Laparoscopic Versus Open Incisional and Ventral Hernia Repair:A Systematic Review and Meta-analysis

Yanyan Zhang • Haiyang Zhou • Yunsheng Chai •

Can Cao • Kaizhou Jin • Zhiqian Hu

� Societe Internationale de Chirurgie 2014

Abstract

Background Laparoscopic incisional and ventral hernia

repair (LIVHR) is an alternative approach to conventional

open incisional and ventral hernia repair (OIVHR). A

consensus on outcomes of LIVHR when compared with

OIVHR has not been reached.

Methods As the basis for the present study, we performed

a systematic review and meta-analysis of all randomized

controlled trials comparing LIVHR and OIVHR.

Results Eleven studies involving 1,003 patients were

enrolled. The incidences of wound infection were signifi-

cantly lower in the laparoscopic group than that in the open

group (laparoscopic group 2.8 %, open group 16.2 %;

RR = 0.19, 95 % CI 0.11–0.32; P \ 0.00001). The rates

of wound drainage were significantly lower in the laparo-

scopic group than that in the open group (laparoscopic

group 2.6 %, open group 67.0 %; RR = 0.06, 95 % CI

0.03–0.09; P \ 0.00001). However, the rates of bowel

injury were significantly higher in the laparoscopic

group than in the open group (laparoscopic group 4.3 %,

open group 0.81 %; RR = 3.68, 95 % CI 1.56–8.67;

P = 0.003). There were no significant differences between

the two groups in the incidences of hernia recurrence,

postoperative seroma, hematoma, bowel obstruction,

bleeding, and reoperation. Descriptive analyses showed a

shorter length of hospital stay in the laparoscopic group.

Conclusions Laparoscopic incisional and ventral hernia

repair is a feasible and effective alternative to the open

technique. It is associated with lower incidences of wound

infection and shorter length of hospital stay. However,

caution is required because it is associated with an

increased risk of bowel injury compared with the open

technique. Given the relatively short follow-up duration of

trials included in the systematic review, trials with long-

term follow-up are needed to compare the durability of

laparoscopic and open repair.

Introduction

Ventral hernias are defects of the anterior abdominal wall,

which can be congenital or acquired (incisional). Incisional

ventral hernia (IVH) is a frequent complication of lapa-

rotomy that occurs in up to 11 % of surgical abdominal

wounds and in up to 20 % of patients who develop post-

operative wound infections [1]. IVH is associated with

complications such as pain, incarceration, and obstruction

of the intestinal lumen, as well as strangulation and

ischemia of the hernia contents. Therefore, it often requires

surgical intervention.

Unfortunately, the results of IVH repair are disap-

pointing; in fact, IVH repaired by suturing has high

recurrence rates in the range of 12–54 % [2–4]. Thanks to

the use of meshes in tension-free repair of IVH, the

Yanyan Zhang, Haiyang Zhou, and Yunsheng Chai contributed

equally to this work.

Y. Zhang � H. Zhou (&) � Y. Chai � K. Jin � Z. Hu (&)

Department of General Surgery, Changzheng Hospital, Second

Military Medical University, No. 415 Fengyang Road,

Shanghai 200003, People’s Republic of China

e-mail: haiyang1985_1@aliyun.com

Z. Hu

e-mail: czhuzq@aliyun.com

C. Cao

State Key Laboratory of Molecular Biology, Institute of

Biochemistry and Cell Biology, Shanghai Institutes for

Biological Sciences, Chinese Academy of Sciences, Shanghai,

People’s Republic of China

123

World J Surg

DOI 10.1007/s00268-014-2578-z

recurrence rates have been greatly reduced to the range of

2–36 % [5–7]. Thus it has become the gold standard

treatment. However, the conventional open incisional and

ventral hernia repair (OIVHR) often requires significant

soft-tissue dissection, which may cause several postopera-

tive complications, such as wound infection, hematomas,

and painful recovery. Hence, there is an ongoing search for

better techniques. The use of laparoscopic technique in the

treatment of IVH, first reported in 1993 by LeBlanc and

Booth, marked a step forward [8]. After 20 years of

development, laparoscopic incisional and ventral hernia

repair (LIVHR) is now widely performed all over the world

with the expectation of earlier recovery, fewer complica-

tions, and decreased recurrence rates [9]. As a consensus

regarding outcome when comparing LVIHR with OVIHR

has not been reached [10], we conducted a systematic

review and meta-analysis to provide the current best evi-

dence on this topic.

Materials and method

Data sources and selection criteria

Relevant studies were identified and selected by searching

several databases, including Medline, Embase, Cochrane

controlled trials register, and Science citation index (updated

to July 2013) under the search terms ‘‘abdominal wall her-

nia’’ or ‘‘ventral hernia’’ or ‘‘incisional hernia,’’ and ‘‘lapa-

roscopic’’ or ‘‘laparoscopy,’’ and ‘‘randomized controlled

trial’’ or ‘‘RCT,’’ as well as a review of reference bibliog-

raphies from original research articles and reviews.

Two authors (Y. Z. and H. Z.) reviewed the articles for

the inclusion criteria as follows: (1) study design: RCTs;

(2) study population: patients undergoing IVH repair

(including congenital and acquired); (3) intervention:

comparison between laparoscopic and open IVH repair; (4)

outcomes: each study should contain information on the

incidences of hernia recurrence; (5) the study must have

been published in English. The exclusion criteria included

repeat publication of a study, articles describing other types

of hernias, and non-RCTs.

Data extraction and outcomes of interest

Data extractions were performed by two reviewers (Y. Z.

and H. Z.) independently, and the results were checked by

a third reviewer (Y. C.). Data extracted from the studies

included the following: (1) patient characteristics [age,

body mass index (BMI), gender ratio, defect size, types of

prosthesis, surgical technique, and duration of follow-up];

(2) effectiveness outcomes (hernia recurrence, conversion

to open surgery, operative time, and length of hospital

stay); (3) safety outcomes (wound drainage usage, wound

infection, bowel injury, postoperative seroma, hematoma,

bowel obstruction, bleeding, reoperation, and pain).

Quality appraisal and publication bias

Methodological quality was assessed with the Jadad com-

posite scale [11]. This is a 7-point quality scale, with low-

quality studies scoring 1–3 points and high-quality studies

scoring 4–7 points. Each study included in the systematic

review was given an overall quality score based on the

Jadad composite scale. To check publication bias, a funnel

plot was constructed using Egger’s linear regression

method [12].

Statistical methods

The effect measures estimated were weighted mean differ-

ence (WMD) for continuous data and risk ratio (RR) for

dichotomous data, both reported with 95 % confidence

intervals (CI). Summary RR (or WMD) and their corre-

sponding 95 % CI were estimated by a fixed effect model

(Mantel–Haenszel) or a random effect (DerSimonian and

Laird) model. Tests for heterogeneity were performed with

each meta-analysis using the Cochran Q statistic and the I2

test, with P \ 0.05 indicating significant heterogeneity. The

random effect model was used when heterogeneity was

present. Statistical analyses were performed with the Rev-

Man 5.0 and STATA 9.0 software packages. A P value\0.05

was considered statistically significant.

Results

Characteristics of the included studies

A total of 135 records were identified by the search strat-

egy; 124 records were excluded for the reasons shown in

Fig. 1. Finally, 11 RCTs were included in the meta-ana-

lysis (Table 1) [13–23]. The meta-analysis involved 1,003

patients: 501 were randomized to the laparoscopic group

and 502 to the open group. The two groups were compa-

rable with regard to patient age, BMI, and hernia size. The

meshes were placed exceeding the edge of the incision by

more than 3 cm in all the trials. The prosthetic grafts used

in the studies included polypropylene and polytetrafluoro-

ethylene (PTFE), among various other types of prosthesis.

Suturing, stapling, or both techniques were applied in

included studies. Follow-up ranged from 2 to 35 months.

The methodological quality scores ranged from 2 to 5. Five

studies were low-quality studies, with Jadad scores of 2–3

points. The other 6 were high-quality studies, with JADAD

scores of 4–5 points (Table 2).

World J Surg

123

Effectiveness outcomes

Four studies reported that 28 of 276 procedures (10.1 %)

were converted from laparoscopic repair to open repair

during the operation [13–16]. Because of the heteroge-

neous data of included studies, pooled analyses of

operative time and length of hospital stay could not be

performed. Six studies [14–19] showed a significant dif-

ference in duration of surgery (Table 3). Among those six

studies, two [18, 19] reported that laparoscopic repair was

faster, and four others [14–17] stated the opposite conclu-

sion. Six studies [17–22] showed a significant difference in

Fig. 1 Flow chart shows the

method of inclusion of trials in

the meta-analysis

Table 1 Baseline characteristics of trials included in meta-analysis

Author Patients

(LR/

OR)

Age (LR/

OR),

years

BMI

(LR/OR)

Hernia size

(LR/OR)

Overlap

(LR/OR),

cm

Mesh

type

(LR/OR)

Fixed

(LR/OR)

Conversion

to OR

Follow-up

(loss)

(LR/OR),

months

Carbajo et al. [19] 30/30 57.8/54.9 – 139.5/

141.23 cm2– P2/

P1?P2

S?A/

S?A

– 27/27

Moreno-Egea et al.

[20]

11/11 60.7/58.6 – – – P1/P1 S/S – –

Misra et al. [22] 33/33 45.96/

45.2

26.28/

25.43

65.66/

42.12 cm23–5/3 P1/P1 S/S – 13.73(2)/

12.9(5)

Barbaros et al. [17] 23/23 50.7/54.1 31.6/31.2 – 3/5 P1/P1 S?A/S – 18/20

Olmi et al. [18] 85/85 60/65 28/28 9.7/10.5 cm 9.7/10.5 P3/P1 A/S – 24/24

Navarra et al. [21] 12/12 59.3/64.1 – 37.2/45.2 cm2 5/4–5 P1?P2/

P1

S/S – 6/6

Pring et al. [23] 31/27 64.5/55 – 23.8/23.2 cm2 3–4/3–4 P2/P2 S/S – 18/24

Asencio et al. [14] 45/39 58.02/

60.55

31.35/

30.61

9.51/10.18 cm 3/3 P2/P1 S?A/S 5 12(6)/12(4)

Itani et al. [16] 73/73 61.2/59.6 30.6/31.2 45.7/45.9 cm2 3/3 P2/P1 S?A/S 10 2(7)/2(6)

Eker et al. [15] 94/100 59.1/56.7 28.3/29.3 5/5 cm 5/5 P1/P1 S/S 8 35/35

Rogmark et al. [13] 64/69 58/58 29.3/29.3 36/25 cm2 5/5 P3/P1 S/A 5 2(0)/2(2)

S sutures; A staples; S?A sutures and staples; – not reported; P1 polypropylene mesh; P2 polytetrafluoroethylene (PTFE); P3 others

World J Surg

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length of hospital stay, consistently indicating a shorter

length of hospital stay in the laparoscopic group (Table 4).

There was no significant difference in the rates of hernia

recurrence between the laparoscopic group and the open

group (laparoscopic group 6.99 %, open group 4.82 %;

RR = 1.21, 95 % CI 0.77–1.91; P = 0.41) (Fig. 2)

Safety outcomes

The incidence of wound infection was significantly lower

in the laparoscopic group than in the open group (laparo-

scopic group 2.8 %, open group 16.2 %; RR = 0.19, 95 %

CI 0.11–0.32; P \ 0.00001) (Fig. 3). The rates of wound

drainage were significantly lower in the laparoscopic group

than in the open group (laparoscopic group 2.6 %, open

group 67.0 %; RR = 0.06, 95 % CI 0.03–0.09;

P \ 0.00001) (Fig. 4). However, the rates of bowel injury

were significantly higher in the laparoscopic group than in

the open group (laparoscopic group 4.3 %, open group

0.81 %; RR = 3.68, 95 % CI 1.56–8.67; P = 0.003)

(Fig. 5). There was no significant difference between the

two groups in the incidences of postoperative seroma,

hematoma, bowel obstruction, bleeding, or reoperation

(Table 5).

Table 2 Jadad quality score of

trials included in meta-analysisAuthor Randomization Concealment of

allocation

Double

blinding

Withdrawals

and dropouts

Total

score

Carbajo et al. [19] 1 1 0 0 2

Moreno-Egea et al. [20] 2 1 0 0 3

Misra et al. [22] 2 2 0 0 4

Barbaros et al. [17] 2 2 0 0 4

Olmi et al. [18] 1 1 0 0 2

Navarra et al. [21] 2 2 0 0 4

Pring et al. [23] 1 1 0 0 2

Asencio et al. [14] 1 1 0 0 2

Itani et al. [16] 2 2 0 0 4

Eker et al. [15] 2 2 0 0 4

Rogmark et al. [13] 2 2 0 1 5

Table 3 Operative time

Author Mean operative time, min

Laparoscopic

repair

Open repair P value

Carbajo et al. [19] 87 (30–180)a 111.5 (60–180)a \0.05

Moreno-Egea et al.

[20]

41 (29–65)a 45 (27–65)a 0.08

Misra et al. [22] 75 (25–245)a 86 (30–150)a 0.371

Barbaros et al. [17] 99 (32)c 72 (18)c \0.05

Olmi et al. [18] 61.0 (54.1,

68.9)b150.9 (132.1,

169.7)b\0.005

Navarra et al. [21] 73.7 (45–140)a 88.7 (60–190)a 0.15

Pring et al. [23] 43.5 (14)c 42.5 (11.2)c 0.77

Asencio et al. [14] 101.9 (91.7,

112.1)b70.0 (62.9, 77.0)b \0.001

Itani et al. [16] 155 127 0.02

Eker et al. [15] 100 (49)c 76 (33)c 0.001

Rogmark et al. [13] 100 (70–139)a 110 (78–137)a \0.05

a Rangesb 95 % confidence intervalc Standard deviation

Table 4 Hospital stay

Author Mean length of hospital stay, days

Laparoscopic

repair

Open repair P value

Carbajo et al. [19] 2.23 (1–15)a 9.06 (3–21)a \0.05

Moreno-Egea

et al. [20]

1 (5 h–2 days)a 5.2 (2–9)a \0.001

Misra et al. [22] 1.47 (1–3)a 3.43 (1–34)a 0.007

Barbaros et al.

[17]

2.5 (1.5)c 6.3 (4.2)c \0.05

Olmi et al. [18] 2.7 (2.2, 3.2)b 9.9 (5.2, 14.6)b \0.005

Navarra et al. [21] 5.7 (1–13)a 10 (5–19)a 0.006

Pring et al. [23] 1 (1–2)d 1 (1–1.8)d 0.43

Asencio et al. [14] 3.5 (2.7, 4.2)b 3.3 (2.8, 3.9)b 0.787

Itani et al. [16] 3.9 (3.1)c 4.0 (3.5)c 0.91

Eker et al. [15] 3 (2–4)a 3 (2–5)a 0.50

Rogmark et al.

[13]

2 (1.5–3)a 2 (1–3)a \0.861

a Rangesb 95 % confidence intervalc Standard deviationd Interquartile range

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Among the 11 included studies, 8 reported the results of

postoperative pain (Table 6) [13–17, 21–23]. All of them

showed no significant difference in postoperative pain

between the laparoscopic and open groups.

Heterogeneity and publication bias

Significant heterogeneity was found in two outcomes

(wound drainage usage, P = 0.007; seroma formation,

P = 0.003). Thus we used the random effects model to

pool results of the two outcomes. No significant hetero-

geneity was shown in other outcomes, for which we used

the fixed effects model to pool the results.

We assessed the publication bias based on the results of

hernia recurrence. No evidence of publication bias existed

in the studies included in the meta-analysis, based on the

Egger’s publication bias plots (Fig. 6).

Discussion

This systematic review and meta-analysis examined the

current best evidence comparing the outcomes of laparo-

scopic and open incisional and ventral hernia repair. Ele-

ven studies involving 1,003 patients were identified in the

systematic review. Compared with open repair, the lapa-

roscopic approach was found to have lower rates of wound

infection and wound drainage, higher rates of bowel injury,

and shorter length of hospital stay. There was no significant

difference between the two groups in the incidences of

hernia recurrence and other postoperative complications, as

well as in postoperative pain.

Four studies reported that 28 of 276 procedures (10.1 %)

were converted from laparoscopic repair to open repair

during the operation, which implied that LIVHR was a

technically demanding procedure that might not be

Fig. 2 Forest plot shows meta-analysis of hernia recurrence rates

Fig. 3 Forest plot shows meta-analysis of wound infection rates

Fig. 4 Forest plot shows meta-analysis of wound drainage rates

World J Surg

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appropriate in all cases. The conversion usually occurred

because of intraoperative complications, such as bleeding

or organ injury (bowel or bladder). In such situations,

surgeons are advised to convert to an open procedure

without hesitation, which could reduce the incidence of

postoperative complications and lead to an uneventful

recovery.

Because of the heterogeneous data in the studies inclu-

ded, pooled analyses of operative time and length of hos-

pital stay could not be performed. According to the

descriptive analyses, included studies had conflicting

operative times. One possible explanation is that many

confounding factors, such as the surgeons’ experience,

location and size of the hernias, and the surgical technique,

Fig. 5 Forest plot shows meta-analysis of bowel injury rates

Table 5 Results of meta-

analysis comparing

laparoscopic versus open repair

for incisional ventral hernia

RR risk ratio; WMD weighted

mean difference; HG

heterogeneity; Fix fix effect

model; Random random effects

model

Outcomes No. of

studies

No. of

patients

HG,

v2HG,

P value

Model RR/

WMD

P value 95 % CI

Recurrence 11 1,003 2.66 0.91 Fix 1.21 0.41 0.77, .91

Wound

infection

11 1,003 0.25 10.26 Fix 0.19 \0.00001 0.11, .32

Seroma 9 893 23.55 0.003 Random 0.99 0.97 0.46, .10

hematoma 8 768 6.77 0.45 Fix 0.94 0.82 0.53, .65

Bowel injury 10 977 4.78 0.57 Fix 3.68 0.003 1.58, .67

Bowel

obstruction

6 711 1.72 0.79 Fix 1.58 0.40 0.55, .58

Postoperative

bleeding

3 473 0.32 0.85 Fix 1.88 0.42 0.41, .71

Reoperative 4 431 2.79 0.42 Fix 0.42 0.07 0.16, .09

Wound drainage 8 752 19.31 0.007 Random 0.06 \0.00001 0.03, .09

Table 6 Postoperative pain

VAS visual analog scale; IR

interquartile range

Author P value Laparoscopic

repair

Open repair

Misra et al. [22] 0.333 3.77 3.50 Injection analgesic doses

in first 3 days (VAS score)

Barbaros et al. [17] [0.05 1.53 1.61 Postoperative pain scoring

Navarra et al. [21] 0.05 1.4 (range 0–3) 4.9 (range 2–8) Analgesic requirement

Pring et al. [23] 0.2 5 (4–6.3) 5 (5–7) Median pain score at 4 days (IR)

Asencio et al. [14] [0.05 10.38

(1.98–10.01)

6 (4.93–5.83) Mean VAS (0–100) (1 year)

95 % CI

Itani et al. [16] 0.07 19.2 18.0 Perception of worst pain (8 weeks)

Eker et al. [15] 0.54 23 24 Analgesia use

Rogmark et al. [13] [0.05 \10 \10 Mean VAS score (30 days)

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could affect the operative time. As for the length of

hospital stay, the results seemed to be consistent among

the studies. Laparoscopic repair reduced the length of

hospital stay compared with open repair. This might be

mainly owing to the disadvantages of the open technique

that include the need for soft-tissue dissection and

undermining to raise subcutaneous skin flaps, which have

the potential for increased morbidity and prolonged con-

valescence [24].

There was no significant difference between the two

groups in the incidence of hernia recurrence. Our meta-

analysis found low incidences of recurrence after both

procedures (laparoscopic group 7.0 %; open group 5.8 %).

The results showed that laparoscopic repair if not better,

was as efficient as open repair. However, the results were

not conclusive because of the relatively short follow-up

(2–35 months) and the heterogeneities of trials included in

the systematic review. It deserves attention that the use of

mesh and its proper placement, such as exceeding the edge

of the incision by about 3–5 cm, could reduce hernia

recurrence, no matter which approach is used [25].

The rates of wound drainage were significantly lower in

the laparoscopic group than in the open group (laparo-

scopic group 2.6 %, open group 67.0 %; P \ 0.00001).

Because open repair is associated with more soft tissue

damage, a larger surgical wound, and more bleeding,

wound drainage is mandatory in most situations to clear

seepage. However, drainage may increase the incidence of

wound infection and the severity of postoperative pain, and

it may also prolong the postoperative hospital stay [26].

The wound infection rates were significantly lower in

the laparoscopic group than that in the open group (lapa-

roscopic 2.8 %, open 16.2 %; P \ 0.00001). The mini-

mally invasive approach eliminates the need for tissue

undermining and wound drainage, thereby minimizes the

inherent wound healing problems associated with the open

technique.

Despite the advantage of laparoscopic repair in reducing

the incidence of wound infection, the risk of bowel injury

was significantly higher in the laparoscopic group than that

in the open group (laparoscopic group 4.3 %, open group

0.81 %; P = 0.003). Abdominal adhesion presents a par-

ticular problem during laparoscopic repair, with the atten-

dant risk of bowel injury during establishment of

pneumoperitoneum and in dissection around the neck of the

hernia. If intraoperative bowel injury cannot be dealt with

promptly, 30 % of patients may eventually die from intes-

tinal perforation and acute peritonitis [27]. Thus, the sur-

geon must be careful, and recognize and repair the injury

promptly. As for other postoperative complications, there

were no significant differences between the two groups.

Minimally invasive procedures are often assumed by

patients and surgeons to be less painful. However, this did

not prove to be true in LIVHR. There were consistent

findings that postoperative pain was not different between

the laparoscopic and open groups. Our own experience also

suggest that patients often have considerable discomfort

after laparoscopic repair. Although the exact reason is

unclear, we may suppose that the postoperative pain should

be mainly attributed to the hernioplasty, no matter which

approach is used.

Our study has several limitations. First, there was sig-

nificant heterogeneity among the included trials. The first

possible cause of heterogeneity is research bias, as all

included trials were not performed under double-blind

conditions. The second possible cause of heterogeneity is

the presence of confounding variables [e.g., different her-

nia sizes and locations, different meshes, patients with

variable surgical risks: patients of American Society of

Anesthesiologists (ASA) categories I–IV]. A second limi-

tation is that the trials included in the systematic review

used dissimilar definitions of complications, making com-

parison across studies difficult. Third, there was significant

variability in operative techniques among the trials, as

shown in Table 1.

Based on the systematic review and meta-analysis, we

conclude that LIVHR is a feasible and effective alternative

to the open technique. It is associated with lower inci-

dences of wound infection and shorter length of hospital

stay. However, caution is required because the laparo-

scopic procedure is associated with an increased risk of

bowel injury compared with the open technique. Given the

relatively short follow-up duration of trials included in the

systematic review, trials with long-term follow-up are

needed to compare the durability of laparoscopic and open

repair.

Acknowledgments This work was supported by the National Nat-

ural Science Foundation of China (No. 31100681), Shanghai Nano-

technology Program (No. 11nm0504800), Shanghai Basic Research

Fig. 6 Egger’s publication bias plots for hernia recurrence

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123

Program (No. 12JC1411402), and Shanghai Rising Star Program (No.

11CG42).

Conflict of interest Yanyan Zhang, Haiyang Zhou, Yunsheng Chai,

Can Cao, Kaizhou Jin, and Zhiqian Hu have no conflicts of interest or

financial ties to disclose.

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