International Journal of Surgery

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1 International Journal of Surgery 8 (2010) 479e483 Contents lists available at ScienceDirect International Journal of Surgery journal homepage: Laparoscopic and open incisional hernia repair using polypropylene mesh - A comparative single centre study Syed Javid Farooq Qadri *, Muneer Khan, Shadab Nabi Wani, Syed Sajad Nazir, Ajaz Rather Department of Surgery, Govt Medical College Srinagar, J&K, India article info abstract Article history: Received 2 June 2010 Accepted 15 June 2010 Available online 3 July 2010 Keywords: Incisional hernia Laparoscopic repair Open repair Polypropylene mesh Wound infections Hernia recurrence Introduction: Repair of incisional hernias continues to be a challenging surgical procedure for general surgeons. Currently open mesh repair and laparoscopic repair are the two main options available for general surgeon for managing this complication. Laparoscopic repair though offers all the advantages of minimal access surgery but is a costly procedure especially due to the use of costly composite mesh. The present study is aimed to compare the open and laparoscopic repair of incisional hernia and at the same time evaluate the safety and feasibility of using comparatively cheaper polypropylene mesh. Methods: Between December 2005 and December patients underwent incisional hernia repair, 40 open repairs and 40 laparoscopic repair. The results of the two procedures were compared with a mean follow up of 26 months for open repair and 28 months for laparoscopic repair. Results: Obstetrical or gynecological procedure was the most common index surgery leading to incisional hernia and lower midline incision was the most common site of hernia. The mean defect size in open repair group was 55.2 cm 2 and 62.2 cm 2 in laparoscopic repair group. Polypropylene mesh was used in all cases. We had 1(2.5%) major complication of enterotomy and 1(2.5%) conversion in laparoscopic repair group. Postoperative complications were most commonly seen in open repair group 10(25%) and 2(5%) in laparoscopic repair group. Mean hospital stay in open repair group is 4.33 days and 1.53 days in laparoscopic repair group. We had 1(2.5%) recurrence in both groups. Conclusion: Laparoscopic repair of incisional hernia is a much better procedure for curing incisional hernia as compared to open mesh repair and additionally intraperitoneal use of polypropylene mesh was not associated with any significant complication. Ó 2010 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. 1. Introduction Incisional hernia represents an important element of morbidity after abdominal surgery. 3e20% of patients undergoing a laparotomy will develop a fascial defect in their abdominal scar. 1 Repair of incisional hernia is recommended to avoid complications such as incarceration and strangulation of intestines and improve severe disability due to loss of abdominal wall domain. Lasting surgical repair of these hernias continues to be elusive. 18e41% of ventral hernias recur after initial repair and once repaired, the incidence of a second recurrence can exceed 50 percent. 2 An effective ventral hernia repair should be achieved, with the goals of minimal perioperative morbidity and low recurrence rate. A variety of surgical techniques have been described in attempts to meet these goals. The use of prosthetic mesh has resulted in * Corresponding author. Tel.: þ / address: drjavid11@gmail.com (S.J.F. Qadri). a lower recurrence rate when compared with a primary repair. 3 The disadvantage of herniorraphy involving mesh is the need for an extensive surgical dissection and an increased rate of incision site infection. Patients undergoing open repair, usually spend several days in the hospital postoperatively, frequently require abdominal drains, and often need a long recovery period. 4 With the advent of laparoscopy in minimizing the disadvantages of open surgery the repair of incisional hernia is no exception. The laparoscopic approach to incisional hernias can minimize the disadvantages of open herniorraphy without compromising the ability to implement a tension-free, mesh repair. Patients undergoing laparoscopic ventral hernia repairs generally have shorter postoperative stays, require less analgesics, and return to their normal activity level quickly. The rate of recurrence is low. 5 The main limiting factor of laparoscopic procedure in developing countries like India is the cost which is mainly due to the use of costly composite mesh and disposable tacker. The present study is aimed to compare the laparoscopic and open mesh repair of incisional hernias and additionally evaluate the safety and /$ e see front matter Ó 2010 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. doi: /j.ijsu

2 480 S.J.F. Qadri et al. / International Journal of Surgery 8 (2010) 479e483 feasibility of using low price polypropylene mesh in the management of incisional hernias. 2. Material and methods This study was conducted in the Surgical Discipline of the Govt. Medical College Srinagar, between December 2005 and December patients underwent incisional hernia repair during this period, open (n-40) and laparoscopic repair (n-40). The procedures were done as elective surgeries, including only patients with uncomplicated hernias. The patients were initially evaluated in the out patient department (OPD) and then admitted for surgery. Each patient and his/her attendants were fully explained about the nature of both laparoscopic and open repairs in the language which they understood, and written consent was taken from the patient before surgery. Preoperative prophylactic antibiotics (Inj. Cefazolin 1 gm IV at the time of intubation) were given in all cases. Good skin hygiene was maintained. Meticulous part preparation with povidine iodine 10% was done in all cases to ensure asepsis. 3. Operative technique 3.1. Open repair All cases were done under general anesthesia. With appropriate skin incision subcutaneous flaps were raised for 3e4 cm around the margins of the defect. After identifying the sac it was carefully separated and reduced. The margins of the sheath were defined for about 3e4 cm from the edge of the defect. Depending on the hernia characteristics polypropylene mesh of appropriate size was placed in an overlay fashion (Fig. 1). Transfascial 2-0 polypropylene suture were used to fix the mesh. Skin margins were freshened and closed. Subcutaneous suction drains were placed in all patients Laparoscopic repair All cases were done under general anesthesia and after safe pneumoperitoneum using closed technique 10 mm laparoscopic port for 30 telescope was introduced away from the margin of the defect. Two additional 5 mm ports were placed as deemed appropriate. Omental and bowel adhesions were dissected. The defect (Fig. 2) was identified and additional defects carefully looked for. A polypropylene mesh (Fig. 3) of appropriate size was used to overlap all the defects, on the peritoneal surface, with a margin of at least 3e4 cm. Mesh fixation was done with transfascial polypropylene 1-0 sutures (Fig. 4) and with 5 mm tacks (Protack 5 mm, Autosuture). The tacks were placed at all four corners of the mesh and then at 2 cm distance along the peripheral margin. At the end of procedure pneumoperitonium was decompressed and ports closed. A ball of gauze was placed over the region of hernia and pressure dressing applied and maintained for about 15 days. Foley s catheter was removed on table at the end of procedure Postoperative care For the immediate postoperative pain relief injectable diclofenac sodium 50 mg intramuscular was used. Later oral diclofenac 50 mg tab was used. Patients were made ambulatory on the next day in case of open repair and on the same day of operation, at evening, in case of laparoscopic repair. Orals were usually started on the 1st postoperative day in laparoscopic repair group and on 1e3 day in open repair group. After discharge from hospital patients were called for follow up at 1 week, 4 weeks, 12 weeks, and 6 monthly thereafter. 4. Results Fig. 2. This study included patients only having incisional hernias no case of primary ventral hernia was included. The overall results of our study are shown in Table 1. Fig. 1. Fig. 3.

3 S.J.F. Qadri et al. / International Journal of Surgery 8 (2010) 479e Table 2 Location of Hernia defect and index surgery. Location Open repair group Laparoscopic repair group Upper midline (Upper gastrointestinal 2(5%) 1(2.5%) surgery) Lower midline (Gynecological and 22(55%) 24(60%) Obstetrical Surgery) Right paramedian (Exploratory 10(25%) 9(22.5%) laparotomy for acute abdomen) Right subcostal (Open cholecystectomy) 4(10%) 4(10%) Right upper quadrant, transverse e 1(2.5%) (Transverse loop colostomy closure) Right iliac fossa, oblique (Open 2(5%) 1(2.5%) appendectomy) Total The majority of hernias were located in lower abdomen and gynecological and obstetrical surgeries were most common index surgeries (Table 2) We had 10(25%) complications in postoperative period in open group and 2(2.5%) in laparoscopic group, all were wound related (Table 3). We had recurrence in 1(2.5%) patients at mean follow up of 26(14e48) months in open repair group and in 1(2.5%) patient at mean follow up of 28(5e40) months in laparoscopic repair group. 5. Discussion Fig. 4. Incisional hernia is one of the most common long term complication of abdominal incisions, with an overall incidence of 3e20%. 1 Before the introduction of mesh prosthesis for repair of incisional hernia only open suture repairs were used for its cure but with an unacceptable rate of recurrence of more than 50%. 2 With the introduction of mesh prosthesis the rate of recurrence has been brought down but surgeons world wide had to face wound related Table 1 Surgical results. Variable Open repair group Laparoscopic repair group Age, years 35.5(18e58) 33.6(23e62) Male:female ratio 1:3 1:2.34 BMI 28.5(22e33) 29.1(21e37) Most common index Obs or Gyne Surgery, Obs or Gyne Surgery, 57.5% operation 52.5% Most common site of Lower midline, 55% Lower midline, 60% hernia Defect size, cm (16e120) 62.2(20e135) No of defects 1.2(1e3) 1.4(1e5) Type of mesh Polypropylene Polypropylene Most common content of Omentum, 25(62.5%) Omentum, 28(70%) hernia Intraoperative e 1(2.5%) complication Conversion to open n/a 1(2.5%) Drain 40(100%) 1(2.5%) Operative time, minutes 90.3(46e120) 75.1(55e170) Analgesic, Diclofenac mg 150(50e450) 100(50e350) Postoperative 10(25%) 2(5%) complication Postoperative hospital 4.33(2e57) 1.53(1e6) stay, days Follow up, months 26(14e48) 28(5e40) Recurrence 1(2.5%) 1(2.5%) complications thus increasing the morbidity of the procedure. Laparoscopic incisional hernia repair has been steadily accepted by surgeons as it eliminates the main complication of open mesh repair ie wound related complications and at the same time even further decreases the risk of recurrence, 16.5% open mesh repair v/s 4.0 for laparoscopic incisional hernia repair. 3 In the present study which consists of 80 patients (40 patients in open repair group and 40 patients in the laparoscopic repair group) the overwhelming majority of the patients were females in their reproductive age group. 44(55%) patients were in the age group of 31e40 years, 59(73.76%) were females with the male female ratio of 1:2.8 and 46(57.5%) of the hernias were located in the lower abdomen. This reflects the caesarean section and other gynecological operations as the prime etiology of incisional hernias in the Indian population, which is in contrast to the published English literature where in the majority of hernia repairs are undertaken for hernias following procedures like aortic surgery, gastric surgery, and colonic surgery. 6,7 Obesity is an important factor in the causation of incisional hernias and also complicates the treatment of these hernias. In our study 22(27.5%) patients were obese, 12 in the laparoscopic group and 10 in the open hernia repair group. These patients poorly followed the preoperative advice of weight reduction and muscle toning exercises. Laparoscopic repair is especially suited for these patients as they are more prone for developing wound related complications. With respect to operative time in the published literature it takes longer to perform laparoscopic repair of incisional hernias. 8e10 In our study mean operative time was shorter for laparoscopic repair group (laparoscopic repair 75.1 min and in open repair group 90.3 min). This may be explained on the basis that no abdominal wall dissection is needed in laparoscopic group and our experience, beyond learning curve, in performing this procedure. In laparoscopic repair blood loss was consistently significantly less as compared to open repair group and this is an important consideration as most of our female patients are usually anemic. With respect to intraoperative complications there was no complication in open repair group but there was one major complication of inadvertent enterotomy (ileal perforation) in Table 3 Postoperative complications. Variable Open repair group Superficial wound 4 2 infection Deep wound infection 2 e Mesh infection 1 e Flap necrosis 1 e Seroma 2 e Total 10(25%) 2(5%) Laparoscopic repair group

4 482 S.J.F. Qadri et al. / International Journal of Surgery 8 (2010) 479e483 laparoscopic repair group which was managed by intracorporial suturing (Fig. 5) no conversion was done and mesh was also placed. Some studies have reported that there is no risk of mesh infection with laparoscopic repair of small bowel perforation and simultaneous LIHR. 11,12 A safe option if laparotomy has been undertaken because of the bowel injury, is to perform simply a suture-repair of the hernia and accept the higher risk of hernia recurrence. Due to the amount of tissue dissection needed in open incisional hernia repair group wound related infectious complications are higher. Moreover the infection during the previous surgery puts them at a higher risk probably due to some bacteria lying dormant as shown by Davis and Houck. 13,14 In our study postoperative complications are significantly higher in open repair group 25% as compared to laparoscopic group 5%. There were 7(17.5%) wound related infectious complications in the open group compared to 2 (5%) in the laparoscopic group. Most of the wound related infectious complications were superficial and responded to local wound toilet and antibiotics. Control of mesh infection can be problematic though it has been documented that infection of polypropylene mesh can be controlled without removal of mesh where as in case of eptfe mesh removal is usually required. 15 Unfortunately one patient in open mesh repair developed severe prolonged mesh infection which responded poorly to antibiotics and local wound toilet techniques and was eventually managed by removal of mesh and this patient later developed hernia recurrence. Seroma formation, one of the complications of incisional hernia repair and occurs both in open repair and laparoscopic repair and varies from 1 to 14%. 11,12,16e24 There was no seroma formation in laparoscopic repair in our study. There were 2 (5%) seroma formation in open repair group which was managed by percutaneous aspiration. The overall seroma formation rate in our study is 2.5% which is quite low and is in conformity to the published reports. 25e27 One patient in open repair group developed flap necrosis which was manged by debridement, dressings and antibiotics. The literature on wound related complications of open mesh repair has the most compelling argument in favor of laparoscopic repair. For open mesh repair the wound related complications range from 3.5% to 18% 3,25,26,28e36 with an average of 8.1% where as for laparoscopic repair it is overall 2%. 11,12,16e24 De-Maria 37 and Raftopoulos 38 in their series found that patients had less pain following laparoscopic repair. In our study we found that postoperative pain was definitely less in laparoscopic group as compared to open repair group (mean VAS e 3.6/4.0; mean Diclofenac sodium used e 100/150). Most of our patients in laparoscopic group were subjectively more comfortable in the postoperative period and were ambulant on 1st postoperative day. The mean hospital stay was significantly shorter in laparoscopic incisional hernia repair group(1.53days) as compared to open repair group(4.33days). In the numerous series of open and laparoscopic incisional hernia repair the recurrence rate is 4% for the laparoscopic approach and 16.5% 3 for the open technique. At a mean follow up of 28(12e40)months we had 1(2.5%) recurrence in the laparoscopic repair group. The low recurrence in our series may be explained by the total adhesionolysis which we did to expose all Swiss Cheese hernias in all cases and in no case mesh overlap was less than 3 cm. In addition to it in no case mesh was fixed with tacks only. At a mean follow up of 26(14e48) months in open repair group we had one recurrence which developed in the patient in whom mesh was removed for resistant mesh infection. The recurrence rate in our study, 2.5% in laparoscopic group and 2.5% in open group, is well below the published literature, 4% in laparoscopic repair and 16% in open repair. 12,19 Cost factor needs to be addressed with respect to laparoscopic incisional hernia repair. The main contributor to the cost of laparoscopic repair is the mesh (composite mesh) and the disposable tacker which is used to fix to mesh in place. The use of tacker can be omitted by using intracorporeal suturing to fix the mesh but this markedly increases technical difficulty of the procedure and the operative time. Additionally the results of our study does not abandon one in considering to use polypropylene mesh for laparoscopic incisional hernia repair. In our study in laparoscopic incisional hernia repair group, during a mean follow up of 28(12e40) months, we didn t faced any complication like adhesion obstruction and/or gut erosion or readmission for any symptom arising due to intraperitoneal use of polypropylene mesh. Vrijland WW 39 in his study has concluded that there is low risk of intestinal complications for intraperitoneal use of polypropylene mesh. 6. Conclusion Thus with lower postoperative morbidity, reduced operative time, early oral feeds and ambulation, reduced hospital stay and advantages in terms of blood loss, avoidance of drains, better cosmesis, reduced recurrence and ability to do the procedure in obese patients and multiply scarred abdomen, the laparoscopic repair has gained wide acceptance and should be considered the standard of care for the treatment of incisional hernias. At present use of substantially-expensive composite mesh is the current standard of care but one can consider to use low price simple polypropylene mesh in selected circumstances Conflict of interest statement None to declare Funding None Ethical approval None declared. References Fig Read RC, Yoder G. Recent trends in the management of incisional herniation. Arch Surg 1989;124(4):485e8. 2. Hesselink VJ, Luijendijk RW, de Wilt JH, et al. An evaluation of risk factors in incisional hernia recurrence. Surg Gynecol Obstet 1993;176(3):228e Temusom T, Siadati M, Sarr MG. Repair of complex giant or recurrent incisional hernias by using tension-free intraparietal prosthetic mesh (Stoppa technique):

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