BOCA RATON, FLA. – Laparoscopic repair of anterior abdominal wall hernia was associated with significantly less morbidity, a shorter hospitalization stay, and lower mortality than was open repair in a study of more than 71,000 patients in the American College of Surgeons’ National Surgical Quality Improvement Program database.
"Laparoscopic repair is underutilized," Dr. Rodney J. Mason said, noting that only 17% of the repairs in the study were performed laparoscopically.
Dr. Rodney J. Mason
The laparoscopic and open-repair patients were quite different in terms of baseline characteristics, so he and his coinvestigators performed two separate analyses of the NSQIP data. The first incorporated the full 71,026 patients; a second matched-pair analysis involved a subgroup comprising 7,060 open-repair patients and 7,069 similar patients with laparoscopic repair, Dr. Mason explained at the annual meeting of the American Surgical Association.
He and his colleagues turned to the NSQIP database because adverse-event rates associated with anterior abdominal wall hernia repair are so low that a definitive, randomized, controlled trial would require more than 100,000 patients in each study arm, according to Dr. Mason of the University of Southern California in Los Angeles.
In the matched-pair analysis, the 30-day overall morbidity rate was significantly lower in the laparoscopic repair group (2.83%) than in the patients undergoing open repair (5.14%). The serious complication rate was also significantly less (0.99% vs. 1.71% with open repair). Pulmonary embolism, sepsis, wound infection, and urinary tract infection were among the serious complications that were significantly less frequent with laparoscopic repair. In contrast, 30-day mortality rates weren’t significantly different (0.08% with laparoscopic and 0.06% with open repair).
However, in the full analysis of 71,026 patients, mortality was significantly lower in the laparoscopic repair group at 0.18%, which was roughly half the 0.33% rate with open repair. Similarly, the laparoscopic repair group’s 1.57% serious complication rate was significantly better than the 2.54% rate with open repair. Overall complication rates were 3.8% for laparoscopic repair vs. 6.02% for open repair.
Overall and serious morbidity rates were significantly lower with laparoscopic repair of nearly all types of abdominal wall hernias, including umbilical, incisional, ventral, incarcerated, strangulated, recurrent, and reducible hernias. In fact, the only setting in which there was no significant difference in complications between the two surgical approaches was in repair of initial primary hernias.
The average length of hospital stay was 2.71 days with laparoscopic repair in the matched-pair comparison – significantly shorter than the 3.36 days with open repair. The margin of difference was larger in the full analysis (3.25 days with laparoscopic vs. 4.43 days for open repair).
The new analysis of NSQIP data is particularly timely in light of a recent Cochrane review that concluded that laparoscopic repair hasn’t been shown to be superior to open repair in terms of complications, Dr. Mason observed (Cochrane Database Syst. Rev. 2011 [doi:10.1002/14651858.CD007781.pub2]).
Discussant Dr. Hobart W. Harris commented that with more than 400,000 incisional and ventral hernia repairs being performed annually, the incidence of this problem rivals that of acute appendicitis. Yet to date, no standardized hernia classification systems or evidence-based treatment guidelines exist.
"This is a common yet inadequately studied condition that adds several billion dollars to our annual health care expenditures," said Dr. Harris, professor of surgery and chief of the division of general surgery at the University of California, San Francisco.
He offered some tough love for Dr. Mason and his coinvestigators: "Enthusiasm must not overshadow the evidence or lack thereof. Due to the limitations of the ACS NSQIP data, my respected colleagues are unable to comment on postoperative pain or recovery time, let alone operating room time or costs, or – perhaps most importantly – the recurrence rates for the two techniques," Dr. Harris pointed out.
Although the NSQIP analysis demonstrated statistically significant differences favoring laparoscopic repair, these differences are arguably too small to be clinically meaningful, in his view.
"In the absence of equivalent or superior long-term recurrence rate data, I fear that the jury is still out. And I am not alone in that view, given that only one in five of these hernias were repaired using laparoscopic techniques," Dr. Harris said.
Dr. John M. Kellum Jr. cautioned Dr. Mason against making sweeping declarations regarding the superiority of laparoscopic repair.
"I have a concern that the message from your study will be that if you don’t do a laparoscopic incisional hernia repair, you’re lacking in testosterone," said Dr. Kellum, professor of surgery at Virginia Commonwealth University, Richmond.
Dr. Kellum said that he likes doing laparoscopic hernia repairs, but if the CT scan of a large hernia shows significant adhesions of intestine to the abdominal wall, an open repair is probably the best way to go.