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Kingsnorth's modified score as predictor of complications in open inguinal hernia repair. Updates Surg 2022; 74:1985-1993. [PMID: 35943664 PMCID: PMC9361253 DOI: 10.1007/s13304-022-01341-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 07/19/2022] [Indexed: 11/27/2022]
Abstract
Purpose This study aims to analyse the postoperative complications (30 days) on unilateral primary inguinal hernia repair and prove their correlation with the preoperative modified scoring system of Kingsnorth (KN). Methods Prospective study design collecting data from patients who underwent surgery for unilateral primary inguinal hernia in a University Hospital. The data were collected in the National Inguinal Hernia Registry (EVEREG). A statistical analysis to assess the association between the presence of postoperative complications and the preoperative and intraoperative variables was performed. The patients were classified depending on their KN score. Surgical complications and their relationship with the classification were specifically analysed. Study design was performed following STROBE statements. Results The sample included 403 patients who met the inclusion criteria from which 62 (15.3%) subjects presented postoperative complications. The variables that presented a statistically significant relationship with the appearance of complications were a KN score of 5–8 (OR 2.7; 95% CI 1.07–4.82; P = 0.03) and the involvement of a member of the abdominal wall surgery unit in the procedure (OR 0.28; 95% CI 0.08–0.92; P = 0.03). The KN score correlated with a longer duration of surgery (Pearson's correlation 0.291; P < 0.0001). Conclusion The KN classification can predict the onset of surgical wound complications on patients who undergo a primary unilateral inguinal hernia surgery. A KN score of 5–8 has a higher probability of wound complications. When surgery is performed by the abdominal wall surgery unit, the chances of postoperative complications decrease.
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Surgical Antimicrobial Prophylaxis in Abdominal Surgery for Neonates and Paediatrics: A RAND/UCLA Appropriateness Method Consensus Study. Antibiotics (Basel) 2022; 11:antibiotics11020279. [PMID: 35203881 PMCID: PMC8868062 DOI: 10.3390/antibiotics11020279] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/16/2022] [Accepted: 02/18/2022] [Indexed: 01/26/2023] Open
Abstract
Surgical site infections (SSIs), i.e., surgery-related infections that occur within 30 days after surgery without an implant and within one year if an implant is placed, complicate surgical procedures in up to 10% of cases, but an underestimation of the data is possible since about 50% of SSIs occur after the hospital discharge. Gastrointestinal surgical procedures are among the surgical procedures with the highest risk of SSIs, especially when colon surgery is considered. Data that were collected from children seem to indicate that the risk of SSIs can be higher than in adults. This consensus document describes the use of preoperative antibiotic prophylaxis in neonates and children that are undergoing abdominal surgery and has the purpose of providing guidance to healthcare professionals who take care of children to avoid unnecessary and dangerous use of antibiotics in these patients. The following surgical procedures were analyzed: (1) gastrointestinal endoscopy; (2) abdominal surgery with a laparoscopic or laparotomy approach; (3) small bowel surgery; (4) appendectomy; (5) abdominal wall defect correction interventions; (6) ileo-colic perforation; (7) colorectal procedures; (8) biliary tract procedures; and (9) surgery on the liver or pancreas. Thanks to the multidisciplinary contribution of experts belonging to the most important Italian scientific societies that take care of neonates and children, this document presents an invaluable reference tool for perioperative antibiotic prophylaxis in the paediatric and neonatal populations.
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Quantity and quality profiles of antibiotics pre, on, and post surgery in a hospital setting. Int J Clin Pharm 2021; 43:1302-1310. [PMID: 33651252 DOI: 10.1007/s11096-021-01251-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 02/16/2021] [Indexed: 10/22/2022]
Abstract
Background Providing proper antibiotics is undoubtedly crucial to prevent infections during surgery. Objective This study set out to evaluate the medication administration in antibiotic prophylaxis using both quantitative and qualitative methods. Setting The study employed a retrospective design and observed patients who underwent surgical procedures during hospitalization at a private hospital in Indonesia within the period of January-June 2019. Methods The data obtained were evaluated quantitatively and qualitatively; and analyzed descriptively. The quantitative evaluation used the defined daily dose (DDD) per 100 bed-days. The qualitative evaluation was expressed as the percentage of antibiotic suitability based on antibiotic administration, i.e. (1) type; (2) timing; (3) dosage; (4) duration; and (5) route. Main outcome measure Suitability of antibiotic prophylaxis in a hospital setting. Results There were 164 prescriptions recorded from 20 types of surgical procedures, of which the most common was cholecystectomy (23 patients, 14%). Most antibiotics were administered 61-120 min before the incision time (55 patients, 37%), and had a duration of more than 24 h (119 patients, 80%). The total DDD per 100 bed-days for pre-, on-, and post-surgery antibiotic use were 44.2, 33.3, and 66.7 respectively. The suitability profiles of the antibiotics used according to the Antibiotic Use Guideline for Hospital (2018) were as follows: 26.3% right type, 52.9% right time, 24.8% right dosage, 19.1% right duration, 91.8% right route, while according to American Society of Health-System Pharmacists Therapeutic Guidelines (2014) there were 17.6% right type, 53.4% right time, 16.4% right dosage, 19.1% right duration, and 96.6% right route. Conclusion Ceftriaxone was the first-choice prophylactic antibiotic administered in this Indonesian hospital. The data indicate a considerable non-compliance with local and international guidelines.
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Razafinimanana M, Aoun O, Durond S, Pasquier P, Kassi F, Malgras B. Relevance of Antibiotic Prophylaxis in Non-Mesh Inguinal Hernia Repair in Remote and Poor Medical Settings in Sub-Saharan Africa. Surg Infect (Larchmt) 2021; 22:752-756. [PMID: 33538650 DOI: 10.1089/sur.2020.387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Because of the poor local medical conditions, and because the surgical site infection (SSI) rate after hernia repair in sub-Saharan Africa is higher than in developed countries, deployed surgeons within Role 2 usually perform non-mesh inguinal herniorrhaphy. Regarding antimicrobial prophylaxis, the latter currently is not recommended in non-mesh inguinal hernia repairs. Our study aimed at assessing the relevance of antibiotic prophylaxis in non-mesh inguinal hernia repair within a Role 2 surgical structure deployed in sub-Saharan Africa. Methods: From January 1 to December 31, 2019, we conducted a non-randomized prospective study in a French Role 2 military surgical structure deployed to Abidjan, Republic of Côte d'Ivoire. We included all patients presenting with uncomplicated inguinal hernia. All subjects underwent open herniorrhaphy through a groin incision. The primary endpoint was the occurrence of an SSI. Results: We recorded 120 open hernia repairs. Antimicrobial prophylaxis was administered in 70 interventions (60%). An SSI was reported in 13 cases (11%). Multivariable logistic regression analysis of SSI occurrence, according to the administration of intra-operative antimicrobial prophylaxis, showed a 0.219 odds ratio with a 95% confidence interval of 0.05-0.84 and p = 0.028. This finding was in favor of its significant protective effect on the risk of SSI after open non-mesh inguinal hernia repair, taking into account the American Society of Anesthesiologists score, Body Mass Index, and recurrence status. Conclusion: Administration of intra-operative antimicrobial prophylaxis in open non-mesh inguinal hernia repair in remote and poor medical settings, for example during deployment conditions as in our study, was associated with a reduction of the SSI rate.
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Affiliation(s)
- Meva Razafinimanana
- Department of Digestive Surgery, Begin Military Teaching Hospital, Saint Mandé, France
| | - Olivier Aoun
- 5th Armed Forces Medical Center, Strasbourg, France
| | - Sandrine Durond
- French Military Center for Epidemiology and Public Health, Marseille, France
| | - Pierre Pasquier
- Department of Anesthesiology and Intensive Care, Percy Military Training Hospital, Clamart, France.,French Military Medical Academy, Ecole du Val-de-Grâce, Paris, France
| | - Fulgence Kassi
- Department of Digestive and General Surgery, Cocody Teaching Hospital, Abidjan, République de Côte d'Ivoire
| | - Brice Malgras
- Department of Digestive Surgery, Begin Military Teaching Hospital, Saint Mandé, France.,French Military Medical Academy, Ecole du Val-de-Grâce, Paris, France
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Orelio CC, van Hessen C, Sanchez-Manuel FJ, Aufenacker TJ, Scholten RJ. Antibiotic prophylaxis for prevention of postoperative wound infection in adults undergoing open elective inguinal or femoral hernia repair. Cochrane Database Syst Rev 2020; 4:CD003769. [PMID: 32315460 PMCID: PMC7173733 DOI: 10.1002/14651858.cd003769.pub5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Claudia C Orelio
- Diakonessenhuis Utrecht, Research Support, Bosboomstraat 1, Utrecht, Netherlands, 3582 KE
| | - Coen van Hessen
- Diakonessenhuis Utrecht, Liesbreukcentrum Nederland, Bosboomstraat 1, Utrecht, Netherlands, 3582 KE
| | | | | | - Rob Jpm Scholten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Cochrane Netherlands, Room Str. 6.126, P.O. Box 85500, Utrecht, Netherlands, 3508 GA
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Russell D, Cole W, Yheulon C, Wren S, Kellicut D, Lim R. USA Department of Defense audit of surgical antibiotic prophylaxis prescribing patterns in inguinal hernia repair. Hernia 2020; 25:159-164. [PMID: 32107656 DOI: 10.1007/s10029-020-02145-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 02/11/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Antibiotic prophylaxis in inguinal hernia repair (IHR) is contentious in literature and practice. In low-risk patients, for whom evidence suggests antibiotic prophylaxis is unnecessary, many surgeons still advocate for its routine use. This study surveys prescription patterns of Department of Defense (DoD) general surgeons. METHODS An anonymous survey was sent electronically to approximately 350 DoD general surgeons. The survey asked multiple-choice and free text answers about prescribing patterns and knowledge of current evidence for low-risk patients undergoing elective open inguinal hernia repair without mesh (OIHRWOM), open inguinal hernia repair with mesh (OIHRWM), or laparoscopic inguinal hernia repair (LIHR). RESULTS 110 DoD general surgeons consented to participate. 58.6, 95 and 84.2% of surgeons always administer antibiotic prophylaxis in OIHRWOM, OIHRWM, and LIHR, respectively. 37.9, 70.9, and 63.2% of surgeons believe that it reduces rates of surgical site infection in OIHRWOM, OIHRWM, and LIHR, respectively. The most common reasons for empirically prescribing antibiotic prophylaxis include "I think the evidence supports it" (27 of 72 responses), "I would rather be conservative and safe" (15 of 72 responses), and "I am following my hospital/department guidelines" (9 of 72 responses). 11.8, 40.8, and 32.9% of surgeons believe current evidence supports antibiotic prophylaxis use in OIHRWM, OIHRWOM, and LIHR, respectively. 50, 18.4, and 22.4% of surgeons believe current evidence refutes antibiotic prophylaxis use in OIHRWM, OIHRWOM, and LIHR, respectively. CONCLUSION The survey results indicate that the majority of practicing DoD general surgeons still empirically prescribe surgical antibiotic prophylaxis in IHR despite more conflicting opinions that it has no meaningful effect or that current evidence does not supports its use.
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Affiliation(s)
- D Russell
- Tripler Army Medical Center, Honolulu, HI, 96815, USA.
| | - W Cole
- Tripler Army Medical Center, Honolulu, HI, 96815, USA
| | - C Yheulon
- Tripler Army Medical Center, Honolulu, HI, 96815, USA
| | - S Wren
- Stanford University, Stanford, CA, 94305, USA
| | - D Kellicut
- Tripler Army Medical Center, Honolulu, HI, 96815, USA
| | - R Lim
- University of Oklahoma, Tulsa, OK, 74104, USA
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Predictive factors for the development of surgical site infection in adults undergoing initial open inguinal hernia repair. Hernia 2019; 24:173-178. [PMID: 31552553 DOI: 10.1007/s10029-019-02050-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 09/09/2019] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Despite being one of the most commonly performed general surgery procedures, surgical site infection (SSI) is still seen in primary, elective, open inguinal hernia repair. Studies have reported a wide range of infection rates, yet predictive risk factors have not been definitely identified leading to variability and controversy in the use of pre-operative antibiotics. In this study, the authors seek to identify factors predictive of SSI development in a large cohort of patients undergoing initial unilateral open inguinal repair. METHODS The American College of Surgery National Surgical Quality Improvement Program (ACS NSQIP) personal use file (PUF) database was queried for initial, open, reducible inguinal hernia repair cases in adults with clean surgical sites performed from 2012 to 2015 (CPT 49,505 and class one wound). Patient data were analyzed using univariate and multivariate analysis to identify factors predictive of surgical site infection. RESULTS 57,951 cases were identified. 90.8% were men with an average age of 58.2 years and a median operative time of 53.0 min. Of all variables evaluated with univariate logistic regression, 17 demonstrated an association with surgical site infection. Performing multiple logistic regression on those 17 variables yielded 3 factors independently associated with surgical site infection: diabetes (OR 2.017, 95% CI 1.012-4.023), BMI ≥ 35 kg/m2 (OR 2.587, 95% CI 1.123-5.964), and current smoking (OR 2.071, 95% CI 1.126-3.811). CONCLUSION Diabetes, BMI ≥ 35 kg/m2, and current smoking are significantly associated with an increased odds surgical site infection after initial, open, reducible inguinal hernia repair in adults with clean surgical sites.
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Antibiotics for Groin Hernia Repair According to Evidence-Based Guidelines: Time for Action in Ghana. J Surg Res 2019; 238:90-95. [PMID: 30769249 DOI: 10.1016/j.jss.2019.01.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 11/05/2018] [Accepted: 01/11/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUD Groin hernia repairs (GHR), though classified as clean surgeries, are associated with varying rates of surgical site infections. We assessed the practices of surgeons in Ghana regarding antibiotic use for GHR in comparison to evidence-based international guidelines (EBIG). METHODS We interviewed surgeons trained by the Ghana College of Physicians and Surgeons (GCPS), from inception (2003) through 2016, about their use of antibiotics for GHR. We defined the outcome variable of consistently following EBIG in antibiotics use for GHR. Logistic regression was used to examine how a priori selected covariates contributed to the outcome. RESULTS Eighty-two of 117 surgeons reported performing/supervising at least one GHR per week. They performed/supervised a mean of five GHR per week. Thirty-two (40%) reported using mesh for at least 50% of GHR. For primary GHR, 75% of surgeons administered antibiotics according to EBIG, whereas for GHR with mesh only, 45% did so. Predictors of consistently following EBIG were increasing number of GHR performed per week (adjusted odds ratio 1.44, 95% CI 1.07-1.96) and increasing time spent for clinical work (adjusted odds ratio 0.95, 95% CI 0.91-0.99). Years of practice since GCPS graduation, total operations performed per week, and hospital level of practice were not predictive of the outcome variable. CONCLUSIONS Two-thirds of Ghanaian surgeons interviewed do not consistently administer antibiotics for GHR per EBIG, raising the need to improve access to evidence-based medical information overall to guide practice. Determining local surgical site infections rates to guide antibiotic use in GHR will be useful in Ghana and other LMICs.
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Inguinal hernia repair in Nigeria: a survey of surgical trainees. Hernia 2019; 23:625-629. [PMID: 30656498 DOI: 10.1007/s10029-019-01885-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 01/09/2019] [Indexed: 01/22/2023]
Abstract
PURPOSE Africa's inguinal hernia burden is high with large numbers of untreated hernias. Mesh repair is recommended in developed countries, but the best repair in developing countries is unknown. Little is known about knowledge and practice of surgeons in Nigeria performing inguinal hernia repair. Surgical trainees can provide this information. METHODS A questionnaire-based survey was administered to surgical trainees from all over Nigeria who had attended the West African College of Surgeons' integrated revision course in Jos, on their practice and recommendations concerning elective inguinal hernia repair. RESULTS One hundred and nine surgical trainees (90.8%) consisting of 78 (71.6%) registrars and 30 (27.5%) senior registrars responded. Thirty-two (29.4%) used antibiotics routinely for inguinal hernia surgery. Ceftriaxone was the most widely used antibiotic (45%). Ninety-two (84.4%) respondents will perform this surgery as day case. Forty (36.7%) respondents stated modified Bassini repair as their preferred method of repair. Mesh repair was recommended by 93 (85.3%) respondents while 65 of 100 respondents (65%) recommended laparoscopic surgery. Of 103 respondents, 93 (90.3%) had performed inguinal hernia repair and 34 (33%), mesh repair. For 56 (51.4%) respondents, the most difficult part of open hernia surgery was sac dissection. CONCLUSIONS Surgical trainees in Nigeria perform more tissue-based inguinal hernia repair than mesh but majority would recommend both mesh repair and laparoscopic surgery. Majority found sac dissection as the most difficult part of open hernia surgery.
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Sun BJ, Kamal RN, Lee GK, Nazerali RS. Quality measures in ventral hernia repair: a systematic review. Hernia 2018; 22:1023-1032. [PMID: 29961197 DOI: 10.1007/s10029-018-1794-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 06/09/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND The US healthcare system is shifting towards reimbursement for quality over quantity of care. Quality measures are tied to financial incentives in these healthcare models. It is important that surgeons become familiar with quality measures addressing ventral hernia repair and understand candidate measures that may drive future quality measure development. STUDY DESIGN We performed a systematic review of society websites, quality measure databases, and the literature (Pubmed, Embase/Scopus, and Google Scholar) for quality measures addressing ventral hernia surgery. Clinical practice guidelines were included as candidate quality measures. All measures were categorized as structure, process or outcome according to Donabedian domains, as well as within the six National Quality Strategy (NQS) domains. RESULTS Thirty quality measures and candidate measures were identified. Eight candidate measures from the American Hernia Society addressed ventral hernia repair, and 22 quality measures in general surgery were also relevant to ventral hernia repair. Of the candidate measures, 6 (75%) were outcome and 2 (25%) were process measures. Of existing general surgery quality measures, 9 (41%) were outcome and 13 (59%) were process measures. No structural measures were identified. Overall, the majority of measures addressed NQS priorities of effective clinical care (33%) and patient safety (27%), while few addressed other domains. CONCLUSION Both the Donabedian domains of quality and NQS priorities were unequally represented in the current measures addressing ventral hernia repair. Recognizing and addressing the under-represented areas will provide a more balanced framework for developing quality measures and ensure that ventral hernia surgery is appropriately evaluated in value-based payment models.
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Affiliation(s)
- B J Sun
- UC Irvine School of Medicine, 101 The City Dr, Orange, CA, 92868, USA.
| | - R N Kamal
- Department of Orthopedic Surgery, Stanford University School of Medicine, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063, USA
| | - G K Lee
- Department of Surgery-Plastic and Reconstructive Surgery, Stanford University School of Medicine, 770 Welch Rd, Suite 400, Palo Alto, CA, 94304, USA
| | - R S Nazerali
- Department of Surgery-Plastic and Reconstructive Surgery, Stanford University School of Medicine, 770 Welch Rd, Suite 400, Palo Alto, CA, 94304, USA
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Liu Z, Dumville JC, Norman G, Westby MJ, Blazeby J, McFarlane E, Welton NJ, O'Connor L, Cawthorne J, George RP, Crosbie EJ, Rithalia AD, Cheng H. Intraoperative interventions for preventing surgical site infection: an overview of Cochrane Reviews. Cochrane Database Syst Rev 2018; 2:CD012653. [PMID: 29406579 PMCID: PMC6491077 DOI: 10.1002/14651858.cd012653.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Surgical site infection (SSI) rates vary from 1% to 5% in the month following surgery. Due to the large number of surgical procedures conducted annually, the costs of these SSIs can be considerable in financial and social terms. Many interventions are used with the aim of reducing the risk of SSI in people undergoing surgery. These interventions can be broadly delivered at three stages: preoperatively, intraoperatively and postoperatively. The intraoperative interventions are largely focused on decontamination of skin using soap and antiseptics; the use of barriers to prevent movement of micro-organisms into incisions; and optimising the patient's own bodily functions to promote best recovery. Both decontamination and barrier methods can be aimed at people undergoing surgery and operating staff. Other interventions focused on SSI prevention may be aimed at the surgical environment and include methods of theatre cleansing and approaches to managing theatre traffic. OBJECTIVES To present an overview of Cochrane Reviews of the effectiveness and safety of interventions, delivered during the intraoperative period, aimed at preventing SSIs in all populations undergoing surgery in an operating theatre. METHODS Published Cochrane systematic reviews reporting the effectiveness of interventions delivered during the intraoperative period in terms of SSI prevention were eligible for inclusion in this overview. We also identified Cochrane protocols and title registrations for future inclusion into the overview. We searched the Cochrane Library on 01 July 2017. Two review authors independently screened search results and undertook data extraction and 'Risk of bias' and certainty assessment. We used the ROBIS (risk of bias in systematic reviews) tool to assess the quality of included reviews, and we used GRADE methods to assess the certainty of the evidence for each outcome. We summarised the characteristics of included reviews in the text and in additional tables. MAIN RESULTS We included 32 Cochrane Reviews in this overview: we judged 30 reviews as being at low risk of bias and two at unclear risk of bias. Thirteen reviews had not been updated in the past three years. Two reviews had no relevant data to extract. We extracted data from 30 reviews with 349 included trials, totaling 73,053 participants. Interventions assessed included gloving, use of disposable face masks, patient oxygenation protocols, use of skin antiseptics for hand washing and patient skin preparation, vaginal preparation, microbial sealants, methods of surgical incision, antibiotic prophylaxis and methods of skin closure. Overall, the GRADE certainty of evidence for outcomes was low or very low. Of the 77 comparisons providing evidence for the outcome of SSI, seven provided high- or moderate-certainty evidence, 39 provided low-certainty evidence and 31 very low-certainty evidence. Of the nine comparisons that provided evidence for the outcome of mortality, five provided low-certainty evidence and four very low-certainty evidence.There is high- or moderate-certainty evidence for the following outcomes for these intraoperative interventions. (1) Prophylactic intravenous antibiotics administered before caesarean incision reduce SSI risk compared with administration after cord clamping (10 trials, 5041 participants; risk ratio (RR) 0.59, 95% confidence interval (CI) 0.44 to 0.81; high-certainty evidence - assessed by review authors). (2) Preoperative antibiotics reduce SSI risk compared with placebo after breast cancer surgery (6 trials, 1708 participants; RR 0.74, 95% CI 0.56 to 0.98; high-certainty evidence - assessed by overview authors). (3) Antibiotic prophylaxis probably reduce SSI risk in caesarean sections compared with no antibiotics (82 relevant trials, 14,407 participants; RR 0.40, 95% CI 0.35 to 0.46; moderate-certainty evidence; downgraded once for risk of bias - assessed by review authors). (4) Antibiotic prophylaxis probably reduces SSI risk for hernia repair compared with placebo or no treatment (17 trials, 7843 participants; RR 0.67, 95% CI 0.54 to 0.84; moderate-certainty evidence; downgraded once for risk of bias - assessed by overview authors); (5) There is currently no clear difference in the risk of SSI between iodine-impregnated adhesive drapes compared with no adhesive drapes (2 trials, 1113 participants; RR 1.03, 95% CI 0.66 to 1.60; moderate-certainty evidence; downgraded once for imprecision - assessed by review authors); (6) There is currently no clear difference in SSI risk between short-term compared with long-term duration antibiotics in colorectal surgery (7 trials; 1484 participants; RR 1.05 95% CI 0.78 to 1.40; moderate-certainty evidence; downgraded once for imprecision - assessed by overview authors). There was only one comparison showing negative effects associated with the intervention: adhesive drapes increase the risk of SSI compared with no drapes (5 trials; 3082 participants; RR 1.23, 95% CI 1.02 to 1.48; high-certainty evidence - rated by review authors). AUTHORS' CONCLUSIONS This overview provides the most up-to-date evidence on use of intraoperative treatments for the prevention of SSIs from all currently published Cochrane Reviews. There is evidence that some interventions are useful in reducing SSI risk for people undergoing surgery, such as antibiotic prophylaxis for caesarean section and hernia repair, and also the timing of prophylactic intravenous antibiotics administered before caesarean incision. Also, there is evidence that adhesive drapes increase SSI risk. Evidence for the many other treatment choices is largely of low or very low certainty and no quality-of-life or cost-effectiveness data were reported. Future trials should elucidate the relative effects of some treatments. These studies should focus on increasing participant numbers, using robust methodology and being of sufficient duration to adequately assess SSI. Assessment of other outcomes such as mortality might also be investigated as part of non-experimental prospective follow-up of people with SSI of different severity, so the risk of death for different subgroups can be better understood.
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Affiliation(s)
- Zhenmi Liu
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Jo C Dumville
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Gill Norman
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Maggie J Westby
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Jane Blazeby
- University of BristolNIHR Bristol Biomedical Research Centre, School of Social and Community Medicine, Bristol Medical SchoolBristolUK
| | - Emma McFarlane
- National Institute for Health and Care ExcellenceCentre for GuidelinesLevel 1A, City TowerPiccadilly PlazaManchesterUKM1 4BD
| | - Nicky J Welton
- University of BristolNIHR Bristol Biomedical Research Centre, School of Social and Community Medicine, Bristol Medical SchoolBristolUK
| | - Louise O'Connor
- Central Manchester University Hospitals NHS Foundation TrustInfection Prevention and Control / Tissue Viability TeamCobbett HouseOxford RoadManchesterUKM13 9WL
| | - Julie Cawthorne
- Central Manchester University Hospitals NHS Foundation TrustInfection Prevention and Control / Tissue Viability TeamCobbett HouseOxford RoadManchesterUKM13 9WL
| | - Ryan P George
- Central Manchester University Hospitals NHS Foundation TrustInfection Prevention and Control / Tissue Viability TeamCobbett HouseOxford RoadManchesterUKM13 9WL
| | - Emma J Crosbie
- Faculty of Biology, Medicine and Health, University of ManchesterDivision of Cancer Sciences5th Floor ‐ ResearchSt Mary's HospitalManchesterUKM13 9WL
| | - Amber D Rithalia
- Independent Researcher7 Victoria Terrace, KirkstallLeedsUKLS5 3HX
| | - Hung‐Yuan Cheng
- University of BristolBristol Centre for Surgical Research, Bristol Medical SchoolOffice 2.01Canynge Hall, 39 Whatley RoadBristolUKBS8 2PS
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12
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Malik HT, Marti J, Darzi A, Mossialos E. Savings from reducing low-value general surgical interventions. Br J Surg 2017; 105:13-25. [DOI: 10.1002/bjs.10719] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 06/06/2017] [Accepted: 09/06/2017] [Indexed: 01/26/2023]
Abstract
Abstract
Background
Finding opportunities for improving efficiency is important, given the pressure on national health budgets. Identifying and reducing low-value interventions that deliver little benefit is key. A systematic literature evaluation was done to identify low-value interventions in general surgery, with further assessment of their cost.
Methods
A multiplatform method of identifying low value interventions was undertaken, including a broad literature search, a targeted database search, and opportunistic sampling. The results were then stratified by impact, assessing both frequency and cost.
Results
Seventy-one low-value general surgical procedures were identified, of which five were of high frequency and high cost (highest impact), 22 were of high cost and low frequency, 23 were of low cost and high frequency, and 21 were of low cost and low frequency (lowest impact). Highest impact interventions included inguinal hernia repair in minimally symptomatic patients, inappropriate gastroscopy, interval cholecystectomy, CT to diagnose appendicitis and routine endoscopy in those who had CT-confirmed diverticulitis. Their estimated cost was €153 383 953.
Conclusion
Low-value services place a burden on health budgets. Stopping only five high-volume, high-cost general surgical procedures could save the National Health Service €153 million per annum.
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Affiliation(s)
- H T Malik
- Department of Surgery and Cancer, St Mary's Campus, Imperial College London, London, UK
| | - J Marti
- Department of Surgery and Cancer, St Mary's Campus, Imperial College London, London, UK
| | - A Darzi
- Department of Surgery and Cancer, St Mary's Campus, Imperial College London, London, UK
| | - E Mossialos
- Department of Surgery and Cancer, St Mary's Campus, Imperial College London, London, UK
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13
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Development and Validation of a Scoring System to Predict Surgical Site Infection After Ventral Hernia Repair: A Michigan Surgical Quality Collaborative Study. World J Surg 2017; 41:914-918. [PMID: 27872976 DOI: 10.1007/s00268-016-3835-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Surgical site infections (SSIs) are a rare but significant complication following an elective ventral hernia repair. This study aims to develop a risk assessment tool in order to predict the risk of developing SSIs postoperatively. METHODS All patients undergoing an elective ventral hernia repair were identified using the Michigan Surgical Quality Collaborative (MSQC) database. Patients' demographics, comorbidities and technical aspects of the operations were extracted. Logistic regressions were used to create a predictive scoring system for SSIs. RESULTS A total of 4983 were included. SSIs occurred in 3.4% of the patient population. A stepwise forward logistic regression identified the need to use drains, BMI, wound classification at the end of the surgery, presence of severe adhesions, a history of CAD, the need for intensive care after surgery, the use of pressors, EtOH abuse and history of PVD as being independently associated with the development of postoperative surgical site infections. CONCLUSION In patients undergoing an elective hernia repair, the incidence of SSI is low. Several preoperative and perioperative factors can contribute to the development of SSIs.
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Ayeleke RO, Mourad SM, Marjoribanks J, Calis KA, Jordan V. Antibiotic prophylaxis for elective hysterectomy. Cochrane Database Syst Rev 2017; 6:CD004637. [PMID: 28625021 PMCID: PMC6441670 DOI: 10.1002/14651858.cd004637.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Elective hysterectomy is commonly performed for benign gynaecological conditions. Hysterectomy can be performed abdominally, laparoscopically, or vaginally, with or without laparoscopic assistance. Antibiotic prophylaxis consists of administration of antibiotics to reduce the rate of postoperative infection, which otherwise affects 40%-50% of women after vaginal hysterectomy, and more than 20% after abdominal hysterectomy. No Cochrane review has systematically assessed evidence on this topic. OBJECTIVES To determine the effectiveness and safety of antibiotic prophylaxis in women undergoing elective hysterectomy. SEARCH METHODS We searched electronic databases to November 2016 (including the Cochrane Gynaecology and Fertility Group Specialised Register, the Cochrane Central Register of Studies (CRSO), MEDLINE, Embase, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), as well as clinical trials registers, conference abstracts, and reference lists of relevant articles. SELECTION CRITERIA All randomised controlled trials (RCTs) comparing use of antibiotics versus placebo or other antibiotics as prophylaxis in women undergoing elective hysterectomy. DATA COLLECTION AND ANALYSIS We used Cochrane standard methodological procedures. MAIN RESULTS We included in this review 37 RCTs, which performed 20 comparisons of various antibiotics versus placebo and versus one another (6079 women). The quality of the evidence ranged from very low to moderate. The main limitations of study findings were risk of bias due to poor reporting of methods, imprecision due to small samples and low event rates, and inadequate reporting of adverse effects. Any antibiotic versus placebo Vaginal hysterectomyModerate-quality evidence shows that women who received antibiotic prophylaxis had fewer total postoperative infections (risk ratio (RR) 0.28, 95% confidence interval (CI) 0.19 to 0.40; five RCTs, N = 610; I2 = 85%), less urinary tract infection (UTI) (RR 0.58, 95% CI 0.43 to 0.77; eight RCTs, N = 1790; I2 = 44%), fewer pelvic infections (RR 0.28, 95% CI 0.20 to 0.39; 11 RCTs, N = 2010; I2 = 57%), and fewer postoperative fevers (RR 0.43, 95% CI 0.34 to 0.54; nine RCTs, N = 1879; I2 = 48%) than women who did not receive such prophylaxis. This suggests that antibiotic prophylaxis reduces the average risk of postoperative infection from about 34% to 7% to 14%. Whether this treatment has led to differences in rates of other serious infection remains unclear (RR 0.20, 95% CI 0.01 to 4.10; one RCT, N = 146; very low-quality evidence).Data were insufficient for comparison of adverse effects. Abdominal hysterectomyWomen who received antibiotic prophylaxis of any class had fewer total postoperative infections (RR 0.16, 95% CI 0.06 to 0.38; one RCT, N = 345; low-quality evidence), abdominal wound infections (RR 0.64, 95% CI 0.45 to 0.92; 11 RCTs, N = 2434; I2 = 0%; moderate-quality evidence), UTIs (RR 0.39, 95% CI 0.29 to 0.51; 11 RCTs, N = 2547; I2 = 26%; moderate-quality evidence), pelvic infections (RR 0.50, 95% CI 0.35 to 0.71; 11 RCTs, N = 1883; I2 = 11%; moderate-quality evidence), and postoperative fevers (RR 0.60, 95% CI 0.51 to 0.70; 11 RCTs, N = 2581; I2 = 51%; moderate-quality evidence) than women who did not receive prophylaxis, suggesting that antibiotic prophylaxis reduces the average risk of postoperative infection from about 16% to 1% to 6%. Whether this treatment has led to differences in rates of other serious infection remains unclear (RR 0.44, 95% CI 0.12 to 1.69; two RCTs, N = 476; I2 = 29%; very low-quality evidence).It is unclear whether rates of adverse effects differed between groups (RR 1.80, 95% CI 0.62 to 5.18; two RCTs, N = 430; I2 = 0%; very low-quality evidence). Head-to-head comparisons between antibiotics Vaginal hysterectomyWe identified four comparisons: cephalosporin versus penicillin (two RCTs, N = 470), cephalosporin versus tetracycline (one RCT, N = 51), antiprotozoal versus lincosamide (one RCT, N = 80), and cephalosporin versus antiprotozoal (one RCT, N = 78). Data show no evidence of differences between groups for any of the primary outcomes, except that fewer cases of total postoperative infection and postoperative fever were reported in women who received cephalosporin than in those who received antiprotozoal.Only one comparison (cephalosporin vs penicillin; two RCTs, N = 451) yielded data on adverse effects and showed no differences between groups. Abdominal hysterectomyWe identified only one comparison: cephalosporin versus penicillin (N = 220). Data show no evidence of differences between groups for any of the primary outcomes. Adverse effects were not reported. Combined antibiotics versus single antibiotics Vaginal hysterectomyWe identified three comparisons: cephalosporin plus antiprotozoal versus cephalosporin (one RCT, N = 78), cephalosporin plus antiprotozoal versus antiprotozoal (one RCT, N = 78), and penicillin plus antiprotozoal versus penicillin (one RCT, N = 230). Data were unavailable for most outcomes, including adverse effects. We found no evidence of differences between groups, except that fewer women receiving cephalosporin with antiprotozoal received a diagnosis of total postoperative infection, UTI, or postoperative fever compared with women receiving antiprotozoal. Abdominal hysterectomyWe identified one comparison (penicillin plus antiprotozoal vs penicillin only; one RCT, N = 230). Whether differences between groups occurred was unclear. Adverse effects were not reported. Comparison of cephalosporins in different regimensSingle small trials addressed dose comparisons and provided no data for most outcomes, including adverse effects. Whether differences between groups occurred was unclear. No trials compared route of administration.The quality of evidence for all head-to-head and dose comparisons was very low owing to very serious imprecision and serious risk of bias related to poor reporting of methods. AUTHORS' CONCLUSIONS Antibiotic prophylaxis appears to be effective in preventing postoperative infection in women undergoing elective vaginal or abdominal hysterectomy, regardless of the dose regimen. However, evidence is insufficient to show whether use of prophylactic antibiotics influences rates of adverse effects. Similarly, evidence is insufficient to show which (if any) individual antibiotic, dose regimen, or route of administration is safest and most effective. The most recent studies included in this review were 14 years old at the time of our search. Thus findings from included studies may not reflect current practice in perioperative and postoperative care and may not show locoregional antimicrobial resistance patterns.
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Affiliation(s)
- Reuben Olugbenga Ayeleke
- University of AucklandDepartment of Obstetrics and GynaecologyPrivate Bag 92019AucklandNew Zealand
| | | | - Jane Marjoribanks
- University of AucklandDepartment of Obstetrics and GynaecologyPrivate Bag 92019AucklandNew Zealand
| | - Karim A Calis
- National Institutes of HealthNational Institute of Child Health and Human Development31 Center Drive (MSC 2423)Building 31, Suite 2A25, Room 2A25EBethesdaMarylandUSA20892
| | - Vanessa Jordan
- University of AucklandDepartment of Obstetrics and GynaecologyPrivate Bag 92019AucklandNew Zealand
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15
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Boonchan T, Wilasrusmee C, McEvoy M, Attia J, Thakkinstian A. Network meta-analysis of antibiotic prophylaxis for prevention of surgical-site infection after groin hernia surgery. Br J Surg 2017; 104:e106-e117. [PMID: 28121028 PMCID: PMC5299528 DOI: 10.1002/bjs.10441] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 10/03/2016] [Accepted: 11/01/2016] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- T Boonchan
- Section for Clinical Epidemiology and Biostatistics and, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - C Wilasrusmee
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - M McEvoy
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - J Attia
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - A Thakkinstian
- Section for Clinical Epidemiology and Biostatistics and, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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16
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Resanovic A, Resanovic V, Djordjevic M, Resanovic M, Arafeh M. Scoring Systems are Crucial in Prediction of the Risk of SSI Development After Ventral Hernia Repair. World J Surg 2017; 41:1660-1661. [PMID: 28097407 DOI: 10.1007/s00268-017-3882-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
| | - Vladimir Resanovic
- Emergency Center, Surgery Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Milica Resanovic
- General surgery, Klinicko Bolnicki Centar Bezanijska kosa, Belgrade, Serbia
| | - Mazen Arafeh
- Plastic and Reconstructive Surgery, Coccona Centre, Delhi, India
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17
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Erdas E, Medas F, Pisano G, Nicolosi A, Calò PG. Antibiotic prophylaxis for open mesh repair of groin hernia: systematic review and meta-analysis. Hernia 2016; 20:765-776. [DOI: 10.1007/s10029-016-1536-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 08/28/2016] [Indexed: 11/25/2022]
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18
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Olasehinde O, Lawal OO, Agbakwuru EA, Adisa AO, Alatise OI, Arowolo OA, Adesunkanmi ARK, Etonyeaku AC. Comparing Lichtenstein with darning for inguinal hernia repair in an African population. Hernia 2016; 20:667-74. [PMID: 27146504 DOI: 10.1007/s10029-016-1498-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 04/22/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Being a relatively new entrant into our practice, mesh repair has not been compared with previously existing tissue-based techniques in our setting. This study is set out to compare darning with Lichtenstein technique of inguinal hernia repair in terms of frequency of post-operative complications, recovery and cost. METHOD Patients with uncomplicated, primary inguinal hernia were randomized to have their hernias repaired either by the Lichtenstein or darning technique. Details of their socio-demographic, hernia characteristics and intra-operative findings were recorded. Postoperatively patients were assessed for pain, wound site complications and recurrence. Both direct and indirect costs were calculated. Mean duration of follow-up was 7.5 months. RESULT Sixty-seven patients were studied. Thirty-three had Lichtenstein repair while 34 had darning repair. Lichtenstein repair was associated with less post-operative pain, less analgesic requirement, and shorter time of return to work activities, these were all statistically significant (p < 0.05). Frequency of post-operative complications was comparable in both groups with wound haematoma and scrotal oedema being the commonest. There was no recurrence in any of the groups. Total cost was comparable between the two groups. CONCLUSION Lichtenstein is superior to darning in terms of post-operative recovery while both techniques are comparable in terms of frequency of early post-operative complications and total cost.
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Affiliation(s)
- O Olasehinde
- Department of Surgery, Obafemi Awolowo University Teaching Hospitals, PMB 5538, Ile-Ife, Nigeria.
| | - O O Lawal
- Department of Surgery, Obafemi Awolowo University Teaching Hospitals, PMB 5538, Ile-Ife, Nigeria
| | - E A Agbakwuru
- Department of Surgery, Obafemi Awolowo University Teaching Hospitals, PMB 5538, Ile-Ife, Nigeria
| | - A O Adisa
- Department of Surgery, Obafemi Awolowo University Teaching Hospitals, PMB 5538, Ile-Ife, Nigeria
| | - O I Alatise
- Department of Surgery, Obafemi Awolowo University Teaching Hospitals, PMB 5538, Ile-Ife, Nigeria
| | - O A Arowolo
- Department of Surgery, Obafemi Awolowo University Teaching Hospitals, PMB 5538, Ile-Ife, Nigeria
| | - A R K Adesunkanmi
- Department of Surgery, Obafemi Awolowo University Teaching Hospitals, PMB 5538, Ile-Ife, Nigeria
| | - A C Etonyeaku
- Department of Surgery, Obafemi Awolowo University Teaching Hospitals, PMB 5538, Ile-Ife, Nigeria
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Pérez-Köhler B, García-Moreno F, Brune T, Pascual G, Bellón JM. Preclinical Bioassay of a Polypropylene Mesh for Hernia Repair Pretreated with Antibacterial Solutions of Chlorhexidine and Allicin: An In Vivo Study. PLoS One 2015; 10:e0142768. [PMID: 26556805 PMCID: PMC4640885 DOI: 10.1371/journal.pone.0142768] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 10/27/2015] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Prosthetic mesh infection constitutes one of the major complications following hernia repair. Antimicrobial, non-antibiotic biomaterials have the potential to reduce bacterial adhesion to the mesh surface and adjacent tissues while avoiding the development of novel antibiotic resistance. This study assesses the efficacy of presoaking reticular polypropylene meshes in chlorhexidine or a chlorhexidine and allicin combination (a natural antibacterial agent) for preventing bacterial infection in a short-time hernia-repair rabbit model. METHODS Partial hernia defects (5 x 2 cm) were created on the lateral right side of the abdominal wall of New Zealand White rabbits (n = 21). The defects were inoculated with 0.5 mL of a 106 CFU/mL Staphylococcus aureus ATCC25923 strain and repaired with a DualMesh Plus antimicrobial mesh or a Surgipro mesh presoaked in either chlorhexidine (0.05%) or allicin-chlorhexidine (900 μg/mL-0.05%). Fourteen days post-implant, mesh contraction was measured and tissue specimens were harvested to evaluate bacterial adhesion to the implant surface (via sonication, S. aureus immunolabeling), host-tissue incorporation (via staining, scanning electron microscopy) and macrophage response (via RAM-11 immunolabeling). RESULTS The polypropylene mesh showed improved tissue integration relative to the DualMesh Plus. Both the DualMesh Plus and the chlorhexidine-soaked polypropylene meshes exhibited high bacterial clearance, with the latter material showing lower bacterial yields. The implants from the allicin-chlorhexidine group displayed a neoformed tissue containing differently sized abscesses and living bacteria, as well as a diminished macrophage response. The allicin-chlorhexidine coated implants exhibited the highest contraction. CONCLUSIONS The presoaking of reticular polypropylene materials with a low concentration of chlorhexidine provides the mesh with antibacterial activity without disrupting tissue integration. Due to the similarities found with the antimicrobial DualMesh Plus material, the chlorhexidine concentration tested could be utilized as a prophylactic treatment to resist infection by prosthetic mesh during hernia repair.
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Affiliation(s)
- Bárbara Pérez-Köhler
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá. Madrid, Spain
- Networking Research Center on Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Madrid, Spain
| | - Francisca García-Moreno
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá. Madrid, Spain
- Networking Research Center on Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Madrid, Spain
| | | | - Gemma Pascual
- Department of Medicine and Medical Specialties, Faculty of Medicine and Health Sciences, University of Alcalá. Madrid, Spain
- Networking Research Center on Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Madrid, Spain
| | - Juan Manuel Bellón
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá. Madrid, Spain
- Networking Research Center on Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Madrid, Spain
- * E-mail:
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20
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Köckerling F, Bittner R, Jacob D, Schug-Pass C, Laurenz C, Adolf D, Keller T, Stechemesser B. Do we need antibiotic prophylaxis in endoscopic inguinal hernia repair? Results of the Herniamed Registry. Surg Endosc 2015; 29:3741-9. [PMID: 25786905 PMCID: PMC4648957 DOI: 10.1007/s00464-015-4149-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 02/06/2015] [Indexed: 11/29/2022]
Abstract
Introduction The use of antibiotic prophylaxis in inguinal hernia repair is a controversial issue. Accepted randomized controlled trials or registry data with specific analysis of endoscopic repaired patients do not exist. Patient and methods The data presented in this study compared the prospectively collected data from the Herniamed Registry on all patients who had undergone unilateral, bilateral or recurrent repair of inguinal hernias using either endoscopic or open techniques between September 1, 2009, and March 5, 2014. In total, 85,033 patients were enrolled. Of these patients, 48,201 (56.7 %) had an endoscopic and 36,832 (43.3 %) an open repair. The target variables analyzed were impaired wound healing and deep infections with mesh involvement within 30 days after the operation. Results Analysis of the patient group with endoscopic/laparoscopic inguinal hernia repair (n = 48,201) did not identify any significant influence of antibiotic prophylaxis on postoperative impaired wound healing, which occurred in 53 cases (p = 0.6431). Nor was it possible to identify any significant impact of antibiotic prophylaxis on the deep infections seen in 27 cases (p = 0.8409). Analysis of the open inguinal hernia repair group revealed that, unlike the laparoscopic/endoscopic group, antibiotic prophylaxis had a significant impact on the postoperative impaired wound healing and deep infection rates. The risk of postoperative impaired wound healing with antibiotic prophylaxis was significantly lower [OR 0.677 (0.479; 0.958), p = 0.027]. Conclusion The positive impact of the endoscopic/laparoscopic technique on avoidance of impaired wound healing and deep infections with mesh involvement is already so great that antibiotic prophylaxis has no additional benefit. In contrast, antibiotic prophylaxis should be administered for open inguinal hernia repair.
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Affiliation(s)
- F Köckerling
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Neue Bergstraße 6, 13585, Berlin, Germany.
| | - R Bittner
- Winghofer Medicum, Hernia Center, Winghofer Straße 42, 72108, Rottenburg am Neckar, Germany
| | - D Jacob
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Neue Bergstraße 6, 13585, Berlin, Germany
| | - C Schug-Pass
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Neue Bergstraße 6, 13585, Berlin, Germany
| | - C Laurenz
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Neue Bergstraße 6, 13585, Berlin, Germany
| | - D Adolf
- StatConsult GmbH, Halberstädter Straße 40 a, 39112, Magdeburg, Germany
| | - T Keller
- StatConsult GmbH, Halberstädter Straße 40 a, 39112, Magdeburg, Germany
| | - B Stechemesser
- Hernia Center Cologne, PAN - Hospital, Zeppelinstraße 1, 50667, Cologne, Germany
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21
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A national trainee-led audit of inguinal hernia repair in Scotland. Hernia 2014; 19:747-53. [DOI: 10.1007/s10029-014-1298-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 07/28/2014] [Indexed: 10/24/2022]
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Wiegering A, Sinha B, Spor L, Klinge U, Steger U, Germer CT, Dietz UA. Gentamicin for prevention of intraoperative mesh contamination: demonstration of high bactericide effect (in vitro) and low systemic bioavailability (in vivo). Hernia 2014; 18:691-700. [PMID: 25112382 DOI: 10.1007/s10029-014-1293-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 07/28/2014] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Mesh infection is a severe complication after incisional hernia repair and occurs in 1-3 % of all open mesh implantations. For this reason, topical antimicrobial agent applied directly to the mesh is often used procedure. So far, however, this procedure lacks a scientific basis. MATERIALS AND METHODS Two different meshes (Parietex™, Covidien; Ultrapro™, Ethicon Johnson & Johnson) were incubated with increasing amounts of three different Staphylococcus aureus strains (ATCC 25923; Mu50; ST239) with or without gentamicin and growth ability were determined in vitro. To further address the question of the systemic impact of topic gentamicin, serum levels were analyzed 6 and 24 h after implantation of gentamicin-impregnated multifilament meshes in 19 patients. RESULTS None of the gentamicin-impregnated meshes showed any bacterial growth in vitro. This effect was independent of the mesh type for all the tested S. aureus strains. In the clinical setting, serum gentamicin levels 6 h after implantation of the gentamicin-impregnated meshes were below the through-level (range 0.4-2.9 mg/l, mean 1.2 ± 0.7 mg/l). After 24 h the gentamicin serum levels in all patients had declined 90-65 % of the 6 h values. CONCLUSION Local application of gentamicin to meshes can completely prevent the growth of even gentamicin-resistant S. aureus strains in vitro. The systemic relevance of gentamicin in the clinical controls showed to be very low, without reaching therapeutic concentrations.
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Affiliation(s)
- A Wiegering
- Department of General, Visceral, Vascular and Pediatric Surgery (Department of Surgery I), University Hospital of Wuerzburg, Oberduerrbacher Strasse 6, 97080, Würzburg, Germany
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Uehara T, Takahashi S, Ichihara K, Hiyama Y, Hashimoto J, Kurimura Y, Masumori N. Surgical site infection of scrotal and inguinal lesions after urologic surgery. J Infect Chemother 2014; 20:186-9. [PMID: 24462435 DOI: 10.1016/j.jiac.2013.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 10/01/2013] [Accepted: 10/03/2013] [Indexed: 11/19/2022]
Abstract
To clarify the incidence of surgical site infection (SSI) after urological scrotal and inguinal surgical procedures and the preventive effect of antimicrobial prophylaxis for SSI, retrospective analysis was performed. The patients who underwent scrotal and inguinal operations from 2001 to 2010 were included in this analysis. A first or second generation cephalosporin was administered as antimicrobial prophylaxis just before the start of surgery and no additional prophylaxis was conducted. The surgery was classified into 76 (38%) cases with testicular sperm extraction (TESE), 72 (36%) with radical orchiectomy, 29 (14.5%) with bilateral orchiectomy (surgical castration) and 23 (11.5%) with other scrotal and inguinal operations. The median age and age range were 36 years and 18-81 years, respectively. SSI occurred in 7 (3.5%) cases. The frequencies of SSI were 6.5% in the patients with urological inguinal surgery and 1.6% in those with scrotal surgery. The frequency of SSI in the patients with urological inguinal surgery was not negligible even though it is considered a clean operation, and further analysis is warranted to prevent SSI.
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Affiliation(s)
- Teruhisa Uehara
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Satoshi Takahashi
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan.
| | - Kohji Ichihara
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Yoshiki Hiyama
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Jiro Hashimoto
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Yuichiro Kurimura
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Naoya Masumori
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
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Klinge U, Koch A, Weyhe D, Nicolo E, Bendavid R, Fiebeler A. Bias-Variation Dilemma Challenges Clinical Trials: Inherent Limitations of Randomized Controlled Trials and Meta-Analyses Comparing Hernia Therapies. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/ijcm.2014.513105] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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25
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EAES Consensus Development Conference on endoscopic repair of groin hernias. Surg Endosc 2013; 27:3505-19. [PMID: 23708718 DOI: 10.1007/s00464-013-3001-9] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 04/23/2013] [Indexed: 02/07/2023]
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26
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Aiken AM, Haddow JB, Symons NRA, Kaptanis S, Katz-Summercorn AC, Debnath D, Dent H, Tayeh S, Kung V, Clark S, Gahir J, Dindyal S, Farag S, Lazaridis A, Bretherton CP, Williams S, Currie A, West H, Davies J, Arora S, Kheraj A, Stubbs BM, Yassin N, Mallappa S, Garrett G, Hislop S, Bhangu A, Abbey Y, Al-Shoek I, Ahmad U, Sharp G, Memarzadeh A, Patel A, Ali F, Kaderbhai H, Knowles CH. Use of antibiotic prophylaxis in elective inguinal hernia repair in adults in London and south-east England: a cross-sectional survey. Hernia 2013; 17:657-64. [PMID: 23543332 PMCID: PMC3788180 DOI: 10.1007/s10029-013-1061-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 02/08/2013] [Indexed: 11/30/2022]
Abstract
Purpose Evidence regarding whether or not antibiotic prophylaxis is beneficial in preventing post-operative surgical site infection in adult inguinal hernia repair is conflicting. A recent Cochrane review based on 17 randomised trials did not reach a conclusion on this subject. This study aimed to describe the current practice and determine whether clinical equipoise is prevalent. Methods Surgeons in training were recruited to administer the Survey of Hernia Antibiotic Prophylaxis usE survey to consultant-level general surgeons in London and the south-east of England on their practices and beliefs regarding antibiotic prophylaxis in adult elective inguinal hernia repair. Local prophylaxis guidelines for the participating hospital sites were also determined. Results The study was conducted at 34 different sites and received completed surveys from 229 out of a possible 245 surgeons, a 93 % response rate. Overall, a large majority of hospital guidelines (22/28) and surgeons’ personal beliefs (192/229, 84 %) supported the use of single-dose pre-operative intravenous antibiotic prophylaxis in inguinal hernia repair, although there was considerable variation in the regimens in use. The most widely used regimen was intravenous co-amoxiclav (1.2 g). Less than half of surgeons were adherent to their own hospital antibiotic guidelines for this procedure, although many incorrectly believed that they were following these. Conclusion In the south-east of England, there is a strong majority of surgical opinion in favour of the use of antibiotic prophylaxis in this procedure. It is therefore likely to be extremely difficult to conduct further randomised studies in the UK to support or refute the effectiveness of prophylaxis in this commonly performed procedure.
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Affiliation(s)
- A M Aiken
- c/o National Centre for Bowel Research and Surgical Innovation, 1st Floor Abernathy Building, 2 Newark St, Whitechapel, London, E1 2AT, UK
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Effect of mesh type, surgeon and selected patients' characteristics on the treatment of inguinal hernia with the Lichtenstein technique. Randomized trial. Wideochir Inne Tech Maloinwazyjne 2013; 8:99-106. [PMID: 23837093 PMCID: PMC3699769 DOI: 10.5114/wiitm.2011.32824] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Revised: 11/12/2012] [Accepted: 12/03/2012] [Indexed: 12/28/2022] Open
Abstract
Introduction Though not entirely free of complications, the Lichtenstein technique is still considered the “gold standard” for inguinal hernia repair due to the low recurrence rate. Aim In our study we determined the effect of mesh type, surgeon and selected patients’ characteristics on treatment results. The latter were determined by the frequency of early complications, recovery time and return to normal activities, chronic pain and hernia recurrence. Material and methods Tension-free hernia repair with the Lichtenstein technique was performed in 149 male patients aged 20-89 years randomized to two trial groups. One group comprised 76 patients with heavyweight non-absorbable polypropylene mesh (HW group) and the other included 73 patients with lightweight partially absorbable mesh (LW group). The control schedule follow-up took place on the 7th day as well as in the 3rd and 6th month after the operation. Statistical analysis was performed with multi-factor regression models. Results In the LW group patients returned to normal activity faster (p = 0.031), experienced less intensive chronic pain (p = 0.01) and expressed higher treatment satisfaction (p = 0.024) than the patients from the HW group. The type of mesh had an insignificant influence on the risk of early complications and hernia recurrence. Statistically significant differences were observed however with regard to surgeon, type and hernia duration, patient's general condition and body mass. Conclusions Both types of mesh are equally effective for prevention of hernia recurrence. Lightweight partially absorbable meshes are more beneficial to patients than the heavyweight non-absorbable type. The surgeon and patients’ characteristics have a significant impact on the treatment outcome.
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