 days for laparoscopic and 2.7 days for open repair group. This agrees with Lobato et al., as hospital stay was 2.15 days for laparoscopic and 5.28 days for open repair. Moreover, in the studies done by Qadri et al., Asti et al., and Barakaat et al., the results showed shorter hospital stay for laparoscopic group than open repair group. On the contrary, studies by Eker et al. and Rogmark et al. did not show significant statistical difference between both groups regarding this issue. Regarding the short-term postoperative pain, the second group showed less degree of pain in comparison with the first group. This complies with the study of Qadri et al. and Itani et al.. However, this is not similar to the studies by Walter et al. and Eker et al. where the pain scales did not show statistical difference between the two groups. Regarding postoperative infection, the superficial wound infection was more in the open than laparoscopic group. This agrees with Itani et al., Walter et al., and Qadri et al.. However, in the studies done by Eker et al. and Barakaat et al., there were no statistical differences regarding superficial infection between open and laparoscopic repairs. Cases that presented with superficial infection were treated as outpatient by frequent wound dressing and antibiotics and achieved good response within days. No cases presented with deep mesh infection that required mesh removal. Regarding recurrence, eight cases had recurrent incisional hernia during the follow-up period of 1 year: four in the first group and four in the second group. This confirms with many other studies, such as Barakaat et al., Asti et al., Eker et al., and Qadri et al., that there is no significant statistical difference regarding recurrence and repair durability between these methods of repair. However, in Walter et al., the laparoscopic repair showed statistically significant less recurrence than the open repair. Postoperative seroma were reported in nine (18%) cases of the open repair group and six (12%) cases of the laparoscopic repair group, and there was no statistical difference between the two groups. This matches with the results found by Eker et al. and Asti et al., where in Asti et al., the seroma occurred in 10% of both laparoscopic and open group. However, in the study done by Qadri et al., the seroma occurred less in the laparoscopic group than the open repair group. Moreover, in the study done by Itani et al., seroma was less in the laparoscopic group and showed significant statistical difference. All cases of seroma in our study were treated conservatively with success, and no intervention was needed. Postoperative ileus was reported in five cases, representing 5% of the cases: two in the second group, representing 4%, and three in the first one, representing 6% of the group cases. In the study of Asti et al., prolonged ileus was reported in 10% of open group and 4% in laparoscopic group, whereas Eker et al. reported ileus in 2% of the laparoscopic group. Lobato et al. reported only one (1%) case of ileus among the laparoscopic group, and the patient needed hospital readmission with extra financial cost. On the contrary, Misra et al. did not report any cases of ileus in their study. In our study, patients followed conservative course with regain of intestinal movement and no other intervention was needed. Last but not the least, the total number of cases that had postoperative complications were more in the open group than laparoscopic group (23 vs. 13), and this agrees with Qadri et al. and Itani et al.. However, in the study done by Eker et al., the laparoscopic group showed more complications, but no significant statistical difference.
| Conclusion|| |
Based on the results and discussion of our study, laparoscopic incisional hernia repair is a safe alternative to open incisional hernia repair with a shorter hospital stay and a lower wound infection complications. We recommend increased application of laparoscopic repair of incisional hernia and a large multicenter randomized trial with long follow-up to measure the long-term results.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]