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Laparoscopy For Hernia Repair Of Mixed Benefit

Mon, 03/25/2013 - 12:43pm

Laparoscopic repair of incisional hernia offered some advantages compared with open surgical repair, but failed to reduce postoperative pain or improve other outcome measures, according to a randomized trial.

At the 4-week follow-up, 25% of the laparoscopic group and 24% of the open group reported persistent pain requiring prolonged use of analgesics, wrote Hasan Eker, MD, of Erasmus Medical Center in Rotterdam, the Netherlands, and colleagues in the March issue of JAMA Surgery.

The minimally invasive approach was associated with a modest but statistically significant reduction in blood loss (P=0.05) and a substantially reduced need for a wound drain (P<0.001), they noted.

However, the operative time increased by a third with laparoscopic procedures, and perioperative complications occurred four times more often than with open surgery, the authors said.

"Short-term benefits of laparoscopic incisional repair described in previous studies -- for example, perioperative complications, operative time, and length of hospital stay -- could not be confirmed," Eker's group pointed out.

Incisional hernia complicates as many as 30% of laparotomies, leading to repair procedures necessitated by morbidity and patient dissatisfaction. Despite improvements in operative technique and prosthetic materials in hernia repair, reported rates of recurrence range as high as 63%, according to the authors.

Adoption of laparoscopic surgery has expanded to include incisional hernia repair, and recent studies have suggested superior short-term results with minimally invasive versus open surgery for incisional hernia, with respect to blood loss, perioperative complications, and length of stay, they said. However, few randomized trials have compared laparoscopic and open surgical repair of incisional hernia.

Unresolved issues related to the comparative efficacy of the surgical approaches prompted the authors to conduct a randomized clinical trial between 1999 and 2006.

Only surgeons experienced in open ventral incisional hernia repair participated in the trial. They enrolled and randomized adults who had incisional hernias 3 cm to 15 cm in diameter, located at the ventral abdominal wall at least 5 cm from the costae and inguinal area.

Participating surgeons followed standardized procedures for laparoscopic and open surgical repair. The primary outcome was postoperative pain, as assessed by a visual analog scale (VAS) before surgery and at 3 days, 1 week, and 4 weeks after surgery. Secondary outcomes included analgesic use, peri- and postoperative complications, operative time, postoperative nausea, length of stay, and recurrence.

Patients were followed for as long as 5 years. The authors reported data for 206 patients followed for an average of 35 months.

Pain scores did not differ significantly between patients at any assessment (P=0.54). VAS scores for postoperative nausea also did not differ between the groups.

Operative time averaged 100 minutes in the laparoscopic group versus 76 minutes with open surgery (P<0.001). The authors suggested that extensive adhesiolysis in the midline of the abdominal wall may have been a "major factor" in the longer operative time for laparoscopy.

"Adhesiolysis was necessary for positioning the mesh but also for observing any other small hernia or 'Swiss-cheese' defects," they explained, adding that 100 minutes is not an unreasonable amount of time for this procedure.

Perioperative complication rates were 2% with open surgery and 10% with laparoscopic surgery (P=0.049).

Estimated blood loss averaged 10 mL in the laparoscopic and 50 mL in the open group, a clinical difference the authors characterized as negligible. In the open-surgery arm, 45% of patients required a wound drain compared with 3% in the laparoscopic group.

At a mean follow-up of 35 months, hernia recurrence rates were 14% with open surgery and 18% with laparoscopic surgery, a nonsignificant difference (P=0.30). Hernia size had a positive correlation with the risk of subsequent recurrence (P<0.001).

Finally, the median duration of hospital stay was about 3 days for both groups (P=0.50).

The authors called for studies with long-term results and data on cost-effectiveness to develop a more complete picture of how the two operative techniques compare.

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