Incisional hernia is a common complication after abdominal surgery. Optimal repair technique for incisional hernia is still conflicting. After the introduction of laparoscopic repair, comparison of laparoscopic and open repair has been questioned by the literature. Although laparoscopic repair promises less pain and faster return to daily activities, these advantages are blamed to be impaired by longer operation time and higher complications such as bowel injury 15
. One disadvantage of laparoscopic repair is the higher costs. However Earle et al. found that laparoscopic repair does not increase cost to the health care system in overall looking 17
. Recently, laparoscopic and open hernia repair was compared by meta-analysis 16-19
. Al Chalabi et al. in 2015 published a meta-analysis of 5 randomized controlled trials with a total of 611 patients and found laparoscopic repair to be associated with less wound infection (only wound infection rate (p<0.001) was statistically different), shorter hospital stay but longer operation time 16
. In a recent meta-analysis consisted of 751 patients, laparoscopic and open repair was found to have comparable results 19
In our study, mean operation time for laparoscopic repair was shorter than open repair group (103.89±40.57 versus 109.34±44 minutes). Some authors found operation time for laparoscopic repair to be longer 20 than open repair whereas others found it shorter 21. Our findings were longer than the literature average which may be due to the learning curve of our surgeons for laparoscopic repair and large hernias were found in the open group with an average hernia size of 187.37 cm2. But Tsuruta et al. 22 found longer operation time than our findings around 143.1 minutes in laparoscopic group and 152.7 minutes in open group.
Laparoscopic surgery has the advantage of shorter hospital stay and early return to work is the general acceptance. In our study, laparoscopic repair group had shorter length of hospital stay than open group which was statistically different (p<0.05). Olmi et al. 21 also found laparoscopic repair with shorter hospital stay which is statistically different (p<0.005). However Asencio et al. 20 found laparoscopic group to have longer hospital stay which is similar with the open group.
The overall complication rate in our study for laparoscopic and open repair groups were 2.1% and 23.9%, respectively. These findings are similar with the percentages reported in literature 23. The most common complication was seroma with a percentage of 10.3%. Stipa et al. 23 also found seroma to be the most common complication for both groups and explained that in laparoscopic approach the hernia sac is not dissected leading empty space between the mesh and abdominal wall further leading to seroma. For this reason, we applied compressive dressings to the area where the hernia sac exists. We believe that this compressive dressings cause hernia sac to adhere on the mesh and prevent seroma formation. Wide dissection in open repair also causes seroma but the use of drains prevent it to a point. When the drains occlude or a potential space exists, seroma formation and infection becomes inevitable.
In a recent meta-analysis involving 11 studies and 1003 patients, recurrence rate of laparoscopic and open incisional hernia repair were found to be 7% and 5.8%, respectively 24. Our recurrence rate was higher than literature findings. We believe that this is due to our patient population consisting of large incisional hernias and the study was conducted at the beginning of learning curve of our surgeons for laparoscopic repair. Thus most of recurrence (77.7%) in the laparoscopic group occurred in the first 6 months after we start performing laparoscopic repair in our clinic. Higher average hernia area may also increase the recurrence rate. Froylich et al. 25 evaluated long-term results of laparoscopic and open ventral hernia repair in obese patients and found similar results to our findings with recurrence rates of 20% and 27.1% in laparoscopic and open groups, respectively. The most unfortunate limitation of our study is the lack of body mass index data of our patients which may also affect the recurrence rate.
One of the advantages of laparoscopic incisional hernia repair is less pain which was investigated in the literature with several studies 20,23,26,27. Although Asencio et al. states laparoscopic approach to be safe, feasible, and effective, laparoscopic IH repair does not seem to be a better procedure than the open anterior technique in terms of pain or quality of life 20. Stipa et al. found no statistical difference between laparoscopic and open groups however difference in visual analogue scale (VAS) for postoperative pain results were more remarkable for patients with defects larger than 10 cm 23. Wolter et al. 26 found pain score of the patients to be statistically significant (p=0.001) in the follow-up period but no difference (p=0.82) in the postoperative period. In a non-randomized prospective study including 100 patients, similar pain scores in both groups were found 24 h and 48 h postoperatively but significantly less pain at 72 h in the laparoscopic group 27. In our study, pain score of the patients, however not statistically different, were higher in laparoscopic than open repair which was the opposite of literature findings. Our findings of pain score in the follow-up period was similar to only one study 26. Although all our findings represent the follow-up period results between 3rd and 12th months, other studies investigated the early postoperative pain score of the patients. This makes some comparative conflict which is one of the limitations of our study. But this is a result of retrospective design of this study. Another limitation is that only 73.17 % of the patients were evaluated via telephone survey. Pain in laparoscopic repair can be as a result of intraperitoneal fixation of mesh with spiral tacks to the areas of course of the nerves. Mesh fixation techniques have been also investigated in a study including 199 patients but none of three techniques was found to have a pain-reduction advantage over the others 28.
Better satisfaction rates in laparoscopic group were found in a retrospective study including 123 patients 26. Although laparoscopic surgery is expected to have better satisfaction rates due to less scar formation, overall patient satisfaction was better in open group (90.6% vs. 94.4%) in our study. This similarity in both groups can be explained by the higher expectations of patients from laparoscopic surgery. Patients do not care about new or old skin incision while there is already scar in incisional hernia patients. Till there is no superiority of laparoscopic repair regarding pain scores, higher expectancy of laparoscopic repair gives no additional advantage for patient satisfaction rates.