Comparison between the open and the laparoscopic approach in the primary ventral hernia repair: a systematic review and meta-analysis

Abstract

Background: Ventral hernia repair underwent various developments in the previous decade. Laparoscopic primary ventral hernia repair may be an alternative to open repair since it prevents large abdominal incisions. However, whether laparoscopy improves clinical outcomes has not been systematically assessed.

Objectives: The aim is to compare the clinical outcomes of the laparoscopic versus open approach of primary ventral hernias.

Methods: A systematic search of MEDLINE (PubMed), Scopus, Web of Science, and Cochrane Central Register of Controlled Trials was conducted in February 2023. All randomized controlled trials comparing laparoscopy with the open approach in patients with a primary ventral hernia were included. A fixed-effects meta-analysis of risk ratios was performed for hernia recurrence, local infection, wound dehiscence, and local seroma. Meta-analysis for weighted mean differences was performed for postoperative pain, duration of surgery, length of hospital stay, and time until return to work.

Results: Nine studies were included in the systematic review and meta-analysis. The overall hernia recurrence was twice less likely to occur in laparoscopy (RR = 0.49; 95%CI = 0.32-0.74; p < 0.001; I² = 29%). Local infection (RR = 0.30; 95%CI = 0.19-0.49; p < 0.001; I² = 0%), wound dehiscence (RR = 0.08; 95%CI = 0.02-0.32; p < 0.001; I² = 0%), and local seroma (RR = 0.34; 95%CI = 0.19-0.59; p < 0.001; I² = 14%) were also significantly less likely in patients undergoing laparoscopy. Severe heterogeneity was obtained when pooling data on postoperative pain, duration of surgery, length of hospital stay, and time until return to work.

Conclusion: The results of available studies are controversial and have a high risk of bias, small sample sizes, and no well-defined protocols. However, the laparoscopic approach seems associated with a lower frequency of hernia recurrence, local infection, wound dehiscence, and local seroma.

Keywords: Epigastric hernia; Laparoscopic repair; Open repair; Paraumbilical hernia; Umbilical hernia; Ventral hernia.

Fig. 1

Flow diagram for the researched studies (February 2023). A total of 14,936 studies were identified although only 9 studies were included in the final analysis. The other studies were excluded due to ineligibility

Fig. 2

Methodological quality summary using the RoB2 and robvis tools. Assessment of the risk of bias in the included studies

Fig. 3

Methodological quality graph using the RoB2 and robvis tools. Assessment of each methodological quality item across all studies

Fig. 4

Forest plot of hernia recurrence

Fig. 5

Forest plot of local infection

Fig. 6

Forrest plot of wound dehiscence

Fig. 7

Forest plot of local seroma

Fig. 8

Forest plot of postoperative pain

Fig. 9

Forest plot of duration of the surgery

Fig. 10

Forest plot of length of hospital stay

Fig. 11

Forest plot of time until return to work