The medical records of adult patients (> 18 years of age) who underwent giant ventral hernia repair at the Department of Hernia and Abdominal Wall, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China, from January 2006 to June 2013, were retrospectively reviewed.

Adolescents < 18 years were excluded because they are still in the growth and development phase. Also, the use of synthetic materials can result in complications. Thus, the institution of this study prohibits the use of artificial materials in persons < 18 years.

A preoperative computed tomography (CT) of the abdomen was performed in all patients to diagnose the hernia and evaluate the hernia characteristics. A giant ventral hernia was defined as a hernia defect with a diameter ≥ 10 cm. The hernias were classified based on the 29^th Congress of the European Hernia Society[3]. Patients with a giant ventral hernia, who received a planned hernia repair procedure, open, laparoscopic, or hybrid, were included in the analysis. Exclusion criteria were as follows: (1) The presence of skin ulceration or infection; (2) The use of anticoagulants or high-dose hormones within 4 wk before the procedure (anticoagulants can result in bleeding and may affect hematoma formation; hormones can affect the immune system and alter postoperative changes of inflammatory mediators); (3) Participation in other clinical studies within 3 mo before the procedure; (4) A history of atopic allergy; (5) Major mental illness (e.g., schizophrenia, severe anxiety, or depression); (6) Conditions that can significantly increase intra-abdominal pressure (e.g., ascites associated with liver cirrhosis, cough from chronic obstructive pulmonary disease, and intractable constipation); (7) Infection at the operative site or bacteremia; and (8) Patients requiring emergency surgery (e.g., bowel strangulation).

The local Ethics Review Boards of Chao-Yang Hospital approved the study protocol. All procedures were performed following established European and American guidelines for hernia repair, and all patients provided written informed consent for all procedures performed.

All procedures were performed under general anesthesia by surgeons with a minimum of 10 years of experience repairing ventral hernias by open and laparoscopic approaches.

Open and laparoscopic repairs were performed using the intraperitoneal onlay mesh technique. Composix E/X mesh (15.5 cm × 20.5 cm to 20 cm × 30 cm; Davol Inc., Warwick, RI, United States) was used for hernia repair. Every patch was extended 5 cm beyond the exterior margin of the inner defect and was fixed to the abdominal wall. In the open procedures, the mesh was fixed with an abdominal wall suturing device (Covidien, Dublin, Ireland). A full-thickness abdominal wall penetrating hanging suturing line (single polypropylene suture) was fixed at the 12 or 10 o’clock position. The mesh patch was fixed in the laparoscopic group at one central and two side points using an abdominal wall hanging penetrating suture. The surrounding area and edge were fixed with laparoscopic tacks. The basic principle was that the distance between tacks was not < 3 cm.

The treatment of abdominal hernias using the hybrid method explored and separated the intra-abdominal adhesions under laparoscopy. Open surgery was then used to remove the extra hernia sac to extensively separate tissues along the interstitial muscle line, place the patch in the abdominal cavity, suture and close the hernia ring, and close the incision. The patch was then fixed under laparoscopy. Pneumoperitoneum (12–14 mmHg pressure) was established in hybrid procedures. The laparoscope was introduced to explore the abdominal cavity, separate adhesions, and reduce the hernia content. The hernia defect was dissected 5 cm beyond the exterior margin of the inner defect (Figure 1A). Conversion to laparotomy was performed if the hernia contents could not be completely reduced. The pneumoperitoneum was evacuated with the trocars retained. A targeted fusiform incision (usually 4–8 cm long and 1–3 cm wide) was made at the weakest point of the hernia sac along the original incision line (Figure 1B). The hernia sac was completely resected by stripping, and the intestines were explored. The posterior component separation technique with transversus abdominis release was used to close the abdominal wall defect with low or no tension[17,18]. The hernia defect was closed by continuous suture using PDS-II at 1 cm intervals after the Composix E/X mesh was implanted in the abdominal cavity.

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Figure 1 The surgical process. A: The hernia defect was dissected 5 cm beyond the exterior margin of the inner defect; B: A targeted fusiform incision (usually 4–8 cm long and 1–3 cm wide) was made at the weakest point of the hernia sac along the original incision line; C: A low-pressure (8–10 mmHg) pneumoperitoneum was reestablished, and the mesh was laparoscopically fixed with spiral tacks; D: The skin was closed with staples or a continuous 4-0 absorbable suture.

The anti-adhesive surface of the mesh was placed facing the abdominal cavity. The center of the mesh patch and the hernia ring was sutured using PDS-II sutures, and laparoscopic tacks fixed the surrounding mesh. The basic principle was that the distance between the tacks was not < 3 cm. A low-pressure (8–10 mmHg) pneumoperitoneum was reestablished, and the mesh was laparoscopically fixed with spiral tacks (Medtronic Inc., Minneapolis, MN, United States; Figure 1C) using double-loop multipoint fixation at 1.5–2.0 cm intervals. The pneumoperitoneum was evacuated, and the trocars removed. Superficial tissues were closed with a 2-0 absorbable interrupted suture. The skin was closed with staples or a continuous 4-0 absorbable suture (Figure 1D).

Intraoperative serosal injuries in all cases were repaired with 3-0 absorbable sutures. Full-thickness injuries were repaired by resection, and drains were placed in the abdominal cavity if a large dissection was performed in all three procedures. Drains were placed in the pelvic cavity via the paracolic sulcus to be at the lowest position. Similarly, suction drains were subcutaneously placed. All drains were typically removed 2–3 d after the procedure. Postoperative care was the same for all three groups. All cases were advised to take necessary measures to protect the repair, including an abdominal bandage for 6 mo after the procedure and control of body weight to minimize abdominal pressure. After consulting the allergy history, patients were treated with second-generation cephalosporins. Quinolones were used if patients were allergic to cephalosporins.

The hernia recurrence rate was calculated. Intraoperative and postoperative complications, surgical time, blood loss, length of hospital stay, and mortality were also recorded. Intraoperative and postoperative complications included intraoperative intestinal injury, postoperative intestinal fistula formation, chronic pain, postoperative infection, hematoma or seroma, and perioperative mortality. Patients were followed at 1, 3, and 6 mo after the procedure and then yearly by outpatient visit or telephone interview with the surgeon. Hernia recurrence was diagnosed via physical examination and abdominal CT scan. A CT scan was requested to determine if a hernia recurrence existed if a patient described a bulge or pain in the area of the operation. Diagnosis of all recurrent hernias was based on CT and/or abdominal examination.

Chronic pain was defined as moderate or severe pain (C4) in the mesh fixation area 3 mo after the procedure based on a visual analog scale: 0 points, no pain; 1–3 points, mild pain; 4–7 points, moderate pain; and 8–10 points, severe pain. Ultrasound examination was performed in patients with suspected hematoma or seroma (suspected fluid collection on physical examination or a complaint of pain). If fine-needle aspiration produced a minimum of 10 mL of fluid, the diagnosis was made. Wound infections were defined as the presence of swelling, increased pain and temperature at the incision site, and purulent drainage.

Systemic or intra-abdominal infections were defined as a body temperature > 38 °C for 3 consecutive days, excluding respiratory and urinary tract infections and a white blood cell count > 10000 with a neutrophil ratio > 80%.

Data were expressed as mean ± SD for continuous variables and frequencies and percentages for categorical variables. Normally distributed data were compared using a one-way analysis of variance followed by the Bonferroni test. Moreover, categorical variables were analyzed with the χ² test. A statistically significant difference was defined as a P < 0.05. SPSS version 20 (SPSS Statistics, IBM Corp., Armonk, NY, United States) was used for all statistical analyses.

A total of 754 patients received surgical treatment for incisional hernias, and 308 cases were included. A flow diagram of patient inclusion is shown in Figure 2. Table 1 summarizes patient characteristics. The minimum and maximum hernia diameters were 10 and 30 cm, respectively. An open procedure, laparoscopic approach, and hybrid approach were performed in 82, 94, and 132 patients, respectively. Moreover, 58.7% of the patients were women, and the mean diameter of hernias was 13.11 ± 3.4 cm (range, 10–30 cm). Patients had a mean body mass index of 29.7 ± 44.6 kg/m² (range, 16.7–38.3 kg/m²), and the three groups were comparable in demographic and baseline characteristics (all, P > 0.05).

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Figure 2 A flow diagram of patient inclusion.

The surgical details of the three groups are summarized in Table 2. The mean operation times were 76.7 ± 23.7, 63.6 ± 12.1, and 113.6 ± 21.8 min for the hybrid groups, respectively (P < 0.001). Overall, the incidence of postoperative complications was significantly lower in the hybrid group (7.23%) than in the open (17.1%; P = 0.019) or laparoscopic (26.0%; P < 0.05) groups. The intraoperative intestinal injury rates were 6.1%, 4.1%, and 1.5% in the open, laparoscopic, and hybrid groups, respectively (hybrid vs open and laparoscopic procedures; P < 0.05). In addition, the postoperative intestinal fistula formation rates in the open, laparoscopic, and hybrid groups were 2.4%, 6.8%, and 3.3%, respectively, and these differences were not significant (P > 0.05). The postoperative intestinal fistula ratio vs intraoperative intestinal injury was markedly lower in the hybrid group than in the laparoscopic group (hybrid group, 0.2; laparoscopic group, 0.7; P = 0.013) but was not different from the open group (0.4; P > 0.05). The reoperation rate was lowest in the hybrid group (3.9%; open group, 12.2%; laparoscopic group, 24.78%; P < 0.001) because it had the lowest postoperative hernia recurrence. The patients with seroma were asymptomatic. The laparoscopic procedure group had the highest seroma formation rate (32.8%; open group, 6.1%; and hybrid group, 2.6%; P < 0.001) but the lowest incidence of operative site infections (1.4%; open group, 0.3%; and hybrid group, 5.2%; P > 0.05). Patients who received an open procedure had a longer hospital stay (13.0 ± 8.7 d) than those who received laparoscopic (6.9 ± 14.2 d) and hybrid (8.5 ± 7.9 d) procedures (P = 0.002).

All patients were followed up 1 wk after the operation. The outpatient clinic follow-up rates at 1 mo, 3 mo, and 1 year were 40.6%, 37.3%, and 14.6%, respectively. Other patients were followed via telephone interview. The mean follow-up times for the open, laparoscopic, and hybrid groups were 45, 40, and 39 mo, respectively. Thus, the mean follow-up time for the three groups was 41 mo (range, 12–88). The follow-up time in the hybrid group was shorter than in the other two groups. The hernia recurrence rate in patients who received a hybrid procedure was 1.3% at the final follow-up. This finding was significantly lower than that in the laparoscopic (12.3%) or open groups (8.5%; P < 0.05; Figure 3).

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Figure 3 This finding was significantly lower than that in the laparoscopic (12.3%) or open groups (8.5%; P < 0.05).

Patients who received an open procedure had the highest rate of chronic pain (vs laparoscopic group, 1.4%; open group, 7.3%; and hybrid group, 2.0%; P > 0.05) but the lowest hospitalization costs (P < 0.001). Perioperative mortality was comparable among the three groups (open, 3.7%; laparoscopic, 2.7%; and hybrid, 2.0%; P > 0.05).

Incisional hernia is a common complication of abdominal surgery. The traditional method, including open or laparoscopic surgery, still has many limitations.

This study motivated us to investigate the potential advantages of a hybrid application of open and laparoscopic approaches in giant ventral hernia repair.

This study tried to determine if a hybrid application of open and laparoscopic approaches is more effective and safer in the repair of giant ventral hernias than a single open or laparoscopic procedure.

Patients were retrospectively reviewed and divided into open (n = 82), laparoscopic (n = 73), and hybrid group (n = 153), respectively. The hernia recurrence rate, intraoperative and postoperative complications, operative time, blood loss, length of hospital stay, and mortality in the three groups were also recorded and analyzed.

Patients in the three groups were comparable in demographic and baseline characteristics (all, P > 0.05). The mean operation times of the hybrid group were significantly longer than the open and laparoscopic groups (76.7 ± 23.7 vs 63.6 ± 12.1 and 113.6 ± 21.8, P < 0.001). However, the incidence of postoperative complications was significantly lower in the hybrid group (7.23%) than in the open (17.1%; P = 0.019) or laparoscopic (26.0%; P < 0.05) groups. Besides, the hybrid group had a significantly lower intraoperative intestinal injury rate, reoperation rate, and seroma formation than the open and laparoscopic groups (1.5% vs 6.1% and 4.1%, P < 0.05; 3.9% vs 12.2% and 24.78%, P < 0.001; 2.6% vs 6.1% and 32.8%, P < 0.001).

The hybrid approach of laparoscopic and open procedures is associated with lower complication and hernia recurrence rates. It combines the advantages of laparoscopic and open repair and minimizes the disadvantages of the two approaches.

The hybrid approach of the laparoscopic and open procedures, which is worthy of clinical application, is an effective method for giant ventral hernia repair.