Incisional hernia is a common complication after abdominal surgery and may develop in approximately 10–20% of patients following laparotomy. It can cause pain, limitation of physical activity, impaired quality of life and increased healthcare use [1]. Despite advances in operative technique, prosthetic materials and perioperative care, postoperative complications and recurrence remain important concerns.

The introduction of prosthetic mesh substantially changed the management of incisional hernia. Compared with primary suture repair, mesh reinforcement provides tension-free support to weakened fascial structures and reduces the risk of recurrence [2]. However, mesh implantation may be associated with surgical-site infection, seroma, hematoma, chronic postoperative pain, foreign-body sensation, mesh migration and occasional reoperation.

Open mesh repair remains a commonly used and reliable approach. Depending on the defect and abdominal-wall anatomy, the mesh may be placed in an onlay, sublay, retrorectus or another open position. Open repair offers direct visualization of the defect and is technically reproducible, including in settings where laparoscopic equipment and expertise are limited. Nevertheless, the larger incision and greater soft-tissue dissection may contribute to increased postoperative pain, wound complications, delayed mobilisation and longer recovery [2,5].

Minimally invasive repair has increasingly been adopted for selected incisional hernias. Laparoscopic intraperitoneal onlay mesh and newer minimally invasive extraperitoneal approaches use smaller incisions and generally require less disruption of the abdominal wall. Comparative evidence suggests that laparoscopic repair may reduce postoperative pain and wound complications, shorten hospital stay and facilitate earlier recovery [3,4]. However, it may require longer operative time, specialized equipment, general anaesthesia and appropriate technical expertise.

Prevention of recurrence is a central objective of incisional hernia surgery. Recurrence is influenced by several patient-, disease- and procedure-related factors. Patient-related factors include obesity, smoking, diabetes mellitus, malnutrition, chronic pulmonary disease, immunosuppression and conditions associated with increased intra-abdominal pressure. Disease-related factors include defect size, tissue quality and previous abdominal surgery. Technical factors such as inadequate mesh overlap, inappropriate fixation, insufficient dissection, mesh infection and surgeon experience may also influence the durability of repair [1,9]. Therefore, recurrence should be interpreted in relation to both the operative approach and the clinical characteristics of the patient.

Comparative studies generally show that laparoscopic and open mesh repair can provide similar recurrence outcomes when appropriate surgical principles are followed. Laparoscopic repair has frequently been associated with less early postoperative pain, fewer wound infections, shorter hospitalization and faster functional recovery [3,4,7]. Conversely, open repair may remain preferable for patients with large or complex defects, extensive intra-abdominal adhesions, previous complex abdominal surgery, contraindications to pneumoperitoneum or limited access to minimally invasive facilities. Thus, the operative technique should be individualized according to defect characteristics, patient factors, available resources and surgeon experience.

Patient-reported outcomes are increasingly recognized as important measures of surgical success. Incisional hernia repair should not only prevent recurrence but should also reduce pain, restore physical functioning and improve the patient’s ability to perform daily and occupational activities. Standardized instruments such as the EuroQol Five-Dimension Five-Level questionnaire allow health-related quality of life to be evaluated before and after surgery. Minimally invasive repair may provide better early quality-of-life outcomes because of reduced postoperative pain and faster recovery [9,10].

The management of incisional hernia can be particularly challenging because affected patients may have obesity, previous wound infection, multiple abdominal operations, poor tissue quality or large abdominal-wall defects. These factors may increase operative complexity and the risk of recurrence. Retromuscular mesh placement, component-separation procedures and minimally invasive extraperitoneal techniques have expanded the available treatment options. Nevertheless, careful patient selection and consistent operative technique remain essential [1,5].

In low- and middle-income countries such as Pakistan, open mesh repair remains more widely available because of limitations in laparoscopic equipment, costs and trained surgical personnel. As access to minimally invasive surgery increases, locally generated evidence is needed to assess its short-term clinical benefits in relation to the additional technical and financial requirements. Regional data comparing recurrence, postoperative morbidity, functional recovery and patient-reported quality of life remain limited [6].

Therefore, this prospective comparative study aimed to compare laparoscopic and open mesh repair among adult patients undergoing elective surgery for incisional hernia. The primary outcome was hernia recurrence, while secondary outcomes included operative time, postoperative pain, hospital stay, return to normal activities, postoperative complications, chronic postoperative abdominal-wall pain and health-related quality of life.

Study Design and Setting

This prospective comparative study was conducted in the Department of General Surgery, Ayub Teaching Hospital, Abbottabad, Pakistan, over a period of six months. The study compared the short-term clinical outcomes of laparoscopic and open mesh repair among adult patients undergoing elective surgery for incisional hernia.

Ethical Considerations

Ethical approval was obtained from the Institutional Research and Ethics Committee of Ayub Teaching Hospital before commencement of the study. Written informed consent was obtained from all participants before enrolment. The study was conducted in accordance with the principles of the Declaration of Helsinki and Good Clinical Practice guidelines. Patient confidentiality was maintained throughout data collection, analysis and reporting.

Sample Size and Sampling Technique

A total of 80 patients were enrolled using a consecutive non-probability sampling technique and divided into two groups of equal size: 40 patients underwent laparoscopic mesh repair and 40 underwent open mesh repair.

Eligibility Criteria

Adult patients aged 18 years or older with a diagnosis of incisional hernia who were scheduled for elective mesh repair were eligible for inclusion.

Patients were excluded if they had:

• An obstructed or strangulated hernia;
• A recurrent hernia previously repaired using mesh;
• An active local or systemic infection;
• Severe cardiopulmonary disease that made general anaesthesia or laparoscopy unsafe;
• A coagulation disorder;
• Pregnancy; or
• Refusal to participate in the study.

Allocation to Surgical Groups

Patients were assigned to the laparoscopic or open repair group according to the surgical approach selected by the treating consultant surgeon after clinical evaluation. The choice of procedure was based on defect size and complexity, the patient’s clinical condition, previous abdominal surgery, suitability for general anaesthesia and laparoscopy, surgeon expertise and availability of laparoscopic resources.

As the operative approach was selected clinically rather than through a defined random-allocation procedure, the study was treated as a prospective comparative study rather than a randomized controlled trial.

Surgical Procedures

Patients in the laparoscopic group underwent laparoscopic intraperitoneal onlay mesh repair.

Patients in the open group underwent open mesh repair for incisional hernia.

Data Collection

Patient information was recorded using a structured data-collection proforma. Baseline variables included age, sex, body mass index, diabetes mellitus, hypertension, smoking status and relevant operative characteristics.

Outcome Measures

The primary outcome was short-term hernia recurrence within six months after surgery. Recurrence was assessed clinically during scheduled postoperative follow-up visits. Where clinically indicated, radiological evaluation was used to confirm suspected recurrence.

Secondary outcomes included:

• Operative time;
• Duration of hospital stay;
• Postoperative pain;
• Time required to return to normal activities;
• Surgical-site infection;
• Seroma formation;
• Hematoma;
• Urinary retention;
• Chronic postoperative pain;
• Overall postoperative complications; and
• Health-related quality of life.

Postoperative pain was assessed 24 hours after surgery using the Visual Analogue Scale, ranging from 0, representing no pain, to 10, representing the worst possible pain.

Persistent postoperative abdominal-wall pain was assessed during follow-up.

Quality-of-Life Assessment

Health-related quality of life was assessed using the validated EuroQol Five-Dimension Five-Level questionnaire. The questionnaire evaluates mobility, self-care, usual activities, pain or discomfort, and anxiety or depression.

EQ-5D-5L assessments were performed before surgery and again at six months after surgery. Index scores were calculated according to the scoring method used by the investigators. Higher scores represented better health-related quality of life.

Postoperative Follow-up

Patients were followed in the outpatient clinic at 1, 3 and 6 months after surgery. During follow-up, patients were evaluated for wound complications, persistent pain, functional recovery, mesh-related complications and recurrence.

All 80 patients completed the six-month follow-up and were included in the final analysis. No laparoscopic procedure required conversion to open surgery.

Statistical Analysis

Data were entered and analysed using IBM SPSS Statistics version 26.0. Continuous variables were expressed as mean and standard deviation, while categorical variables were presented as frequencies and percentages.

The independent-samples t-test was used to compare continuous variables between the laparoscopic and open groups. The chi-square test or Fisher’s exact test was used to compare categorical variables, depending on the expected cell frequencies. A two-sided p-value of less than 0.05 was considered statistically significant.

Participant Characteristics

A total of 80 patients were included in the study. Forty patients underwent laparoscopic mesh repair, and 40 underwent open mesh repair. All participants completed the six-month follow-up and were included in the final analysis. No patient was lost to follow-up, and no laparoscopic procedure required conversion to open surgery.

The baseline demographic and clinical characteristics of the two groups are presented in Table 1. The mean age was 46.3±12.5 years in the laparoscopic group and 48.1±13.2 years in the open group. Most participants were male in both groups. No statistically significant differences were observed between the groups regarding age, sex, body mass index, diabetes mellitus, hypertension or smoking status. The two groups were therefore comparable in terms of the measured baseline characteristics.

Table 1. Baseline demographic and clinical characteristics of the study participants

BMI: body mass index; SD: standard deviation.

Primary Outcome: Hernia Recurrence

At six months, hernia recurrence was observed in 1 patient (2.5%) in the laparoscopic group and 3 patients (7.5%) in the open group. Although the recurrence rate was numerically lower following laparoscopic repair, the difference between the two groups was not statistically significant (p=0.307).

Perioperative and Postoperative Outcomes

The perioperative and postoperative outcomes are presented in Table 2. The mean operative time was significantly longer in the laparoscopic group than in the open group (88.4±15.2 versus 71.5±13.1 minutes, p<0.001).

In contrast, laparoscopic repair was associated with a significantly shorter hospital stay (2.1±0.8 versus 4.3±1.2 days, p<0.001), lower postoperative pain scores at 24 hours (3.4±1.1 versus 5.8±1.4, p<0.001) and an earlier return to normal activities (12.5±3.8 versus 20.7±5.1 days, p<0.001).

Chronic postoperative abdominal-wall pain was reported in 2 patients (5.0%) following laparoscopic repair and 8 patients (20.0%) following open repair. This difference was statistically significant (p=0.043).

Surgical-site infection occurred in 2 patients (5.0%) in the laparoscopic group and 7 patients (17.5%) in the open group. Seroma developed in 3 patients (7.5%) and 6 patients (15.0%), respectively, while hematoma occurred in 1 patient (2.5%) and 4 patients (10.0%), respectively. Although these complications occurred less frequently in the laparoscopic group, the differences did not reach statistical significance.

Table 2. Comparison of perioperative and postoperative outcomes

Statistically significant at p<0.05. SD: standard deviation; VAS: Visual Analogue Scale.

Health-Related Quality of Life

Preoperative EQ-5D-5L index scores were comparable between the laparoscopic and open groups (0.63±0.09 versus 0.64±0.08, p=0.652).

At six months, quality-of-life scores had improved in both groups. However, patients who underwent laparoscopic repair had significantly higher EQ-5D-5L scores than those who underwent open repair (0.93±0.04 versus 0.87±0.06, p<0.001).

The mean improvement in the EQ-5D-5L index score was also significantly greater in the laparoscopic group than in the open group (+0.30±0.07 versus +0.23±0.08, p<0.001).

Table 3. Health-related quality of life assessed using the EQ-5D-5L index

Statistically significant at p<0.05. EQ-5D-5L: EuroQol Five-Dimension Five-Level questionnaire; SD: standard deviation.

Postoperative Complications

Individual postoperative complications occurred less frequently in the laparoscopic group than in the open group. Surgical-site infection occurred in 5.0% versus 17.5%, seroma in 7.5% versus 15.0%, hematoma in 2.5% versus 10.0%, chronic postoperative pain in 5.0% versus 20.0%, and recurrence in 2.5% versus 7.5% of patients, respectively. Of these outcomes, only the difference in chronic postoperative pain reached statistical significance.

The figure compares the proportions of patients who developed surgical-site infection, seroma, hematoma, chronic postoperative pain and hernia recurrence during the six-month follow-up period.

The present prospective comparative study evaluated short-term outcomes following laparoscopic and open mesh repair in patients with incisional hernia. The primary outcome was hernia recurrence at six months, while secondary outcomes included operative time, postoperative pain, hospital stay, return to normal activities, postoperative complications, chronic postoperative abdominal-wall pain and health-related quality of life. The results demonstrated no statistically significant difference in short-term recurrence between the two groups. However, laparoscopic repair was associated with lower postoperative pain, a shorter hospital stay, earlier return to normal activities, less chronic postoperative abdominal-wall pain and better six-month quality-of-life scores. These benefits were accompanied by a significantly longer operative time.

Hernia recurrence is an important indicator of the durability of surgical repair. In the present study, recurrence occurred in 2.5% of patients in the laparoscopic group and 7.5% in the open group. Although recurrence was numerically less frequent after laparoscopic repair, the difference was not statistically significant. This finding is consistent with evidence indicating that laparoscopic and open approaches can produce comparable recurrence outcomes when mesh placement and other technical principles are appropriately followed [3,4,7].

The absence of a statistically significant recurrence difference should be interpreted cautiously. Only four recurrence events occurred in the entire study, limiting statistical power, and the six-month follow-up period may not capture later recurrence. Therefore, the present findings indicate comparable short-term recurrence rather than equivalent long-term effectiveness.

Postoperative pain was significantly lower in the laparoscopic group. This finding is consistent with systematic reviews and meta-analyses of laparoscopic versus open incisional or ventral hernia repair, which have reported less early postoperative pain and faster recovery after minimally invasive repair [3,4,7].

The difference in postoperative pain may be explained by the smaller incisions and reduced soft-tissue dissection associated with laparoscopic surgery. Open repair may involve wider tissue exposure and greater manipulation of the abdominal wall. Nevertheless, pain is influenced by several additional factors, including defect size, mesh characteristics, fixation technique, perioperative analgesia and surgeon experience. Because these factors were not fully standardized or reported in the present study, the lower pain scores cannot be attributed exclusively to the operative approach.

Patients undergoing laparoscopic repair had a significantly shorter hospital stay than those undergoing open repair. This finding agrees with comparative studies and systematic reviews of laparoscopic and open ventral or incisional hernia repair. Reduced tissue disruption, lower early pain and earlier mobilization may contribute to earlier discharge after laparoscopic surgery [3,4,7,8]. A shorter hospital stay may improve patient convenience and reduce inpatient resource utilization. However, the overall economic effect also depends on operative time, equipment costs, mesh type, readmissions and postoperative complications.

Return to normal activities was also significantly earlier following laparoscopic repair. Patients in the laparoscopic group resumed their usual activities approximately eight days earlier than those in the open group. Randomized evidence on ventral hernia repair similarly suggests that minimally invasive surgery can facilitate earlier functional recovery [8]. Earlier recovery is particularly relevant for working-age patients because prolonged absence from employment and routine activities may impose substantial personal and socioeconomic burdens.

Surgical-site infection occurred in 5.0% of laparoscopic patients and 17.5% of open-repair patients. Although the difference did not reach statistical significance, the direction of the finding is consistent with published evidence. Meta-analyses of ventral and incisional hernia repair have reported fewer wound infections following laparoscopic repair, probably because the mesh is introduced through smaller incisions and extensive open soft-tissue dissection is avoided [3,4,7]. The lack of statistical significance in the present study may reflect its small sample size and the limited number of infection events.

Seroma and hematoma were also numerically less frequent after laparoscopic repair, but neither difference was statistically significant. These complications can be influenced by the extent of dissection, residual dead space, defect size, mesh position, anticoagulant use and drainage practices. Randomized evidence indicates that laparoscopic and open ventral hernia repair are generally comparable for several postoperative complications, although individual complication patterns vary between studies [8,10]. Consequently, the observed differences should be interpreted as descriptive trends rather than evidence of a confirmed protective effect.

Chronic postoperative abdominal-wall pain was significantly less frequent in the laparoscopic group, occurring in 5.0% of patients compared with 20.0% in the open group. Persistent pain is clinically important because it can impair mobility, daily functioning and satisfaction even when the anatomical repair remains intact. The lower frequency observed after laparoscopic repair may be related to reduced soft-tissue dissection, although the small number of events and absence of a hernia-specific pain instrument require cautious interpretation [9,10].

Health-related quality of life improved in both groups, indicating that both operations provided meaningful patient benefit. However, patients undergoing laparoscopic repair demonstrated significantly higher EQ-5D-5L scores and greater mean improvement at six months. The differences in pain, hospital stay and functional recovery may have contributed to this finding. Contemporary hernia research increasingly emphasizes patient-reported outcomes in addition to recurrence and postoperative morbidity [9,10].

The laparoscopic approach required a significantly longer operative time. This finding is consistent with evidence showing that minimally invasive repair may take longer because of port placement, creation of the operative working space, adhesiolysis, mesh preparation and intracorporeal fixation [3,4,7]. Operative duration may also depend on the surgeon’s experience and position on the learning curve. Therefore, the longer operative time observed in the present study may not apply equally to all centres or surgeons.

The selection of a surgical approach should not be based on one outcome alone. Laparoscopic repair may provide advantages in postoperative pain, wound morbidity and recovery, but it requires appropriate equipment, general anaesthesia and relevant technical expertise. Open repair remains a reasonable option for patients with complex defects, extensive adhesions, contraindications to laparoscopy or limited access to minimally invasive facilities. Expert consensus recommends that the operative approach be individualized according to patient characteristics, defect features, contamination risk and surgeon experience [9].

The present study has several limitations. First, the sample size was small, particularly for assessing uncommon outcomes such as recurrence and individual postoperative complications. Second, it was conducted at a single centre, which may restrict generalizability. Third, follow-up was limited to six months and therefore reflects short-term rather than long-term recurrence. Fourth, allocation was based on the treating surgeon’s choice rather than randomization, creating a risk of selection bias. Fifth, potentially influential factors—including defect size, mesh type, mesh position, fixation technique and surgeon experience—were not fully reported. Finally, no adjusted analysis was presented for potential confounders such as age, body mass index, diabetes and smoking.

Despite these limitations, the study provides useful prospective local evidence regarding short-term recovery after laparoscopic and open mesh repair for incisional hernia. Laparoscopic repair demonstrated advantages in postoperative pain, hospital stay, functional recovery, chronic postoperative abdominal-wall pain and quality of life, while short-term recurrence did not differ significantly. These findings should not be interpreted as proof of universal superiority because of the limited sample, non-random allocation and short follow-up. Larger multicentre prospective studies should standardize operative protocols, adjust for relevant confounders and include adequate follow-up to evaluate recurrence and mesh-related complications.

Laparoscopic mesh repair demonstrated better short-term postoperative outcomes than open mesh repair among patients undergoing elective surgery for incisional hernia. It was associated with lower postoperative pain, shorter hospital stay, earlier return to normal activities, a lower frequency of chronic postoperative abdominal-wall pain and greater improvement in health-related quality of life. However, laparoscopic repair required a longer operative time.

Hernia recurrence at six months was numerically lower in the laparoscopic group, but the difference between the two surgical approaches was not statistically significant. Therefore, the findings do not establish the superiority of either technique for recurrence prevention.

The results should be interpreted cautiously because of the small sample size, single-centre design and short follow-up period. Laparoscopic repair may be considered for appropriately selected patients when adequate surgical expertise and resources are available, while open mesh repair remains an effective and reliable option. Larger multicentre studies are required to evaluate long-term recurrence, mesh-related complications and cost-effectiveness.

Recommendations

Laparoscopic mesh repair may be considered for appropriately selected patients with incisional hernia when suitable equipment and experienced surgical teams are available. Patient selection should be individualized according to defect size, comorbidities, previous abdominal surgery, anaesthetic risk and the complexity of the planned repair.

Open mesh repair should continue to be used as an effective and reliable option, particularly in patients with complex hernias, contraindications to laparoscopy or limited access to minimally invasive facilities. The choice of surgical approach should be based on clinical suitability rather than a universal preference for one technique.

Structured training in laparoscopic hernia repair should be strengthened in surgical training programmes to improve technical proficiency, reduce the effect of the learning curve and standardize operative outcomes. Hospitals planning to expand minimally invasive hernia services should ensure the availability of appropriate mesh materials, fixation devices, laparoscopic equipment and postoperative support.

Perioperative management should include optimization of modifiable risk factors such as obesity, smoking, diabetes mellitus and poor nutritional status. Standardized protocols for antibiotic prophylaxis, pain control, mobilization, wound care and follow-up should also be adopted to reduce postoperative complications and recurrence.

Future research should include larger multicentre prospective studies with longer follow-up. Further studies should evaluate long-term recurrence, mesh-related complications, chronic postoperative abdominal-wall pain, cost-effectiveness and patient-reported quality-of-life outcomes.

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