Open intraperitoneal versus retromuscular mesh repair for umbilical hernias less than 3 cm diameter

Frederik Berrevoet, Frederik D'Hont, Xavier Rogiers, Roberto Troisi, Bernard de Hemptinne
American Journal of Surgery 2011, 201 (1): 85-90

BACKGROUND: mesh techniques are the preferable methods for repair of small ventral hernias, as a primary suture repair shows high recurrence rates. The aim of this prospective study was to compare the retromuscular sublay technique with the intraperitoneal underlay technique for primary umbilical hernias.

METHODS: from February 2004 to April 2007, all patients treated for umbilical hernias with maximum diameters of 3 cm were prospectively followed. During the first period of 15 months, all patients were treated with retromuscular repair using a large pore mesh (Vypro). After that period, for all patients, mesh repair using an intraperitoneal Ventralex patch was performed. All patients underwent general anesthesia. This analysis included 116 patients, of whom 56 had retromuscular repair (group I; mean age, 54.8 years; mean body mass index, 28.2 kg/m(2)) and 60 had open intraperitoneal repair (group II; mean age, 48.1 years; mean body mass index, 29.4 kg/m(2)). Operating time was evaluated as skin-to-skin time, and drain management was noted for both techniques. Follow-up was ≥ 2 years for all patients, and both early and late complications were registered, including seroma and hematoma formation, wound infection, fistula formation, and recurrence rates. Preoperative and postoperative pain was evaluated using a visual analogue scale (range, 0-10) on the day of the first outpatient visit; on postoperative days 1, 7, and 21; and after 1 year. Quality of life was estimated using the EQ-5D questionnaire 1 year after surgery. All data were analyzed using SPSS version 15 software. Wilcoxon's rank-sum test was used to analyze continuous variables, and repeated-measures analysis of variance was used for visual analogue scale scores. The χ(2) test and Fisher's exact test were used to assess the differences between categorical data. P values < .05 were considered statistically significant.

RESULTS: the mean operative times were 79.9 minutes in group I and 33.9 minutes in group II (P < .001). The mean hospital stay was significantly longer in group I (3.8 vs 2.1 days, P < .001). Seromas and superficial wound infections in the early postoperative period were not different between both groups, although seromas occurred more frequent in the retromuscular group. Postoperative visual analogue scale scores were significantly lower with the intraperitoneal technique at all time points (P < .003, repeated-measures analysis of variance). However, 3 patients with the Ventralex patch had to be readmitted for severe pain. The recurrence rate was higher with the intraperitoneal repair (n = 5 [8.3%] vs n = 2 [3.6%]) than for the retromuscular mesh repair, but not statistically significant. Quality of life was comparable in the two groups after 1 year.

CONCLUSIONS: the open intraperitoneal technique using a Ventralex mesh for umbilical hernias seems a very elegant and quick technique. However, possibly because of the less controllable mesh deployment, recurrence rates seem higher. In case open mesh repair is the preferred treatment, a retromuscular repair should be the first choice.

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