Laparoscopic Ventral Hernia Repair – Does Primary Repair in Addition to Placement of Mesh Decrease Recurrence?

AMBAR BANERJEE, MD, VIMAL K NARULA, MD, DEAN J MIKAMI, MD. Center for Minimally Invasive Surgery, Division of Gastrointestinal Surgery, The Ohio State University

Introduction: The advent of laparoscopic ventral hernia repair (LVHR) not only reduced the morbidity associated with open repairs but also led to a decrease in the hernia recurrence rate. However, the rate continues to remain significant. In the quest for the ideal technique to manage this condition, we retrospectively reviewed the cases of LVHR performed at our institution to evaluate if primary laparoscopic repair along with underlay mesh placement yielded superior results in terms of reducing hernia recurrence.

Methods: After obtaining Institutional Review Board (IRB) approval, we conducted a retrospective review of the medical records of 98 patients who were treated with LVHR from January 2008 through December 2009 at The Ohio State University Medical Center (OSUMC) by two minimally invasive surgeons. The patient population was broadly divided into two groups based on the laparoscopic repair of the fascial defect with mesh underlay, or with primary suture repair and mesh underlay. Primary repair with mesh placement was performed in selected small hernias or in some large ones where adequate approximation of the edges was ensured prior to mesh deployment for satisfactory overlap. Patient demographics, rates of hernia recurrence, and other associated complications were compared among the two groups. Patient variables and the clinical outcomes were analyzed with descriptive statistics and chi-square test.

Results: Ninety-eight patients with a mean age of 48.7 years (SD 13.8) underwent LVHR for incisional (N=62), umbilical (N=28), epigastric (N=6), and parastomal (N=2) hernias. Hernia recurrence was documented in 11 patients (11.2%). The average area of the fascial defects was 38.04 cm². The mean follow-up period was 14.5 months (range 1-36 months). Recurrence was found to be 10% in patients with initial hernias compared to 16.7% in those with recurrent hernias (p=0.4). Incisional hernias accounted for nine recurrences (14.5%) while umbilical and parastomal hernias were associated with one recurrence each (3.6% and 50% respectively). (p=0.1) The rate of recurrence in patients treated with primary suture repair along with mesh was 2.8% (1 of 36 cases) when compared to 16.1% (10 of 62 cases) associated with mesh alone (p=0.04). Two of ten recurrences with mesh repair were further treated with primary repair alongside underlay mesh placement without occurrence of re-recurrence to date.

Conclusions: Primary laparoscopic repair along with mesh placement for the management of ventral hernia was found to be effective in selected cases as evidenced by the low rate of recurrence when compared to conventional repair with a mesh alone. Further retrospective and prospective studies with larger patient enrollment are warranted to confirm the benefit of this technique over the traditional laparoscopic repair.