Literature review on the outcome after laparoscopic and open repair of incisional hernia
Rosario Vecchio, Serena Scilletta, Eva Intagliata
Contributions: (I) Conception and design: S Scilletta; (II) Administrative support: R Vecchio; (III) Provision of study materials or patients: R Vecchio; (IV) Collection and assembly of data: S Scilletta; (V) Data analysis and interpretation: E Intagliata; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.
Background and Objective: Although the trend is to prefer the less invasive laparoscopic over the open technique for repairing the incisional hernia, disputes on its routine use are present in the literature because of different types of benefits coming from the two methods. In this review of the literature, we analyze the outcomes after laparoscopic and open incisional hernia repair in order to clarify the issue.
Methods: Retrospective, prospective, and randomized clinical trials in English language were selected from a search of the PubMed and Scopus databases from 2006. The outcomes were iatrogenic intraoperative lesions, postoperative complications, seroma and hematoma onset, surgical site infections (SSIs), recurrences, operative time, and days of hospital stay. Randomized clinical trials, retrospective and prospective observational studies written in English language have been selected. We excluded huge incisional hernia, recurrent incisional hernia, obesity and chronic pulmonary disease, hand-assisted and robotic approach, and emergency treatment of complicated incisional hernia.
Key Content and Findings: Discordant data were found in almost all the outcomes considered, and since the type of intra-operative complication is peculiar to the surgical technique performed, the different results may be linked to the short-term follow-up reported in most of the studies and to the surgeons’ experience. Although complications may be always possible, the more is the surgical team expert, the less is their incidence.
Conclusions: We emphasize the need for studies with longer follow-up periods to better assess long-term outcomes, and the creation of a universal fillable registry accessible to all surgeons, reporting all the data required for creating standardized studies on incisional hernia repair.
Keywords: Incisional hernia; laparoscopic repair; post-operative complications
Received: 10 February 2025; Accepted: 18 November 2025; Published online: 01 April 2026.
doi: 10.21037/ls-25-7
Introduction
Incisional hernia is a post-operative complication that leads to leakage of the abdominal viscera through a muscle-aponeurotic breach of the wall in correspondence with a previous surgical incision (1). Its incidence ranges from 5% to 15% of the abdominal surgical interventions in the literature (2). Risk factors are infection, obesity, diabetes, chronic bronchitis, radiotherapy, constipation, drugs (corticosteroids, chemotherapy, anticoagulants), collagen disorders, incorrect closure of the surgical incision, and inadequate hemostasis. Big incisional hernia leads to muscular, visceral, respiratory, vascular, and cutaneous alterations defined as “incisional hernia disease”. Loss of abdominal domicile and/or visceral disproportion are possible complications of huge incisional hernia (1). These feared complications make the incisional hernia repair an essential treatment often not postponable.
The advent of laparoscopic surgery with its advantages of less invasiveness and better visualization of the operative field, has scaled down the use of open surgery for incisional hernia repair. Nevertheless, both the procedures are not free from disadvantages and complications that are analyzed in this study.
Despite the benefits arising from its less invasiveness, the routine use of the laparoscopic technique for incisional hernia repair is still controversial, and discordant data are present in the literature on some outcomes of open and laparoscopic procedures.
The aim of our review of the literature is to compare the outcomes of the two most used methods for incisional hernia repair, laparoscopic and open surgery, in order to define the best procedure for routine incisional hernia repair. We present this article in accordance with the Narrative Review reporting checklist (available at https://ls.amegroups.com/article/view/10.21037/ls-25-7/rc).
Methods
A search from the literature published in PubMed and Scopus databases from 2006 to 2025 was performed using the search strings “incisional hernia repair” and “laparoscopic versus open repair”.
Randomized clinical trials, retrospective and prospective observational studies written in English language have been selected for performing the review.
We excluded patients affected by huge incisional hernia, recurrent incisional hernia, obesity, and chronic pulmonary disease, as well as surgical techniques like hand-assisted and robotic approaches, and emergency treatment of complicated incisional hernia.
We found 84 eligible articles, but studies that did not satisfy the inclusion and exclusion criteria were deleted. Twenty-nine papers were selected for our study.
The considered outcomes were iatrogenic intraoperative lesions, postoperative complications, onset of surgical site infections (SSIs), seroma or hematoma, recurrence rate, operative time, and days of hospital stay (Table 1).
Table 1
| Items | Specification |
|---|---|
| Date of search | December 2024–May 2025 |
| Databases searched | PubMed and Scopus |
| Search terms used | “Incisional hernia repair” and “laparoscopic versus open repair” |
| Timeframe | From 2006 up to 2025 |
| Inclusion criteria and exclusion criteria | Inclusion: randomized clinical trials, retrospective and prospective observational studies written in English language |
| Exclusion: huge incisional hernia, recurrent incisional hernia, obesity, chronic pulmonary disease, hand-assisted and robotic approach, complicated incisional hernia | |
| Selection process | S.S. conducted the selection and I.E. interpreted the data in common consensus. The supervisor V.R. approved the study |
| Additional considerations | Outcomes: iatrogenic intraoperative lesions, postoperative complications, onset of SSIs, seroma or hematoma, recurrence rate, operative time, days of hospital stay |
SSI, surgical site infection.
Results
Considering the intraoperative complications rate, there is no unanimity in the literature on which surgical procedure carries fewer complications. Köckerling et al. and Ahonen-Siirtola et al. reported contrasting outcomes in their studies on big cohort of patients operated by open and laparoscopic surgery. The first described a highly significant disadvantage in terms of intraoperative complications rate in the laparoscopic group, such as bleeding and organ injuries (3). The second revealed a mean intraoperative blood loss significantly lower in the laparoscopic group (4).
Eker et al. reported an overall perioperative complication rate for laparoscopic procedure significantly higher than open surgery in their multicenter randomized controlled trial on 206 patients. In particular, the operative complications included enterotomy (5 patients in the laparoscopic group vs. 1 patient in the open group), serosal bowel injury (1 case in the laparoscopy vs. 0 in the open), urinary bladder perforation (1 case in the laparoscopy vs. 0 in the open), and other (1 in the open vs. 2 in the laparoscopy) (5).
Similar results were found by Itani et al. in their randomized trial, who reported a complication rate of 1.4% on 73 patients in the open group and of 9.6% on 73 patients in the laparoscopic group (P=0.05). The complications included injury to bowel (3 cases in the laparoscopy vs. 0 in the open), problems related to anesthesia (1 in the laparoscopy vs. 0 in the open), and other (3 in the laparoscopy vs. 1 in the open) (6).
On the other hand, the randomized clinical trial by Asencio et al. on 39 open patients and 45 laparoscopic patients did not demonstrate any significant difference between the two surgical approaches (1).
The type of intra-operative complication is peculiar to the surgical technique performed, and according to us, the different results were linked to the surgeons’ experience. Although complications may be always possible, the more is the surgical team expert, the less is their incidence.
Results on intraoperative complication rate are reported in Table 2.
Table 2
| Authors | Study type | Patients, n | Complications | Complication rate (%) | P value | ||
|---|---|---|---|---|---|---|---|
| Open | Lap. | Open | Lap. | ||||
| Köckerling et al. (3) | Prospective analysis | 5,797 | 4,110 | Bleeding, organ injuries | 1.3 | 2.3 | ≤0.001 |
| Mann et al. (7) | Case series | – | 144 | Inferior epigastric artery lesion | – | 1.3 | – |
| Ahonen-Siirtola et al. (4) | Retrospective study | 291 | 527 | Enterotomies, SSI, intraoperative blood loss | 23.4 | 18.4 | 0.09 |
| Itani et al. (6) | Randomized trial | 73 | 73 | SSI, pain | 1.4 | 9.6 | 0.05 |
| Asencio et al. (1) | Randomized clinical trial | 39 | 45 | Colonic perforation, parietal hemorrhage | 0 | 6.66 | – |
Lap., laparoscopy; SSI, surgical site infection.
Also, about the post-operative complication rate, discordant results can be found in the literature. While for some authors intraperitoneal onlay mesh (IPOM) was found to have a highly significant disadvantage in terms of post-operative seroma and bleeding rate (3), some prospective, retrospective and randomized studies reported overall postoperative complications, such as SSIs, hematoma evacuations, closure of wound dehiscence and pain, significantly less frequent in the laparoscopic group compared to the open group (4,6-9). Although the database research by Henriksen et al. on 2,288 open and 3,090 laparoscopic patients agreed with these outcomes, readmission due to pain was more common among patients operated laparoscopically (10).
On the other hand, three randomized controlled trials (2,5,11), two retrospective cohort studies (9,12), and a multicenter randomized controlled trial (13) did not report any significant variation between the two techniques.
On the contrary, a recent comprehensive review and meta-analysis on 20 studies involving a total of 16,247 patients found that laparoscopic repair was associated to a shorter hospital stay (14).
Other results are shown in Table 3.
Table 3
| Authors | Study type | Patients, n | Complications | Complication rate (%) | P value | ||
|---|---|---|---|---|---|---|---|
| Open | Lap. | Open | Lap. | ||||
| Köckerling et al. (3) | Prospective analysis | 5,797 | 4,110 | SSI, seroma, bleeding | 10.5 | 3.4 | <0.001 |
| Kohler et al. (8) | Prospective observational cohort study | 207 | 154 | SSI, seroma | 9.3 | 21.3 | 0.01 |
| Ahonen-Siirtola et al. (4) | Retrospective comparative study | 291 | 527 | SSI, hematoma, wound dehiscence | 5.5 | 2.2 | 0.09 |
| Itani et al. (6) | Randomized trial | 73 | 73 | SSI, pain | 45.2 | 20.8 | 0.001 |
| Henriksen et al. (10) | Database research | 2,288 | 3,090 | SSI, pain, recurrence | 12.5 | 7 | <0.001 |
Lap., laparoscopy; SSI, surgical site infection.
Probably, the difference in this outcome laid on the surgeons’ experience on performing laparoscopic surgery. According to our experience, deflating the abdomen at the end of the laparoscopic procedure and reducing the number of staples applied lower the risk of pain after laparoscopic surgery; preferring the laparoscopic procedure to the open one for repairing larger incisional hernia reduces the width of dissection and lower the post-operative pain.
Incidence of seroma after open incisional hernia repair varies in the literature from 3% to 41% (15-20), while it varies from 3% to 12% after laparoscopic procedure (3,6,8,9,18,21-23).
The prospective observational study by Kohler et al. on 360 patients did different follow up: at hospital discharge, open 2.7% vs. laparoscopy 0.7% (P=0.37); at 3 months, open 11.1% vs. laparoscopy 7.3% (P=0.30); at 12 months, open 12.1% vs. laparoscopy 4.8% (P=0.06); at 36 months, open 5.5% vs. laparoscopy 2.2% (P=0.28). All these findings suggested a lower risk of seroma after laparoscopic repair, but none of them was significant (8).
However, Asti et al. in their cohort study on 70 open and 54 laparoscopic patients showed that there was not a significant difference between laparoscopic and open repair (21).
Only two studies found a significant higher risk of seroma onset in the open group (3,6).
Results are shown in Table 4.
Table 4
Seroma onset was mainly consequent to a pre-muscular prosthesis positioning. We think that the higher incidence of seroma after open surgery was due to the larger tissue dissection performed for properly positioning the prosthesis.
Hemorrhagic complications, such as sac hematoma, are generally related to an inadequate hemostasis or to a vascular lesion. Three randomized controlled trials (2,5,6), the Köckerling’s analysis (3) and a retrospective study by Ahonen-Siirtola et al. on 818 patients (291 open, 527 laparoscopic), examined either patients with hematoma or those with seroma: data suggested that there was no significant difference between the two surgical methods (open 6.9% vs. laparoscopy 4.2%, P=0.13) (4).
The incidence of SSI seemed to be higher in patients treated by open incisional hernia repair (2,4,6,8,10,15,17,21-24).
In their prospective research on 360 patients, Kohler et al. demonstrated that the laparoscopic approach minimizes the SSI. At hospital discharge, open surgery accounted for 5.3% of SSI while laparoscopy accounted for 0.7% (P=0.04); at 3-month 14.8% of cases treated by open surgery suffered from SSI, and 4.4% of cases were recorded after laparoscopic repair (P=0.004) (7).
Asti et al. in their single-center cohort study on 26 open and 28 laparoscopic patients reported no significant differences between the two methods in terms of infection requiring mesh removal (open 6% vs. laparoscopy 0%, P=0.20) (21).
According to Itani et al. in their randomized trial on 146 patients (73 open and 73 laparoscopic), the risk was 21.9% after open surgery and 2.8% after laparoscopy (P=0.003) (6). Rogmark et al. in their randomized controlled trial on 69 open patients and 64 laparoscopic patients reported a risk of 23% after open surgery and 1.5% after laparoscopy (P<0.001) (2). According to the review of Sauerland et al., the risk of intraoperative enterotomy was slightly higher during laparoscopic hernia repair, but on the other hand, laparoscopic surgery reduced the risk of wound infections in their meta-analysis (23).
Other results are shown in Table 5.
Table 5
| Authors | Study type | Patients, n | SSI rate (%) | |||
|---|---|---|---|---|---|---|
| Open | Lap. | Open | Lap. | |||
| Ahonen-Siirtola et al. (4) | Retrospective comparative study | 291 | 527 | 8.7 | 0 | |
| Tsuruta et al. (19) | Retrospective study | 21 | 24 | 0.21 | 0.24 | |
| Misra et al. (15) | Retrospective randomized study | 33 | 24 | 2.97 | 0.48 | |
| McGreevy et al. (20) | Prospective study | 71 | 65 | 4.26 | 0.65 | |
| Henriksen et al. (10) | Database research | 2,288 | 3,090 | 13.1 | 2.8 | |
Lap., laparoscopy; SSI, surgical site infection.
A lower incidence of infective complication after laparoscopic procedure may be due to the smaller length of the surgical incisions than the incision performed in open procedure, which makes the prosthesis to be exposed to the external environment for a shorter time during the surgical procedure.
The review of the literature comparing open and laparoscopic procedures revealed significant different operative times (1,4,5,8,21,24-28).
According to some studies, open surgery has a longer operative time (4,8,21,25,27,29), but six articles showed the opposite (1,5,6,24,26,28).
In the trial by Soliani et al. on 175 open and 94 laparoscopic patients, the open approach was associated with a longer operative time (P<0.0001) (25), and a recent comprehensive review and meta-analysis on 20 studies involving a total of 16,247 patients found that laparoscopic repair was associated to a shorter hospital stay (14).
On the contrary, a retrospective cohort study from Chue et al. on 194 patients (103 open, 91 laparoscopic) showed no difference in terms of operative duration between open and laparoscopic incisional hernia repair (12).
Other results are shown in Table 6.
Table 6
| Authors | Study type | Patients, n | Operative time (minutes) | P value | |||
|---|---|---|---|---|---|---|---|
| Open | Lap. | Open | Lap. | ||||
| Earle et al. (26) | Prospective study | 415 | 469 | 89 | 149 | <0.001 | |
| Kohler et al. (8) | Prospective observational study | 207 | 154 | 140 | 106 | <0.001 | |
| Ahonen-Siirtola et al. (4) | Retrospective study | 291 | 527 | 121 | 93 | 0.003 | |
| Asti et al. (21) | Cohort study | 26 | 28 | 140 | 90 | <0.001 | |
| Lavanchy et al. (27) | Propensity score-matched analysis | 64 | 120 | 180 | 120 | <0.001 | |
Lap., laparoscopy.
We think that such differences found in the literature on operative time between the two techniques were due to the surgeons’ experience.
It was difficult to compare data about the recurrence rate from different follow-up intervals.
In their retrospective investigation, Ballem et al. used a Kaplan-Meier graph to highlight the patterns of recurrence across different repair procedures. The early part of these curves indicated recurrences due to a technical failure, with a slightly higher recurrence rate for the laparoscopic repair over the open repair, and then a 5-year plateau was showed. No statistical difference was recorded in terms of recurrence rate comparing IPOM with open repair (30).
Also, a retrospective cohort study on 194 patients (103 open, 91 laparoscopic) (12) with an 8-month follow-up and a multicenter randomized control trial on 88 patients (44 open, 44 laparoscopic) with a mean follow-up of about 6 years (13) revealed no difference in recurrence rate between the two techniques.
A recent meta-analysis by Elhadidi et al. (14) showed a lower recurrence rate after laparoscopic procedure.
Other results are shown in Table 7.
Table 7
| Authors | Study type | Follow-up | Recurrence rate (%) | P value | |
|---|---|---|---|---|---|
| Open | Lap. | ||||
| Asencio et al. (1) | Randomized clinical trial | 15 days | 0 | 0 | – |
| 1 month | 2.56 | 0 | 0.29 | ||
| 3 months | 2.56 | 2.22 | 0.92 | ||
| 12 months | 7.89 | 9.75 | 0.77 | ||
| Navarra et al. (11) | Randomized controlled trial | 6 months | 0 | 0 | – |
| Köckerling et al. (3) | Prospective analysis | 12 months | 4.1 | 4.2 | 0.78 |
| Olmi et al. (28) | Open randomized controlled study | 24 months | 1.1 | 2.3 | – |
| Alizai et al. (9) | Prospective study | 28 months | 7.3 | 12.5 | 0.51 |
| Eker et al. (5) | Randomized clinical trial | 35 months | 14 | 18 | 0.30 |
| Asti et al. (21) | Cohort study | 36 months | 9 | 7 | 0.69 |
| Itani et al. (6) | Randomized controlled trial | 48 months | 8.2 | 12.5 | 0.44 |
| Soliani et al. (25) | Retrospective cohort study | 50 months | 12 | 8.5 | 0.42 |
| Lavanchy et al. (27) | Propensity score-matched analysis | 66 months | 19 | 20 | 1.00 |
Lap., laparoscopy.
Discordant results stress the importance of a long-term follow-up for appropriately reporting the recurrence rate (30).
Discussion
Laparoscopic incisional hernia repair is a procedure of recent onset, and its less invasiveness makes it preferable to the open technique, but the possibility of complications that may also be severe must be evaluated.
Discordant data were found in almost all the outcomes considered, and considering that the type of intra-operative complication is peculiar to the surgical technique performed, the different results and the type of complication may be linked not only to the short-term follow-up reported in most of the studies, but also to the surgeons’ experience. Although complications may be always possible, the more is the surgical team expert, the less is their incidence.
Different observation intervals make it difficult to compare data, especially the probability of incisional hernia relapse. We think that the recurrence rates should be calculated after 5–10 years of follow-up. Most studies on incisional hernia repair have a follow-up period of only 1–5 years (3,4,8-10,21,25-27), and studies with a 10-year follow-up are an absolute exception (3).
Since the reason why there are discordant results on the outcomes of open and laparoscopic surgery cannot be clarified, it cannot be stated which procedure is better to perform for routine incisional hernia repair. Therefore, we think that the type of surgical procedure has to be chosen based on the patient’s clinic. According to our experience and opinion, open incisional hernia repair should be performed to patients with little and very large incisional hernia. Small, superficial, and uncomplicated hernias can be repaired under local anesthesia. Conversion to open surgery is always possible if a high risk of iatrogenic injury during laparoscopic surgery is present, e.g., in case of severe adherences.
Some limitations affect this study. The non-homogeneous data and the short follow-up period found in the studies of the literature limit our study, especially on the recurrence rate outcome.
The other limitation that may influence many of the outcomes is consequent to the different positions in which the mesh can be placed by the open repair. Most of the studies describing open technique reported the sublay mesh position (2,3,5,8,9,11,17), four studies reported the onlay mesh position (8,14,26,27), and one randomized controlled study (28) reported the inlay mesh position.
Another limitation may derive from the fact that we did not consider adherence incidence and bowel injury complication with related mesh infection, because these data in the literature are lacking.
Conclusions
Although, these difficulties interesting conclusions came out from this review of the literature. The laparoscopic repair technique has shown a significant higher risk of intra-abdominal complications, whereas the open technique showed a higher risk of postoperative complications, SSI, and a longer hospital stay. There is no unanimity on what is the procedure with a higher long-term recurrence rate.
Therefore, we emphasize the need for studies with longer follow-up periods to better assess long-term outcomes, such as recurrence rates, and the creation of a universal fillable registry accessible to all surgeons in the world, reporting all the data required for creating standardized studies on incisional hernia repair, thus overtaking the limitations of the present study.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://ls.amegroups.com/article/view/10.21037/ls-25-7/rc
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Cite this article as: Vecchio R, Scilletta S, Intagliata E. Literature review on the outcome after laparoscopic and open repair of incisional hernia. Laparosc Surg 2026;10:1.
