Introduction
The incidence of umbilical hernias has been reported to be as high as 2% in the adult population and comprises 10% of all hernia repairs performed annually. Umbilical hernias are believed to result from either incomplete closure of the umbilical stalk from birth or from conditions resulting in increased intra-abdominal pressure, such as pregnancy, ascites, malignancy, and obesity. Obesity has become a major issue within the population, and it is expected that there will be an increase in obese patients who will require repair. Operations in obese patients are challenging. Obesity leads to multiple arrays of physiologic disturbances such as diabetes mellitus, hypertension, coronary artery disease, and certain types of cancer that impair immunity. Many studies have shown increased postoperative complications in obese patients who undergo operations. For umbilical hernias specifically, studies show that obese patients have a much higher risk of postoperative wound infections as well as higher hernia recurrence rates. The combination of heavily contaminated areas (umbilicus) and the body habitus with skin folds in obese patients can raise the possibility of infection and consequential recurrence. Higher rates of infection may in part contribute to increased hernia recurrence because recurrences are more likely in patients who develop wound infection.
In recent years, the laparoscopic approach has been shown to significantly reduce postoperative pain and the risk of bleeding and has been associated with a shorter recovery time. Some studies have also proposed a decrease in wound infection rates. We hypothesized that decreasing exposure to the contaminated umbilical area via the laparoscopic approach would decrease the likelihood of infection and possibly decrease hernia recurrence rates. The purpose of this study was to compare the laparoscopic with the open approach to umbilical hernia repair (UHR) in the obese population.
Method
A retrospective chart review was conducted on 123 obese patients (body mass index [BMI] who underwent UHR from 2003 to 2009 at a single institution. Patients were grouped by surgical approach (open vs. laparoscopic). Intraoperative and postoperative courses were compared. Follow-up in the postoperative period was obtained from patient records and telephone interviews.
Operative technique
Antibiotic prophylaxis was given to all patients undergoing mesh placement. All patients received cefazolin (or clindamycin when a significant allergy was documented) before incision. The abdomen was prepped with either iodine or chlorhexidine gluconate. For laparoscopic cases, access into the peritoneal cavity was accomplished using the Hassan cannula, the Veress needle, or the Optiview (Ethicon Endo- Surgery, Cincinnati, OH) trocar technique. This port was usually placed in the left upper quadrant. Two other ports were placed to create proper triangulation around the target site. A total of two 5-mm ports and an 11- to 12-mm port (to introduce the mesh) were used to perform the procedure. Hernia contents were reduced into the abdominal cavity. The size of the defect was measured, and the mesh was tailored to cover the defect at least 3 cm circumferentially.
The mesh was anchored in 4 quadrants with sutures, and additional sutures or tacks were placed 1 cm apart for secure fixation. The decision between polytetrafluoroethylene (WL Gore, Newark, DE) and Polyester composite (Covidien, Mansfield, MA) or Prolene mesh (Ethicon, Somerville, NJ) was not standardized. Trocars greater than 5 mm were closed using a 2-0 Vicryl (Ethicon) in a figure of 8. Open repairs were performed via a supra- or infraumbilical incision. The hernia sac was dissected free, and the contents were reduced into the peritoneal cavity. The defect was closed with a nonabsorbable suture. In some cases, a mesh was tailored to fit the defect. If a mesh was used, it was anchored to the fascial edges with interrupted sutures. The decision to perform a primary repair or to use mesh and the type of mesh used was also not standardized.
Results
Of the 123 patients undergoing UHR, 40 and 83 patients were operated on with the laparoscopic and open approach, respectively. Patients were well matched by demographics as well as comorbidities. No difference in the mean BMI was shown between the laparoscopic and open groups (37 vs. 35, P 5 not significant, respectively). The operative time was significantly prolonged in the laparoscopic group (106 vs. 71 minutes, P .01). Intraoperatively, no complications occurred in either group. In the immediate postoperative period, 1 patient who underwent laparoscopic UHR was readmitted for small bowel obstruction, and 2 patients in the open group were readmitted, 1 for pain control and 1 for wound infection. Follow-up was achieved in 63% of the laparoscopic group and 58% of the open group with a mean follow-up of 15 months in the laparoscopic group and 20 months in the open group (P 5 not significant). A significant increase in wound infection was reported in the open group with mesh insertion when compared with the laparoscopic procedure (26% vs. 4%, P .05, respectively). No hernia recurrence was shown in the laparoscopic vs. the open group with mesh insertion (0% vs. 4%, P 5 not significant, respectively).
Conclusion
In obese patients, the laparoscopic approach was associated with a significantly lower rate of postoperative infection and no hernia recurrence. Laparoscopic hernia repair may be the preferred option in the obese patient.
Reference
M.J. Colon, R. Kitamura, D.A. Telem, S. Nguyen, C.M. Divino, “Laparoscopic umbilical hernia repair is the preferred approach in obese patients”, The American Journal of Surgery (2013) 205, 231-236.