Laparoscopic Incisional Hernia Repair After Colorectal Surgery. Is It Possible To Maintain a Mini-invasive Approach?

Emmanuel E Sadava, MD, Francisco Schlottmann, MD, Manuel E Maya, MD, Ana L Campos Arbulú, MD, Natalia A Ferrentino, MD, Alejandro G Canelas, MD, Maximiliano E Bun, MD, Nicolas A Rotholtz, MD. Hospital Aleman de Buenos Aires

INTRODUCTION: Although several benefits had been described in laparoscopic surgery, hernia formation at trocar and specimen retrieving sites is not uncommon. Mini-invasive approach to treat this complication may reduce postoperative morbidity. However, there is lack of evidence concerning laparoscopic repair of incisional hernia after laparoscopic colorectal surgery (LCRS). The aim of this study was to evaluate the feasibility and the results of laparoscopic incisional hernia repair after laparoscopic colorectal surgery compared with open approach.

METHODS AND PROCEDURES: From May 2001 to March 2014 all charts of consecutive patients who underwent LCRS and developed incisional hernia were evaluated. Patients who had incisional hernia after open colorectal resection were included in an intention-to-treat analysis. Those patients with paraostomal hernias and those with less than 6 months of follow up were excluded. Patients were divided in two groups: laparoscopic repair group (LR) or open repair group (OR). Decision making on the approach was based on surgeon´s discretion. Demographics, operative factors and 30-day postoperative complications were analyzed.

RESULTS: During the period of the study 1290 LCRS were performed. An incisional ventral hernia rate of 7 % was found and a total of 82 incisional hernia repairs were performed. In 49 patients (60 %) an open approach was performed and there were 33 laparoscopic repairs (2 converted to open due to small bowel injury). Demographics included age of 62 +/- 14,8 years, 65 % were male and the average body mass index was 27,4 +/- 5,2 kg/m2. Smoking and chronic obstructive pulmonary disease were more frequent in LR (LR: 54% vs OR: 26%, p= 0.02; LR: 42% vs OR: 12%, p < 0.01; respectively). There were 6 % (8 patients) of trocar-site incisional hernias and no difference was found with comparing midline and off-midline incisions (p=NS). Mean defect size was: 56 (4-527) cm2 and no significant difference between groups was identified (LR: 48 cm2 vs OR: 64 cm2; p=NS). Average operative time was 107 (45-240) minutes (LR: 93min vs OR: 116 min, p= 0.02). The open approach showed a higher rate of postoperative complications (OR: 51% vs LR: 18%, P=0.003) and longer hospital stay (OR: 2,77 +/- 4 d vs LR: 0,7 +/- 0.4 d; p=0.02). The recurrence rate was 15% (12 patients, 6 each group; p=NS) with a follow up of 48 (r: 6-141) months.

CONCLUSIONS: Laparoscopic approach for incisional hernia repair after LCRS seems to be safe and feasible, maintaining benefits of mini-invasive surgery as well. In addition, patients who received laparoscopic approach showed lower postoperative complications and reduction in length of hospital stay. These observations suggest that mini-invasive surgery may be the initial approach in patients that develop an incisional hernia after LCRS and prospective investigations are warranted.

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