1. Lap vs Open Ventral Hernia Repair: Experience and Evidence Archana Ramaswamy MD

2. Surgery, Gynecology & Obstetrics, March 1993 298 patients evaluated after primary hernia repair 36% recurred 45% in first year, 78% by third year Increased recurrence rate if previous repairs 2 nd repair = 56%, 3 rd repair = 48% 4 th repair = 47% Risks Factors for Hernia Recurrence

3. SizeRecurrence rate < 4 cm25% > 4 cm41% p = 0.01 Surgery, Gynecology & Obstetrics, March 1993

4. Open Repair of Ventral Hernias primary suture repair

5. Suture Repair vs Mesh Repair Randomized Trial Hernias primary or 1 st recurrence – ≤6 cm defect N=200 patients randomized N=200 patients randomized Suture repair – running prolene – 1 cm bites Mesh repair – – 2-4 cm overlap – No transfixing sutures – Continuous suture to posterior fascia Mean follow up 26 months August 10, 2000

6. Suture Repair vs Mesh Repair Randomized Trial August 10, 2000 3 yr recurrence rate: 43%primary repair 23%mesh repair p = 0.005

7. Open Hernia Repair Mesh vs Suture Compared only RCTs 7 trials compared Pooled recurrence data – Suture repair recurrence 33.3% – Mesh repair 16.4%

8. Open Ventral Hernia Technique of mesh placement Retrospective study – 53 total patients, 3 different hospitals – Mean age 60.4 – 25 women, 28 men – Unable to close fascia primarily – Each hospital performed a different technique utilizing monofilament (heavyweight) polypropylene mesh – Mesh Overlaps of 2 cm (onlay, underlay) – 30 month average follow-up

9. Open Ventral Hernia Technique of mesh placement Type of repairNumber Early complications Recurrence (%) Onlay13173 (5.6) Inlay23310 (18.9) Underlay1722 (3.8) Total532215 (28.3)

10. Open Ventral Hernia Technique of mesh placement

12. Open Ventral Hernia Open technique # patients Mos. Follow- up Recurrence rate primary 167847647 (39%) Inlay 297314 (48%) Onlay 3474649 (14%) Underlay (extraperitoneal) 8495068 (8%) Underlay (intraperitoneal) 3522916 (4.5%)

13. 850 consecutive cases –Follow up: 20.2 months –Laparoscopic completion: 96% –OR time: 120 mins –Blood loss: 49 ml –Hospital stay: 2.3 days –Complications: 13.2% Prolonged ileus: 3.0% Prolonged seroma: 2.6% Visceral injury: 1.7% Mesh infection: 0.7% –Recurrence: 4.7% LVH outcomes Case Series

14. Wound and mesh complications

15. LVH outcomes Case Series Recurrence rates

16. Laparoscopic vs Open Ventral Hernia Repair

17. Goodney, Birkmeyer, Birkmeyer. Arch Surg, 2002 LVH outcomes Meta-analysis Included 8 studies with comparative groups – Open repair: various techniques – Lap repair: no strict definition – 700 patients total

18. LVH outcomes Meta-analysis Perioperative complications Goodney, Birkmeyer, Birkmeyer. Arch Surg, 2002

19. LVH outcomes Meta-analysis Operative time Goodney, Birkmeyer, Birkmeyer. Arch Surg, 2002

20. LVH outcomes Meta-analysis Hospital stay Goodney, Birkmeyer, Birkmeyer. Arch Surg, 2002