REVIEW

L. R. Rudmik Æ C. Schieman Æ E. Dixon

E. Debru

Laparoscopic incisional hernia repair: a review of the literature

Received: 31 August 2005 / Accepted: 14 December 2005 / Published online: 2 February 2006� Springer-Verlag 2006

Abstract Incisional hernia is a common long-termcomplication of abdominal surgery. Historically theopen repair with or without mesh was the mainstay oftreatment. However, many recently published laparo-scopic repair studies have challenged surgeons to re-evaluate which technique provides the best short andlong-term outcomes. A Medline search of all English-language literature was performed using the keywords‘incisional’, ‘ventral’, ‘hernia’, ‘laparoscopic’, and‘open’. Further references were obtained by cross-refer-encing the bibliography in each paper. Current evidencesuggests that the laparoscopic incisional hernia repair isthe optimal surgical treatment. A laparoscopic repairappears to shorten hospital stay, decrease perioperativecomplication rates, and decrease recurrence rates.However, there is no randomized trial utilizing a stan-dardized complication grading system making it difficultto draw a definitive conclusion as to which repair is best.

Keywords Incisional Æ Hernia Æ Laparoscopic ÆOpen Æ Review

Background

Risk factors

Incisional hernia is a common long-term complicationfollowing abdominal surgery as it is estimated to occur inapproximately 10% of cases [1], however the true inci-dence is probably higher since the majority are asymp-tomatic. Approximately 50% of all incisional herniasdevelop within the first 2 years and 74% occur within3 years [2–5]. There are several risk factors for develop-

ing an incisional hernia and in a recent review byYahchouchy-Chouillard et al. [6], they were categorizedinto major and minor patient risk factors, and wound-related risk factors. See Table 1 for a list of incisionalhernia risk factors. Despite several studies supporting therisk factors outlined by Yahchouchy-Chouillard et al., alarge review of 1,000 midline laparotomies described byCarlson et al. [7] did not identify age, male gender, orwound infection as risk factors for incisional hernia.

It is hypothesized that incisional hernias stem fromacute sub clinical fascial separations early in the post-operative setting [2]. During post-operative days 0–30,wound tensile strength is lowest resulting in a heavydependence upon suture integrity for strength and pre-vention of acute wound separation [8]. Several studieshave compared different techniques of fascial closureand have demonstrated no difference between continu-ous and interrupted closures in the development of in-cisional hernias [9–14]. Since a continuous closure isfaster and more cost effective most surgeons utilize thisclosure technique. Several studies have compared suturematerial and it is recommended that an absorbable su-ture be used for fascial closure as it decreases infectiouscomplications and eventually dissolves preventing a‘saw-like’ effect on the fascia, which could predispose tofascial dehiscence [12, 15].

Genetics

Wound healing is dependent upon many molecular andcellular factors capable of inducing hemostasis, inflam-mation, angiogenesis, fibroplasia, and wound remodel-ing. Aberrancy in any of these pathways will impairfascial wound healing and predispose to incisional hernia.

Collagen is an important extracellular protein in-volved in wound healing. Although 19 collagen sub-types have been identified, 95% of the body’s collagen iseither type I or type III collagen. Type I collagen hashigh tensile strength and is mainly found in fascia, bone,and skin [16]. Type III collagen has lower tensile

L. R. Rudmik (&) Æ C. Schieman Æ E. Dixon Æ E. DebruDepartment of Surgery, University of Calgary,121-1811 34th ave. S.W, Calgary, AB, Canada, T2T2B9E-mail: Lukerudmik@shaw.caTel.: +1-403-8375853Fax: +1-403-2700148

Hernia (2006) 10: 110–119DOI 10.1007/s10029-006-0066-6

strength but increased flexibility and is found in bloodvessels, smooth muscle, and organ parenchyma, such asthe lungs.

Early fascial wound healing comprises mainly typeIII collagen which provides very little tensile strengthowing to the early dependence on technical closure.Fascial strength increases later as type I collagen in-creases and forms stable intermolecular crosslinks [17].Abnormalities in collagen synthesis will predispose toweak fascial healing and subsequent incisional herniadevelopment.

Many studies have demonstrated that patients withabnormalities in collagen synthesis, such as Ehlers-Danlos syndrome, Marfan’s syndrome, and osteogenesisimperfecta syndrome, have increased incidence of herniaformation [18–20]. Abnormal collagen ratios have alsobeen shown to increase the incidence of incisional her-nia. For example, a study by Si et al. [21] demonstratedthat patients with primary and recurrent incisional her-nias have a lower type I:type III collagen ratio, with arelative increase in type III collagen, as compared tonormal controls. Recently, an animal study by Dubayet al. demonstrated a significant reduction in primaryincisional hernias, from 60 to 30%, and recurrent inci-sional hernias, 86–23%, with the implantation of afibroblast growth factor (bFGF)-releasing rod into thefascial wound [22]. This study found that type I collagenstaining was significantly increased around the bFGFtreated fascia, which was thought to contribute to thedemonstrated increase in the breaking strength of12.3 N compared to 8.6 N in controls. With the in-creased understanding of the underlying molecular andcellular mechanisms of incisional wound healing, noveltherapeutic agents may be developed to strengthen andexpedite wound closure.

Open repair

Early incisional hernia repair’s included primary fasciaclosures, however, recurrence rates ranged from 12 to54% [5, 23–32], and in our review we calculated a rate of39% which was higher than the primary occurrence rate.See Table 2 for a summary of open primary repairstudies. Luijendijk et al. [29] challenged the primary re-pair technique when he performed a randomized-con-trolled trial comparing primary suture repair to repairwith mesh (polypropylene). He demonstrated a statisti-cally significant reduction in recurrences rates betweenprimary suture repair compared to mesh repair, 43% to24%, respectively, for first time incisional hernia repairs[29].

Suture repair with mesh is now considered the gold-standard repair when an open technique is undertaken.However, there may be a role for the open primary su-ture repair in patients with small hernias. In a recentstudy by Shukla et al. [23], they conclude that primarysuture repair is justified for small incisional hernias whilemesh should be used for hernias larger than 10 cm.Despite convincing evidence for the benefit of mesh forincisional hernia repairs their still exists a debate as towhich open mesh repair provides the lowest recurrenceand complication rates. In the above study by Luijendijket al. they used an extraperitoneal underlay technique, orStoppa technique, whereby the mesh was sutured intoplace on the posterior rectus sheath with approximately4 cm of fascia overlap. Peritoneum was closed oromentum was placed between the mesh and intra-abdominal organs to prevent mesh contact. The othertwo repair options include an inlay technique, such thatthe mesh is sutured to the fascial edges, and an onlaytechnique whereby the mesh is placed and sutured ontothe anterior rectus sheath. The underlay technique canplace the mesh within the peritoneal cavity, intraperi-toneal, or extraperitoneal, which was first described byStoppa [33] in 1989. Both variations have the advantageof minimal soft-tissue dissection thus reducing devas-cularized tissue.

In 1981 McCarthy et al. [34] were the first to accu-rately describe the intraperitoneal underlay techniquewhen they followed 25 patients and reported an 8%recurrence rate, both occurring at 7 months post-oper-atively. The first large series for the intraperitonealunderlay repair was in 1997 by Gillion et al. [35] wherethey followed 60 patients for a mean of 3 years and re-ported a 6.6% recurrence rate. In 1999 Utrera et al. [36]followed 84 patients and demonstrated a 2% recurrencerate, with a follow-up between 1 and 3 years. This studyfocused on patients with large incisional hernias as 75%of patients had hernias >10 cm and 25% had herniasbetween 5 and 10 cm. A recent study by Millikan et al.[37] followed 102 patients prospectively and demon-strated a 0% recurrence rate using the intra-peritonealunderlay technique with full-thickness fascial fixationsutures. The median follow-up was 28 months and theaverage size of hernia defect was 15 cm. Long-term post-

Table 1 List of incisional hernia risk factors

Patient-related risk factorsMajor MinorMalnutrition AgeObesity Male genderSteroids Mechanical ventilationType II diabetes Renal failureChronic lung Connective tissueDisease DiseaseJaundice MalignancyRadiotherapy TransfusionChemotherapy AnemiaOral anticoagulants

Wound-related risk factorsDecreased collagen I/III ratioIncreased MMP-2 expressionDecreased MMP-1 and MMP-13Wound infectionType of incisionLateral paramedian < midlineTransverse or oblique < midlineWound closureContinuous = interruptedType of sutureAbsorbable < non-absorbable

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operative pain occurred in 1% of patients and this re-solved spontaneously within 1 year. This study restrictedpatients from heavy lifting for 6 months to allow colla-gen ingrowth prior to stressing the repair. The mostrecent study was performed by Heartsill et al. [38] andthey demonstrated a recurrence rate of 10% after fol-lowing 81 patients for a median of 30 months. Whencomparing the five studies [34–38] identified in this re-view the overall calculated recurrence rate for theintraperitoneal underlay technique was 4.5%. See Ta-ble 1 for a summary of studies.

Since 1989, when Stoppa et al. first described theextraperitoneal underlay technique, there have beenseveral studies demonstrating its effectiveness in pre-venting recurrences and low complication rates [29, 32,35, 39–45]. The largest study was performed by Martin-Duce et al. and they retrospectively analyzed 152

patients with a median follow-up of 72 months. Theyreported only two recurrences for a rate of 2% and bothrecurrences occurred in patients requiring the removal oftheir mesh prosthesis secondary to infection. In a large25 year retrospective study performed by Langer et al.[46], they demonstrated that the underlay repair had astatistically significant lower recurrence rate comparedto both onlay and inlay techniques. They also reportedthat the underlay technique produced lower complica-tion rates while the onlay technique yielded the highestcomplication rates. These findings were supported by deVries Reilingh et al. [45] as they demonstrated that theunderlay and inlay techniques resulted in significantlylower complication rates compared to the onlay tech-nique, 12, 13, and 69%, respectively. When comparingthe ten studies using the extraperitoneal underlaytechnique identified in this review [29, 35, 39–46] we

Table 2 Summary of open incisional hernia repair studies categorized by technique

Open technique Study Type of study Number ofpatients

Recurrencerate

Medianfollow-up(months)

Primary closure alone George et al. [25] Retrospective 81 37 (46%) 13.5Van der Linden et al. [26] Retrospective 151 74 (49%) 39Read et al. [27] Retrospective 169 41 (24%) 12–36Luijendijk et al. [28] Retrospective 68 28 (41%) 35Paul et al. [30] Retrospective 114 61 (54%) 68Anthony et al. [5] Retrospective 48 26 (54%) 45Luijendijk et al. [29] RCT 97 39 (46%) 26Reingruber et al. [31] Retrospective 560 246 (44%) 52Korenkov et al. [24] RCT 33 4 (12%) 14Langer et al. [46] Retrospective 241 89 (37%) 116Shukla et al. [23] Retrospective 116 2 (2%) 85Total 1,678 647 (39%) 47

Underlay (intraperitoneal) McCarthy et al. [34] Retrospective 25 2 (8%) 27Gillion et al. [35] Retrospective 60 4 (7%) 37Utrera et al. [36] Retrospective 84 2 (2%) 12–36Millikan et al. [37] Retrospective 102 0% 28Heartsill et al. [38] Retrospective 81 8 (10%) 30Total 352 16 (4.5%) 29

Underlay (extraperitoneal) Schumpelick et al. [41] Retrospective 74 5 (7%) 64Temudom et al. [40] Retrospective 48 0% 24Gillion et al. [35] Retrospective 98 2 (2%) 37McLanahan et al. [39] Retrospective 86 3 (3%) 24Leber et al. [42] Retrospective 78 15 (19%) 80Luijendijk et al. [29] RCT 84 17 (20%) 26Martin-Duce et al. [43] Retrospective 152 2 (1%) 72Bauer et al. [44] Retrospective 57 0% 29DeVries Reilingh et al. [45] Retrospective 17 2 (12%) 30Langer et al. [46] Retrospective 155 22 (14%) 116Total 849 68 (8%) 50

Onlay mesh Read et al. [27] Retrospective 32 20 (27%) 13.5Leber et al. [42] Retrospective 118 17 (14%) 80Khaira et al. [48] Retrospective 33 0 20Korenkov et al. [24] RCT 39 3 (8%) 14Machairas et al. [45] Retrospective 43 4 (9%) 54deVries Reilingh et al. [45] Retrospective 13 3 (23%) 30Langer et al. [46] Retrospective 14 2 (14%) 116Shukla et al. [23] Retrospective 55 0 37Total 347 49 (14%) 46

Inlay deVries Reilingh et al. [45] Retrospective 23 10 (44%) 30Langer et al. [46] Retrospective 6 4 (70%) 116Total 29 14 (48%) 73

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calculated a recurrence rate of 8%. See Table 1 for asummary of studies.

The onlay technique can be performed with orwithout closure of the fascial defect. The onlay repairappears to be a popular technique as a 2003 survey of1,000 American surgeons done by Millikan et al. [47],demonstrated that approximately 50% were using eitherthe onlay alone or onlay with primary fascial closuretechniques. This was surprising since there was no evi-dence at that time to support the onlay technique asproviding the optimal repair. In fact recent evidencesuggest that the onlay technique produces higher com-plication rates compared to the underlay and inlay re-pairs [32, 45]. The most likely explanation for thepopular use of the onlay technique is that it is technicallyeasier and faster to perform. The largest series analyzingthe onlay repair was performed by Leber et al. [42] asthey followed 118 patients for a median of 80 months.They reported 17 recurrences for a rate of 14%. A recentstudy by Shukla et al. [23] followed 55 patients for amedian of 37 months and reported a 0% recurrence rateusing the Cardiff repair, far and near sutures with rein-forcement sutures. When comparing all eight onlay re-pair studies identified in this review [23, 24, 27, 42, 45,46, 48, 49] we calculated an overall rate of 14%. SeeTable 1 for a summary of studies.

Compared to the underlay and onlay techniques theinlay technique has been relatively under-evaluated. Thiscreates difficulty in determining its role in incisionalhernia repair. Using the two studies identified in thisreview we calculated a recurrence rate of 48% which ismarkedly higher than the other repairs. The most likelyreason for this is the low numbers represented in thestudies. A true recurrence rate will be difficult to assessuntil larger studies are produced.

There is a large portion of studies which do not re-port specific perioperative complications. Also, none ofthe discussed studies used a standardized complicationscoring system, such as Claviens Classification of Sur-gical Complications [50], therefore direct comparisoncannot be performed. Despite poor reporting of com-plications a review performed by Cassar et al. [51] re-ported the following complication rates for open meshrepairs: seroma 6.3%, wound complications 10%, ileus2%, and pain 16%.

To summarize, the advent of the open repair withmesh significantly improved incisional hernia repairoutcomes when compared to primary closure. Tech-niques include the intraperitoneal underlay repair, ex-traperitoneal underlay repair (Stoppa Technique),onlay repair, inlay repair, with calculated recurrencerates of 4.5, 8, 14, and 48%, respectively. The lowestrecurrence rate was produced from the intraperitonealunderlay repair. As will be discussed in the next sec-tion, this repair is the most similar to the laparoscopicrepair, thus is expected to have similar recurrence rates.As is expected the open intraperitoneal underlay repairand laparoscopic repair have similar recurrence rates at4.5%. Despite marked improvements compared to

primary suture repair, calculated recurrence rates forthe other open repair techniques from this review arestill high. This prompted many recent investigationsinto whether laparoscopic techniques can further im-prove outcomes.

Laparoscopic repair

In 1993, LeBlanc et al. [52] were first to report the lap-aroscopic repair of an incisional hernia. Since then lap-aroscopic incisional hernia repairs have becomeincreasingly popular because of the demonstrated de-creased hospital stay, decreased complication rates, andlower recurrence rates [53–63]. A major disadvantage ofthe open repair is the requirement for extensive softtissue dissection around the hernia, which is performedto provide adequate mesh overlap. This disruption ofsurrounding tissue results in devascularization and pre-disposes to hematoma and infection. The laparoscopicapproach utilizes the intraperitoneal space to place themesh directly onto the peritoneum of the anteriorabdominal wall thus minimizing the amount of softtissue dissection necessary to attain adequate meshoverlap. Also, by placing the mesh intra-peritoneally thenatural intra-abdominal pressures push outward andhelp hold the mesh in place. Another benefit of thelaparoscopic approach is identifying small fascial de-fects, known as ‘‘Swiss cheese’’ defects, which may bemissed during an open repair. These small fascial defectsare a source of incisional hernia recurrence; thereforeidentification is important for a successful hernia repair.The major debate for this repair is which mesh fixationtechnique should be employed, tacks plus transmuscu-lar/fascial sutures or tacks alone.

The main advantage of using full-thickness fixationsutures along with tacks is the added strength forabdominal wall mesh fixation. A study by Van’t Rietet al. [64] demonstrated that the tensile strength oftransfascial fixation sutures was 2.5 times stronger thantacks alone. They conclude that if the mesh remainswhere it is placed, and there is adequate overlap, thereshould be no recurrence. The disadvantage of usingtransmuscular sutures is persistent pain at the suturesites. It is estimated that suture site pain occurs inapproximately 1–3% [65–68] while most resolve within6–8 weeks [69].

There have been several prospective and retrospectivestudies analyzing both laparoscopic repair with trans-muscular fixation sutures and repairs with only tacks.These studies will be reviewed in the next section.

Laparoscopic repair with transfascial suturesand tack mesh fixation

In a large prospective series, Heniford et al. followed 819of a possible 850 consecutive patients, for a median of22 months, who were able to undergo a laparoscopic

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incisional hernia repair. Gore-tex dual mesh with acombination of full-thickness ePTFE stitches passedthrough the abdominal wall and 5 mm spiral tacksplaced 1–1.5 cm apart, was used in 97% of repairs. Themedian defect size was 118 cm2. They demonstrated anoverall post-operative complication rate of 13.2%, withprolonged ileus and seroma formation >8 weeksaccounting for almost half of the complications (6.4%).The average length of stay was 2.3 days and the overallrecurrence rate was 4.7%, while patients with a previousrepair had a 7.1% of recurrence compared to 2.3% ofpatients without a previous repair [65].

A long-term follow-up study of 384 patients byFranklin et al. reported their 11 year experience withlaparoscopic ventral hernia repair using full-thicknesssuture fixation. There was no report of the median sizeof hernia defect and the median follow-up was47.1 months. This study demonstrated a post-operativecomplication rate of 10.1%, while prolonged ileus andseroma formation >6 weeks accounted for almost halfof the complications (4.5%). The average length of stayof 2.9 days and the recurrence rate was 2.9% [66].

A retrospective study by LeBlanc et al. reported acomparison between two patient cohorts, an early andlate laparoscopic repair group, both containing 100 pa-tients. The median follow-up was 36 months and theaverage defect size was 111 cm2. They demonstrated apost-operative complication rate of 18%, median lengthof stay of 1.25 days, and an overall recurrence rate of7.5%. When comparing the early and late groups therecurrence rate decreased from 9 to 4%, which wasattributed to increased mesh overlap, minimum of 3 cm,and the use of transfascial sutures [67]. They concludedthat the use of transfascial sutures is important for aneffective laparoscopic repair.

A prospective study done by Berger et al. followed150 patients, median hernia size of 96 cm2, for a medianof 15 months. They demonstrated a perioperative com-plication rate of 13.3% and a recurrence rate of 2.7%. Inthis study, the median hospital stay was 9 days which issubstantially longer than previous reports. The authorscontribute this finding to post-operative suture site pain,

which the majority of patients experienced, although apercentage was not reported [70].

The most recent study, performed by Perrone et al.[71], followed 116 patients for a median of 22 monthsand demonstrated an overall complication rate of 27%and recurrence rate of 9.3%. Although the majority ofrepairs were performed with transfascial sutures, 65%, aminority of cases were performed with only tack fixa-tion. When they compared transfascial suture group tothe tack alone group they found similar recurrence rates,9.2 and 8.5%, respectively.

During this review ten studies containing more than100 patients were identified and analyzed. A total of2,234 patients were included in our outcome analysis ofwhom only 2,060 patients were available for follow-upof recurrence data. See Tables 3 and 4 for a summary ofstudies using full-thickness fixation sutures with morethan 100 patients [65–68, 70–75].

Laparoscopic repair with tack alone mesh fixation

This review identified seven studies with a minimum of100 patients assessing the laparoscopic repair with onlytack fixation [63, 74, 76–80] (Tables 5 and 6). The largeststudy performed by Carbajo et al. [78] followed 270patients prospectively for a median follow-up of44 months. Approximately 95% of patients had herniadefects greater than 5 cm, as 147 had defects between 5and 10 cm while 108 patients had defects greater than10 cm. They demonstrated a post-operative complica-tion rate of 14%, a median hospital stay of 1.5 days, anda recurrence rate of 4.4%.

A recent large retrospective review performed byFrantzides et al. [77] followed-up 208 patients for amedian of 24 months and demonstrated a recurrence rateof 1.4% which is the lowest rate reported for tack alonefixation. Their operative technique involved a minimumof 3 cm mesh overlap and tacks placed 1 cm apart.

A long-term retrospective study by Bageacu et al. [63]collected data on 159 patients with a median follow-upof 49 months. In contrast to the above Carbajo et al.

Table 3 Summary of perioperative results for laparoscopic incisional hernia studies using transfascial sutures

Study Type of study No. of patients Mean herniasize (cm2)

Mean operatingtime (min)

Mean hospitalstay (days)

Conversion rate

Berger et al. [70] Retrospective 150 96 90 9 2 (1.32%)Ben-Hiam et al. [72] Retrospective 100 39 119 5 7 (7%)Heniford et al. [65] Prospective 850 118 120 2.3 31 (3.6%)LeBlanc et al. [67] Retrospective 200 111 84 1.3 7 (3.5%)Rosen et al. [74] Retrospective 114 95 126 1.8 14 (12%)Chelala et al. [75] Retrospective 120 – 75 3 0Franklin et al. [66] Retrospective 384 – 68 2.9 11 (3%)Ujiki et al. [73] Prospective 100 97 128 2 3 (3%)Bower et al. [68] Retrospective 100 124 – – 1 (1%)Perrone et al. [71] Retrospective 116 115 146 1.7 12 (10%)Total 2,234 99 106 3.2 88/2,234 (4%)

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study, this study included smaller hernia defects as 46%were smaller than 5 cm, 24% of defect were between 5and 10 cm, and 23% were greater than 10 cm. Theydemonstrated an early complication rate of 44% withseroma formation accounting for 16%, hematoma 8%,and prolonged ileus 4%. The recurrence rate was high at15.7% and all recurrences were confirmed with a CTscan after clinical suspicion. The authors suggest thattheir higher recurrence rate may be attributable to atechnical learning curve since their recurrence ratedropped from 20 to 10% between the periods of 1993–95and 1996–98.

Another study using only tack fixation was per-formed by Kirshtein et al. [79] which followed 103 pa-tients with a median hernia size of 175 cm2 for a mean of26 months. They demonstrated a complication rate of6%, mean hospital stay of 3.1 days, and recurrence rateof 4.0%. All four recurrences occurred within the firstmonth suggesting a preventable etiology such as inap-propriate fascial patch placement with mesh dislodge-ment. They conclude that using a double row of tacksmay be required to prevent mesh migration. Table 3summarizes all seven studies using only tack fixationwith more than 100 patients.

Table 4 Summary of complications for laparoscopic incisional hernia studies using transfascial sutures

Study No. of patients Bowel injury Overall complicationrate

Recurrence Mean follow-up(months)

Berger et al. [70] 150 3 (2%) 20a (13%) 4/147 (2.7%) 15Ben-Hiam et al. [72] 100 6 (6%) 28 (28%) 2 (2%) 19Heniford et al. [65] 850 14 (1.7%) 112 (13.2%) 35/744 (4.7%) 22LeBlanc et al. [67] 200 8 (4%) 47 (18%) 13 (6.5%) 36Rosen et al. [74] 114 2 (1.8%) 16 (13%) 10/49b (20%) 30Chelala et al. [75] 120 0 20 (16%) 1 (0.8%) 10Franklin et al. [66] 384 5 (1.3%) 39 (10%) 11 (2.9%) 47Ujiki et al. [73] 100 3 (3%) 22 (22%) 6 (6%) 3Bower et al. [68] 100 0 15 (15%) 2 (2%) 6.5Perrone et al. [71] 116 4 (3.4%) 33 (27%) 9 (9.3%) 22Total 2,234 45/2,234 (2%) 352/2,234 (16%) 93/2,060c (4.5%) 21

aExcluded 139 seromas which give a complication rate of 93%bAbout 49 of the 114 patients received transfascial suturescAbout 2,060 of the 2,234 patients available for follow-up recurrence data

Table 5 Summary of perioperative results from laparoscopic incisional hernia studies using only tack fixation

Study Type of study No. of patients Mean herniasize (cm2)

Mean operatingtime (min)

Mean hospitalstay (days)

Conversion rate

Chowbey et al. [80] Retrospective 202 – 50 1.8 1 (0.5%)Bageacu et al. [63] Retrospective 159 – 89 3.5 21 (13%)Kirshtein et al. [79] Retrospective 103 175 63 3.1 3 (3%)Gillian et al. [76] Retrospective 100 – – – –Rosen et al. [74] Retrospective 114 95 126 1.8 14 (12%)Carbajo et al. [78] Prospective 270 145 85 1.5 1 (0.4%)Frantzides et al. [77] Retrospective 208 173 126 1.4 0Total 1,156 147 90 2.2 40/1,056 (3.7%)

Table 6 Summary of complications from laparoscopic incisional hernia studies using only tack fixation

Study No. of patients Bowel injury Overall complicationrate

Recurrence Mean follow-up(months)

Chowbey et al. [80] 202 0 10 (5%) 2 (2%) 39Bageacu et al. [63] 159 10 (6%) 61 (44%) 19 (15.7%) 49Kirshtein et al. [79] 103 2 (2%) 6 (6%) 4 (4%) 26Gillian et al. [76] 100 3 (3%) 7 (7%) 1 (1%) 27Rosen et al. [74] 114 2 (1.8%) 16 (13%) 6/35a (17%) 30Carbajo et al. [78] 270 6 (2%) 60 (22%) 12 (4.4%) 44Frantzides et al. [77] 208 2 (1%) 6 (3%) 3 (1.4%) 24Total 1,156 25/1,156 (2.1%) 166/1,156 (14.3%) 47/1,077 (4.4%) 34

aAbout 35 of the 114 patients received tacks alone for fixation

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Comparison of laparoscopic and open repairs

There have been several studies directly comparing theopen and laparoscopic incisional hernia repairs [53–62].A recent meta-analysis performed by Goodney et al. [81]identified eight studies for a total of 712 patients whichexplicitly compared laparoscopic and open incisionalhernia repairs. They demonstrated that patients under-going a laparoscopic incisional hernia repair were 58%less likely to develop a perioperative complicationcompared to undergoing an open repair. However,similar to above studies none of the studies in the meta-analysis report using a standardized complication scor-ing system, making it very difficult to compare compli-cation rates. Future studies will need to utilizestandardized scoring systems such as the Clavien’sClassification of Surgical Complications [50]. This meta-analysis also demonstrated that there is a significantlength of stay reduction when a laparoscopic repair wasutilized as compared to an open repair, 2.0 versus4.0 days, respectively. When operative time was com-pared there was no significant difference between lapa-roscopic and open repairs.

From the studies discussed above, it is evident thatthe laparoscopic incisional repair is equal or better thanthe open repair with respect to peri-operative compli-cation rates, hospital stay, and recurrence rates. How-ever, there has been no published randomized-controlledtrial comparing the two techniques making a definitiveconclusion difficult.

In a recent review of laparoscopic incisional herniarepairs, Cobb et al. [82] calculated an overall recurrencerate of 3.8% when full-thickness sutures were used and arecurrence rate of 5.6% with only tack fixation. In ourreview the open intraperitoneal underlay repair, lapa-roscopic repair with full-thickness trans-muscular fixa-tion sutures, and laparoscopic repair with tacks alonehad similar recurrence rates, 4.5, 4.5, and 4.4%,respectively. Although we cannot provide definitiveconclusions, the current evidence suggests that thesethree repairs provide the lowest recurrence rates.

Laparoscopic complications

In all the previously discussed studies, none utilized avalidated standardized complication scoring system.This limits the ability to directly compare complicationrates among different studies. Future studies will needto use these standardized scoring systems to allow

reproducible and reliable complication rate comparisonamong studies performed at different centers.

The most common post-operative complication oflaparoscopic incisional hernia repair is seroma forma-tion, incidence reports range from 1 to 24% [63, 65–68,70, 72, 74, 76, 78–80, 83–89], while Cobb et al. [82]calculated the overall incidence to be 11.4%. Althoughnot all seromas are clinically relevant, Berger et al. [70]performed post-laparoscopic ultrasound examinationson 139 patients and identified that all patients had ser-oma formation. In a large study by Heniford et al. [65],only 2.6% of patients had clinically relevant seromas at8 weeks. A study by LeBlanc et al. [90] demonstratedthat applying a post-operative compressive bandage orwearing an abdominal binder decreases clinically sig-nificant seroma formation. However, most cases of ser-oma formation are asymptomatic and resolvespontaneously without any required intervention.

Infected mesh prosthesis occur in the range of 0–2%[63, 65–68, 70, 72, 74, 76, 78–80, 83–89], with an overallcalculated incidence of 0.6% [82]. Mesh infection is avery serious complication and most often always requiresa reoperation to remove the mesh and drain any associ-ated abscess. In the review by Cobb et al. [82] the inci-dence of fistula formation was 0.1%. Trocar enterotomyis an especially serious complication that if missed carriesa very high mortality from intra-abdominal sepsis. In aretrospective review of 159 patients who underwent alaparoscopic repair, Bageacu et al. [63] reported a 1.9%trocar enterotomy incidence rate. In our review we cal-culated an overall risk of enterotomy of 2.1%.

Conclusion

Laparoscopic incisional hernia repair appears to havelower complication rates, length of stay, and recurrencerates as compared to open incisional hernia repair.When comparing the two different techniques of lapa-roscopic mesh fixation, it appears that transfascial su-tures plus tacks is similar to using tacks alone. The useof tacks alone resulted in a shorter calculated operatingtime, 90 min compared to 106 min, and a lower calcu-lated overall complication rate, 14.3% compared to16%. There was very little difference between conversionrate, 4% compared to 3.7%, and enterotomy rate, 2.1and 2%. Overall it appears that the two laparoscopicincisional mesh fixation techniques are similar in out-comes. See Table 7 for a summary of calculated out-comes in this review.

Table 7 Summary of calculated outcomes between the two different laparoscopic mesh fixation techniques

Laparoscopicmesh fixationtechnique

Operating time(min)

Length ofhospitalstay (days)

Conversionrate (%)

Bowel injuryrate (%)

Overall complicationrate (%)

Recurrencerate (%)

Transfascial sutures and tacks 106 3.2 4 2 16 4.5Tacks alone 90 2.2 3.7 2.1 14.3 4.4

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Despite an increasing number of studies analyzinglaparoscopic incisional hernia repair, there has been nomulticenter randomized controlled trial comparing theopen to laparoscopic repair, making a definitive con-clusion difficult. Also, the complication rates reported inthe above studies are difficult to interpret since noneutilized a standardized scoring system such as the Cla-vien’s complication grading system [50].

For this reason we believe a future multi-center ran-domized controlled trial utilizing a validated complica-tion scoring system is warranted.

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