Laparoscopic versus open hernioplasty of ventral and incisional hernias

Laparoscopic versus open hernioplasty of ventral  and incisional hernias

Yaser Hatata, MD; NaderShabaan, MD;

Salah Said Soliman, MD, MRCS; Mohamed Elfayoumy, MD General Surgery Department, Fayoum University, Egypt.

Background:     Although  open  repair,  preferably with  mesh  has  long  been  the  standard approach for ventral and incisional herniasrepair, laparoscopic repairis becomingincreasingly popular among  surgeons   and  patients  following  the  development  of  minimally invasive techniques. Laparoscopic ventral  hemia  repair  may  be associated with  fewer complications decreased length of hospital stay and lower recurrence rates.

The  aim of this comparative study is to evaluate the outcome  and  benefits of laparoscopic over conventional ventral and incision hernia repair.

Methods: The  study  was conducted in  Surgery Department Faculty of Medicine Fayoum University, on  forty patients with incisional and primary ventral hernias with defect  size more than  Jcm,  from September 2009  to  December 2011.  Patients were randomly selected    and allocated into two groups using coin and flip method, Group A included twenty patients operated on by laparoscopy and Group B included twenty patients who underwent open surgical repair.

Results: Both groups had nearly similar demographics and clinical data. The procedure  was successfully completed in all patients of both groups, with no mortality or conversion to open procedure in group  A The mean  diameter of hernia defect  was 5.6 em in group  A, compared to 6.1 em in group B. Polypropylene mesh  was used  for all patients in group  Band in group  A different types of composite mesh  was used.

There was a significant decrease in the need for postoperative analgesia in group A compared to group B (P value <0.05).

The study showed less complications and shorter hospital stay in group A, with no recurrence in both groups during a period of follow up for two years.

Conclusion:  Laparoscopic ventral   and  incisional hernia   repair is  safe,  effective and technically feasible approach with statistically significant reduction in postoperative morbidity, earlier recovery and shorter hospital stay and with similar  recurrence rate to the conventional open group.

Key words:  Ventral, incisional hernia, laparoscopic, open tension  free repair.

Introduction:

(VH) is a collective term used to describe hernias occurring as a result of weakness in the musculofascial  layer  of  anterior  abdominal wall   and  are   one  of  the   most   common problems  confronting  general  surgeons. 1  It represents  10%  of  hernias.  Ventral hernias can develop as a result of prior surgery (inicisional) or spontaneously (umbilical, paraumbilial  and epigastric). 2 The incidence of ventral incisional hernia after laparotomy

has been reported to be as high as 20 to 25%.3

Primary suture repair of ventral hernias yield unsatisfactory  results. The use of mesh in open  ventral and incisional  hernia  repair had become the rule since the superiority  of abdominal wall prosthetic reinforcement  was demonstrated.4

Although the introduction of a prosthetic mesh to ensure abdominal wall strength without tension has decreased the recurrence rate, however open repair requires use oflong

incisions, significant soft tissue dissection as well as large subcutaneous flap creation and prolonged drainage, increasing complication rates and affecting recurrence rate.3

Successful laparoscopic repair for ventral

hernia  was  done  by  LeBlanc  in  1993,  and since  then,   many  authors  have  published reports of laparoscopic incisional and ventral hernia repair (LIVHR) as an accepted surgical technique. This procedure is fast emerging as an alternative to open technique.2

While   the   advantages   of   laparoscopy over the open repair of ventral and incisional hernias are still unclear with a lot of debate, the risk of recurrence seems to be equivalent with rates of 9% or less for the most recent publications,  when compared to large series of open repair with meshs.

Although  there  is  no  general  agreement on whether the laparoscopic treatment of ventral and incisional hernias should be used in very small or very large ventral hernias, or as a primary method for repair, yet for more than a decade the laparoscopic  approach for ventral hernia repair has demonstrated its feasibility  and  reliability  to treat small  and large abdominal wall defects with a low rate of conversion to open procedure.6

Intraperitoneal  mesh placement in contact with  viscera  has  been  made  possible  and secure with the use of composite mesh, avoiding the risk of bowel fistula and with a reduction in adhesion formation.

Improvements in mesh fixation techniques could  reduce  the  risk of  postoperative  pain and make the laparoscopic approach with intraperitoneal composite mesh placement feasible. 7

In this study a minimally invasive approach was applied to the repair of ventral and in cisional hernias with the expectation of earlier recovery, fewer postoperative complications and decreased  recurrence  rates. The  aim of this study was to analyse and compare the outcomes  after open and laparoscopic  repair of ventral and incisional hernias and the difference in postoperative complications, operative time, length of hospital stay and recurrence.

Patients and methods:

This study was conducted m Surgery Department Faculty of Medicine Fayoum University, on forty  patients with incisional and primary ventral hernia with defect size more than 3 em from September 2009 to December  2011, who underwent  ventral hernia repair with mesh using open and laparoscopic  technique.   The  forty  patients were  randomly  selected  and  allocated  into two   groups   using   coin  and  flip  method, twenty  patients  each.  Group  A include twenty  patients operated  on by laparoscope, and Group B included twenty patients who underwent open surgical repair for ventral and incisional  hernias.  Composite  meshes  were used  in group  A while  polypropylene  mesh was used for group B. All patients in both groups were subjected to full history taking (Personal and Medical), followed by physical examination that included clinical assessment of the hernia defect size. In addition, routine preoperative  laboratory investigations  (CBC

- liver function  tests - blood sugar -kidney

function  tests  - ECG  and  chest  x-ray  and abdominal ultrasonography  were done).

Patients   with  complicated   or  recurrent

hernias, ASA score more than  2, BMI more than 40, and any contraindications for laparoscopic   surgery   were   excluded  from the study. Patients were fully informed about the  risks and  benefits of the  procedure  and the possibility of conversion to open surgery in laparoscopic group. Written consent was taken from every patient. Patients were hospitalized the day before surgery and kept fasting 8 hours before surgery and, on clear fluids  24   hours   before   surgery.  Charcoal tablets were given to reduce gut distension. Single intravenous dose of 3rd generation cephalosporin    was   given   with   induction of anesthesia for the purpose of surgical prophylaxis.   All   patients   were   subjected to general anesthesia with insertion of nasogastric tube and urinary catheter after intubation and both were removed at the end of  the  procedure.  The  surgical  procedures were performed by the same surgical team.

In group  A; A verus needle  was inserted below  the  left  costal  margin  for  induction

of pneumoperitoneum, the first trocar was inserted using 1Omm port, being placed away as far  as  possible from  the defect.  Oblique view  scope   (30°)  is  inserted  to  facilitate the  insertion of the  other two  5mm trocars. The abdominal wall defects were freed of peritoneal  and visceral  adhesions  by means of electrosurgical dissection. Then the hernial content  was  reduced  and  the  defect  in the fascia was outlined. A minimum of 3 em arround the border of the defect was cleared of adhesions. The hernia defect has been defined by pushing an intra-abdominal instrument against a palpating finger on the abdomen and working out the hernia or by placing needles through the abdominal  wall and confirming the position of the hernial defect, the defect was narrowed or closed via polypropylene number 1 intracorporial suturing Figure (1).

We  attempted  to  narrow  the  defect  in

some  patients  and succeeded  to  close it  in the  majority   of  patients,  as  closure  or  at least narrowing of the defect decrease the incidence of seroma formation.  A composite mesh  was introduced  through  10 mm  port. The size of the mesh depends on the size of the defect, the mesh size should cover the defect with 3 to 5 em overlapping the defect. We did fix the composite mesh via 5mm tuckers,  one em apart with double crowning technique. Identification of the defect and the four  comers  of the mesh  was facilitated via needle inserted through the abdominal wall Figure (2).

No drain was used in laparoscpic  group,

closure of the fascial defect at the lOmm port site was done via vicry 10 and skin incision via 4/0 vicryl subcuticular closure. Patients were   given   sips   of   water   after   passing flatus  or  feces  or  after  hearing   intestinal sounds. Postoperatively all patients received analgesics  in  the  form  of  narcotics  for  24 hours then non steroidal anti inflammatory injections  and  oral  analgesics  were  given upon the patient request.

In      group      B:      prefascial      prosthetic

implantation was the used technique. After identification and proper dissection of the hernial sac with adequate preparation of the fascial  edge,  the  sac  was  opened  and  any

adhesions were freed and contents were reduced completely. The hernia defect was closed by fascial plication with continuous polypropylene   sutures   (No.   1).  In   cases where  the  defect  was too  large, closure  of the peritoneum was done first by continuous vicryl 2/0 stitches then plication of the fascial covering was done to narrow the defect as much as possible without tension. Onlay implantation of the prepared polypropylene mesh was done and fixed to the aponeurosis without   tension   with   polypropylene    (no.

1) sutures.  Then suction  drain  was inserted

under the raised subcutaneous flaps, then subcutaneous and skin closure were done.The postoperative  pain was evaluated in the first

48 hours  postoperative.  The  operative time, hospital stay, intraoperative and postoperative morbidities were recorded. Comparisons between the two groups  were assessed  with t-test and chi-square test. Results were expressed as mean values.  Differences were considered significant when P<0.05. The discharge criteria are met once the patients were afebrile with audible bowel sounds and able to tolerate liquid diet and oral analgesia.

All the patients were followed up weekly

for one month after discharge from hospital, then monthly for six months for late complications,  then  after  9  and  12 months and lastly at the end of second postoperative year.

Results:

The  study  was  conducted  on  fourty patients presented to General Surgery Department at Fayoum University between September 2009 to December 2011, with clinically diagnosed ventral and incisional hernias.  The patients  were  eligible  for double-blinded random assignment to open tension-free or laparoscopic tension-free hemioplasty. Patients were randomized by using the coin flip method into two groups. Group  A  included   twenty   patients  (50%) who   underwent   laparoscopic   tension   free repair and Group B included twenty patients (50%) who underwent the open tension free repair   for   ventral   and  incisional   hernias. The  procedure  was  successfully  completed

in  all  patients  of  both groups.  No  patients from group A required conversion to open procedure.   No   mortality.   The  two   study groups   had   nearly   similar   demographics, with a mean age of 40.2 in group A,and 45.1 in group B and female to male ratio of almost

2:1 in both groups.

In group B 8 patients (40%) had incisional ventral   hernia   compared   with   4  patients (20%) in group A" P. value is less than 0.05 ".

The duration ofthe hernia was as follow less than 6 months-1 year and more than 1-year. represented  55%, 30%, 15% in groupA and

65%,25%,10% in group B respectively.The hernia contents were omentum in 12 patients (60%) and 14 patients (70%), and omentum with small bowel in 8 patients (40%) and 6 patients (30%) in group A and B respectively.

In group  A the  mean diameter  of  hernia defect  was  5.6  em  compared  to  6.1  em  in group B, with no statistical significance, and the mean mesh size was 170 cm2  in group A and 212  cm2   in group B, P.  value less than

0.05.

While polypropylene mesh was used for all patients in group B; in group A Proceed mesh was  in  6  patients  (30%),  Physiomesh  was used in 6 patients (30%), and the extended polytetraflouroethylene  mesh (Gore tex) was used in 8 patients (40%). The mean operative time in group A was relatively longer (130 minutes) than that of group B (100 minutes) with P. value less than 0.05. This may be due to extensive adhesolysis done in 8 patients (40%) in group A that accounts for the cases with longer operative time.

In group A, there was asignificant decrease in the need for narcotic therapy to control pain during  early postoperative  period  compared to group B (20% of patients in group A versus

80% of patients in group B, with P. value less than 0.05). However on subjective assessment of  postoperative   pain  in  patients,  in  spite of parenteral narcotic therapy was more frequently needed in group B the patients still experienced more pain than those in group A (P. value less than 0.05).

There were fewer complications in group A

than group B which collectively didn't  reach a  statistical  significance.  While  6  patients

(30%) in group B got wound infection which was treated by wound drainage antibiotics and repeated dressing, no similar complication was reported in group A (P. value less than 0.05). One patient (5%) in group B developed a skin necrosis at wound edge that required surgical debridement  under  local anaesthesia  on the

7th postoperative day. Two patients (10%) of

group B had a prolonged paralytic ileus (lasts more than 48 hours postoperatively) managed conservatively.  In group B, 6 patients (30%) got seroma that required repeated (2 -4 times) aspiration, also in group A seroma developed in 6 patients (30%) in 4 (20%) of those it resolved spontaneously, however 2 patients (10%) had persistent infected seroma that required ultrasound guided percutaneous drainage  and antibiotic therapy. No patients in either group  had shown  signs of infected mesh or required mesh removal. Group A had a significant shorter mean hospital stay than group B (P. value less than 0.05).

Patients in both groups were followed  up by mean of visits or telephone call, 3 patients (15%) in group A were lost during follow up (2  patients  after  6 months  and  one  patient after 9 months), in group B only one patient (5%) was lost after 12 months of follow up. No recurrences were reported in any patients of both groups during the whole period of follow up.

Discussion:

Pimary ventral and postoperative incisional hernias are one of the most common problems confronting  general  surgeons. The principle of laparoscopic  ventral and incisional hernia is based  on  Rives-Stoppa  repair  which involve extensive tissue dissection in a myofascial  plane for placement  of mesh. Le Blanc first described laparoscopic repair of ventral hernias in 1993.8 Technical feasibility of the laparoscopic repair for abdominal wall defects has been demonstrated  by various reports published since 1993.8

The   laparoscopic   technique    carried   a large   number   of   theoretical    advantages; lesser abdominal wall trauma, smaller fascial dissection, lesser wound and prosthetic contamination,   fewer  visceral  injuries  and

Figure {1): Closure of defect.

Figure (2): Gore tex mesh fixed via tuckers

with double crowning technique.

Table 1: Patients demographic and clinical data.

*NS : not stat:J.st:J.cally stgruficant.

*BMI : body mass index.

Table 2: Anatomical site of hernia and different types of incisional hernia

Table 3: Hernia defect, mesh size, and operative time

no need for drainage. These advantages have

that may be incru·cerated or closely adherent

been confinned  in numerous reports9 as well

to the scaning site. The  C0

itself  help  to

as in our study. The laparoscopic approach facilitates the adhesiolysis which is the most challenging  prut of  lapru·oscopic vent:J.·al hernia repair, with more comprehensive exploration of the abdominal cavity and less

1isk ofiat:J.·ogenic injmy of the intestinal loops

sepru·ate  the   adhesions   through   creating a smgical emphysematous  plane that can delineate adherent  tissue and bowel borders for more safe sharp dissection.

In  our  study  we  didn't   encounter   any

case  of  int:J.·aoperative  bowel  injury  dming

Table 4: Postoperative pain.

* postoperative

Table 5: Postoperative complications  and hospital stay.

Table 6: Follow up time and recurrence rate.

adhesiolysis. Erosions and fistulization did not occur in any of the patients in the laparoscopic group. This is a major complication of intraperitoneal mesh placement for ventral hernia repair. The composite and Gore tex mesh were used in this study in an attempt to minimize the risk of erosion and fistulization. The composite mesh is characterized  by two different surface, one that promotes fibrous ingrowth into the mesh and another that is relatively resistant to adhesion formation and placed adjacent to the abdominal viscera.lO,ll In this study, we found that  Gore tex mesh is  very  thick,  nontransparent,   and  difficult to be introduced into the peritoneal cavity. However both Proceed and Physiomesh are excellent   composite   mesh,   they   are  thin, easy  to  be  introduced   into  the  peritoneal cavity,   also    Physiomesh    is   transparent, unrolls              spontaneously    in   the    peritoneal cavity, and has affinity to stick into the peritoneum, facilitating its fixation via tacks. It has  absorbable  marker  which  facilitates identification  of mesh center. In all cases of laparoscopic  group, we used non absorbable 5mm  tacks  that  were  applied  to  the  mesh 1cm apart with double crowning technique. Several studies had shown that laparoscopic associated with fewer complication rate, decreased postoperative pain, shorter hospital stay and lower recurrence rate. Our study showed  that  laparoscopic  approach  have  a very  low complication  rate  with no wound or mesh infection and less seroma formation. Seroma formation was not a significant problem except in two patients (10%) where infected seroma  was treated  with antibiotics and ultrasound  guided aspiration.  In ventral incisional hernia, placing polypropylene mesh in a preperitoneal position via laparoscopic approach is virtually impossible.

Holzmanand   Eubanks,12  commented   on the use of polypropylene mesh and stated that a  peritoneal  approach  to  incisional  hernias is virtually prohibitive. Attempts to separate the peritoneum of the hernia sac are met with serious obstacles, results in large peritoneal defect and leaves exposed mesh. Any attempt to dissect outthe sac will leadto more bleeding, with the potential of creating a communication between the frequently thinned out overlying skin and mesh.  In our study no attempt  was made to excise the hernia sac. Due to the extreme adhesions between polypropylene mesh    and   intraabdominal    contents    that others experienced in laparoscopic ventral hernia   repair,   considering   the   placement of   mesh   in   a   preperitoneal    position   in these  cases  is  not  possible.  Polypropylene mesh is not an acceptable material for laparoscopic ventral hernia repair, given the advantages of composite mesh as regards to adhesion formation.  The substantial  fixation of the composite mesh with permanent transabdominal  wall sutures  is important to the success ofthe laparoscopic ventral hernia repair. However fixation of the mesh using tacks via a standard double crown technique is enough to secure the mesh, save time, and avoid the  occurrence  of chronic  pain when the sutures are used to fix the mesh. We had at least between 3-5 em overlap of the mesh over the defect based on Stoppa tension free repmr.

Compared   to  the  laparoscopic   group, the  open  group   had  overall  more  wound related complications  where wound infection 6  patients   (30%)   and   skin   sloughing   in one  patient   (5%).   In  laparoscopic   group the     earliest    postoperative     complication was seroma formation that was found in 6 patients (30%), in other studies the incidence of this complication  ranged from 0-36%.3,12 Laparoscopic  ventral  hernia  repair  involves no long incision,  no wide fascial  dissection or flap creation, no opening of the sac and no drains and this contribute to the lower risk of wound  complication  and seroma  formation. We reported  a  significant  decrease  in  the need for  parenteral  narcotics therapy  in the laparoscopic  group  patients  postoperatively. In   addition           subjective   analysis    of   pain suggested  that  patients  in  the  open  group, in spite of narcotic therapy, still experience more  pain  than  in the  laparoscopic  group. The same findings were reported in a study by Zanghi et al 13 suggesting  that  postoperative pain contributed to the longer hospital stay in the open repair group.

In our study the mean operative time in group  A  (150  minutes)   was   significantly longer than in group B (120 minutes) which is comparable to that reported by Park and Holzman14,15 and Zanghi et aP3 who reported also a similar difference with mean operative time  of  140  minutes  and  120  minutes  in the laparoscopic group and the open group respectively. We believe that the time for laparoscopic  repair  decreases  with  the progress in the learning curve, but as in open repair this remains linked to the complexity of the defect and the entity of adhesion. Postoperative hospital stay in our study had been significantly shorter in the laparoscopic group  with a mean stay of  4 days versus  7 days  in  the  open  group.  The  majority  of studies had documented a decrease in overall hospital stay  in laparoscopic  group  that can be attributed to decreased postoperative pain, absence of surgical drains, a more rapid return of oral intake, less wound complications and early return to ambulatory activity_l6,17

In our study, patients  of the  laparoscopic group and open group were followed  up for a mean time period of 20 and 22 months respectively,  with  no  recurrence  found  in any  patient of both  groups. However isolated studies had argued thatthe recurrence rate with laparoscopic repair may  not  be that  low over a long-term follow up and is almost the  same as with  open  repairs. The recurrence rates reported for  open  mesh  repair was  (0-10%) and  Laparoscopic mesh repair produces similarly low recurrence rate (0-9%).18 The lower recurrence rates  in laparoscopic repair of  ventral hernia can  be attributed to placing the    prosthesis   under    the    fascial  margins and,  intrabdominal pressures are essentially buttressing  the   repair  attachments  if   it  is placed  anteriorly. The   other   is  that   it  can clearly and  definitively identify the  defect margin, so  that  the  extent of  the  defect can be accurately delineated laparoscopically. We can  clearly establish the  amount of  overlap required, in  practice it is  to  overlap 3-5  em all margins.

Conclusion:

The  laparoscopic ventral and  incisional hernia repair  is safe,  effective and technically feasible  approach  with    a   significant reduction in  postoperative morbidity, earlier recovery and  shorter hospital stay  than the conventional open  group. The recurrence rate in the  laparoscopic group is similar or lower than the  open  mesh group. When  properly performed, the  laparoscopic approach does not and should not compromise the principles for  successful mesh repair of ventral and incisional hernias. The  outcome and  cost benefits  of   LRVH   over   conventional open repair need  further evaluation in countries of third world  where resources are deficient.

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