Abstract
Purpose
There is increasing emphasis on value in health care, defined as quality over cost required to deliver care. We analyzed outcomes and costs of repairing medium-sized ventral hernias to identify whether an open retromuscular or laparoscopic intraperitoneal onlay approach would provide superior value to the patient and healthcare system.
Methods
A retrospective analysis of prospectively collected data from the Americas Hernia Society Quality Collaborative was performed for patients undergoing clean, elective repair of ventral hernias between 4 and 8 cm in width at our institution between 4/2013 and 12/2016 for whom at least 1-year follow-up was available. Recurrence rates, wound complications, length of stay, patient-reported outcomes, and perioperative costs were compared.
Results
One hundred and eighty-six patients met criteria (105 open, 81 laparoscopic) with 93.5% having ≥ 2-year follow-up. Patients undergoing laparoscopic repair had higher BMI, lower ASA classification, slightly lower prevalence of recurrent hernias and less prior mesh utilization, and slightly smaller hernias. Length of stay was shorter in the laparoscopic group (median 1 vs. 3 days, p < 0.001), without increased readmissions. Recurrence rates, wound complications, and patient-reported outcomes were similar. Laparoscopic repair had higher up-front surgical costs, yet equivalent total perioperative costs.
Conclusion
Both laparoscopic and open approaches for elective repair of medium-sized ventral hernias offer similar clinical outcomes, patient-reported outcomes, and total perioperative costs. Laparoscopic repair appears to offer superior value based on a significantly reduced postoperative length of stay.
Similar content being viewed by others
References
Poulose BK, Shelton J, Phillips S et al (2012) Epidemiology and cost of ventral hernia repair: making the case for hernia research. Hernia 16:179–183. https://doi.org/10.1007/s10029-011-0879-9
Reynolds D, Davenport DL, Korosec RL, Roth JS (2013) Financial implications of ventral hernia repair: a hospital cost analysis. J Gastrointest Surg 17:159–167. https://doi.org/10.1007/s11605-012-1999-y
Deerenberg EB, Harlaar JJ, Steyerberg PEW et al (2015) Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial. Lancet 6736:1–7. https://doi.org/10.1016/S0140-6736(15)60459-7
Kohler A, Lavanchy JL, Lenoir U et al (2018) Effectiveness of prophylactic intraperitoneal mesh implantation for prevention of incisional hernia in patients undergoing open abdominal surgery: a randomized clinical trial. JAMA Surg. https://doi.org/10.1001/JAMASURG.2018.4221
Fischer JP, Basta MN, Krishnan NM et al (2016) A cost-utility assessment of mesh selection in clean-contaminated ventral hernia repair. Plast Reconstr Surg 137:647–659. https://doi.org/10.1097/01.prs.0000475775.44891.56
Schneeberger S, Phillips S, Huang L-C et al (2018) Cost-utility analysis of biologic and biosynthetic mesh in ventral hernia repair: when are they worth it? J Am Coll Surg. https://doi.org/10.1016/j.jamcollsurg.2018.10.009
Majumder A, Fayezizadeh M, Neupane R et al (2016) Benefits of multimodal enhanced recovery pathway in patients undergoing open ventral hernia repair. J Am Coll Surg 222:1106–1115. https://doi.org/10.1016/j.jamcollsurg.2016.02.015
Jensen KK, Brondum TL, Harling H et al (2016) Enhanced recovery after giant ventral hernia repair. Hernia 20:249–256. https://doi.org/10.1007/s10029-016-1471-0
Colvin J, Rosen M, Prabhu A et al (2019) Enhanced recovery after surgery pathway for patients undergoing abdominal wall reconstruction. Surgery (US). https://doi.org/10.1016/j.surg.2019.05.023
Porter ME, Lee TH (2016) From volume to value in health care. JAMA 316:1047. https://doi.org/10.1001/jama.2016.11698
Colavita PD, Tsirline VB, Walters AL et al (2013) Laparoscopic versus open hernia repair: outcomes and sociodemographic utilization results from the nationwide inpatient sample. Surg Endosc 27:109–117. https://doi.org/10.1007/s00464-012-2432-z
Ecker BL, Kuo LEY, Simmons KD et al (2016) Laparoscopic versus open ventral hernia repair: longitudinal outcomes and cost analysis using statewide claims data. Surg Endosc 30:906–915. https://doi.org/10.1007/s00464-015-4310-y
Soliani G, De Troia A, Portinari M et al (2017) Laparoscopic versus open incisional hernia repair: a retrospective cohort study with costs analysis on 269 patients. Hernia 21:609–618. https://doi.org/10.1007/s10029-017-1601-3
Poulose BK, Roll S, Murphy JW et al (2016) Design and implementation of the Americas Hernia Society Quality Collaborative (AHSQC): improving value in hernia care. Hernia 20:177–189. https://doi.org/10.1007/s10029-016-1477-7
Haskins IN, Horne CM, Krpata DM et al (2018) A call for standardization of wound events reporting following ventral hernia repair. Hernia 22:729–736. https://doi.org/10.1007/s10029-018-1748-6
Baucom RB, Ousley J, Feurer ID et al (2016) Patient reported outcomes after incisional hernia repair—establishing the ventral hernia recurrence inventory. Am J Surg 212:81–88. https://doi.org/10.1016/j.amjsurg.2015.06.007
Krpata DM, Schmotzer BJ, Flocke S et al (2012) Design and initial implementation of HerQLes: a hernia-related quality-of-life survey to assess abdominal wall function. J Am Coll Surg 215:635–642. https://doi.org/10.1016/j.jamcollsurg.2012.06.412
Decker MR, Dodgion CM, Kwok AC et al (2014) Specialization and the current practices of general surgeons. J Am Coll Surg 218:8–15. https://doi.org/10.1016/j.jamcollsurg.2013.08.016
Sauerland S, Walgenbach M, Habermalz B, et al (2011) Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. Cochrane Database Syst Rev CD007781. https://doi.org/10.1002/14651858.CD007781.pub2
Al Chalabi H, Larkin J, Mehigan B, McCormick P (2015) A systematic review of laparoscopic versus open abdominal incisional hernia repair, with meta-analysis of randomized controlled trials. Int J Surg 20:65–74. https://doi.org/10.1016/j.ijsu.2015.05.050
Eker HH, Hansson BME, Buunen M et al (2013) Laparoscopic vs open incisional hernia repair a randomized clinical trial. JAMA Surg 148:259–263. https://doi.org/10.1001/jamasurg.2013.1466
Schlosser KA, Arnold MR, Otero J et al (2019) Deciding on optimal approach for ventral hernia repair: laparoscopic or open. J Am Coll Surg 228:54–65. https://doi.org/10.1016/j.jamcollsurg.2018.09.004
Colavita PD, Tsirline VB, Belyansky I et al (2012) Prospective, long-term comparison of quality of life in laparoscopic versus open ventral hernia repair. Ann Surg 256:714–723. https://doi.org/10.1097/SLA.0b013e3182734130
Rogmark P, Petersson U, Bringman S et al (2016) Quality of life and surgical outcome 1 year after open and laparoscopic incisional hernia repair PROLOVE: a rand omized controlled trial. Ann Surg 263:244–250. https://doi.org/10.1097/SLA.0000000000001305
Bernardi K, Olavarria OA, Holihan JL, et al (2019) Primary fascial closure during laparoscopic ventral hernia repair improves patient Quality of Life. Ann Surg XX:1. https://doi.org/10.1097/sla.0000000000003505
Funk LM, Perry KA, Narula VK et al (2013) Current national practice patterns for inpatient management of ventral abdominal wall hernia in the United States. Surg Endosc 27:4104–4112. https://doi.org/10.1007/s00464-013-3075-4
Mikami DJ, Melvin WS, Murayama MJ, Murayama KM (2017) Impact of minimally invasive surgery on healthcare utilization, cost, and workplace absenteeism in patients with Incisional/Ventral Hernia (IVH). Surg Endosc 31:4412–4418. https://doi.org/10.1007/s00464-017-5488-y
Earle D, Seymour N, Fellinger E, Perez A (2006) Laparoscopic versus open incisional hernia repair: a single-institution analysis of hospital resource utilization for 884 consecutive cases. Surg Endosc Other Interv Tech 20:71–75. https://doi.org/10.1007/s00464-005-0091-z
Krpata DM, Prabhu AS, Tastaldi L et al (2018) Impact of inadvertent enterotomy on short-term outcomes after ventral hernia repair: an AHSQC analysis. Surgery (US) 164:327–332. https://doi.org/10.1016/j.surg.2018.04.003
Acknowledgments
No external funding was received for this work. The authors would also like to thank Aashish Rajesh and Deepa Cherla for assistance with data collection.
Author information
Authors and Affiliations
Contributions
All authors contributed to the study conception and design. Material preparation and data collection were performed by Luciano Tastaldi, Hemasat Alkhatib, Erika Lampert, Kevin Brown, and Aldo Fafaj. Analysis was performed by Samuel Zolin. The first draft of the manuscript was written by Samuel Zolin and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Corresponding author
Ethics declarations
Conflict of interest
Aldo Fafaj and Luciano Tastaldi have received the AHSQC Resident/Fellow Research Grant Award that is not related to the present work. Ajita Prabhu receives personal fees from Medtronic and Intuitive Surgical Inc. and has an ongoing research grant from Intuitive Inc. Michael Rosen received salary support for his leadership position in the AHSQC, is a board member and has stock/stock options from Ariste Medical and has ongoing research grants from Pacira Pharmaceuticals Inc. and Intuitive Inc. David Krpata has received an educational grant from W.L. Gore not related to the present work. Remaining authors declare no conflicts of interest.
Ethical approval
All procedures related to the current study were compliant with current US law. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Human and animal rights
No experiments were performed on humans or animals in this study. The institutional review board approved the use of retrospective data.
Informed consent
All patients gave informed consent for procedure and scientific data use as is standard in our hospital system.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Zolin, S.J., Tastaldi, L., Alkhatib, H. et al. Open retromuscular versus laparoscopic ventral hernia repair for medium-sized defects: where is the value?. Hernia 24, 759–770 (2020). https://doi.org/10.1007/s10029-019-02114-4
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10029-019-02114-4