Open retromuscular versus laparoscopic ventral hernia repair for medium-sized defects: where is the value?
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.
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.
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.
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.
KeywordsOpen ventral hernia repair Laparoscopic ventral hernia repair Value Cost Economics Ventral hernia repair
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.
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.
Compliance with ethical standards
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.
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.
All patients gave informed consent for procedure and scientific data use as is standard in our hospital system.
- 4.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 CrossRefPubMedCentralGoogle Scholar
- 5.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 CrossRefPubMedGoogle Scholar
- 19.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
- 25.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