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Original Article |

Short-term Outcomes of Laparoscopic and Open Ventral Hernia Repair:  A Meta-analysis FREE

Philip P. Goodney, MD; Christian M. Birkmeyer, MS; John D. Birkmeyer, MD
[+] Author Affiliations

From the VA Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, Vt (Drs Goodney and J. D. Birkmeyer); the Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (Drs Goodney and J. D. Birkmeyer and Mr C. M. Birkmeyer); and the Center for the Evaluative Clinical Sciences, Dartmouth Medical School, Hanover, NH (Drs Goodney and J. D. Birkmeyer and Mr C. M. Birkmeyer).


Arch Surg. 2002;137(10):1161-1165. doi:10.1001/archsurg.137.10.1161.
Text Size: A A A
Published online

Background  Although laparoscopic repair of ventral hernia has become increasingly popular, its outcomes relative to open repair have not been well characterized. For this reason, we performed a meta-analysis of studies comparing open and laparoscopic ventral (including incisional) hernia repair.

Hypothesis  Laparoscopic ventral hernia repair results in better short-term outcomes than open ventral hernia repair.

Data Sources  Structured MEDLINE search for published studies. One unpublished study was also identified.

Study Selection  Studies were selected on the basis of study design (comparison of laparoscopic and open ventral hernia repair). The 3 main outcome measures were perioperative complications, operative time, and length of hospital stay. Of 83 potential studies identified by abstract review, 8 (10%) met the inclusion criteria.

Data Extraction  Two reviewers assessed each article to determine eligibility for inclusion and, where appropriate, abstracted information on patient characteristics and main outcome measures.

Data Synthesis  Across 8 studies, 390 patients underwent open repair and 322 underwent laparoscopic repair. Perioperative complications were less than half as likely to occur in patients undergoing laparoscopic repair (14% vs 27%; P = .03; odds ratio, 0.42; 95% confidence interval, 0.29-0.68). Average length of stay was shorter in the laparoscopic group (2.0 vs 4.0 days; P = .02). No statistically significant difference in operative times was noted between laparoscopic and open repair (99 vs 96 minutes; P = .38).

Conclusions  Laparoscopic ventral hernia repair offers lower complication rates and shorter length of stay than open repair. However, randomized controlled trials and studies with long-term follow-up are needed to confirm these findings and to assess long-term rates of hernia recurrence.

Figures in this Article

APPROXIMATELY 90 000 ventral hernias are repaired yearly in the United States,1 including incisional, epigastric, and spigelian defects. Although open repair, preferably with mesh,27 has long been the standard approach, laparoscopic repair is becoming increasingly popular among surgeons and patients following the development of minimally invasive techniques. Several observational studies816 have raised the possibility that laparoscopic ventral hernia repair may be associated with fewer complications, decreased length of postoperative hospital stay, and lower recurrence rates.

Although numerous studies have described outcomes of laparoscopic ventral hernia repair, there remains uncertainty about the relative outcomes of laparoscopic and open ventral hernia repair. Most studies815 have been case series, lacking control groups. Studies1719 with control groups have been relatively small, single-center series. To better understand the outcomes of these 2 techniques, we performed a meta-analysis of studies evaluating both laparoscopic and open ventral hernia repair.

STUDY SELECTION AND DATA ABSTRACTION

Studies were selected from MEDLINE using the strategy described in Figure 1. We searched with the medical subject headings terms ventral hernia and umbilical hernia, and then we combined these studies with those with the medical subject headings term laparoscopy. In addition, we hand searched references of included articles for other relevant studies. One unpublished study was identified.20 After excluding non-English articles, we were left with 83 studies. We then systematically reviewed abstracts. Studies without explicit comparison of laparoscopic and open ventral hernia repair were excluded. Eight studies met the inclusion criteria.

Place holder to copy figure label and caption
Figure 1.

MEDLINE search strategy (OVID).

Graphic Jump Location

Two reviewers (P.P.G. and C.M.B.) independently reviewed the 8 studies and extracted information about the study design, sample size, patient characteristics, hernia characteristics, and outcomes. Rate of complications was the primary outcome measure. In addition, we abstracted information on operative time and length of hospital stay.

STATISTICAL ANALYSIS

We compared the odds of developing complications for patients treated laparoscopically and those treated with the open approach. Complication rates were weighted inversely with the variance and event rates across studies, related to the overall sample size. Because most studies did not provide confidence intervals, we conservatively calculated these using the Fisher exact method.21 In primary analysis, we aggregated these results across studies using the Mantel-Haenszel method22 and used a fixed-effects model to determine confidence intervals. We also analyzed the data using a random-effects model. However, because this approach changed the point estimates minimally, we present only the former. Study uniformity was assessed using the test of homogeneity.

We calculated the mean operative time and length of hospital stay from each study, weighted by the number of patients in each study. The unpaired t test was then used to determine significance between the weighted averages. All tests of significance are at the 5% level, and all P values are 2-tailed. All calculations were performed using Stata (Stata Corp, College Station, Tex).

PATIENT AND STUDY CHARACTERISTICS

We included 1 randomized controlled trial19 and 7 cohort studies17,18,20,2326 (Table 1). One cohort study17 used historical controls (open repair cases from an earlier period). Patient characteristics, such as demographics, body mass index, comorbidities, and previous attempt at hernia repair, were abstracted when available. However, only information on patient age and sex was consistently available in most studies. Average patient age ranged from 46 to 60 years (Table 2). Other than the study by Holzman et al,26 patient age was similar in the laparoscopic and open groups. Similar trends were noted for patient sex, with the exception of the study by Robbins et al.18 Last, patients undergoing laparoscopic repair were more likely to have undergone previous (failed) hernia repair in all studies in which that information was available; this difference was statistically significant in 2 of 5 studies.

Table Graphic Jump LocationTable 1. Characteristics of the 8 Studies Included in the Meta-analysis of Studies Comparing Open With Laparoscopic Ventral Hernia Repair*

The operative technique used for open repair varied across studies (Table 1). Whereas 7 of 8 studies used mesh in all open repairs, some open procedures in one study26 involved primary repair with nonabsorbable sutures. The position of the mesh placement was either not noted explicitly19,24,26 or varied from onlay20,23 to inlay25 to underlay.17,18 Onlay was defined as placed anteriorly to the fascia, inlay was defined as sewn to the edges of the fascial defect, and underlay was defined as placed retromuscular to the rectus sheath.17,18

COMPLICATIONS

Of the 6 studies included in the complications summary measure, 5 (83%) reported trends toward decreased risks of complications with laparoscopy (Table 3 and Figure 2). Three of these reductions were statistically significant. The only study showing no benefit with laparoscopic repair was the smallest study, with only 14 patients in each arm.17 In evaluating complication rates, 2 studies were excluded from meta-analysis. The first excluded study18 recorded only wound complications, excluding any other type of complication, such as pulmonary embolism or pneumonia. They reported wound complication rates of 28% in the open group and 16% in the laparoscopic group. The other excluded study19 reported only total number of complications, not number of patients with complications. They identified 2 complications in 30 laparoscopic patients compared with 15 in 30 open patients.

Table Graphic Jump LocationTable 3. Summary of Complication Rates, Laparoscopic vs Open Ventral Hernia Repair*
Place holder to copy figure label and caption
Figure 2.

Odds of perioperative complications for laparoscopic vs open ventral hernia repair. Error bars represent 95% confidence intervals. Carbajo et al19 assessed total complications (rather than rate of complications) and Robbins et al18 included only wound complications. These 2 studies were excluded from the summary measure calculation.

Graphic Jump Location

In pooled analysis, the summary odds ratio was 0.42 (95% confidence interval, 0.29-0.68; P = .03) for risk of complications with laparoscopic relative to open repair. In other words, patients undergoing laparoscopic ventral hernia repair were 58% less likely to experience a complication as those undergoing open repair. Our test of homogeneity (5 df) yielded a P = .59, demonstrating that the outcomes from these studies were consistent enough for aggregation.

LENGTH OF STAY

Seven studies reported shorter postoperative hospital stays for patients undergoing laparoscopic repair (Figure 3). Three studies19,23,25 reported statistically significant reductions in length of stay, 3 studies17,24,26 did not assess statistical significance, and the final study20 found a statistically nonsignificant reduction. One study18 did not report data on length of stay. In pooled analysis, average length of stay was shorter in the laparoscopic group (2.0 vs 4.0 days; P = .02). The study showing the largest reduction in length of stay was the only randomized controlled trial19 in our analysis.

Place holder to copy figure label and caption
Figure 3.

Comparison of average hospital lengths of stay for laparoscopic vs open ventral hernia repair.

Graphic Jump Location
OPERATIVE TIME

Six studies compared average operating room times in the 2 groups (Figure 4). Four17,20,25,26 of the 6 studies noted longer operative time (range, 17-46 minutes longer) with laparoscopic repair. The 2 remaining studies19,24 found average operating room times 24 and 29 minutes shorter with laparoscopy. In pooled analysis, we found no statistically significant difference in operative times between the laparoscopic and open groups (99 vs 96 minutes; P = .38).

Place holder to copy figure label and caption
Figure 4.

Comparison of average operative times for laparoscopic vs open ventral hernia repair.

Graphic Jump Location

This study examined the current surgical literature comparing laparoscopic and open ventral hernia repair. Eight studies, with a total of 712 patients, were identified in the meta-analysis. Compared with open repair, laparoscopic surgery was found to have lower risks of complication, longer operative times, and shorter length of hospital stay.

This study has several limitations. First, it is difficult to rule out unmeasured differences in case-mix as an explanation for the findings, particularly since 7 of the 8 studies reviewed had observational designs. However, there is little reason to believe that differences in case-mix explain the findings. Measured patient characteristics did not imply that "sicker" patients were undergoing open repair. In fact, more patients in the laparoscopic group had undergone previous (failed) attempts at hernia repair. Also, the only randomized controlled trial19 in our analysis, in which patient characteristics should have been evenly distributed between the 2 groups, found similar results to our pooled analysis. Therefore, we believe it is unlikely that our findings can be attributed to unmeasured differences in case-mix.

Second, we did not assess postoperative pain, another potentially important outcome measure. Minimally invasive procedures are often assumed by patients and surgeons to be less painful. However, this assumption has not been well tested in the literature; only one study23 in our analysis used a pain assessment scale to show a small decrease in pain with laparoscopic repair. Our own clinical observations suggest that patients often have considerable discomfort after laparoscopic repair of abdominal wall hernias. More studies assessing this outcome rigorously are needed.

Third, the nature of postoperative complications may differ substantially between the 2 techniques. With open repair, most complications tend to be wound related, only infrequently requiring reoperation and rarely causing permanent disability. In contrast, the risk of unrecognized enterotomy in laparoscopic repair is significant (2%-4%),8,9,14 and delay in diagnosis can result in intra-abdominal contamination and life-threatening sepsis. Therefore, although complications are less frequent in laparoscopic repair, their sequelae may be more severe. Furthermore, several studies used different definitions of what constituted a complication, making comparison across studies difficult. Future trials should use consistent definitions and scales to account for the differences in complications between laparoscopic and open repair.

Fourth, there was significant variability in operative technique, particularly in open ventral hernia, across the 8 studies included in our analysis. Seven studies used mesh in all open repairs. However, the mesh location varied across studies, with 2 studies using an onlay technique,20,23 1 an inlay technique,25 and 2 a retromuscular technique.17,18 Despite this variation, we find little reason to believe that mesh location would affect short-term complications; mesh location in open repair is much more likely to affect recurrence rate.3

Finally, we did not assess hernia recurrence rates, which is one of the most important outcomes of ventral hernia repair. Considerable uncertainty exists surrounding recurrence rates in open and laparoscopic ventral hernia repair. The 3-year cumulative recurrence rate in a large randomized controlled trial2 of open ventral hernia repair was 24%. This study used retromuscular mesh placement with a 2- to 3-cm overlap, considerably less overlap than that described by Stoppa4 and Rives.3 Uncontrolled studies3,2730 using the Stoppa/Rives technique have reported recurrence rates as low as 2% to 6%. In laparoscopic repair, retrospective studies9,31,32 have reported recurrence rates as low as 3% to 4%. Of the 8 studies included in our meta-analysis, only 32325 contained data regarding recurrence rates for the laparoscopic technique (range, 3%-13%). These data were short term (usually <2 years) and often were not evaluated by independent examiners or objective measures (eg, imaging). Given uncertainty about long-term recurrence rates after laparoscopic repair, trials with long-term follow-up are needed to compare the durability of open and laparoscopic repair.

In conclusion, laparoscopic ventral hernia repair offers lower complication rates and shorter length of hospital stay compared with traditional open repair. However, randomized controlled trials are necessary to confirm these findings and to provide information on long-term recurrence rates.

This study was supported by a Career Development Award from the Veterans Administration Health Services Research and Development Service, Washington, DC (Dr J. D. Birkmeyer).

Corresponding author: Philip P. Goodney MD, VA Outcomes Group (111B), Department of Veteran Affairs Medical Center, 215 N Main St, White River Junction, VT 05009 (e-mail: philip.goodney@hitchcock.org).

Toy  FKBailey  RWCarey  S  et al.  Prospective, multicenter study of laparoscopic ventral hernioplasty: preliminary results. Surg Endosc. 1998;12955- 959
Luijendijk  RWHop  WCvan den Tol  MP  et al.  A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med. 2000;343392- 398
Not Available, Incisional hernia: the problem and the cure. J Am Coll Surg. 1999;188429- 447
Stoppa  RE The treatment of complicated groin and incisional hernias. World J Surg. 1989;13545- 554
Amid  PKLichtenstein  IL Retromuscular alloplasty of large scar hernias: a simple staple attachment technique [in German]. Chirurg. 1996;67648- 652
Amid  PKShulman  AGLichtenstein  IL A simple stapling technique for prosthetic repair of massive incisional hernias. Am Surg. 1994;60934- 937
Wantz  GE Incisional hernioplasty with Mersilene. Surg Gynecol Obstet. 1991;172129- 137
Heniford  BTPark  ARamshaw  BJVoeller  G Laparoscopic ventral and incisional hernia repair in 407 patients. J Am Coll Surg. 2000;190645- 650
Heniford  BTRamshaw  BJ Laparoscopic ventral hernia repair: a report of 100 consecutive cases. Surg Endosc. 2000;14419- 423
Sanders  LMFlint  LMFerrara  JJ Initial experience with laparoscopic repair of incisional hernias. Am J Surg. 1999;177227- 231
Amid  PK Laparoscopic repair of anterior abdominal wall herniation using composite mesh. Am J Surg. 1996;171542- 543
Costanza  MJHeniford  BTArca  MJMayes  JTGagner  M Laparoscopic repair of recurrent ventral hernias. Am Surg. 1998;641121- 1125discussion, 1126-1127
Farrakha  M Laparoscopic treatment of ventral hernia: a bilayer repair. Surg Endosc. 2000;141156- 1158
Kyzer  SAlis  MAloni  YCharuzi  I Laparoscopic repair of postoperation ventral hernia: early postoperation results. Surg Endosc. 1999;13928- 931
LeBlanc  KABooth  WVWhitaker  JMBellanger  DE Laparoscopic incisional and ventral herniorrhaphy in 100 patients. Am J Surg. 2000;180193- 197
Larson  GM Ventral hernia repair by the laparoscopic approach. Surg Clin North Am. 2000;801329- 1340
Chari  RChari  VEisenstat  MChung  R A case controlled study of laparoscopic incisional hernia repair. Surg Endosc. 2000;14117- 119
Robbins  SBPofahl  WEGonzalez  RP Laparoscopic ventral hernia repair reduces wound complications. Am Surg. 2001;67896- 900
Carbajo  MAMartin del Olmo  JCBlanco  JI  et al.  Laparoscopic treatment vs open surgery in the solution of major incisional and abdominal wall hernias with mesh. Surg Endosc. 1999;13250- 252
McGreevy  JMGoodney  PPLaycock  WSBirkmeyer  CMBirkmeyer  JD A prospective study of complication rates after laparoscopic and open ventral hernia repair. Surg Endosc. In press.
D'Agostino  RChase  WBelanger  A The appropriateness of some common procedures for testing the equality of two independent binomial populations. Am Stat. 1988;42198- 202
Mantel  NHaenszel  M Statistical aspects of the analysis of data from retrospective studies of disease. J Natl Cancer Inst. 1959;22719- 748
DeMaria  EJMoss  JMSugerman  HJ Laparoscopic intraperitoneal polytetrafluoroethylene (PTFE) prosthetic patch repair of ventral hernia: prospective comparison to open prefascial polypropylene mesh repair. Surg Endosc. 2000;14326- 329
Ramshaw  BJEsartia  PSchwab  J  et al.  Comparison of laparoscopic and open ventral herniorrhaphy. Am Surg. 1999;65827- 831discussion, 831-832.
Park  ABirch  DWLovrics  P Laparoscopic and open incisional hernia repair: a comparison study. Surgery. 1998;124816- 821discussion, 821-822.
Holzman  MDPurut  CMReintgen  KEubanks  SPappas  TN Laparoscopic ventral and incisional hernioplasty. Surg Endosc. 1997;1132- 35
Korenkov  M Classification and surgical treatment of incisional hernia: results of an experts' meeting. Langenbecks Arch Surg. 2001;38665- 73
Avisse  CPalot  JPFlament  JB Treatment of inguinal hernia by the Jean Rives technique: replacement of the fascia traversalis by a Dacron prosthesis: apropos of the reports of G.E. Wantz and E.P. Pelissier: session of 12 May 1993 [in French]. Chirurgie. 1993;119362- 365
Rives  JFortesa  LDrouard  FHibon  JFlament  JB Subperitoneal abdominal approach in the treatment of inguinal hernia [in French]. Ann Chir. 1978;32245- 253
Schumpelick  VConze  JKlinge  U Preperitoneal mesh-plasty in incisional hernia repair: a comparative retrospective study of 272 operated incisional hernias. Chirurg. 1996;671028- 1035
Reitter  DRPaulsen  JKDebord  JREstes  NC Five-year experience with the "four-before" laparoscopic ventral hernia repair. Am Surg. 2000;66465- 468discussion, 468-469.
Chowbey  PKSharma  AKhullar  RMann  VBaijal  MVashistha  A Laparoscopic ventral hernia repair. J Laparoendosc Adv Surg Tech A. 2000;1079- 84

Figures

Place holder to copy figure label and caption
Figure 1.

MEDLINE search strategy (OVID).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Odds of perioperative complications for laparoscopic vs open ventral hernia repair. Error bars represent 95% confidence intervals. Carbajo et al19 assessed total complications (rather than rate of complications) and Robbins et al18 included only wound complications. These 2 studies were excluded from the summary measure calculation.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Comparison of average hospital lengths of stay for laparoscopic vs open ventral hernia repair.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

Comparison of average operative times for laparoscopic vs open ventral hernia repair.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Characteristics of the 8 Studies Included in the Meta-analysis of Studies Comparing Open With Laparoscopic Ventral Hernia Repair*
Table Graphic Jump LocationTable 3. Summary of Complication Rates, Laparoscopic vs Open Ventral Hernia Repair*

References

Toy  FKBailey  RWCarey  S  et al.  Prospective, multicenter study of laparoscopic ventral hernioplasty: preliminary results. Surg Endosc. 1998;12955- 959
Luijendijk  RWHop  WCvan den Tol  MP  et al.  A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med. 2000;343392- 398
Not Available, Incisional hernia: the problem and the cure. J Am Coll Surg. 1999;188429- 447
Stoppa  RE The treatment of complicated groin and incisional hernias. World J Surg. 1989;13545- 554
Amid  PKLichtenstein  IL Retromuscular alloplasty of large scar hernias: a simple staple attachment technique [in German]. Chirurg. 1996;67648- 652
Amid  PKShulman  AGLichtenstein  IL A simple stapling technique for prosthetic repair of massive incisional hernias. Am Surg. 1994;60934- 937
Wantz  GE Incisional hernioplasty with Mersilene. Surg Gynecol Obstet. 1991;172129- 137
Heniford  BTPark  ARamshaw  BJVoeller  G Laparoscopic ventral and incisional hernia repair in 407 patients. J Am Coll Surg. 2000;190645- 650
Heniford  BTRamshaw  BJ Laparoscopic ventral hernia repair: a report of 100 consecutive cases. Surg Endosc. 2000;14419- 423
Sanders  LMFlint  LMFerrara  JJ Initial experience with laparoscopic repair of incisional hernias. Am J Surg. 1999;177227- 231
Amid  PK Laparoscopic repair of anterior abdominal wall herniation using composite mesh. Am J Surg. 1996;171542- 543
Costanza  MJHeniford  BTArca  MJMayes  JTGagner  M Laparoscopic repair of recurrent ventral hernias. Am Surg. 1998;641121- 1125discussion, 1126-1127
Farrakha  M Laparoscopic treatment of ventral hernia: a bilayer repair. Surg Endosc. 2000;141156- 1158
Kyzer  SAlis  MAloni  YCharuzi  I Laparoscopic repair of postoperation ventral hernia: early postoperation results. Surg Endosc. 1999;13928- 931
LeBlanc  KABooth  WVWhitaker  JMBellanger  DE Laparoscopic incisional and ventral herniorrhaphy in 100 patients. Am J Surg. 2000;180193- 197
Larson  GM Ventral hernia repair by the laparoscopic approach. Surg Clin North Am. 2000;801329- 1340
Chari  RChari  VEisenstat  MChung  R A case controlled study of laparoscopic incisional hernia repair. Surg Endosc. 2000;14117- 119
Robbins  SBPofahl  WEGonzalez  RP Laparoscopic ventral hernia repair reduces wound complications. Am Surg. 2001;67896- 900
Carbajo  MAMartin del Olmo  JCBlanco  JI  et al.  Laparoscopic treatment vs open surgery in the solution of major incisional and abdominal wall hernias with mesh. Surg Endosc. 1999;13250- 252
McGreevy  JMGoodney  PPLaycock  WSBirkmeyer  CMBirkmeyer  JD A prospective study of complication rates after laparoscopic and open ventral hernia repair. Surg Endosc. In press.
D'Agostino  RChase  WBelanger  A The appropriateness of some common procedures for testing the equality of two independent binomial populations. Am Stat. 1988;42198- 202
Mantel  NHaenszel  M Statistical aspects of the analysis of data from retrospective studies of disease. J Natl Cancer Inst. 1959;22719- 748
DeMaria  EJMoss  JMSugerman  HJ Laparoscopic intraperitoneal polytetrafluoroethylene (PTFE) prosthetic patch repair of ventral hernia: prospective comparison to open prefascial polypropylene mesh repair. Surg Endosc. 2000;14326- 329
Ramshaw  BJEsartia  PSchwab  J  et al.  Comparison of laparoscopic and open ventral herniorrhaphy. Am Surg. 1999;65827- 831discussion, 831-832.
Park  ABirch  DWLovrics  P Laparoscopic and open incisional hernia repair: a comparison study. Surgery. 1998;124816- 821discussion, 821-822.
Holzman  MDPurut  CMReintgen  KEubanks  SPappas  TN Laparoscopic ventral and incisional hernioplasty. Surg Endosc. 1997;1132- 35
Korenkov  M Classification and surgical treatment of incisional hernia: results of an experts' meeting. Langenbecks Arch Surg. 2001;38665- 73
Avisse  CPalot  JPFlament  JB Treatment of inguinal hernia by the Jean Rives technique: replacement of the fascia traversalis by a Dacron prosthesis: apropos of the reports of G.E. Wantz and E.P. Pelissier: session of 12 May 1993 [in French]. Chirurgie. 1993;119362- 365
Rives  JFortesa  LDrouard  FHibon  JFlament  JB Subperitoneal abdominal approach in the treatment of inguinal hernia [in French]. Ann Chir. 1978;32245- 253
Schumpelick  VConze  JKlinge  U Preperitoneal mesh-plasty in incisional hernia repair: a comparative retrospective study of 272 operated incisional hernias. Chirurg. 1996;671028- 1035
Reitter  DRPaulsen  JKDebord  JREstes  NC Five-year experience with the "four-before" laparoscopic ventral hernia repair. Am Surg. 2000;66465- 468discussion, 468-469.
Chowbey  PKSharma  AKhullar  RMann  VBaijal  MVashistha  A Laparoscopic ventral hernia repair. J Laparoendosc Adv Surg Tech A. 2000;1079- 84

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