Research Article ISSN 2689-1093

Research Article Surgical Research

Incisional Hernia Repair: Laparoscopy versus Open Surgery - A

Prospective Study
LAMARA Abdelhak1*, BENYARABAH Saliha1, GUADDA Mounir1, BELHATEM Mohamed Salah1, NINI
Badereddine1, BOUKHENE Mohamed1, MEDJAHDI Sid Ahmed1, NIBOUCHA Mohamed Lamine2
and Dr. Meriem Rayen LAMARA3

*
Correspondence:
General Surgery, Regional Military Hospital of Constantine /5RM Algeria.
1
Professor Abdelhak LAMARA, Head of General Surgery,
2
Department of Medical Activity, Regional Military Hospital of Constantine Regional Military Hospital, Abdelaali BENBAATOUCHE -
/5RM Algeria. Constantine / 5 RM, BP: 61 C, 25001 - Constantine – Algeria,
Tel: (213) 697289929.
Peterborough, UK.
3

Received: 28 Jul 2023; Accepted: 30 Aug 2023; Published: 05 Sep 2023

Citation: LAMARA A, BENYARBAH S, GUADDA M, et al. Incisional Hernia Repair: Laparoscopy versus Open Surgery - A Prospective
Study. Surg Res. 2023; 5(2): 1-6.

ABSTRACT
Objective: To assess the feasibility of laparoscopic incisional hernia repairs and to examine possible differences in
operative time, morbidity, recurrence rates and length of hospital stay compared to repairs performed by open surgery.

Patients: Between January 2016 and June 2019, sixty patients who underwent parietal repair were enrolled in this
study. Patients were divided into two non-randomised groups. Data were collected prospectively and recorded in a
database. The statistical analysis was performed using SPSS24 biomedical statistics software and Microsoft Excel.
The statistical analysis was performed using the chi-two test, with calculation of the P value (Pearson test).

Results: Thirty patients who underwent parietal repair by laparoscopic preperitoneal prosthesis placement (first
group), and 30 patients who underwent open repair (2nd group). The two groups were comparable in terms of
gender distribution and body mass index. No significant differences were observed in age and comorbidities between
the two groups.

In the first group, implantation of an intraperitoneal bifacial prosthesis was possible in 93.3% of patients. In the
second group, the prosthesis was placed retromuscularly in 56.6% of patients and perifascial in 41% of patients.
The conversion rate to open surgery was 6.6%. The average operating time was (81mn vs 92min). The complication
rate was (26.6% vs 43.3%). The average length of hospital stay was 2 days 5.6 days. The recurrence rate at 3 years
is (3.3% 6.6%; P< 0.05).

Conclusion: The results of this study suggest that parietal repair by laparoscopic intraperitoneal prosthesis
placement has some advantages over open surgery.

Keywords incisional hernias, thanks to the use of adapted prosthetic material

Incisional hernia, Laparoscopic repair, Open surgeon repair, that allows the implantation sites on the abdominal wall to be
Morbidity, Hospital stay, Recurrence. enlarged according to their physicochemical characteristics [1-
3]. Over time, several surgical techniques have been validated
Introduction depending on the nature and type of prosthesis used.
Significant progress has been made in the treatment of ventral
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Tension-free parietoplasty with prosthetic reinforcement is An abdominal ultrasound was performed in all patients, mainly
considered the technique of choice for the repair of incisional and to look for associated intraperitoneal pathology. In addition,
primary ventral hernias by open surgery. In contrast, the repair of a CT scan of the abdominal wall was performed to clarify the
ventral incisional hernias by laparoscopy consists of parietoplasty exact dimensions of the hernia, the nature of the hernial contents,
by intraperitoneal composite prosthesis, aimed at filling the parietal measure the diastasis of the rectus muscles of the abdomen and
defect by overlapping the edges of the defect by 3-5 cm, without assess the thickness of the adipose tissue.
deterioration of the wall. This technique is currently considered
a quality reference because of its feasibility, cost-effectiveness, Risk factors and comorbidities were considered and assessed.
reduced morbidity and improved quality of life [1,2].
Patients who are candidates for laparoscopic surgery were
informed during the preoperative consultation about the
The main challenge in repairing ventral hernias is to reduce the
rate of recurrence, and the effectiveness of each technique is advantages and disadvantages of this technique, as well as the
evaluated according to the incidence of recurrence. Based on possibility of conversion to open surgery if necessary. Patients'
recent data from the literature and in order to contribute to the consent was obtained regarding the surgical technique chosen and the
development of new minimally invasive techniques in our possibility of discharge from hospital on the first post-operative day in
hospital, we chose the technique of parietal repair of incisional the absence of complications. The intraperitoneal site has been used in
hernias by laparoscopy using the intraperitoneal site. To reinforce laparoscopic repairs, while the retromuscular site has been preferred
the value of this prospective study, we compared this technique to in the majority of cases during open surgery repairs.
other open surgery parietal repair procedures performed during the
same study period. Results
In this study, a total of sixty patients were operated on for a ventral
The main objective of this prospective comparative study is to incisional hernia, divided into two groups of thirty patients each.
evaluate the feasibility of this technique on a scarred abdomen The first group was operated on by laparoscopic surgery and the
in patients who have undergone several surgical procedures, second group by open surgery. The mean age of patients was 52.53
except for patients with a recurrent hernia already treated with a
years, with an age range of 27 to 82 years. Women accounted for
prosthesis. In addition, we sought to analyze the rate and causes of
78% of cases, a sex ratio of 3.61. The majority of females were
conversion, the rate of recurrence, and to evaluate the advantages
housewives (68.3%) of cases. Not all patients included in the study
of this technique compared to other procedures.
were morbidly obese, but all had at least one predisposing factor for
The use of minimally invasive incisional hernia repair using the hernia. In the majority of cases, eventration was secondary to anterior
intraperitoneal site with adapted prostheses aims to reduce the rate laparotomy (83.3%), followed by hernia on a trocar orifice (10%).
of recurrence on the one hand and to improve quality of life and The most common type of hernia was type M2, accounting for 60% of
reduce economic costs on the other hand. Since our department is cases and evenly distributed between the two groups (Table1).
a training center, we tried, during the study period, to allow other
surgeons and residents to learn this technique. Table 1: Features of patients and hernia.
Features of patients and Laparoscopy Open Surgery
P
It should be noted that other surgical techniques are still used. hernia N (%) N (%)
Overall, the aim of this prospective study is to evaluate the M 07 (23) 06 (20) 0.07
Gender
feasibility of repairing ventral eventrations using intraperitoneal F 23 (76.6) 24 (80)
prostheses by laparoscopy, and to compare the results obtained with 27-42 11 (36.6) 03 (10)
those of repairs performed by open surgery. Endpoints assessed in Age (Years) 43-65 12 (40) 13 (43.3) 0.1
this study include duration of surgery, rate of conversion to open 66-82 07 (23.3) 14 (46.6)
surgery, incidence of complications, length of hospital stay, and ≤ 25 9 (30) 8 (26,6)
recurrence rate. kg/m2 ≥ 25 ≤ 30 14 (46,6) 17 (56,6)
≥30 ≤35 7 (23,3) 5 (16,6)
Patients and Method Respiratory disorder 21 (70) 14 (46)
This is a prospective, non-randomized controlled study of sixty M1 - - 06 20 P 0.3
patients who underwent surgery for ventral incisional hernia. M2 18 60 18 60
Thirty patients underwent laparoscopic surgery and thirty patients M3 03 5 03 10
underwent open surgery from January 2016 to June 2019. Topography
M4 - - 02 6.6
Inclusion criteria in this study included all ventral incisional L1 01 3.3 01 3.3
hernias of the anterolateral wall, recurrent abdominal eventrations L3 02 6.6 -
not treated with prosthesis, incisional hernias on trocar orifice, and OR 06 20 -
eventrations with a diameter greater than 6 cm. IBM SPSS24 and < à 05 cm 14 (46.6) 09 (30) NS
Microsoft Excel biomedical software were used, as well as the 05 à 10 cm 13 (43.3) 19 (63.3) p : 0,03
Defect size
chi-two test with p-value calculation (Pearson test), to analyze the Double orifice 01 (3.3) 01 (3.3) NS
study results. Multiorifice 02 (6.6) NS

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The size of the hernial collar ranged from 5 to 10 cm, with 23 level analgesics. Only two patients in the first group developed
patients having a collar less than 5 cm, and 32 patients having wall sepsis, while six patients in the second group developed
a collar between 10 and 15 cm. Two patients had double-orifice wall sepsis. The average length of hospital stay was 2 days for
hernias and two other patients had multi-orificial hernias (Table1). laparoscopic surgery and 5 to 6 days for open surgery. The overall
recurrence rate was 5%, with one recurrence in the first group and
The creation of pneumoperitoneum was achieved by an opening two recurrences in the second group (Table 2).
in the abdominal wall (open laparoscopy) in 27 patients and by a
Veress needle in three patients. In the laparoscopic repair group, Table 2: Complications and recurrences.
hernia repair was performed by three trocars in 96.6% of cases, Laparoscopy Open Total
Complications Khi-deux
with dissection and hernial sac release required in 16.6% of N (%) N (%) N (%)
patients. Persistent pain" 2 (7) 3 (10) 5 (8.6) NS
Seroma 2 (7) 0 (0) 2 (3.4) NS
Adesiolysis was difficult in two patients operated by laparoscopy and Parietal hematoma 1 (3.5) 2 (6.6) 3 (5) NS
Parietal infection" 1 (3.5) 6 (20) 7 (12) <0.05
seven patients operated by open surgery. In two cases, conversion
Rate of
to open surgery was required, representing a conversion rate of complications
6 (21.4) 11 (36.6) 17 (29.3) NS
6.6%. The size of the parietal defect, measured during surgery, Recurrence
was identical to radiological data in 17 patients, underestimated
in 42 patients and overestimated in a single patient. The average Discussion
duration of surgery was 81.51 minutes for laparoscopic repairs and Incisional hernia is a major complication of any abdominal surgery.
92.06 minutes for open surgery repairs. Its incidence varies between 13% and 20% after a laparotomy and
is common in the first five years postoperatively. About 50% of
In the first group, repair of incisional ventral hernias was performed cases occur within the first two years [2-6].
using intraperitoneal prostheses in 28 patients (46.66%), (Figures
1 a, b, and c). However, in two patients in this group, laparoscopic The predominance of women is found in most studies published in
repair was impossible due to dissecting difficulties in one patient the literature [5,6]. Obesity is one of the main causes of postoperative
and an iatrogenic intestinal wound in the other. Both cases required complications affecting cardiorespiratory and metabolic function
conversion to retromuscular repair in one of the patients, while the and can be life-threatening with an insignificant mortality rate. The
other patient did not receive immediate repair. laparoscopic approach offers the possibility of incisional hernia
repair in patients with morbid obesity with a significant reduction
in postoperative complications especially those related to parietal
infection [7,8]. Previous research has demonstrated the feasibility
and safety of laparoscopic repair of VIH in obese patients and
those with morbid obesity (BMI ≥ 35kg/m2) [9,10].

In some situations where difficulties prevent the continuation

of laparoscopic surgery, it is sometimes necessary to resort
to perform open surgery. In our study, we encountered two
situations where we were no longer able to continue the procedure
a b c laparoscopically, resulting in conversion to open surgery. The
Figure 1: Laparoscopic hernia repair. conversion rate generally varies between 2.1% and 3.2% [5,11].
a. M3 hernia Dissection difficulties, intestinal wounds and intraoperative
b. Adhesiolysis and hernia content reduction hemorrhages are the most common causes of conversions to open
c. Fixation of the prosthesis surgery. The incidence of iatrogenic intestinal wounds that require
conversion to open surgery typically ranges from 1% to 3%. In
In the second group, implantation of the prosthesis was performed contrast, intraoperative bleeding as a cause of conversion is not
using an extraperitoneal technique in 29 patients. In one patient often reported by most practitioners and researchers. In some
in this group, parietal repair was delayed due to an iatrogenic series, conversions relating to the occurrence of intraoperative
intestinal wound. complications are clearly indicated and range from 1% to 5%
[5,10-13].
In laparoscopic repairs, the size of the prosthesis used ranged from
15 to 20 cm. In the open repair group, 30 cm prostheses were used In our study, the conversion rate is 6.6%. This is due to an iatrogenic
in 11 patients. An intestinal wound occurred during adhesiolysis wound of the small intestine in one case, where parietal repair was
in one patient in each group, which resulted in the postponement performed by simple plasty and final repair was postponed. In
of incisional hernia repair. Two patients operated by laparoscopy another case, dissection proved impossible due to enteroparietal
experienced significant postoperative pain (3.5%), requiring first- adhesions, and as a precaution, we preferred to complete the

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procedure with open surgery. The conversion rate in some series Postoperative comfort is one of the major advantages of laparoscopic
remains low, ranging from 0.5 to 1% [14-16]. parietal repairs of incisional hernias. Patients who have undergone
this surgical approach usually express great satisfaction and
The duration of surgery for laparoscopic hernia repairs is usually recommend this method to their relatives. In addition, the early
shorter than that of open surgery. However, the duration of the resumption of social activities is also an objective of this technique.
operation can vary depending on several factors, including the The main goal of laparoscopic parietal repairs of incisional hernias
experience of the surgeon. In our study, the average duration of the is to reduce the rate of postoperative recurrence. This rate can vary
intervention was 81.51 minutes, with a range of 40 to 185 minutes. from one series to another in a large series of 7516 laparoscopic
For open surgery, the operating time ranged from 40 to 150 ventral incisional hernia repairs. Moreau [23], finds a recurrence
minutes, with an average duration of 92.02 minutes. These results rate of 4.6%, comparable to the results obtained by Heniford [17].
are consistent with those reported in the literature [10,13,14,17]. The recurrence rate is lower in Cardin's study [5], but this rate is
It's worth noting that the reported duration of HIV surgery in a 13.5% in the Levard study [12].
large series of 1029 laparoscopic procedures was 40 minutes.
However, this result might not have taken into consideration the The difference in the prevalence of complications after laparoscopic
learning curve of the techniques [13]. In another series of 819 repair of incisional ventral hernias depending on the modalities
laparoscopic cures reported by Herniford, the average duration of fixation of the prosthesis is not very significant. Postoperative
was 120 minutes [17]. complications are related to adhesions. The detection of these
adhesions radiologically is possible thanks to high-resolution
Postoperative complications of primary or incisional ventral ultrasound [6,24-27]. The effectiveness of laparoscopic repair
hernia repairs by laparoscopic surgery mainly include seromas, of incisional ventral hernias in large hernias in obese patients is
persistent postoperative pain at 3 months, surgical site infection, possible and even with encouraging results [6,28].
and hemorrhage. It is important to note that the prevalence of these
complications may vary depending on the surgeon's experience In a comparative meta-analysis of retrospective studies based on
[18]. The American Hernia Society confirms the decrease in the several outcomes, Rudmik et al. [25] have proven the optimal
rate of postoperative complications after laparoscopic incisional approach for laparoscopic repair of incisional ventral hernias. The
hernia repair compared to open surgery repairs (05% to 30% repair of incisional ventral hernias has become a gold standard.
versus 27% to 34%), the same findings are made by Mc Greey et The effectiveness and safety of this technique is based on its
al., in a prospective study published in 2003 [19]. Similarly, in our
advantages over open repair, regardless of the site of implantation,
study, the postoperative complication rate of laparoscopic parietal
in terms of the incidence of early complications, and especially
repairs is significantly lower than the complication rate of open
the rate of recurrence. Other factors were also analyzed, mainly
repairs (P<0.005).
operating time, hospital stay, and resumption of postoperative
activities [3,20,29,30].
The duration of postoperative hospitalization is one of the
advantages of laparoscopic surgery. In our study, the average
hospital stay in the laparoscopic repair group was 2 days, but the The laparoscopic approach in the repair of incisional ventral
stay in patients operated on by the open route was longer (5.63 hernias is considered a valid and safe technique. Some consider
days). This benefit of laparoscopic incision hernia surgery is it the best technique. Although, the financial impact related to the
reported by the majority of authors [15, 20-22]. This route first prosthetic equipment used is high, the good results expected, in
makes possible the application of the ambulatory concept in the terms of length of stay, the resumption of activities, and especially
treatment of incisional hernias, the duration of hospitalization in a low rate of postoperative complications and recurrence, has put
fifteen patients of our study did not exceed 24 hours (Single Night). the balance of the financial cost in its favor compared to open
surgery techniques [29]. All these benefits have led surgeons to
The reoperation rate for postoperative surgical complications varies use this route, and thus the increased incidence of laparoscopic
from 0 to 3.5% depending on the series [6,15,17,23]. The main ventral incision hernia repairs over the years compared to open
causes of revision surgery are mainly postoperative hemorrhages, surgery [29,30].
unknown intestinal wounds, and intestinal obstructions. Persistent
pain resistant to medical treatment was also reported as a cause of Conclusion
early postoperative recovery, this pain is usually related to stapling Laparoscopic repair of ventral incisional hernias offers many
the prosthesis [6,24]. benefits. This technique is feasible and easy to perform by
respecting the protocols and tips specific to hernia repair. It is
The operative mortality of laparoscopic incisional ventral hernia particularly suitable for obese patients. In addition, it allows a
repairs is low, in addition to medical complications, such as reduction in the duration of hospitalization, with the possibility of a
pulmonary embolism, unknown intraoperative intestinal wounds discharge the day after the intervention for the majority of patients
discovered at the stages of advanced peritonitis are the most - "single night". The reduction in the incidence of postoperative
common mortality factors [14,17,23]. complications, especially hernia recurrences, as well as the early

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resumption of usual social activities, contribute to the overall 14. Alfredo Moreno-Egea, José Antonio Castillo Bustos, Enrique
satisfaction of operated patients. Girela, et al, Long-term results of laparoscopic repair of
incisional hernias using an intraperitoneal composite mesh.
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© 2023 LAMARA A, et al. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License

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