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Laparoscopic and open incisional hernia repair: A comparison study
Laparoscopic and open incisional hernia repair: A comparison study Adrian Park, MD, Daniel W. Birch, MD, and Peter Lovrics, MD, Lexington, Ky, and Hamilton, Ontario, Canada
Background. Techniques for performing laparoscopic incisional hernia repair have been described and some advantages over conventional open repair reported. However, most reported series of laparoscopic incisional hernia procedures are small, and only one has included a comparison with open repairs. Methods. From December 1993 to January 1998, we prospectively collected operative and outcome data on 56 consecutive laparoscopic prosthetic repairs of large incisional hernias. The data were compared with those from a retrospective review of 49 open incisional hernia repairs done in January 1991 to December 1993. Results. The open and laparoscopic repair groups were comparable in patient age, sex, preoperative American Society of Anesthesiologists score, hernia size, and history of previous repair. Operative time was significantly longer in the laparoscopic group; duration of hospitalization and number of perioperative complications were significantly greater in the open group. Conclusions. In this series, laparoscopic repair of incisional hernias took longer to perform than open repair but was associated with fewer perioperative complications and a shorter hospital stay. (Surgery 1998;124:816-22.) From the Division of General Surgery, University of Kentucky Medical Center, Lexington, Ky, and the Department of Surgery, St Joseph’s Hospital, McMaster University, Hamilton, Ontario, Canada
AN INCISIONAL HERNIA DEVELOPS in about 2% to 11% of patients who undergo abdominal surgical procedures.1 Unfortunately, results of repairs of these hernias are often unsatisfactory; about 20% to 46% of the lesions recur.1 This experience has led to a continuing search for new repair techniques. An important innovation was the introduction of meshes or patches made of polypropylene, expanded polytetrafluoroethylene (ePTFE), or other materials for use in tension-free incisional herniorrhaphy. These prostheses are now widely used, especially in repairing large hernias, and their use has been reported to decrease recurrence rates.2,3 The current interest in minimally invasive surgery has encouraged development of techniques for performing incisional hernia repair laparoscopically.4-10 However, most series in which these methods were used have been small, and only one report described a comparison between Presented at the Fifty-fifth Annual Meeting of the Central Surgical Association, Ann Arbor, Mich, March 5-7, 1998. Reprint requests: Adrian Park, MD, Division of General Surgery, University of Kentucky Medical Center, 800 Rose St, Room C 220, Lexington, KY 40536-0084. Copyright © 1998 by Mosby, Inc. 0039-6060/98/$5.00 + 0
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laparoscopic and conventional open repairs.10 In this study we compared operative and outcome data in patients who underwent laparoscopic repair of large incisional hernias with those in patients (historical controls) who had open repair. PATIENTS AND METHODS Patients undergoing laparoscopic repair of an incisional hernia (using a prosthetic patch or mesh) consecutively at 2 teaching hospitals in December 1993 to January 1998 were considered for the prospective portion of this study. Data on these patients were collected with use of a data form on which were recorded age, sex, previous operation, preoperative American Society of Anesthesiologists (ASA) status, hernia size and location, previous hernia repairs, operating time, intraoperative and postoperative complications, postoperative hospital stay, date of last follow-up evaluation, and whether there had been a hernia recurrence. The same data form was used to collect information retrospectively from the medical records of patients who underwent a traditional open incisional hernia repair in which a prosthetic material was used (hernia larger than 3 cm in its smallest dimension and requiring a prosthesis for a tensionfree repair) in January 1991 to December 1993. In addition, an attempt was made to contact each
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Surgery Volume 124, Number 4 Table I. Patient characteristics Laparoscopic repair group
Open repair group
P value
No. of patients Sex (M/F) Mean age in yr (range) Mean ASA score (range) Incisional hernia data Lateral location Central/midline location
56 30/26 58.8 (25–84) 2.1 (1–3)
49 23/26 58.5 (35–82) 2.2 (1–3)
NS NS NS NS
8 33
14 32
NS
Upper abdomen location Lower abdomen location
9 5
22 9
NS
First repair Previous repair
40 16
40 9
NS
NS, Not significant.
patient for a follow-up evaluation. Each patient interviewed was examined by a senior surgical resident. The patient’s medical history was reviewed and additional details obtained. A recurrent hernia was diagnosed if a hernia was demonstrable on examination and the fascial edges were palpable. The technique used for the laparoscopic incisional hernia repairs in this study has been described previously.6 Briefly, pneumoperitoneum was established with use of a Veress needle inserted in either the left or right subcostal space. A directview trocar was inserted laterally in a window between the iliac crest and costal margin. A 30degree or 45-degree 5- or 10-mm laparoscope was used. Most hernias could be repaired with 1 10-mm and 2 5-mm ports placed laterally in the upper and lower quadrant, respectively. Adhesiolysis was performed, and the margins of the defect were clearly delineated. A prosthetic patch or mesh was sized to overlap all hernia margins by at least 2.5 cm and then oriented externally, wrapped around a laparoscopic forceps, introduced through the trocar site, and unfurled. It was secured with a combination of nonabsorbable sutures placed through the abdominal wall (buried subcutaneously) 4- to 5-cm apart, and laparoscopically placed staples were positioned no more than 1 cm apart around the circumference of the prosthesis. The hernia sac was not opened or dissected free. All of the open hernia repairs were performed using a prosthetic patch to effect a tension-free repair. An incision was made over the hernia defect. Where possible the hernia sac was dissected free and left intact. In most cases, however, it was incised in the process of exposing the fascial margins. The subcutaneous tissue was dissected to clear a fascial rim extending 11/2 to 2 cm from the defect margin. The prosthetic patch was selected and sized to
overlap the defect by 11/2 cm on all sides. The mesh was then secured to the cleaned fascial rim with interrupted nonabsorbable sutures. Either 1 or 2 drains (depending on the amount of soft tissue dissection and resulting dead space) were then placed into the wound before final closure. Categorical data from patients who underwent laparoscopic repair were compared with those from patients who had open repair with use of chisquare testing. Correlational analysis used Pearson’s product moment correlation coefficient. A two-sample t test was used to compare continuous variables in the two groups. A P value less than .05 was considered significant. RESULTS Fifty-seven patients were scheduled for laparoscopic incisional hernia repair in December 1993 to January 1998, but one required conversion to open repair when pneumoperitoneum could not be established because of the density of adhesions from previous operations. Therefore 56 patients were enrolled in the laparoscopic group. The open repair group contained 49 patients after exclusion of 3 patients with inadequate documentation, 1 patient in whom the hernia repair was combined with another abdominal procedure, and 6 patients who had died. Patient characteristics in the 2 groups were comparable (Table I). Perioperative findings in the laparoscopic repair and open repair groups are shown in Table II. There was no significant difference between the 2 groups in mean hernia size. In the laparoscopic group, 44 ePTFE patches and 12 polypropylene meshes were used. In the open group, 3 ePTFE patches, 42 polypropylene meshes, and 4 polyglactin meshes were used. Laparoscopic incisional hernia repair took significantly longer (P < .01) to perform than open repair. However, the postoperative length of
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Table II. Perioperative findings Laparoscopic repair group Mean defect size in cm2 (range) Mean prosthesis size in cm2 (range) Mean patch:defect size ratio Mean operating time in min (range) Mean postoperative hospital stay in days (range)
Open repair group
99.4 (9–420) 231 (24–600) 2:3 95.4 (45–170) 3.4 (1–17)
105.3 (6.3–495) Not available Not available 78.5 (27–148) 6.5 (2–26)
P value NS
<.01 <.001
Table III. Perioperative complications Total complications Wound infection Hematoma Seroma Protracted pain Infected seroma Infected prosthesis Pulmonary Cardiac Genitourinary Prolonged ileus Bowel injury Bowel fistula
Laparoscopic repair group
Open repair group
P value
10 — — 2 2 — 2 1 — — 3 — —
18 1 5 1 2 1 1 — 2 3 — 1 1
<.05
stay was significantly shorter (P < .001) in patients who underwent a laparoscopic procedure. Table III shows the perioperative complications in the 2 study groups. Overall, there were significantly fewer complications in the laparoscopic repair group. There were 2 serious bowel injuries in the open repair group. One was an abscess and fistula that resulted from erosion of polypropylene mesh into the small bowel. The other was an enterotomy that was repaired with suture. Because the hernia sac was left in situ in the laparoscopic repair group, a transient seroma (sterile fluid accumulation) developed in most patients. A seroma was considered a complication, however, if it persisted for more than 6 weeks, increased in size steadily, or produced symptoms. Both seromas listed on Table III met these criteria and both resolved after aspiration. Forty-five patients (80%) in the laparoscopic repair group were followed by means of a postoperative visit or telephone call. Twenty-eight patients (57%) in the open repair group returned for a follow-up examination for this study. The remaining patients could not be contacted, declined to participate, or had died. The mean follow-up time in the 45 evaluated patients in the laparoscopic group was 24.1 months (range, 1 to 48 months); in the 28 evaluated patients in the
open group it was 53.7 months (range, 36 to 85 months; P = .001). The follow-up time in the open group was longer because the operations were performed 1 or more years earlier. During follow-up, hernia recurrence developed in 6 patients in the laparoscopic repair group and in 17 in the open repair group. Because of the differences in follow-up times and numbers of patients with follow-up assessments in the open repair and laparoscopic repair groups, a meaningful comparison of recurrence rates in the 2 groups could not be made. Factors related to recurrence in both groups are shown in Table IV. There were significantly fewer recurrences in patients who had a central or midline defect than in those who had a lateral defect. Patients who had no postoperative complications also had fewer recurrences. Use of an ePTFE patch compared with a polypropylene mesh appeared to be significantly associated with fewer recurrences, although this finding may have been influenced by the fact that most laparoscopic repairs used ePTFE. Smaller hernias (<50 cm2) were significantly less likely to recur than larger hernias (P < .03 by Pearson testing). In the laparoscopic repair group, there was a nonsignificant trend toward an increased recurrence rate in patients who had undergone a previous repair. No relation was observed between her-
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Table IV. Factors related to hernia recurrence in 73 patients having follow-up evaluations
Central/midline defect Lateral defect ePTFE patch Polypropylene mesh Perioperative complications No perioperative complications
Patients with recurrence
Patients without recurrence
11 11 6 15 10 13
25 6 21 14 4 31
nia recurrence and patient age, sex, or ASA status. Interestingly, in 3 of the 6 patients with recurrence in the laparoscopic group, a rerepair was done laparoscopically, with a second ePTFE patch being placed over a corner of the previous repair site. All 3 of these repairs have so far remained intact. In the open repair group, in which follow-up extended to 85 months, the time of recurrence ranged from 1 to 24 months postoperatively (mean, 10.5 months). In the laparoscopic repair group, the range was 2 to 12 months (mean, 6 months). DISCUSSION In this study we found that although laparoscopic incisional hernia repair took longer to perform than open repair, it was a feasible and practical approach to a common problem and may have some advantages over the open procedure. The benefits of minimally invasive surgery that have already been observed in studies comparing laparoscopic and inguinal hernia repair—shorter hospital stay,11 faster recovery,12,13 and decreased postoperative pain13,14—may also apply to laparoscopic incisional hernia repair. Although we did not assess recovery time or postoperative pain in this study, our patients in the laparoscopic repair group had a shorter duration of hospitalization than those in the open repair group. Laparoscopic incisional hernia repair involves no long incision, no wide fascial dissection or flap creation, no opening of the hernia sac, and no drains. Theoretically, this should lower the risk of wound infections caused by perioperative bacterial contamination. In this study fewer wound complications occurred in patients who underwent laparoscopic operation than in those who had an open procedure. The laparoscopic repair group also had no bowel complications, whereas there were 2 in the open repair group. The lack of bowel injury in the laparoscopic group may have been related to improved adhesiolysis associated with laparoscopy. Pneumoperitoneum facilitates identification of planes of dissection and the hernia defect itself. The bowel fistula in this study occurred in a
P value .02 .02 .005
patient in whom polypropylene mesh was used. Polypropylene mesh has previously been observed to cause bowel erosion and fistulization,15-17 and this is a special concern in laparoscopic repairs in which the prosthesis may be in direct contact with the bowel and abdominal contents. Therefore, like others,4,5,18,19 we prefer ePTFE for laparoscopic incisional herniorrhaphy. This prosthesis has been found to be less easily infected than polypropylene20 and to produce fewer and less tenacious adhesions21,22 but good tissue attachment.23 On the other hand, ePTFE generally costs more than polypropylene, and it may be more difficult to maneuver laparoscopically because of its lack of stiffness (memory)7 and relatively opaque nature. More cases of prolonged ileus were observed in the laparoscopic repair group than in the open repair group in this study. This may have been because the condition was more evident in the quickly recovering patients in the laparoscopic group and was overlooked or underreported in patients in the open group, who had a more prolonged convalescence. Our data did not allow a comparison of hernia recurrence rates in the open repair and laparoscopic repair groups. However, we found that recurrence was associated with larger hernias, hernias in a central or midline location compared with lateral hernias, and wound complications after hernia repair. Large size was also found to be a significant risk factor for recurrence by Hesselink et al.24 In addition, they found a relationship with wound infections, although it was not significant. However, if a wound infection requires removal of the implanted prosthesis, recurrence is clearly more likely.18 The site of the original incision had no influence on recurrence rate in the study by Hesselink et al.24 A randomized, controlled prospective study comparing laparoscopic with open incisional hernia repair, especially with respect to recurrence rates, has not yet been done, although one is clearly needed. To our knowledge, our study and that by Holzman et al10 have thus far been the only investigations to compare the 2 operative techniques. Holzman et al retrospectively reviewed 21
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laparoscopic and 16 open ventral and incisional hernia repairs performed during the same time period. Five of the open repairs and 3 of the laparoscopic repairs did not use a prosthesis. For all but 1 of the remaining repairs, polypropylene mesh was used. Mean operating times in the laparoscopic and open groups were 129 and 98 minutes, respectively; however, the difference was not significant. Complications in the laparoscopic group were 1 wound infection, 1 bowel obstruction, and 1 case of hypoxia. The open group had 1 wound infection, 1 bowel obstruction, 2 cases of prolonged ileus, and 1 case of hypoxia. Overall complication rates were 31% in the open group and 23% in the laparoscopic group. Hospital stay was shorter in the laparoscopic group. During a follow-up period of about 19 months, there were two recurrences in each group. Our results are generally in agreement with those of Holzman et al, especially their findings on duration of hospitalization and operating time. Some of the differences in postoperative morbidity between the two studies may have been due to varying practices regarding prosthetic use, selection, and fixation. We have found that prosthetic patches must be secured with sutures and staples to prevent slippage. The largest (noncomparative) prospective study of laparoscopic ventral hernia repairs described so far is the ongoing investigation by Toy et al.8 Only preliminary results in 144 patients have been presented. All repairs were done with a peritoneal onlay technique using an ePTFE patch. Mean operating time was 120 minutes. Postoperative complications were 5 infections, 3 cases of prolonged ileus, 1 partial bowel obstruction, and 8 seromas. Hospital discharge took place a mean of 2.3 days after operation, and return to normal activity was a mean of 15 days postoperatively. The mean followup was 222 days (range, 5 to 731 days). Six hernias recurred. The 3% infection rate and 4% recurrence rate in this study compare favorably with rates in series of open repairs. In summary, in a study comparing well-matched cohorts of patients who underwent laparoscopic and open incisional hernia repair, we found that the laparoscopic procedure took longer to perform but that it was associated with fewer complications and a shorter postoperative hospital stay. More extensive studies are needed to confirm the advantages of the laparoscopic approach. We thank Don Witzke for statistical analysis and Renée J. Robillard for editorial assistance.
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REFERENCES 1. Santora TA, Roslyn JJ. Incisional hernia. Surg Clin North Am 1993;73:557-70. 2. Stoppa RE. The treatment of complicated groin and incisional hernias. World J Surg 1989;13:545-54. 3. Langer S, Christiansen J. Long-term results after incisional hernia repair. Acta Chir Scand 1985;151:217-9. 4. LeBlanc K, Booth WV. Laparoscopic repair of incisional abdominal hernias using expanded polytetrafluoroethylene: preliminary findings. Surg Laparosc Endosc 1993;3: 39-41. 5. LeBlanc KA, Booth WV, Spaw AT. Laparoscopic ventral herniorrhaphy using an intraperitoneal onlay patch of expanded polytetrafluoroethylene. In: Arregui ME, Nagan RF, editors. Inguinal hernia: advances or controversies? Oxford: Radcliffe Medical Press; 1994. p 515-7. 6. Park A, Gagner M, Pomp A. Laparoscopic repair of large incisional hernias. Surg Laparosc Endosc 1996;6:123-8. 7. Saiz AA, Willis IH, Paul DK, Sivina M. Laparoscopic hernia repair: a community hospital experience. Am Surg 1996;62:336-8. 8. Toy FK, Bailey RW, Carey S, et al. Multicenter prospective study of laparoscopic ventral hernioplasty: preliminary results. Surg Endosc In press. 9. Frantzides CT, Carlson MA. Minimally invasive ventral herniorrhaphy. J Laparoendosc Adv Surg Tech 1997;7: 121-4. 10. Holzman MD, Purut CM, Reintgen K, Eubanks S, Pappas TN. Laparoscopic ventral and incisional hernioplasty. Surg Endosc 1997;11:32-5. 11. Wilson MS, Deans GT, Brough WA. Prospective trial comparing Lichtenstein with laparoscopic tension-free mesh repair of inguinal hernia. Br J Surg 1995;82:274-7. 12. Liem MSL, van der Graaf Y, van Steensel CJ, et al. Comparison of conventional anterior surgery and laparoscopic surgery for inguinal-hernia repair. N Engl J Med 1997;336:1541-7. 13. Stoker DL, Spiegelhalter DJ, Singh R, Wellwood JM. Laparoscopic versus open inguinal hernia repair: randomised prospective trial. Lancet 1994;343:1243-5. 14. Kozol R, Lange PM, Kosir M, et al. A prospective, randomized study of open vs laparoscopic inguinal hernia repair: an assessment of postoperative pain. Arch Surg 1997;132:292-5. 15. Nagy KK, Fildes JJ, Mahr C, et al. Experience with three prosthetic materials in temporary abdominal wall closure. Am Surg 1996;62:331-5. 16. Kaufman Z, Engelberg M, Zager M. Fecal fistula: a late complication of Marlex mesh repair. Dis Colon Rectum 1981;24:543-4. 17. Voyles CR, Richardson JD, Bland KI, Tobin GR, Flint LW, Polk HC Jr. Emergency abdominal wall reconstruction with polypropylene mesh: short-term benefits versus long-term complications. Ann Surg 1981;194:219-33. 18. Bauer JJ, Salky BA, Gelernt IM, Kreel I. Repair of large abdominal wall defects with expanded polytetrafluoroethylene (PTFE). Ann Surg 1987;206:765-9. 19. Annibali R, Fitzgibbons RJ Jr. Prosthetic materials and adhesion formation. In: Arregui ME, Nagan RF, editors. Inguinal hernia: advances or controversies? Oxford: Radcliffe Medical Press; 1994. p 115-24. 20. Brown GL, Richardson JD, Malangoni MA, Tobin GR, Ackerman D, Polk HC Jr. Comparison of prosthetic materials for abdominal wall reconstruction in the presence of contamination and infection. Ann Surg 1985;210:705-11.
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21. Law NW, Ellis H. Adhesion formation and peritoneal healing on prosthetic materials. Clin Mater 1988;3:95-101. 22. Murphy JL, Freeman JB, Dionne PG. Comparison of Marlex and Gore-tex to repair abdominal wall defects in the rat. Can J Surg 1989;32:244-7. 23. Bellón JM, Contreras LA, Sabater C, Buján J. Pathologic and clinical aspects of large incisional hernias after implant of a polytetrafluoroethylene prosthesis. World J Surg 1997;21:402-7. 24. Hesselink VJ, Luijendijk RW, de Wilt JHW, Heide R, Jeekel J. An evaluation of risk factors in incisional hernia recurrence. Surg Gynecol Obstet 1993;176:228-34.
DISCUSSION Dr James R. DeBord (Peoria, Ill). You have analyzed your data comparing laparoscopic and conventional open repair of ventral incisional hernias. Your conclusions seem to favor the laparoscopic technique. However, a critical look at your data pose several questions. First, what role did the time interval differences, 1991 to 1993 versus 1993 to 1998, and the cultural, social, and health care system differences between the United States and Canada play in your length of hospital stay data? Second, because a number of your complications are more related to the type of prosthetic biomaterial used than to the actual technique, how did you evaluate the role of a 79% use of ePTFE in the laparoscopic repair but only a 6% use of ePTFE in the open repair? Also, were there any recurrences related to the use in 4 of your open cases of absorbable mesh? In summary, there are a number of variables that have clouded my ability to analyze the value of the different techniques. I agree with you that a randomized, controlled, prospective study is clearly needed. This study should include open and laparoscopic techniques of hernia repair that are as similar as possible, that use the same prosthetic biomaterial, are followed for an adequate period of time, and where outcome analysis also includes a comparison of costs and a standardized evaluation of time to return to normal activities. The benefits of minimally invasive surgery are pretty well acknowledged now by all surgeons with respect to cholecystectomy, by many surgeons with respect to antireflux procedures, and a few surgeons believe that these techniques are beneficial in other arenas of abdominal surgery. With respect to hernia surgery, however, there are strong opinions that seem to exist, but little data have been available to properly evaluate the role of laparoscopic surgery in hernia repair. We are beginning to establish some data with respect to inguinal hernia repair, and a critical analysis of these data with respect to the time of operation, the length of hospitalization, patient discomfort, the issues of general anesthesia versus local anesthesia, costs of treatment, and ultimately rates of recurrence will likely reveal a limited but useful role for laparoscopic inguinal hernia repair. Dr Park. With regard to the first question, I don’t
Park, Birch, Lovrics 821
think that the time difference of 3 or 4 years between the two groups reflects a tremendous difference in the sophistication of health care delivery between the early and mid 1990s. There is a different culture in the delivery of health care between Canada and here at times. This is reflected in a slightly longer hospital stay. Although when we took out the Lexington data, we still found that the hospital stay was less than half the time for the laparoscopic as it was for the open patients. The type of prosthesis was significantly related to the type of repair. Clearly the case of bowel erosion and abscess in fistula formation was related to the propylene mesh patch and has not been reported with a PTFE patch. Nevertheless, the issues of wound complication, hematoma, and seroma infection have more to do with the extensive subcutaneous soft tissue dissection that is necessary with open repair. Dr Michael Brunt (St Louis, Mo). Why do you think the recurrence rate should be lower with the laparoscopic approach? You had a mixed group of patients in the open group. Some had the mesh placed posteriorly, others anteriorly. My practice has been to place the mesh posteriorly because I think that intra-abdominal pressure is more likely to keep the mesh up against the abdominal wall, whereas anteriorly placed mesh is pushed away from the fascia. Why should the recurrence rate be lower with the laparoscopic approach? Are you covering a broader area or using a bigger piece of mesh? What did you find at laparoscopy in the patients who had recurrence after the laparosocopic repair and what technical factors led to recurrences in those patients? I was concerned by the fact that you had 2 infected prostheses in the laparoscopic group. In general, with laparoscopy the risk of infectious complications should be lower because of the smaller incisions and less subcutaneous soft tissue dissection. What were the factors that led to the infection in those 2 cases? Finally, what are your contraindications to using a laparoscopic approach in a patient with an incisional hernia? I would also emphasize the need for a prospective randomized trial of this problem. Dr Park. I will answer the second question first about why these patches were infected in the laparoscopic group. Both patients had had multiple previous repairs, had had infected prostheses in the past and had been treated, and I obviously believed that the infection had completely resolved. Getting back to your first question about why do I think the recurrence rate may be lower with laparoscopic repair, I would echo your comments that by placing the prosthesis under the fascial margins intraabdominal pressures are essentially buttressing the repair and not disrupting the patch from its fascial attachments if it is placed anteriorly. The other thing that we can do laparoscopically is we can clearly and definitively identify the defect margins, and we can define Swiss cheese deformities that extend
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beyond that which you can palpate with open surgery, so the extent of the defect can be accurately delineated laparoscopically. The other thing is that you can then clearly establish the amount of overlap you want. Sometimes it is a lot more difficult with open repair. Our practice is to overlap by 2.5 to 3 cm all margins of the defect. What I found with laparoscopic recurrences was that there had been patch slippage. There have been some
Surgery October 1998 reports in the literature about doing this simply with clips. My strong feeling is that shouldn’t be done, these patches need to be secured well with sutures. We had slippage in the corner on 2 cases. The third one was a situation that was a very difficult repair, high in the epigastrium, where there is no good tissue to which to attach a secure patch. We actually had to go underneath the ribs to attach the patch there.
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Background. Techniques for performing laparoscopic incisional hernia repair have been described and some advantages over conventional open repair reported. However, most reported series of laparoscopic incisional hernia procedures are small, and only one has included a comparison with open repairs. Methods. From December 1993 to January 1998, we prospectively collected operative and outcome data on 56 consecutive laparoscopic prosthetic repairs of large incisional hernias. The data were compared with those from a retrospective review of 49 open incisional hernia repairs done in January 1991 to December 1993. Results. The open and laparoscopic repair groups were comparable in patient age, sex, preoperative American Society of Anesthesiologists score, hernia size, and history of previous repair. Operative time was significantly longer in the laparoscopic group; duration of hospitalization and number of perioperative complications were significantly greater in the open group. Conclusions. In this series, laparoscopic repair of incisional hernias took longer to perform than open repair but was associated with fewer perioperative complications and a shorter hospital stay. (Surgery 1998;124:816-22.) From the Division of General Surgery, University of Kentucky Medical Center, Lexington, Ky, and the Department of Surgery, St Joseph’s Hospital, McMaster University, Hamilton, Ontario, Canada
AN INCISIONAL HERNIA DEVELOPS in about 2% to 11% of patients who undergo abdominal surgical procedures.1 Unfortunately, results of repairs of these hernias are often unsatisfactory; about 20% to 46% of the lesions recur.1 This experience has led to a continuing search for new repair techniques. An important innovation was the introduction of meshes or patches made of polypropylene, expanded polytetrafluoroethylene (ePTFE), or other materials for use in tension-free incisional herniorrhaphy. These prostheses are now widely used, especially in repairing large hernias, and their use has been reported to decrease recurrence rates.2,3 The current interest in minimally invasive surgery has encouraged development of techniques for performing incisional hernia repair laparoscopically.4-10 However, most series in which these methods were used have been small, and only one report described a comparison between Presented at the Fifty-fifth Annual Meeting of the Central Surgical Association, Ann Arbor, Mich, March 5-7, 1998. Reprint requests: Adrian Park, MD, Division of General Surgery, University of Kentucky Medical Center, 800 Rose St, Room C 220, Lexington, KY 40536-0084. Copyright © 1998 by Mosby, Inc. 0039-6060/98/$5.00 + 0
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laparoscopic and conventional open repairs.10 In this study we compared operative and outcome data in patients who underwent laparoscopic repair of large incisional hernias with those in patients (historical controls) who had open repair. PATIENTS AND METHODS Patients undergoing laparoscopic repair of an incisional hernia (using a prosthetic patch or mesh) consecutively at 2 teaching hospitals in December 1993 to January 1998 were considered for the prospective portion of this study. Data on these patients were collected with use of a data form on which were recorded age, sex, previous operation, preoperative American Society of Anesthesiologists (ASA) status, hernia size and location, previous hernia repairs, operating time, intraoperative and postoperative complications, postoperative hospital stay, date of last follow-up evaluation, and whether there had been a hernia recurrence. The same data form was used to collect information retrospectively from the medical records of patients who underwent a traditional open incisional hernia repair in which a prosthetic material was used (hernia larger than 3 cm in its smallest dimension and requiring a prosthesis for a tensionfree repair) in January 1991 to December 1993. In addition, an attempt was made to contact each
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Surgery Volume 124, Number 4 Table I. Patient characteristics Laparoscopic repair group
Open repair group
P value
No. of patients Sex (M/F) Mean age in yr (range) Mean ASA score (range) Incisional hernia data Lateral location Central/midline location
56 30/26 58.8 (25–84) 2.1 (1–3)
49 23/26 58.5 (35–82) 2.2 (1–3)
NS NS NS NS
8 33
14 32
NS
Upper abdomen location Lower abdomen location
9 5
22 9
NS
First repair Previous repair
40 16
40 9
NS
NS, Not significant.
patient for a follow-up evaluation. Each patient interviewed was examined by a senior surgical resident. The patient’s medical history was reviewed and additional details obtained. A recurrent hernia was diagnosed if a hernia was demonstrable on examination and the fascial edges were palpable. The technique used for the laparoscopic incisional hernia repairs in this study has been described previously.6 Briefly, pneumoperitoneum was established with use of a Veress needle inserted in either the left or right subcostal space. A directview trocar was inserted laterally in a window between the iliac crest and costal margin. A 30degree or 45-degree 5- or 10-mm laparoscope was used. Most hernias could be repaired with 1 10-mm and 2 5-mm ports placed laterally in the upper and lower quadrant, respectively. Adhesiolysis was performed, and the margins of the defect were clearly delineated. A prosthetic patch or mesh was sized to overlap all hernia margins by at least 2.5 cm and then oriented externally, wrapped around a laparoscopic forceps, introduced through the trocar site, and unfurled. It was secured with a combination of nonabsorbable sutures placed through the abdominal wall (buried subcutaneously) 4- to 5-cm apart, and laparoscopically placed staples were positioned no more than 1 cm apart around the circumference of the prosthesis. The hernia sac was not opened or dissected free. All of the open hernia repairs were performed using a prosthetic patch to effect a tension-free repair. An incision was made over the hernia defect. Where possible the hernia sac was dissected free and left intact. In most cases, however, it was incised in the process of exposing the fascial margins. The subcutaneous tissue was dissected to clear a fascial rim extending 11/2 to 2 cm from the defect margin. The prosthetic patch was selected and sized to
overlap the defect by 11/2 cm on all sides. The mesh was then secured to the cleaned fascial rim with interrupted nonabsorbable sutures. Either 1 or 2 drains (depending on the amount of soft tissue dissection and resulting dead space) were then placed into the wound before final closure. Categorical data from patients who underwent laparoscopic repair were compared with those from patients who had open repair with use of chisquare testing. Correlational analysis used Pearson’s product moment correlation coefficient. A two-sample t test was used to compare continuous variables in the two groups. A P value less than .05 was considered significant. RESULTS Fifty-seven patients were scheduled for laparoscopic incisional hernia repair in December 1993 to January 1998, but one required conversion to open repair when pneumoperitoneum could not be established because of the density of adhesions from previous operations. Therefore 56 patients were enrolled in the laparoscopic group. The open repair group contained 49 patients after exclusion of 3 patients with inadequate documentation, 1 patient in whom the hernia repair was combined with another abdominal procedure, and 6 patients who had died. Patient characteristics in the 2 groups were comparable (Table I). Perioperative findings in the laparoscopic repair and open repair groups are shown in Table II. There was no significant difference between the 2 groups in mean hernia size. In the laparoscopic group, 44 ePTFE patches and 12 polypropylene meshes were used. In the open group, 3 ePTFE patches, 42 polypropylene meshes, and 4 polyglactin meshes were used. Laparoscopic incisional hernia repair took significantly longer (P < .01) to perform than open repair. However, the postoperative length of
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Table II. Perioperative findings Laparoscopic repair group Mean defect size in cm2 (range) Mean prosthesis size in cm2 (range) Mean patch:defect size ratio Mean operating time in min (range) Mean postoperative hospital stay in days (range)
Open repair group
99.4 (9–420) 231 (24–600) 2:3 95.4 (45–170) 3.4 (1–17)
105.3 (6.3–495) Not available Not available 78.5 (27–148) 6.5 (2–26)
P value NS
<.01 <.001
Table III. Perioperative complications Total complications Wound infection Hematoma Seroma Protracted pain Infected seroma Infected prosthesis Pulmonary Cardiac Genitourinary Prolonged ileus Bowel injury Bowel fistula
Laparoscopic repair group
Open repair group
P value
10 — — 2 2 — 2 1 — — 3 — —
18 1 5 1 2 1 1 — 2 3 — 1 1
<.05
stay was significantly shorter (P < .001) in patients who underwent a laparoscopic procedure. Table III shows the perioperative complications in the 2 study groups. Overall, there were significantly fewer complications in the laparoscopic repair group. There were 2 serious bowel injuries in the open repair group. One was an abscess and fistula that resulted from erosion of polypropylene mesh into the small bowel. The other was an enterotomy that was repaired with suture. Because the hernia sac was left in situ in the laparoscopic repair group, a transient seroma (sterile fluid accumulation) developed in most patients. A seroma was considered a complication, however, if it persisted for more than 6 weeks, increased in size steadily, or produced symptoms. Both seromas listed on Table III met these criteria and both resolved after aspiration. Forty-five patients (80%) in the laparoscopic repair group were followed by means of a postoperative visit or telephone call. Twenty-eight patients (57%) in the open repair group returned for a follow-up examination for this study. The remaining patients could not be contacted, declined to participate, or had died. The mean follow-up time in the 45 evaluated patients in the laparoscopic group was 24.1 months (range, 1 to 48 months); in the 28 evaluated patients in the
open group it was 53.7 months (range, 36 to 85 months; P = .001). The follow-up time in the open group was longer because the operations were performed 1 or more years earlier. During follow-up, hernia recurrence developed in 6 patients in the laparoscopic repair group and in 17 in the open repair group. Because of the differences in follow-up times and numbers of patients with follow-up assessments in the open repair and laparoscopic repair groups, a meaningful comparison of recurrence rates in the 2 groups could not be made. Factors related to recurrence in both groups are shown in Table IV. There were significantly fewer recurrences in patients who had a central or midline defect than in those who had a lateral defect. Patients who had no postoperative complications also had fewer recurrences. Use of an ePTFE patch compared with a polypropylene mesh appeared to be significantly associated with fewer recurrences, although this finding may have been influenced by the fact that most laparoscopic repairs used ePTFE. Smaller hernias (<50 cm2) were significantly less likely to recur than larger hernias (P < .03 by Pearson testing). In the laparoscopic repair group, there was a nonsignificant trend toward an increased recurrence rate in patients who had undergone a previous repair. No relation was observed between her-
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Table IV. Factors related to hernia recurrence in 73 patients having follow-up evaluations
Central/midline defect Lateral defect ePTFE patch Polypropylene mesh Perioperative complications No perioperative complications
Patients with recurrence
Patients without recurrence
11 11 6 15 10 13
25 6 21 14 4 31
nia recurrence and patient age, sex, or ASA status. Interestingly, in 3 of the 6 patients with recurrence in the laparoscopic group, a rerepair was done laparoscopically, with a second ePTFE patch being placed over a corner of the previous repair site. All 3 of these repairs have so far remained intact. In the open repair group, in which follow-up extended to 85 months, the time of recurrence ranged from 1 to 24 months postoperatively (mean, 10.5 months). In the laparoscopic repair group, the range was 2 to 12 months (mean, 6 months). DISCUSSION In this study we found that although laparoscopic incisional hernia repair took longer to perform than open repair, it was a feasible and practical approach to a common problem and may have some advantages over the open procedure. The benefits of minimally invasive surgery that have already been observed in studies comparing laparoscopic and inguinal hernia repair—shorter hospital stay,11 faster recovery,12,13 and decreased postoperative pain13,14—may also apply to laparoscopic incisional hernia repair. Although we did not assess recovery time or postoperative pain in this study, our patients in the laparoscopic repair group had a shorter duration of hospitalization than those in the open repair group. Laparoscopic incisional hernia repair involves no long incision, no wide fascial dissection or flap creation, no opening of the hernia sac, and no drains. Theoretically, this should lower the risk of wound infections caused by perioperative bacterial contamination. In this study fewer wound complications occurred in patients who underwent laparoscopic operation than in those who had an open procedure. The laparoscopic repair group also had no bowel complications, whereas there were 2 in the open repair group. The lack of bowel injury in the laparoscopic group may have been related to improved adhesiolysis associated with laparoscopy. Pneumoperitoneum facilitates identification of planes of dissection and the hernia defect itself. The bowel fistula in this study occurred in a
P value .02 .02 .005
patient in whom polypropylene mesh was used. Polypropylene mesh has previously been observed to cause bowel erosion and fistulization,15-17 and this is a special concern in laparoscopic repairs in which the prosthesis may be in direct contact with the bowel and abdominal contents. Therefore, like others,4,5,18,19 we prefer ePTFE for laparoscopic incisional herniorrhaphy. This prosthesis has been found to be less easily infected than polypropylene20 and to produce fewer and less tenacious adhesions21,22 but good tissue attachment.23 On the other hand, ePTFE generally costs more than polypropylene, and it may be more difficult to maneuver laparoscopically because of its lack of stiffness (memory)7 and relatively opaque nature. More cases of prolonged ileus were observed in the laparoscopic repair group than in the open repair group in this study. This may have been because the condition was more evident in the quickly recovering patients in the laparoscopic group and was overlooked or underreported in patients in the open group, who had a more prolonged convalescence. Our data did not allow a comparison of hernia recurrence rates in the open repair and laparoscopic repair groups. However, we found that recurrence was associated with larger hernias, hernias in a central or midline location compared with lateral hernias, and wound complications after hernia repair. Large size was also found to be a significant risk factor for recurrence by Hesselink et al.24 In addition, they found a relationship with wound infections, although it was not significant. However, if a wound infection requires removal of the implanted prosthesis, recurrence is clearly more likely.18 The site of the original incision had no influence on recurrence rate in the study by Hesselink et al.24 A randomized, controlled prospective study comparing laparoscopic with open incisional hernia repair, especially with respect to recurrence rates, has not yet been done, although one is clearly needed. To our knowledge, our study and that by Holzman et al10 have thus far been the only investigations to compare the 2 operative techniques. Holzman et al retrospectively reviewed 21
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laparoscopic and 16 open ventral and incisional hernia repairs performed during the same time period. Five of the open repairs and 3 of the laparoscopic repairs did not use a prosthesis. For all but 1 of the remaining repairs, polypropylene mesh was used. Mean operating times in the laparoscopic and open groups were 129 and 98 minutes, respectively; however, the difference was not significant. Complications in the laparoscopic group were 1 wound infection, 1 bowel obstruction, and 1 case of hypoxia. The open group had 1 wound infection, 1 bowel obstruction, 2 cases of prolonged ileus, and 1 case of hypoxia. Overall complication rates were 31% in the open group and 23% in the laparoscopic group. Hospital stay was shorter in the laparoscopic group. During a follow-up period of about 19 months, there were two recurrences in each group. Our results are generally in agreement with those of Holzman et al, especially their findings on duration of hospitalization and operating time. Some of the differences in postoperative morbidity between the two studies may have been due to varying practices regarding prosthetic use, selection, and fixation. We have found that prosthetic patches must be secured with sutures and staples to prevent slippage. The largest (noncomparative) prospective study of laparoscopic ventral hernia repairs described so far is the ongoing investigation by Toy et al.8 Only preliminary results in 144 patients have been presented. All repairs were done with a peritoneal onlay technique using an ePTFE patch. Mean operating time was 120 minutes. Postoperative complications were 5 infections, 3 cases of prolonged ileus, 1 partial bowel obstruction, and 8 seromas. Hospital discharge took place a mean of 2.3 days after operation, and return to normal activity was a mean of 15 days postoperatively. The mean followup was 222 days (range, 5 to 731 days). Six hernias recurred. The 3% infection rate and 4% recurrence rate in this study compare favorably with rates in series of open repairs. In summary, in a study comparing well-matched cohorts of patients who underwent laparoscopic and open incisional hernia repair, we found that the laparoscopic procedure took longer to perform but that it was associated with fewer complications and a shorter postoperative hospital stay. More extensive studies are needed to confirm the advantages of the laparoscopic approach. We thank Don Witzke for statistical analysis and Renée J. Robillard for editorial assistance.
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REFERENCES 1. Santora TA, Roslyn JJ. Incisional hernia. Surg Clin North Am 1993;73:557-70. 2. Stoppa RE. The treatment of complicated groin and incisional hernias. World J Surg 1989;13:545-54. 3. Langer S, Christiansen J. Long-term results after incisional hernia repair. Acta Chir Scand 1985;151:217-9. 4. LeBlanc K, Booth WV. Laparoscopic repair of incisional abdominal hernias using expanded polytetrafluoroethylene: preliminary findings. Surg Laparosc Endosc 1993;3: 39-41. 5. LeBlanc KA, Booth WV, Spaw AT. Laparoscopic ventral herniorrhaphy using an intraperitoneal onlay patch of expanded polytetrafluoroethylene. In: Arregui ME, Nagan RF, editors. Inguinal hernia: advances or controversies? Oxford: Radcliffe Medical Press; 1994. p 515-7. 6. Park A, Gagner M, Pomp A. Laparoscopic repair of large incisional hernias. Surg Laparosc Endosc 1996;6:123-8. 7. Saiz AA, Willis IH, Paul DK, Sivina M. Laparoscopic hernia repair: a community hospital experience. Am Surg 1996;62:336-8. 8. Toy FK, Bailey RW, Carey S, et al. Multicenter prospective study of laparoscopic ventral hernioplasty: preliminary results. Surg Endosc In press. 9. Frantzides CT, Carlson MA. Minimally invasive ventral herniorrhaphy. J Laparoendosc Adv Surg Tech 1997;7: 121-4. 10. Holzman MD, Purut CM, Reintgen K, Eubanks S, Pappas TN. Laparoscopic ventral and incisional hernioplasty. Surg Endosc 1997;11:32-5. 11. Wilson MS, Deans GT, Brough WA. Prospective trial comparing Lichtenstein with laparoscopic tension-free mesh repair of inguinal hernia. Br J Surg 1995;82:274-7. 12. Liem MSL, van der Graaf Y, van Steensel CJ, et al. Comparison of conventional anterior surgery and laparoscopic surgery for inguinal-hernia repair. N Engl J Med 1997;336:1541-7. 13. Stoker DL, Spiegelhalter DJ, Singh R, Wellwood JM. Laparoscopic versus open inguinal hernia repair: randomised prospective trial. Lancet 1994;343:1243-5. 14. Kozol R, Lange PM, Kosir M, et al. A prospective, randomized study of open vs laparoscopic inguinal hernia repair: an assessment of postoperative pain. Arch Surg 1997;132:292-5. 15. Nagy KK, Fildes JJ, Mahr C, et al. Experience with three prosthetic materials in temporary abdominal wall closure. Am Surg 1996;62:331-5. 16. Kaufman Z, Engelberg M, Zager M. Fecal fistula: a late complication of Marlex mesh repair. Dis Colon Rectum 1981;24:543-4. 17. Voyles CR, Richardson JD, Bland KI, Tobin GR, Flint LW, Polk HC Jr. Emergency abdominal wall reconstruction with polypropylene mesh: short-term benefits versus long-term complications. Ann Surg 1981;194:219-33. 18. Bauer JJ, Salky BA, Gelernt IM, Kreel I. Repair of large abdominal wall defects with expanded polytetrafluoroethylene (PTFE). Ann Surg 1987;206:765-9. 19. Annibali R, Fitzgibbons RJ Jr. Prosthetic materials and adhesion formation. In: Arregui ME, Nagan RF, editors. Inguinal hernia: advances or controversies? Oxford: Radcliffe Medical Press; 1994. p 115-24. 20. Brown GL, Richardson JD, Malangoni MA, Tobin GR, Ackerman D, Polk HC Jr. Comparison of prosthetic materials for abdominal wall reconstruction in the presence of contamination and infection. Ann Surg 1985;210:705-11.
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21. Law NW, Ellis H. Adhesion formation and peritoneal healing on prosthetic materials. Clin Mater 1988;3:95-101. 22. Murphy JL, Freeman JB, Dionne PG. Comparison of Marlex and Gore-tex to repair abdominal wall defects in the rat. Can J Surg 1989;32:244-7. 23. Bellón JM, Contreras LA, Sabater C, Buján J. Pathologic and clinical aspects of large incisional hernias after implant of a polytetrafluoroethylene prosthesis. World J Surg 1997;21:402-7. 24. Hesselink VJ, Luijendijk RW, de Wilt JHW, Heide R, Jeekel J. An evaluation of risk factors in incisional hernia recurrence. Surg Gynecol Obstet 1993;176:228-34.
DISCUSSION Dr James R. DeBord (Peoria, Ill). You have analyzed your data comparing laparoscopic and conventional open repair of ventral incisional hernias. Your conclusions seem to favor the laparoscopic technique. However, a critical look at your data pose several questions. First, what role did the time interval differences, 1991 to 1993 versus 1993 to 1998, and the cultural, social, and health care system differences between the United States and Canada play in your length of hospital stay data? Second, because a number of your complications are more related to the type of prosthetic biomaterial used than to the actual technique, how did you evaluate the role of a 79% use of ePTFE in the laparoscopic repair but only a 6% use of ePTFE in the open repair? Also, were there any recurrences related to the use in 4 of your open cases of absorbable mesh? In summary, there are a number of variables that have clouded my ability to analyze the value of the different techniques. I agree with you that a randomized, controlled, prospective study is clearly needed. This study should include open and laparoscopic techniques of hernia repair that are as similar as possible, that use the same prosthetic biomaterial, are followed for an adequate period of time, and where outcome analysis also includes a comparison of costs and a standardized evaluation of time to return to normal activities. The benefits of minimally invasive surgery are pretty well acknowledged now by all surgeons with respect to cholecystectomy, by many surgeons with respect to antireflux procedures, and a few surgeons believe that these techniques are beneficial in other arenas of abdominal surgery. With respect to hernia surgery, however, there are strong opinions that seem to exist, but little data have been available to properly evaluate the role of laparoscopic surgery in hernia repair. We are beginning to establish some data with respect to inguinal hernia repair, and a critical analysis of these data with respect to the time of operation, the length of hospitalization, patient discomfort, the issues of general anesthesia versus local anesthesia, costs of treatment, and ultimately rates of recurrence will likely reveal a limited but useful role for laparoscopic inguinal hernia repair. Dr Park. With regard to the first question, I don’t
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think that the time difference of 3 or 4 years between the two groups reflects a tremendous difference in the sophistication of health care delivery between the early and mid 1990s. There is a different culture in the delivery of health care between Canada and here at times. This is reflected in a slightly longer hospital stay. Although when we took out the Lexington data, we still found that the hospital stay was less than half the time for the laparoscopic as it was for the open patients. The type of prosthesis was significantly related to the type of repair. Clearly the case of bowel erosion and abscess in fistula formation was related to the propylene mesh patch and has not been reported with a PTFE patch. Nevertheless, the issues of wound complication, hematoma, and seroma infection have more to do with the extensive subcutaneous soft tissue dissection that is necessary with open repair. Dr Michael Brunt (St Louis, Mo). Why do you think the recurrence rate should be lower with the laparoscopic approach? You had a mixed group of patients in the open group. Some had the mesh placed posteriorly, others anteriorly. My practice has been to place the mesh posteriorly because I think that intra-abdominal pressure is more likely to keep the mesh up against the abdominal wall, whereas anteriorly placed mesh is pushed away from the fascia. Why should the recurrence rate be lower with the laparoscopic approach? Are you covering a broader area or using a bigger piece of mesh? What did you find at laparoscopy in the patients who had recurrence after the laparosocopic repair and what technical factors led to recurrences in those patients? I was concerned by the fact that you had 2 infected prostheses in the laparoscopic group. In general, with laparoscopy the risk of infectious complications should be lower because of the smaller incisions and less subcutaneous soft tissue dissection. What were the factors that led to the infection in those 2 cases? Finally, what are your contraindications to using a laparoscopic approach in a patient with an incisional hernia? I would also emphasize the need for a prospective randomized trial of this problem. Dr Park. I will answer the second question first about why these patches were infected in the laparoscopic group. Both patients had had multiple previous repairs, had had infected prostheses in the past and had been treated, and I obviously believed that the infection had completely resolved. Getting back to your first question about why do I think the recurrence rate may be lower with laparoscopic repair, I would echo your comments that by placing the prosthesis under the fascial margins intraabdominal pressures are essentially buttressing the repair and not disrupting the patch from its fascial attachments if it is placed anteriorly. The other thing that we can do laparoscopically is we can clearly and definitively identify the defect margins, and we can define Swiss cheese deformities that extend
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beyond that which you can palpate with open surgery, so the extent of the defect can be accurately delineated laparoscopically. The other thing is that you can then clearly establish the amount of overlap you want. Sometimes it is a lot more difficult with open repair. Our practice is to overlap by 2.5 to 3 cm all margins of the defect. What I found with laparoscopic recurrences was that there had been patch slippage. There have been some
Surgery October 1998 reports in the literature about doing this simply with clips. My strong feeling is that shouldn’t be done, these patches need to be secured well with sutures. We had slippage in the corner on 2 cases. The third one was a situation that was a very difficult repair, high in the epigastrium, where there is no good tissue to which to attach a secure patch. We actually had to go underneath the ribs to attach the patch there.
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