The impact of comorbidities and surgical approach in incisional hernia development after minimally invasive cholecystectomy: a systematic review and meta-analysis of multivariate regression-adjusted studies

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Abstract
Background Laparoscopic cholecystectomy is a widely preferred method for gallbladder removal due to its minimally invasive benefits, including reduced postoperative pain and quicker recovery. However, the risk of incisional hernia remains a significant concern. Understanding the role of comorbidities in influencing this risk is crucial for improving patient management and surgical planning. This systematic review and meta-analysis aim to identify and evaluate the impact of comorbidities on the risk of incisional hernia following minimally invasive laparoscopic cholecystectomy. Methods We conducted a comprehensive search of PubMed, Embase, and Cochrane databases from inception until August 2024. We included studies that investigated risk factors for incisional hernia in minimally invasive cholecystectomy. A subgroup analysis was performed to compare hernia rates between single-incision laparoscopic cholecystectomy (SILC) and multi-port laparoscopic cholecystectomy (MPLC). Comorbidities analyzed were age, diabetes mellitus (DM), BMI > 30 kg/m2, female gender, and history of umbilical hernia repair for single-port cholecystectomy studies. We also analyzed perioperative factors: acute versus chronic cholecystitis, incision enlargement, and SSI. Statistical analyses were conducted using the meta package in R Studio. Results 551 articles were screened by title and abstract, from which 19 were selected for full-text review. A total of 9 studies were included, comprising 7,052 patients. The proportional meta-analysis found an IH rate of 3.82%; 95%CI [0.98; 8.27]; I2 = 97%). We found that older age (MD 9.6 years; 95% CI [6.9; 12.3]; P < 0.001), DM (RR 2.15; 95%CI [1.1; 4.2]; p = 0.02), and a BMI higher than 30 kg/m2 (RR 2.65; 95% CI [2.1; 3.3]; p < 0.01) were associated with postoperative IH development. We found no association between sex (RR 1.09; 95% CI [0.95; 1.26]; P = 0.68) and IH development. SSI was identified as a risk factor for IH (RR 5.3; 95%CI 3-9.1; p < 0.01), but no association was found for incision enlargement (OR 3.7; 95%CI 0.3–51.8; p = 0.33) and acute cholecystitis (RR 2.6; 95%CI 0.95–7.1; p = 0.06). Also, for studies performing SILC, previous umbilical hernia repair was not associated with increased IH rates (RR 2.12; 95% CI [0.86; 5.22]; p = 0.1). No subgroup differences were found between SILC (2.96%; 95%CI [0.47; 7.14]) and MPLC (4.4%; 95% CI [0.21; 13.2]; p = 0.73). Conclusion Our meta-analysis revealed that older age, BMI > 30 kg/m2, DM, ASA score > 2 and SSI are risk factors linked to IH following MIS cholecystectomy.

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