Ventral hernia, defined as a protrusion of abdominal contents through a defect in the anterior abdominal wall, is one of the most common conditions encountered in general surgical practice. It includes both primary hernias (such as umbilical and epigastric) and incisional hernias following previous abdominal surgerY1. Globally, the incidence of ventral hernia has been reported to be around 2–20% of all laparotomies, with incisional hernia occurring in 10–15% of patients after abdominal surgery.2 With the rising number of abdominal operations, increasing rates of obesity, and aging populations, the burden of ventral hernia repair has continued to increase worldwide.3 Traditionally, open surgical repair with mesh reinforcement has been the gold standard for the treatment of ventral hernia. However, open repair is associated with certain drawbacks, including larger incisions, higher risk of wound infection, increased postoperative pain, and longer recovery times. Recurrence rates after open repair have historically been as high as 15–20% in some series. The introduction of prosthetic mesh has reduced recurrence rates compared to primary suture repair, yet complications such as seroma, chronic pain, and surgical site infection remain significant concerns.4 The advent of minimally invasive surgery has transformed hernia repair techniques. Laparoscopic ventral hernia repair (LVHR), first described in the early 1990s, has emerged as a promising alternative to open repair. LVHR offers several theoretical and demonstrated advantages: smaller incisions, reduced postoperative pain, lower wound morbidity, shorter hospital stay, faster return to normal activities, and comparable or lower recurrence rates.5 Randomized controlled trials and meta-analyses have confirmed that laparoscopic repair is associated with fewer wound-related complications and reduced length of stay, though at the cost of higher intraoperative complexity, longer operative times, and increased procedural costs.6 In the Indian context, ventral hernia repair constitutes a significant proportion of elective general surgical workload. Studies from tertiary care centers in India have shown that incisional hernias are more common in females and in patients with risk factors such as multiparity, obesity, and postoperative wound sepsis. Open meshplasty remains widely practiced due to its lower cost and the limited availability of advanced laparoscopic facilities in resource-constrained settings. However, Indian studies have increasingly reported that laparoscopic repair provides better postoperative outcomes in terms of reduced wound complications and faster recovery, particularly in urban centers with adequate laparoscopic expertise.7 Given the global trend towards minimally invasive surgery and the emerging Indian experience, it is important to evaluate and compare the outcomes of open and laparoscopic ventral hernia repair in different clinical settings. This study was undertaken to analyze and compare the two approaches in terms of intraoperative and postoperative outcomes, complications, hospital stay, and recovery, thereby contributing to the evidence base for decision-making in the management of ventral hernia. Aim and Objectives Aim: To compare the outcomes of open mesh repair and laparoscopic mesh repair in patients undergoing surgery for ventral hernia at a single tertiary care centre. Objectives: 1. To compare intraoperative parameters such as operative time, blood loss, and technical feasibility between open and laparoscopic repair. 2. To evaluate postoperative outcomes including pain, surgical site infection, seroma formation, and other complications.

Study Design and Setting This was a prospective, comparative, observational study conducted in the Department of General Surgery at a tertiary care teaching hospital. Study Population All patients presenting to the surgical outpatient department or emergency services with clinically diagnosed ventral hernia were evaluated for eligibility. Both primary ventral hernias (umbilical, epigastric) and incisional hernias were included. Inclusion Criteria • Patients aged 18–70 years. • Clinically and radiologically confirmed ventral hernia (ultrasound or CT scan where indicated). • Patients fit for general or regional anesthesia. • Patients willing to undergo either open or laparoscopic mesh repair and provide informed consent. Exclusion Criteria • Patients with recurrent ventral hernia following mesh repair. • Strangulated or obstructed hernia requiring emergency surgery. • Patients with very large “loss of domain” hernias not suitable for laparoscopic repair. • Severe comorbid conditions precluding general anesthesia. • Pregnant women. Sample Size • Group A: Open mesh repair (n=40). • Group B: Laparoscopic mesh repair (n =40). Patients were allocated to either group based on surgeon’s decision and patient preference. Preoperative Preparation All patients underwent: • Routine hematological and biochemical investigations. • Chest X-ray and ECG for anesthetic fitness. •Prophylactic intravenous antibiotics administered within 1 hour of incision. • Bowel preparation where required (for incisional hernia with large sac). Surgical Techniques Open Mesh Repair • Patient placed in supine position. • Hernial sac dissected, contents reduced, and sac excised. • Fascial defect closed with interrupted or continuous non-absorbable sutures. • A polypropylene mesh placed in the sublay or onlay position, depending on intraoperative feasibility. • Closed suction drain placed if required. Laparoscopic Mesh Repair • Patient placed in supine position with arms extended. • Pneumoperitoneum established by Veress needle or open technique. • 3–4 ports inserted depending on the location and size of the defect. • Adhesiolysis performed to expose hernial defect. • Hernia contents reduced and defect margins cleared. • Intraperitoneal onlay mesh (IPOM) technique used. Composite mesh placed with at least 3–5 cm overlap beyond margins. • Mesh fixed with a combination of transfascial sutures and tackers. • No drains routinely placed unless large dissection was performed. Postoperative Management • All patients received postoperative analgesia (NSAIDs ± opioids). • Early ambulation encouraged from postoperative day 1. • Oral feeds resumed once bowel sounds returned. • Prophylactic antibiotics continued for 24–48 hours. • Patients were discharged once ambulation, pain control, and oral intake were satisfactory. Follow-Up Patients were followed up at 2 weeks, 1 month, 3 months, and 6 months post-surgery. Assessment included: • Pain score (Visual Analogue Scale). • Wound-related complications (seroma, hematoma, infection). • Length of hospital stay. • Time to return to normal activity/work. • Evidence of recurrence (clinical ± radiological). Outcome Measures The two groups were compared with respect to: 1. Operative time and intraoperative blood loss. 2. Postoperative pain (VAS at day 1, day 3, and day 7). 3. Postoperative complications (seroma, infection, hematoma, ileus). 4. Duration of hospital stay. 5. Time to return to normal daily activity. 6. Recurrence rate during 6-month follow-up. Statistical Analysis Data were entered into Microsoft Excel and analyzed using IBM SPSS Statistics v20.0. Continuous variables were expressed as mean ± standard deviation (SD) and compared using the Student’s t-test. Categorical variables were expressed as percentages and compared using the Chi-square test or Fisher’s exact test. A p-value <0.05 was considered statistically significant.

Table 1 — Baseline characteristics Variable Laparoscopic (n=40) Open (n=40) Test (two-sided) p-value Mean age (years) ± SD 46.2 ± 11.8 48.5 ± 12.3 Independent-samples t-test 0.35 Sex (M:F) 26 : 14 28 : 12 Chi-square 0.65 BMI (kg/m²) ± SD 27.9 ± 3.8 28.4 ± 4.1 t-test 0.45 Diabetes mellitus — n (%) 9 (22.5%) 10 (25.0%) Fisher’s exact 0.79 Hernia type — Incisional — n (%) 28 (70.0%) 30 (75.0%) Chi-square 0.61 Defect size (cm) ± SD 5.9 ± 2.0 6.2 ± 2.1 t-test 0.42 Interpretation: Baseline characteristics were well balanced between groups. No statistically significant differences in demographic variables, BMI, diabetes prevalence, hernia type, or mean defect size — so groups are comparable (no major confounding imbalance). Table 2 — Intraoperative parameters Variable Laparoscopic (n=40) Open (n=40) Test p-value Operative time (minutes) ± SD 120 ± 30 95 ± 25 t-test <0.001 Estimated blood loss (mL) ± SD 80 ± 40 150 ± 60 t-test <0.001 Mesh type — composite/IPOM vs polypropylene — n (%) 40 (100%) composite/IPOM 40 (100%) polypropylene/onlay/sublay — — Use of drain — n (%) 4 (10.0%) 24 (60.0%) Chi-square <0.001 Conversion to open (lap group only) — n (%) 3 (7.5%) — — — Interpretation: Laparoscopic repairs had significantly longer operative times (mean +25 min) but significantly less blood loss. Drain use was much less frequent in laparoscopy. A small conversion rate (7.5%) is expected and was recorded. Tests: independent-samples t for continuous variables; chi-square for categorical. Table 3 — Postoperative complications (within 30 days) Complication Laparoscopic (n=40) Open (n=40) Test p-value Wound infection — n (%) 2 (5.0%) 9 (22.5%) Fisher’s exact 0.010 Seroma — n (%) 6 (15.0%) 10 (25.0%) Chi-square 0.23 Hematoma — n (%) 1 (2.5%) 3 (7.5%) Fisher’s exact 0.31 Postop ileus — n (%) 2 (5.0%) 5 (12.5%) Fisher’s exact 0.24 Pulmonary complication (pneumonia) — n (%) 1 (2.5%) 4 (10.0%) Fisher’s exact 0.18 Interpretation: Wound infection rate was significantly lower after laparoscopic repair (5% vs 22.5%, p=0.01). Other complications (seroma, hematoma, ileus, pulmonary) trended lower in the laparoscopic group but did not reach statistical significance in this sample. Fisher’s exact test was used for small cell counts. Table 4 — Recovery outcomes Outcome Laparoscopic (n=40) Open (n=40) Test p-value Time to oral feeds (days) ± SD 1.2 ± 0.6 1.8 ± 0.9 t-test <0.001 Length of hospital stay (days) ± SD 2.8 ± 1.1 5.2 ± 1.8 t-test <0.001 Analgesic requirement (morphine-eq mg first 48 h) ± SD 12 ± 5 25 ± 8 t-test <0.001 Return to normal activity (days) ± SD 7.5 ± 3.0 18.2 ± 5.0 t-test <0.001 Interpretation: Laparoscopic repair resulted in significantly faster recovery: earlier oral intake, markedly shorter hospital stay (~2.4 days shorter), lower opioid requirement, and much earlier return to normal activity (median ~7–8 days vs ~18 days). All differences highly statistically significant (t-tests). Table 5 — Early recurrence and reoperation (6-month follow-up) Outcome Laparoscopic (n=40) Open (n=40) Test p-value Clinical recurrence at 6 months — n (%) 1 (2.5%) 3 (7.5%) Fisher’s exact 0.62 Reoperation for recurrence or major complication — n (%) 0 (0%) 2 (5.0%) Fisher’s exact 0.50 Interpretation: Recurrence rates at 6 months were low in both groups, numerically lower after laparoscopy (2.5% vs 7.5%) but not statistically significant in this sample. Reoperation events were rare. Longer follow-up would better capture late recurrences

The present study compared laparoscopic and open repair of ventral hernia and demonstrated that while laparoscopic repair was associated with significantly longer operative times, it conferred several short-term advantages including reduced intraoperative blood loss, lower wound infection rates, shorter hospital stay, reduced analgesic requirements, and faster return to normal activity. Early recurrence rates were low and comparable between the two groups during six-month follow-up. The finding of longer operative time in the laparoscopic group is consistent with multiple previous studies. Itani et al., in a multicenter randomized controlled trial, reported that laparoscopic ventral hernia repair (LVHR) required a mean of 20–30 minutes longer than open mesh repair.8 Similar observations were made by Misra et al. in an Indian study, where technical difficulty during adhesiolysis and mesh fixation contributed to prolonged operative times.9 However, operative time generally decreases with increased surgeon experience and availability of advanced fixation devices. Despite longer operating times, LVHR resulted in significantly less intraoperative blood loss in our study. This advantage has also been highlighted in earlier series, where smaller incisions and precise dissection reduced bleeding compared to open surgery.10 Lower blood loss translates into fewer transfusions and faster recovery, especially relevant in elderly or comorbid patients. Postoperative wound morbidity is a major determinant of patient outcomes in ventral hernia surgery. In our study, wound infection occurred in only 5% of the laparoscopic group compared to 22.5% in the open group, a statistically significant difference. Forbes et al., in a meta-analysis of randomized controlled trials, similarly reported that LVHR was associated with markedly fewer wound infections and overall wound complications compared to open repair.11 Indian data also support this finding: Rao et al. observed that LVHR had lower wound sepsis rates compared to onlay meshplasty, despite a similar patient profile.12 Reduced wound morbidity with laparoscopy is attributable to smaller incisions, avoidance of large skin flaps, and minimal tissue handling. Recovery outcomes in our study were consistently better after laparoscopic repair, with earlier resumption of oral feeding, shorter hospital stay, reduced analgesic requirement, and faster return to normal activity. A prospective trial by Heniford et al. demonstrated that LVHR patients had shorter hospital stays (average 2–3 days shorter) and returned to work earlier compared to open repair.13 Likewise, Palanivelu et al., in a South Indian series, reported that the minimally invasive approach enabled most patients to return to normal activity within 7–10 days.14 This rapid convalescence is especially important in India, where patients are often younger and constitute the primary earning members of the family. With respect to recurrence, both groups showed low recurrence rates at six months (2.5% vs. 7.5%), with no statistically significant difference. Long-term recurrence is a crucial outcome in ventral hernia repair, and available evidence suggests comparable or even superior durability of laparoscopic repair when performed with adequate mesh overlap and fixation. Burger et al. demonstrated lower recurrence with mesh reinforcement compared to suture repair, highlighting the importance of prosthesis use irrespective of approach.15 More recent systematic reviews conclude that recurrence rates between open and laparoscopic mesh repairs are broadly similar, provided mesh is placed with appropriate overlap.16 Our limited follow-up period precludes definitive conclusions on recurrence, underscoring the need for long-term surveillance. The strengths of our study include its prospective design and direct comparison of two commonly practiced techniques in an Indian tertiary-care setting. However, limitations include the relatively small sample size, short follow-up, and the lack of cost-effectiveness analysis, which is highly relevant in resource-constrained environments. Overall, the present study reinforces global and Indian evidence that laparoscopic ventral hernia repair, despite longer operative times and higher technical demands, offers significant short-term benefits with at least comparable recurrence rates.

Laparoscopic ventral hernia repair is a safe and effective alternative to open mesh repair. Despite longer operative times, it offers significant advantages including less intraoperative blood loss, fewer wound infections, shorter hospital stay, reduced analgesic requirement, and faster return to normal activity. Early recurrence rates are comparable between the two techniques. In the Indian context, where socioeconomic factors and resource limitations play a major role, laparoscopic repair demonstrates clear patient-centered benefits and should be promoted in centers with adequate expertise and infrastructure. Long-term multicentre studies are warranted to further validate these findings and establish standardized guidelines for ventral hernia repair.

1. Kingsnorth A, LeBlanc K. Hernias: inguinal and incisional. Lancet. 2003;362(9395):1561–71. 2. Luijendijk RW, Hop WC, van den Tol MP, de Lange DC, Braaksma MM, IJzermans JN, et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med. 2000;343(6):392–8. 3. Itani KM, Hur K, Kim LT, Anthony T, Berger DH, Reda D, et al. Comparison of laparoscopic and open repair with mesh for the treatment of ventral incisional hernia: a randomized trial. Arch Surg. 2010;145(4):322–8. 4. Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel J. Long-term follow-up of a randomized controlled trial of suture vs mesh repair of incisional hernia. Ann Surg. 2004;240(4):578–83. 5. Forbes SS, Eskicioglu C, McLeod RS, Okrainec A. Meta-analysis of randomized controlled trials comparing open and laparoscopic ventral and incisional hernia repair with mesh. Br J Surg. 2009;96(8):851–8. 6. Rao MP, Ramakrishnan TS, Vinayagam R, Palanivelu C. Laparoscopic vs open incisional hernia repair: a prospective comparative study from a tertiary care centre in South India. Indian J Gastroenterol. 2004;23(4):145–6. 7. Kumar S, Ramakrishnan TS, Prabhu R, Palanivelu C. Laparoscopic ventral hernia repair: an Indian experience. J Minim Access Surg. 2006;2(2):67–71. 8. Itani KM, Hur K, Kim LT, Anthony T, Berger DH, Reda D, et al. Comparison of laparoscopic and open repair with mesh for the treatment of ventral incisional hernia: a randomized trial. Arch Surg. 2010;145(4):322–8. 9. Misra MC, Bansal VK, Kulkarni MP, Pawar DK. Comparison of laparoscopic and open repair of incisional and primary ventral hernia: results of a prospective randomized study. Surg Endosc. 2006;20(12):1839–45. 10. Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic ventral and incisional hernia repair in 407 patients. J Am Coll Surg. 2000;190(6):645–50. 11. Forbes SS, Eskicioglu C, McLeod RS, Okrainec A. Meta-analysis of randomized controlled trials comparing open and laparoscopic ventral and incisional hernia repair with mesh. Br J Surg. 2009;96(8):851–8. 12. Rao MP, Ramakrishnan TS, Vinayagam R, Palanivelu C. Laparoscopic vs open incisional hernia repair: a prospective comparative study from a tertiary care centre in South India. Indian J Gastroenterol. 2004;23(4):145–6. 13. Heniford BT, Walters AL, Lincourt AE, Novitsky YW, Hope WW, Kercher KW. Comparison of generic and brand-name mesh products for laparoscopic ventral hernia repair: long-term follow-up. Ann Surg. 2008;247(5):928–35. 14. Palanivelu C, Rangarajan M, Jani K, John SJ, Senthilnathan P, Parthasarathi R. Laparoscopic repair of ventral hernias: experience of 150 cases. Hernia. 2008;12(3):241–6. 15. Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel J. Long-term follow-up of a randomized controlled trial of suture vs mesh repair of incisional hernia. Ann Surg. 2004;240(4):578–83. 16. Sajid MS, Bokhari SA, Mallick AS, Cheek E, Baig MK. Laparoscopic versus open repair of incisional/ventral hernia: a meta-analysis. Am J Surg. 2009;197(1):64–72.