incisional hernia repair represents a frequent problem for the general surgeon and is often a source of complications and prolonged hospital stay .
it develops in 11% of patients after surgery and in 23% of patients who develop a postoperative wound infection .
treatment of incisional hernias can be done by an anterior approach with direct suture or mesh or by a laparoscopic transperitoneal approach using mesh . which is the best treatment is still being debated , and recent reviews confirm the controversies that exist . still lacking are randomized ,
controlled trials with long - term follow - up that confirm that laparoscopic repair of incisional hernias has a lower complication rate , a decreased hospital stay , and a recurrence rate similar to that of open repairs .
this study analyzed results of a single center experience in laparoscopic and open incisional hernia repairs .
the aim of the present study was the prospective evaluation of a case series of laparoscopic incisional hernia repairs , performed at the same institution with broad experience in laparoscopy , compared with a historical control group of open anterior incisional hernia repairs .
fifty patients underwent laparoscopic incisional and abdominal hernia repair between september 2001 and may 2003 .
these patients represent the entire number of incisional and abdominal hernias that came to our attention at a primary referral center .
no selection of patient characteristics or hernia types was done . in 7 patients , a primary abdominal hernia , principally umbilical ,
patient data were recorded prospectively and noted age , sex , american society of anaesthesiologists ( asa ) score , body mass index ( bmi ) , previous incisional hernia repairs , operative time , hernia diameter , use of drainage , length of stay , complication rate , follow - up , and recurrence .
follow - up consisted of an outpatient visit 1 month after the operation and a phone call as the last contact .
the historical control group consisted of 50 patients operated on between february 1998 and december 2001 .
they underwent an anterior incisional hernia mesh repair and represent the last patients operated on with this technique in our department .
patient preparation for the laparoscopic technique was accomplished with bowel washout ( selg esse , promefarm srl milan , italy ) and bowel gas reduction ( mylicon , warner lambert consumer healthcare , milan , italy ) .
patients were placed in the supine position , and the surgical equipment was positioned according to the site of the hernia .
pneumoperitoneum was established with a veress needle usually placed most distally to the previous surgical incision . a 3-trocar ( ethicon endosurgery
a security test with a water - filled syringe was performed before insertion of the first 5-mm to 12-mm trocar , as laterally as possible to the hernia .
a 30-degree scope was used because it provides a good view of the inner face of the anterior abdominal wall .
two additional trocars ( 5 mm to 12 mm and 5 mm , respectively ) were placed on the same side in a triangular fashion ( figure 1 ) .
adhesiolysis was performed with a 5-mm ultrasonic scalpel ( ultracision , ethicon endosurgery , new brunswick , nj , usa ) and scissors . in case of severe adhesions , we use the sole active blade of the dissector or cold scissors for complete exposure of the hernial ring .
the mesh ( parietex composite mesh , sofradim , france ) , composed of polyester fibers with a collagen coating ( figure 2 ) , was rolled and introduced via the 5-mm to 12-mm trocar .
the collage coating was positioned inside the roll to avoid damaging the collagen during cannula transit .
the mesh must overlap the defect at least 4 cm to 5 cm . a first ring of 5-mm spiral tacks ( pro - tack ; auto suture , us surgical corp , norwalk , ct , usa ) was positioned , at least 1 cm from the mesh border .
an inner one was positioned 1 cm to 2 cm from the hernial ring ( figure 3 ) .
no drainage was used . before abdominal decompression , bowel , omentum , and trocar site
patients were allowed to eat a soft diet on the first postoperative day and usually discharged between the second and fourth postoperative days .
quick , complete tissue growth is essential for an ideal mesh . to have both good tissue growth on 1 side and no adhesions on the other , a new generation of polyester mesh in which a hydrophilic absorbable film protects the bowel side has been designed ( parietex composite mesh , sofradim , france ) .
this mesh is made of a soft , adaptable 3-dimensional multifilament polyester fiber , the structure of which hastens cellular integration and vascularization of the mesh , avoiding formation of a tissue capsule and fluid loculation , thus reducing the risk of seroma .
the particular texture of this mesh confers unique elasticity in all directions , allowing adaptability to all anatomical situations and reducing the typical aggressiveness of conventional polypropylene meshes .
one side of the mesh is coated with a smooth , absorbable hydrophilic film made of collagen , glycerol , and glycolic polyethylene to reduce the risk of adhesions .
the open technique consists of a wide dissection of the subcutaneous fat , isolation of the ring , and creation , whenever possible , of a space beneath the rectal muscles .
the sac is not usually opened or resected . when needed , an absorbable mesh ( vicryl knitted mesh , ethicon endosurgery , new brunswick , nj , usa ) is used to separate the bowel from the mesh .
the mesh ( polypropylene , surgimesh , nrnberg , germany ) is usually positioned inlay , ie , under the rectal muscles .
the mesh is fixed with nonabsorbable separate stitches . a number of stitches varying from 6 to 12 is usually used to fix the mesh to the fascial and muscular layer of the lateral abdominal wall , according to the diameter of the defect and the integrity of the edges , in a tension - free manner .
patients are allowed a clear diet on the first postoperative day and a soft diet on the second one .
patients were placed in the supine position , and the surgical equipment was positioned according to the site of the hernia .
pneumoperitoneum was established with a veress needle usually placed most distally to the previous surgical incision . a 3-trocar ( ethicon endosurgery
a security test with a water - filled syringe was performed before insertion of the first 5-mm to 12-mm trocar , as laterally as possible to the hernia .
a 30-degree scope was used because it provides a good view of the inner face of the anterior abdominal wall .
two additional trocars ( 5 mm to 12 mm and 5 mm , respectively ) were placed on the same side in a triangular fashion ( figure 1 ) .
adhesiolysis was performed with a 5-mm ultrasonic scalpel ( ultracision , ethicon endosurgery , new brunswick , nj , usa ) and scissors . in case of severe adhesions , we use the sole active blade of the dissector or cold scissors for complete exposure of the hernial ring .
the mesh ( parietex composite mesh , sofradim , france ) , composed of polyester fibers with a collagen coating ( figure 2 ) , was rolled and introduced via the 5-mm to 12-mm trocar .
the collage coating was positioned inside the roll to avoid damaging the collagen during cannula transit .
the mesh must overlap the defect at least 4 cm to 5 cm . a first ring of 5-mm spiral tacks ( pro - tack ; auto suture , us surgical corp , norwalk , ct , usa ) was positioned , at least 1 cm from the mesh border .
an inner one was positioned 1 cm to 2 cm from the hernial ring ( figure 3 ) .
no drainage was used . before abdominal decompression , bowel , omentum , and trocar site
patients were allowed to eat a soft diet on the first postoperative day and usually discharged between the second and fourth postoperative days .
quick , complete tissue growth is essential for an ideal mesh . to have both good tissue growth on 1 side and no adhesions on the other , a new generation of polyester mesh in which a hydrophilic absorbable film protects the bowel side has been designed ( parietex composite mesh , sofradim , france ) .
this mesh is made of a soft , adaptable 3-dimensional multifilament polyester fiber , the structure of which hastens cellular integration and vascularization of the mesh , avoiding formation of a tissue capsule and fluid loculation , thus reducing the risk of seroma .
the particular texture of this mesh confers unique elasticity in all directions , allowing adaptability to all anatomical situations and reducing the typical aggressiveness of conventional polypropylene meshes .
one side of the mesh is coated with a smooth , absorbable hydrophilic film made of collagen , glycerol , and glycolic polyethylene to reduce the risk of adhesions .
the open technique consists of a wide dissection of the subcutaneous fat , isolation of the ring , and creation , whenever possible , of a space beneath the rectal muscles .
the sac is not usually opened or resected . when needed , an absorbable mesh ( vicryl knitted mesh , ethicon endosurgery , new brunswick , nj , usa ) is used to separate the bowel from the mesh .
the mesh ( polypropylene , surgimesh , nrnberg , germany ) is usually positioned inlay , ie , under the rectal muscles .
a number of stitches varying from 6 to 12 is usually used to fix the mesh to the fascial and muscular layer of the lateral abdominal wall , according to the diameter of the defect and the integrity of the edges , in a tension - free manner .
patients are allowed a clear diet on the first postoperative day and a soft diet on the second one .
between september 2001 and may 2003 , 50 laparoscopic incisional and abdominal hernia repairs were carried out in 30 patients in our department .
the control group consisted of the last 50 anterior incisional hernia repairs done in our department .
patient characteristics american society of anaesthesiologists ( asa ) scores ninety - eight percent of patients in the lg underwent their first attempt at hernia repair ( 1 patient was undergoing her third mesh repair ) , while 90% of patients in the og underwent their first repair .
one patient in the og had her fourth repair ( none with mesh ) , one patient a second repair ( after a suture repair ) , and the last underwent a second repair after an initial attempt with mesh repair .
the lg comprised 7 patients ( 14% ) who had a primary abdominal hernia ( 6 umbilical , 1 epigastric ) .
mean hernia diameter was 10.6 cm ( range , 4 to 23 ) in the lg and 10.5 cm ( range , 7 to 21 ) in the og .
no drainage was used in the lg while in the og it was used in 96% of cases . mean length of stay was 2.1 days ( range , 1 to 4 ) in the lg and 8.1 days ( range , 6 to 14 ) in the og . in 5 ( 10% ) lg patients
, we had to repair serosal tears in small bowel loops because injury had occurred during dissection ( 3 patients ) and for loops caught in previous fascial sutures ( 2 patients ) .
. in 1 patient , infection of the seroma occurred after 1 month , requiring removal of the mesh via laparoscopy and direct suture of the abdominal wall .
twenty - three were minor complications ( 7 wound infections with removal mesh in 1 patient ; 5 persistent serous secretions ; 8 patients with persistent neuralgia ; 3 small bowel occlusions ) ; and 2 were major complications ( 1 pulmonary embolism , requiring admittance to the intensive care unit and 1 postoperative hemorrhage , requiring reintervention ) .
median follow - up was 9.0 months in the lg ( range , 2 to 20 ) and 24.5 months ( range , 14 to 43 ) in the og ( table 4 ) .
hernia recurred in 1 patient ( 2% ) in the lg 1 month after surgery .
this recurrence developed in a patient with a large hernia ( 20 cm ) in which the mesh overlapped the defect by only 2 cm .
a second laparoscopic repair was performed by placing a second mesh ( 10x15 cm ) over the defect and obtaining a wide overlap of the hernia margins .
we calculated a direct cost of 1,900 euros ( mesh , ultrasonic dissector , disposable trocars , and tacks ) for each laparoscopic repair and 300 italian lira ( polypropylene mesh , no absorbable sutures , drainages , skin stapler ) for each open repair . in 3 og patients , vicryl knitted mesh , costing 200 euros , was needed to close the peritoneum , and in 100% of cases a polypropylene mesh was used .
we calculated indirect costs multiplying per day hospitalization costs for the mean length of stay for each group and added it to obtain the total cost for each group . for laparoscopic repair , with or without complications , we considered the corresponding drg ( disease related group ) , which gives a different reimbursement than the national health service ( nhs ) .
total costs are lower for laparoscopic repair if the shorter length of stay is considered .
analysis of hospital costs and disease related group ( drg ) reimbursement calculated by multiplying mean length of stay for cost of hospital day plus direct cost .
incisional hernias remain a large problem in general surgery . despite the introduction of meshes ,
about 13% of patients operated on for incisional hernia undergo one subsequent reoperative repair within 5 years .
mesh repair has proven to be superior to direct suture repair , but recurrence rates remain as high as 24% .
open incisional hernia repair has a high complication rate due to extensive lateral dissection and the need for drainage , which increases infection rates .
moreover , infection is one of the major risk factors in developing recurrent abdominal hernias .
laparoscopic incisional hernia repair is thought to be superior because it does not require an extensive dissection of subcutaneous tissue and postoperative drainage .
risk of wound infection should be lower , as should the overall complication rate . moreover ,
placement of mesh on the inner layer of the abdominal wall ( beneath the peritoneum ) is the more physiological method of repair and should allow for a lower recurrence rate .
since our group started with laparoscopic abdominal and incisional hernia repairs , we have used the same technique .
. the inner ring of tacks should be near the border of the defect , and the mesh must overlap the defect at least 4 cm to 5 cm to lower the risk of recurrence .
we feed patients a clear fluid on the first postoperative day and a soft diet on the second .
the characteristics of the patients were not different between the 2 groups , that is , the 2 groups can be considered comparable .
it should be remembered , on the other hand , that the lg comprised 7 ( 23.3% ) patients having a primary abdominal hernia ( 6 umbilical hernias , 1 epigastric hernia ) .
this fact did not have an impact on the diameter of the hernia , even if it could have some impact on the operating time , because it does not imply extensive adhesiolysis .
mean length of stay was dramatically shorter in lg ( 2.1 days ) , which is confirmed by many recent studies .
we did not assess postoperative pain or resumption of basic functions , such as oral food intake or bowel movements or return to work , but we can presume that length of stay is an indirect measure of them in favor of laparoscopy .
we did not experience problems with the mesh : no cases of intestinal adherence have been documented up to this time .
we did not have any cases of trocar - site bleeding . in 4 patients , laparoscopic repair of intestinal serosal tears
serosal tears were repaired with a running stitch of absorbable suture tied with an intracorporeal knot .
we did not use drains in the lg , as compared with drains placed in 96.7% of og . in the beginning
subsequently , we realized that seromas resolve without intervention in the majority of cases , and we now evacuate only persistent seromas ( more than 4 weeks or symptomatic ones ) . in 2 cases with an incisional hernia diameter of 4 cm to 5 cm , we performed the operation with mini - trocars ( two 3-mm trocars and one 5-mm or 12-mm one ) without problems . in both cases ,
the infection rate was 2% , which is comparable to infection rates in the most recent series , confirming that the decreased dissection of subcutaneous fat and the absence of drains favor wound healing .
it occurred in a patient with a large hernia in which the mesh overlapped the defect by only 2 cm .
other groups experienced higher recurrence rates , perhaps because of a high number of prior attempted hernia repairs .
this study demonstrates that laparoscopic incisional hernia repair has advantages over the traditional anterior approach , namely a shorter operative time , hospital stay , and a lower wound infection rate .
even cost , if we consider total cost , seems to favor laparoscopic repair . due to the shorter length of stay , laparoscopic repair compensates for the higher direct cost . on the other hand ,
the lack of randomization lowers the power of the statistical analysis , and the short follow - up , compared with follow - up for og could underestimate the problem of recurrences .
we believe that recurrence due to technical error should occur within the first year and during the first cases of the learning curve .
we need to further evaluate our patients to rule out a higher recurrence rate than that for og .
this study also confirms the excellent performance of laparoscopic composite mesh ( parietex composite mesh , sofradim , france ) in the treatment of incisional hernia repair .
laparoscopic incisional hernia repair seems to be superior to open mesh repair , because of the shorter operative time , a shorter hospital stay , and lower total cost .
the recurrence rate does not seem to be different , even if follow - up is too short to provide clear evidence of it .
we need further study , above all randomized controlled trials , to provide evidence of this conclusion .
 background : incisional hernia is a frequent complication of abdominal surgery . the object of this study was to confirm the safety , efficacy , and feasibility of laparoscopic treatment of abdominal wall defects.methods:fifty consecutive laparoscopic abdominal and incisional hernia repairs from september 2001 to may 2003 were compared with 50 open anterior repairs.results:the 2 groups were not different for age , body mass index , or american society of anaesthesiologists scores . 
 mean operative time was 59 minutes for the laparoscopic group , 164.5 minutes for the open group . 
 mean hernia diameter was 10.6 cm for the laparoscopic group , 10.5 cm for the open group . 
 mean length of stay was 2.1 days for the laparoscopic group , 8.1 days for the open group . 
 complications occurred in 16% of the laparoscopic and 50% of open group . 
 median follow - up was 9.0 months for the laparoscopic group , 24.5 months for the open group . 
 recurrence rates were 2% for laparoscopic group and 0% for the open group.conclusion:results for laparoscopic abdominal and incisional hernia repair seem to be superior to results for open repair in terms of operative time , length of stay , wound infection , major complications , and overall hospital reimbursement . 
INTRODUCTION
METHODS
Laparoscopic Technique
Prosthesis
Open Technique
RESULTS
DISCUSSION
CONCLUSION