Open versus laparoscopic intraperitoneal on-lay mesh repair: A comparison of outcomes in small ventral hernia

Laparoscopic versus open mesh repairs for small-sized ventral and incisional hernias: a propensity score analysis of a retrospective cohort of patients

INTRODUCTION

For ventral/incisional hernias between 1 and 4 cm, there is still controversy regarding open or laparoscopic mesh repairs. The study evaluated via a propensity-score adjusted analysis, the differences in outcomes between a laparoscopic and open ventral hernia mesh repair.

METHODOLOGY

A single institution retrospective cohort study was performed. All patients with a ventral or incisional hernia between 1 and ≤ 4 cm, with a mesh repair, were reviewed. A propensity-score adjusted analysis was performed to account for baseline differences. Subgroup analyses were also performed. Outcome measures included recurrence, chronic pain, complications, postoperative adhesive occurrences, length of stay and operative duration.

RESULTS

Over a 6-year period, 194 patients (91 laparoscopic; 103 open) were included. Mean follow-up duration and defect size were 8.0 months and 2.6 cm, respectively. Baseline differences in the univariate analysis between groups were adjusted for via propensity scoring. In the propensity-score adjusted analysis, a laparoscopic mesh repair was significantly associated with a lower likelihood of postoperative adhesive occurrences, with no differences in recurrence, chronic pain, complications, length of stay and operative duration. This association remained for hernia defects down to ≤ 3 cm. There were no significant differences between the laparoscopic and open groups when stratified for hernia defects of 1-2 cm. For the subgroup analysis, in contrast to an intraperitoneal on-lay mesh placement, open on-lay mesh placement was associated with a higher likelihood of postoperative adhesive occurrences.

CONCLUSION

For patients with small-sized ventral/incisional hernias between 1 and 4 cm, laparoscopic mesh repairs may be associated with reduced postoperative adhesive occurrences, with no difference in other outcomes.

Is Minimally Invasive Surgery the Standard of Care for Ventral Hernia Repair?

When patients undergoing ventral or incisional hernia repair are reoperated for recurrence with an incidence rate of 16.0% following open repair and 18.8% following minimally invasive repair, it is time for re-evaluation of the real benefit of laparoscopy in ventral hernia repair.

Long-term mesh-related complications from minimally invasive intraperitoneal onlay mesh for small to medium-sized ventral hernias

INTRODUCTION

Intraperitoneal onlay mesh (IPOM) placement for small to medium-sized hernias has garnered negative attention due to perceived long-term risk of mesh-related complications. However, sparse data exists supporting such claims after minimally invasive (MIS) IPOM repairs and most is hindered by the lack of long-term follow-up. We sought to report long-term outcomes and mesh-related complications of MIS IPOM ventral hernia repairs.

METHODS AND PROCEDURES

Adult patients who underwent MIS IPOM ventral hernia repair at our institution were identified in the Abdominal Core Health Quality Collaborative database from October 2013 to October 2020. Outcomes included hernia recurrence and mesh-related complications or reoperations up to 6 years postoperatively.

RESULTS

A total of 325 patients were identified. The majority (97.2%) of cases were elective, non-recurrent (74.5%), and CDC class I (99.4%). Mean hernia width was 4.16 ± 3.86 cm. Median follow-up was 3.6 (IQR 2.8-5) years. Surgeon-entered or patient-reported follow-up was available for 253 (77.8%) patients at 3 years or greater postoperatively. One patient experienced an early small bowel obstruction and was reoperated on within 30 days. Two-hundred forty-five radiographic examinations were available up to 6 years postoperatively. Twenty-seven patients had hernia recurrence on radiographic examination up to 6 years postoperatively. During long-term follow-up, two mesh-related complications required reoperations: mesh removed for chronic pain and mesh removal at the time of colon surgery for perforated cancer. Sixteen additional patients required reoperation within 6 years for the following reasons: hernia recurrence (n = 5), unrelated intraabdominal pathology (n = 9), obstructed port site hernia (n = 1), and adhesive bowel obstruction unrelated to the prosthesis (n = 1). The rate of reoperation due to intraperitoneal mesh complications was 0.62% (2/325) with up to 6 year follow-up.

CONCLUSION

Intraperitoneal mesh for repair of small to medium-sized hernias has an extremely low rate of long-term mesh-related complications. It remains a safe and durable option for hernia surgeons.

Comparison between the open and the laparoscopic approach in the primary ventral hernia repair: a systematic review and meta-analysis

BACKGROUND

Ventral hernia repair underwent various developments in the previous decade. Laparoscopic primary ventral hernia repair may be an alternative to open repair since it prevents large abdominal incisions. However, whether laparoscopy improves clinical outcomes has not been systematically assessed.

OBJECTIVES

The aim is to compare the clinical outcomes of the laparoscopic versus open approach of primary ventral hernias.

METHODS

A systematic search of MEDLINE (PubMed), Scopus, Web of Science, and Cochrane Central Register of Controlled Trials was conducted in February 2023. All randomized controlled trials comparing laparoscopy with the open approach in patients with a primary ventral hernia were included. A fixed-effects meta-analysis of risk ratios was performed for hernia recurrence, local infection, wound dehiscence, and local seroma. Meta-analysis for weighted mean differences was performed for postoperative pain, duration of surgery, length of hospital stay, and time until return to work.

RESULTS

Nine studies were included in the systematic review and meta-analysis. The overall hernia recurrence was twice less likely to occur in laparoscopy (RR = 0.49; 95%CI = 0.32-0.74; p < 0.001; I2 = 29%). Local infection (RR = 0.30; 95%CI = 0.19-0.49; p < 0.001; I2 = 0%), wound dehiscence (RR = 0.08; 95%CI = 0.02-0.32; p < 0.001; I2 = 0%), and local seroma (RR = 0.34; 95%CI = 0.19-0.59; p < 0.001; I2 = 14%) were also significantly less likely in patients undergoing laparoscopy. Severe heterogeneity was obtained when pooling data on postoperative pain, duration of surgery, length of hospital stay, and time until return to work.

CONCLUSION

The results of available studies are controversial and have a high risk of bias, small sample sizes, and no well-defined protocols. However, the laparoscopic approach seems associated with a lower frequency of hernia recurrence, local infection, wound dehiscence, and local seroma.

[Is vTAPP for small ventral hernias a potential «gold standard» for less than 24 hours hospitalization?]

OBJECTIVE

To evaluate clinical efficacy and cost-effectiveness of vTAPP for small/M3W1 hernias compared to IPOM.

MATERIAL AND METHODS

We retrospectively analyzed a prospectively recruited group of patients. Study objects were patients undergoing ventral laparoscopic transabdominal preperitoneal hernia repair (vTAPP) for primary Midline/Lateral Small hernias up to 2 cm. The control group comprised patients after IPOM procedure.

RESULTS

We analyzed 179 patients: vTAPP (n=132) and IPOM groups (n=47). The vTAPP group was characterized by significantly shorter hospitals-stay (Q1-Q3: 8-70 hours, p<0.001), fewer relapses (n=2, p=0.047) and slightly longer surgery (Q1-Q3: 40-80 min, p=0.037). Cost-effectiveness analysis revealed 3.39 times more profitable vTAPP compared to IPOM.

CONCLUSION

Laparoscopic preperitoneal hernia repair is a safe and effective method not requiring special tools and consumables. This approach is applicable as an outpatient (or <24h hospital-stay) method.

What is the ideal mesh location for incisional hernia prevention during elective laparotomy? A network meta-analysis of randomized trials

BACKGROUND

Incisional hernia (IH) represents an important complication after surgery. Prophylactic mesh reinforcement (PMR) with different mesh locations [onlay (OL), retromuscular (RM), preperitoneal (PP), and intraperitoneal (IP)] has been described to possibly reduce the risk of postoperative IH. However, data reporting the 'ideal' mesh location are sparse. The aim of this study was to evaluate the optimal mesh location for IH prevention during elective laparotomy.

METHODS

Systematic review and network meta-analysis of randomized controlled trials (RCTs). OL, RM, PP, IP, and no mesh (NM) were compared. The primary aim was postoperative IH. Risk ratio (RR) and weighted mean difference (WMD) were used as pooled effect size measures, whereas 95% credible intervals (CrI) were used to assess relative inference.

RESULTS

Fourteen RCTs (2332 patients) were included. Overall, 1052 (45.1%) had no mesh (NM) while 1280 (54.9%) underwent PMR stratified in IP ( n =344 pts), PP ( n =52 pts), RM ( n =463 pts), and OL ( n =421 pts) placement. Follow-up ranged from 12 months to 67 months. RM (RR=0.34; 95% CrI: 0.10-0.81) and OL (RR=0.15; 95% CrI: 0.044-0.35) were associated with significantly reduced IH RR compared to NM. A tendency toward reduced IH RR was noticed for PP versus NM (RR=0.16; 95% CrI: 0.018-1.01), while no differences were found for IP versus NM (RR=0.59; 95% CrI: 0.19-1.81). Seroma, hematoma, surgical site infection, 90-day mortality, operative time and hospital length of stay were comparable among treatments.

CONCLUSIONS

RM or OL mesh placement seems associated with reduced IH RR compared to NM. PP location appears promising; however, future studies are warranted to corroborate this preliminary indication.