The aim of this multicenter cohort study was to compare the clinical courses between open and laparoscopic PH reductions. The postoperative recovery course is generally better, and operative wounds are generally smaller with the laparoscopic approach than with open surgery. However, to the best of our knowledge, no one has reported the benefits of laparoscopic PH reduction. The present multicenter observational cohort study is the first to report the advantage of laparoscopic PH reduction in terms of postoperative recovery.
PH is a very rare disease that occurred in only 0.54% of patients who underwent gastrectomy for gastric cancer (2,417; the number of patients requiring PH reduction surgery was 13) between 2015 and 2018. In a previous study, the incidence of PH after gastrectomy was 0.42%, which was similarly low compared to our data [2, 3]. For PH reduction surgery, the open method is the standard procedure due to the following: first, it is difficult to develop pneumoperitoneum due to bowel edema and bowel dilation in the abdominal cavity; second, bowel reduction is difficult due to bowel wall and mesentery edema, and usually the whole small bowel is herniated; third, experience in laparoscopic PH reduction is limited [2, 9, 11]. In our group, the first laparoscopic reduction was performed in 2014 in Kosin University Hospital; since then, gastric experts from the four centers share their experiences with laparoscopic PH reduction during regular meetings. Sharing their experiences facilitates the application of laparoscopic PH reduction because all surgeons are gastric cancer surgery specialists with experience in performing more than 200 laparoscopic gastrectomies.
Laparoscopic surgery has advantages. We found that the number of days on a soft fluid diet and postoperative hospital length of stay were significantly less in the laparoscopic reduction group than in the open group. The reason for the faster recovery is likely that laparoscopic surgery resulted in fewer operative wounds and less pain than open surgery. Additionally, if the bowels were not manipulated excessively by the surgeon during laparoscopy, a postoperative diet could be permitted quickly, causing a potential decrease in the length of hospital stay.
Recently, the application of the laparoscopic approach for primary gastrectomy has increased; however, one study reported the possibility of an increased incidence of internal hernia . They reported that laparoscopic TG was associated with a higher incidence of internal hernia than open TG (4.5%, 29/638 vs. 0.8%, 4/475), with the same results for laparoscopic DG compared with open DG (2.7% vs. 0.9%). In the multivariate analysis, they found that non-closure of mesenteric defects, the laparoscopic approach, and a total laparoscopic approach were independent risk factors for internal hernia. We expected the incidence of PH to be higher in primary laparoscopic gastrectomy patients; however, the incidence of PH was higher in primary open gastrectomy patients. This may be because more patients underwent open gastrectomy than laparoscopic gastrectomy in the past. Even though there was only a small number of PH cases included in this study, interestingly, the laparoscopic or open primary approach for gastrectomy did not affect the incidence of PH. In contrast, a recent study reported that closure of the mesenteric space (5.5%) significantly decreased the cumulative incidence of reoperation for small bowel obstruction by internal hernia after surgery compared to no mesenteric closure (10.2%) . Therefore, to reduce postoperative complications, especially the incidence of internal hernia after gastrectomy surgery, the closure of mesenteric defects should be performed . The centers included in this study routinely repair mesenteric defects after gastrectomy and have recently started performing closure of Petersen’s space to prevent PH.
In terms of postoperative complications, pneumonia generally occurs more frequently in patients who undergo open surgery; open surgery patients also experience more wound pain than patients who undergo minimally invasive surgery . In this study, the one pneumonia patient was an 80-year-old individual who was at increased risk for postoperative complications due to age. In the laparoscopic group, a complication of internal hernia recurrence after reduction surgery was observed. This suggests that we need to close defects more carefully because reduction and closure after laparoscopic surgery is more difficult than after manual open surgery.
Despite the very low incidence of PH, there were some limitations to our study, such as the small number of PH reduction surgeries especially laparoscopic reduction surgeries. The surgeons did not have extensive experience with the laparoscopic approach for PH reduction because it is not a common technique, and PH is a rare disease. Nevertheless, to the best of our knowledge, this is the first report comparing the surgical outcomes associated with open and laparoscopic approaches for PH reduction.