Laparoscopic versus open ventral hernia repair in patients with chronic liver disease

Yen-Yi Juo, MD, MPH, Matthew Skancke, MD, Jeremy Holzmacher, MD, Richard L Amdur, PhD, Khashayar Vaziri, MD. George Washington University Medical Center

Introduction: Laparoscopic ventral hernia repair is associated with favorable short-term outcomes in comparison with an open approach. However, it has been hypothesized that in chronic liver disease patients, the intraperitoneal mesh placement in ascites increases risk of infection; the evacuation of ascites and induction of pneumoperitoneum can lead to hemodynamic instability. We aim to explore whether the favorable outcomes associated with laparoscopic ventral hernia repair persists in patients with chronic liver disease.

Methods: Records of patients undergoing elective ventral hernia repair between 2005 and 2013 in the National Surgical Quality Improvement Program Database were examined. Patients with Model for End-Stage Liver Disease (MELD) score greater than 9 were identified as having chronic liver disease. Multivariate logistic regression was performed to explore the impact of surgical approach (laparoscopic versus open) on short-term postoperative morbidities after adjusting for MELD score and confounders including age, gender, Body Mass Index, serum albumin, Charlson comorbidity index, and nature of hernia (reducible versus incarcerated). Sensitivity analysis was carried out with a 1:1 propensity score matched comparison between laparoscopic and open repair.

Results: Of the 5,190 chronic liver disease patients who underwent ventral hernia repair, 695 (13.4%) received laparoscopic repairs. After adjusting for MELD score, presence of varices, and other confounders, the laparoscopic approach was still associated with improved outcomes including lower incidence of wound-related complications (Odds Ratio (OR)=0.25, p<0.01), systemic complications (OR=0.40, p<0.01), significant bleeding (OR=0.28, p<0.01), as well as a shorter average length of stay (3.3 vs 6.9 days, p<0.01). Sensitivity analysis showed similar conclusions for all examined outcomes. Of the 669 (12.9%) patients with ascites, 105 (7%) received laparoscopic repair. In comparison with open repair, laparoscopic repair, when performed on patients with ascites, demonstrated equivalent complication rates to open repair in most examined outcome variables and is associated significantly higher infectious complications, including pneumonia, deep organ space infection, and urinary tract infection (OR=4.04, p=0.04), even after adjusting for MELD score and other confounders.

Conclusion: The favorable outcomes conferred by laparoscopic ventral hernia in comparison with open repair appear to persist in patients with chronic liver disease. While higher MELD score is associated with higher postoperative complication rates in both open and laparoscopic ventral hernia repair, laparoscopic repair is associated with lower morbidities after adjusting for MELD score. This advantage, however, appears to be lost when patients have chronic liver disease severe enough to manifest with ascites.

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