Discussion
pain, hernia, hernias, ’
RECURRENCES, WOUND INFECTIONS, RECURRENCE, COMPLICATION
This randomized controlled trial showed that laparoscopic incisional hernia repair was not superior to conventional open repair for length of hospital stay. Median length of hospital stay was similar in both groups, with 3 days in both the open and laparoscopic group. There were no significant between-group differences in QoL at short- and long-term follow-up. A remarkably high number of patients were symptomatic according to the CCS having ‘mild but bothersome’ to ‘disabling’ pain, with 89%, 83%, and 35% at, respectively, 2 weeks, 3 months, and long-term follow-up. A third of the patients in the open group was not satisfied at long-term follow-up compared to fifteen percent in the laparoscopic group, and would not go for this operation again.The results of this study do not change the ongoing debate of conventional open or laparoscopic surgical repair. Although laparoscopic techniques have become the standard of care for many operations, convincing evidence to conclude that laparoscopic incisional hernia repair is superior to conventional open repair is lacking. Laparoscopic incisional hernia repair is found to lead to significantly fewer wound infections as compared with open approach, but superiority for other outcomes is still not proven [However, the laparoscopic technique used in the INCH-trial is getting less popular. In the last years, there is a shift toward the use of the robot in abdominal wall surgery [Length of hospital stay is assumed to be shorter in laparoscopic incisional hernia repair [QoL was comparable for both groups at short- and long-term follow-up. Only a trend of better QoL outcomes in the laparoscopic group was observed, but scores differed not significantly. Improvement of QoL was mostly reflected in the physical subscales of the SF-36 instrument, which is in line with previous studies [In this study, two QoL questionnaires were used. The SF-36 is a generic instrument and the CCS is a widely accepted, disease-specific QoL instrument validated in all hernia types with mesh repair. Although QoL improved according to the SF-36, the CCS showed that a significant group of patients experienced ‘mild to bothersome pain’ at different timepoints of follow-up. Besides, 26% of the patients were not satisfied and 46% thought the abdominal wall was similar or worse compared to before the operation at long-term follow-up. Therefore, the question whether or not a patient would undergo incisional hernia repair again knowing the results of the operation is characteristic for the level of satisfaction.QoL questionnaires seem to vary in their outcomes making interpretation of the results rather difficult. Given the huge variety in different assessment measures used in hernia research [Overall recurrence rate at long-term follow-up was 19%, of which 16% in the open and 23% in the laparoscopic group (The high incidence and high recurrence rate make incisional hernias the most common complication after abdominal wall surgery. The majority of patients with incisional hernias develop symptoms such as pain, discomfort or cosmetic complaints. Incisional hernias can be invalidating for patients, and the QoL in these patients as well as their chances for employment are reduced. Approximately, eighty percent of the patients with an incisional hernia undergo surgical repair [This study should be seen in light of several limitations. First of all, the design of this trial can be considered a limitation. A randomized controlled trial with a superiority design is the most optimal study design to determine if one surgical intervention is superior to the prevailing one. However, the likelihood to find a minimal clinically important difference is challenging [Another limitation was the evolution of new surgical techniques during the trial, with promising results [The high level of heterogeneity in surgical procedures in the INCH-trial can be considered another limitation. The variety in surgical techniques makes it difficult to compare all the cases. However, with the design of this study, we aimed for an adequate reflection of daily practice.The potential bias and loss of statistical power due to the loss of follow-up can be considered another limitation of this study. Response rates at 5 years follow-up were 78% for recurrence rate evaluation and 57% for QoL questionnaires. Although a cut-off of 80% follow-up is ideal in Evidence-Based Medicine (EBM) [Lastly, the hospital visiting restrictions due to the COVID-19 pandemic were a limitation for the follow-up of this study. Unfortunately, physical examination could not be conducted, potentially resulting in missing recurrences. Awareness about this limitation elicited more extensive interviews to complete thorough follow-up. However, the high number of reported symptoms at long-term follow-up is suggestive for an underestimation of the actual recurrence rates.