I do a lot of hernia surgery. My bias has always been towards minimally invasive (laparoscopic) repair of ventral hernias – I think that I can see better and get a better repair while at the same time the risks of infection and wound complication are less. The big criticism of lap hernia repair is that most hernias get bridged – in other words the fascial edges of the hernia defect aren’t brought together and the hernia is repaired with a patch, like fixing a hole in a pair of jeans.
Over the last couple of years there has been a resurgence in the use of open surgery for ventral hernia repair. It’s important to note that the newer approaches to open hernia repair are much improved, and now often involve “abdominal wall reconstruction.” In this approach we use muscle flap techniques (component separation) to relieve stress on the abdominal wall, allowing the edges of the hernia to closed primarily. A mesh patch (synthetic or biologic) is then used to buttress the repair, rather than to hold all of the tension. The purported advantage of this approach is better abdominal wall function, at the cost of a more invasive operation with longer recovery and greater risk of complications.
Perhaps the best known hernia surgeon in the country is Todd Heniford at Carolinas Medical Center in Charlotte. His group recently published a great study: “Prospective, Long-Term Comparison of Quality of Life in Laparoscopic Versus Open Ventral Hernia Repair” in the Annals of Surgery. Bottom line: Lap hernias had fewer infections (odds ratio of 0.1) and a shorter hospital length of stay, but more pain and worse quality of life (QOL) at 1 month after surgery. A year later there was no difference in pain or QOL, and there was no difference in recurrence rate.
Their conclusions: “If a surgeon were to utilize this study to discuss technique choices with a patient, the emphasis would be that a laparoscopic repair offers a lower rate of infection and shorter hospitalization while an open approach has an improved short-term QOL and offers a greater chance of abdominal wall fascial closure.”
The increased pain at one month after lap repair actually makes sense, even though traditionally laparoscopic surgery is supposed to have less pain than open surgery. In the lap hernia repair we secure the mesh using sutures that go through the muscle – and this hurts. I also think lap patients in general are more active earlier, which may actually increase pain. On the other hand, 87% of the open group had their fascia closed, which may help support the abdominal wall and reduce pain.
Even though pain is slightly higher and QOL is slightly worse at 1 month after lap hernia repair in most patients, I think that the slight increase in pain at one month is worth it for most patients, given the lower infection risk and shorter hospital stay. It’s important to note that this study isn’t randomized, and is therefore also presumably population biased. In particular the lap group were significantly heavier, which may affect post-op outcomes.
I also think the study doesn’t give enough information to figure out the role of abdominal wall reconstruction. They don’t separately report this group, or address abdominal wall function in comparison to more traditional open or lap techniques. Until data becomes available I think the jury is still out. That being said, I am doing more and more complex abdominal wall reconstructions these days, mostly because I am seeing increasingly more complex patients.
While about half of my practice is hernia surgery, and has been for some time, we are now starting a formal University of Washington hernia center. I’ll be seeing patients in a dedicated clinic at Northwest Hospital beginning Dec. 3rd. Should be exciting! More information is available at uwmedicine.org/hernia.
Andrew Wright MD 