LAPAROSCOPIC VS.

OPEN VENTRAL HERNIA REPAIR

Types of Incisional Hernia repair: Primary closure only Primary closure with relaxing incisions Primary closure with mesh reinforcement Onlay mesh placement only Inlay mesh placement Retrorectus mesh placement Intraperitoneal mesh placement Advantages of open: Can be done in virtually all patients Minimizes the chance of unrecognized bowel injury Advantages of Laparoscopic: Allows the surgeon to thoroughly dissect adhesions around the hernia Inspect for occult adjacent defects Place the mesh over a larger space thereby minimizing the chances of recurrence. EVIDENCE: In 2 prospective studies, the group that was operated on laparoscopically had a lower rate of postoperative and longer-term complications, surgery time was significantly lower, and hospitalization was shorter than with an open approach (1,2) In one retrospective study there was lower rate of perioperative complications, shorter hospital stay and lower rate of recurrence in patients who underwent laparoscopic surgery as compared to open approach(3) In a meta-analysis of 8 studies three major outcomes compared were perioperative complications, operative time and length of hospital stay (4). All outcomes were significantly better for the laparoscopic approach. REF #1 Surg Endosc 1999 Mar;13(3):250-2. Total of 60 patients were assigned at random over a 3-year period Half of them were operated upon laparoscopically and the rest with open surgery. RESULTS: Groups were homogeneous in terms of demographic and clinical characteristics 1. Laparoscopic group had lower rate of postoperative and longer-term complications 2. Surgery time was significantly lower (p < 0.05) 3. Hospitalization time was also significantly lower (p < 0.05). CONCLUSIONS: Laparoscopic treatment of postoperative eventration and primary ventral hernia reduces complications and relapse rates, eliminates reintervention through mesh infection, reduces operative time, and considerably shortens the hospital stay.

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REF #2 Surg Endosc. 2003 Nov;17(11):1778-1780. Epub 2003 Sep 10. Prospective study comparing early outcomes after laparoscopic and open ventral hernia repairs. n = 257 approx 2 years To increase the homogeneity of the sample, umbilical hernia repairs, parastomal hernia repairs, nonelective procedures, procedures not involving mesh, and repairs performed concurrently with another surgical procedure were excluded. Postoperative complications (in-hospital or within 30-days) were assessed prospectively RESULTS o Of the 136 ventral hernia repairs that met the study criteria, 65 (48%) were laparoscopic repairs (including 3 conversions to open surgery) and 71 (52%) were open repairs. The patients in the laparoscopic group were more likely to have undergone a prior (failed) ventral hernia repair (40% vs 27%; p = 0.14), but other patient characteristics were similar between the two groups. 1. Overall, fewer complications were experienced by patients undergoing laparoscopic repair (8% vs 21%; p = 0.03). The higher complication rate in the open ventral hernia repair group came from wound infections (8%) and postoperative ileus (4%), neither of which was observed in the patients who underwent laparoscopic repair. 2. The laparoscopic group had longer operating room times (2.2 vs 1.7 h; p = 0.001), and there was a nonsignificant trend toward shorter hospital stays with laparoscopic repair (1.1 vs 1.5 days; p = 0.10). CONCLUSIONS: The patients undergoing laparoscopic repair had fewer postoperative complications than those receiving open repair. Wound infections and postoperative ileus accounted for the higher complication rates in the open ventral hernia repair group. Otherwise, these groups were very similar. Long-term studies assessing hernia recurrence rates will be required to help determine the optimal approach to ventral hernia repair. REF #3 Am Surg 1999 Sep;65(9):827-31; discussion 831-2. Retrospectively review over a 3-year period 174 open and 79 laparoscopic Similar demographics. The hernias in the open group averaged 34.1 cm2 in size, and mesh used averaged 47.3 cm2. In the laparoscopic group, the hernia defect averaged 73.0 cm2, and the mesh size averaged 287.4 cm2. 1. Operative time was longer in the open group, 82.0 versus 58.0 minutes. 2. In the open group, there were 38 (21.8%) minor and 8 (4.6%) major complications, compared with 13 (16.5%) minor and 2 (2.5%) major complications in the laparoscopic group 3. Hospital stay was shorter for the laparoscopic group, 1.7 versus 2.8 days. 4. At an average follow-up of 21 months (range, 2-40 months), there have been 36 recurrences in the open group (20.7%) compared with 2 recurrences in the laparoscopic group (2.5%).

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CONCLUSION: In this series, laparoscopic ventral herniorrhaphy compares favorably to open ventral herniorrhaphy with respect to wound complications, hospital stay, operative time, and recurrence rate.

REF #4 Arch Surg. 2002 Oct;137(10):1161-5 Meta-analysis of studies comparing open and laparoscopic ventral (including incisional) hernia repair. HYPOTHESIS: Laparoscopic ventral hernia repair results in better short-term outcomes than open ventral hernia repair. 3 main outcome measures were perioperative complications, operative time, and length of hospital stay. Across 8 studies, 390 patients underwent open repair and 322 underwent laparoscopic repair. 1. Perioperative complications were less than half as likely to occur in patients undergoing laparoscopic repair (14% vs 27%; P =.03; odds ratio, 0.42; 95% confidence interval, 0.29-0.68). 2. Average length of stay was shorter in the laparoscopic group (2.0 vs 4.0 days; P =.02). 3. No statistically significant difference in operative times was noted between laparoscopic and open repair (99 vs 96 minutes; P =.38). CONCLUSIONS: Laparoscopic ventral hernia repair offers lower complication rates and shorter length of stay than open repair. However, randomized controlled trials and studies with long-term follow-up are needed to confirm these findings and to assess long-term rates of hernia recurrence. Component Separation: This method uses bilateral, innervated, bipedicle, rectus abdominis-transversus abdominis-internal oblique muscle flap complexes transposed medially to reconstruct the central abdominal wall. The plane of separation is the interface between the external and internal oblique muscles(5) 8% recurrence rate and approximately 10% significant skin and wound problems with the separation-of-parts technique(6)

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REFERENCES 1. Laparoscopic treatment vs open surgery in the solution of major incisional and abdominal wall hernias with mesh. Carbajo MA; Martin del Olmo JC; Blanco JI; de la Cuesta C; Toledano M; Martin F; Vaquero C; Inglada L. Surg Endosc 1999 Mar;13(3):250-2. 2. A prospective study comparing the complication rates between laparoscopic and open ventral hernia repairs. McGreevy JM, Goodney PP, Birkmeyer CM, Finlayson SR, Laycock WS, Birkmeyer JD. Surg Endosc. 2003 Nov;17(11):1778-1780. Epub 2003 Sep 10. 3. Comparison of laparoscopic and open ventral herniorrhaphy. Ramshaw BJ; Esartia P; Schwab J; Mason EM; Wilson RA; Duncan TD; Miller J; Lucas GW; Promes J Am Surg 1999 Sep;65(9):827-31; discussion 831-2. 4. Short-term outcomes of laparoscopic and open ventral hernia repair: a meta-analysis. Goodney PP, Birkmeyer CM, Birkmeyer. Arch Surg. 2002 Oct;137(10):1161-5. 5. The Separation of Anatomic Components Technique for the Reconstruction of Massive Midline Abdominal Wall Defects: Anatomy, Surgical Technique, Applications, and Limitations RevisitedShestak, Kenneth C. M.D.; Edington, Howard J. D. M.D.; Johnson, Ronald R. M.D. Plast Reconstr Surg. 2000 Feb;105(2):731-8; quiz 739 6. Incisional hernia repair. MedScape review article. Keith W. Millikan, MD, FACS Kashaf Sherafgan, MD. Oct. 25, 2004

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