Recurrence after laparoscopic ventral hernia repair

A five-year experience

M. Rosen, F. Brody, J. Ponsky, R. M. Walsh, S. Rosenblatt, F. Duperier, A. Fanning, A. Siperstein

Department of General Surgery, Minimally Invasive Surgery Center, Cleveland Clinic Foundation, 9500 Euclid Avenue,Cleveland, OH 44195, USA

Received: 13 February 2002/Accepted: 15 May 2002/Online publication: 4 October 2002

AbstractBackground: Although the early results of laparoscopicventral hernia repair have shown a low recurrence rate,there is a paucity of long-term data. This study reviews asingle institution’s experience with laparoscopic ventralhernia repair (LVHR).Methods: We carried out a retrospective analysis of allLVHR performed at the Cleveland Clinic Foundationfrom January 1996 to March 2001. Recurrence rateswere determined by physical exam or telephone follow-up. Factors predictive of recurrence were determinedusing Cox regression.Results: Of 100 ventral hernias completed laparoscopi-cally, 96 were available for long-term follow-up (aver-age, 30 months; range 4–65). There were no deaths andmajor morbidity occurred in seven patients. Recurrenceswere identified in 17 patients. Nine recurrences occurredin the 1st postoperative year; however, hernia recurrencecontinued throughout the period of follow-up. Multi-variate analysis showed that a prior failed hernia repairwas associated with a more likely chance of anotherrecurrence (65% vs 35%, odds ratio (OR) 3.6; p = 0.05)and that an increased estimated blood loss (106 cc vs 51cc, OR 1.03; p = 0.005) predicted recurrence. Othervariables, including body mass index (BMI) (32 vs 31kg/m2, p = 0.38), defect size (115 cm2 vs 91 cm2;p = 0.23), size of mesh (468 cm2 vs 334 cm2, p = 0.19),type of mesh (p = 0.62), and mesh fixation (p = 0.99),did not predict recurrence. An additional 14 cases re-quired conversion to an open operation, and seven ofthese cases (50%) had recurrence on long-term follow-up.Conclusion:Although LVHR remains the preferredmethod of hernia repair at our institution, this studydocuments a higher recurrence rate than many othershort-term series. There results underscore the impor-

tance of long-term follow-up in assessing hernia surgeryoutcome.

Key words: Laparoscopy — Ventral hernia repairs —Recurrence rate — Hernia

The Repair of ventral hernias poses a significant chal-lenge for the general surgeon. Incisional hernias are themost common long-term complication following lapa-rotomy, occurring in 3–13% of cases [15]. These defectsresult in the performance of �90,000 ventral hernia re-pairs in the United States annually [15]. Despite theprevalence of this problem, the optimal solution for therepair of these defects has not been found. Primary re-pair of ventral hernias is associated with a 25–52% rateof recurrence [8, 24]. For this reason, a variety of opentension-free hernia repairs using bioprosthetic meshhave been developed, reducing the recurrence rate to 11–21% [8, 14, 19, 21, 24]. However, the open repair ofventral hernias with mesh placement often requires longincisions, wide fascial dissection and flap creation, andfrequent drain placement [7]. These factors lead to sig-nificant postoperative morbidity and wound complica-tion rates [12, 26]. For example, in a series of 466 openincisional mesh repairs, Stoppa reported a 12% rate ofwound infection, a 1.8% mortality rate, and a 14.5%recurrence rate with a mean follow-up of >5 years [21].The laparoscopic approach to the treatment of

ventral hernias was initially described in 1993 [13]. Withthe use of the laparoscopic methods, large incisions anddrain placement can be eliminated, which is postulatedto reduce postoperative wound infections and sub-sequent mesh removal [1, 26]. Recently, reports of lap-aroscopic repair of ventral hernias have confirmed thatis associated with minimal postoperative morbidity,shorter hospital stays, and an earlier return to normalactivities [3, 5, 6, 9, 14, 17, 19, 23]. However, the ulti-mate measure of the effectiveness of hernia surgery is therecurrence rate. With short-term follow-up, these series

Presented at the Society of Gastrointestinal Endoscopic Surgeons

(SAGES) meeting, New York, New York, USA, 13–16 March 2002

Correspondence to: A. Siperstein

Surg Endosc (2003) 17: 123–128

DOI: 10.1007/s00464-002-8813-y

� Springer-Verlag New York Inc. 2002

document a 1.1–13% recurrence rate and complicationrates ranging from 4% to 22%. The purpose of this studywas to review a single academic institution’s five-yearexperience with the laparoscopic repair of ventral her-nias, with particular attention to recurrence rates andpostoperative morbidity.

Methods

We carried out a retrospective review of 114 consecutive patients whounderwent attempted laparoscopic ventral hernia repair at the Cleve-land Clinic Foundation between January 1996 and March 2001. Pa-tient records were reviewed for preoperative, intraoperative, andpostoperative data. Pertinent information for analysis included patientage, gender, body mass index (BMI), comorbidities, number of pre-vious abdominal surgeries, number of previous hernia repairs, type ofprevious repair, operating times (as measured from skin incision toapplication of dressings), estimated blood loss (EBL) (from attendinganesthesiology record), number of fascial defects, size of fascial defects(measured by multiplying length and width in centimeters), size andtype of mesh, method of mesh fixation (sutures, tacks, or both), ad-hesion scores, intraoperative and postoperative complications, lengthof hospital stay, and long-term follow-up. Follow-up was determinedby review of clinic visits when appropriate or by phone follow-up.Phone follow-up was performed by one reviewer using a standardquestionnaire. Recurrence was defined on phone follow-up if the pa-tients reported similar symptoms to their preoperative hernia or no-ticed a bulge with straining. All patients with hernia recurrencedocumented by phone follow-up were encouraged to return to theclinic for examination.

Univariate comparisons of categorical factors between recurrentand non-recurrent hernias were performed with the chi-square test andFisher’s exact test. Summary statistics for these factors are presented asfrequency and percent. Univariate comparisons of quantitative factorswere performed with the Wilcoxon rank-sum Test. Multivariateanalysis of recurrence risk factors was performed with Cox propor-tional-hazard regression analysis. This analysis also provided hazardratios and corresponding 95% confidence intervals. Kaplan-Meier es-timates illustrate overall hernia recurrence rates. Statistical significancewas assessed with two-tailed tests with p < 0.05. Calculations wereperformed with SAS version 8.1 (SAS Institute Inc., Cary, NC, USA).

The technique of laparoscopic ventral hernia repair has been de-scribed extensively in the literature. Our own technique is describedbriefly below. The patients are given a dose of preoperative antibiotics(first-generation cephalosporin) and placed in the supine position. AFoley catheter and oral gastric tube are placed to decompress thebladder and stomach, respectively. The abdomen is entered at a pointfar from the hernia defect using the open technique, a Veress needle, ora Visiport trocar (US Surgical Corporation, Norwalk, CT, USA).After pneumoperitoneum is established, the laparoscope is introduced,the abdomen is explored, and additional trocars are placed. On aver-age, three trocars are used, but depending on the size and location ofthe defect, up to five trocars are placed on occasion. Every effort ismade to place these trocars as far laterally as possible. Adhesiolysis isperformed ‡4 cm beyond the fascial defect. The hernia sac contents arereduced, and the sac is left in situ. After the size of the defect ismeasured, a patch is cut to overlap the edges of the hernia defect by‡3–4 cm. Type of mesh used depended on the individual surgeon’spreference. The mesh is fixed to the abdominal wall using spiral tacks,sutures, or a combination. The fascia is closed on all ‡10 mm trocarsites. Drains are not used.

Results

Between January 1996 and March 2001, 114 patientsunderwent attempted laparoscopic ventral hernia repair.Fourteen patients (12%) required conversion to an openprocedure. The most common indication for conversionwas severe adhesions (nine cases), followed by bleeding

(two cases), enterotomy (one case), morbid obesity(BMI ‡49 kg/m2) preventing trocars from accessing theabdomen (on case), and inability to adequately spreadand place a large piece of mesh to cover the defect(which occurred in our initial experience) (one case).Nine of these patients had prior hernia repairs, with amean of 3.5 previous attempts at open hernia repair(range, 1–15). Interestingly, with a mean follow-up of 23months (range, 8–48), seven (50%) of the 14 patientsrequiring conversion to an open procedure have hadanother recurrence. Since these patients had a funda-mentally different operation than those completed la-paroscopically, because the mesh was only secured tothe fascial edges with no overlap, they were not analyzedon an intent-to-treat basis.The remaining 100 patients underwent successful

laparoscopic ventral hernia repair and comprise thestudy group. There were 54 men and 46 women, with amean age of 57 years (range, 24–87). The patients tendedto be obese (mean BMI, 31 kg/m2; range 15–48). Pa-tients also tended to have significant comorbidities(mean ASA, 2.64). Eight patients required chronicimmunosupression for various reasons, and 40 patientssmoked cigarettes regularly. Ninety-one percent of pa-tients had had prior intra-abdominal surgery. A total of38 of the laparoscopic ventral hernias were performedfor recurrent hernias. Patients with a recurrent herniaunderwent an average of 2.1 previous repairs (range, 1–12). Of this group, 21 had undergone prior mesh repair.Eighty-four patients had incisional hernia defects, 13

patients had umbilical hernias, and one patient each hada spigelian, lumbar, and epigastric hernia repaired la-paroscopically (Table 1). Almost all of the hernias (97)were reducible; three were incarcerated, and none werestrangulated. Patients tended to have more than onefascial defect identified (mean number of defects, 1.9;range, 1–17). The mean defect size was 95.5 cm2 range,4–480).The type of mesh used primarily depended on the

attending surgeon’s preference. Gore-Tex Dual Mesh(W.L. Gore & Associates, Falgstaff, AZ, USA) was themost common choice (57 patients), followed by Prolene(24 patients), Composix mesh (C.R. Bard, Murray Hill,NJ, USA) (18 patients), and Surgisis (Wilson CookBiotech, Lafayette, IN, USA) (one patient). The averagemesh size was 354 cm2 (range, 16–2400), and the meshoverlapped the edge of the defect on average by 3.9 cm.Mesh fixation was achieved with both spiral tacks andsutures in 49 patients; 35 patients had only tacks placed,and three patients had only sutures placed.Intraperitoneal adhesions were deemed severe in 26

patients, moderate in 32 patients, and minimal in 39

Table 1. Types of hernias

Hernia type n

Incisional 84Umbilical 13Spigelian 1Lumbar 1Epigastric 1

124

patients. Average operative time was 126 min (range,28–324). There were intraoperative complications. Onepatient had a small serosal tear, with no bowel contentspillage, that was repaired with a single silk suture. Thiscase was completed laparoscopically, and a mesh wasplaced. One patient had an enterotomy that requiredconversion to an open procedure and primary closure ofthe hernia defect. The majority of patients remained inthe hospital for one night and were discharged the nextday. The average length of stay was 1.8 days (range, 0–10).Postoperative complications occurred in 14 patients

(Table 2). Four patients had seromas lasting >4 weeks.Two of these seromas were treated with pressure dress-ing, and two patients underwent percutaneous aspira-tion. In all cases, the seromas eventually resolved. Fourpatients had minor wound infections requiring the in-travenous administration of antibiotics. Two patientshad a postoperative ileus. One patient had his dischargedelayed until postoperative day 4 secondary to his ileus,and one patient was treated in the emergency room withan enema and subsequently discharged. Two patientshad major wound infections requiring removal of themesh at 1 and 9 months, respectively. These two casesare considered recurrences. One patient had a port sitehematoma that was managed nonoperatively. One pa-tient had a postoperative pulmonary embolism that re-quired anticoagulation. There were deaths in this series.Ninety-six patients were available for long-term

follow-up for an average of 30 months (range, 4–65).Seventeen recurrences (17.7%) were identified. Ninepatients presented with a recurrence within 1 year ofsurgery. The average time until recurrence for theoverall group was 16.1 months (range, 1–36) (Fig. 1).Fifteen patients had their recurrence documented onphysical exam, and eight have had surgical repair ofthese recurrences. Of note, three patients had surgicalrepair of their recurrence at another hospital and wereonly identified by phone follow-up. Additionally, onphone follow-up, two patients reported similar symp-toms to their preoperative hernia and noticed an ab-dominal bulge when straining at 12 and 15 months,respectively, after laparoscopic repair. Although thesepatients had not been examined at the time of thiswriting, they are considered to have had a recurrence.Patients with recurrence and those without recur-

rence had similar comorbid factors. The factors associ-

ated with adverse hernia recurrence rates are shown inTable 3. Several demographic and operative character-istics of those patients with a hernia recurrence andthose without a recurrence are shown in Table 4. Of the17 patients who developed a recurrence, 11 had a priorfailed hernia repair. Those 11 patients had an average of3.4 prior attempted hernia repairs (range 1–12). Alter-natively, only 28 patients who had a prior failed herniarepair did not develop a recurrence. These patients hadan average of 1.6 prior attempted hernia repairs (range,1–6). In the recurrent group, the mesh was fixed withtacks only in six patients, and sutures only in one pa-tient; in the remaining 10 patients, both tacks and su-tures were placed.Using multivariate analysis, we found that a prior

failed hernia repair was associated with a more likelychance of another recurrence (65% vs 35%, Odds Ratio3.6; p = 0.05) and that a higher mean EBL (106 cc vs 51cc, OR 1.03; p = 0.005) predicted recurrence. Othervariables, including BMI (32 vs 31 kg/m2; p = 0.38),defect size (115 cm2 vs 91 cm2; p = 0.23), size of mesh(468 cm2 vs 334 cm2; p = 0.19), type of mesh, and meshfixation (tacks only, 35% vs 40%; sutures and tacks, 59%vs 55%; p = 0.99) did not predict recurrence.

Discussion

As the field of hernia surgery develops, the pendulumhas swung in favor of mesh-based tension-free hernio-plasties [4]. Several innovative approaches to the treat-ment of ventral hernias using bioprosthetic mesh havebeen reported [21, 22, 25]. The Rives-Stoppa-Wantz(RSW) repair for large ventral hernias is considered bymany to be the gold standard for hernia repair. Thistechnique involves placing a large piece of mesh pos-terior to the fascial defect in the preperitoneal plane withsignificant overlap to normal tissue. In long-term follow-up, this technique has proven valuable; the recurrencerate for these difficult hernias is only 14.5%. However,this operation requires significant subcutaneous flapdissection and carries a wound complication rate of 12%and a mortality rate of 1.8% [21].

Table 2. Intraoperative and postoperative complications in 114attempted laparoscopic ventral hernioplasties

Complications n

IntraoperativeSerosal bowel injury 1Enterotomy 1PostoperativeSeroma (>4 wk) 4Minor wound infection 4Major wound infection 2Ileus 2Hematoma 1Pulmonary embolus 1

Fig. 1. Kaplan-Meier survival curve for hernia recurrence.

125

The laparoscopic approach to ventral herniasmaintains many of the fundamentals of the RSW repair.The laparoscopic technique also involves placing a largepiece of prosthetic material posterior to the defect, yetone anatomic layer deeper, within the peritoneum. Thisallows for substantial ingrowth of tissue for permanentmesh fixation. In addition, intraabdominal pressuretends to hold the mesh in place, keeping it apposed tothe posterior fascia over a wide surface area in accor-dance with Laplace’s law [22, 23]. Although the lapa-roscopic approach affords a number of advantages, itdoes not require large incisions or significant abdominalwall dissection. By eliminating subcutaneous flaps andpercutaneous drain placement, the laparoscopic ap-proach reduces the incidence of wound complicationsassociated with open repair while maintaining a recur-rence rate equivalent to the RSW repair.Several investigators have compared wound compli-

cation rates for laparoscopic and open hernia repairs.When Park et al. compared a prospective series of lap-aroscopic ventral hernia repairs to historic controls un-dergoing open ventral hernia repairs, they found thatthere were fewer wound complications and earlier hos-pital discharge in the laparoscopic group [17]. The onlyprospective, randomized trial comparing laparoscopicand open ventral hernia repairs also documented a lowerrate of postoperative and long-term complications, aswell as significantly shorter postoperative stays in thelaparoscopic group [2]. Other retrospective comparativestudies confirmed these results, with lower wound com-plication rates and shorter hospital stays in the laparo-scopic groups [9, 19]. In our series, there were four minor

wound infections that required antibiotic treatment. Anadditional two patients had significant wound infectionsthat eventually required mesh removal. One of thesepatients had had 12 prior attempted open hernia repairs,all of which were complicated with postoperative infec-tions. In this case, a 4 · 5 cm area of skin eroded andexposed the Gore-Tex Dual Mesh, necessitating remov-al. The other patient had a traumatic lumbar hernia thathad been repaired on two other occasions; after aseemingly uneventful laparoscopic repair, this patientdeveloped an abscess around the Gore-Tex mesh.Thus, our overall infectious complication rate of 6%

compares favorably to the reported 12–45% woundcomplication rate in open series of ventral hernia repairs[10, 16, 21, 25]. The higher rate of infection reported inopen series is most likely due to the extensive subcuta-neous dissection, flap creation, and prolonged exposureof the mesh to skin flora, none of which are required inthe laparoscopic approach. Moreover, the routineplacement of percutaneous drains in the open procedurehas been associated with an increased infection rate [18,20].Theoretically, laparoscopic ventral hernia surgery

provides a faster recovery due to less bowel manipula-tion and the absence of large incisions and dissection.The average length of stay in our series was 1.8 days.Only two patients had a prolonged hospital stay oremergency room visit due to an intestinal ileus. Holz-man et al. performed a cost analysis and found thatdespite longer operative times in laparoscopic ventralhernia repairs, early hospital discharge resulted in sig-nificant overall cost savings as compared to open hernia

Table 3. Comorbidities adversely effecting hernia repair

Nonrecurrent Recurrenct p value

Factor (%) (%)

Number of patients 79 17Obesity (BMI>30) 35 (44) 9 (53) 0.38Age >70 y 19 (24) 1 (6) 0.61CAD/HTN 42 (53) 7 (41) 0.70COPD/asthma 9 (11) 3 (18) 0.21Immunosuppression 5 (6) 2 (12) 0.62Ascites 0 0 —Diabetes 9 (11) 2 (12) 0.73Smoker (>1 ppd) 32 (41) 5 (29) 0.28

CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; HTN, hypertension; ppd, packs per day; BMI, body mass index

Table 4. Univariate comparison of different variables between recurrent and nonrecurrent laparoscopic ventral hernias

Variable Nonrecurrent Recurrent p- value

Mean age (yr) 57 55 0.61Mean BMI (kg/m2) 31 32 0.38Prior hernia repairs (%) 29 65 0.02Mean number of defects 1.93 1.75 0.68Mean defect size (cm2) 91 115 0.23Mean mesh size (cm2) 334 468 0.19Mean estimated blood loss (cc) 51 106 0.0007Operative time (mins) 122 146 0.08Average length of stay (days) 1.8 1.94 0.97

BMI, body mass index

126

repairs [9]. Several authors have documented an earlyreturn to activity for patients who undergo laparoscopicrepairs as well [13, 23]. Although we agree with thesefindings, the retrospective nature of this study preventsus from identifying these advantages of the laparoscopictechnique in our series.A compilation of several recent reports of >1200

laparoscopic ventral hernioplasties is presented in Table5. These studies report an overall complication rate of13% (range, 4.1–22%) and a recurrence rate of 4.7%(range, 1.1–13%) with an average follow-up of 28months [1, 4, 5, 6, 7, 14, 17, 23]. The largest series of 407patients, is from a multicenter study with <2 year’sfollow-up and had a 3.4% recurrence rate and a 13%complication rate [6]. Although these series are certainlyencouraging, postoperative complication rates, long-term follow-up is required before we can make an ac-curate identification of the recurrence rate for laparo-scopic ventral hernia repairs.Several authors have argued that the majority of

hernia recurrences occur within the 1st year after repair,however, our data not support this conclusion [11, 24].Although we agree that the majority of recurrences at-tributable to technical errors occur within the 1st year,hernia recurrence occurred throughout our study peri-od. In fact, eight hernias recurred after 1 year of follow-up in our series, and four of them were after 2 years offollow-up. Thus, almost 50% of our recurrences oc-curred after 1–2 years—and a finding that the under-scores the necessity for long-term follow-up. Bymultivariate analysis, only a higher estimated blood lossand a prior hernia repair predicted recurrence. Likewise,Hesselink et al. noted an increased hernia recurrencerate after second, third, and fourth incisional herniarepairs of 56%, 48%, and 47%, respectively [8]. It ap-pears that some of the more technically challengingcases, with a resultant higher blood loss from extensiveadhesiolysis, mandate increased surgical skills andjudgment. Of the seven recurrent hernias with >100 ccof estimated blood loss, five recurred within the 1stpostoperative year, indicating either technical errors ormissed hernia defects. Although our recurrence rate issimilar to that for open tension-free mesh repair, we stillthink that the low wound complication rates and theearlier discharge and return to function make laparo-scopic ventral hernia repair appealing, with the caveatthat this is a technically demanding procedure that re-

quires advanced laparoscopic skills and a certainlearning curve.To determine the effects of the learning curve on the

recurrence rate, we evaluated the number of recurrencesthat occured within each surgeon’s first 10 cases. Allseven surgeons performing laparoscopic ventral herniarepair during this time period also performed otheradvanced laparoscopic procedures as a part of theirroutine practice. Three surgeons performed >10 lapa-roscopic ventral hernia repairs during the study period.They accounted for 70% of the total cases in this seriesand were responsible for 14 of the 17 recurrences. Ofthese 14 recurrences, eight occurred in the first 10 lap-aroscopic ventral hernia repairs performed by thesethree surgeons. The remaining surgeons accounted forthree hernia recurrences. Each recurrence occurred inthe surgeon’s first three cases. Thus, 65% of our recur-rences occurred during the early learning phase.Several investigators have stressed the importance of

mesh fixation to hernia recurrence in laparoscopic re-pairs. In a series of 100 cases reported by LeBlanc et al.,all of the recurrences (nine patients) resulted from meshfixation with spiral tacks alone [13]. Of the 17 recur-rences in our series, six patients (35%) had only tacksplaced to secure the mesh. Ten other patients had bothtacks and sutures, and one patient had only suturesplaced. In the nonrecurrent group, 30 patients (40%)had only tacks used to secure the mesh. Although itappears that mesh fixation probably had some effect onour higher recurrence rate, not all of the recurrenceswere attributable to isolated tack placement.The retrospective nature of this study obviously

creates certain weaknesses when we attempt to interpretthe data. Since several surgeons were involved in thestudy and standard techniques were not employed, it isdifficult to draw any firm conclusions about our recur-rence rate. However, most of the recurrent cases hadadequate mesh coverage and fixation. Furthermore, thetype of mesh employed was not influential in predictingrecurrence.In conclusion, our series documents a higher recur-

rence rate for laparoscopic ventral hernia repair thanhas previously been reported. The laparoscopic repair ofventral hernias requires meticulous surgical technique,and two-thirds of our recurrences occurred during thelearning curve for the operation. Nevertheless, this re-currence rate still compares favorably to open tension-

Table 5. Recent laparoscopic ventral hernia repair series

n Recurrence Complications Mean follow-up

First author (year) [ref. No.] (%) (%) (mon)

Franklin (1998) [5] 176 1.1 5.1 30.1Toy (1998) [23] 144 4.4 22 7.4Heniford (2000) [7] 100 3 14 22.5LeBlanc (2001) [14] 100 9.3 4.1 51Heniford (2000) [6] 407 3.4 13 23Chowbey (2000) [4] 202 1.6 — 35Carbajo (2000) [1] 100 2 15 30Park (1998) [17] 56 13 18 24Total 1285 4.7 13 28

127

free mesh repair. In addition, the laparoscopic repairavoids large abdominal incisions and extensive subcu-taneous dissection, while providing decreased woundcomplication rates, early hospital discharge, and anearlier return to full function than open hernia repair.For these reasons, we still favor the laparoscopic ap-proach for the repair of ventral hernias.

References

1. Carbajo MA, del Olmo JC, Blanco JI, de la Cuesta C, Martin F,Toledano M, Perna C, Vaquero C (2000) Laparoscopic treatmentof ventral abdominal wall hernias: preliminary results in 100 pa-tients. J Soc Laparoendosc Surg 4: 141–145

2. Carbajo MA, Martin del Olmo JC, Blanco JI, de la Cuesta C,Toledano M, Martin F, Vaquero C, Inglada L (1999) Laparo-scopic treatment vs open surgery in the solution of major inci-sional and abdominal wall hernias with mesh. Surg Endosc 13:250–252

3. Carbajo Caballero MA, Martin del Olmo JC, Blanco Alvarez JI(2001) Laparoscopic incisional hernia repair. Surg Endosc 15:223–224

4. Chowbey PK, Sharma A, Khullar R, Mann V, Baijal M, Vas-histha A (2000) Laparoscopic ventral hernia repair. J Laparos-endosc Adv Surg Tech A 10: 79–84

5. Franklin ME, Dorman JP, Glass JL, Balli JE, Gonzalez JJ (1998)Laparoscopic ventral and incisional hernia repair. Surg LaparoscEndosc 8: 294–299

6. Heniford BT, Park A, Ramshaw BJ, Voeller G (2000) Laparo-scopic ventral and incisional hernia repair in 407 patients. J AmColl Surg 190: 645–650

7. Heniford BT, Ramshaw BJ (2000) Laparoscopic ventral herniarepair: a report of 100 consecutive cases. Surg Endosc 14: 419–423

8. Hesselink VJ, Luijendijk RW, de Wilt JH, Heide R, Jeekel J(1993) An evaluation of risk factors in incisional hernia recur-rence. Surg Gynecol Obstet 176: 228–234

9. Holzman MD, Purut CM, Reintgen K, Eubanks S, Pappas TN(1997) Laparoscopic ventral and incisional hernioplasty. SurgEndosc 11: 32–35

10. Houck JP, Rypins EB, Sarfeh IJ, Juler GL, Shimoda KJ (1989)Repair of incisional hernia. Surg Gynecol Obstet 169: 397–399

11. Langer S, Christiansen J (1985) Long-term results after incisionalhernia repair. Acta Chir Scand 151: 217–219

12. Leber GE, Garb JL, Alexander AJ, Reed WP (1998) Long-termcomplications associated with prosthetic repair of incisional her-nias. Arch Surg 133: 378–382

13. LeBlanc KA, Booth WV (1993) Laparoscopic repair of incisionalabdominal hernias using expanded polytetrafluoroethylene: pre-liminary findings. Surg Laparosc Endosc 3: 39–41

14. LeBlanc KA, Booth WV, Whitaker JM, Bellanger DE (2001)Laparoscopic incisional and ventral herniorraphy: our initial 100patients. Hernia 5: 41–45

15. Mudge M, Hughes LE (1985) Incisional hernia: a 10 year pro-spective study of incidence and attitudes. Br J Surg 72: 70–71

16. Mueller CB (1974) Abdominal incisional hernia—the role ofwound infection [editorial]. Can J Surg 17: 195

17. Park A, Birch DW, Lovrics P (1998) Laparoscopic and open in-cisional hernia repair: a comparison study. Surgery 124: 816–822

18. Park A, Gagner M, Pomp A (1996) Laparoscopic repair of largeincisional hernias. Surg Laparosc Endosc 6: 123–128

19. Ramshaw BJ, Esartia P, Schwab EM, Mason EM, Wilson RA,Duncan TD, Miller J, Lucas GW, Promes J (1999) Comparison oflaparoscopic andopen ventral herniorrhaphy.AmSurg 65: 827–832

20. Saiz A, Willis IH (1994) Laparoscopic ventral hernia repair. JLaparoendosc Surg 4: 365–367

21. Stoppa RE (1989) The treatment of complicated groin and inci-sional hernias. World J Surg 13: 545–554

22. Temudom T, Siadati M, Sarr MG (1996) Repair of complex giantor recurrent ventral hernias by using tension-free intraparietalprosthetic mesh (Stoppa technique): lessons learned from ourinitial experience (fifty patients). Surgery 120: 738–744

23. Toy FK, Bailey RW, Carey S, Chappuis CW, Gagner M,Josephs LG, Mangiante EC, Park AE, Pomp A, Smoot, UddoJF Jr, Voeller GR (1998) Prospective, multicenter study of lap-aroscopic ventral hernioplasty: preliminary results. Surg Endosc12: 955–959

24. van der Linden FT, van Vroonhoven TJ (1988) Long-term resultsafter surgical correction of incisional hernia. Neth J Surg 40: 127–129

25. vom Smitten K, Heikel HV, Sundell B (1982) Repair of incisionalhernias by F. Langenskiold’s operation. Acta Chir Scand 148:257–261

26. White TJ, Santos MC, Thompson JS (1998) Factors affectingwound complications in repair of ventral hernias. Am Surg 64:276–280

128