Abstract
There is an ever increasing number of hernia repair surgeries required likely due to decreasing levels of physical activity amongst young adults and concurrent muscle wastage in the abdomen. Time off from work, staffing issues at hospitals, and cost of hospital bed space are some of the issues associated with the high cost of open surgical methods. Wound infection, decreased mobility, and recurrence of the hernia are problems associated with all surgeries. The last thirty years has seen the advent of laparoscopy and minimally invasive techniques of surgical repair. These methods offer the promises of decreased surgical morbidity, less pain, and faster mobilization post-operatively, as well as smaller scars. This study seeks to conduct a literature review to determine whether or not the outcomes of open and laparoscopic methods are identical and what benefits exist to one method over another.
Introduction
Hernias are defined as the abnormal protrusions of tissues or organs through a hole in the surrounding walls. They can occur anywhere throughout the body, but hernias of the abdominal wall are the most common site. Hernias occur where muscular tissues do not cover the underlying fascia. Common sites of herniation are the inguinal, femoral, and umbilical areas. Additionally, sites of prior surgical incisions may become prone to hernias (Sabiston, 2012).
Approximately 5% of the population will develop a hernia of the abdominal wall. The most common site of herniation is the inguinal region where approximately seventy-five percent of them occur. Men are significantly more likely to develop a hernia in the inguinal area with a 25:1 ration of occurrence. Women are more likely than men to develop hernias in the femoral and umbilical areas with rations of 10:1 and 2:1, respectively. Even though the epidemiology of the femoral and umbilical hernias favors females, the most likely type of hernia a woman will develop is an inguinal hernia (Sabiston, 2012). Hernia repair is thus one of the most common surgeries that occur. Over six hundred thousand hernia repairs are performed every year, however, the procedures used are far from perfect and complications ranging from infection to recurrence are common (Sabiston, 2012).
Diagnosis occurs with the finding of a bulge in the affected region. The bulge may be reducible or irreducible, meaning that the contents being spilled through the opening can be pushed back into the cavity. There may be pain or some discomfort, but a painless presentation is very common unless the hernia is irreducible and becomes strangulated by the surrounding tissues. Paresthesias may also occur in relation to a hernia depending on the involvement of any nerves in the area of the hernia. When diagnosing a hernia, other masses must be differentiated and alternative pathologies eliminated (Sabiston, 2012).
Many classifications of hernias exist, the most widely used being the Nyhus classification. According the Nyhus classification system, four types exist. Type I hernias are indirect inguinal hernias with a normal inguinal ring (pediatric), type II are indirect inguinal hernias with a dilated internal inguinal ring, type III are posterior wall defects, and type IV are recurrent hernias (Sabiston, 2012).
Surgical management of a hernia is recommended due to the progressive nature of the pathology with enlargement and further weakening of the surrounding musculature, and the potential for strangulation. In patients with minimal symptoms however, recent research has shown that a watchful waiting approach did not lead to worse outcomes in those patients. In Europe, a common non-surgical approach is the use of a truss that must be properly fitted. The use of a truss is not without complications though and testicular atrophy and neuritis may occur (Sabiston, 2012).
Anterior repair is the most common approach for inguinal hernias and tension-free repair is considered the standard. There are several types of tension-free repairs. Open hernia repair is begun with a 2-3 cm incision above and parallel to the inguinal ligament. Careful dissection and identification of the anatomy is performed eventually leading to the hernia sac. If the sac is large it is dissected to visualize the contents. The sac is then mobilized and placed into the preperitoneal space. In certain cases tissue repair is undertaken, however, this is no longer the first method due to unacceptable recurrence rates. Thus, in most cases a synthetic mesh prostheses is used to repair the defect in order to create a tension free repair since tension is the main cause of hernia recurrence. Mesh is the dominant repair method used today with the Lichtenstein repair, the plug-and-patch repair, the prolene hernia system, and a self-expanding polypropylene patches being some common methods (Sabiston, 2012).
Aside from the open methods, today minimally invasive approaches are also often used. Advocates of laparoscopic repair believe that quicker recovery times, less pain, better visualization of anatomy, and decreased site infections, are some of the advantages over open hernia repairs. Two techniques are widely used laparoscopically, the total extraperitoneal approach and the transabdominal preperitoneal approach (Sabiston, 2012).
The continued overall decrease in fitness levels in the young is leading to less confining muscle walls in the body. This progression has dramatically increased the number of inguinal hernia repairs being required. With the many repairs, it is not economically or medically viable to continue doing open repairs. Increased time-off from work and increased personnel involved can be viewed as downsides of the traditional repair, while the increased resources required and training needed by the surgeon to become proficient will also be viewed as downsides to smaller, more general, or underserviced hospital surgical areas. Thus, it is hypothesized that the use of laparoscopic uncomplicated inguinal hernia repair surgery will decrease recovery time, with decreased operative complications and improve post-operative mobility of patients when compared with traditional (open) hernia repair.
In order to determine whether or not laparoscopic techniques indeed improve surgical outcomes for patients a search of literature was performed using pubmed.gov. The search term “hernia repair” returned over fourteen thousand articles.
Articles were excluded that were older than eight years old. Furthermore, only studies that discussed a comparison between open and laparoscopic methods were utilized, thus, articles examining the differences between different open or different laparoscopic methods were excluded from the analysis.
A full profile of the entire perioperative and surgical outcomes were considered acceptable. Some articles discuss the differences in recurrence rates for the two procedure types, while others discuss the differences in intraoperative complications such as bleeding and perioperative infections, still others discuss the differences in quality of life outcomes between the procedures. Furthermore, whereas the immediate interest was in the treatment of adult abdominal hernias, studies of childhood hernias were not excluded due to the belief that the surgical outcomes and risks were largely similar – namely, perioperative infections, painful poor healing, and recurrence were just as likely to occur.
A significant number of meta-analyses were returned in the pubmed search. There was no specific intention of excluding them from the analysis because it was believed that they would provide a veritable treasure trove of information from case studies and well formed syntheses of the outcomes of the procedures. However, the vast majority of meta-analyses incorporated studies that were much older than the exclusion criteria permitted and thus they were all excluded.
Finally, head-to-head comparisons between open repair and laparoscopic repair was preferred in order to limit confounders and analytical bias as much as possible. This provided the extra advantage of reducing statistical modeling which may lead to error and inaccurate reporting of data.
In total, ten studies of various design were selected to evaluate the benefits and outcomes of the methods under review.
Results
Ten studies were found that matched the chosen inclusion criteria defined above. The studies evaluated several types of hernias to be repaired including incisional, inguinal, pediatric, and adult hernia types. All included studies were head-to-head comparisons of open repair and laparoscopic repair. The dependent variables evaluated by the studies included: infection rates, pain levels, operative time, mobilization time, testicular volume and blood flow, and quality of life. The study designs of the studies reviewed are presented below in table 1.
All but one study compared adult outcomes following surgeries. The significance in this is that the etiological factors of pediatric and adult hernias are different. Adult hernias usually occur as a result of straining a weak muscle whereas pediatric hernias are a result of incomplete closure of the inguinal ring in embryologic development.
The results are rather mixed. Most studies showed that hospital stays were lower, infection rates were lower, and that there was less pain with laparoscopic techniques (7/10 studies). 3/10 studies concluded that there was no difference in the outcomes of the two operational approaches. Another 3/10 studies noted that operating room time was increased in laparoscopic procedures. Two studies stated that there was less recurrence with open procedures, however, most indicated that recurrence rates between open and laparoscopic methodologies were similar. Two of the studies also stated that quality of life measurements were better following laparoscopic repair. Quality of life was assessed using a questionnaire, the Quality of Life assessment form (SF-36) (Singh, N.A., et al, 2011; Abbas, A.E., et al, 2011) One study, which happened to be the most recent and a controlled clinical trial, stated that the perioperative complication rate was higher with the laparoscopic procedure. The perioperative complications cited were: enterotomy, serosal bowel injury, and bladder perforation (Eker, H.H., et al., 2013). Finally, of note was that most studies indicated that operative time was significantly longer with laparoscopic surgery.
Two of the studies reviewed testicular complications following hernia surgery. In the case of pediatric hernia repair there was no difference reported in the vascularization of the testes by the two methods. In the case of adult hernia repair though, open surgeries were associated with restricted blood flow that lead to a decrease in testicular volume, a decrease in testicular size, and a concurrent increase in FSH and LH.
Discussion
There is no clear cut answer to the hypothesis that the use of laparoscopic uncomplicated inguinal hernia repair surgery will decrease recovery time, with decreased operative complications and improve post-operative mobility of patients when compared with traditional open hernia repair. The hypothesis was partially supported by a slight majority of the studies reviewed insofar as 6/10 of the studies believed that there were fewer complications and improved post-operative mobility. The several studies that reviewed longer term outcomes seemed to indicate that there was no difference between the two methods and in fact in those few studies that looked at long-term results, they found that open hernia repair had fewer recurrence rates. Thus, a narrow majority of studies seemed to support a conclusion that the hypothesis was strictly correct and that operative complications were reduced and the mobility of patients was faster following a laparoscopic repair. However, one study noted that the complication rates of laparoscopic repair are lower, but the complications that do occur tend to be more severe. Bowel injury was the most common complication during laparoscopic surgery and never occurred during open surgical repair of the hernia. When there was a bowel injury, the operation immediately converted to open and was controlled thus (Itani, K.M.F., et al, 2010). Surgical time seemed to be significantly longer when the operation was performed laparoscopically – with some studies suggesting that laparoscopic operating time was up to 30% longer (100 minutes vs. 76 minutes)(Eker, H.H., et al, 2013). On the otherhand, other studies had a much smaller time difference (46 minutes vs. 45 minutes)(Abbas, A.E., et al, 2011).
There are many factors that may contribute to the different outcomes in the surgical results. The most commonly cited factor is physician experience with the techniques that are being used to perform the repair. In the case of physicians performing a high volume of laparoscopic repairs the complications are diminished and recurrence rates are low. However, in the hands of inexperienced surgeons laparoscopic techniques seem to provide no benefit and actually cause an increase in the rates of severe complications. Another repeatedly cited factor regarding the outcomes of hernia repair is the size of the herniated sac. A large hernia was associated with higher recurrence rates in the majority of the studies reviewed.
The limitations of this study include the search terms used and the reliance on reported studies. None of the studies provide a reference regarding physician training and furthermore none of the reviewed studies discussed other independent risk factors and their relationship to complications and results.
In sum, the choice of surgical method is dependent on several factors, namely the type of hernia present, and the skills of the surgeon performing the operation. Laparoscopic techniques provide several advantages related to scar size, however, the benefits regarding surgical complications and risk of recurrence have not been proven in any appreciable manner.
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