International Journal of Surgery 20 (2015) 65e74

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International Journal of Surgery

journal homepage: www.journal-surgery.net

Original research

A systematic review of laparoscopic versus open abdominal incisional

hernia repair, with meta-analysis of randomized controlled trials
Hasanin Al Chalabi*, John Larkin, Brian Mehigan, Paul McCormick
GEMS Directorate, General & Colorectal Unit, St James Hospital, Dublin 8, Ireland

h i g h l i g h t s

Safe and reliable method of hernia repair.

The hospital stay between the two arms of the study is equal.

The infection rate post operatively is higher in the open hernia repair group.

The operation time is longer in the laparoscopic group but not statistically significant.

The recurrence of hernia is the same between the study cohorts.

a r t i c l e i n f o a b s t r a c t

Article history:
Introduction: Development of an incisional hernia after abdominal surgery is a common complication
Received 21 December 2014
following laparotomy. Following recent advancements in laparoscopic and open repair a literature re-
Received in revised form
19 April 2015 view has demonstrated no difference in the short term outcomes between open and laparoscopic repair,
Accepted 31 May 2015 concluding there was no favourable method of repair over the other and that both techniques are
Available online 12 June 2015 appropriate methods of surgical repair. However, long term outcomes in the available literature between
these two approaches were not clearly analysed or described.
Keywords: The objective of this study is to assess the effectiveness and safety of laparoscopic versus open abdominal
Laparsocopic hernia repair incisional hernia repair, and to evaluate the short and long term outcomes in regards to hernia recur-
Abdominal incisional hernia rence using meta-analysis of all randomised controlled trials from 2008 to end of 2013.
Open ventral hernia repair Study aims and objectives: Population: Patients who developed an abdominal hernia or abdominal
…etc incisional hernia following a laparotomy.
Intervention: Two methods of surgical repair, laparoscopic and open abdominal wall hernia repair.
Comparison: To compare between laparoscopic and open repair in abdominal wall incisional hernia.
Outcome: length of hospital stay, operation time, wound infection and hernia recurrence rate.
Methods: This study is a systematic review on all randomized controlled trials of laparoscopic versus
open abdominal wall and incisional hernia repair. Medline, Pubmed, Cochrane library, Cinahl and Embase
were the databases interrogated.
Inclusion & exclusion criteria had been defined. The relevant studies identified from January 2008 to
December 2013, are included in the analysis. The primary end point can be described as hernia recur-
rence, and secondary outcomes can be described as length of hospital stay post operatively, operation
time and wound infection.
Results: Five randomized controlled trials (RCTs) were identified and included in the final analysis with a
total number of 611 patients randomized. Three hundreds and six patients were in the laparoscopic
group and 305 patients in the open repair group. The range of follow up in the studies was two months to
35 months. The recurrence rate was similar (P ¼ 0.30), wound infection was higher in the open repair
group (P < 0.001), length of hospital stay was not statistically different (P ¼ 0.92), and finally the
operation time was longer in the laparoscopic group but did not reach statistical significance (P ¼ 0.05)

* Corresponding author.
E-mail address: hasan_chalabi@hotmail.com (H. Al Chalabi).

http://dx.doi.org/10.1016/j.ijsu.2015.05.050
1743-9191/© 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.
66 H. Al Chalabi et al. / International Journal of Surgery 20 (2015) 65e74
Conclusion: The short and long-term outcomes of laparoscopic and open abdominal wall hernia repairs
are equivalent; both techniques are safe and credible and the outcomes are very comparable.
© 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.
1. Introduction
Ventral hernias can be defined as protrusion of a portion of
organ or tissue through an abdominal wall defect [1,2]. The inci-
dence of these hernias can be as high as 13% following abdominal
wall surgery [3,4]. An incisional hernia is perceived as a morbidity
following an abdominal wall operation. Risk factors that increase
the chances of developing these hernias are wound infection, male
sex, obesity, abdominal distension, underlying disease process and
occasionally poor surgical closure [5,6]. Incisional hernia is associ-
ated with significant morbidity such as pain, intestinal obstruction,
strangulation, and ischemia of the hernia contents. Despite the
improvement in the methods of repair, there is still significant
morbidity and even mortality associated with repairs [7]. Surgical
intervention is the only method of repair [8], with two techniques
available: open repair with or without mesh, and laparoscopic
mesh repair.
It is estimated that over 120,000 laparotomies are carried out in
the United Kingdom every year, with more than 7000 incisional
hernia repairs subsequently performed. This represents almost 6%,
but the actual incidence of incisional hernia development may be
higher, as this figure does not take into account patients who opt
not to consider or attend for surgery for either personal or medical
reasons [9]. Considering this incidence and the morbidity and
mortality associated with the condition and the methods of repair
[10], it is quite evident that selecting the ideal method of repair is
crucial.
Some early evidence showed that laparoscopic incisional hernia
repair had a number of disadvantages: the longer operating times,
the costs involved with equipment provision and the specialised
tools and mesh used. However, several studies have demonstrated
that in experienced hands laparoscopic repair takes a similar
amount of time compared to open repair [11,12]. Cost benefit
analysis has also demonstrated that laparoscopic incisional hernia
repair is cost comparable to the open incisional hernia repair even
without considering patients benefits such as early hospital
discharge and early return to work [13].
Laparoscopic incisional hernia repair was first described by Le
Blanc and Booth in 1993 [14]. They demonstrated the benefit of
laparoscopic repair in hernia surgery, showing better results and
lower complication rates compared to the open method [15]. In the
current times, only massive tissue defect with complete loss of
abdominal muscle structure is considered unsuitable for laparo-
scopic approach [16].
But despite the improvement in the hernia repair in the last two
decades in terms of the overall technique, results in the eyes of
many experts are still unsatisfactory. Incisional hernias repaired
with primary suturing have a recurrence rate between 12% and 54%
[17,18], whereas the mesh repair recurrence rate can be as high as
36% [19,20]. In addition, the introduction of a foreign body such as
the Prolene mesh can lead to serious adverse results, such as pain,
infection, fistula, bowel injury and bowel adhesions [21]. The newer
models of the mesh products have evolved over time, with more
attention in the manufacturing features to avoid the above
mentioned complications. Laparoscopic repair had then been rec-
ognised as a credible alternative to open hernia repair and had been
widely practised since.
The laparoscopic approach entails a minimal access technique
with a few stab-like incisions for the use of laparoscopic in-
struments. The technique does not involve repairing the fascial
defect; rather the defect is covered using mesh with or without
reducing the hernia sac. A careful and meticulous dissection is
fundamental to safe surgery with fewer complications like seroma,
infection, bleeding and intestinal injury.
Some reports suggest improved results with laparoscopic inci-
sional hernia repair, where recurrence rate is very low at 4.3%, and
less wound complication compared to the open technique [22,23].
1.1. Literature review
There is a lack of evidence to support one method of repair over
the other. The efficiency and efficacy of laparoscopic repair
compared to the open technique is lacking. It is still unclear if one
method of repair is superior to the other [24], and it is unknown if
one repair method is more appropriate to certain types of hernia in
comparison to the other. The clinical guidelines of the Society for
Surgery of The Alimentary Tract (SSAT 2005) showed that hernia of
less than 3 cm can be repaired primarily without the use of the
prosthetic mesh, and any hernia where extensive tissues dissection
is required such as in component separation technique is then
qualified for open repair, yet any other hernia types that do not fall
in the above category can be considered where possible for lapa-
roscopic repair [25]. Hence, the success of the repair need to
address the guidelines with taking into consideration the individ-
ual circumstances of each hernia, and to plan in advance the best
method of repair. Additionally, the current evidence available looks
at the best method of repair with various outcomes like recurrence
rate, the costs involved, post-operative complications and long
term results [32e34].
Sajid 2009 had demonstrated that laparoscopic incisional her-
nia repair is an acceptable method of surgical approach. The
recurrence rate was similar to the open technique, but shorter
hospital stay and better pain tolerance. Although the short term
results were promising for both techniques, the study could not
comment on the long term outcomes similar to Cochrane review
2011 results [26].
Forbes 2009 on the other hand demonstrated that laparoscopic
incisional hernia repair is not superior to the open technique in
terms of hernia recurrence, but this study included patients with
primary hernias also. This potentially could bias some of the re-
sults as primary ventral hernias are much easier to repair
compared to incisional hernias; however results showed less
wound infection rate, less haemorrhage and earlier return to work
by almost 50%, but the laparoscopic repair carries higher rate of
bowel injury with 2.9% compared to only 0.9% in the open group.
Therefore, the study concluded laparoscopic repair is still as safe as
the open conventional repair and rather open repair has signifi-
cant advantages of less small bowel injury and seroma formation
[27].
Furthermore, recent researchers have shown that laparoscopic
incisional hernia repair is far better than open hernia repair in the
short term outcomes, like blood loss and hospital stay, with earlier
return to work [28,29], however the long term results remain the
main challenge to identify in many of randomised controlled
 H. Al Chalabi et al. / International Journal of Surgery 20 (2015) 65e74
trials. As no study had looked into longer follow up period post
surgery, the follow up period varied between the studies and
meta-analyses and mostly cover up to two years after repair
[28,29].
Up to now, there is only limited number of studies that specif-
ically addresses the risks and benefits of laparoscopy in incisional
hernia repair. The first Cochrane review was published 2011 [24],
and this review included 880 patients in the final analysis, with a
total number of ten studies involved. The review included studies
from 1999 to 2010, and did not conclude that laparoscopy was the
preferred method of repair. The review had identified a lot of het-
erogeneity in the pooled studies, with challenges addressing the
missing outcomes due to heterogeneous studies that came from
various backgrounds. This aspect has been addressed in our meta-
analysis as heterogeneity was minimised using very strict inclusion
and exclusion criteria, and also to include randomised controlled
studies only within short time period to avoid diversity and to
ensure maximum homogeneity. The clinical heterogeneity was one
of the identified weak components in the Cochrane review, and the
authors had recognised this shortcoming, as the diverse methods of
repair can be seen as a significant cofounder in the final analysis, as
it is impossible to unify the surgical repair. The methodological
heterogeneity was also mentioned due to various concealment and
randomisation diversity, while some trials did not mention much
about the blinding techniques, others did not reveal their alloca-
tions or randomisation tools. The reviewers of the Cochrane study
had acknowledged the difficulties in addressing the results due to
the significant and obvious studies diversity. That could explain
why the summary in the Cochrane review was soft and not very
affirmative, It is however fundamental to highlight that the
Cochrane review concluded that laparoscopy is a promising
approach but with some emphasis on short term outcomes, and not
the long term results.
In summary, despite the few randomised controlled trials and
retrospective studies available, there is an obvious lack of data that
supports one method of repair over the other, and also there is
unclear data in most of these studies on long term outcomes. Long
term outcome was defined by Cochrane review as the outcome
measured after 3 years of follow up, but there is no study or trial
looks at that time scale. Since the Cochrane review was published
in 2011, where it included studies up to 2010, there are only limited
number of randomized controlled trials published since. This sys-
tematic review, therefore, will be looking at the suitable studies
from 2008 to end of 2013. The rationale behind the choice of this
time period was to achieve a meta-analysis with maximum ho-
mogeneity in the surgical repair as it is within a very close time
frame and surgical repair has become more standardised in recent
years. As Cochrane review had looked into retrospective and pro-
spective trials, our analysis looks only at randomised controlled
studies within the last six years, and that is to narrow down the
outcomes in order to find out if there is any new finding to be added
to the Cochrane results.
1.2. Study aims and objectives
This is a systematic review with meta-analysis of all the rand-
omised controlled trials from January 2008 to the end of December
2013, through applying the PICO structure, the objectives in this
study are:
- Population: Patients who developed an abdominal hernia or
abdominal incisional hernia following abdominal wall incision
or laparotomy that required a surgical intervention to correct
the abdominal wall defect are included in the systematic review
and the meta-analysis.
67
- Intervention: This study is looking at two methods of surgical
repair, laparoscopic and open abdominal wall hernia repair.
Each method of repair has its own technical approach. Although
there are occasional minor differences in the way the repairs are
performed, they are generally performed in standardised tech-
niques notwithstanding minor deviations between centres.
- Comparison: This is to compare and evaluate the two different
methods of repair, i.e., the standardized laparoscopic and open
abdominal wall incisional hernia repair.
- Outcome: This study is identifying the different outcomes be-
tween the two arms of intervention, and to evaluate these as
primary and secondary outcomes. Primary outcome includes
recurrence rate, secondary outcome includes post operative
infection rate, length of hospital stay and length of the operative
time.
2. Methods
2.1. Data source
A systematic review of all the literature that compares laparo-
scopic incisional abdominal wall hernia to the open repair was
conducted. A systematic search of MEDLINE, EMBASE, CINAHL,
PUBMED, Cochrane library, all relevant abstracts, meeting letters
and electronic databases was carried out.
The search was limited to all the randomised controlled trials
with no language restriction between January 2008 and December
2013. Medical subject headings (MeSH) using the terms of lapa-
roscopy, open abdominal incisional hernia repair in conjunction
with mesh repair was used.
The search was also conducted using further and more specific
terms like “laparoscopic incisional hernia”, “abdominal wall hernia”
or “ventral hernia”, “open abdominal wall hernia” and “open inci-
sional hernia”. The relevant studies were reviewed, analysed and
included in final analysis when considered suitable to the meta-
analysis.
2.2. inclusion and exclusion criteria
Only randomised controlled trials comparing the laparoscopic
abdominal wall incisional hernias to the open repair are included in
this review. All non randomised trials, retrospective analysis, re-
ports and abstracts are excluded. Studies on primary hernias are
excluded too. The studies compared the standard laparoscopic
incisional hernia to the open conventional repair, any experimental
studies or techniques that are not considered standard will be
removed from the analysis. Studies with no explicit comparison
between the two surgical techniques are excluded. The relevant
studies are considered from January 2008 to end of December 2013.
All the data was extracted and checked by the researcher using
standardised methods, all the studies were examined and assessed
for certain factors, like study quality, randomisation, blinding,
robust methodology and outcomes (Table 3). The PRISMA checklist
has been identified and incorporated as part of the standardised
reporting system in this study, using systematic review with meta-
analysis of all the relevant RCTs.
2.3. Data extraction and analysis
Literature was searched from January 2008 to December 2013;
the selection process has identified the eligible studies. The in-
formation sources were researched twice in order to maximise
data extraction. Data extraction was performed by the principal
researcher, when any further details were required regarding the
original studies data, then original investigators and authors
68 H. Al Chalabi et al. / International Journal of Surgery 20 (2015) 65e74

Table 1
Show the five studies population characteristics.

Trial name Year Laparoscopic Open repair Follow up duration Outcomes assessed
repair

Rogmark 2013 64 69 8 weeks QoL, Pain score SF-36, recurrence rate, wound infection, operation time,
length of hospital stay
Eker 2013 94 100 35 months Blood loss, operation time, length of hospital stay, wound infection, recurrence rate
Itani 2010 73 73 24 months Pain score, operation time, recurrence rate, wound infection, hospital stay
Asencio 2009 45 39 12 months Operation time, length of hospital stay, wound infection, recurrence rate, pain score EQ5D
Pring 2008 30 24 27.5 months Hernia recurrence, analgesia use, wound infection, length of hospital stay, operation time

Table 2 morbidity recorded in each study varies; some describe bowel

Causes of heterogeneity.
Causes of heterogeneity
Different randomisation techniques
Different inclusion & exclusion criteria
Sample size
Reported outcomes
Variable follow up time period
Inconsistent results
Different hernia sizes
Potential use of various surgical repair techniques
were contacted to ensure obtaining the accurate information if
needed. The methodological quality assessment was carried out
using standardised criteria based on concealment and random-
isation technique, like randomisation allocation, description and
sample size. Adding to that, the criteria include patients' char-
acteristics, blinding and outcome assessment, and also the
achievement of over 80% follow up [30]. Data extracted from the
studies included descriptive assessment of both surgical tech-
niques; laparoscopic and open repair, operative time, post oper-
ative wound infection rate, length of hospital stay and duration of
follow up.
2.4. Participants characteristics
The included participants were patients who suffered from
abdominal wall incisional hernias. Pooling of the data from across
these studies was considered when homogeneity is sufficient. All
other hernia types were excluded from the final analysis.
2.5. Primary and secondary outcomes
The primary end point is the hernia recurrence rate. The
number of hernia recurrence was identified in each study; the
diagnosis of recurrence was established by clinical and/or radio-
logical investigations. Due to different lengths of follow ups in the
included studies, the recurrence was defined when mentioned in
the studies taking into consideration the variability in follow up
time periods.
Secondary end points included the post operative wound
infection rate, operative time, length of hospital stay in days. The
injury and bleeding while other studies include seroma forma-
tion, chronic pain and quality of life assessment, these parame-
ters were excluded from the final analysis and considered a
factor of heterogeneity, since not all studies have included them
all, and therefore they were considered invalid and were
excluded.
2.6. Assessment of bias
All the included trials were examined for blinding of outcomes,
concealment, allocation, randomisation sequence, completeness of
outcome assessment and outcome measurement. In addition, trials
were assessed in relation to experience in the surgical repair, and
studies were evaluated for any expertise bias. Therefore, risk of bias
can be identified within the study when certain outcome measures
change sharply suggesting variability in the surgeons' learning
curve or difference in the experience of surgeon performing the
hernia repair.
2.7. Measures of treatment effect
Risk ratio was used with 95% confidence interval for binary
measures. If the data was presented in the parametric form (i.e.,
means and standard deviation) they were used directly in the
meta-analysis, and posed no problem. Data reported in the non-
parametric form (i.e., Median and interquartile range) can not
be used for the meta-analysis, therefore for these studies, the
mean was assumed to be the same as the median value. A
property of the normal distribution of the data from the 25%e75%
percentile (i.e., the inter-quartile range) should span 1.35 stan-
dard deviations. Thus the width of the inter-quartile range was
used to estimate the standard deviation where this was not
reported.
A further problem for one of the continuous outcomes was
when no measure of spread at all was given. In this instance the
standard deviation was assumed to be the average value obtained
for each of the other studies in the analysis.
2.8. Assessment for heterogeneity and subgroup analysis
There were four outcome variables, two of which were

Table 3
Showing the studies quality and the standardisation criteria.

Quality variables Pring 2008 Asencio 2009 Itani 2010 Rogmark 2013 Eker 2013

Inclusion Yes Yes Yes Yes Yes

Exclusion Yes Yes Yes Yes Yes
Randomisation Yes Yes Yes Yes Yes
Sample-size calculation Not stated Yes Yes Yes Not stated
Lost to follow up No No Not stated No Yes
Allocation concealment Yes No Yes Yes Not stated
 H. Al Chalabi et al. / International Journal of Surgery 20 (2015) 65e74
continuous measures and two others were binary outcomes. The
heterogeneity of the different studies was assessed. Where there
was some evidence of heterogeneity (p < 0.1), random effect
models were used for the analysis. Fixed effect models were used
when no evidence of heterogeneity was demonstrated.
Depending on the degree of heterogeneity, subgroup meta-
analysis could be performed. However, in this study the vari-
ables in the outcomes were all included in the meta-analysis,
but where maximum heterogeneity was found in the out-
comes, no meta-analysis was performed, i.e. some outcomes
were individual results to some studies where no comparison
tool can be used as no similar variable to compare to in the other
studies.
2.9. Statistical analysis
Pooling of data was performed from all the randomised
controlled trials included. Data was expressed as a mean and
standard deviation for the continuous variables, and as Odds or risk
ratio for non-continuous variables. Statistical analysis was carried
out using the Stata software (Verison 13, USA). The student's t-test
and ManneWhitney U-Test were also used as appropriate; with P-
Value less than 0.05 was considered statistically significant.
3. Results
The search identified 35 potentially eligible studies since
January 2008; thirty studies were excluded for reasons related to
deviation from the aim of this analysis. Non-randomised controlled
trials were excluded; any study that does not compare the two
different techniques directly was not included in the analysis. Five
randomised controlled trials were found to meet the inclusion
criteria and were included in this meta-analysis. The five trials
included the analysis of 611 patients. The characteristics of the
trials were summarized in Table 1.
All the included trials report on patients who had abdominal
Fig. 1. PRISMA: flow chart for the researched studies Total number of studies identified was 425, but only five studies were included in final analysis where the rest were excluded
due to ineligibility, and do not serve the purpose of this research.
69
incisional hernias, and were eligible to either laparoscopic or open
repair. Any emergency surgery was excluded from these trials, and
only elective surgery was included. Flow chart of the researched
studies are shown on Fig. 1.
Where specified, randomisation methods were reported on
all the five trials. Three trials were computer generated alloca-
tions, one trial was a sealed envelope and one trial used a
random number sequence. Three trials reported on blinding
being applied while two did not mention it. The trials ranged in
size from 54 to 194 randomised patients and there was no dif-
ference in gender allocation across the entire studies population.
The duration of follow up ranged from eight weeks up to 35
months.
The reported outcomes in the studies varied widely, two
studies reported on visual analogue score while one study
looked at analgesia requirement post operatively as a measure of
pain scale following each method of repair. Several studies re-
ported on quality of life (QoL) and fatigue score and/or return to
work as a measure of outcome. Post operative complications
were described with a varied prevalence across the studies,
however, the five studies shared four similar outcomes namely
recurrence rate, length of hospital stay, operation time and
wound infection, and theses were analysed and reported in this
study.
The quality of life (QoL) assessment is a tool that measures the
patients feeling of well being using subjective assessment param-
eters; it purely relies on patient's own expressions using SF-36
form. Visual analogue score (VAS) is another psychometric
assessment scale that uses different subjective characteristics that
can be measured directly. Validity and reliability of these assess-
ment tools were measured against research standard protocols to
ensure accuracy and to minimize bias.
3.1. Heterogeneity
There was clearly some heterogeneity among the five studies.
70 H. Al Chalabi et al. / International Journal of Surgery 20 (2015) 65e74
Population size varied largely across the trials. Complications and
outcomes also varied. Types of meshes used and surgical technique
did vary slightly between the surgical units and was impossible to
unify this, therefore bias in the analysis can not be avoided and
caution in data interpretation is advisable. Table 2 lists the various
causes of heterogeneity.
3.2. Outcomes
There were four outcome variables, two of which were contin-
uous measures (length of hospital stay and operation time), and
two others were binary outcomes (recurrence and wound
infection).
For a meta-analysis of continuous outcomes, it is necessary to
have data on the mean and standard deviation for the outcome for
each study. Some of the five studies presented this information, and
thus posed no problems [31,35]. While Asencio (2009) presented
mean and confidence interval, so the latter measure can easily be
converted to a standard deviation if the number of subjects is
known.
There were also some problems with the analysis of the out-
comes. For binary outcomes, differences between methods are
usually expressed as risk ratios or odds ratios. Neither of these
quantities can be calculated for instances when the outcome did
not occur for one or both methods. In this data, there were no
wound infections in one trial, and no recurrences in another trial.
Thus to include these studies in the analysis it was necessary to
adjust the data slightly to allow the risk/odds ratios to be
calculated.
The heterogeneity of results between the different studies was
assessed. Where there was some evidence of heterogeneity
(p < 0.1), random effect models were used for the analysis, this was
evidently expressed in the operation time among the studies, but
when little or no evidence of heterogeneity was found, then fixed
effect models were used.
3.2.1. Operation time
The first outcome was the duration of surgery. The analysis of
results suggested a high degree of heterogeneity between the
studies (p < 0.001). Thus a random-effects analysis was per-
formed. This method suggested that the mean difference in time
between the methods (calculated as laparoscopy minus open
surgery) was 15 min, with a 95% CI of 0e31 min. This result was
of borderline statistical significance (p ¼ 0.05). However, three
studies appear to demonstrate longer operating time for lapa-
roscopic repair, while Rogmark (2013) found that laparoscopic
repair is quicker than the open with median difference of
10 min, while on the other hand, Pring (2008) expressed no
difference.
So clearly there is a suggestion that laparoscopic approach took
longer than open surgery.
A Forest plot illustrating the results for this outcome is shown
below:
Forest plot showing operation time.
3.2.2. Length of hospital stay
The second outcome examined was the patient length of hos-
pital stay. The results of the five different studies were fairly ho-
mogenous with little evidence of any heterogeneity (p ¼ 0.99). As a
result a fixed effects analysis was performed. There was a mean
difference between groups of less than one day (calculated as
laparoscopy minus open surgery), with a 95% CI from 0.22e0.24
days. This difference was not statistically significant (p ¼ 0.92).
Therefore there was no difference in the length of hospital stay
between the two surgical methods.
 H. Al Chalabi et al. / International Journal of Surgery 20 (2015) 65e74
A graphical illustration of the results is shown in the next Forest
plot.
Forest plot showing length of hospital stay.
3.2.3. Wound infection rate
The occurrence of wound infection was then examined. There
was some variation in results between studies, but the degree of
heterogeneity was not statistically significant (p ¼ 0.12). As a result
a fixed-effects meta-analysis was performed. The results suggested
71
a highly significant difference in outcome between the two
methods (p < 0.001). The risk ratio (calculated as laparoscopy/open
surgery) was 0.22 with a 95% CI from 0.11 to 0.44. This suggests a
lower risk of infection for laparoscopy compared to open surgery.
The risk of infection was almost five times lower for laparoscopy
than for open surgery. It is clearly demonstrated that open inci-
sional hernia repair carries a higher risk in wound infection
compared to the laparoscopic technique.
A graphical illustration of the results is shown in the next Forest
plot.
72 H. Al Chalabi et al. / International Journal of Surgery 20 (2015) 65e74
Forest plot showing infection rate.
3.2.4. Recurrence rate
The final outcome examined was hernia recurrence. Here there
was no evidence of any heterogeneity between studies (p ¼ 0.99),
and so a fixed effects model was used. The risk ratio (calculated as
laparoscopy/open) was found to be 1.29 with a 95% confidence
interval from 0.79 to 2.11, and associated p-value of 0.30. It is quite
fundamental to highlight that the Eker (2013) study has over 50%
weight on this analysis which potentially could impact signifi-
cantly on the results; however the final analysis suggested no
significant difference in recurrence between the two different
methods. It is also crucial to point out that the follow up time
period is the key to identify recurrence. The duration of follow up
varied between the studies as it ranged from two up to 35 months,
and this could affect the analysis, as longer follow up could yield
further recurrences, therefore cautious interpretation of these
findings is important.
The results are shown graphically below.
Forest plot showing recurrence rate.
4. Discussion
Laparoscopic incisional abdominal wall hernia repair is a rela-
tively new and evolving technique with the potential to replace
open repair. The efficacy and safety of the laparoscopic incisional
hernia repair is still unclear, as the available evidence comparing
the two surgical methods of repair is limited. Despite the Cochrane
review (2011) which analysed retrospective and prospective
studies, the comparison undertaken here was quite challenging due
to different and variable trials included with very heterogeneous
backgrounds, meaning that study cohesion and consistency might
have been a barrier to the formation of a strong conclusion. How-
ever the available data from our meta-analysis suggest that lapa-
roscopic repair is as efficient as open repair if not superior.
While this meta-analysis has shown that the recurrence rate
between the two methods of repair is very similar with a P value of
0.30, some other trials have reported lower hernia recurrence with
a laparoscopic approach [22,23]. It is not clear yet whether lapa-
roscopic repair can result in less recurrence, as no clear conclusion
can be reached because of the limited data available, the fact that
studies are relatively of short follow up, and that the published
studies are so heterogenous. Nevertheless; with the laparoscopic
approach, unlike the open technique it is technically possible to
identify all hernia defects, not just the main one. This allows for the
use of larger meshes covering all defects including those that are
not clinically or radiologically evident likely leading to a reduction
in recurrence or indeed new hernia development.
It is also crucial to mention that the follow up period in the five
randomised controlled trials included varied between two and 35
months, this could to some extent determine the outcome mea-
sures, where longer follow up time period could have demon-
strated more hernia recurrence.
The outcome from this meta-analysis demonstrated a border-
line statistical difference in the operating time among the trials,
with the P value is at 0.05. The mean difference in this meta-
analysis was 15 min with confidence interval of 0e31 min. This
statistical finding is not conclusive and considering the heteroge-
neity observed, this meta-analysis can not strongly support the idea
that laparoscopic repair is necessarily longer than open surgery.
Three RCTs [30e32] in this study demonstrated a considerably
longer operating time with the laparoscopic approach, while one
trial [33] reported a shorter operating time with the laparoscopic
repair. On the other hand, Pring 2008 showed no difference in the
length of operation in both laparoscopic and open repair [35].
Several other studies have reported no significant difference in
operation duration between the two methods of repair, supporting
our findings [11,36].
Some of the outcome data from these studies was so hetero-
geneous so that analysis was not possible as comparison could not
be performed in this study. Three trials reported on pain control.
While Rogmark (2013) used the visual analogue score, others used
 H. Al Chalabi et al. / International Journal of Surgery 20 (2015) 65e74
the QoL assessment with SF-36 as a tool to measure the pain in-
tensity post operatively. Asencio (2009) used a different pain
measurement tool to evaluate the pain after surgery, namely EQ5D
while not all studies included the pain scale as an outcome. This
heterogeneity was perceived as a limiting factor in performing the
analysis regarding pain outcomes, and hence it was not included in
the final analysis. Similarly only one trial described the amount of
blood loss as an outcome measure and so this also excluded [31].
This study examined the length of hospital stay; the outcome in
this meta-analysis is quite clear where fairly homogenous studies
were compared. There was no difference in the hospital stay be-
tween the two methods of repair in all the included RCTs. Several
observational studies have compared the length of hospital stay
and found that laparoscopic repair had a reduced length of stay
compared to open repair [37e39]. One meta-analysis demon-
strated a significant reduction in length of hospital stay in the
laparoscopic group by two days (open repair 4 days versus lapa-
roscopic repair 2 days), but the authors had highlighted that most
of their studies were retrospective and only one randomised
controlled trial was included [40].
Finally, this study examined the wound infection rate post
operatively; with the findings significantly in favour of laparoscopic
repair. The lower risk of wound infection after laparoscopic surgery
was demonstrated with a significant statistical outcome
(p < 0.001), with RR ¼ 0.11 to 0.44 (95% CI), so five times lower
chance of wound infection when laparoscopic option was used
instead of open repair. Our finding is very much in line with the
findings of other studies, where many authors found fewer com-
plications post laparoscopic repair leading to less infection rate, our
results are consistent with these studies [41e43]. It is well under-
stood that open incisional hernia repair requires extensive soft
tissue dissection, raising skin flaps and undermining the various
abdominal wall layers, this contributes to increased morbidity and
local complications post operatively.
Some authors have reported on other complications after sur-
gery, such as seroma formation, mesh infection and small bowel
injury. The nature of complications differ widely between the two
repair techniques: with open surgery it is mainly wound and
infection related complications that are generally considered low
risk, while complications in laparoscopic repair can be quite serious
and life threatening [44,45], including unrecognised small bowel
injury. Additionally, studies use several definitions to what con-
stitutes a complication, making the studies' findings very hetero-
geneous, and rendering comparisons across studies difficult.
Reported complications are therefore largely subjective, and
objective assessment of complications in future randomised studies
should be encouraged.
When our results were compared to the Cochrane review
findings from 2011, it is clearly the rationale was to achieve more
stratified measures to evaluate certain outcomes compared to the
Cochrane review, and since Cochrane results were very broad and
widely spread across all the spectrum of the studies findings, this
would not serve the purpose of this analysis as the comparison in
our outcomes was very focused and narrowed to allow identifying
specific objectives and then to be able to perform the statistical
tests with little heterogeneity.
This meta-analysis has several limitations. First, post operative
pain, which is considered an important outcome in hernia repair,
was not possible to assess and analyse, as discussed above. The
included trials in this analysis had under reported pain control post
surgery. Pain measurement tool was used in three studies only and
were very different, by which direct comparison is not feasible. The
clinical observations reported better pain control post operatively
in laparoscopic surgery [38], however; rigorous assessment with
more dedicated studies are required.
73
Second, this meta-analysis did not consider detailed examina-
tion of the complications from the two surgical techniques. This
study looked only at wound infection rate, however; it was high-
lighted in the study that other complications can arise like injury to
small intestine, mesh infection and Seroma formation. This study
had narrowed the outcomes to include the wound factor only to
avoid data attrition and hence poor results, and instead to produce
more effective and meaningful outcomes.
The third limitation was the challenge to obtain homogenous
data across the five RCTs, as some of the data used mean and
standard deviations; others had used median and interquartile
range. Some of these data had to be converted in order to perform
the statistical tests. There were also some difficulties with outcome
analysis as some outcomes were not assessed in certain trials, e.g.
no wound infections in one trial and no recurrence rate in another.
Therefore to include these studies in the analysis it was necessary
to adjust the data somewhat to allow the risk/odds ratios to be
calculated.
Fourth, this study acknowledged the duration of follow up in the
trials included is in general of relatively short duration excepting
one trial of 35 months follow up [31]. Observational studies have
found that longer follow up time periods will demonstrate more
hernia recurrence, hence while Rogmark 2013 reported on recur-
rence at only eight weeks post operatively and none were seen, this
undoubtedly effects the final outcome in the meta-analysis but
does not reflect the actual long term outcome. Given the uncer-
tainty about the long term recurrence in incisional hernia repair
and lack of data, it is essential to perform long term follow up
studies to compare the durability of laparoscopic incisional hernia
repair.
And finally, the considerably strict inclusion criteria in this
meta-analysis is planned in order to have highly selected studies
that can be as comparable as possible, with less bias, less deviation
from the aims, and to achieve conclusions that are credible and
evidence based as possible. Furthermore, this analysis looked only
at studies from 2008 to 2013 inclusive where the surgical tech-
niques are within same time frame, experience had been well
established and the surgical approach is well beyond experimental
stage.
5. Conclusion
There is no conclusive evidence to support one method of repair
over the other. Laparoscopic repair has been proven to be as
effective and safe as open repair. The findings from the meta-
analysis shows no difference in length of hospital stay, no differ-
ence in hernia recurrence and no difference in duration of oper-
ating time between the two methods of surgical repair. It has
however shown that the laparoscopic technique is associated with
five times less wound infections than the open repair.
The implications from these findings are:
1. Laparoscopic incisional abdominal wall hernia repair can be
used when patient deemed to be suitable for it, and when
experience with the necessary technical skills is available.
2. Laparoscopic repair appears to have a significantly reduced rate
of wound infection.
3. Future studies are required to be well planned in advance with
certain outcome measures to be as homogeneous as possible,
e.g. pain and complications.
4. Multi-centre randomized controlled trials should be performed
to achieve a credible level of evidence to be used in future meta-
analyses.
5. Long follow up periods to observe for hernia recurrence are
required in future studies.
74 H. Al Chalabi et al. / International Journal of Surgery 20 (2015) 65e74
Ethical approval
N/A.
Funding
A complete personal work, no financial support.
Author contribution
Hasan Al Chalabi e idea and structure, statistical analysis and
writing.
John Larkin e introduction.
Brian Mehigan.
Paul McCormick e Supervisor.
Conflict of interest
No conflicts of interest.
Guarantor
Hasan Al Chalabi.
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