Laparoscopic versus open incisional hernia repair: Predictive factors of complications and length of hospital stay

Incisional hernia is one of the most common complications after surgery. In the past two decades, laparoscopic mesh repair has been proposed as an alternative approach to standard open mesh repair. The aims of this study were: 1) to compare laparoscopic and open incisional hernia repairs with regard to complications, operative time, and hospital length of stay (LOS) and 2) to identify predictive factors of postoperative complications and prolonged hospital LOS. This is a retrospective observational cohort study on 270 consecutive patients operated on between May 2004 and July 2014 at the Departments of Surgery of the S. Anna University Hospital in Ferrara, Italy. Patients were divided in two groups according to the surgical approach, laparoscopic surgery (laparoscopic group) or open surgery (open group). Patients’ characteristics, wall defect (European Hernia Society – EHS classification), adhesions (Zuhlke classification), type of mesh, conversions to open, peri-operative complications (Clavien-Dindo classification), hospital LOS, and follow up data were all collected in a database. The analysis of the data was by intention to treat. The laparoscopic group (N=94) and the open group (N=176) were well balanced regarding baseline characteristics. Both small and single wall defects were prevalent in the open group (W1-W2=72% and N1=86%, respectively), while big and multiple defects were mainly represented in the laparoscopic group (W3-W4=66% and N≥2=52%, respectively) (p<0.001). Median operative time and hospital LOS were both increased in the open vs. laparoscopic group (148 vs. 138 min, p=0.001 and 5 vs. 3 days, p<0.001, respectively) (Tab 1). No difference was found within the two groups in postoperative complications and recurrence (Tab 1). Full-adjusted logistic regression analysis showed that open approach and increasing width of wall defect were not significantly associated to major complications (Clavien Dindo ≥III) (Tab 2). Full adjusted Cox regression analysis showed that increasing age [HR 0.97( 95%CI 0.95-0.99), p=0.02], increasing width of wall defect [HR 0.79 (95%CI 0.61-1.00), p=0.05], and the open surgical approach [HR 0.55 (95%CI 0.34-0.89), p=0.02) were independent factors predictive of prolonged hospital LOS (Tab 3). These data suggest that, in high-volume centers, laparoscopic incisional hernia repair is feasible and safe; compared to the open procedure, it has similar postoperative outcomes, offering the advantage of reduced operating time and hospital LOS . The type of surgical approach and size of wall defect were not associated to a higher risk of major complications. Increasing patients’ age and size of wall defect, and open approach independently predicted prolonged hospital LOS. Further analysis focused on the correlation between the hospital LOS, complications, feasibility, and costs for the Health Care System are warranted in the perspective of a balance between technical innovation and economic sustainability of optimal health care.