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Mesh repair of incisional Hernia: Comparison of Laparoscopic and open repair
M. van't Riet a; W. W. Vrijland a; J. F. Lange b; W. C. J. Hop c; J. Jeekel a; H. J. Bonjer a
a
Department of Surgery, Erasmus University Medical Center Rotterdam -Dijkzigt, Rotterdam, The
Netherlands b Department of Surgery, Medical Center Rijnmond Zuid, Rotterdam, The Netherlands c
Department of Epidemiology and Biostatistics, Erasmus University Medical Center Rotterdam, Rotterdam,
The Netherlands
Online Publication Date: 01 January 2002
To cite this Article Riet, M. van't, Vrijland, W. W., Lange, J. F., Hop, W. C. J., Jeekel, J. and Bonjer, H. J.(2002)'Mesh repair of
incisional Hernia: Comparison of Laparoscopic and open repair',European Journal of Surgery,168:12,684 — 689
To link to this Article: DOI: 10.1080/000000000000003
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2. ORIGINAL ARTICLE
Mesh Repair of Incisional Hernia: Comparison of
Laparoscopic and Open Repair
M. van ’t Riet1, W. W. Vrijland1, J. F. Lange2, W. C. J. Hop3, J. Jeekel1 and H. J. Bonjer1
From the 1Erasmus University Medical Center Rotterdam – Dijkzigt, Department of Surgery. 2Medical Center Rijnmond Zuid,
Rotterdam, Department of Surgery, 3Erasmus University Medical Center Rotterdam, Department of Epidemiology and
Biostatistics, Rotterdam, The Netherlands
Eur J Surg 2002; 168: 684–689
ABSTRACT
Objective: To compare our results of open and laparoscopic mesh repair of incisional hernias.
Design: Retrospective cohort study.
Setting: Teaching hospitals, The Netherlands.
Subjects: All patients who had had a laparoscopic (n = 25) or an open (n = 76) mesh repair of incisional hernia between
January 1996 and January 2000.
Interventions: Physical examination at the time of the study.
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Main outcome measures: Morbidity and recurrence.
Results: The groups were comparable. 11 patients (14%) developed postoperative infections after open repair and 1 (4%) after
laparoscopic repair (p = 0.29). Median hospital stay was 5 days (range 1–19) in the open group and 4 (range 1–11) in the
laparoscopic group (p = 0.28). The 2-year cumulative incidence of recurrence was 18% after open repair (median follow-up of
17 months (range 1–46) and 15% after laparoscopic repair (median follow-up of 15 months, range 1–44). Recurrences in the
laparoscopic group were all among the first 7 cases in which the mesh was fixed with staples alone.
Conclusion: There were fewer infections and hospital stay was shorter in the laparoscopic group, but not significantly so.
Recurrence rates were comparable.
Key words: incisional, hernia, mesh, laparoscopic.
INTRODUCTION operative wound complications and recurrence rates
than open repair.
Incisional hernia is one of the most common long-term
complications of abdominal surgery. In prospective
studies, the incidence has been reported to range from
PATIENTS AND METHODS
11 to 20% after a laparotomy (4, 13, 15, 18). Although
many techniques have been described for their repair, All patients who had had open or laparoscopic
results are often disappointing. After primary suture, incisional hernias repaired between January 1996 and
recurrence rates of 24% to 54% have been reported January 2000 at the Erasmus University Medical
(7, 9, 10, 16, 20). A tension-free repair using a pros- Center Rotterdam and the Medical Center Rijnmond
thetic mesh seems to be associated with lower Zuid in Rotterdam were entered into the study. Criteria
recurrence rates of 10% to 34% (8, 22). However, for inclusion were midline incisional hernia and mesh
open mesh repair requires more tissue-dissection than repair. Patients had a physical examination at the
primary suture, which predisposes to wound infection outpatient department at the time of the study (mid-
and painful recovery (1, 6, 19, 23). 2000), to detect recurrent incisional hernias.
Laparoscopic incisional hernia repair is an alter- All operations were done under general anaesthesia
native to open incisional hernia repair. Because large and patients were given antibiotic prophylaxis with a
abdominal incisions and extensive tissue dissection are first generation cephalosporin. There were no consis-
avoided, less wound infection, and faster recovery with tent guidelines about how patients were selected for the
shorter hospital stay are likely. This technique may also open or laparoscopic groups.
reduce recurrence rates as a result of better visual In the open procedure, the dorsal side of the fascia
peroperative detection of other subclinical fascial adjacent to the hernia was freed from the underlying
defects. tissue by at least 4 cm. The hernial sac was reduced into
The purpose of this study was to compare open and the abdominal cavity, without resection. A polypropy-
laparoscopic mesh repairs, to find out if laparoscopic lene mesh (Marlex1 or Prolene1) was tailored to the
incisional hernia repair is associated with fewer post- defect in a sublay position with a continuous suture of
 2002 Taylor & Francis. ISSN 1102–4151 Eur J Surg 168

3. Mesh repair of incisional hernia 685
Table I. Characteristics of patients
Data given are number of patients or mean (range).
Laparoscopic Open
(n = 25) (n = 76)
Age (years) 60 (33–79) 57 (29–85)
Male: Female ratio 13:12 40:36
Body mass index (kg/m2) 28 (20–35) 29 (21–44)
Number of previous
abdominal operations:
1 12 34
2 7 18
= or >3 6 24
Fig. 1. Laparoscopic mesh fixation with staples and trans- Number of previous
abdominal sutures. incisional hernia repairs:
0 16 56
1 6 16
0/0 or 1/0 Prolene, with an overlap of the fascial edges 2 1 4
= or >3 2 0
of at least 3 cm. The hernial defect was not sutured. Diameter of hernial defect 6 (2–10) 7 (1–30)
In the laparoscopic procedure, a polypropylene mesh (cm)
was fixed intraperitoneally. The laparoscopic technique
started with the establishment of CO2 pneumoperito-
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neum. A 30° laparoscope and two or three additional 5
or 10 mm trocars were inserted, some way from body mass index, history of previous abdominal
previous incisions, and as far as possible from the surgery, number of previous incisional hernia repairs,
hernial defect. Adhesions at or around the defect were and size of the hernial defect (Table I). Median
taken down carefully using blunt and sharp dissection operating time was 120 minutes in the laparoscopic
to allow sufficient surface to place a mesh. The hernial group (range 90–160) and 110 minutes in the open
sac was not resected. After lysis of adhesions, a group (range 45–203), which was not significantly
polypropylene mesh was introduced into the abdominal different.
cavity. It was fixed to the circumference of the defect Intraoperative complications occurred in five pa-
with an overlap of at least 3 cm with staples (Origin tients (7%) in the open group (bowel perforation n = 2,
Med-systems, Menlo Park, CA, USA). In some cases, serosal damage n = 2, superficial hepatic rupture n = 1)
transfascial sutures that were positioned with an and in two patients (8%) in the laparoscopic group
Endoclose-needle1 (United States Surgical Coopera- (intestinal perforation, n = 2). In the two patients with
tion, Norwalk, CT, USA) were added for mesh fixation bowel perforations in the open group, the perforation
(Fig. 1). was closed and a polypropylene mesh was placed
Mild wound infection was defined as redness and subfascially. In the two patients with peroperative
discharge of pus from the wound, while severe bowel perforation in the laparoscopic group, the
infection was defined as fever with pathogens cultured procedure was converted to an open approach and the
from the mesh. Seroma was defined as postoperative bowel injury was repaired. In one of these patients, the
accumulation of fluid at the site of the former hernial defect of the abdominal wall was closed by a suture,
sac. while the other patient had a mesh repair. Prophylactic
Statistical analysis was based on the intention-to antibiotics were continued for 5 days in these patients.
treat principle. Percentages were compared using Another laparoscopic procedure was converted be-
Fisher’s exact test. The Mann-Whitney test was used cause of severe adhesions, a conversion rate of 12% (3/
to evaluate hospital stay. Cumulative incidence of 25).
recurrence of incisional hernia was determined using In the laparoscopic procedures, the mesh was fixed
Kaplan Meier curves and compared with the logrank- solely by staples in 16 patients and by a combination of
test. Probabilities of less than 0.05 (two-tailed) were staples and transfascial sutures in six patients.
accepted as significant. Median postoperative hospital stay was 4 days
(range 1–11) after the laparoscopic procedure and 5
days (range 1–19) after an open repair. This difference
RESULTS
was not significant (P = 0.28)
A total of 101 patients, 25 in the laparoscopic group Postoperative complications are shown in Table II.
and 76 in the open group, were included in the study. Postoperative wound infection developed in 11 patients
The two groups were comparable in terms of age, sex, in the open group, and in one patient in the
Eur J Surg 168

4. 686 M van ’t Riet et al.
Table II. Postoperative complications and recurrences peration for enterocutaneous fistula (n = 1), and severe
Data are number (%) of patients. wound infection (n = 2).
At the time of the study, 94 patients (93%) had a
Laparoscopic Open
(n = 25) (n = 76)
physical examination in the outpatient department. One
patient from the laparoscopic group and 6 from the
Early postoperative open group could not be traced or did not respond to the
complications:
Seroma/haematoma 9 (36%) 13 (17%)
invitation. For these patients, the general practitioner
Wound infection: 1 (4%) 11 (14%) was contacted and follow-up was defined as the last
mild 1 (4%) 1 11 (14%) 7 physical examination that had been made.
severe 0 4 During a median follow-up time of 17 months in the
Ileus 1 3 open group (range 1–46) and 15 months in the
Retention of urine 1 1
Pneumonia 0 2
laparoscopic group (range 1–44), there were 14
Pulmonary embolism 1 0 recurrences after open repair and four after laparo-
Mean follow-up (months) 16 19 scopic repair. Six of these recurrences (two in the open
Recurrence 4 (16%) 14 (18%) group and four in the laparoscopic group) had not been
Readmission 1 (4%) 8 (11%) detected before and were only diagnosed at per-
Re-operation indication: 1 (4%) 6 (8%) protocol physical examination. The time of occurrence
recurrence 1 5 of these recurrences could be calculated retrospectively
enterocutaneous fistula 0 1 when the patient was interviewed. Calculated with the
Kaplan Meier method, the 2-year cumulative incidence
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There were no significant differences between the groups.
of recurrence was 18% after open repair and 15% after
laparoscopic repair, which was not significantly dif-
ferent (p = 0.91). There was no significant relation
laparoscopic group, in whom the procedure had been between initial diameter of the hernial defect and
converted to an open repair (p = 0.29). Wound infec- recurrence. All four recurrences in the laparoscopic
tion was considered mild in eight patients, but severe in group occurred during the first series of 7 laparoscopic
four patients, including all three patients in whom a incisional hernia repairs that were done in each
mesh was placed after intraoperative bowel injury. In hospital. In one of these cases the laparoscopic
three of the patients with mesh infection, conservative procedure had been converted to an open procedure.
treatment with drainage and antibiotics was successful. The other three recurrences after a laparoscopic
The fourth patient however, in whom open incisional procedure developed in the group of 16 patients
hernia repair had been complicated by two peropera- in whom the mesh was fixed with staples alone
tive bowel perforations, developed two enterocuta- (3/16 = 19%). No recurrences were seen in the six
neous fistulas. For this reason, the patient was patients in whom the mesh was fixed by a combination
reoperated on 7 months postoperatively. During this of staples and transfascial sutures.
reoperation, the mesh was removed and a segment of Only five of the patients with recurrences (all in the
small bowel was resected, followed by primary suture open group) had the recurrent hernia repaired, all open
of the fascia. After this the patient recovered well. procedures with mesh. One patient in the laparoscopic
Seroma was the most common complication in both group had a reoperation because of suspicion of a
groups, with an incidence of 13/76 (17%) in the open, recurrent incisional hernia, but at reoperation no
and 9/25 (36%) in the laparoscopic group (not recurrence could be detected and a blind hernial sac
significantly different, p = 0.09). In most of the that was filled with fluid was resected.
patients, the seroma resolved spontaneously, or after
one or two aspirations. However, one patient in the
laparoscopic group developed a persisting seroma that
DISCUSSION
resolved only after 12 aspirations.
Other postoperative complications consisted of Laparoscopic repair of incisional hernia has been
urinary retention (n = 1), pneumonia (n = 2), and studied by several authors, and the results of all
pulmonary embolism (n = 1). All were treated success- published comparative studies on open and laparo-
fully. Three patients died during follow-up. Their scopic incisional hernia repair to our knowledge are
causes of death were related to malignancy and not to shown in Table III (1, 5, 14, 17, 19, 23).
the incisional hernia repair. In these studies, operating time of laparoscopic
Nine patients (eight in the open group and one in the repair varied, which seemed to be related to the
laparoscopic group) were readmitted to hospital: for laparoscopic experience of the operating team. In the
symptomatic recurrent incisional hernia (n = 6), reo- present study, operating time was comparable in both
Eur J Surg 168

5. Downloaded By: [HINARI Consortium (T&F)] At: 17:48 20 October 2009
Table III. Overview of published comparative studies between laparoscopic and open ventral incisional hernia repair
Data are number (%) of patients.
DeMaria et al. (4) Ramshaw et al. (18) Carbajo et al. (2) Holzman et al. (6) Park et al. (16) Chari et al. (3)
Prospective not Prospective Prospective not Matched case-
randomised Retrospective randomised Retrospective randomised control
Laparoscopic Open Laparoscopic Open Laparoscopic Open Laparoscopic Open Laparoscopic Open Laparoscopic Open
No. of patients 21 18 79 174 30 30 22 16 56 49 14 14
Material ePTFE PP ePTFE Suture ePTFE 8 ePTFE PP 10 PP 1 44 PTFE 12 3 ePTFE ePTFE PP
or 22 PP ePTFE 5 PP 42 PP 4
mesh suture Vicryl
Operating time (min) 58 82 87* 112* 129 98 96* 79* 124 78
Blood loss (ml) 17 70 68 168
Peroperative bowel injury 3 2 2 1 0 1 2 1
Hospital stay (days) 0.8* 4.4* 1.7 2.8 2* 9* 1.5 3.9 3.4* 6.5* 5 5.5
Postoperative complications:
Wound infection 2 (10) 6 (33) 2 (3) 11 (6) 0 5 (17) 0 1 (7) 2 (4) 3 (6) 1 (7) 0
Iinfected mesh removed 1 0 0 5 0 3 0 0 0 0 1 0
Haematoma/Seroma 9 (43) 4 (22) 2 (3) 12 (7) 4 (13) 26 (87) 1 (5) 0 2 (4) 6 (12)
Other complications 2 3 5 15 1 1 3 3 4 6 1
Total 62% 72% 20% 27% 17%* 90%* 23% 31% 18%* 37%* 14% 7%
Mean follow-up (months) 12–24 12–24 21 21 27 27 20 19 24 54
Recurrence (%) 5 0 3 20 0 6 9 13 11 35
ePTFE = polytetrafluoroethylene, PP = polypropylene, Vicryl = polyglactin.
* Significant difference between open and laparoscopic group.
Mesh repair of incisional hernia
Eur J Surg 168
687

6. 688 M van ’t Riet et al.
groups, although surgeons had limited experience with is contaminated, the risk of developing an enterocuta-
laparoscopic incisional hernia repair. nous fistula is probably increased. We recommend that
During both open and laparoscopic incisional hernia the mesh is not placed intraperitoneally and that
repair the most delicate part of the procedure is the lysis prophylactic antibiotics are continued for several
of adhesions, during which the bowel may be injured. days in these patients.
In our series, bowel injury was encountered in 8% in Hospital stay is an important variable used to assess
both groups. In other series, comparable percentages postoperative recovery, and was reduced after laparo-
were reported after both open incisional hernia repair scopic repair in three comparative studies (1, 5, 19).
(0–7%) and laparoscopic repair (0–14%) (1, 5, 14, 17, However, although hospital stay was slightly reduced
19, 23). Probably, the incidence of peroperative bowel after laparoscopic repair in the present study, this
injury will decrease with the increasing experience of difference was not significant.
the surgeon. The recurrence rate after laparoscopic repair in the
Most published comparative studies have reported present study was higher than the recurrence rate that
fewer wound infections after laparoscopic repair than was found by other authors (1, 5, 14, 17, 19, 23). The
after open repair. (1, 5, 14, 19, 23) We saw the same explanation for this is not clear, although it is
trend in the present study, with 4% postoperative remarkable that all the recurrences developed in the
wound infection in the laparoscopic group and 15% in first series of 7 repairs. For this reason, a learning curve
the open group. This difference was, however, not may have played a part in the higher incidence of
significant, which may be because there were so few recurrence after laparoscopic repair. Another factor is
patients in the laparoscopic group. Possibly the the method of fixing the mesh. As all recurrences in the
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combination of a smaller port of entry for micro- laparoscopic group occurred in the patients in whom
organisms and the lack of large tissue dissection in the mesh was fixed with staples alone, the addition of
laparoscopic repair may contribute to a lower risk for transfascial sutures to fix the mesh may reduce
infection. recurrence rates. Unfortunately, the group in which it
In both the present study and other comparative was fixed with both staples and transfascial sutures in
studies, the most common complication after incisional the present study was too small from which to draw any
hernia repair was the formation of a seroma or a conclusions.
haematoma, with reported incidences between 2% and Another factor, which may have played a part in the
36% for the laparoscopic group and between 4% and higher recurrence rate in the present study, is the fact
87% for the open group (1, 5, 14, 17, 19, 23). The wide that in most other studies follow-up was not by physical
spread of incidence of this complication is remarkable, examination (1, 14, 17, 19, 23). Six of the 18 recur-
and probably results from differences in definition. The rences that had developed were only diagnosed at
most plausible explanation for the occurrence of physical examination in the outpatient department at
seroma is the collection of fluid in a persisting hernial the time of the study. A physical examination is
sac or in the cavity that remains after removal of the therefore essential for adequate follow-up.
hernial sac. Seromas can be drained by aspiration, but We found no significant difference between recur-
resolve spontaneously in most cases, so resection of the rence rates after laparoscopic or open incisional hernia
hernial sac does not seem indicated in laparoscopic repair, which has been confirmed by other authors (1,
incisional hernia repair. To differentiate seroma from 14, 17, 19). However, two comparative studies found
recurrent incisional hernia, which can be clinically fewer recurrences after laparoscopic repair than after
difficult in obese patients, an ultrasound or computed open repair (5, 23). In contrast to the present study, in
tomogram can be obtained. both of these studies mesh material varied between the
Seven patients were reoperated on (six in the open open and laparoscopic group, and both studies also
group and one in the laparoscopic group). One of these included patients in the open group in whom open
patients had developed an enterocutaneous fistula after repair was by primary suture without a mesh (5, 23). As
an open procedure. Although this complication has has been shown by various authors, incisional hernia
been previously reported after intraperitoneal mesh repair without the use of a mesh is associated with
placement, it is a rare complication with a long-term higher recurrence rates (2, 18, 20, 21). In addition, both
incidence of about 1% (3, 9, 11, 12). Its occurrence is these studies included a variety of incisional hernias,
mostly restricted to cases in which the mesh was placed while the present study included only incisional hernias
in an infected abdomen (11). In the patient in the that had developed after midline laparotomy.
present study who developed the enterocutaneous In conclusion, laparoscopic incisional hernia repair
fistula, the mesh was also placed in a contaminated seems to be an effective technique, and as safe as the
abdomen, as the incisional hernia repair had been open procedure. Although the differences were not
complicated by two bowel perforations. If the abdomen significant, there were fewer postoperative wound
Eur J Surg 168

7. Mesh repair of incisional hernia 689
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