**6.10 Costs**

188 Updated Topics in Minimally Invasive Abdominal Surgery

inflammation [26]. Asencio et al. showed in their study that 22% of the laparoscopic group and 7% of the open group reported significantly pain three months after the operation [13]. But all were pain free one year after the operation [13] . Therefore when pain persists a surgical revisions due to nerve irritation is not recommended earlier than 6 months. Alternatively a postoperative local injection of bupivacaine and steroids or removal of the

Recurrence rate is one of the most important long-term outcome parameters in laparoscopic incisional hernia repair. Forbes et al. showed in their meta-analysis no difference in the recurrence rate between laparoscopic and open incisional hernia repair [18]. The pooled recurrence rate in the laparoscopic group was 3.4% and in the open group 3.5% in this study. Such a low recurrence rate after either laparoscopic and open repair can be explained with a relatively short follow-up and the small size of the hernias [18]. A follow-up of at least three years is mandatory to evaluate correctly the real incidence of incisional hernia due to the fact that incisional hernia can occur up to 5 years after the operation. With such a long-term follow-up the incidence of recurrence has been reported to be up to 15-20% in

Two technical details can minimize the recurrence rate. First a sufficient overlap of the mesh and second the mesh fixation. We showed a significant decrease in horizontal mesh size after tack fixation (mean difference -3.1% ±3.9%) versus fixation using sutures (-0.1% ±2.3%; p=0.018) [26]. Mean vertical mesh size was not significantly different between the two groups: tack fixation -2.8% ±6.1%, suture fixation -0.7% ±4.1% (p=0.16). Mean mesh area in the tack fixation group was -12% and in the suture fixation group -2.9% at 6 months post operatively when compared to post-op day 2 (p=0.061) [26]. Therefore a sufficient mesh-

Typical locations for hernia recurrences due to the mesh shrinkage are at the margin of the mesh as shown in Fig. 6. Because the risk to gain a second incisional hernia or a recurrent hernia along the full length of the incision, it is recommended to cover the whole length of

The retained hernia sac is responsible for seroma formation. Seroma formation is classified as a complication if it lasts more than 6 weeks after the operation. A randomized controlled trial of Olmi et al. showed an incidence of seroma formation of 7% [15]. In most cases no intervention is necessary. In cases of symptoms or if the seroma lasts longer than 8 weeks a drainage is recommended. Potentially a compression dressing over a period of 7 days may

Forbes et al. showed in their meta-analysis that duration of hospital stay is significantly shorter in laparoscopic incisional hernia repair compared to open surgery [18]. Less amount of pain [24] and a significantly lower rate of surgical site infections in laparoscopic repair [18] are reflected in a shorter hospital stay. Influence of shorter hospital stay on overall costs

overlap of the hernial orifice is mandatory in order to reduce recurrence rate.

offending suture is recommended [27].

laparoscopic and open repair [11, 13].

the incision during the first operation.

in laparoscopic hernia repair is discussed below.

**6.8 Seroma formation** 

prevent seroma formation.

**6.9 Hospitalisation time** 

**6.7 Recurrence rate** 

On the one hand operative costs of laparoscopic incisional hernia repair compared to open surgery are significantly higher due to expensive surgical tools in laparoscopy. On the other hand in hospital costs are significantly lower in laparoscopic surgery due to shorter hospital stay, lower infection rate and less postoperative pain. However, laparoscopic incisional hernia repair is associated with significant lower overall costs. Therefore laparoscopic incisional hernia repair is cost effective [15, 28].

Fig. 6. Intraoperative laparoscopic view of a recurrent hernia along the incision at the edge of the mesh.

Laparoscopic Incisional Hernia Repair 191

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