Primary Fascial Closure with Mesh Placement During Laparoscopic Ventral Hernia Repair: A Risk-Adjusted Comparative Study

J E Wennergren, MD1, E P Akenasy, MD2, J A Greenberg, MD3, J L Holihan, MD4, J Keith, MD5, M K Liang, MD4, R G Martindale, MD6, M A Plymale, MSN, RN1, J S Roth, MD1. 1University of Kentucky, 2Baylor College of Medicine, 3University of Wisconsin, 4University of Texas Health Science Center, 5University of Iowa, 6Oregon Health Science Center

INTRODUCTION: Laparoscopy is a popular method to repair ventral hernias and relies upon on a mesh bridge technique. While laparoscopy has decreased the incidence of surgical site infection, hernia recurrence rates remain unchanged. Some surgeons advocate laparoscopic primary fascial closure (PFC) with placement of intra-peritoneal mesh to decrease recurrence rates. Advocates of this technique argue that closing the fascia decreases wall tension through LaPlace’s law. We hypothesize that in patients undergoing laparoscopic ventral hernia repair (LVHR), PFC compared to a bridged mesh repair decreases hernia recurrence rates.

METHODS: A multi-center database of all ventral hernia repairs performed from 2010-2011 was accessed. Patients who underwent laparoscopic ventral hernia repair with mesh were reviewed. Exclusion criteria included any contamination and <6 months of follow-up. Patients who had PFC were compared to bridged repair. Primary outcome was hernia recurrence determined by clinical examination or CT scan. Secondary outcome included surgical site infection(SSI) and reoperation.

RESULTS: A total of 280 patients underwent LVHR with mesh. Following exclusion for contamination(n=39) and <6 months of follow-up(n=108), 132 patients were followed for a median(range) of 18(6-49) months. PFC was associated with a lower recurrence rate(4.1%vs32.5%,p=<0.0001) and reoperation rate(0%vs9.6%,p=0.03). There was no difference in SSI (4.1%vs12.0%,p=0.21).

CONCLUSION: PFC was associated with lower rates of hernia recurrence and reoperation compared to bridged repair. The diagnosis of hernia recurrence was through clinical examination and it is unclear if many of these recurrences were simply mesh eventration or continued bulging following bridged repair. The advantages of PFC are biologically plausible and the retrospective data evaluating its outcomes is clinically compelling. A prospective randomized controlled trial is warranted to definitively evaluate its effectiveness.

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