Laparoscopic versus open surgical techniques for ventral or incisional hernia repair

 

Abstract

Background

There are many different techniques currently in use for ventral and incisional hernia repair. Laparoscopic techniques have become more common in recent years, although the evidence is sparse.

Objectives

We compared laparoscopic with open repair in patients with (primary) ventral or incisional hernia.

Search methods

We searched the following electronic databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, metaRegister of Controlled Trials. The last searches were conducted in July 2010. In addition, congress abstracts were searched by hand.

Selection criteria

We selected randomised controlled studies (RCTs), which compared the two techniques in patients with ventral or incisional hernia. Studies were included irrespective of language, publication status, or sample size. We did not include quasi-randomised trials.

Data collection and analysis

Two authors assessed trial quality and extracted data independently. Meta-analytic results are expressed as relative risks (RR) or weighted mean difference (WMD).

Main results

We included 10 RCTs with a total number of 880 patients suffering primarily from primary ventral or incisional hernia. No trials were identified on umbilical or parastomal hernia. The recurrence rate was not different between laparoscopic and open surgery (RR 1.22; 95% CI 0.62 to 2.38; I² = 0%), but patients were followed up for less than two years in half of the trials. Results on operative time were too heterogeneous to be pooled. The risk of intraoperative enterotomy was slightly higher in laparoscopic hernia repair (Peto OR 2.33; 95% CI 0.53 to 10.35), but this result stems from only 7 cases with bowel lesion (5 vs. 2). The most clear and consistent result was that laparoscopic surgery reduced the risk of wound infection (RR = 0.26; 95% CI 0.15 to 0.46; I²= 0%). Laparoscopic surgery shortened hospital stay significantly in 6 out of 9 trials, but again data were heterogeneous. Based on a small number of trials, it was not possible to detect any difference in pain intensity, both in the short- and long-term evaluation. Laparoscopic repair apparently led to much higher in-hospital costs.

Authors' conclusions

The short-term results of laparoscopic repair in ventral hernia are promising. In spite of the risks of adhesiolysis, the technique is safe. Nevertheless, long-term follow-up is needed in order to elucidate whether laparoscopic repair of ventral/incisional hernia is efficacious.

 

Plain language summary

The repair of a defect in the anterior abdominal wall with minimal invasive (laparoscopic) or conventionally (open) technique

A defect in the abdominal wall through which organs can protrude is called hernia. Hernias may occur spontaneously (primary hernia) or at the site of a previous surgical incision (incisional hernia). A hernia is usually recognized as a bulge or tear under the abdominal skin. Occasionally it causes no discomfort for the patient but it can hurt while lifting heavy objects, coughing, or having bowel movements. Also after prolonged standing or sitting it can cause heavy discomfort.

For the repair of these hernias many different surgical techniques are in use. The conventional technique is the open technique, where with either a suture or a mesh prosthesis the defect of the abdominal wall will be closed. A mesh prosthesis is a synthetic material that reinforces the tissue or bridges the defect. On the other hand the laparoscopic hernia repair is a technique to repair the defect in the abdominal wall also with a mesh but using small incisions and a laparoscope. In this case, the mesh is always placed in the abdominal cavity. This review analysed randomised controlled trials, comparing the conventional, open technique with the laparoscopic technique.

Based on the results of nearly 1000 adult patients, the laparoscopic technique appears to be effective at least in the short-term evaluation. As laparoscopic surgery requires smaller incisions than open surgery, wound infection was fourfold less likely to occur in patients with laparoscopic repair. However, there is a rare but theoretically higher risk that intraabdominal organs are more likely to be injured during a laparoscopic procedure. Length of hospital stay after laparoscopic hernia repair was found to be shorter in the majority of trials. As most studies had evaluated only a follow-up of 1 or 2 years, data on the long-term effectiveness are still lacking. Most importantly, the risks of the hernia coming back (i.e. recurrence) are relatively unknown.

Therefore, the authors of the review believe that further studies are necessary, before laparoscopic repair can be considered a standard procedure for primary ventral or incisional hernia repair. Short-term results, however, are promising.

 

Resumen

Antecedentes

Técnicas de cirugía laparoscópica versus técnicas abiertas para la reparación de la hernia ventral o incisional

Hay muchas técnicas diferentes actualmente en uso para la reparación de la hernia ventral e incisional. Las técnicas laparoscópicas se han tornado más frecuentes en los años recientes, aunque las pruebas son escasas.

Objetivos

Comparar la reparación laparoscópica con la reparación abierta en pacientes con hernia ventral (primaria) o incisional.

Estrategia de búsqueda

Se hicieron búsquedas en las siguientes bases de datos electrónicas: MEDLINE, EMBASE, Registro Cochrane Central de Ensayos Controlados (Cochrane Central Register of Controlled Trials, CENTRAL), metaRegister of Controlled Trials. Las últimas búsquedas se realizaron en julio 2010. Además, se realizó una búsqueda manual en los resúmenes de congresos.

Criterios de selección

Se seleccionaron los estudios controlados con asignación aleatoria (ECAs), que compararon las dos técnicas en pacientes con hernia ventral o incisional. Se incluyeron los estudios, independientemente del idioma, el estado de publicación o el tamaño de muestra. No se incluyeron ensayos con asignación cuasialeatoria.

Obtención y análisis de los datos

Dos autores evaluaron la calidad de los ensayos y extrajeron los datos de forma independiente. Los resultados metanalíticos se expresan como riesgos relativos (RR) o diferencia de medias ponderada (DMP).

Resultados principales

Se incluyeron diez ECAs con un número total de 880 pacientes que sufrían principalmente de hernia ventral primaria o incisional. No se identificaron ensayos sobre hernia umbilical o paraestomal. La tasa de recurrencia no difirió entre la cirugía laparoscópica y la cirugía abierta (RR 1,22, IC del 95%: 0,62 a 2,38; I² = 0%), pero los pacientes tuvieron un seguimiento inferior a dos años en la mitad de los ensayos. Los resultados del tiempo operatorio fueron demasiado heterogéneos como para ser agrupados. El riesgo de enterotomía intraoperatoria fue algo mayor en la reparación de hernia laparoscópica (OR de Peto 2,33; IC del 95%: 0,53 a 10,35), pero este resultado proviene de sólo siete casos con lesión intestinal (5 versus 2). El resultado más claro y consistente fue que la cirugía laparoscópica redujo el riesgo de infección de la herida (RR 0,26, IC del 95%: 0,15 a 0,46; I²= 0%). La cirugía laparoscópica acortó de forma significativa la estancia hospitalaria en seis de nueve ensayos, pero nuevamente los datos fueron heterogéneos. Debido al escaso número de ensayos, no fue posible detectar diferencias en la intensidad del dolor, tanto en la evaluación a corto plazo como a largo plazo. A parecer, la reparación laparoscópica dio lugar a costes hospitalarios mucho mayores.

Conclusiones de los autores

Los resultados a corto plazo de la reparación laparoscópica en la hernia ventral son alentadores. A pesar de los riesgos de adherenciotomía, la técnica es segura. No obstante, se necesita seguimiento a largo plazo para dilucidar si la reparación laparoscópica de la hernia ventral/incisional es eficaz.

Traducción

Traducción realizada por el Centro Cochrane Iberoamericano