Recurrence is one of the major problems after open incisional hernia repair. Laparoscopic incisional hernia repair has brought down the recurrence rate to less than 10%. The main causes of recurrence have been inadequate mesh size, fixation of mesh and patient factors. The issue of mesh fixation to the abdominal wall in laparoscopic ventral hernia repair is an area of ongoing debate. This prospective randomized study was done to compare the intra operative and post operative outcomes between two mesh fixation techniques in laparoscopic repair- Trans-fascial sutures alone vs Tacks and four corner sutures.
The study was conducted in a single surgical unit between 1st April 2007 to 31st May 2009. 50 patients were randomized using random numbers generated from www.randomisation.com and divided into two groups (Group I- tacker + four corner suture and Group II -suture fixation alone). Patients with defect size less than or equal to 25 cm2 were included in the study. Recurrent incisional hernias and patients with significant co morbidities were excluded from the study. In group I four corner polypropylene sutures and a double crown of tackers was used. In group II, for suture fixation, 2-0 polypropylene sutures were placed using modified epidural needle or a suture passer and were placed at a distance of 1.5 to 2 cm. Various intra operative variables and postoperative outcomes were recorded and analyzed. The variables were compared using chi – square and unpaired Student’s‘t’ test for qualitative and quantitative parameters as appropriate. A ‘p’ value of <0.05 was considered significant. Mann Whitney test was used for the comparative data analysis.
Fifty patients were randomized into two groups with 26 patients in Group I and 24 in Group II. The mean age of the patients was 46.3 years with a male to female ratio of 1: 2.1. Incisional hernia (60%) was the most common type seen in both the groups followed by primary ventral hernias (40%). The operative time was significantly higher in Group II (50 min. vs 76.3 min., p=0.001). Patients in Group I had significantly higher pain scores at 1 hour, 1 week, 1 month and 3 months postoperatively (p=0.001,p=0.0001, p=0.001, p=0.009 respectively). The incidence of seroma was higher in Group II (20.8% vs 11.5%, p=0.46). The cost of surgery was higher in Group I compared to Group II with a cost difference of about $2600 per procedure between the two groups.
For small and medium sized defects in anatomically accessible areas, suture fixation is a feasible alternative to tacker fixation in terms of intraoperative and postoperative outcomes with a significant advantage in early postoperative pain and significant cost reduction.