European Journal of Cardiovascular Medicine

Ventral hernia repair is one of the most frequently performed abdominal wall procedures and is often associated with notable postoperative complications, especially surgical site infections (SSIs) [1]. SSIs contribute substantially to increased morbidity, healthcare utilization, and prolonged hospitalization, posing a significant burden on healthcare systems [2]. The introduction of minimally invasive surgical techniques, particularly laparoscopic ventral hernia repair, has been shown to offer several benefits over open approaches, such as reduced wound complications and shorter hospital stays [3].

Open surgical techniques, despite their long-standing usage, have consistently been linked with higher rates of SSI due to extensive dissection and larger incisions [4]. Conversely, laparoscopic repair, characterized by smaller incisions and reduced exposure of tissues to external contaminants, is associated with lower infection rates and faster recovery [5]. Studies have also suggested that individual patient factors such as obesity, diabetes mellitus, smoking, and anemia are significant predictors of postoperative SSIs, regardless of the surgical approach [6].

Accurate risk stratification and assessment are critical in optimizing patient outcomes. Tools such as the Ventral Hernia Working Group (VHWG) grading system have been employed to categorize patients based on comorbidities and predict postoperative complications [7]. Additionally, procedural variables—including mesh type, placement technique, and operative duration—can influence the likelihood of SSI [8]. The clinical and economic implications of these infections highlight the importance of selecting an optimal surgical approach based on patient risk profiles [9].

This prospective study was designed to compare the incidence of SSIs between open and laparoscopic ventral hernia repair while evaluating the impact of patient-related risk factors. By providing evidence on the relative safety and efficacy of each approach, the study aims to contribute to informed surgical decision-making and improved patient care.

Aims and Objectives

Aim:
This study aimed to compare the incidence of surgical site infections (SSIs) following open versus laparoscopic ventral hernia repair.

Objectives:

1. To determine the incidence of SSIs in patients undergoing open ventral hernia repair.
2. To determine the incidence of SSIs in patients undergoing laparoscopic ventral hernia repair.
3. To compare postoperative SSI rates between the two surgical approaches.
4. To evaluate risk factors associated with the development of SSIs in both groups.
5. To assess related postoperative outcomes, including duration of hospital stay and readmission rates.

This randomized comparative prospective study was conducted over a two-year period in the Department of General Surgery at Raja Rajeswari Medical College and Hospital, Bengaluru. Sixty patients with a clinical diagnosis of ventral hernia were enrolled and randomly assigned into two equal groups: Group A (open ventral hernia repair, n = 30) and Group B (laparoscopic ventral hernia repair, n = 30). Randomization was performed using computer-generated numbers.

Inclusion criteria consisted of adult patients (age >18 years) with a clinical diagnosis of ventral hernia who provided informed consent for either surgical approach. Exclusion criteria included pregnant women, immunocompromised individuals, critically ill patients, and those unwilling to consent.

Baseline patient characteristics, including age, sex, BMI, and comorbidities (e.g., diabetes, smoking), were recorded. Operative details such as duration of surgery and type of mesh used were documented. All patients were followed up on postoperative days 3, 7, 15, and 30 for signs of surgical site infection and other wound-related complications.

Surgical site infection was defined based on CDC criteria and included signs such as purulent wound discharge, erythema, gaping, induration, or positive microbiological cultures. Additional outcomes like duration of hospital stay and requirement for readmission were also noted.

Statistical analysis was conducted using SPSS version 26. Descriptive statistics summarized patient demographics and operative variables. Categorical variables were analyzed using the Chi-square test or Fisher’s exact test, and continuous variables using the independent t-test or Mann–Whitney U test as applicable. A p-value < 0.05 was considered statistically significant. Logistic regression analysis was used to assess independent predictors of SSI.

Demographic and Clinical Profile

A total of 60 patients diagnosed with ventral hernia were included in the study, with 30 undergoing open mesh repair and 30 undergoing laparoscopic repair. The mean age of patients in the open group was 50.1 ± 12.6 years, which was significantly higher than that in the laparoscopic group (45.3 ± 10.2 years, p = 0.048).

Regarding comorbidities, 40% of patients in the open group were diabetic compared to 20% in the laparoscopic group (p = 0.093). Similarly, the prevalence of smokers was higher in the open group (30%) versus 10% in the laparoscopic group, approaching statistical significance (p = 0.064). The proportion of patients with a BMI > 30 was similar between groups (33.3% vs. 36.7%, p = 0.781), indicating no significant difference in obesity prevalence.

Table 1: Baseline Demographic and Clinical Characteristics

Incidence of Surgical Site Infections (SSI)

The incidence of surgical site infections (SSIs) was significantly higher in the open repair group compared to the laparoscopic group. Out of 30 patients in the open group, 6 developed SSIs, resulting in an infection rate of 20%. In contrast, only 1 out of 30 patients in the laparoscopic group developed an SSI, yielding a rate of 3.3%. The difference in SSI incidence between the two groups was statistically significant (p = 0.045).

Table 2: SSI Rates in Open vs Laparoscopic Repair

Figure1: Bar Chart Comparing SSI Incidence in Open vs Laparoscopic Groups

Risk Factor Association with SSI

Risk factor analysis revealed a statistically significant association between diabetes and the development of surgical site infection (SSI). Among patients who developed SSI, 71.4% were diabetic compared to 24.5% in the non-SSI group (p = 0.013). Although not statistically significant, a higher prevalence of smoking (42.9% vs. 15.1%, p = 0.072) and anemia (57.1% vs. 28.3%, p = 0.098) was also observed among SSI patients, suggesting a potential trend. All comparisons were analyzed using Fisher’s exact test.

Table 3: Comorbidities in Patients with and without SSI

Figure2: Prevalence of risk factors in SSI vs Non-SSI Groups

This figure illustrates the comparative prevalence of diabetes, smoking, and anaemia between the two groups.

Postoperative Outcomes

The postoperative outcomes demonstrated that patients undergoing open ventral hernia repair had a significantly longer hospital stay compared to those undergoing laparoscopic repair. The mean duration of hospital stay was 5.4 ± 2.3 days for the open group, versus 3.1 ± 1.2 days for the laparoscopic group (p = 0.002).

Although not statistically significant, the readmission rate was higher in the open group (13.3%) compared to the laparoscopic group (3.3%) (p = 0.271). Among all patients who developed SSIs, 28.5% required readmission.

Table 4: Postoperative Outcomes by Group

Figure 3: Box Plot of Hospital Stay

This study demonstrates that laparoscopic ventral hernia repair is associated with a significantly reduced incidence of surgical site infections (SSIs) compared to open repair. Specifically, the SSI rate in the open group was 20%, while in the laparoscopic group it was 3.3%, a difference that was statistically significant (p = 0.045). These findings are in alignment with those of Karthik et al. [10], who documented infection rates of 16% in open repair and only 3.5% in laparoscopic procedures. Similarly, Bittner et al. [11] reported that minimally invasive techniques significantly lower wound-related complications due to smaller incisions and reduced tissue trauma.

Our study also observed that the mean age of patients undergoing open repair (50.1 ± 12.6 years) was significantly higher than that in the laparoscopic group (45.3 ± 10.2 years, p = 0.048). Though age itself was not directly linked to higher SSI risk in this study, its distribution may reflect a selection bias toward open surgery in older or more comorbid individuals, which has also been suggested by Sharma et al. [12] in similar cohorts from Indian tertiary centres.

Among risk factors, diabetes mellitus was significantly associated with SSI occurrence. In the SSI group, 71.4% of patients were diabetic versus only 24.5% in the non-SSI group (p = 0.013). This strong association aligns with findings from studies such as that by Sahu et al. [13], which reported an adjusted odds ratio of 4.1 for SSI in diabetic patients undergoing abdominal surgeries. Diabetes may impair neutrophil function and delay wound healing, predisposing surgical sites to infection. While smoking (42.9% vs. 15.1%, p = 0.072) and anaemia (57.1% vs. 28.3%, p = 0.098) were not statistically significant, their higher frequency among SSI patients reflects similar risk trends reported in large meta-analyses, including by Singh et al. [14], who identified anaemia as a borderline modifiable risk factor for infection in gastrointestinal surgeries.

Regarding postoperative recovery, patients in the open repair group had a significantly longer hospital stay compared to those in the laparoscopic group (5.4 ± 2.3 vs. 3.1 ± 1.2 days, p = 0.002). This result is consistent with international literature, including the review by LeBlanc et al. [15], which noted hospital stays of up to 6 days for open repair versus 2–3 days for laparoscopic procedures. Prolonged hospitalization is often attributed to increased wound care needs and delayed ambulation in open surgery patients. Additionally, while the readmission rate was higher in the open group (13.3%) compared to the laparoscopic group (3.3%), this difference was not statistically significant (p = 0.271). Nonetheless, it is notable that 28.5% of patients who developed SSI required readmission, highlighting the economic and clinical implications of preventable wound infections, a concern echoed in the cost-effectiveness study by Itani et al. [16].

Finally, our findings reinforce the value of laparoscopic hernia repair not only in reducing SSI rates but also in improving overall postoperative outcomes. These advantages are particularly relevant in resource-constrained settings where SSI-related morbidity contributes significantly to healthcare burden. Studies from similar Indian centres [17][18] have called for increased training in minimally invasive techniques as a measure to improve patient safety and reduce surgical complications

This randomized comparative study demonstrates that laparoscopic ventral hernia repair offers a significant clinical advantage over open repair in terms of lower surgical site infection (SSI) rates and shorter hospital stay. With an SSI incidence of only 3.3% in the laparoscopic group compared to 20% in the open group (p = 0.045), minimally invasive surgery proves to be a safer option for eligible patients. Furthermore, a significant reduction in hospital stay (mean 3.1 vs. 5.4 days; p = 0.002) reinforces its efficiency and potential to reduce healthcare burden. Diabetes mellitus emerged as a major risk factor for SSI (p = 0.013), underscoring the need for targeted preoperative optimization.

These findings support the broader adoption of laparoscopic repair as a standard surgical approach, especially in settings where postoperative infection control and resource optimization are crucial. However, patient selection, comorbidity management, and surgical expertise remain key determinants of favourable outcomes.

Limitations

This study has certain limitations that should be acknowledged. The relatively small sample size of 60 patients may limit the generalizability and statistical power of subgroup analyses. As a single-centre study conducted at a tertiary care institution, the findings may not be directly applicable to other healthcare settings or populations. Additionally, the follow-up was confined to the immediate postoperative period, without assessment of long-term outcomes such as hernia recurrence or chronic pain. Lastly, despite randomization, the higher mean age in the open repair group suggests potential selection bias that could have influenced outcome measures.

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