Current Opinions About Laparoscopic Incisional Hernia Repair - A Survey of Practicing Surgeons
Adam C. Alder, MD
1,4, Stephen C. Alder, Ph.D2, Edward H. Livingston, MD1,4, and Charles3,5UT Southwestern Medical Center in Dallas
2University of Utah School of Medicine
3Baylor College of Medicine
4VA Medical Center Dallas
5Michael E. Debakey VA Medical Center
Abstract
Background—
debated topics. There is no consensus as to the appropriate surgical technique.Incisional hernias are common. The optimal repair is one of the most analyzed and
Methods—
(www.surveymonkey.com) to assess practices and opinions regarding incisional hernia repair.An IRB approved protocol was designed using an internet-based survey site
Results—
hospital. 85–96% performed basic laparoscopic procedures. The median percentage of laparoscopic
to total hernia repair was <10%. Use of the laparoscopic technique was associated with a higher
volume of hernia repair (r
(z
(z
hernia repair, 81% indicated “no”. In that group, 52% indicated that a lack of improved results was
the main reason, followed by risk of enterotomy > operative time > cost > experience. Those who
would start indicated that the main reason was patient request (54%). Among those that use the
laparoscopic technique, 85% indicated that they would perform more. The main reason for this was
a lower recurrence rate (42%).Of 766 surgeons, 204 (27%) responded. Most respondents practice in an academic, urbanSpearman’s=0.315, p=0.001), concurrent advanced laparoscopic experienceWilcoxon rank sum=−2.348, p=0.019) and completion of a laparoscopic fellowshipWilcoxon rank sum=−3.317, p=0.001). When asked how many would start to perform laparoscopic
Conclusions—
of incisional hernias. Surgeons with experience with advanced laparoscopic techniques, laparoscopic
fellowship training, and higher volume of hernia repair are more likely to use a laparoscopic approach.There continues to be a lack of consensus on the most appropriate repair method
Corresponding Author: Adam C. Alder, MD, Department of Surgery, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas,
TX 75390-9159, adam.alder@mac.com.
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Summary Statement: This survey of practicing surgeons reveals remarkable consistency in the use of mesh, a preference for a traditional
open repair of incisional hernia and a positive outlook on the laparoscopic approach from those that use it. Use of the laparoscopic
technique for incisional hernia repair is associated with volume of hernia repair procedures, use of other advanced laparoscopic techniques
and the completion of a laparoscopic fellowship.This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers
NIH Public Access
Author Manuscript
Am J Surg. Author manuscript; available in PMC 2008 November 1.
Published in final edited form as:
Am J Surg. 2007 November ; 194(5): 659–662. doi:10.1016/j.amjsurg.2007.08.002.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Keywords
survey; laparoscopy; incisional hernia
Introduction
Incisional hernias are a common complication of surgical procedures. Risk factors for their
occurrence have been well documented. [1]Multiple procedures, techniques, and materials
have been developed for the treatment of incisional hernias, but none have been universally
accepted or effective.[2–4] Consequently, the surgical community continues to debate the ways
to repair these abdominal wall defects and there is no consensus on the best management.
Minimally invasive techniques have changed the approach to multiple surgical conditions
including incisional hernia. The theoretical advantages of a minimally invasive approach to
incisional hernia repair are well described. [2,4–9] To this date, there have been several direct
comparisons of the open hernia repair techniques to the laparoscopic techniques with favorable,
but not conclusive results. [5,10–19] Despite the support of this new technique, there are many
who remain unconvinced of any advantage of the laparoscopic approach to the repair of
incisional hernias. Surveys of practicing surgeons in West Scotland reveal a lack of utilization
of laparoscopic hernia repair and variation in techniques for repair of incisional hernia.[20,
21]
Opinions of currently practicing surgeons in the United States are unknown. As well, it is
unclear how often this technique is utilized. Therefore the purpose of this study is to identify
current practice trends and opinions about hernia repair in the US.
Methods
An on-line survey instrument using a commercially available survey sponsor
(www.surveymonkey.com) was designed by the authors (ACA, CFB). This survey site allowed
us to send the invitations and then anonymously, and securely, collect the responses. The
respondents were limited to a single response. This survey was sent out to practicing surgeons
in the US whose names and e-mail addresses were obtained from publicly available
membership lists of surgical professional organizations. The institutional review board (IRB)
approved the protocol and survey instrument with the requirement that the authors not have
any access to protected health information of the individual respondents. The IRB granted a
waiver of both HIPPA and written Informed Consent.
The survey was designed to collect the type of data we needed to answer our study question.
The survey employs basic conditional logic, and, therefore, the denominator for each question
differs. Respondents were encouraged to add free text comments. After the survey support site
received the responses, all data were downloaded. We determined the response rate by
comparing the successfully sent invitations (sent - returned = successfully sent) to the number
of responses. Statistical methods included standard descriptive statistics, Spearman rank order
correlation, and Wilcoxon sign rank tests. For all inferential tests,
analyzed using SPSS version 15.0 (Chicago, IL).α was set at 0.05. Data were
Results
Of 766 surgeons surveyed, 204 (27%) responded. Data are presented in table 1. Three quarters
of the respondents report that repair of incisional hernias is a part of their practice. The majority
(85%) of respondents describe their practice as being in an academic, urban hospital
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environment. Although 12% report completing a laparoscopic fellowship, a majority of
respondents (85–96%) perform basic laparoscopic procedures (cholecystectomy,
appendectomy, or diagnostic laparoscopy) and many (14–52%) perform advanced
laparoscopic procedures (gastric bypass, colon resection, inguinal hernia repair, splenectomy,
adrenalectomy). The respondents performed incisional hernia repair procedures at a median
rate of 24 cases per year (range 3–100). The median percentage of laparoscopic to total hernia
repair was <10% (range 0–100%). The median length of time respondents reported employing
the laparoscopic technique was 3–5 years.
Among respondents that do not presently perform laparoscopic incisional hernia repair, 82%
indicated they would not begin. Of these, the majority (52%) indicated that they believe the
results of laparoscopic repair are “not better than the traditional open repair”. Other reasons
included: risk of enterotomy > longer operative time > higher cost > lack of experience. It is
interesting to note that the 19% of surgeons who report that they were going to start to perform
laparoscopic hernia repairs indicated that the main reason was patient request (54%); whereas
only 31% reported that improved results reported in the literature prompted adoption of the
laparoscopic technique.
Among those that use the laparoscopic technique, 85% indicated that they would perform more.
The main reason for this was that the laparoscopic approach was associated with a lower
recurrence rate (42%). Additional reasons included fewer number of complications > less pain
> shorter hospital stay > patient request > easier procedure to perform. Use of the laparoscopic
technique was associated with a higher volume of hernia repair (r
concurrent advanced laparoscopic experience (z
completion of a laparoscopic fellowship (z
Our survey identifies a wide acceptance of the use of mesh to repair even small hernia defects.
In fact, mesh repair was reported in over 86% of procedures for repair of incisional hernias
from 3 to over 10 cm in diameter. However, for hernias smaller than 3 cm in diameter only
48% of respondents offered repair with mesh. When asked if they would offer surgical repair
to all patients 75% answered “no” and the main reasons were presence or absence of symptoms
(78%) then patient comorbidities (45%) followed by hernia size (35%). Most (80%) reported
that they do not use a bowel preparation in their patients prior to the repair of an incisional
hernia.
When asked about the specific management of complications associated with incisional hernia
repair, most (56%) report that they would delay placement of mesh if an enterotomy was
identified. However, 3% of respondents reported they would place mesh regardless of the
amount of spill identified during an incisional hernia repair. Among those that would postpone
mesh placement the median interval was 4 weeks (range 3 days to 6 months). Nine out of ten
respondents stated that they use intra-abdominal tacks and transfascial sutures to secure the
mesh during the incisional hernia repair compared to tacks (6%) or sutures (4%) alone.Spearman’s=0.315, p=0.001),Wilcoxon rank sum=−2.348, p=0.019) andWilcoxon rank sum=−3.317, p=0.001).
Discussion
Incisional hernias continue to complicate current surgical practice. The repair of an incisional
hernia continues to be a challenge and many operations have been described to repair this
defect. Currently there is no consensus regarding the best approach to incisional hernia repair.
[21,22] Our survey of practicing surgeons echoes this lack of consensus. We identified a median
utilization rate of less than ten percent for the laparoscopic approach with respondents
indicating that they believe the results are not better than the open repair. Despite the apparent
lack of utilization, there exists a definite interest in adopting the laparoscopic hernia repair
technique. The forces influencing the interest in the repair are complex and include patient
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request and a belief that the procedure is associated with lower recurrence, shorter recovery
and less pain. Interestingly, but not surprisingly, use of the laparoscopic approach is associated
with higher volume of hernia repair procedures. We identified a significant relationship
between advanced laparoscopic experience and use of a laparoscopic approach to incisional
hernia repair.
Our survey identified a remarkably strong consensus among the respondents with respect to
use of mesh and management of complications associated with incisional hernia repair. A
majority of respondents indicate the use of mesh for all hernia repairs, especially for those
fascial defects greater than 3 cm in diameter. This is consistent with multiple published reports
about the improved out comes of hernia repair when mesh is employed.[1,3,4,23] Another area
of solidarity relates to the way mesh is secured. Controversy regarding the means of securing
the mesh exists in the literature. Some espouse use of intra-abdominal tacks or transfascial
sutures alone. Others recommend the use of both.[6,23–25] Respondents in our survey almost
uniformly employ both. In the face of the consensus regarding use of mesh and methods of
securing the mesh, we conclude that the lack of consensus regarding the use of the laparoscopic
technique for incisional hernia repair is not simply a lack of knowledge of the literature related
to hernia repair. Rather, it is more likely related to differences in interpretation of available
data and experience of the practitioners.
Fear of enterotomy was an identified impediment to a more widespread acceptance of the
laparoscopic incisional hernia repair technique. This is a widely recognized complication of
both open and laparoscopic hernia repair techniques.[1,4,7,11–13,15,18,23,25–30]
Respondents in our survey approach this complication conservatively, that is by delay of mesh
placement for several weeks. It is interesting to note that 3% would place mesh in a field
regardless of the presence of spillage of enteric contents.
Repair of asymptomatic hernias is of interest to both patients and physicians. Watchful waiting
has been espoused by some for inguinal hernias[31] and questioned by others.[32] Over three
quarters of respondents indicate that they use watchful waiting for asymptomatic hernias,
especially when comorbidities make operative risks high. Long-term effects of this approach
are unknown. Quality of life is a consideration in the decision to implement an expectant
approach to the asymptomatic incisional hernia. No clear advantage to the laparoscopic hernia
repair in terms of quality of life, return to work and recurrence has been identified.[16,26]
Of interest in this study, those that stated that they would not start using the laparoscopic
technique for incisional hernia repair indicated that it was because the outcomes were no
different. Multiple prospective trials have been completed to answer this question.[10,14,15,
17–19,25,29] These trials have been contradictory in their conclusions. They have been
generally small trials without significant numbers of events to make powerful conclusions.
Even meta-analyses have been inconclusive regarding the possible benefits in recovery,
recurrence, and cost.[26,29] Our results echo this controversy. Namely, that each group bases
their use or avoidance of the laparoscopic technique based on the perceived conclusions of the
literature.
Our study has a modest response rate of 27%. Thus, our conclusions might be subject to a
response bias and may only be valid in our population of responders. Despite this, our survey
has a greater number of respondents than previous survey studies of this subject.[20,21]
The authors developed this survey instrument based on the concepts and controversies that
were felt to be important in the decision to use or not use the individual techniques of ventral
incisional hernia repair among surgeons. This study surveyed opinions and perceptions of
surgeons and was not designed to identify which technique performs better in patients.
Additional randomized studies will likely need to be completed to identify which technique
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performs best in patients with incisional hernias. Cost, quality-of-life and recurrence are critical
areas that need to be addressed in these additional studies.
Finally, there are potentially unmeasured factors that would explain or change the conclusions
of this study. The survey was entirely digital from invitation to completion. As such, invitees
unfamiliar or uncomfortable using the internet or a computer to complete a survey might not
respond. While we concede this as a possibility, we would expect the more technologically
savvy individuals to be inclined to prefer a technologically “advanced” approach to hernia
repair.
Our findings do not appear to suffer from a significant response effect in this regard.
Additionally, most of our respondents practice in a similar environment. Responses from
surgeons outside of the academic urban environment might identify different practice patterns
or different reported reasons for adopting or avoiding the various techniques.
Conclusions
This survey identifies a wide acceptance of the use of mesh to repair even small hernia defects.
However, there is still no universally accepted technical approach to the repair of incisional
hernias in the United States. Those surgeons who have experience with advanced laparoscopic
techniques, have a higher volume of hernia repair in their practice, or have completed a
laparoscopic fellowship are significantly more likely to use the laparoscopic hernia repair
technique. Given the choice, the majority of surgeons who responded to our survey still prefer
an open hernia repair possibly due to a lack of consensus in the published data to support the
theoretic benefits of the laparoscopic approach.
Acknowledgment
Jake Hathaway
Dr. Adam Alder is partially supported by NIH K12 RR023251-03.
References
1. Anthony T, Bergen PC, Kim LT, et al. Factors affecting recurrence following incisional herniorrhaphy.
World J Surg 2000;24(1):95–100. [PubMed: 10594211]discussion 101
2. Millikan KW. Incisional hernia repair. Surg Clin North Am 2003;83(5):1223–1234. [PubMed:
14533912]
3. Bellows CF, Alder A, Helton WS. Abdominal wall reconstruction using biological tissue grafts: present
status and future opportunities. Expert Rev Med Devices 2006;3(5):657–675. [PubMed: 17064250]
4. Ponsky TA, Nam A, Orkin BA, Lin PP. Open, intraperitoneal, ventral hernia repair: lessons learned
from laparoscopy. Arch Surg 2006;141(3):304–306. [PubMed: 16549698]
5. Raftopoulos I, Vanuno D, Khorsand J, Ninos J, Kouraklis G, Lasky P. Outcome of laparoscopic ventral
hernia repair in correlation with obesity, type of hernia, and hernia size. J Laparoendosc Adv Surg
Tech A 2002;12(6):425–429. [PubMed: 12590723]
6. Carbajo MA, Martp del Olmo JC, Blanco JI, et al. Laparoscopic approach to incisional hernia. Surg
Endosc 2003;17(1):118–122. [PubMed: 12399849]
7. Cobb WS, Kercher KW, Matthews BD, et al. Laparoscopic ventral hernia repair: a single center
experience. Hernia 2006;10(3):236–242. [PubMed: 16453072]
8. Eitan A, Bickel A. Laparoscopically assisted approach for postoperative ventral hernia repair. J
Laparoendosc Adv Surg Tech A 2002;12(5):309–311. [PubMed: 12470403]
9. Itani KM, Neumayer L, Reda D, Kim L, Anthony T. Repair of ventral incisional hernia: the design of
a randomized trial to compare open and laparoscopic surgical techniques. Am J Surg 2004;188(6A
Suppl):22S–29S. [PubMed: 15610889]
Alder et al. Page 5
Am J Surg. Author manuscript; available in PMC 2008 November 1.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
10. Barbaros U, Asoglu O, Seven R, et al. The comparison of laparoscopic and open ventral hernia repairs:
a prospective randomized study. Hernia 2007;11(1):51–56. [PubMed: 17131072]
11. Bencini L, Sanchez LJ, Boffi B, Farsi M, Scatizzi M, Moretti R. Incisional hernia: repair retrospective
comparison of laparoscopic and open techniques. Surg Endosc 2003;17(10):1546–1551. [PubMed:
12915971]
12. Chari R, Chari V, Eisenstat M, Chung R. A case controlled study of laparoscopic incisional hernia
repair. Surg Endosc 2000;14(2):117–119. [PubMed: 10656940]
13. Earle D, Seymour N, Fellinger E, Perez A. Laparoscopic versus open incisional hernia repair: a singleinstitution
analysis of hospital resource utilization for 884 consecutive cases. Surg Endosc 2006;20
(1):71–75. [PubMed: 16333530]
14. Lomanto D, Iyer SG, Shabbir A, Cheah WK. Laparoscopic versus open ventral hernia mesh repair:
a prospective study. Surg Endosc 2006;20(7):1030–1035. [PubMed: 16703430]
15. Misra MC, Bansal VK, Kulkarni MP, Pawar DK. Comparison of laparoscopic and open repair of
incisional and primary ventral hernia: results of a prospective randomized study. Surg Endosc. 2006
16. Mussack T, Ladurner R, Vogel T, Lienemann A, Eder-Willwohl A, Hallfeldt KK. Health-related
quality-of-life changes after laparoscopic and open incisional hernia repair: a matched pair analysis.
Surg Endosc 2006;20(3):410–413. [PubMed: 16424985]
17. Olmi S, Erba L, Magnone S, Bertolini A, Croce E. Prospective clinical study of laparoscopic treatment
of incisional and ventral hernia using a composite mesh: indications, complications and results.
Hernia 2006;10(3):243–247. [PubMed: 16609820]
18. Olmi S, Magnone S, Erba L, Bertolini A, Croce E. Results of laparoscopic versus open abdominal
and incisional hernia repair. Jsls 2005;9(2):189–195. [PubMed: 15984708]
19. Olmi S, Scaini A, Cesana GC, Erba L, Croce E. Laparoscopic versus open incisional hernia repair:
an open randomized controlled study. Surg Endosc 2007;21(4):555–559. [PubMed: 17364151]
20. Courtney CA, Lee AC, Wilson C, O'Dwyer PJ. Ventral hernia repair: a study of current practice.
Hernia 2003;7(1):44–46. [PubMed: 12612798]
21. Witherspoon P, O'Dwyer PJ. Surgeon perspectives on options for ventral abdominal wall hernia
repair: results of a postal questionnaire. Hernia 2005;9(3):259–262. [PubMed: 15891813]
22. Korenkov M, Sauerland S, Paul A, Neugebauer EA. [Incisional hernia repair in Germany at the
crossroads: a comparison of two hospital surveys in 1995 and 2001]. Zentralbl Chir 2002;127(8):
700–704. [PubMed: 12200733]discussion 704-5
23. Eid GM, Prince JM, Mattar SG, Hamad G, Ikrammudin S, Schauer PR. Medium-term follow-up
confirms the safety and durability of laparoscopic ventral hernia repair with PTFE. Surgery 2003;134
(4):599–603. [PubMed: 14605620]discussion 603-4
24. LeBlanc KA. Laparoscopic incisional hernia repair: are transfascial sutures necessary? A review of
the literature. Surg Endosc 2007;21(4):508–513. [PubMed: 17287923]
25. McGreevy JM, Goodney PP, Birkmeyer CM, Finlayson SR, Laycock WS, Birkmeyer JD. A
prospective study comparing the complication rates between laparoscopic and open ventral hernia
repairs. Surg Endosc 2003;17(11):1778–1780. [PubMed: 12958679]
26. Goodney PP, Birkmeyer CM, Birkmeyer JD. Short-term outcomes of laparoscopic and open ventral
hernia repair: a meta-analysis. Arch Surg 2002;137(10):1161–1165. [PubMed: 12361426]
27. Majewski WD. Long-term outcome, adhesions, and quality of life after laparoscopic and open surgical
therapies for acute abdomen: follow-up of a prospective trial. Surg Endosc 2005;19(1):81–90.
[PubMed: 15529189]
28. Muysoms F, Daeter E, Vander Mijnsbrugge G, Claeys D. Laparoscopic intraperitoneal repair of
incisional and ventral hernias. Acta Chir Belg 2004;104(6):705–708. [PubMed: 15663279]
29. Sains PS, Tilney HS, Purkayastha S, et al. Outcomes following laparoscopic versus open repair of
incisional hernia. World J Surg 2006;30(11):2056–2064. [PubMed: 17058029]
30. van't RM, Vrijland WW, Lange JF, Hop WC, Jeekel J, Bonjer HJ. Mesh repair of incisional hernia:
comparison of laparoscopic and open repair. Eur J Surg 2002;168(12):684–689. [PubMed:
15362576]
31. Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, et al. Watchful waiting vs repair of inguinal hernia
in minimally symptomatic men: a randomized clinical trial. Jama 2006;295(3):285–292. [PubMed:
16418463]
Alder et al. Page 6
Am J Surg. Author manuscript; available in PMC 2008 November 1.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
32. Stroupe KT, Manheim LM, Luo P, et al. Tension-free repair versus watchful waiting for men with
asymptomatic or minimally symptomatic inguinal hernias: a cost-effectiveness analysis. J Am Coll
Surg 2006;203(4):458–468. [PubMed: 17000388]
Alder et al. Page 7
Am J Surg. Author manuscript; available in PMC 2008 November 1.
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Alder et al. Page 8
Table I
Data presented as percentages or median (range). Statistical tests indicated.
Response rate 204/766 (27%)
Demographics
Do you repair incisional hernias 70/90 (75%)
Median number of hernia repairs 24/year (3 – 100/yr)
Laparoscopic Fellowship 19/155 (12%)
Academic Urban Hospital 131/154 (85%)
Perform Cholecystectomy 147/154 (96%)
Perform Advanced Laparoscopic procedures 14–52%
Length of time using laparoscopic incisional hernia
repair technique
3–5 years (1 - >10 years)
What percentage of hernia repairs do you perform
laparoscopically?
<10% (0 – 100%)
Do you anticipate performing more? 87/102 (85%) indicated yes
Lower recurrence rates, fewer complications, and patient request
Do you anticipate starting to perform this procedure? 56/69 (81%) indicated no
Results no better than open repair
How do you secure the mesh Tacks only 6/96 (6%)
Transfascial sutures only 4/96 (4%)
Both 86/96 (90%)
Would you repair the defect with mesh? <3cm - 75/155 (48%)
3–5 cm - 134/155 (86%)
5–10 cm - 151/155 (97%)
>10 cm - 151/155 (97%)
If you encounter an enterotomy, how would you
proceed?
Place mesh regardless of spillage - 3/96 (3%)
Place mesh only if minimal spillage - 39/96 (41%)
Would not place mesh - 54/96 (56%)
How long would you delay after an enterotomy? 4 weeks (range 3 days – 6 months)
Do you routinely bowel prep patients? Yes - 32/159 (20%)
Volume of hernia repair was correlated with use of the laparoscopic technique
r
Use of other advanced procedures predicts use of laparoscopic hernia repair
z
Completion of a laparoscopic fellowship prediscts use of laparoscopic hernia repairSpearman’s=0.315 (p=0.001)Wilcoxon rank sum=−2.348 (p=0.019)
Wilcoxon rank sum=−3.317 (p=0.001)
Am J Surg. Author manuscript; available in PMC 2008 November 1.
F. Bellows, MD
1