Systematic review

Meta-analysis of closure of the fascial defect during

laparoscopic incisional and ventral hernia repair
A. Tandon1 , S. Pathak3 , N. J. R. Lyons3 , Q. M. Nunes1,2 , I. R. Daniels3 and N. J. Smart3
1
Department of General Surgery, Aintree University Hospital, and 2 National Institute for Health Research Liverpool Pancreas Biomedical Research
Unit, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Department of Molecular and Clinical Cancer Medicine, University of
Liverpool, Liverpool, and 3 Exeter Surgical Health Services Research Unit, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
Correspondence to: Mr N. J. Smart, Department of Colorectal Surgery, Royal Devon and Exeter Hospital, Barrack Road, Exeter EX2 5DW, UK
(e-mail: drneilsmart@hotmail.com)

Background: Laparoscopic incisional and ventral hernia repair (LIVHR) is being used increasingly, with
reported outcomes equivalent to those of open hernia repair. Closure of the fascial defect (CFD) is a
technique that may reduce seroma formation and bulging after LIVHR. Non-closure of the fascial defect
makes the repair of larger defects easier and reduces postoperative pain. The aim of this systematic
review was to determine whether CFD affects the rate of adverse outcomes, such as recurrence,
pseudo-recurrence, mesh eventration or bulging, and the rate of seroma formation.
Methods: A systematic search was performed of PubMed, Ovid, the Cochrane Library, Google Scholar
and Scopus to identify RCTs that analysed CFD with regard to rates of adverse outcomes. A meta-analysis
was done using fixed-effect methods. The primary outcome of interest was adverse events. Secondary
outcomes were seroma, postoperative pain, mean hospital stay, mean duration of operation and surgical
techniques employed.
Results: A total of 16 studies were identified involving 3638 patients, 2963 in the CFD group and 675
in the non-closure of facial defect group. Significantly fewer adverse events were noted following CFD
than non-closure (4⋅9 per cent (79 of 1613) versus 22⋅3 per cent (114 of 511)), with a combined risk ratio
(RR) of 0⋅25 (95 per cent c.i. 0⋅18 to 0⋅33; P < 0⋅001). CFD resulted in a significantly lower rate of seroma
(2⋅5 per cent (39 of 1546) versus 12⋅2 per cent (47 of 385)), with a combined RR of 0⋅37 (0⋅23 to 0⋅57;
P < 0⋅001), and shorter duration of hospital stay. No significant difference was noted in postoperative pain.
Conclusion: CFD during LIVHR reduces the rate of seroma formation and adverse hernia-site events.

Paper accepted 10 June 2016

Published online 22 August 2016 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.10268

Introduction shorter hospital admissions than open hernia repairs6 – 9 .

Abdominal wall hernia, primary ventral hernia and con-
genital incisional hernia are common, and often require
surgical treatment. It is estimated that 3–20 per cent1 of
abdominal incisions are complicated by incisional hernia,
with significantly higher rates after postoperative wound
infection2,3 . There is debate about the optimal manage-
ment of incisional and ventral hernias4 . Surgical techniques
employed for the repair of primary and recurrent hernia
are similar5 .
Most laparoscopic incisional and ventral hernia repairs
(LIVHRs) use the technique of placing an intraperitoneal
onlay mesh, effectively bridging the hernia defect fol-
lowing reduction of the hernia contents, but leaving the
hernia sac in situ. Non-fascial closure techniques have
lower rates of postoperative pain and wound infection, and
However, an unsightly swelling at the hernia site is
common7 . Swelling at the site of laparoscopic repair due
to the sac remnant has been variably described in the liter-
ature using terms such as bulging, pseudo-recurrence and
mesh eventration, which appear to be synonymous. These
outcomes are different from true recurrence, defined on
cross-sectional imaging such as CT where there is dis-
ruption of the continuity of the anterior abdominal wall
fascia at the hernia site. Although various attempts have
been made to clarify this distinction, it does not matter
to the patient who is left with a symptomatic swelling at
the hernia site following LIVHR, especially if they require
further surgery10 . For research purposes, a composite out-
come encompassing all these adverse events at the hernia
site is more likely to reflect the patient’s perspective.

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Closure of the fascial defect during laparoscopic incisional and ventral hernia repair 1599

a Division of adhesions b Insertion of needle grasper c Needle grasper on both sides of defect

d Insertion of interrupted sutures e Sutures tied to close defect f Mesh tacked over repair

Fig. 1Fascial closure of incisional hernia using extracorporeal technique. a Adhesions are divided and the hernia defect defined. b A
suture needle grasper is inserted percutaneously through the hernia sac loaded with a braided 1 nylon suture. c The needle grasper is
passed through the tissue on both sides of the defect. d Multiple interrupted sutures are placed using this technique at approximately
1⋅5–2-cm intervals. e With pneumoperitoneum released, the sutures are tied to close the defect and obliterate the hernia sac; the knots
are buried under the skin. f An intraperitoneal onlay mesh is tacked over the repair

Closure of the fascial defect (CFD) techniques11 aim to
restore the integrity, and hence function, of the abdominal
wall (Fig. 1). The underlying principle is that, by closing
the surgical dead space, seroma formation will reduce,
cosmesis will improve and recurrence will decrease as
the abdominal wall muscle layer is intact with the rectus
muscles restored to the midline position. As with many
surgical techniques, there are few published studies com-
paring these techniques, often limited to single-centre
series with significant variation in results12 .
The aim of this systematic review was to determine
the effectiveness of LIVHR, with regard to the frequency
of adverse hernia-site outcomes, defined as a combina-
tion of recurrence, pseudo-recurrence, mesh eventration or
bulging, as well as important secondary outcome measures
such as seroma, following CFD or non-closure repairs.
Methods
(PubMed, Ovid, Scopus, Cochrane Library, Google
Scholar) was conducted independently by two authors.
Search terms used included: ‘primary closure’ OR ‘trans-
cutaneous closure’ OR ‘extracorporeal closure’ AND
‘laparoscopic ventral hernia repair’ OR ‘incisional hernia’.
To achieve maximum sensitivity, all search terms were
combined with Boolean operators and searched as both
keywords and medical subject heading (MeSH) terms. All
citations and abstracts identified were reviewed thoroughly.
The last date for this search was 11 January 2016.
Inclusion criteria
Included studies considered the effects of CFD, with
respect to adverse outcomes described below, after LIVHR
compared with non-closure, where available. When insti-
tutions published duplicate or overlapping data sets, only
the most recent or best quality reports were included.

Search strategy Exclusion criteria

The search was undertaken according to the PRISMA Studies were excluded if they were case reports or small case
guidance13 . An electronic search of several databases series (fewer than 10 procedures)14 , conference abstracts

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1600 A. Tandon, S. Pathak, N. J. R. Lyons, Q. M. Nunes, I. R. Daniels and N. J. Smart

and editorials. Non-English-language reports were also Potentially relevant studies identified
excluded. through databases and screened for
retrieval
n = 8101

Outcome measures Excluded n = 5567

Duplicate study n = 5226
This study combined all terms of recurrence, Non-English study n = 189
pseudo-recurrence, mesh eventration, tissue eventra- Animal study n = 152

tion, clinical eventration or bulging into a single category

Relevant studies retrieved for more
of adverse hernia-site outcome. This was the primary detailed evaluation
outcome for the review. Secondary outcome measures n = 2534
were seroma formation, postoperative pain, mean duration
Excluded n = 2470
of hospital stay, mean duration of surgery and surgical Title and abstract screening n = 2414
technique (laparoscopic/robot-assisted, intracorporeal/ Case report n = 56
extracorporeal defect closure), and for comparative studies
Potentially appropriate studies to be
CFD or non-closure of the fascial defect. included in the analysis
n = 64

Study selection Excluded n = 47

Inappropriate outcomes n = 39
Two authors implemented the search strategy indepen- Case series (< 10 patients) n = 8
dently. Both reviewed the abstracts identified by the search
to exclude those that did not meet the inclusion criteria. Studies included in analysis
n = 17
When no abstract was available or the abstract details were
inadequate, the full article was reviewed. Differences of
Excluded n = 1
opinion were resolved by consensus with the senior author. Conference abstract n = 1

Studies with usable information

Data extraction n = 16

Primary and secondary outcome data were collected using

a standard form. Any disagreement was resolved by con-
sensus. Study characteristics (first author, year of pub-
lication, study design) and patient demographics (age,
sex) were also recorded. Other data extracted were: mesh
size, patient characteristics (demographics and mean her-
nia defect size), co-morbidities and study characteristics
(number of patients, type of study and mean follow-up).
Diagnosis of seroma formation and recurrence of inci-
sional hernia could be clinical or radiological (detected
by ultrasound imaging or CT). Where the data pro-
vided in the included studies were insufficient, the corre-
sponding author of the study was contacted and the raw
data requested.
Statistical analysis
Statistical analysis was undertaken with RevMan version
5.3 (The Cochrane Collaboration, The Nordic Cochrane
Centre, Copenhagen, Denmark). Data were pooled and
risk ratios (RRs) as well as standard mean differences were
calculated with their 95 per cent confidence intervals. A
fixed-effect model was used for meta-analysis15 . Hetero-
geneity was tested and reported using the I 2 value.
Fig. 2 PRISMA diagram showing study selection for the review
Quality assessment
The Methodological Index for Non-Randomized Studies
(MINORS)16 was used to evaluate the methodological
quality and potential bias of the articles selected for this
review.
Results
Description of included studies
The search strategy returned 8101 articles, of which 2534
remained after exclusion of duplicates. These articles were
reviewed by title and screened. After exclusion of review
articles, letter, case reports, non-English-language stud-
ies and studies reporting inappropriate outcome mea-
sures, 64 articles were taken forward for abstract review
(Fig. 2). A further 47 were then excluded, leaving 17 arti-
cles for full-text review. One was rejected at this stage as
it was a conference abstract and failed to provide sufficient
detail for inclusion. The remaining 16 articles11,17 – 31 were

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Closure of the fascial defect during laparoscopic incisional and ventral hernia repair 1601

Table 1 Patient characteristics, study type and quality scoring

No. of patients
Country Mean follow-up MINORS
Reference of origin Study type Total (M : F) CFD NCFD Age (years)* BMI (kg/m2 )* (months) score

Franklin et al.25 USA Retrospective 384 (172 : 212) 384 – 58⋅2 – 47⋅1 7
Palanivelu et al.23 India Retrospective 736 (108 : 613‡) 721 15 – – 50 5
Palanivelu et al.24 India Retrospective 17 (5 : 12) 17 – 55⋅9 (23–76) 30 (25–35) – 10
Agarwal et al.21 India Prospective 29 (9 : 20) 29 – 39 (22–67) 35⋅6 (20–74) 34 12
Agarwal et al.27 India Retrospective 30 (−) 30 – – – 58 12
Sharma et al.26 India Retrospective 75 (−) 17 58 – – 52 NCDF; 16 CFD 4
Orenstein et al.20 USA Retrospective 47 (21 : 26) 47 – 56 (30–85) 31⋅8 (22–50) 16⋅2 7
Rea et al.18 Italy Retrospective 132 (−) 87 45 – – – 10
Liang et al.19 USA Retrospective 22 (6 : 16) 22 – 52 35 21 9
Allison et al.30 USA Retrospective 13 (5 : 8) 13 – 51⋅2 31⋅5(4⋅4)† 23 7
Banerjee et al.29 USA Retrospective 193 (−) 67 126 49⋅9 (17–81) 35⋅6 (20–74) 10⋅5 15
Clapp et al.22 USA Retrospective 176 (42 : 30) 36 140§ – – 24 16
Zeichen et al.17 USA Retrospective 128 (53 : 75) 35 93 63⋅3 (26–91) 31 (20–71) 26⋅5 14
Gonzalez et al.28 USA Retrospective 134 (47 : 87) 67 67 57⋅5 27 (20–39) 48 18
Wennergren et al.31 USA Retrospective 196 (101 : 95) 97 99 52⋅8 32⋅7 17⋅5 18
Chelala et al.11 Belgium Retrospective 1326 (629 : 697) 1294 32 52⋅2 (19–95) 32⋅6 (21–66) 78 11

*Values are mean (range) unless indicated otherwise; †values are mean(s.d.). ‡Numbers for closure of fascial defect (CFD) only. §Thirty-six controls
included in case-matched analysis. NCFD, non-closure of fascial defect; MINORS, Methodological Index for Non-Randomized Studies.

Table 2 Hernia sizes and clinical outcomes

Adverse hernia-site outcomes

Mesh Tissue Clinical eventration/

Seroma formation (%) Recurrence eventration eventration bulging
Defect diameter or area
Reference in CFD group* CFD NCFD CFD NCFD CFD NCFD CFD NCFD CFD NCFD

Franklin et al.25 n.r. 3⋅1 – 2⋅9 – n.r. – n.r. – n.r. –

Palanivelu et al.23 96 (11–128) cm2 7⋅6 n.r. 0⋅6 n.r. n.r. n.r. n.r. n.r. n.r. n.r.
Palanivelu et al.24 87⋅5 (6–169) cm2 8 – 6 – n.r. – n.r. – n.r.
Agarwal et al.21 5⋅7 (3–10) cm 0 – 0 – n.r. – n.r. – 0 –
Agarwal et al.27 9⋅6 cm 0 – 0 – n.r. – n.r. – 0 –
Sharma et al.26 16⋅5 cm2 ‡; 16⋅2 cm2 § (15⋅8 cm2 NCFD) 0 14 0 3 n.r. n.r. n.r. n.r. 0 21
Orenstein et al.20 82 cm2 0 – 0 – n.r. – n.r. – 0 –
Rea et al.18 n.r. 12 n.r. 0 n.r. n.r. n.r. n.r. n.r. n.r. n.r.
Liang et al.19 37 cm2 0 – 0 – 0 – 0 – 0 –
Allison et al.30 37⋅4(35⋅6) cm2 † 0 – 8 – n.r. – n.r. – n.r. –
Banerjee et al.29 41⋅2 (1–500) cm2 n.r. n.r. 3 5⋅0 n.r. n.r. n.r. n.r. n.r. n.r.
Clapp et al.22 28⋅1(6⋅8) cm2 † 6 27⋅8 0 16⋅7 0 41⋅4 4 37⋅9 8 69⋅4
Zeichen et al.17 44⋅0 (9–225) cm2 11 4 6 19 n.r. n.r. n.r. n.r. n.r. n.r.
Gonzalez et al.28 n.r. 0 3 2 8 n.r. n.r. n.r. n.r. n.r. n.r.
Wennergren et al.31 20 cm2 8 14 20 18 n.r. n.r. n.r. n.r. n.r. n.r.
Chelala et al.11 n.r. 1⋅9 30 2⋅5 63 n.r. n.r. n.r. n.r. 2 40

*Values are mean (range) unless indicated otherwise; †values are mean(s.d.). ‡Continuous; §interrupted. CFD, closure of fascial defect; NCFD,
non-closure of fascial defect; n.r., not reported.

included. There were no RCTs; there was one prospective
trial21 and 15 retrospective case series (Table 1).
Study and patient characteristics
A total of 3638 patients were included in the study: 2963
had CFD and 675 had non-closure of the fascial defect. The
mean age was reported in 11 studies11,17,19 – 21,24,25,28 – 31
and ranged from 39 to 63⋅3 years. Mean BMI was
reported in ten studies11,17,19 – 21,24,28 – 31 , with a range of
27–35⋅6 kg/m2 (Table 1). Mean defect sizes were reported
in 12 studies as either diameter (5⋅7–9⋅6 cm)21,27 or
area (15⋅8–96 cm2 )17,19,20,22 – 24,26,29 – 31 (Table 2). Median
hernia size was not reported. Duration of follow-up
was reported in all studies, and ranged from 10⋅5 to
78 months (Table 1). Co-morbidities (diabetes mellitus,

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1602 A. Tandon, S. Pathak, N. J. R. Lyons, Q. M. Nunes, I. R. Daniels and N. J. Smart

Adverse hernia-site outcomes

Reference CFD NCFD Weight (~) Risk ratio Risk ratio
Sharma et al.26 0 of 17 14 of 58 5·2 0·11 (0·01, 1·80)
Banerjee et al.29 2 of 67 6 of 126 3·2 0·63 (0·13, 3·02)
Zeichen et al.17 2 of 35 14 of 93 5·9 0·38 (0·09, 1·59)
Clapp et al.22 3 of 36 25 of 36 19·3 0·12 (0·04, 0·36)
Gonzalez et al.28 1 of 67 5 of 67 3·9 0·20 (0·02, 1·67)
Wennergren et al.31 19 of 97 18 of 99 13·7 1·08 (0·60, 1·93)
Chelala et al.11 52 of 1294 32 of 32 48·8 0·04 (0·03, 0·05)

Total 79 of 1613 114 of 511 100·0 0·25 (0·18, 0·33)

Heterogeneity: 2 = 199·83, 6 d.f., P < 0·001; I2 = 97~
Test for overall effect: Z = 9·40, P < 0·001 0·01 0·1 1 10 100
Favours CFD Favours NCFD

Fig. 3Forest plot comparing adverse hernia-site outcomes after laparoscopic incisional and ventral hernia repair with (CFD) and
without (NCFD) closure of the fascial defect. A Mantel–Haenszel fixed-effect model was used for meta-analysis. Risk ratios are shown
with 95 per cent confidence intervals

Seroma formation
Reference CFD NCFD Weight (~) Risk ratio Risk ratio
Sharma et al.26 0 of 17 8 of 58 7·9 0·19 (0·01, 3·18)
Clapp et al.22 2 of 36 10 of 36 20·0 0·20 (0·05, 0·85)
Zeichen et al.17 4 of 35 4 of 93 4·4 2·66 (0·70, 10·05)
Gonzalez et al.28 0 of 67 2 of 67 5·0 0·20 (0·01, 4·09)
Wennergren et al.31 8 of 97 14 of 99 27·7 0·58 (0·26, 1·33)
Chelala et al.11 25 of 1294 9 of 32 35·1 0·07 (0·03, 0·14)

Total 39 of 1546 47 of 385 100·0 0·37 (0·23, 0·57)

Heterogeneity: 2 = 34·33, 5 d.f., P < 0·001; I2 = 85~
Test for overall effect: Z = 4·38, P < 0·001 0·01 0·1 1 10 100
Favours CFD Favours NCFD

Fig. 4Forest plot comparing seroma formation after laparoscopic incisional and ventral hernia repair with (CFD) and without (NCFD)
closure of the fascial defect. A Mantel–Haenszel fixed-effect model was used for meta-analysis. Risk ratios are shown with 95 per cent
confidence intervals

chronic obstructive pulmonary disease and smoking status)
were recorded in five studies: three non-comparative20,21,27
and two comparative22,31 studies (Table S1, supporting
information).
Primary outcome
Adverse events in the form of recurrence, pseudo-
recurrence, mesh eventration, tissue eventration or clinical
eventration/bulging were reported in a number of stud-
ies. Seven studies11,19 – 22,26,27 reported mesh eventration,
tissue eventration and clinical eventration, three11,22,26
of which were comparative studies (Table 2). All studies
provided rates of recurrence for the CFD group. Seven
studies11,17,22,26,28,29,31 reported a comparator recurrence
rate after non-closure. The results from various types of
eventration and recurrence were pooled, which demon-
strated fewer total adverse hernia-site events after CFD
than no closure (4⋅9 per cent (79 of 1613) versus 22⋅3 per
cent (114 of 511)), with a combined risk ratio (RR) of 0⋅25
(95 per cent c.i. 0⋅18 to 0⋅33; P < 0⋅001). Heterogeneity
was 97 per cent (Fig. 3).
Secondary outcomes
Seroma formation
Seroma formation was reported by 15 studies11,17 – 28,30,31
with rates ranging from 0 to 12 per cent (Table 2). Six
studies11,17,22,26,28,31 had a comparator non-fascial closure
group. There were significantly higher rates of seroma

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Closure of the fascial defect during laparoscopic incisional and ventral hernia repair 1603

Table 3 Secondary outcome measures

Hospital stay (days)* Duration of surgery (min)*

Method of
Reference CFD NCFD Pain CFD NCFD defect closure

Franklin et al.25 2⋅9 (0–36) – n.r. 68 (14–405) – Extracorporeal

Palanivelu et al.23 2 (1–6) n.r. 5% 95 (60–115 ) n.r. Intracorporeal
Palanivelu et al.24 1⋅5 (1–2) – 1 (> 5 weeks) 95 (65–125) – Intracorporeal
Agarwal et al.21 1 (0⋅5–3) – 4 had hernia-site 65 (50–135) – Extracorporeal
pain at week 1
Agarwal et al.27 n.r. – n.r. 90 (75–110) – Extracorporeal
Sharma et al.26 n.r. n.r. 7 days after 139 95 Intracorporeal
surgery: 2 in
CFD, 11 in NCFD
group had pain
Orenstein et al.20 2⋅9 (1–10) – n.r. 134 (40–280) – Extracorporeal
Rea et al.18 3 n.r. 48 h after CFD n.r. n.r. Extracorporeal
surgery: 37 with
VAS score 1–3,
48 with VAS
score 4–6, 2 with
VAS score
7–10
Liang et al.19 1 (0–3) – n.r. n.r. – Extracorporeal
Allison et al.30 2⋅4(1⋅1)† – n.r. n.r. – Intracorporeal
Banerjee et al.29 n.r. n.r. n.r. n.r. n.r. Extracorporeal
Clapp et al.22 1⋅33(0⋅17)† 3⋅77(0⋅98)† Worst pain score: n.r. n.r. Extracorporeal
2⋅47(0⋅46)‡ CFD
3⋅68(0⋅76)‡ NFCD
Zeichen et al.17 1⋅23 (1–3) 1⋅38 (1–6) n.r. 89⋅0 (45–143) 75⋅0 (18–215) Intracorporeal and
extracorporeal
Gonzalez et al.28 2⋅5 3⋅7 n.r. 107⋅6(33⋅9) (61–198)§ 87⋅9(53⋅1) (23–279)§ Intracorporeal
Wennergren et al.31 n.r. n.r. n.r. n.r. n.r. n.r.
Chelala et al.11 2 (1–30) 2 Transient pain VAS 68⋅4 (35–180) 60 Intracorporeal and
score 5–7 in extracorporeal
3⋅2%
Chronic pain in
2⋅6%

*Values are mean (range) unless indicated otherwise; values are †mean(s.d.), ‡mean(s.e.m.) and §mean(s.d.) (range). CFD, closure of fascial defect; NCFD,
non-closure of fascial defect; n.r., not reported; VAS, visual analogue scale.

formation after non-fascial closure (2⋅5 per cent (39 of Methods and type of recording of pain were highly variable
1546) versus 12⋅2 per cent (47 of 385)), with a combined between studies, limiting comparison (Table 3).
RR of 0⋅37 (95 per cent c.i. 0⋅23 to 0⋅57; P < 0⋅001). The
heterogeneity in the studies was also high at 85 per cent
Duration of operation
(Fig. 4).
The mean duration of surgery was reported in ten
studies11,17,20,21,23 – 28 (Table 3), and was between 68 and 139
Duration of hospital stay
(range 14–405) min for CFD and from 60 to 95 (range
The mean hospital stay was reported by 12 studies, with
18–279) min for non-fascial closure. Four studies11,17,26,28
a range of 1–3 days in the CFD group11,17 – 25,28,30 . Four
compared the mean duration between the procedures, but
studies11,17,22,28 compared hospital stay between the tech-
statistical analysis was not possible because the ranges were
niques and it was found to be significantly shorter with
not provided. One study28 used a robotically assisted tech-
CFD (mean difference −0⋅36, 95 per cent c.i. –0⋅56 to
nique that took significantly longer for CFD (mean(s.d.)
−0⋅16; P < 0⋅001) (Fig. S1, supporting information).
107⋅6(33⋅9) versus 87⋅9(53⋅1) min; P = 0⋅012).

Pain
Postoperative pain was compared between groups in only Fascial closure technique
one study22 , which demonstrated no significant difference Both intracorporeal and extracorporeal approaches
in pain scores (mean(s.e.m.) 2⋅47(0⋅46) versus 3⋅68(0⋅76)). were used for CFD. Eight studies18 – 22,25,27,29 used an

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1604 A. Tandon, S. Pathak, N. J. R. Lyons, Q. M. Nunes, I. R. Daniels and N. J. Smart
extracorporeal approach alone, five23,24,26,28,30 intra-
corporeal only and two11,17 used combinations of the
techniques.
Quality of studies
The quality of the studies was evaluated using MINORS
criteria. None of the studies in this review reached the
minimum global score of 16 for non-comparative and 24
for comparative studies. The maximum score achieved was
12 for non-comparative studies21,27 and 18 for comparative
studies28,31 (Table 1).
Discussion
Incisional hernias are common after abdominal surgery1 ;
laparoscopic repair has advantages over open repair includ-
ing lower rates of wound infection, shorter hospital admis-
sion and less pain. There is no improvement in the rate of
recurrence7 – 9 . This systematic review examined whether
CFD before mesh placement reduces rates of common
adverse complications.
CFD appears to have improved outcomes compared with
non-closure techniques, with significantly lower rates of
adverse wound complications and seroma formation. It also
has a shorter duration of hospital stay, although there was
a tendency towards longer operating times in the CFD
group. The two techniques could not be compared with
respect to postoperative pain as this outcome was reported
inadequately in most of the included studies.
LIVHR with CFD has generally better outcomes than
when the fascial defect is left open; however, it has lim-
itations when the hernia defect is large. Patients with a
large defect are likely to require component separation to
repair the hernia, which requires open surgery. Although
there is no definition of a large defect in the literature,
defects of more than 10 cm have been considered large in
studies that have investigated component separation32,33 .
Moreno-Egea and colleagues34 reported that patients with
large defects have a higher risk of recurrence. The abdom-
inal wall is a dynamic structure relying on variable com-
pliance governed by muscle contraction to lend rigidity
to an otherwise soft structure, a process that is under-
mined by defects in the abdominal fascia35,36 . Increases
in intra-abdominal pressure required to generate rigid-
ity will lead to eventration of mesh/abdominal contents if
the hernia defect remains open. Although cross-sectional
imaging, such as CT, has been recommended to identify
and define adverse hernia-site outcomes37 , the patient is
unlikely to appreciate the difference between recurrence
and pseudo-recurrence if they still have a palpable and
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unsightly bulge following the procedure. The principles
of repairing a hernia are resection of the sac and closure
of the defect38 . LIVHR is not exempt from these princi-
ples. Seroma formation is a separate pathology, and itself
causes unsightly bulging; it can also lead to secondary infec-
tion. Removing the peritoneal sac24 , closure of the dead
space after closure of the defect and/or decreased mesh
contact with the sac are all ways to reduce the risk of seroma
formation19 .
Defects in the abdominal wall alter the compliance
experienced locally by tissues39,40 . CFD is likely to reduce
local stress on scarred tissue that already has reduced
tensile strength41 . It leads to a restoration of abdomi-
nal wall integrity and better distribution of tension across
the repaired abdominal wall and mesh11 . It has also been
hypothesized that CFD increases the size of the overlap
ratio of mesh to defect12 and increases the contact sur-
face area of the mesh with the abdominal wall, which is
likely to promote improved tissue ingrowth and strength of
the repair11 . The technique of primary fascial closure with
mesh reinforcement also reduces recurrence after open
repairs of abdominal wall defects42 . Although increasing
the size of a mesh will mitigate against mesh migration,
misplacement and contracture, the role of synthetic mesh
is in promoting a fibrotic scar and providing a mechan-
ical barrier against early recurrence. The synthetic mesh
does not form a long-term structural barrier. Patients with
an incisional hernia have already had one failed primary
wound closure and may well represent a different group
from those with primary ventral hernia. It may be beneficial
to use guidelines such as those from the Palmero Consen-
sus meeting in practice and for reporting future studies43 .
Although both extracorporeal and intracorporeal sutur-
ing (or a combination) for CFD were used in studies
included in this meta-analysis, none compared these sutur-
ing methods. It has been suggested that the placement of
extracorporeal sutures facilitates better closure of a large
hernia defect, allowing desufflation of the abdomen and
relatively decreased tension along the suture line (Fig. 1).
This technique, however, requires multiple skin incisions,
which may increase the risk of infection12,18 . The included
studies also reported the use of absorbable as well as
non-absorbable sutures for CFD, but these were not com-
pared formally.
There are several limitations associated with this review.
First, only non-randomized studies could be included.
Their inclusion in meta-analysis remains controversial but
they are increasingly being included44 . Although RCTs are
designed to minimize the risk of bias, their selection criteria
are sometimes restrictive, which may not be the case with
observational studies, which are often more representative
www.bjs.co.uk BJS 2016; 103: 1598–1607
Closure of the fascial defect during laparoscopic incisional and ventral hernia repair
of routine clinical practice45 . Furthermore, information
from well conducted meta-analyses of non-randomized
studies can play an important role in informing practice46
and identify areas for future investigation47 . The exclusion
of studies in languages other than English may introduce a
language bias, but this is minimal in meta-analyses48 . There
were small numbers of patients in mostly single-centre,
retrospective studies, which also increased the risk of bias
(Table 1). The follow-up in the included studies was highly
variable. The variability in study quality means that conclu-
sions must be guarded. There was heterogeneity in surgical
technique, in both materials and methods, in these studies
of LIVHR.
Based on the present analysis, adoption of CFD dur-
ing LIVHR would reduce seroma formation and adverse
hernia-site outcomes. This raises the issue of why the
principles of hernia repair are not employed routinely for
LIVHR in favour of bridging techniques.
Acknowledgements
The authors are grateful to A. Bhargava of Barking Haver-
ing and Redbridge University Trust, UK, for permission to
reproduce photographs of his surgical technique for CFD
with extracorporeal sutures.
Disclosure: The authors declare no conflict of interest.
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Closure of the fascial defect during laparoscopic incisional and ventral hernia repair 1607

Supporting information

Additional supporting information may be found in the online version of this article:
Table S1 Patient co-morbidities (Word document)
Fig. S1 Forest plot comparing mean hospital stay between closure versus non-closure of the fascial defect (Word
document)

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