Incisional Hernia Repair – Laparoscopic or Open Surgery?

Abstract

Incisional herniation represents a significant, and often underestimated, drawback to invasive abdominal surgery. With anything up to 20% of patients developing an incisional hernia at some stage postoperatively, the effects on those affected – poor cosmesis, social embarrassment, impaired quality of life – represent a major detriment to the nation's abdominal surgical population, even before the more obvious problems of pain, strangulation and skin erosion are considered. There will be no imminent shortage of patients requesting incisional hernia repair. But how should they be best served? As with other forms of hernia repair, the debate regarding suture versus mesh repair should probably be considered obsolete. But is laparoscopic surgery a reasonable alternative to open mesh repair, or even the preferred solution? Laparoscopic incisional hernia repair is clearly technically feasible, and its potential advantages – reduced postoperative pain, shorter hospital stay, increased patient satisfaction – are clearly enticing. Banerjea and Bhargava cite meta-analyses supporting the benefits of the laparoscopic route, although perhaps of interest is the relative lack of evidence for any significant reduction in recurrence rates. Kingsnorth argues that large and complex incisional hernias, especially those with loss of domain, can only be repaired using open surgery, with component separation techniques facilitating fascial closure and onlay mesh re-inforcement. Such hernias probably remain beyond the scope of laparoscopic surgery, but the optimal treatment for smaller hernias remains contentious. As with many other areas of healthcare, prevention – in the form of fewer open and more laparoscopic abdominal procedures – may be preferable to cure.