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. Author manuscript; available in PMC: 2016 Jul 1.
Published in final edited form as: Surg Endosc. 2014 Oct 8;29(7):1769–1780. doi: 10.1007/s00464-014-3859-1

Laparoscopic Repair Reduces Incidence of Surgical Site Infections for All Ventral Hernias

Nestor A Arita 1, Mylan T Nguyen 2, Duyen H Nguyen 2, Rachel L Berger 1, Debbie F Lew 2, James T Suliburk 1, Erik P Askenasy 1, Lillian S Kao 2, Mike K Liang 2
PMCID: PMC4390429  NIHMSID: NIHMS634123  PMID: 25294541

Abstract

Background

The role of laparoscopic repair of ventral hernias remains incompletely defined. We hypothesize that laparoscopy, compared to open repair with mesh, decreases surgical site infection (SSI) for all ventral hernia types.

Methods

MEDLINE, EMBASE, and Cochrane databases were reviewed to identify studies evaluating outcomes of laparoscopic versus open repair with mesh of ventral hernias and divided into groups (primary or incisional). Studies with high risk of bias were excluded. Primary outcomes of interest were recurrence and SSI. Fixed effects model was used unless significant heterogeneity, assessed with the Higgins I-square (I2), was encountered.

Results

There were five and fifteen studies for primary and incisional cohorts. No difference was seen in recurrence between laparoscopic and open repair in the two hernia groups. SSI was more common with open repair in both hernia groups: primary (OR 4.17, 95%CI [2.03–8.55]) and incisional (OR 5.16, 95%CI [2.79–9.57]).

Conclusions

Laparoscopic repair, compared to open repair with mesh, decreases rates of SSI in all types of ventral hernias with no difference in recurrence. This data suggests that laparoscopic approach may be the treatment of choice for all types of ventral hernias.

Keywords: ventral hernia, primary hernia, incisional hernia, laparoscopic repair, meta-analysis

Introduction

The advent of laparoscopy has revolutionized the field of surgery. The implementation of laparoscopy has been associated with a reduction in wound complications, hospital length of stay, and time required to return to work as well as an increase patient satisfaction across various surgical specialties. Particularly, in general surgery laparoscopy has improved outcomes for cholecystectomies, [1, 2] appendectomies, [3, 4] inguinal hernia repairs, [5, 6] and upper gastrointestinal procedures.[7, 8]

However, the role of laparoscopy in ventral hernia repair has not been fully delineated. Ventral hernias encompass a heterogeneous group of hernias that are classified, according to the European Hernia Society, as either primary or incisional. [9] Primary hernias include umbilical, epigastric, spigelian, and lumbar hernias. Incisional hernias include any recurrent ventral hernia, hernia from prior incision, or traumatic hernia. These hernia types are very different in their pathophysiology, outcomes, and management. [9-11] Previous studies and meta-analyses evaluating laparoscopic versus open repair have often mixed these hernia types making the results difficult to interpret. [12-14] The role of laparoscopy in primary versus incisional hernias is also unclear. In addition, while mesh reinforcement during the repair of primary and ventral incisional hernias is considered standard of care, [15, 16] many previous studies included suture repairs in the open-technique cohort. [17, 18]

The objective of this study is to evaluate the role of laparoscopy in ventral hernia repair by comparing the early and late outcomes of laparoscopic and open repair with mesh of all ventral hernia cohorts. We hypothesize that laparoscopy reduces surgical complications in all ventral hernia repairs. To assess this hypothesis, we performed a systematic review and two separate meta-analyses of comparative studies evaluating outcomes of laparoscopic versus open repair with mesh of primary only and incisional only cohorts.

Methods

Systematic Review and Meta-Analysis

The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were followed. [19] MEDLINE, EMBASE and Cochrane Library databases were queried. The search phrase utilized was “(laparoscopy OR laparoscopic) AND (open hernia repair OR herniorrhaphy OR hernioplasty)” and limited to: 1) Publishing date between Jan 1, 1990 and July 1, 2013, 2) English articles, and 3) Human studies. In addition, all reference lists of selected manuscripts, reviews, and meta-analyses were reviewed for additional articles. Two independent reviewers performed the title, abstract, and paper review. Any discrepancy was discussed and a consensus reached among the reviewers.

Inclusion and Exclusion Criteria

Eligible studies were those comparing early and late outcomes of laparoscopic and open repair of ventral hernias. This included randomized controlled trials, case-controlled studies, and comparative prospective/retrospective studies. Exclusion criteria included reviews, systematic reviews, meta-analyses, editorials, technique descriptions, sample sizes < 10 in any treatment group, studies not utilizing mesh for all repairs, and studies of non-ventral hernias such as inguinal, hiatal, parastomal or internal hernias. Studies not reporting outcomes of interest were also excluded.

Data Extraction

Two independent reviewers extracted the data from each study. Any discrepancy was addressed and a consensus reached among the reviewers. The following was extracted from each study: publication year, study type, number of patients, age, hospital length of stay (LOS), and follow-up duration as well as rates of hernia recurrence, SSI, seroma, hematoma, mesh explantation, mortality, trocar-site hernia, laparoscopic-to-open conversion, readmission, reoperation, and enterotomy.

Each study was evaluated for risk of bias using Down and Black's 26-item checklist for the assessment of both randomized and nonrandomized studies in which there are 10 items assessing quality of reporting, 7 for bias, 6 for confounding, and 3 for external validity. [20] Each study was scored between 0 (lowest) and 26 (highest) and given a global rating of having low, moderate, or high risk of bias. Any study with high risk of bias was excluded. Reviewers were not blinded and the studies were not reviewed in any particular order.

Statistical Analysis

A meta-analysis on rates of hernia recurrence and SSI was performed to calculate the odds ratios (OR) with 95% confidence intervals (CI). Higgins I-square (I2) statistic was used to test for heterogeneity. The fixed effects model was used when there was little heterogeneity (defined as an I2<25%) in which case a random effects model was used. Publication bias was assessed by visual assessment of funnel plots for symmetry.

Results

Literature Search

The results of the systematic search are seen in Figure 1. A total of 1813 citations were obtained after searching, reviewing references, and de-duplication. A total of 277 studies remained after the title search and 61 papers remained after the abstract search. Twenty-eight studies were excluded for: “primary” hernias having prior fascial repairs, repairs not utilizing mesh, overlapping data, treatment group size <10, or not reporting outcomes of interest. Remaining studies were grouped into Primary Ventral Hernia (PVH) and Incisional Ventral Hernia (IVH). There were a total of 5 PVH and 15 IVH studies (Table 1).

Figure 1.

Figure 1

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Flow Diagram of Systematic Literature Search

Table 1.

Included studies in PVH and IVH cohorts.

Cohort Type Author Year Study Type Bias Lap N Lap Age Open N Open Age
Primary Liang[21] 2013 Retrospective Case Controlled Moderate 79 56 (1.0) [mean (SEM)] 79 57 (0.95) [mean SEM)]
Primary Othman[22] 2012 RCT Moderate 20 37 (7.8) [mean (SD)] 20 43 (12) [mean (SD)]
Primary Solomon[23] 2010 Retrospective Moderate 301 41 (19-62) [mean (range)] 277 56 (3-86) [mean (range)]
Primary Bencini[24] 2009 Retrospective Case Controlled Moderate 28 53 (32-89) [mean (range)] 36 52 (22-81) [mean (range)]
Primary Moreno-Egea[25] 2002 RCT Moderate 11 61 (39-92) [mean (range)] 11 59 (17-82) [mean (range)]
Incisional Eker[26] 2013 RCT Low 94 59.1 (12.8) [mean (SD)] 100 56.7 (12.8) [mean (SD)]
Incisional Marchesi[27] 2011 Prospective Moderate 20 63 [mean] 21 65 [mean]
Incisional Kurmann[28] 2011 Prospective Moderate 69 63.0 (29-87) [mean (range)] 56 63.5 (38-83) [mean (range)]
Incisional Itani[29] 2010 RCT Low 73 61.2 (9.9) [mean (SD)] 73 59.6 (9.0) [mean (SD)]
Incisional Moreno-Egea[30] 2009 Prospective Moderate 30 - 20 -
Incisional Wolter[31] 2009 Retrospective Moderate 41 64.3 (38-86) [mean (range)] 82 62.6 (26-83) [mean (range)]
Incisional Asencio[32] 2009 RCT Low 45 58.0 (54.0-62.0) [mean (95CI)] 39 60.6 (56.5-64.6) {mean (95CI)]
Incisional Ceccarelli[33] 2008 Prospective/ Retrospective Moderate 94 61.8 (13.0) [mean (SD)] 87 58.2 (14.7) [mean (SD)]
Incisional Bingener[34] 2007 Prospective Moderate 127 47.1 (21-68) [mean (range)] 233 49.9 (18-86) [mean (range)]
Incisional Zografos[35] 2007 Retrospective Moderate 30 (20-87) [range] 76 (20-87) [range]
Incisional Olmi[36] 2007 RCT Moderate 85 60 (8.7) [median (IR)] 85 65 (20.8) [median (IR)]
Incisional Navarra[37] 2007 RCT Moderate 12 59.3 (34-73) [mean (range)] 12 64.1 (40-78) [mean (range)]
Incisional Bencini[38] 2003 Retrospective Moderate 42 66 (49-81) [mean (range)] 49 62 (36-86) [mean (range)]
Incisional Chari[39] 2000 Retrospective Case Controlled Moderate 14 - 14 -
Incisional Park[40] 1998 Prospective/ Retrospective Moderate 56 58.8 (25-84) [mean (range)] 49 58.5 (35-82) [mean (range)]
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RCT=randomized controlled trial

Primary Hernia Meta-Analysis

Studies evaluating laparoscopic versus open repair of PVH are listed in Table 1. [21-25] There were two randomized controlled trials (RCTs), two retrospective case-controlled studies, and one retrospective study. Clinically, the patients in the included studies were similar and the surgical techniques used were similar without substantial heterogeneity. There were a total of 439 and 423 laparoscopic and open repairs, respectively. Table 2 lists the extracted data from all five studies. Figure 2 displays the funnel and forest plots from the analysis performed on hernia recurrence and SSI rates.

Table 2.

Data from included studies in the PVH cohort.

Study Laparoscopic Repair Open Repair
N C SSI S H LOS (d) R TH F/U (mo) Size N SSI S H LOS (d) R F/U (mo) Size
Liang[21] 79 0 6 16 - 1 (0-13) mean (range) 9 2 36 (1-133) mean (range) <2 cm (25) ≥2-4 cm (30) ≥4 cm (22) not reported (2) size (n) 79 27 7 - < 1 (0-10) mean (range) 9 56 (1-142) mean (range) <2 cm (25) ≥2-4 cm (30) ≥4 cm (22) not reported (2) size (n)
Othman[22] 20 1 0 2 - 1.05 (0.224) mean (SD) 0 0 35.2 (15.1) mean (SD) - 20 3 3 - 1.25 (0.550) mean (SD) 0 32.8 (14.5) mean (SD) -
Solomon[23] 301 0 4 2 0 - 3 - 47 (3-126) mean (range) - 277 6 3 1 - 5 68 (3-126) mean (range) -
Bencini[24] 28 - 0 3 - 3 (2-10) mean (range) 4 0 46 (1-80) mean (range) 20 cm2 (8-260) median (range) 36 3 1 - 2 (1-11) mean (range) 4 60 (7-80) mean (range) 32 cm2 (8-140) median (range)
Moreno-Egea[25] 11 0 0 - 0 - 0 0 41 mean - 11 0 - 4 - 0 41 mean -
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C: converted, S: seroma, H: hematoma, R: recurrence, TH: trocar (port) hernia

Figure 2.

Figure 2

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Funnel and Forest Plots of Outcomes of Laparoscopic versus Open Repair of Primary Ventral Hernias

The pooled hernia recurrence rate was 3.6% (16/439) at mean (range) follow-up of 44 (1-133) months for laparoscopic repair and 4.3% (18/423) for open repair at a mean (range) follow-up of 62 (1-142) months. There was no statistical difference in recurrence (OR 0.95, 95%CI [0.46–1.98]) and no heterogeneity among the studies (I2=0%). The pooled SSI rate was 2.3% (10/439) for laparoscopic repair and 9.2% (39/423) for open repair. This difference was significant (OR 4.17, 95%CI [2.03–8.55]) and there was no heterogeneity among the studies (I2=0%).

There were no mortalities reported. No study reported mesh explantation rates. Only one study (n=79) reported rates of port site hernias (n=2, 2.5%), bulging (lap n=17, 21.5%; open n=1, 1.3%), readmission (lap n=7, 8.9%; open n=15,19%), and reoperation (lap n=2,2.5%; open n=5, 6.3%). 33 Only Bencini et al. reported an enterotomy (lap n=1, 3.6%). 36

Incisional Ventral Hernia Meta-Analysis

Studies evaluating laparoscopic versus open IVH are listed in Table 1. [26-40] There were five RCTs, four prospective studies, four retrospective studies (one case-controlled), and two mixed studies where data on laparoscopic repair was collected prospectively and compared to retrospective data on open repair. Pooled sample sizes were 832 and 996 for laparoscopic and open repair. Table 3 lists the extracted data from these studies. Figure 3 displays the funnel and forest plots from the analysis performed on hernia recurrence and SSI rates.

Table 3.

Data from included studies in the IVH cohort.

Study Laparoscopic Repair Open Repair
N C SSI S H LOS (d) R TH F/U (mo) Size N SSI S H LOS (d) R F/U (mo) Size
Eker[26] 94 8 4 7 10 3 (2-4) median (IQR) 17 - 34.2 (33.5) mean (SD) 5 cm (4-8) median (IQR) 100 5 4 11 3 (2-5) median (IQR) 14 36.5 (33.1) mean (SD) 5 cm (4-10) median (IQR)
Marchesi[27] 20 0 - 0 - 7 (3-16) [mean (range) 0 - 14.8 mean - 21 - 0 - 11 (4-58) mean (range) 0 16.7 mean -
Kurmann[28] 69 7 4 4 - 6 (1-23) mean (range) 11 - 32.5 (1-62) mean (range) 25.7 cm2 (3.9-117.8) median (range) 56 16 8 - 7 (1-67) mean (range) 10 65 (1-80) mean (range) 20.9 cm2 (3.5-94.6) median (range)
Itani[29] 73 10 2 6 - 4.0 (3.5) mean (SD) 9 1 24 mean 45.7 cm2 (50.5) mean (SD) 73 16 18 - 3.9 (3.1) mean (SD) 6 24 mean 45.9 cm2 (52.5) mean (SD)
Moreno-Egea[30] 30 - 0 - - 2 (1-4) mean (range) 0 - 8 mean 17 (8) mean (SD) 20 0 - - 4 (3-7) mean (range) 0 8 mean 17 (8) mean (SD)
Wolter[31] 41 2 1 2 1 8.3 (2-31) mean (range) 3 0 23 mean 101.1 cm2 (9-250) mean (range) 82 9 0 5 8.6 (2-26) mean (range) 18 24 mean Onlay 117 cm2 (25-300) Sublay 108.7 cm2 (6-400) Mean (range)
Asencio[32] 45 5 0 - - 3.46 (2.68 - 4.25) mean (95CI) 4 - 12 mean 9.51 cm (8.5-10.6) mean (95CI) 39 0 - - 3.33 (2.76 - 3.90) mean (95CI) 3 12 mean 10.2 cm (9.0-11.4) mean (95CI)
Ceccarelli[33] 94 0 0 9 2 2.2 (1-4) mean (range) 2 - 38 (12-72) mean (range) 6.5 cm (9.9) mean (SD) 87 9 7 6 3.8 (1-9) mean (range) 6 96 (60-80) mean (range) 7.3 cm (12) mean (SD)
Bingener[34] 127 5 - 21 - 0.9 (1.4) mean (SD) 16 - 30 / 36 mean/median - 233 - 18 - 1.4 (2.0) mean (SD) 21 36 / 25 mean / median -
Zografos[35] 30 - 0 - - 3.5 (2-5) mean (range) 1 - 40 mean - 76 4 - - 5.5 (3-25) mean (range) 2 40 mean -
Olmi[36] 85 - 0 6 - 2.7 (2.2 - 3.2) mean (95CI) 2 - 24 (16-55) median (range) 9.7 cm (8.3-11.1) mean (95CI) 85 7 1 - 9.9 (5.2 - 14.6) mean (95CI) 1 24 (16-55) median (range) 10.5 cm (8.8-12.5) mean (95CI)
Navarra[37] 12 0 0 2 - 5.7 (1-13) mean (range) 0 - 6 mean 5.9 (4-9) mean (range) 12 1 0 - 10 (5-19) mean (range) 0 6 mean 6.9 cm (3-12) mean (range)
Bencini[38] 42 - 0 6 - 5 (3) mean (SD) 0 - 17 (10) mean (SD) 83 cm2 (12-264) mean (range) 49 6 5 - 8 (5) mean (SD) 3 18 (9) mean (SD) 122 cm2 (16-410) mean (range)
Chari[39] 14 - 0 - - 5 (1-33) mean (range) 0 - - - 14 0 - - 5.5 (2-30) mean (range) 0 - -
Park[40] 56 - 0 2 0 3.4 (1-17) mean (range) 6 - 24.1 (1-48) mean (range) 99.4 cm2 (9-420) mean (range) 49 2 1 5 6.5 (2-26) mean (range) 17 53.7 (36-85) mean (range) 105.3 cm2 (6.3-495) mean (range)
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C: converted, S: seroma, H: hematoma, R: recurrence, TH: trocar (port) hernia

Figure 3.

Figure 3

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Funnel and Forest Plots of Outcomes of Laparoscopic versus Open Repair of Incisional Venrtal Hernias

The pooled hernia recurrence rate was 8.5% (71/832) at a mean (range) follow-up of 22.8 (1-72) months for laparoscopic repair and 10.1% (101/996) at a mean (range) follow-up of 27.9 (1-85) months for open repair. There was no statistical difference in recurrence (OR 1.14, 95%CI [0.81–1.60]) and little heterogeneity among the studies (I2=19.4%). The pooled SSI rate was 1.6% (11/685) for laparoscopic repair and 10.1% (75/742) for open repair. This difference was significant (OR 5.16, 95%CI [2.79–9.57]) and there was no heterogeneity among the studies (I2=0%).

Port site hernias were likely under-reported (n=1/114, 0.9%) while reoperation (lap n=21/361, 5.8%; open n=27/392, 6.9%) and enterotomy (lap n=15/628, 2.4%; open n=6/758, 0.8%) were uncommon. Mesh explanation rates were reported by 9 studies (lap n=7/484, 1.4%; open n=15/665, 2.3%). Mortality rates were reported by six studies and occurred only with open repair (n=3/544, 0.6%).

Discussion

Our results demonstrate that laparoscopy, compared to open repair with mesh, lowers rates of SSI for primary and incisional ventral hernias. However, laparoscopy did not demonstrate a reduction in hernia recurrence rates for either primary or incisional ventral hernias.

Laparoscopy has helped to reduce the risk of SSI for most abdominal surgeries, in particular obese patients. [41-44] It may decrease rates of SSI by simply decreasing incision length. In addition, by decreasing manipulation and surgeon-contact with the incisions, infection rates may be reduced. Laparoscopy may have less impact on immune function than open surgery. [45, 46] Finally, laparoscopy may have the added benefit of decreasing prosthetic infections by not having a surgical incision overlying the mesh. [47] While our study did not investigate this outcome due to the low reported incidence of prosthetic infections in the included studies, there is substantial biologic plausibility for this. In large datasets with long-term follow-up, mesh explantation and complication rates range from 5-10% of cases following open ventral hernia repair.[48, 49]

SSIs are not benign complications. Multiple studies have demonstrated that SSI is related to higher rates of hernia recurrence, longer-hospital stays, higher incidence of hospital readmission, and increased likelihood for reoperation. [48, 50] SSI have been estimated to cost the healthcare system $11,000 per event while complications such as mesh infection cost over $75,000 and enterocutaneous fistulas cost over $200,000. [51]

Laparoscopic repair has the additional benefit of allowing full visualization of the hernia defect and identification of multiple fascial defects facilitating adequate mesh overlap. However, despite these advantages, laparoscopic repair has not been found to lower recurrence. This may be attributed to multiple patient/hernia factors or surgical factors. Patient and hernia factors include defect type (primary or incisional), obesity, low albumin, defect size, history of recurrence, or medical co-morbidities. [47, 50, 52] Surgical factors that may affect recurrence include type of mesh utilized, mesh location, extent of mesh overlap, mesh securement technique, and failure to close the fascial defect.[53-59]

Laparoscopic ventral hernia repair continues to be plagued by port site hernia and clinical bulging. [28, 60, 61] With laparoscopic ventral incisional hernia repair, closure of the central defect[61, 62] may help to obviate eventration or central bulging. In addition, closing the defect may help to decrease rates of seroma formation and hernia recurrence. High quality studies are needed to clarify the role of primary fascial closure in laparoscopic ventral incisional hernia repair. With primary ventral hernia repair, excision of the hernia sac and preperitoneal fat may be an important component of the repair.[21]

Fascial defect size is important for preoperative planning, may alter the decision to proceed with an open or laparoscopic repair for both PVH and IVH, and may impact outcomes. For example, many surgeons opt to perform open suture repair for small PVHs (<1-2 cm in width) and laparoscopic mesh repair for large PVHs (>3-4 cm width) or PVHs in obese patients. To correct for this, we excluded studies that did not repair all of their PVHs with mesh. Of the 5 PVH studies included for analysis, only 2 reported hernia size details. One was risk adjusted for size and the other had larger hernia defects with open repair [21,24].

For IVH, many surgeons opt to perform laparoscopic repair for smaller defects (<4-10 cm width) and open repair for larger defects. While the IVH studies reported hernia size in 11 of 15 studies, how the hernia sizes were determined (pre-operative or intra-operative, measured (extra-peritoneal, intra-peritoneal, with/without insufflation), and reported (width, length, area) was heterogenous between the studies; in fact, most studies failed to describe how they determined hernia size. Most of the IVH were large (> 4 cm hernia width) according to the European Hernia Society Classification system [9]. Of the 11 studies reporting IVH size, 7 studies reported larger hernias with the open cohort, 1 reported larger hernias with the laparoscopic cohort, and 3 reported identical sizes with both cohorts. Standardized methods for measuring and reporting ventral hernias are needed to improve comparisons between studies. The European Hernia Society Classification system provides a starting point for key stakeholders (including clinicians, payors, administrators, patients, and researchers) to unify communication and compare outcomes of a heterogenous disease; however, validation of this classification system is needed.

Currently, laparoscopic ventral hernia repair may be most appropriate in large primary ventral hernias (width > 3 cm), small/medium ventral incisional hernias (width < 6-10 cm), lateral hernias, multiple or multi-focal hernias, obese patients, and patients at high risk for surgical site infection. 56,57,58 In patients with dense adhesions, multiple prior operations, or prior intra-abdominal sepsis, laparoscopic ventral hernia repair may be challenging to perform.

This meta-analysis focused on hernia recurrences and SSI. However, consideration of cost and quality of life (QoL) following laparoscopic and open repair of ventral hernias is important. Laparoscopic repair has higher operative costs but shorter hospital stays which ultimately results in comparable total costs to open repair. [63] No long-term difference in QoL has been found between the two techniques.[64]

Ventral hernia research has been thwarted by the lack of a standardized hernia classification system. Previous meta-analyses have proposed evaluating primary and incisional hernias separately to reduce heterogeneity among included studies. Our meta-analyses produced the same conclusions in the primary only and incisional only cohorts suggesting it is appropriate to pool hernia types when assessing an intervention.

This meta-analysis is limited by the quality of the studies evaluated. There is a paucity of high quality studies in ventral hernia research. We opted to include all studies with low or moderate risk of bias. Additionally, several studies’ primary endpoint was not hernia recurrence or studies were not powered to detect a difference in recurrence: underscoring the utility of a meta-analysis. Also, most studies did not report the degree of surgeon proficiency with laparoscopy. Only a handful of studies specified adequate surgeon expertise[21, 25, 29, 33, 34] and Wolter reported a learning curve with laparoscopic repair. Furthermore, absence of a widely accepted staging system, lack of standardized outcomes, and variable follow-up duration make comparisons between studies challenging.

Conclusion

Laparoscopic repair, compared to open repair with mesh, lowers rates of SSI in all ventral hernia types and should be the treatment of choice for most ventral hernias. More high quality studies in ventral hernia research are needed. It may be appropriate to study primary and incisional ventral hernias together when evaluating laparoscopic versus open repair with mesh.

Acknowledgments

Funding:

This work was supported by the Center for Clinical and Translational Sciences, which is funded by National Institutes of Health Clinical and Translational Award UL1 TR000371 and KL2 TR000370 from the National Center for Advancing Translational Sciences. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.

Author Mike Liang discloses and investigator research grant and consulting work for LifeCell and KL2 TR000370 from the National Institutes of Health.

Footnotes

Disclosures

Authors Nestor A. Arita, Mylan T. Nguyen, Duyen H. Nguyen, Rachel L. Berger, Debbie F. Lew, James T. Suliburk, Erik P. Askenasy, and Lillian S. Kao have no conflicts of interest or financial ties to disclose.

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