Hernia
DOI 10.1007/s10029-015-1351-z
REVIEW
Meta-analysis and systematic review of laparoscopic versus open
mesh repair for elective incisional hernia
A. Awaiz • F. Rahman • M. B. Hossain •
R. M. Yunus • S. Khan • B. Memon •
M. A. Memon
Received: 9 August 2014 / Accepted: 22 January 2015
Ó Springer-Verlag France 2015
Abstract
Context The utility of laparoscopic repair in the treatment
of incisional hernia repair is still contentious.
Objectives The aim was to conduct a meta-analysis of
RCTs investigating the surgical and postsurgical outcomes
of elective incisional hernia by open versus laparoscopic
method.
Data sources A search of PubMed, Medline, Embase,
Science Citation Index, Current Contents, and the Coch-
rane Central Register of Controlled Trials published
between January 1993 and September 2013 was performed
using medical subject headings (MESH) ‘‘hernia,’’ ‘‘inci-
sional,’’ ‘‘abdominal,’’ ‘‘randomized/randomised controlled
trial,’’ ‘‘abdominal wall hernia,’’ ‘‘laparoscopic repair,’’
‘‘open repair’’, ‘‘human’’ and ‘‘English’’.
A. Awaiz
Jinnah Sindh Medical University and Dow University of Health
Sciences, Karachi, Pakistan
e-mail: aiman.awaiz@gmail.com
F. Rahman
M. B. Hossain
Department of Statistics, Biostatistics and Informatics, Dhaka
University, Dhaka, Bangladesh
e-mail: frshuweb@gmail.com
M. B. Hossain
e-mail: bjoardar2003@yahoo.com
R. M. Yunus
Institute of Mathematical Sciences, University of Malaya,
Kuala Lumpur, Malaysia
e-mail: rossita@um.edu.my
S. Khan
School of Agricultural, Computing and Environmental Sciences,
International Centre for Applied Climate Science, University of
Southern Queensland, Toowoomba, QLD, Australia
e-mail: Shahjahan.khan@usq.edu.au
Study eligibility criteria, participants and interven-
tions Prospective RCTs comparing surgical treatment of
only incisional hernia (and not primary ventral hernias)
using open and laparoscopic methods were selected.
Study appraisal and synthesis methods Data extraction
and critical appraisal were carried out independently by
two authors (AA and MAM) using predefined data fields.
The outcome variables analyzed included (a) hernia
diameter; (b) operative time; (c) length of hospital stay;
(d) overall complication rate; (e) bowel complications;
(f) reoperation; (g) wound infection; (h) wound hematoma
or seroma; (i) time to oral intake; (j) back to work;
(k) recurrence rate; and (l) postoperative neuralgia. These
outcomes were unanimously decided to be important since
they influence the practical and surgical approach towards
B. Memon
M. A. Memon (&)
Sunnybank Obesity Centre and SEQS, Suite 9, McCullough
Centre, 259 McCullough Street, Sunnybank, QLD 4109,
Australia
e-mail: mmemon@yahoo.com
B. Memon
e-mail: bmemon@yahoo.com
M. A. Memon
Mayne Medical School, School of Medicine, University of
Queensland, Brisbane, QLD, Australia
M. A. Memon
Faculty of Health Sciences and Medicine, Bond University,
Gold Coast, QLD, Australia
M. A. Memon
Faculty of Health and Social Science, Bolton University, Bolton,
Lancashire, UK
123

hernia management within hospitals and institutions. The
quality of RCTs was assessed using Jadad’s scoring sys-
tem. Random effects model was used to calculate the effect
size of both binary and continuous data. Heterogeneity
amongst the outcome variables of these trials was deter-
mined by the Cochran Q statistic and I2 index. The meta-
analysis was prepared in accordance with PRISMA
guidelines.
Results Sufficient data were available for the analysis of
twelve clinically relevant outcomes. Statistically significant
reduction in bowel complications was noted with open
surgery compared to the laparoscopic repair in five studies
(OR 2.56, 95 % CI 1.15, 5.72, p = 0.02). Comparable
effects were noted for other variables which include hernia
diameter (SMD -0.27, 95 % CI -0.77, 0.23, p = 0.29),
operative time (SMD -0.08, 95 % CI -4.46, 4.30,
p = 0.97), overall complications (OR -1.07, 95 % CI
-0.33, 3.42, p = 0.91), wound infection (OR 0.49, 95 %
CI 0.09, 2.67, p = 0.41), wound hematoma or seroma (OR
1.54, 95 % CI 0.58, 4.09, p = 0.38), reoperation rate (OR
-0.32, 95 % CI 0.07, 1.43, p = 0.14), time to oral intake
(SMD -0.16, 95 % CI -1.97, 2.28, p = 0.89), length of
hospital stay (SMD -0.83, 95 % CI -2.22, 0.56,
p = 0.24), back to work (SMD -3.14, 95 % CI -8.92,
2.64, p = 0.29), recurrence rate (OR 1.41, 95 % CI 0.81,
2.46, p = 0.23), and postoperative neuralgia (OR 0.48,
95 % CI 0.16, 1.46, p = 0.20).
Conclusions On the basis of our meta-analysis, we con-
clude that laparoscopic and open repair of incisional hernia
is comparable. A larger randomized controlled multicenter
trial with strict inclusion and exclusion criteria and stan-
dardized techniques for both repairs is required to dem-
onstrate the superiority of one technique over the other.
Keywords Hernia
Incisional
Abdomen
Abdominal
wall
Abdominal wall surgery
Hernia surgery

Randomized controlled trials
Open methods

Laparoscopic methods
Introduction
Generally every surgical procedure that requires access
through the abdominal wall, no matter how small, carries a
risk of development of incisional hernia. Approximately
four million laparotomies are performed in the United
States annually, 2–30 % of them resulting in incisional
hernia [1]. Between 100,000 and 150,000 ventral incisional
hernia repairs are performed annually in the United States
[2]. Incisional hernias are mostly related to failure of the
fascia to heal and involve technical and biological factors.
Approximately 50 % of all incisional hernias develop or
present within the first 2 years following surgery, and 74 %
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Hernia
occur within 3 years. Incisional hernias may cause pain,
increase in size over time, and may also result in severe
complications such as bowel incarceration and
strangulation.
A vast majority of open surgical repair of incisional
hernias are achieved using a prosthetic mesh. Even though
it is a tensionless repair, it is still associated with early or
late complications such as mesh infection, chronic pain,
seroma, hematoma, mesh shrinkage, etc. [3]. The recur-
rence rate following mesh repair is still as high as
approximately 32 % over a 10-year follow-up period [4].
In order to improve upon the recurrence rate of open
mesh repair of incisional hernia, LeBlanc, in 1993, reported
the first case of laparoscopic incisional hernia repair using
a synthetic mesh [5, 6]. This technique supposedly reduces
the surgical insult, allowing better visualization of the
defect, reducing the risk of bleeding, infectious complica-
tions, seroma formation and recurrence rate. Since the
introduction of this technique, a number of randomized
control trials (RCTs) comparing laparoscopic and open
methods have been published analyzing various aspects of
these approaches. The objective of this meta-analysis was
to determine the clinical outcomes, safety and effectiveness
of laparoscopic repair compared with open repair for
elective surgical treatment of incisional hernia only, with
the exclusion of RCTs which also includes the primary
abdominal wall hernia repair.
Materials and methods
Search strategy and data collection
RCTs were identified by conducting comprehensive search
of electronic databases, PubMed, Medline, Embase, Sci-
ence Citation Index, Current Contents and the Cochrane
Central Register of Controlled Trials published between
January 1993 and September 2013 using medical subject
headings (MESH); ‘‘hernia,’’ ‘‘incisional,’’ ‘‘abdominal,’’
‘‘randomized/randomised controlled trial,’’ ‘‘abdominal
wall hernia,’’ ‘‘laparoscopic repair,’’ and ‘‘open repair’’;
‘‘Human’’; and ‘‘English’’. We further searched the refer-
ence lists of all included primary studies and existing meta-
analysis by hand for additional citations. Data extraction,
critical appraisal and quality assessment of the identified
studies were analytically done by two authors (AA, MAM).
The authors were not blinded to the source of the document
or authorship for the purpose of data extraction. Stan-
dardized data extraction forms [7] were used by authors to
independently and blindly summarize all the data available
in the RCTs meeting the inclusion criteria. The data
obtained were entered directly into MS Excel. Double data
entry method was used to avoid errors in data extraction.
Hernia
The data were compared and discrepancies were addressed
with discussion until consensus was achieved. The analysis
was prepared in accordance with the preferred reporting of
systematic reviews and meta-analyses (PRISMA) state-
ment [8]. Random effect model was used for analysis of all
the variables.
Inclusion and exclusion criteria
Two reviewers (AA and MAM) individually considered the
abstracts of the identified articles for prospective eligibility.
We retrieved all the eligible full text articles, which were
later reviewed in detail and checked against our inclusion
and exclusion criteria. Appropriateness was determined by
these independent reviewers and by discussion in case of
inconsistency. The RCTs must have reported on at least one
clinically relevant outcome pertaining to the intraoperative
and postoperative period. Outcomes assessed were those
considered to exert influence over practical aspects of sur-
gical practice. All studies reporting on outcomes of this
nature were considered and final analyses were run on
outcome variables where numbers were sufficient to allow
statistical analysis. Additional exclusion criteria included
studies that investigated the effect of open versus laparo-
scopic repair in a mixture of primary and incisional hernia
repair and duplicate publications.
Type of participants
Only adult ([18 years) patients requiring elective surgical
intervention purely for the repair of incisional hernia were
the target population for this meta-analysis.
Types of intervention
Two different elective surgical approaches for the man-
agement of purely incisional hernia (excluding primary
ventral hernia), namely laparoscopic and conventional
open surgical repair (suture or mesh), were being assessed
for the differences in short and long-term surgical
outcomes.
Types of outcome measures analyzed
The 12 outcome variables analyzed included (a) hernia
diameter; (b) operative time; (c) length of hospital stay;
(d) overall complication rate; (e) bowel complications;
(f) reoperation; (g) wound infection; (h) wound hematoma
or seroma; (i) time to oral intake; (j) back to work;
(k) recurrence rate; and (l) postoperative neuralgia. These
outcomes were unanimously decided to be important since
they influence the practical and surgical approach towards
hernia management within hospitals and institutions.
Methodological quality
We used the Jadad scoring system to evaluate the meth-
odological quality of the identified RCT’s [9, 10]. Each
study was allocated a score from zero to five, zero being
the lowest quality and five being the highest quality based
on reporting of randomization, blinding, and withdrawals
reported during the study period.
Statistical analysis and risk of bias across studies
Meta-analyses were performed using odds ratios (ORs) for
binary outcome and standardized mean differences (SMDs)
for continuous outcome measures. The slightly amended
estimator of OR was used to avoid the computation of
reciprocal of zeros among observed values in the calcula-
tion of the original OR [11]. Random effects model based
on the inverse variance weighted method approach was
used to combine the data [12]. Heterogeneity among
studies was assessed using the Q statistic proposed by
Cochran and I2 index introduced by Higgins and Thompson
[12–16]. If the observed value of Q was greater than the
associated x2 critical value at a given significant level, in
this case 0.05, we conclude the presence of statistically
significance between-studies variation. In order to pool
continuous data, mean and standard deviation of each study
is required. However, some of the published clinical trials
did not report the mean and standard deviation, but rather
reported the size of the trial, the median and range. Using
these available statistics, estimates of the mean and stan-
dard deviation were obtained using formulas proposed by
Hozo et al. [17]. Funnel plots were created to determine the
presence of publication bias in the present meta-analysis.
Both total sample size and precision (reciprocal of standard
error) were plotted against the treatment effects (OR for
dichotomous variables and SMD for continuous variables)
[12, 18–20]. All estimates were obtained using a computer
program written in R [21]. All plots were obtained using
the metafor-package [22]. In the case of tests of hypothe-
ses, the paper reports p values for different statistical tests
on the study variables. In general, the effect is considered
to be statistically significant if the p value is small. If one
uses a 5 % significance level then the effect is significant
only if the associated p value is B5 %.
Results
Included studies
Cross-searching of electronic databases yielded a total of
239 abstracts and hand searches of reference lists provided
a further two citations. After exclusion of 167 duplicate/
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non-relevant citations, 74 unique citations of potential
relevance were retrieved for review. The process by which
these citations were excluded is described in Fig. 1. No
further potentially relevant unpublished studies were
identified through a citation search of a previous published
meta-analysis on this subject. The six studies [23–28] that
met the inclusion criteria are detailed in Table 1. They
collectively demonstrated moderate methodological quality
based on Jadad score with an average score of 2.7 (out of
5), with a range of 2–3. Four studies reported on with-
drawals [25–28], five described an appropriate method of
randomization [24–28], whereas none of the trials reported
on blinding (Table 1).
feel that the pathology behind the causation of primary
ventral hernias is entirely different from that of incisional
hernias. Also the risk of complications such as iatrogenic
enterotomies, conversion to open surgery, bleeding, etc. is
much higher with incisional hernia due to the complexity
of surgery compared to primary ventral hernia repair in a
virgin abdomen. Analyzing these two different types of
hernias as a ‘‘single entity’’ will give misleading and
erroneous results in terms of complications, operating time,
recurrence rate and reoperation to name but a few variables
for both open and the laparoscopic groups.
Clinical outcomes

Excluded studies Statistically significant reductions in bowel complications

Seven studies [29–35] were excluded from our meta-ana-
lysis although they were included in the previous meta-
analyses. These studies included not just incisional hernia
repair but also primary ventral hernia repair. We strongly
were noted with open surgery compared to the laparoscopic
repair based on five studies [23, 25–28] (OR 2.56, 95 % CI
1.15, 5.72, p = 0.02) (Fig. 2). Comparable effects were
noted for other variables which include hernia diameter
(SMD -0.27, 95 % CI -0.77, 0.23, p = 0.29) (Fig. 3),

Records identified through Additional records identified through

database searching other sources
Identification

n=239 n=2

Records after duplicates removed

n=241
Screening

Records screened Records excluded

n=74 n=167

Full-text articles assessed Full-text articles excluded,

for eligibility with reasons
n=28 n=46
Eligibility

Studies included in Studies excluded in

qualitative synthesis qualitative synthesis
n=6 n=22

Studies included in
Included

quantitative synthesis
(meta-analysis)
n=6

Fig. 1 PRISMA flow diagram

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Hernia

Table 1 Salient features of various RCTs

Authors/year/country [ref] RCT Patients Open Lap Follow-up Jadad Score
n n n Months Randomization Blinding Dropouts/withdrawals

Olmi et al./2006/Italy [23] Single center 170 85 85 24 1 0 0

Navara et al./2007/Italy [24] Single center 24 12 12 6 2 0 0
Asencio et al./2008/Spain [25] Multicenter 84 39 45 12 2 0 1
Itani et al./2010/USA [26] Multicenter 146 73 73 2 2 0 1
Eker et al./2013/Netherlands [27] Multicenter 194 100 94 35 2 0 1
Rogmark et al./2013/Sweden [28] Multicenter 133 69 64 2 2 0 1

LAP OPEN

Source Events Total Events Total favors LAP favors OPEN OR [95% CI]

Olmi et al, 2006, Italy 6 85 3 85 2.08 [ 0.50 , 8.59 ]

Navara et al, 2007, Italy 0 12 0 12 1.00 [ 0.02 , 54.46 ]

Asencio et al, 2008, Spain 1 45 0 39 2.66 [ 0.11 , 67.26 ]

Itani et al, 2010, USA 6 73 2 73 3.18 [ 0.62 , 16.30 ]

Eker et al, 2013, Netherlands 6 94 1 100 6.75 [ 0.80 , 57.16 ]

Rogmark et al, 2013, Sweden 3 64 2 69 1.65 [ 0.27 , 10.19 ]

POOLED OR 22 373 8 378 2.56 [ 1.15 , 5.72 ]

Test for Overall Effect: Z = 2.3 ; p-value =0.02

Test for heterogeneity: Q = 1.38 ; p-value =0.93 ; I2 = 0

0.05 0.25 1.00 8.00

Odds Ratio

Fig. 2 Forest plot of bowel complications (Forest plots: Forest plot
draws the 95 % confidence intervals for the odds ratios or weighted
standardized mean differences as horizontal lines. Confidence inter-
vals show arrows when they exceed specified limits. In the forest plot,
squares indicate the estimated treatment effects with the size of the
squares representing the weight attributed to each study. The pooled
estimated OR or SMD is obtained by combining all the ORs or SMDs
of the studies using the inverse variance weighted method, repre-
sented by the diamond and the width of the diamond depicts the 95 %
confidence interval)

operative time (SMD -0.08, 95 % CI -4.46, 4.30,
p = 0.97) (Fig. 4), overall complications (OR -1.07, 95 %
CI -0.33, 3.42, p = 0.91) (Fig. 5), wound infection (OR
0.49, 95 % CI 0.09, 2.67, p = 0.41) (Fig. 6), wound
hematoma or seroma (OR 1.54, 95 % CI 0.58, 4.09,
p = 0.38) (Fig. 7), reoperation rate (OR 0.32, 95 % CI
0.07, 1.43, p = 0.14) (Fig. 8), time to oral intake (SMD -
0.16, 95 % CI -1.97, 2.28, p = 0.89) (Fig. 9), length of
hospital stay (SMD -0.83, 95 % CI -2.22, 0.56,
p = 0.24) (Fig. 10), back to work (SMD -3.14, 95 % CI
-8.92, 2.64, p = 0.29) (Fig. 11), recurrence rate (OR 1.41,
95 % CI 0.81, 2.46, p = 0.23) (Fig. 12), and postoperative
neuralgia (OR 0.48, 95 % CI 0.16, 1.46, p = 0.20)
(Fig. 13).
Heterogeneity
The Q test and I2 Index are commonly used methods in
meta-analysis for detecting heterogeneity. An I2 index
equaling 0 % suggests no between-study variability
occurring within the analysis and that all variations
observed are result of sampling error. Conversely, the
degree to which an I2 index approaches 100 % suggests
the extent to which the observed variation can be
attributed to between-study variability rather than an
exclusive sampling error. In general there was a high
degree of heterogeneity detected for most of the out-
comes in the included studies except for bowel compli-
cations, recurrence rate, reoperation and neuralgia
(Table 2).
Publication bias
Most of the funnel plots demonstrate asymmetry and thus
suggest the presence of publication bias for a majority of
outcomes (Fig. 14). However, the number of studies
included for all these variables were too few to sensitively
detect publication bias.

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LAP OPEN
Source Total Mean (SD) Total Mean (SD) favors LAP favors OPEN SMD [95% CI]

Olmi et al, 2006, Italy 85 9.7 ( 0.71 ) 85 10.5 ( 0.87 ) -1.00 [ -1.32 , -0.68 ]

Navara et al, 2007, Italy 12 5.9 ( 1.45 ) 12 6.9 ( 2.62 ) -0.46 [ -1.27 , 0.35 ]

Asencio et al, 2008, Spain 45 9.51 ( 0.54 ) 39 10.19 ( 0.96 ) -0.88 [ -1.33 , -0.43 ]

Itani et al, 2010, USA 73 123.7 ( 134 ) 73 68.1 ( 71 ) 0.52 [ 0.19 , 0.85 ]

Eker et al, 2013, Netherlands 94 5(6) 100 5(9) 0.00 [ -0.28 , 0.28 ]

Rogmark et al, 2013, Sweden 64 36 ( 109.5 ) 69 25 ( 82.5 ) 0.11 [ -0.23 , 0.45 ]

POOLED SMD 373 378 -0.27 [ -0.77 , 0.23 ]

Test for Overall Effect: Z = -1.06 ; p-value = 0.29

Test for heterogeneity: Q = 56.88 ; p-value = 0 ; I 2 = 90.64

-1.5 -0.75 0 0.75 1.5

Standardized Mean Difference

Fig. 3 Forest plot of hernia diameter

LAP OPEN

Source Total Mean (SD) Total Mean (SD) favors LAP favors OPEN SMD [95% CI]

Olmi et al, 2006, Italy 85 61 ( 14.8 ) 85 150.9 ( 9.59 ) -7.18 [ -8.00 , -6.36 ]

Navara et al, 2007, Italy 12 73.7 ( 23.75 ) 12 88.7 ( 32.5 ) -0.51 [ -1.32 , 0.30 ]

Asencio et al, 2008, Spain 45 101.88 ( 5.2 ) 39 70 ( 3.6 ) 6.97 [ 5.84 , 8.11 ]

Itani et al, 2010, USA

Eker et al, 2013, Netherlands 94 100 ( 49 ) 100 76 ( 33 ) 0.58 [ 0.29 , 0.86 ]

Rogmark et al, 2013, Sweden 64 100 ( 51.19 ) 69 110 ( 43.77 ) -0.21 [ -0.55 , 0.13 ]

POOLED SMD 300 305 -0.08 [ -4.46 , 4.30 ]

Test for Overall Effect: Z = -0.03 ; p-value = 0.97

Test for heterogeneity: Q = 456.71 ; p-value = 0 ; I2 = 99.73

-10 -5.75 -1.5 2.75 7

Standardized Mean Difference

Fig. 4 Forest plot of operative time

Discussion laparoscopic versus open hernia repair for incisional her-

In the modern surgical era, laparoscopic repair has
increasingly been utilized in the management of incisional
hernia. First described by LeBlank [5, 6], the technique
has evolved and is now replacing open repairs where
possible. Large multi-centered series have described out-
standing outcomes with laparoscopic techniques citing
less complications and recurrence rates of less than 10 %
[36–40].
There have been several meta-analyses comparing the
outcomes of laparoscopic and open repairs but all of them
have erroneously included not just the incisional hernia but
also the primary ventral hernia repair as well [41–43]. Our
meta-analysis focuses on RCTs comparing the outcome of
nia only and excluding primary ventral hernia repair. Our
search revealed only six RCTs [23–28] which focused
exclusively on the outcomes of the two procedures purely
for incisional hernia.
There was no difference in the demographics of the
patient population included in our analysis. The mean
patients’ age in the laparoscopic and open repair groups
displayed little variation. The BMI of all the patients in
these six studies [23–28] fell within a median range of
28–31.2, indicating that most of these patients were clini-
cally obese or overweight.
We observed that laparoscopic technique was used to
repair larger hernia diameters at times (Fig. 3). There could
be a number of explanations for this discrepancy. First of

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Hernia

LAP OPEN

Source Events Total Events Total favors LAP favors OPEN OR [95% CI]

Olmi et al, 2006, Italy 14 85 25 85 0.47 [ 0.23 , 0.99 ]

Navara et al, 2007, Italy 2 12 1 12 2.20 [ 0.17 , 28.14 ]

Asencio et al, 2008, Spain 15 45 2 39 9.25 [ 1.96 , 43.67 ]

Itani et al, 2010, USA 28 73 37 73 0.61 [ 0.31 , 1.17 ]

Eker et al, 2013, Netherlands 60 94 37 100 3.00 [ 1.67 , 5.39 ]

Rogmark et al, 2013, Sweden 26 64 55 69 0.17 [ 0.08 , 0.38 ]

POOLED OR 145 373 157 378 1.07 [ 0.33 , 3.42 ]

Test for Overall Effect: Z = 0.11 ; p-value = 0.91

Test for heterogeneity: Q = 47.22 ; p-value = 0 ; I2 = 90.64

0.05 0.25 1.00 8.00

Odds Ratio

Fig. 5 Forest plot of overall complications

LAP OPEN

Source Events Total Events Total favors LAP favors OPEN OR [95% CI]

Olmi et al, 2006, Italy 0 85 7 85 0.06 [ 0.00 , 1.09 ]

Navara et al, 2007, Italy 0 12 1 12 0.31 [ 0.01 , 8.31 ]

Asencio et al, 2008, Spain 0 45 0 39 0.87 [ 0.02 , 44.77 ]

Itani et al, 2010, USA 17 73 3 73 7.08 [ 1.98 , 25.39 ]

Eker et al, 2013, Netherlands 4 94 5 100 0.84 [ 0.22 , 3.24 ]

Rogmark et al, 2013, Sweden 1 64 16 69 0.05 [ 0.01 , 0.41 ]

POOLED OR 22 373 32 378 0.49 [ 0.09 , 2.67 ]

Test for Overall Effect: Z = - 0.83; p-value = 0.41

Test for heterogeneity: Q = 21.11 ; p-value = 0 ; I2 = 74.07

0.05 0.25 1.00 8.00

Odds Ratio

Fig. 6 Forest plot of wound infection

all the laparoscopic technique quite often detects more than
one hernia defects whether large or small with ease. Sec-
ond, it is entirely possible that by inflating the abdomen in
the laparoscopic technique, the size of these defects may
become exaggerated. Therefore, by measuring the size of
all visible defects during laparoscopy, small or large, and
documenting it as a combined defect, large-diameter her-
nias are reported during laparoscopic repair. Whereas an
open repair in a non-distended abdomen only measures the
largest defect which the surgeon can feel at the time of
dissecting the tissue and possibly missing the adjacent
smaller defects. Itani et al. [26] and Rogmark et al. [28]
studies showed markedly large hernias were repaired using
laparoscopic techniques compared to their open
counterpart.
The operative time taken by laparoscopic as well as the
open repair was comparable in our meta-analysis based on
five [24–28] out of six studies. No information on the time
delay due to complications during the procedure was
available.
For our analysis, we considered enterotomies, serosal
tears and postoperative small bowel obstruction as bowel
complications (during intra- and postoperative periods).
Bowel complications in a variety of forms were reported by
all the six RCTs [23–28]. Pooling of this data revealed a
statistically significant increase in bowel complications in

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 Hernia

LAP OPEN

Source Events Total Events Total favors LAP favors OPEN OR [95% CI]

Olmi et al, 2006, Italy 6 85 3 85 2.08 [ 0.50 , 8.59 ]

Navara et al, 2007, Italy 2 12 0 12 5.95 [ 0.26 , 138.25 ]

Asencio et al, 2008, Spain 16 45 2 39 10.21 [ 2.17 , 48.01 ]

Itani et al, 2010, USA 8 73 20 73 0.33 [ 0.13 , 0.80 ]

Eker et al, 2013, Netherlands 17 94 15 100 1.25 [ 0.59 , 2.67 ]

Rogmark et al, 2013, Sweden 8 64 8 69 1.09 [ 0.38 , 3.10 ]

POOLED OR 57 373 48 378 1.54 [ 0.58 , 4.09 ]

Test for Overall Effect: Z = 0.87 ; p-value = 0.38

Test for heterogeneity: Q = 16.99 ; p-value = 0 ; I2 = 74.03

0.05 0.25 1.00 8.00

Odds Ratio

Fig. 7 Forest plot of wound hematoma or seroma

LAP OPEN

Source Events Total Events Total favors LAP favors OPEN OR [95% CI]

Olmi et al, 2006, Italy 0 85 1 85 0.33 [ 0.01 , 8.20 ]

Navara et al, 2007, Italy 0 12 0 12 1.00 [ 0.02 , 54.46 ]

Asencio et al, 2008, Spain 0 45 0 39 0.87 [ 0.02 , 44.77 ]

Itani et al, 2010, USA

Eker et al, 2013, Netherlands

Rogmark et al, 2013, Sweden 1 64 6 69 0.17 [ 0.02 , 1.42 ]

POOLED OR 1 206 7 205 0.32 [ 0.07 , 1.43 ]

Test for Overall Effect: Z = -1.49 ; p-value = 0.14

Test for heterogeneity: Q = 0.91 ; p-value = 0.82 ; I2 = 0

0.05 0.25 1.00 8.00

Odds Ratio

Fig. 8 Forest plot of reoperation

the laparoscopic group. Unrecognized enterotomies, asso-
ciated with blind first trocar entry can potentially have a
significant mortality rate in the laparoscopic group [44–47].
The issue of bowel injury has been addressed in detail by
Forbes et al. [42]. The severity of bowel injury is deter-
mined by the type of intestine injured, i.e. small or large,
the time delay between the occurrence, detection and
treatment, and the amount of soiling that occurs [48, 49].
Unrecognized enterotomies or recognized bowel injuries
lead to conversion to open repair as discussed in Itani et al.
[26] and Asencio et al. [25]. Rogmark et al. [27] also
reported bowel injuries but this did not directly lead to
conversion.
The overall complication rate was comparable in the
two groups based on six RCTs [23–28]. However, sur-
gical site infections, hematomas, seromas and superficial
wound infections, etc. were noted more often in the open
group than the laparoscopic group, which is completely in
line with other laparoscopic procedures like cholecystec-
tomy and appendectomy [50]. Nonetheless when all these
variables (i.e. wound infection, wound hematoma and
seroma) were analyzed separately, the results were once
again comparable for both groups. We feel that since
there are no set criteria for the measurement of seroma
formation, and that it can be interpreted differently as in
most of the RCTs, it is imperative to prevent and

123
Hernia

LAP OPEN

Source Total Mean (SD) Total Mean (SD) favors LAP favors OPEN SMD [95% CI]

Olmi et al, 2006, Italy

Navara et al, 2007, Italy 12 53 ( 24.8 ) 12 77 ( 23.52 ) -0.96 [ -1.80 , -0.11 ]

Asencio et al, 2008, Spain 45 25.44 ( 2.57 ) 39 21.36 ( 4.04 ) 1.21 [ 0.75 , 1.68 ]

Itani et al, 2010, USA

Eker et al, 2013, Netherlands

Rogmark et al, 2013, Sweden

POOLED SMD 57 51 0.16 [ -1.97 , 2.28 ]

Test for Overall Effect: Z = 0.14 ; p-value = 0.89

Test for heterogeneity: Q = 19.45 ; p-value = 0 ; I2 = 94.86

-3 -1.5 0 1.5 3
Standardized Mean Difference

Fig. 9 Forest plot of time to oral intake

LAP OPEN
favors favors
Source Total Mean (SD) Total Mean (SD) LAP OPEN SMD [95% CI]

Olmi et al, 2006, Italy 85 2.7 ( 0.25 ) 85 9.9 ( 2.4 ) -4.20 [ -4.74 , -3.66 ]

Navara et al, 2007, Italy 12 5.7 ( 3.06 ) 12 10 ( 3.57 ) -1.25 [ -2.12 , -0.37 ]

Asencio et al, 2008, Spain 45 3.46 ( 0.4 ) 39 3.33 ( 0.29 ) 0.36 [ -0.07 , 0.80 ]

Itani et al, 2010, USA 73 4 ( 3.5 ) 73 3.9 ( 3.1 ) 0.03 [ -0.29 , 0.35 ]

Eker et al, 2013, Netherlands 94 3 ( 0.51 ) 100 3 ( 0.76 ) 0.00 [ -0.28 , 0.28 ]

Rogmark et al, 2013, Sweden 64 2 ( 0.38 ) 69 2 ( 0.51 ) 0.00 [ -0.34 , 0.34 ]

POOLED SMD 373 378 -0.83 [ -2.22 , 0.56 ]

Test for Overall Effect: Z = -1.17 ; p-value = 0.24

Test for heterogeneity: Q = 226.4 ; p-value = 0 ; I2 = 98.64

-4.5 -3 -1.5 0 1.5

Standardized Mean Difference

Fig. 10 Forest plot of length of hospital stay

differentiate between asymptomatic and clinically note-
worthy seromas. Olmi et al. [23] reported that subcuta-
neous drain placement was required by 97.6 % of the
open group patients, as was also highlighted in all the
other trials [24–28]. However, very few drains were used
in the laparoscopic group. Drains being a potential source
of infection may be the cause of increased incidence of
wound or mesh infection in the open group [34]. Olmi
et al. [23], Rogemark et al. [28] and Itani et al. [26] all
showed significantly higher wound infection rates for
open repairs compared to laparoscopic repairs. Wound
infection rates were comparable in two groups in Eker
et al. [27] study whereas Asencio et al. [25] noticed no
wound infection in either group.
Reoperation rate was reported by four [23–25, 28] out of
six studies. Analysis showed comparable outcomes for
both groups. Rogemark et al. [28] RCTs showed the largest
number of reoperations i.e. seven reoperations in six
patients for various reasons such as small bowel obstruc-
tion, postoperative bleeding/hematoma, necrosis of the
umbilicus, neuralgia and deep wound infections.
The time taken to oral intake was statistically insignif-
icant for both groups based on only two studies [24, 25]. As
the number of patients analyzed for this variable is so
small, any meaningful conclusion is not possible.
Only two studies [23, 24] out of six RCTs documented
shorter length of hospital stay following laparoscopic
repair compared to the open group. As documented by

123
 Hernia

LAP OPEN

Source Total Mean (SD) Total Mean (SD) favors LAP favors OPEN SMD [95% CI]

Olmi et al, 2006, Italy 85 13 ( 1.5 ) 85 25 ( 2.33 ) -6.10 [ -6.81 , -5.38 ]

Navara et al, 2007, Italy

Asencio et al, 2008, Spain

Itani et al, 2010, USA 73 23 ( 22.22 ) 73 28.5 ( 32.59 ) -0.20 [ -0.52 , 0.13 ]

Eker et al, 2013, Netherlands

Rogmark et al, 2013, Sweden

POOLED SMD 158 158 -3.14 [ -8.92 , 2.64 ]

Test for Overall Effect: Z = -1.06 ; p-value = 0.29

Test for heterogeneity: Q = 217.09 ; p-value = 0 ; I2 = 99.54

-10 -5.75 -1.5 2.75 7

Standardized Mean Difference

Fig. 11 Forest plot of back to work

LAP OPEN

Source Events Total Events Total favors LAP favors OPEN OR [95% CI]

Olmi et al, 2006, Italy 2 85 1 85 2.02 [ 0.18 , 22.75 ]

Navara et al, 2007, Italy 0 12 0 12 1.00 [ 0.02 , 54.46 ]

Asencio et al, 2008, Spain 4 39 3 35 1.22 [ 0.25 , 5.87 ]

Itani et al, 2010, USA 9 72 6 73 1.60 [ 0.54 , 4.74 ]

Eker et al, 2013, Netherlands 17 94 14 100 1.36 [ 0.63 , 2.93 ]

Rogmark et al, 2013, Sweden 0 64 0 69 1.08 [ 0.02 , 55.10 ]

POOLED OR 32 366 24 374 1.41 [ 0.81 , 2.46 ]

Test for Overall Effect: Z = 1.21 ; p-value = 0.23

Test for heterogeneity: Q = 0.22 ; p-value = 1 ; I2 = 0

0.05 0.25 1.00 8.00

Odds Ratio

Fig. 12 Forest plot of recurrence

several other studies [30, 37, 41, 51], we concluded that
since there is a need for intensive soft tissue dissection and
raising multiple subcutaneous skin flaps in open technique,
this may lead to prolonged hospital stay and complications
in this group. The economic factor associated with a
shorter postoperative hospital stay can be a potential
advantage of the laparoscopic procedure as discussed by
Olmi et al. [23] and Earle et al. [52]. However, four out of
six RCTs [25–28] found comparable length of hospital stay
for both these procedures.
Olmi et al. [23] and Itani et al. [26] reported that patients
in the laparoscopic group took less time to recover and
went back to work quicker. Comparable findings were
reported by Carbajo et al. [30]. Rogmark et al. [28] on the
other hand reported time taken to full recovery, instead of
time taken to return to work. SF-36 subscales favored the
laparoscopic repair group in this study but one of the
limitations pointed out by Rogmark et al. [28] was that the
patients were only followed up to 31 days in both groups
and not followed until full recovery. For example, at day
31, 59 % of the patients in the laparoscopic group had fully
recovered as compared to 38 % in the open group. The
authors concluded that the laparoscopic group recovered
comparatively faster, as also reflected by our results.
Ascenio et al. [25] and Itani et al. [26] used the EQ5D
tariffs [53] and MOS SF-36 [54] scores, respectively, for

123
Hernia

LAP OPEN

Source Events Total Events Total favors LAP favors OPEN OR [95% CI]

Olmi et al, 2006, Italy 4 85 8 85 0.48 [ 0.14 , 1.64 ]

Navara et al, 2007, Italy

Asencio et al, 2008, Spain

Itani et al, 2010, USA

Eker et al, 2013, Netherlands

Rogmark et al, 2013, Sweden 1 65 2 69 0.52 [ 0.05 , 5.91 ]

POOLED OR 5 150 10 154 0.48 [ 0.16 , 1.46 ]

Test for Overall Effect: Z = -1.28 ; p-value = 0.2

Test for heterogeneity: Q = 0 ; p-value = 0.94 ; I2 = 0

0.05 0.25 1.00 8.00

Odds Ratio

Fig. 13 Forest plot of neuralgia

Table 2 Pooled Statistics

Clinical Variable Studies Patients Pooled statistics Test for overall effect Test for heterogeneity
n n SMD or OR [CI] Z Pr Q df Pr I2 [CI] in %

Hernia diameter 6 751 -0.27 [-0.77; 0.23] -1.06 0.29 56.88 5 \0.0001 90.64 [75.14; 98.37]
Operative time 5 605 -0.08 [-4.46; 4.30] -0.03 0.97 456.7 4 \0.0001 99.73 [NA; NA]
Bowel complications 6 751 2.56 [1.15; 5.72] 2.30 0.02 1.38 5 0.93 0 [0; 42.56]
Complications 6 751 1.07 [0.33; 3.42] 0.11 0.91 47.22 5 \0.0001 90.64 [72.87; 98.53]
Wound infection 6 751 0.49 [0.09; 2.67] -0.83 0.41 21.11 5 \0.0001 74.07 [30.43; 94.84]
Wound hematoma/seroma 6 751 1.54 [0.58; 4.09] 0.87 0.38 16.99 5 0.0045 74.03 [25.06; 96.09]
Reoperation 4 411 0.32 [0.07; 1.43] -1.49 0.14 0.91 3 0.82 0 [0; 73.66]
Time to oral intake 2 108 0.16 [-1.97; 2.28] 0.14 0.89 19.45 1 \0.0001 94.86 [NA; NA]
LOS 6 751 -0.83 [-2.22; 0.56] -1.17 0.24 226.4 5 \0.0001 98.64 [96.45; 99.77]
Back to work 2 316 -3.14 [-8.92; 2.64] -1.06 0.29 217.1 1 \0.0001 99.54 [NA; NA]
Recurrence 6 751 1.41 [0.81; 2.46] 1.21 0.23 0.22 5 0.99 0 [NA; NA]
Neuralgia 2 303 0.48 [0.16; 1.46] -1.28 0.20 0.01 1 0.94 0 [0; 84.94]

the two groups during follow-up. The authors concluded
that the difference between the scores for the two groups
was statistically insignificant. Similarly, Pring et al. [34]
failed to show any difference in time taken to return to
work in both laparoscopic and open groups. We concluded
that these results might have been prejudiced by the par-
tiality of the care provider or the outcome evaluator. In our
meta-analysis, only two [23, 26] out of six studies reported
back to work data which failed to show any difference
between the two groups. Unfortunately as the number of
patients analyzed for this variable was so small, any
meaningful conclusion was not possible.
All six RCTs [23–28] reported the recurrence rate.
Pooling of the data revealed no difference between the
two groups. The reasons for recurrent hernia were (a) the
mesh overlapped the defect by less than 2 cm [23],
(b) poor fixation of the mesh; (c) the mesh migrated into
the defects [25], (d) surgical site infection with abscess
[26] and (e) post-op trocar site hernia [27]. There have
been numerous arguments theoretically describing the
superiority of laparoscopic repair over open repair. Sau-
erland et al. [43] propose that as the laparoscopic repair
lets the surgeon inspect the whole previous incision,
multiple hernias can be repaired simultaneously with a
bigger mesh. However, as the laparoscopic repair does not
require closure of the hernia orifice, it relies completely
on the strength and adequate size of the mesh and its
fixation. Still, the data available on the recurrence rate
may be erroneous due to short follow-up in all of these
RCTs. Furthermore as the number of patients recruited in

123
 Hernia

Bowel Complications Complications

0.000

0.000
Standard Error

Standard Error

0.650
1.020

1.300
2.040

-4.00 -2.00 0.00 2.00 4.00 6.00 -4.00 -2.00 0.00 2.00 4.00

Log Odds Ratio Log Odds Ratio

Re-operation Wound infection

0.000

0.000
Standard Error

Standard Error
1.020

1.006
2.040

2.012
-6.00 -4.00 -2.00 0.00 2.00 4.00 -6.00 -4.00 -2.00 0.00 2.00 4.00

Log Odds Ratio Log Odds Ratio

Wound Hematoma or Seroma Recurrence

0.000
0.000
Standard Error

Standard Error

1.020
0.802

2.040
1.605

-4.00 -2.00 0.00 2.00 4.00 -6.00 -4.00 -2.00 0.00 2.00 4.00 6.00
Log Odds Ratio Log Odds Ratio

Neuralgia Hernia Diameter

0.000
0.000
Standard Error

Standard Error
0.619

0.207
1.237

0.414

-4.00 -2.00 0.00 2.00 -1.50 -1.00 -0.50 0.00 0.50 1.00
Log Odds Ratio Standardized Mean Difference

Fig. 14 Funnel plots

123
Hernia

Operative Time Length of Stay

0.000
0.000
Standard Error

Standard Error
0.290

0.223
0.581

0.446
-5.00 0.00 5.00 -4.00 -3.00 -2.00 -1.00 0.00 1.00
Standardized Mean Difference Standardized Mean Difference

Time to Oral Intake Time Back To Work

0.000

0.000
Standard Error

Standard Error
0.216

0.182
0.431

0.364
-1.00 -0.50 0.00 0.50 1.00 1.50 -6.00 -5.00 -4.00 -3.00 -2.00 -1.00 0.00
Standardized Mean Difference Standardized Mean Difference

Fig. 14 continued

all the RCTs is very small, the true recurrence rate may
be underestimated. Additionally, the completeness and
method of the follow-up of these trials may be subjective
(e.g. telephone interview, etc), once again providing
misleading results.
Several studies [6, 40, 49] use less postoperative pain or
neuralgia as strong supporting evidence for laparoscopic
technology. Extensive tissue dissection in open repair and
transfacial sutures may be responsible for more pain in open
repair whereas direct tacking of the mesh on to the peritoneum
may be responsible for pain in laparoscopic repair. Liberal use
of local anesthesia or infiltration of the same in the abdominal
cavity may reduce the incidence of this complication [55]. Our
analysis based on two RCTs [23, 28] showed no significant
difference in the postoperative neuralgia between laparoscopic
and open repair groups. This finding was not in line with other
laparoscopic procedures like appendectomy or cholecystec-
tomy where less pain is observed following laparoscopic
techniques. Once again a small number of patients analyzed for
this variable may be responsible for obscuring the true differ-
ence between the two procedures.
Limitations
There are a number of limitations both statistical and
clinical in this paper. First, publication bias was detected
on the funnel plot analysis for a number of outcomes [56]
(Fig. 14). A second possible limitation within this meta-
analysis is the presence of heterogeneity detected within
several outcomes (Table 2). Although some degree of
heterogeneity is inevitable in a medical meta-analysis due
to the realities of clinical practice [57], the degree of
between-study heterogeneity present may undermine the
quality and legitimacy of the results obtained [58]. Third,
the exclusion of studies published in languages other than
English is another potential limitation to the present work.
Next, the small number of studies included in this meta-
analysis remains a largely unavoidable limitation of this
and many other meta-analyses conducted in surgical fields
[59].
Conclusions
We believe that objective assessment is required to eval-
uate the long-term effectiveness of the two procedures.
Recurrence rates should be measured for a lengthier period
of time (e.g. 5 and 10 years) and not just for 2 years. More
extensive data on cost benefit and cost effective analyses
for both open and laparoscopic repair of incisional hernia
should be available which is not addressed by any of the
RCTs except for Olmi et al. [23]. Also, larger RCTs

123

recruiting greater numbers of patients with strict inclusion
and exclusion criteria and standardized techniques are
crucial for meaningful comparison, effectiveness of the
procedures and accuracy of results. Finally, more stan-
dardized tests should be used to assess the quality of life
and chronic pain, so that impartial conclusions can be made
regarding the superiority of one procedure over the other
both in short and long term.
Acknowledgments We gratefully acknowledge and thank MJB for
presenting the abstract of this paper at The Royal Australasian Col-
lege of Surgeons Annual Scientific Congress, Sands Expo and Con-
vention Centre, Marina Bay Sands, Singapore in 2014. The citation
for published abstract is ‘‘ANZ Journal of Surgery 2014; 84 (Suppl 1):
67’’.
Conflict of interest AA, FR, MBH, RMY, SK, BM and MAM
declare no conflict of interest.
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