Antibiotic prophylaxis for hernia repair

The Role of Antibiotic Prophylaxis in Lichtenstein Repair of Primary Inguinal Hernia: A Prospective Double-Blind Randomized Placebo-Controlled Trial

Objective:

The objective is to study the role of antibiotic prophylaxis, if any, in the prevention of wound infection after open mesh repair of primary inguinal hernias.

Materials and Methods:

Patients coming to outpatient department for open mesh repair of inguinal hernia were randomized into the placebo group and antibiotic group, a total of 150 patients were enrolled in the study. Follow-up was done up to 1 month to look for any evidence of surgical site infection using the criteria of Centers for Disease Control on wound infection.

Results:

Twelve patients in the antibiotic group and nine patients in the placebo group were found to have evidence of surgical site infection. This difference was found to be insignificant with P = 0.14. Three patients in the placebo group developed deep surgical site infection but on analysis, this difference was also found to be insignificant with P = 0.122.None of these patients required mesh removal.

Conclusion:

The result of the present study suggests that the use of prophylactic antibiotics during mesh repair of primary inguinal hernias does not give any extra protection from infections. Multicenter meta-analysis is required to give definite guidelines regarding the use of prophylactic antibiotics.

Antibiotic prophylaxis for prevention of postoperative wound infection in adults undergoing open elective inguinal or femoral hernia repair

BACKGROUND

Inguinal or femoral hernia is a tissue protrusion in the groin region and has a cumulative incidence of 27% in adult men and of 3% in adult women. As most hernias become symptomatic over time, groin hernia repair is one of the most frequently performed surgical procedures worldwide. This type of surgery is considered 'clean' surgery with wound infection rates expected to be lower than 5%. For clean surgical procedures, antibiotic prophylaxis is not generally recommended. However after the introduction of mesh-based hernia repair and the publication of studies that have high wound infection rates the debate as to whether antibiotic prophylaxis is required to prevent postoperative wound infections started again.

OBJECTIVES

To determine the effectiveness of antibiotic prophylaxis in reducing postoperative (superficial and deep) wound infections in elective open inguinal and femoral hernia repair.

SEARCH METHODS

We searched several electronic databases: Cochrane Registry of Studies Online, MEDLINE Ovid, Embase Ovid, Scopus and Science Citation Index (search performed on 12 November 2019). We also searched two trial registers and the reference list of included studies.

SELECTION CRITERIA

We included randomised controlled trials comparing any type of antibiotic prophylaxis versus placebo or no treatment for preventing postoperative wound infections in adults undergoing inguinal or femoral open hernia repair surgery (tissue repair and mesh repair).

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed risk of bias. We separately analysed results for two different surgical methods (herniorrhaphy and hernioplasty). Several studies revealed infection rates that were higher than the expected 5% for clean surgery and we therefore divided studies into two subgroups: high infection risk environments (≥ 5% infection rate); and low infection risk environments (< 5% infection rate). We performed meta-analyses with random-effects models. We analysed three outcomes: superficial surgical site infections (SSSI); deep surgical site infections (DSSI); and all postoperative wound infections (SSSI + DSSI).

MAIN RESULTS

In this review update we identified and included 10 new studies. In total, we included 27 studies with 8308 participants in this review. It is uncertain whether antibiotic prophylaxis as compared to placebo (or no treatment) prevents all types of postoperative wound infections after herniorrhaphy surgery (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.56 to 1.33; 5 studies, 1865 participants; very low quality evidence). Subgroup analysis did not change these results. We could not perform meta-analyses for SSSI or DSSI as these outcomes were not reported separately. Twenty-two studies related to hernioplasty surgery (total of 6443 participants) and we analysed three outcomes: SSSI; DSSI; SSSI + DSSI. Within the low infection risk environment subgroup, antibiotic prophylaxis as compared to placebo probably makes little or no difference for the outcomes 'prevention of all wound infections' (RR 0.71, 95% CI 0.44 to 1.14; moderate-quality evidence) and 'prevention of SSSI' (RR 0.71, 95% CI 0.44 to 1.17, moderate-quality evidence). Within the high infection risk environment subgroup it is uncertain whether antibiotic prophylaxis reduces all types of wound infections (RR 0.58, 95% CI 0.43 to 0.77, very low quality evidence) or SSSI (RR 0.56, 95% CI 0.41 to 0.77, very low quality evidence). When combining participants from both subgroups, antibiotic prophylaxis as compared to placebo probably reduces the risk of all types of wound infections (RR 0.61, 95% CI 0.48 to 0.78) and SSSI (RR 0.60, 95% CI 0.46 to 0.78; moderate-quality evidence). Antibiotic prophylaxis as compared to placebo probably makes little or no difference in reducing the risk of postoperative DSSI (RR 0.65, 95% CI 0.26 to 1.65; moderate-quality evidence), both in a low infection risk environment (RR 0.67, 95% CI 0.11 to 4.13; moderate-quality evidence) and in the high infection risk environment (RR 0.64, 95% CI 0.22 to 1.89; low-quality evidence).

AUTHORS' CONCLUSIONS

Evidence of very low quality shows that it is uncertain whether antibiotic prophylaxis reduces the risk of postoperative wound infections after herniorrhaphy surgery. Evidence of moderate quality shows that antibiotic prophylaxis probably makes little or no difference in preventing wound infections (i.e. all wound infections, SSSI or DSSI) after hernioplasty surgery in a low infection risk environment. Evidence of low quality shows that antibiotic prophylaxis in a high-risk environment may reduce the risk of all wound infections and SSSI, while evidence of very low quality shows that it is uncertain whether antibiotic prophylaxis reduces DSSI after hernioplasty surgery.

Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery

BACKGROUND

Surgery has been used as part of breast cancer treatment for centuries; however any surgical procedure has the potential risk of infection. Infection rates for surgical treatment of breast cancer are documented at between 3% and 15%, higher than average for a clean surgical procedure. Pre- and perioperative antibiotics have been found to be useful in lowering infection rates in other surgical groups, yet there is no consensus on the use of prophylactic antibiotics for breast cancer surgery. This is an update of a Cochrane Review first published in 2005 and last updated in 2014.

OBJECTIVES

To determine the effects of prophylactic (pre- or perioperative) antibiotics on the incidence of surgical site infection (SSI) after breast cancer surgery.

SEARCH METHODS

For this fourth update, in August 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase; and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials of pre- and perioperative antibiotics for patients undergoing surgery for breast cancer. Primary outcomes were rates of surgical site infection (SSI) and adverse reactions.

DATA COLLECTION AND ANALYSIS

Three review authors independently examined the title and abstracts of all studies identified by the search strategy, then assessed study quality and extracted data from those that met the inclusion criteria. We contacted study authors to obtain missing information. We evaluated the certainty of evidence using the GRADE approach. We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

A total of 11 randomised controlled trials (2867 participants) were included in the review. No new studies were identified in this update. All studies included breast cancer patients and were based in the hospital setting. Ten studies evaluated preoperative antibiotic compared with no antibiotic or placebo. One study evaluated perioperative antibiotic compared with placebo or no antibiotic. Pooling of the results demonstrated that prophylactic antibiotics administered preoperatively probably reduce the incidence of SSI for patients undergoing breast cancer surgery without reconstruction (pooled risk ratio (RR) 0.67, 95% confidence interval (CI) 0.53 to 0.85; moderate certainty evidence). Anticipated absolute effects were calculated for the outcome incidence of SSI; 105 per 1000 for the none or placebo group and 71 per 1000 (95% CI 56 to 89) for the preoperative antibiotic prophylaxis group. Analysis of the single study comparing perioperative antibiotic with no antibiotic was inconclusive for incidence of SSI (RR 0.11, 95% CI 0.01 to 1.95; very low certainty evidence). No studies presented separate data for patients who underwent reconstructive surgery at the time of removal of the breast tumour.Secondary outcomes were not consistently included in the studies investigating preoperative antibiotic prophylaxis. It is very uncertain whether there is a difference in incidence of adverse events between the treatment and no treatment or placebo groups (10 studies, 2818 participants); very low certainty evidence downgraded one level for serious risk of bias, one level for serious inconsistency and one level for serious imprecision. It is unclear whether there is a difference in time to onset of infection between the treatment and no treatment or placebo groups (4 studies, 1450 participants); low certainty evidence downgraded one level for serious risk of bias and one level for serious inconsistency. It is unclear whether there is a difference in rates of readmission to hospital between the treatment and placebo groups (3 studies, 784 participants); low certainty evidence downgraded one level for serious inconsistency and one level for serious risk of bias. It is unclear whether there is a difference in cost of care between the treatment and no treatment or placebo groups (2 studies, 510 participants); low certainty evidence downgraded one level for serious risk of bias and one level for serious inconsistency. No analysable secondary outcome data were reported for the single study evaluating perioperative antibiotics.

AUTHORS' CONCLUSIONS

Prophylactic antibiotics administered preoperatively probably reduce the risk of SSI in patients undergoing surgery for breast cancer. However, it is very uncertain whether there is an effect on incidence of adverse events. Furthermore, the effects on time to onset of infection, readmission to hospital and cost of care remain unclear. Further studies are required to establish the best protocols for clinical practice.

International guidelines for groin hernia management

INTRODUCTION

Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery.

METHODS

An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.

CONCLUSIONS

The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

Network meta-analysis of antibiotic prophylaxis for prevention of surgical-site infection after groin hernia surgery

BACKGROUND

First-generation cephalosporins (such as cefazolin) are recommended as antibiotic prophylaxis in groin hernia repair, but other broad-spectrum antibiotics have also been prescribed in clinical practice. This was a systematic review and network meta-analysis to compare the efficacy of different antibiotic classes for prevention of surgical-site infection (SSI) after hernia repair.

METHODS

RCTs were identified that compared efficacy of antibiotic prophylaxis on SSI after inguinal or femoral hernia repair from PubMed and Scopus databases up to March 2016. Data were extracted independently by two reviewers. Network meta-analysis was applied to assess treatment efficacy. The probability of being the best antibiotic prophylaxis was estimated using surface under the cumulative ranking curve (SUCRA) analysis.

RESULTS

Fifteen RCTs (5159 patients) met the inclusion criteria. Interventions were first-generation (7 RCTs, 1237 patients) and second-generation (2 RCTs, 532) cephalosporins, β-lactam/β-lactamase inhibitors (6 RCTs, 619) and fluoroquinolones (2 RCTs, 581), with placebo as the most common comparator (14 RCTs, 2190). A network meta-analysis showed that β-lactam/β-lactamase inhibitors and first-generation cephalosporins were significantly superior to placebo, with a pooled risk ratio of 0·44 (95 per cent c.i. 0·25 to 0·75) and 0·62 (0·42 to 0·92) respectively. However, none of the antibiotic classes was significantly different from the others. SUCRA results indicated that β-lactam/β-lactamase inhibitors and first-generation cephalosporins were ranked first and second respectively for best prophylaxis.

CONCLUSION

β-Lactam/β-lactamase inhibitors followed by first-generation cephalosporins ranked as the most effective SSI prophylaxis for adult patients undergoing groin hernia repair.

Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery

BACKGROUND

Surgery has been used as part of breast cancer treatment for centuries; however any surgical procedure has the potential risk of infection. Infection rates for surgical treatment of breast cancer are documented at between 3% and 15%, higher than average for a clean surgical procedure. Pre- and perioperative antibiotics have been found to be useful in lowering infection rates in other surgical groups, yet there is no consensus on the use of prophylactic antibiotics for breast cancer surgery.

OBJECTIVES

To determine the effects of prophylactic (pre- or perioperative) antibiotics on the incidence of surgical site infection (SSI) after breast cancer surgery.

SEARCH METHODS

For this third update we searched the Cochrane Wounds Group Specialised Register (5 December 2013); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); the Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. We applied no language or date restrictions.

SELECTION CRITERIA

Randomised controlled trials of pre- and perioperative antibiotics for patients undergoing surgery for breast cancer were included. Primary outcomes were rates of surgical site infection (SSI) and adverse reactions.

DATA COLLECTION AND ANALYSIS

Two review authors independently examined the title and abstracts of all studies identified by the search strategy, then assessed study quality and extracted data from those that met the inclusion criteria.

MAIN RESULTS

A total of eleven studies (2867 participants) were included in the review. Ten studies evaluated preoperative antibiotic compared with no antibiotic or placebo. One study evaluated perioperative antibiotic compared with no antibiotic. Pooling of the results demonstrated that prophylactic antibiotics administered preoperatively significantly reduce the incidence of SSI for patients undergoing breast cancer surgery without reconstruction (pooled risk ratio (RR) 0.67, 95% confidence interval (CI) 0.53 to 0.85). Analysis of the single study comparing perioperative antibiotic with no antibiotic found no statistically significant effect of antibiotics on the incidence of SSI (RR 0.11, 95% CI 0.01 to 1.95). No studies presented separate data for patients who underwent reconstructive surgery at the time of removal of the breast tumour.

AUTHORS' CONCLUSIONS

Prophylactic antibiotics administered preoperatively reduce the risk of SSI in patients undergoing surgery for breast cancer. Further studies involving patients undergoing immediate breast reconstruction are needed as studies have identified this group as being at higher risk of infection than those who do not undergo immediate breast reconstruction.

Prophylactic antibiotic guidelines in modern interventional radiology practice

Modern interventional radiology practice is continuously evolving. Developments include increases in the number of central venous catheter placements and tumor treatments (uterine fibroid therapy, radio- and chemoembolization of liver tumor, percutaneous radiofrequency and cryoablation), and new procedures such as abdominal aortic aneurysm stent-graft repair, vertebroplasty, kyphoplasty, and varicose vein therapies. There have also been recent advancements in standard biliary and urinary drainage procedures, percutaneous gastrointestinal feeding tube placement, and transjugular intrahepatic portosystemic shunts. Prophylactic antibiotics have become the standard of care in many departments, with little clinical data to support its wide acceptance. The rise in antibiotic-resistant strains of organisms in all hospitals worldwide have forced every department to question the use of prophylactic antibiotics. The authors review the evidence behind use of prophylactic antibiotics in standard interventional radiology procedures, as well as in newer procedures that have only recently been incorporated into interventional radiology practice.

Antibiotic prophylaxis for hernia repair

BACKGROUND

The use of antibiotic prophylaxis for hernia repair is currently a controversial issue given the disparity among study results in this area.

OBJECTIVES

The objective of this systematic review was to clarify the effectiveness of antibiotic prophylaxis in reducing postoperative wound infection rates in elective open inguinal hernia repair.

SEARCH METHODS

We searched the Cochrane Colorectal Cancer Group specialized register, by crossing the terms herni* and inguinal or groin and the terms antimicr* or antibiot* , as free text and MeSH terms. A similar search were performed in Medline using the following terms: #1 antibiotic* OR antimicrob* OR anti infecti* OR antiinfecti*; #2 prophyla* OR prevent*; #3 #1 AND #2; #4 clean AND (surgery OR tech* OR proced*); #5 herni*; #6 (wound infection) AND #4; #7 #3 AND (#4 or #5 or #6). National Research Register, ISI-Web, DARE, Scirus, TRIPDATABASE, NHS EED, reference list of the included studies and web of clinical trials register (www.controlled-trials.com and clinicaltrials.gov) were checked to identify further studies.

SELECTION CRITERIA

Only randomised clinical trials were included.

DATA COLLECTION AND ANALYSIS

In the present review, we searched for eligible trials in October 2011. This revealed four new included trials, so seventeen trials are included in the meta-analysis. Eleven of them used prosthetic material for hernia repair (hernioplasty) whereas the remaining studies did not (herniorrhaphy). Pooled and subgroup analysis were conducted depending on whether prosthetic material was or not used. A fixed effects model was used in the analysis.

MAIN RESULTS

The total number of patients included was 7843 (prophylaxis group: 4703, control group: 3140). Overall infection rates were 3.1% and 4.5% in the prophylaxis and control groups, respectively (OR 0.64, 95% CI 0.50 - 0.82). The subgroup of patients with herniorrhaphy had infection rates of 3.5% and 4.9% in the prophylaxis and control groups, respectively (OR 0.71, 95% CI 0.51 - 1.00). The subgroup of patients with hernioplasty had infection rates of 2.4% and 4.2% in the prophylaxis and control groups, respectively (OR 0.56, 95% CI 0.38 - 0.81).

AUTHORS' CONCLUSIONS

Based on the results of this systematic review the administration of antibiotic prophylaxis for elective inguinal hernia repair cannot be universally recommended. Neither can the administration be recommended against when high rates of wound infection are observed.

Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery

BACKGROUND

Surgery has been used as part of breast cancer treatment for centuries; however any surgical procedure has the potential risk of infection. Infection rates for surgical treatment of breast cancer are documented at between 3% and 15%, higher than average for a clean surgical procedure. Pre- and perioperative antibiotics have been found to be useful in lowering infection rates in other surgical groups, yet there is no consensus on the use of prophylactic antibiotics for breast cancer surgery.

OBJECTIVES

To determine the effects of prophylactic (pre- or perioperative) antibiotics on the incidence of surgical site infection (SSI) after breast cancer surgery.

SEARCH METHODS

For this second update we searched the Cochrane Wounds Group Specialised Register (searched 31 August 2011); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3); Ovid MEDLINE (2008 to August Week 3 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations 30 August 2011); Ovid EMBASE (1980 to 2011 Week 34); and EBSCO CINAHL (2008 to 25 August 2011). We applied no language or date restrictions.

SELECTION CRITERIA

Randomised controlled trials of pre- and perioperative antibiotics for patients undergoing surgery for breast cancer were included. Primary outcomes were rates of surgical site infection (SSI) and adverse reactions.

DATA COLLECTION AND ANALYSIS

Two review authors independently examined the title and abstracts of all studies identified by the search strategy, then assessed study quality and extracted data from those that met the inclusion criteria.

MAIN RESULTS

A total of nine studies (2260 participants) is included in the review. Eight studies evaluated preoperative antibiotic compared with no antibiotic or placebo. One study evaluated perioperative antibiotic compared with no antibiotic. Pooling of the results demonstrated that prophylactic antibiotics administered preoperatively significantly reduce the incidence of SSI for patients undergoing breast cancer surgery without reconstruction (pooled risk ratio (RR) 0.71, 95% confidence interval (CI) 0.53 to 0.94). Analysis of the single study comparing perioperative antibiotic with no antibiotic found no statistically significant effect of antibiotics on the incidence of SSI (RR 0.11, 95% CI 0.01 to 1.95). No studies presented separate data for patients who underwent reconstructive surgery at the time of removal of the breast tumour.

AUTHORS' CONCLUSIONS

Prophylactic antibiotics administered preoperatively reduce the risk of SSI in patients undergoing surgery for breast cancer. Further studies involving patients undergoing immediate breast reconstruction are needed as studies have identified this group as being at higher risk of infection than those who do not undergo immediate breast reconstruction.

Mesh infection after inguinal hernia mesh repair

INTRODUCTION

Infection after repair of groin hernia is rare, even since the advent of mesh repair. The debate remains open about antibiotic prophylaxis.

AIM OF THE STUDY

Assess incidence of this kind of complication, determine criteria of diagnosis and strategy of therapy by examining the collective experience of 32 surgeons.

METHOD

Fifty surgeons were asked to report their experience with mesh repair of inguinal hernias and specifically mesh infection. Diagnosis and therapy for each mesh infection were detailed.

RESULTS

Forty-five cases were reported in 38 patients who had undergone open or laparoscopic mesh repair. Diagnosis was straightforward and established at a variable delay after mesh insertion: 51% during the first postoperative month; 26% more than one year after the procedure. Infection cured in 33 patients after mesh removal, in one step in 14 cases, but after many attempts for conservative therapy in 19 cases; the mean delay to cure was 12.5 months. Visceral resections had to be associated with mesh removal in 13% of cases.

CONCLUSIONS

This is the largest series of mesh infections after inguinal hernia repair reported in the literature. According to the evidence provided here, mesh removal appears to be the most appropriate treatment of this rare and serious complication.

Prophylactic antibiotic use in elective inguinal hernioplasty in a trauma center

PURPOSE

In this double-blind prospective randomized trial, our objective was to investigate the effect of antibiotic prophylaxis in patients undergoing elective inguinal hernia surgery with mesh repair in a large-volume tertiary referral trauma center.

METHODS

Eligible patients were assigned randomly to either an antibiotic prophylaxis group or a control group. Patients in the prophylaxis group were given 1 g cefazolin by IV bolus injection whereas the placebo control group received an equal volume of sterile saline preoperatively. A Lichtenstein repair was done in all cases. The patients were examined for surgical site infection (SSI) and other postoperative local complications before discharge, and reexamined 3, 5, 7, and 30 days after discharge.

RESULTS

Groups were well matched for age, sex, coexisting diseases, ASA scores, type of hernia, type of anesthesia, duration of surgery. Incidence of infection was 7% in the control group (7/100) and 5% in the prophylaxis group (5/100) (P = 0.38). All the infections were superficial and responded well to drainage and proper antibiotic therapy. All other postoperative complications were similar in the two groups.

CONCLUSIONS

In our settings antibiotic prophylaxis has no significant effect on the incidence of SSI in elective repair of inguinal hernias with mesh. The most effective way to reduce the incidence of infection in prosthetic repair may be a specific center for treatment of abdominal wall hernias.

[Management of mesh-related infections]

Infections of an implanted hernia mesh are a major challenge. The incidence of mesh infections after incisional hernia repair is about 1% for endoscopic techniques and can be more than 15% in open techniques. Intraoperative mesh contamination is considered to be the primary cause. All woven or knitted hernia meshes have recesses where bacteria may adhere and establish colonies. The bacterial spectrum for mesh infection includes skin pathogens, such as Staphylococcus aureus (including MRSA), Streptococcus spp., as well as E. coli, Enterococcus and Mycobacteria. The therapy approach needs to be tailored to the morphological findings and the treatment for uncomplicated phlegmon is broad spectrum antibiotic therapy. If there is encapsulated fluid accumulation, CT-controlled drainage and daily infusion of antiseptics via the drain is a good option. For dermal necrosis, mesh fistula, exposed mesh or enterocutaneous fistula, a precise CT evaluation is necessary to tailor the operation. Vacuum systems are gaining increased acceptance in conditioning the local findings. For most patients the therapeutic concept will be based on individual decisions. If parts of a formerly infected mesh remain in the patient, a lifelong follow-up is necessary.

[Inguinal and femoral hernia repair]

With an incidence of 200,000 new cases per year in Germany, inguinal hernia has a significant socioeconomic impact. The 2009 guidelines from the European Hernia Society established treatment recommendations. Hernia repair is based on reinforcing the posterior wall of the inguinal canal by suture or mesh repair by an anterior or posterior approach. Lightweight mesh reduces recurrence rates and is the treatment of choice even in primary hernias. Laparoscopic hernia repair is associated with specific risks but is superior in postoperative pain and earlier return to work.

Prospective randomized evaluation of prophylactic antibiotic usage in patients undergoing tension free inguinal hernioplasty

OBJECTIVES

Assessment of the usefulness of antibiotic prophylaxis in inguinal hernioplasty.

MATERIALS AND METHODS

This prospective randomized double blind study was conducted on 98 patients. Group A (50 patients) received a single dose of intravenous amoxicillin and clavulanic acid, and Group P (48 patients) received an equal volume of normal saline placebo by intravenous bolus 30 min before the induction of anesthesia. Hernioplasty was performed with polypropylene mesh. Skin was closed using skin staples that were removed after complete wound healing. The surgical site infection was diagnosed according to APIC, CDC criteria ( http://www.apic.org ).

RESULTS

The mean operative time was 38.8  ± 10.8 min in group A versus 40.9 ± 11.1 min in group P (P  = 0.34). The mean hospitalization time was 1.3 ± 0.463 days in group A versus 1.25 ± 0.438 days in group P (P = 0.58). Four patients (2%) in group A and 6 patients (2.88%) in group P had wound infections (P = 0.47). Group A had 3 superficial infections and 1 deep infection while group P had 5 superficial infections and 1 deep infection. Antibiotic treatment of the wound infection was successful in all patients. Wound culture showed Staphylococcus aureus infection in 1 patient each group, Streptococcus pyogenes in 1 group A patient and Pseudomonas aeruginosa in 1 group P patient. Cultures in other patients in both groups were reported to be sterile.

CONCLUSION

Prophylactic antibiotic usage in patients undergoing tension free inguinal hernioplasty did not show any statistically significant beneficial effects in reduction of surgical site infection.

Does mesh offer an advantage over tissue in the open repair of umbilical hernias? A systematic review and meta-analysis

PURPOSE

To determine the best surgical approach for the open repair of primary umbilical hernias.

METHODS

Studies were identified through searching MEDLINE, EMBASE, and the Cochrane database, as well as hand-searching references. Randomized controlled trials (RCTs) and observational studies comparing mesh to suture repair for primary umbilical hernias published between January 1965 and October 2009 were included. Data regarding the recurrence rate, complications, number of subjects, length of follow-up, size of hernia, and type of mesh were extracted. Log odds ratios were calculated and weighed by the Mantel-Haenszel method to obtain a pooled estimate with 95% confidence interval (CI). A fixed effects model was used.

RESULTS

Three RCTs and ten observational studies were identified. The pooled odds ratio (OR) for RCTs was 0.09 in favor of mesh (95% CI 0.02-0.39). The pooled OR for observational studies was 0.40 in favor of mesh (95% CI 0.21-0.75). There was no difference in complication rates between mesh and tissue repair in RCTs or observational studies.

CONCLUSIONS

The use of mesh in umbilical hernia repair results in decreased recurrence and similar wound complications rates compared to tissue repair for primary umbilical hernias.

Prophylactic antibiotic usage in patients undergoing inguinal mesh hernioplasty - A clinical study

BACKGROUND

There is ambiguity about the use of antibiotic prophylaxis in inguinal mesh hernioplasty. We have tried to assess the efficacy of antibiotic prophylaxis in this procedure.

MATERIALS AND METHODS

A randomized double blind placebo controlled study was conducted which included 55 patients who underwent an inguinal mesh hernioplasty over a 2 year period. The patients were evaluated for the status of the suture line as well as the presence of wound infection.

RESULTS

Out of 55 patients 29 were randomized to the antibiotic arm and 26 to the placebo group. The groups were well matched for all variables studied excluding wound infections, which occurred at a rate of 10.34% (n = 3) in the antibiotic group and 15.38% (n = 4) in the placebo arm, (p > 0.01).

CONCLUSION

This study did not document any statistically significant difference observed between those who received antibiotics and those receiving placebo in terms of any of the prognostic end points evaluated for Lichtenstein mesh hernioplasty.

More than 150 consecutive open umbilical hernia repairs in a major Veterans Administration Medical Center

BACKGROUND

The purpose of this study was to determine the rate of surgical site infection for open elective umbilical hernia repairs and to identify the factors related to an increased risk of infection and/or recurrence.

METHODS

A retrospective analysis of 152 open elective umbilical hernia repairs between 2003 and 2007 was performed.

RESULTS

Overall, 19% of repairs became infected. Both high ASA classification (P = .01) and mesh repair (P = .01) significantly predicted wound infection, whereas age >60 years, body mass index >30, smoking, immunosuppression, diabetes, and hernia size did not. Only 2 of 17 infected mesh repairs required removal of the mesh. The recurrence rate was 1.5% for mesh and 9.2% for suture repairs.

CONCLUSIONS

Umbilical hernia repair is associated with a high rate of infection, and most superficial mesh infections can be treated with antibiotics alone. In addition, mesh repair of umbilical hernias decreased the rate of recurrence but increased the risk of infection compared with suture repairs.

Total extraperitoneal (TEP) mesh repair of inguinal hernia in the developing world: comparison of low-cost indigenous balloon dissection versus direct telescopic dissection: a prospective randomized controlled study

BACKGROUND

Creation of extraperitoneal space during TEP repair requires an expensive commercially available balloon.

PATIENTS AND METHODS

Fifty-six patients suffering from uncomplicated primary unilateral or bilateral groin hernia were randomized into two groups; group 1--indigenous balloon dissection and group 2--direct telescopic dissection.

RESULTS

There were 55 males and 1 female, with an average age of 49 years; 50% of the inguinal hernias were bilateral. Creation of extraperitoneal space was considered as satisfactory in majority of patients (94.6%) with satisfactory anatomical delineation. Peritoneal breach was noticed during dissection in 36 (64.3%) patients. There was one (3.8%) conversion of TEP to TAPP in group 2. Distance between pubic symphysis to umbilicus was an important factor, which affected the easiness of dissection. In patients with this distance <or=14 cm lateral placement of ports was considered for easy use of graspers. The incidence of scrotal edema was significantly higher in group 2 as compared with group 1 (p < 0.01). Patients with indirect inguinal hernias in group 2 presented with a greater number of scrotal edema. Pain score on VAS at 6 h after surgery was significantly higher in group 2 (p < 0.021). Patients with age <65 years, bilateral hernias, and indirect hernias had a correlation with higher pain score at 6 h. Of the patients, 17.9% developed seroma in group 1 versus 64.3% in group 2 (p < 0.001).

CONCLUSION

Anatomical delineation of inguinal area and dissection in the extraperitoneal space in TEP repair was equally satisfactory with both low-cost indigenous balloon (group 1) and telescopic dissection (group 2). Balloon dissection was associated with significantly reduced postoperative pain at 6 h, scrotal edema, and seroma formation. However at 3 months follow-up balloon dissection did not offer significant advantage over direct telescopic dissection in the overall long-term outcome of TEP repairs. If balloon dissection is considered useful for the beginner, low-cost indigenous balloon may be used to avoid higher cost of commercially available balloon dissector with added early advantages.

Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery

BACKGROUND

Surgery has been used as part of breast cancer treatment for centuries; however any surgical procedure has the potential risk of infection. Infection rates for surgical treatment of breast cancer are documented at between three and 15%, higher than average for a clean surgical procedure. Pre and peri-operative antibiotics have been found to be useful in lowering infection rates in other surgical groups, yet there is no current consensus on prophylactic antibiotic use in breast cancer surgery.

OBJECTIVES

To determine the effects of prophylactic antibiotics on the incidence of surgical site infection after breast cancer surgery.

SEARCH STRATEGY

We searched the Cochrane Wounds and Breast Cancer Groups Specialised Registers, the Cochrane Central Register of Controlled Trials (CENTRAL) issue 1 2006. MEDLINE 2002-2005, EMBASE 1980-2005, NRR issue 1 2005, CINAHL 1982-2004 and SIGLE 1976-2004. Companies and experts in the field were contacted and reference lists were checked. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials of pre and peri-operative antibiotics for patients undergoing surgery for breast cancer were included. Primary outcomes were, incidence of breast wound infection and adverse reactions to treatment.

DATA COLLECTION AND ANALYSIS

Two authors independently examined the title and abstracts of all studies identified by the search strategy, then assessed study quality and extracted data from those that met the inclusion criteria.

MAIN RESULTS

Six studies met the inclusion criteria. All six evaluated pre-operative antibiotic compared with no antibiotic or placebo. Pooling of the results demonstrated that prophylactic antibiotics significantly reduce the incidence of surgical site infection for patients undergoing breast cancer surgery without reconstruction (pooled RR 0.66, 95% CI, 0.48 to 0.89). No studies presented separate data for patients who underwent reconstructive surgery at the time of removal of the breast tumour.

AUTHORS' CONCLUSIONS

Prophylactic antibiotics reduce the risk of surgical site infection in patients undergoing surgery for breast cancer. The potential morbidity caused by infection, such as delays in wound healing or adjuvant cancer treatments must be balanced against the cost of treatment and potential adverse effects such as drug reactions or increased bacterial resistance. Further studies of patients undergoing immediate breast reconstruction would be useful as studies have identified this group as being at higher risk of infection than those who do not undergo immediate breast reconstruction.