Surgical treatment of umbilical hernias: laparoscopy or laparotomy ? A prospective comparative study of 86 cases

GUIRAT Ahmed | HARBI Houssem | REJAB Haitham | TRIGUI Ayman | KCHAW Ali | KARDOUN Nizar | BEN AMEUR Hazem | AFFES Najmedine | BOUJELBEN Salah | ABID Bassem | FRIKHA Foued | BEN AMAR Mohamed | MZALI Rafik |

La tunisie chirurgicale - 2017 ; Vol 2017

Resumé

Aim: The aim of our study was to investigate the contribution of laparoscopy in the treatment of these hernias in terms of results in the short and medium term.

Patients and Methods: We report a prospective study about 86 cases of uncomplicated umbilical hernia operated by laparoscopy and laparotomy with a mean follow up of 3 years.

Results: Laparoscopy offers a shorter operative time, less wound infection rate and a shorter length of hospital stay compared to laparotomy. By against, the pain is more intense after laparoscopy. The overall surgical morbidity was similar between the 2 techniques. There was no mortality.

Conclusion: the laparoscopic approach is feasible and should be reserved for cases of large umbilical hernias.

Mots Clés

umbilical hernia, laparoscopy, mesh

Introduction :

Umbilical hernia represents a common reason for parietal surgery. Like any parietal hernia, the only curative treatment is surgical. Several techniques are proposed to date for the repair of this type of hernia. The aim purpose of these techniques is to have less morbidity, lower recurrence rates, the lower cost and less esthetical damage. In the last decade, most studies have focused on laparoscopic surgery but with conflicting results. We conducted a non-randomized prospective and comparative study including patients operated for white line hernia by laparoscopy or laparotomy. The aim of our study was to investigate the feasibility and results of laparoscopic approach in the treatment of umbilical hernia.

Article

PATIENTS AND METHODS

We conduct a prospective study extended between January to December 2012 and including 86 cases of umbilical operated in the department of surgery of Habib bourguiba’s hospital. All patients were followed for a period of 36  months. All operations were realized under general anaesthesia.

Patients were divided into two groups (group A: 42 cases operated by laparoscopy ; group B: 44 cases operated by laparotomy). The decision of the surgical technique was made by the surgeon and/or the patient.

A standardized surgical technique was adopted. For patients of groupe A, the creation of pneumoperitoneum at 12 mm Hg was made by «open laparoscopy» in all cases through the left flank. Three trocars were always used. We used an intra-peritoneal (polypropylene + PTFE) mesh measuring 10 x 10 cm. The fixation of the prosthetic mesh was made ​​by two techniques: absorbable Tackers (5mm) or non absorbable suture through a Reverdin needle. For patients of groupe B, the operation has consisted on dissection of hernia’s sac, enlargement of hernia nuck’s and fixation of adjusted prosthetic mesh prior the peritoneum.

The data for each observation were noted in a canvas including: age, sex, the patient's anterior medical history , the intra-abdominal hypertension factors , the body mass index (BMI = weight ( kg) / seize ² (cm) ; data of biological and imagery tests , the type of WLH and there characteristics (size, collar , length ); the performed operative procedures, intra operative incidents and conversions , the method of fixing the prosthetic mesh by laparoscopy : Reverdin or Tackers , duration of surgery, the short post operative courses : evaluation of post- operative pain based on a numerical scale ( EN) by asking patients to give a score from 0 to 10 (pain score was noted 0 as " no pain " while note 10 to "unbearable pain"), and the length of hospital stay. Post-operative complications in the medium term were also noted (12 months of follow-up for all patients). A postoperative clinical control was performed at 1 month, 6 months and 12 months to assess the degree of wound pain, detect recurrence or complications and the degree of patient satisfaction.

Data was analyzed through statistical software (SPSS 11.0), which allowed us to conduct a descriptive and analytical study of different data comparing the two methods of attaching the prosthetic mesh by laparoscopy: absorbable suture (Reverdin) versus Tackers and comparing the two approach modes. For qualitative data, the comparison was performed by the chi-square test and Fisher: a correlation is said to be significant if p was < 0.05. For comparison of quantitative variable, the ANOVA test was used with a significant correlation coefficient if p was < 0.05.

RESULTS:

The median age of patients was 52 years, with extremes ranging from 25 to 87 years. There were 35 men and 51 women with a sex ratio M/F = 0.7. Medical previous histories were present in 51 cases (61.6 % of patients) and were dominated by hypertension, chronic bronchitis and previous abdominal surgery. At least one factor of intra-abdominal hypertension was noted in 75 cases (87.2 %).

The two groups were similar in epidemiological (table I) and clinical parameters (table II). However there were more fat patients in the group B. The mean duration of laparoscopic surgery was lesser (40.4 minutes, with a range of 20 to 60 minutes) than the classic surgery (54.1 minutes with a range of 30 to 90 minutes; p = 0,002) (table III). One case of accidental perforation of the sigmoid colon was noted in group A, which was recognized per operatively and immediately sutured. No case of conversion in the group A has been noted in our series.

In immediate post-operative courses, all patients had intravenous analgesic drugs during the first 24 hours (association Paracetamol 3g / day and Tramadol 150mg / day). Pain, at the first postoperative day, was evaluated with a number average (EN) of 8.4 / 10 (range from 7 to 9) in group A, while it was at 5.8/10 for group B (range from 5 to 8). Eleven cases of medical post operative complications were noted without any significant difference between the two groups. Eleven chirurgical post operative complications were reported (12.8%): 6 cases in Group A (14.3%) (Subcutaneous hematoma: 2 cases, seroma: 4 cases), and 5 cases in Group B (11.3%) (4 wound infections; 1 subcutaneous hematoma); there was no significant difference between the two groups (table III). The restoration of transit and the average of postoperative hospital stay were significantly lesser in group A (table III).

One month after surgery, 57.1% of the Group A patients have described persistent parietal pain, while two patients reported serious difficulties to accomplish daily activities due to pain. In other patients (38%), the outcome was favorable with disappearance of pain and return to usual work and daily activities. For patients of group B, the outcome was favorable in 2/3 of patients, however parietal pain was noted in 12 cases (27.2%). two patients have presented a wound hematoma which was spontaneously resolved.

After 12 months, more than 2/3 of the cases operated on by laparoscopy had good evolution, while 12 patients have kept persistent parietal pain. For patients of group B, 90.6 % of cases showed good evolution, however, 4 patients have kept parietal pain.

After 36 months of intervention, no recurrence was noted.  Two women   of group A reported persistent umbilical parietal pain. No cause explaining the pain has been found. Abdominal computed tomography was performed and was normal. For patients operated by laparotomy, the courses were favorable in all cases. 

DISCUSSION

The incidence of umbilical difficult to assess. On a series of autopsied patients, its prevalence is estimated in the general population between 0.5 % and 10 % [1]. It is almost exclusively adult disease, with a male predominance. In adults, it is an acquired hernia. The diagnosis is usually made between thirty and forty years. Most published studies have investigated the role of laparoscopy including hernia, recurrent hernias and incisional hernias of the white line in the same batch. Recently, «the European Hernia Society » (EHS) recommended separating two entities: a group of abdominal hernia and a group of incisional and recurrent hernia [2].

Similarly, new recommendations on these hernias of the anterior abdominal wall were made in 2009 [3], they divided them according to two criteria: the seat and size. For that, there is small, medium or large epigastric or umbilical hernia (depending on the measurements in centimeters above or below 2 and 4 cm). We note that this classification does not considered size of the neck of the hernia.

A recent meta- analysis [4] have studied all the publications from 1950 to 2009 has selected 8 randomized controlled studies, including white line hernias and incisional white line hernias with a total of 526 patients. According to this meta-analysis, there is no significant difference in rates of " seroma " in six randomized controlled trials ( laparoscopy versus laparotomy: 11.7% vs 15.5% , RR = 1.22; p = 0.74) , hemorrhagic complications in 5 randomized controlled trials ( laparoscopy versus laparotomy: 1.5% versus 5.9% , RR 0.42 : p = 0.35) , intestinal accidental lesions ( laparoscopy versus laparotomy: 2.6 versus 0.9% , RR = 1.95; p = 0.34). Contrariwise, the risk of wound infection requiring removal of the prosthetic mesh is significantly lower in patients undergoing laparoscopic surgery, this result was found in 8 randomized controlled trials ( 1.5 % after laparoscopic versus 10.1 % after laparotomy result , RR = 0.22;  p = 0.001).

Pierce and al [5] studied 5340 patients undergoing surgery for hernias and incisional white line hernias reported in 45 studies. They found similar results with: less wound infections (1.3% against 10.4%, p <0.001), lower prosthetic infections (0.9% against 3.2%, p <0.001), lower hernia recurrence (4.3 against 12.1%, p < 0.001), and shorter duration of hospitalization (2.4 against 4.3 days, p < 0.001) in favor of laparoscopic surgery compared with conventional surgery.

Recently, some studies have been published, addressing only for the WHL and not for incisional and recurrent hernias. Cassie and al [6], who reported a retrospective multicenter study of 14652 umbilical hernias operated with 13109 cases by conventional surgery (89.5 %) and 1543 by laparoscopic one (10.5 %). The overall complication rate was almost similar (1.16% and 1.36 laparoscopy laparotomy, p = 0.49). Wound infections were significantly more frequent after laparotomy (1.55 % versus 0.65%, p = 0.005). Cardiac and respiratory morbidities were against more frequent after laparoscopy (0.52 % and 0.26 % versus 0.10 % and 0.05 %, respectively, p = 0.001 and p = 0.005 respectively).

More recently, Helgstrand and al [7] reported a large multicenter prospective study of 6783 patients undergoing umbilical hernia and epigastric surgery: 5601 patients who underwent conventional surgery (82.6 %) and 1149 patients (16.9 %) underwent laparoscopic surgery. This study found no significant difference in rates of surgical or medical complications and in terms of risk factors for readmission after one month of the intervention (p ≥ 0.229).

Data on postoperative pain after laparoscopic WHL repair are limited. Only a few studies have reported that postoperative pain is more intensive after laparoscopic surgery of incisional WLH in contrast so we should expect [8, 9, and 10]. No scientific explanation has been retained.

Similarly, other studies including incisional hernias [11, 12, and 13] found no significant difference in terms of chronic postoperative pain between the two techniques of fixation of the prosthetic mesh. Our series confirms the intensity of pain in the immediate postoperative courses and persistent chronic pain at 1 year of intervention in 4.7% of cases. Recently, some studies have focused on others methods for intra peritoneal fixation of the prosthetic mesh [14, 15]. The purpose was to reduce the rate of post operative pain. No conclusion was retained. Like for inguinal hernias, in which the use of fibrin glue has proved its utility for reducing the intensity and the rate of post operative chronic pain [16], feature studies should be focalized on the feasibility and results of fibrin glue as a method of fixation of the prosthetic mesh in WLH surgery.

The second problem raised in following up the operated WLH in the long term is represented by the recurrence. Thereof, studied with a follow-up in most studies not exceeding 5 years, is variable with often rates lesser than 10%. Heniford and al. [14] stressed the importance of the simultaneous fixation of the prosthetic mesh by both methods: non absorbable suture (using a Reverdin needle) and Tackers fixation. In a study of 60 patients, Riley and al [12] Found a rate of 8.3% of recurrence after a mean of 2.7 years. Jervild and al [15] Reported 11.4 % of cases of recurrence with a mean of 3 years of follow-up. According to Forbes and al [4], there was no significant difference in risk of recurrence after laparoscopic or laparotomic surgery for hernias or incisional white line hernias (3.4% versus 3.6% respectively, RR = 1.02, p = 0.80).

CONCLUSION:

In conclusion, according data in the literature and in our series, it appears that laparoscopic surgery of umbilical hernia is feasible with almost equivalent or better results than laparotomy. Laparoscopic surgery offer the advantages of better esthetical results and lesser wound infection rates. More studies are required to evaluate other methods of fixation of prosthetic mesh, postoperative pain and its impact on quality of life. Meanwhile, we recommend to reserve the laparoscopic approach for large umbilical hernias that allows take advantage of the esthetical and infectious outcomes.

 

Table I : comparison of epidemiological parameters of the 2 groups

 

Laparoscopy

Laparotomy

p

Age

52 ans

55 ans

0,3

Sex Ratio M/F

1,8

0,23

0,0001

Previous history

Medical

24 (57 ,1%)

27 (61,36%)

0,95

Surgical

11 (26,1%)

15 (34%)

0,4

Obesity

9 (21,4%)

21 (47,7%)

0,002

Chronic Bronchitis

0

1 (1,2%)

0,5

Carrying heavy loads

14 (33,3%)

13 (29,5%)

0,7

Chronic constipation

6 (14,2%)

13 (29,5%)

0,08

multiple pregnancies

13 (30,9%)

31 (70,4%)

0,9

Prostate adenoma

7 (16,6%)

3 (6,8%)

0,5

 

 

Table II : Characteristics of hernias according to the two groups

 

Laparoscopy

Laparotomy

p

History of hernia (in months)

<12

14 (33,3%)

9 (20,4%)

0,6

12-24

9 (21,4%)

11 (25%)

24-36

6 (14,2%)

8 (18,1%)

>36

13 (30,9%)

16 (36,3%)

Mean size of the hernia (cm)

4,45

4,79

0,3

Mean size of the neck of the hernia (cm)

1,64

1,72

0,6

Seat

Umbilical

26 (61,9%)

26 (59%)

0,4

Epigastc

15 (35,7%)

14 (31,8%)

sub umbilical

1 (2,3%)

4 (9%)

 

Table III: Comparative table of postoperative results of the white line hernia after laparoscopy and laparotomy.

Parameters

LAPAROSCOPY

N=42 cases

LAPAROTOMY

N=44 cases

p

Operative time (minutes)

40,4

54,1

0,002

Mean Intensity of pain (EN)

8,4/10

5,8/10

0,0001

Medical complications

5 (11,9%)

6 (13,6%)

        0,25       

Surgical complications

6 (14,3%)

5 (11,4 %)

0,096

Wound infection

0

4 (9,1%)

0,032

Average of transit restoration (day)

1,5

2,3

0,0001

Average of postoperative hospital stay (day)

2,9

4,8

0,002

 

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