A Comparison Of Open Mesh Repair With Laparoscopic Repair For Incisional Hernia

Background and PurposeIncisional hernia is a common complication of most abdominal surgery.They occur in 2%to 11%of all laparotomies,and in up to 23%of those who develop postoperative wound infection.Incisional hernia should be treated by early repair since they may cause bowel obstruction and incarceration.The recurrence rate for open repair using conventional suturing techniques has been reported to be as high as 50%.With the use of a prosthetic mesh repair,the recurrence rate has decreased to less than lO%.But the positioning of the mesh makes it necessary to perform a large incision of soft tissues which increases the rate of wound infection,seromas,hematomas and post-operative pain.With the development of MESH materials and laparoscopic surgery in the 1990s,a novel approach for incisional hernia repair was developed. LeBlanc and Booth first described the laparoscopic repair of incisional hernia using intraperitoneal expanded polytetrafluoroethylene(ePTFE) patch in 1993.Taking a laparoscopic approach allows the surgeon to minimize abdominal wall incisions,avoid extensive flap dissection and muscle mobilization,thereby potentially achieving reductions in pain, recovery time,and duration of hospitalization,as well as lower rates of surgical site infection.This approach was widely accepted in westen country,but in China,it just in the beginning.This study aimed to investigate the feasibility,safety and advantages of laparoscopic incisional hernia repair(LIHR).Methods1.ObjectRetrospectively analyze the 29 patients treated by LIHR and 58 patients treated by open mesh repair in Sir Run Run Shaw Hospital from Nov 2002 to Oct 2007.The clinical manifestation include visible and palpable bulge when standing,abdominal distension,abdominal pain,nausea,vomiting.All of the 29 LIHR were done sucessfully,none was converted to open surgery.2.MeasuresGeneral data:gender,age,body mass index(BMI),surgical history,type of previous laparotomy,ASA grading,risk factors,comorbidity,chief complain.Operative data:type of procedure,operation time,defect size,patch size.Post-operation data:post-operation complication,VAS pain score, discharge time.3.StatisticAll the data collect by SPSS 11.5.All the results is presented with X±s.Student' s t-test was used to compare age,BMI,operative time, defect size,patch size,discharge time,and post-operative pain score. Fisher' s exact test was performed to compare proportions.All values less than 0.05 were considered statistically significant.Results1.LIHR was performed for 29 patients andopen hernia repair was performed for 58 patients in Sir Run Run Shaw Hospital between Nov 2002 and Oct 2007.The LIHR group include 10 men,12 women,with the average age of 63.73±14.73 years(range from 24 to 74).The open group include 19 men,39 women,with the average age of 61.38±12.82 years(range from 27 to 75).The patient's characteristics are outlined in Tables 1,2 and 3.No significant differences in the patients' general and surgical risk factors were identified,except there was more obse(BMI＞30)patients in the laparoscopic incisional hernia repair group(44.83%vs 18.64%,p＜0.05).The time of start of liquid diet was 6h while the patients began to walk at the same time,no operation associated death.2.The operation time was significantly longer in the LIHR group(80～220min,mean156.82±43.03min)than in the open group(30～270min,mean 105.73±48.71min)(p＜0.01).The defect size was found to be significantly larger in the LIHR group(5-252 cm~2,mean 100.64±76.12 cm~2)than in the open group(5-300 cm~2,mean 55.47±55.40 cm~2)(p＜0.05).The mesh size was larger in LIHR group(84-450 cm~2,mean 227.65±106.27 cm~2)than in open group(48-300 cm~2,mean 146.10±75.87 cm~2)(p＜0.01).3.Post-operative pain scors.There was more severe pain in the open group during the first 3 days after surgery.In the first opst-operation day:LIHR group 1-3 scors,mean 2.184±0.60,open group 2-7 scors, mean3.23±0.98(p＜0.01).In the second opst-operation day:LIHR group 1-2 scors,mean 1.46±0.52,open group 2-4 scors,mean2.63±0.55 (p＜0.01).In the third opst-operation day:LIHR group 1-2 scors, mean 1.27±0.47,open group 1-4scors,mean 2.07±0.52(p＜0.01).4.The discharge time was significantly shorter in LIHR group(3-8days,mean 5.50±1.63day)than in open group(2-40days,mean 7.50±5.08day)(p＜0.05).Surgical complications occurred in 4 cases(13.79 %)after LIHR and in 14 cases(24.14%)(p＞0.05)after open repair. The morbidity included:prolonged suture site pain(n=1),seroma(n=1),pneumonia(n=2)in the LIHR group and surgical site infection(n=3),prolonged suture site pain(n=3),seroma(n=4), hematoma(n=1),pneumonia(n=3).No statistical significant difference between two groups when it consider to the overall surgical complications,the group after LIHR trend to have lower complication rate.The follow-up period for the patients was 3-63 months,1 recurrence occurred in the LIHR group(3.45%)and 5 occurred in the open group (8.62%)(p＜0.05).ConclusionLaparoscopic incisioal hernia repair is technically feasible and safe,it avoid reoperating the abdominal wall,just add MESH to enhance the abdominal wall so allwoing shorter hospital stay,early recovery.However,recurrence and complication rates are comparable to and trend to be lower than open mesh hernioplasty.