|Year : 2018 | Volume
| Issue : 3 | Page : 94-98
Outcome assessment of primary ventral versus incisional hernia repair by laparoscopic approach
Saleema Begum, Muhammad Rizwan Khan
Department of Surgery, Aga Khan University, Karachi, Pakistan
|Date of Submission||18-Aug-2018|
|Date of Acceptance||30-Aug-2018|
|Date of Web Publication||19-Nov-2018|
Dr. Muhammad Rizwan Khan
Department of Surgery, Aga Khan University, Stadium Road, Karachi 74800
Source of Support: None, Conflict of Interest: None
INTRODUCTION: The superiority of laparoscopic approach for a ventral and incisional hernia has been well documented over the traditional open repair. However, there is a paucity of literature comparing the outcomes of laparoscopic repair of primary ventral hernias versus incisional hernias. The objective of our study was to compare the operative variables and short-term outcomes of laparoscopic repair of primary ventral hernia as compared to incisional hernia in our setup.
MATERIALS AND METHODS: We reviewed the clinical data of 159 patients who underwent laparoscopic ventral and incisional hernia repair from January 2014 to December 2015. Demographics, operative variables, and short-term outcomes were compared between the two groups. Comparison of outcome variables was done using independent sample t- test for continuous variables and Chi-square test for categorical variables.
RESULTS: Of 159 patients, 90 (57%) had primary ventral hernia repair and 69 (43%) underwent incisional hernia repair. Both groups were similar in terms of age, body mass index, comorbid conditions, and high preponderance of females. The number (P < 0.006) and size (P < 0.000) of the hernia defect were significantly higher in the incisional hernia group. The operating time (P < 0.000) and extent of adhesiolysis (P < 0.011) were significantly higher in patients with incisional hernia. There was no statistically significant difference in intraoperative and postoperative complications in the two groups. The duration of postoperative hospital stay was longer in the incisional hernia group (P < 0.001).
CONCLUSIONS: The patients in the incisional hernia group had higher frequency of complex and large hernias. Laparoscopic repair of incisional hernia was associated with extensive adhesiolysis, longer operating time, and longer hospital stay as compared to primary ventral hernias.
Keywords: Incisional hernia, laparoscopic repair, primary ventral hernia
|How to cite this article:|
Begum S, Khan MR. Outcome assessment of primary ventral versus incisional hernia repair by laparoscopic approach. Int J Abdom Wall Hernia Surg 2018;1:94-8
| Introduction|| |
Primary ventral hernia is a broad term including epigastric, umbilical and paraumbilical, subcostal, lumbar, and flank hernias in a virgin abdomen, while incisional hernias occur at the site of any previous surgery through abdominal wall musculature. The reported incidence of incisional hernia is between 2% and 20% after abdominal surgery. The occurrence of primary ventral and incisional abdominal wall hernia is a common entity requiring surgical intervention, and both types of hernia can be repaired using an open or laparoscopic approach.
Laparoscopic repair of incisional and primary ventral hernia has been validated through large randomized control trials and meta-analysis. The current evidence suggests superior outcomes of laparoscopic approach in terms of postoperative complications, cost-effectiveness, and recurrence when compared with open surgery. However, there is evidence that the complications, if occur, tend to be more severe with laparoscopic approach., Repair of incisional hernias is technically challenging compared to primary ventral hernias due to adhesions of omentum and bowel with abdominal wall as a result of previous surgery requiring more extensive dissection, more operative time, and more chances of complications, including visceral injury. Stirler et al. were the first to point out the difference in the results obtained for primary ventral hernias compared to incisional hernias, and they concluded that they are different entities. Furthermore, Köckerling et al. identified significant differences in the treatment results between primary ventral and incisional hernias in a prospective analysis of data of 31,664 patients who underwent laparoscopic and open repair of both primary and incisional hernias.
Despite the overwhelming support for laparoscopic approach as compared to open technique, there is a paucity of literature comparing the outcomes of laparoscopic repair of primary ventral hernias versus the incisional hernias from developing countries. The objective of our study was to compare the operative variables and short-term outcomes of laparoscopic repair of primary ventral hernia as compared to incisional hernia in our setup.
| Materials and Methods|| |
This was a retrospective review of clinical data of patients who underwent laparoscopic primary ventral and incisional hernia repair from January 2014 to December 2015 at our hospital. Data were retrieved through the International Classification of Diseases 9 Coding System. A total of 159 patients underwent laparoscopic ventral and incisional hernia repair during the study period. The variables studied included demographics, intraoperative details including type of hernia, size of hernia defect, size of mesh used, primary closure of hernia defect, operative time, intraoperative complications, conversion to open as well as the postoperative variables, including local complications such as seroma formation requiring aspiration, wound cellulitis-requiring antibiotics, and hematoma-requiring evacuation, systemic complications, and length of hospital stay. An attempt was made to look at late complications including recurrence, chronic pain, trocar site hernia, chronic mesh infection, enterocutaneous fistula, and bowel obstruction in patients where adequate follow-up was present.
All procedures were done under general anesthesia, and all patients received preoperative prophylactic dose of antibiotics. A nasogastric tube was inserted in all patients, while urethral catheterization was done in selected patients with large lower abdominal hernias. Pneumoperitoneum was established using Veress needle in the left upper quadrant at Palmer's point followed by insertion of optical port and other working ports under vision. Port positioning was dependent on hernia site but usually inserted low down in patients left flank.
Contents of hernia sac were reduced, and in case of adhesions with abdominal wall or hernia sac, the adhesions were taken down with scissors, monopolar cautery, or harmonic scalpel. The adhesions were classified as minimal or extensive as described in the operative notes by the surgeon. When possible, defects were primarily closed with nonabsorbable suture. Small defects were not closed routinely. For mesh placement, adequate area was prepared by taking down falciform ligament when necessary. Appropriate-sized intraperitoneal composite mesh tailored to overlap the defect >5cm in all directions was used to cover the hernia defect using at least two transfascial orientation sutures. Mesh was secured using laparoscopic tacking device. In cases of Swiss cheese defects, single large mesh was used to cover all defects. Ports were removed under vision and skin incisions were closed. The patients were discharged the same day or on the 1st postoperative day depending on condition and patients preference and were followed up in outpatient clinics.
Data were analyzed using SPSS (IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY: IBM Corp). Categorical variables were described in percentages. Mean and standard deviation were used to report continuous variables. The patients were divided into two groups depending upon the type of hernia repair (Group A: primary ventral hernia repair and Group B: incisional hernia repair). Comparison of variables between two groups was done using independent sample t-test for continuous variables and Chi-square test for categorical variables. P < 0.05 was considered statistically significant.
| Results|| |
During the study period, 159 patients underwent laparoscopic repair of primary ventral and incisional hernias. A total of 57% (90) patients underwent repair of primary ventral hernia and 43% (69) underwent repair of incisional hernia. The mean age of patients was 46.7 ± 13.1 years in Group A compared to 49.4 ± 12.7 years in Group B. Majority of patients in both the groups were females and had comparable frequency of Class 1 obesity and comorbid conditions, as shown in [Table 1].
In Group A, paraumbilical hernia was the most common type of primary ventral hernia (67.8%), followed by umbilical hernia (25.6%). The frequency of reducible hernia was similar in two groups (P = 0.583). Significantly higher number of patients in Group B had three or more defects at the previous incision site (P = 0.006) and larger hernia defect (P < 0.000) as compared to Group A. As expected, significantly more omental and bowel adhesions were encountered in patients who had incisional hernia due to the presence of previous surgical scar, so extensive adhesiolysis was done in 43.5% patients in Group B compared to 14.4% patients in Group A (P < 0.000). The mean operating time was significantly longer in Group B (101 ± 54 min compared to 71 ± 33 min) likely due to technical difficulties during surgery (P < 0.000), as shown in [Table 2].
Intraoperative complications occurred in two patients in Group A. One of the patients had Grade 2 liver laceration during the insertion of Veress needle which was conservatively managed. He had uneventful postoperative course. The second patient underwent a laparoscopic paraumbilical hernia repair and had an unrecognized bowel injury. He was discharged home the same day and presented in the emergency room with severe abdominal pain and peritonitis on the 3rd postoperative day. Imaging studies confirmed bowel injury and the patient was taken to operative room and explored. He was found to have jejunal injury, which was primarily repaired, and the mesh was explanted. One patient in Group B had a small serosal injury to small bowel during adhesiolysis which was managed conservatively and had an uneventful course postoperatively.
Postoperative complications were observed in 2.2% patients in Group A and 8.7% patients in Group B (P = 0.078), as shown in [Table 3]. Wound cellulitis-requiring oral antibiotics were observed in one patient in Group A and two patients in Group B. Seroma was aspirated in three patients in Group B, while another three patients had urinary tract infection in the postoperative period. The mean length of hospital stay was 1.49 ± 1.4 days in Group A and 2.32 ± 1.93 days in Group B (P = 0.002). The mean follow-up duration was 53.1 ± 172 days in Group A and 99.9 ± 267 days in Group B. One patient in Group A had adhesive bowel obstruction 3 months after the procedure which was managed conservatively and one patient in Group B had chronic pain-requiring analgesia in Group B. One patient in Group B developed recurrence in the follow-up period.
| Discussion|| |
Repair of ventral hernias by laparoscopic approach has the benefit of smaller incisions, and therefore, fewer complications related to wound, less pain, shorter length of hospital stay, and increased patient satisfaction. Laparoscopic approach enables a surgeon to inspect the whole abdomen and deals with Swiss cheese defects. However, evidence supports that complications associated with this approach tend to be more severe because of visceral or bowel injury. Several meta-analyses and randomized control trials have validated the superiority of laparoscopic approach over open repair for both primary ventral and incisional hernias. Laparoscopic repair of ventral hernias has become a routine procedure in developing world with promising results.
Our study focused on the comparison of laparoscopic approach for primary ventral hernias with incisional hernias, which are considered two different clinical entities. Kroese et al. in a prospective cohort study including 4565 patients demonstrated that primary ventral hernia and incisional hernias are two different entities having different etiologies. Statistically significant difference was noted in each variable included in the study comparing both types, including patient's demographics, intraoperative details, and postoperative outcomes, and the study concluded that primary ventral hernias and incisional hernias are two different entities and should not be combined in hernia research.
Review of demographic data revealed more female patients in both groups of our patients, which is consistent with several other previous studies. Incisional hernia repairs have been reported to be twice as common in females, and our study has shown similar results. Obesity is one of the most important risk factors for the development of hernias, and the mean body mass index of patients in our study population revealed Class 1 obesity. Review of recent literature suggests that the benefit of laparoscopic approach is beneficial in obese patients requiring hernia repair.,
Our study reports that incisional hernias are more complex with greater number and size of hernia defects. The presence of previous surgical scar predisposes to more omental and bowel adhesions requiring more extensive adhesiolysis, supported by similar findings in other studies. The hernia defects in patients with incisional hernia were more complex, requiring difficult closure and placement of larger sizes of mesh. This complexity is reflected in statistically significant longer operating time in patients with incisional hernia as compared to primary hernia, as reported in our study. The longer hospital stay in patients with incisional hernias is also related to the longer operating time and more extensive adhesiolysis as these factors prolong the return of normal bowel function in the postoperative period. Similar results were seen in a study by Kurian et al. including 221 patients that incisional ventral hernias are more complex and their laparoscopic repair is more complicated and takes longer to perform than the laparoscopic repair of primary ventral hernias. The patients stay longer in the hospital after incisional hernias repair as compared to primary ventral hernia patients. We did not review the need or dose of postoperative analgesia in this study. Prolonged and complex operations are associated with postoperative pain and use of narcotics, which can actually prolong the return of normal bowel function, resulting in longer hospital stay.
The most feared complication of laparoscopic hernia repair is inadvertent bowel injury. One of our patients with primary ventral hernia had this complication, which remained unnoticed intraoperatively and the patient presented on the 3rd postoperative day with peritonitis. Bowel adhesions that are away from the direct field of vision can result in serosal tears or full-thickness bowel wall injury with sharp or energy-assisted dissection. Generally, they remain unrecognized during the operation and patient may present later with peritonitis. As discussed earlier, this type of complication is more expected with previous incisions, but our patient had paraumbilical hernia. Meyer et al. reported a high rate of bowel injury in patients undergoing laparoscopic incisional hernias because of complexity of procedure due to more adhesions and need for adhesiolysis. Similar results were also reported by Zhang et al. in a systematic review and meta-analysis of 11 studies including 1003 patients.
Wound-related complications such as cellulitis-requiring antibiotics and seroma-requiring aspiration were more in patients with incisional hernias, which can be explained by the fact that most of these hernias were large with multiple defects. Similar results were also seen in a study by Meyer et al. where the rate of minor and major complications including wound infection, hematoma, abdominal wall abscesses, and recurrence was higher in patients undergoing laparoscopic repair of incisional hernia. Systemic complications such as urinary tract infection were observed with incisional hernias as these were mostly large lower midline defects requiring urinary catheterization. There was no statistically significant difference in the recurrence rates and chronic pain in our study which could be attributed to short follow-up duration but a study by Subramanian et al. demonstrated a greater incidence of recurrence and more chronic pain associated with laparoscopic incisional hernia repair and concluded that incisional and primary ventral hernias should not be considered in the same group when comparing hernia repairs.
The limitations of our study are the relatively small sample size and the shorter duration of follow-up, but this is one of the largest series from the developing world where laparoscopic approach is still going through the phase of evolution. Prospective studies with large sample size and longer follow-up would be helpful to identify the differences between these two entities.
| Conclusions|| |
The patients in the incisional hernia group in our study had higher frequency of complex and large hernias as compared to primary ventral hernias. Laparoscopic repair of incisional hernia was associated with extensive adhesiolysis, longer operating time, and longer hospital stay as compared to primary ventral hernias.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]