Laparoscopic trumps open repair of incisional hernia, leads to fewer infections

Elective laparoscopic repair of incisional hernia (IH) results in outcomes comparable to those of open repair but appears to have the advantage of lower postoperative wound infection rates and blood loss, suggests a Singapore study.

“Recent evidence has suggested that laparoscopic repair is a promising alternative to open repair,” the researchers said. “However, these studies are mostly on Caucasian populations.” [JAMA Surg 2013;148:259-263; Ann R Coll Surg Engl 2009;91:631-636]

The current retrospective study, conducted in an acute general hospital in Singapore between 2010 and 2015, sought to compare the postoperative outcomes between laparoscopic and open elective IH repair in an Asian population.

Patients with an IH repair in an elective setting, IHs with diameter of 3‒15 cm, and location at the ventral abdominal wall were eligible for analysis, while those who underwent emergency repair, had recurrent hernias, or had a loss of abdominal wall domain (ie, hernia sac containing >30 percent of abdominal contents or any solid organs) were excluded.

The researchers then compared postoperative outcomes within a year such as recurrence, pain, infection, haematoma, and seroma formation between the two groups.

Overall, 174 patients met the inclusion criteria, majority of whom were older Chinese women who were overweight. Open and laparoscopic IH repairs were performed in 49.4 percent and 50.6 percent of participants, respectively. The mean operation time was 116 minutes for open repair and 139 minutes for laparoscopic repair (p=0.079). [Singapore Med J 2022;doi:10.11622/smedj.2022005]

Within a year following the procedure, significantly more postoperative wound infections occurred in the open repair group compared to the laparoscopic group (15.1 percent vs 1.1 percent; p=0.0007). On the other hand, postoperative pain, recurrence, and haematoma/seroma formation were comparable.

“Infections in prosthetic mesh repairs can be catastrophic, requiring explantation or mesh salvage and long-term antibiotics,” the researchers said. “Explantation of mesh itself leaves a weakness that predisposes the patient to recurrence of hernia, and long-term antibiotics are not without their side effects.” [Surg Infect (Larchmt) 2011;12:205-210]

In the present study, three patients with deep infections were readmitted for explantation of mesh, drainage of intra-abdominal collections and antibiotics. In the laparoscopic group, only one patient had superficial site infection, which resolved with oral antibiotics.

The lower postoperative infection rates could be explained by less tissue dissection and reduced contact between the prosthetic mesh and the patient’s skin flora during laparoscopy, since it is introduced intraperitoneally relative to the open approach. [JSLS 2008;12:117-125]

“Given the associations with lower intraoperative blood loss, lower postoperative infection rates, and comparable recurrence rates with the literature, the authors are convinced that laparoscopic IH repair is a promising alternative to open repair in an elective setting,” the researchers said.

The current study, however, was limited by its inherent retrospective nature, possible selection bias, lack of standardization of surgical techniques, and short follow-up duration for postoperative outcomes. Additionally, the sample size was small and derived from a single institute.

“Future areas of development include embarking on a multicentre study to compare postoperative outcomes over a longer duration and exploring the role of laparoscopic surgery in emergency surgical repair of IHs,” the researchers said.