In support of mesh for hernia repair

A modified Delphi process to establish research priorities in hernia surgery

BACKGROUND

Abdominal wall hernia repair is one of the most commonly performed surgical procedures worldwide, yet despite this, there remains a lack of high-quality evidence to support best management. The aim of the study was to use a modified Delphi process to determine future research priorities in this field.

METHODS

Stakeholders were invited by email, using British Hernia Society membership details or Twitter, to submit individual research questions via an online survey. In addition, questions obtained from a patient focus group (PFG) were collated to form Phase I. Two rounds of prioritization by stakeholders (phases II and III) were then completed to determine a final list of research questions. All questions were analyzed on an anonymized basis.

RESULTS

A total of 266 questions, 19 from the PFG, were submitted by 113 stakeholders in Phase I. Of these, 64 questions were taken forward for prioritization in Phase II, which was completed by 107 stakeholders. Following Phase II analysis, 97 stakeholders prioritized 36 questions in Phase III. This resulted in a final list of 14 research questions, 3 of which were from the PFG. Stakeholders included patients and healthcare professionals (consultant surgeons, trainee surgeons and other multidisciplinary members) from over 27 countries during the 3 phases.

CONCLUSION

The study has identified 14 key research priorities pertaining to abdominal wall hernia surgery. Uniquely, these priorities have been determined from participation by both healthcare professionals and patients. These priorities should now be addressed by well-designed, high-quality international collaborative research.

Antibiotic Prophylaxis against Surgical Site Infection after Open Hernia Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

The role of antibiotic prophylaxis (AP) in the prevention of surgical site infection (SSI) after hernia repair is debated. We conducted this systematic review and meta-analysis to assess the evidence on the value of prophylactic antibiotics in reducing the risks of SSI after open hernia surgery.

METHODS

We ran an online and manual search to identify relevant randomized controlled trials that compared prophylactic antibiotics to nonantibiotic controls in patients undergoing open surgical hernia repair. Data on SSI risk were extracted and pooled as risk ratios (RRs) with 95% confidence intervals (95% CIs), using RevMan software. We further used the Cochrane risk of bias tool and GRADE assessment to evaluate the quality of generated evidence.

RESULTS

Twenty-nine studies (N = 8,616 patients) were included in the current analysis. Antibiotic prophylaxis reduced the risk of SSI in open hernia repair patients (RR = 0.65, 95% CI = 0.53, 0.79). Subgroup analysis showed a significant benefit for antibiotics in mesh repair patients (RR = 0.60, 95% CI = 0.48, 0.76) yet no significant difference in SSI risk after herniorrhaphy (RR = 0.86, 95% CI = 0.54, 1.36). In addition, AP was associated with a significant reduction in superficial SSI risk (RR = 0.56, 95% CI = 0.43, 0.72) but not deep SSI (RR = 0.70, 95% CI = 0.30, 1.62). Further analysis showed a significant reduction in SSI risk with amoxicillin/clavulanic acid and cefazolin but not with cefuroxime.

CONCLUSION

The present meta-analysis suggests that AP is beneficial prior to open mesh hernia repair. However, the quality of evidence was low, and further well-designed trials are needed.

Prophylactic sublay non-absorbable mesh positioning following midline laparotomy in a clean-contaminated field: randomized clinical trial (PROMETHEUS)

BACKGROUND

Incisional hernia is a frequent postoperative complication after midline laparotomy. Prophylactic mesh augmentation in abdominal wall closure after elective surgery is recommended, but its role in emergency surgery is less well defined.

METHODS

This prospective randomized trial evaluated the incidence of incisional hernia in patients undergoing urgent midline laparotomy for clean-contaminated surgery. Closure using a slowly absorbable running suture was compared with closure using an additional sublay mesh (Parietex ProGrip™). Patients were randomized just before abdominal wall closure using computer-generated permuted blocks. Patients, care providers, staff collecting data, and those assessing the endpoints were all blinded to the group allocation. Patients were followed up for 24 months by means of clinical and ultrasonographic evaluations.

RESULTS

From January 2015 to June 2018, 200 patients were randomized: 100 to primary closure (control group) and 100 to Parietex ProGrip™ mesh-supported closure (mesh group). Eight patients in the control group and six in the mesh group were lost to follow-up. By 24 months after surgery, 21 patients in the control group and six in the mesh group had developed incisional hernia (P = 0.002). There was no difference between groups in the incidence of haematoma (2 versus 5; P = 0.248) and superficial wound infection (4 versus 5; P = 0.733). Multivariable analysis confirmed the role of mesh in preventing incisional hernia (odds ratio 0.11, 95 per cent c.i. 0.03 to 0.37; P  < 0.001). One patient in the mesh group required mesh removal because of deep infection.

CONCLUSION

Prophylactic mesh-augmented abdominal wall closure after urgent laparotomy in clean-contaminated wounds is safe and effective in reducing the incidence of incisional hernia. Registration number: NCT04436887 (http://www.clinicaltrials.gov).

GRAPHICAL ABSTRACT

An RCT was conducted to compare the widely recommended midline laparotomy closure using a slowly absorbable running suture with closure using a sublay mesh (Parietex ProGrip™), in patients undergoing urgent midline laparotomy for clean-contaminated surgery. Patients were followed up for 24 months with clinical and ultrasonographic evaluation during outpatient visits. Prophylactic reinforcement of the midline abdominal wall, using a ProGrip™ Parietex mesh in the retromuscular position, at the time of urgent laparotomy in clean-contaminated wounds was safe and effective in reducing the incidence of incisional hernia, although larger studies with longer follow-up are required.

Management of the uncomplicated primary inguinal hernia in 2019: the practice amongst members of the British Hernia Society

INTRODUCTION

The aim of this study was to survey the current practice of UK-based hernia surgeons in elective inguinal hernia repair.

MATERIALS AND METHODS

A questionnaire was created using SurveyMonkey™ and sent electronically to registered members of the British Hernia Society.

RESULTS

A total of 368 responses were obtained (a response rate of 55%); 83% were consultant surgeons, 91% were male and 91% stated that they had an interest in laparoscopic surgery. For an uncomplicated inguinal hernia in a male patient, 60% would perform an open Lichtenstein repair, 20% trans-abdominal pre-peritoneal repair and 20% totally extra-peritoneal repair. In a female patient, 54% would perform an open Lichtenstein repair, 25% trans-abdominal pre-peritoneal repair and 21% totally extra-peritoneal repair. 90% always use mesh in inguinal hernia repair. 93% of surgeons rarely or never perform a tissue repair.

CONCLUSIONS

Despite recent controversy, UK surgeons support the use of mesh in the repair of inguinal hernias with an open Lichtenstein repair being the most common choice. There has only been a modest increase in the use of laparoscopic surgery over the past 20 years.

Current trends in hernia surgery in NHS England

BACKGROUND

Mesh is recommended for the repair of most hernias when prevention of recurrence is the primary endpoint. However, mesh may be associated with increased complications for the patient. The aim of this study was to quantify the use of mesh for abdominal wall hernia surgery in NHS England in recent years.

MATERIALS AND METHODS

The NHS Digital Secondary Uses Service database for 2016/17 and 2017/18 was interrogated for numbers of patient undergoing elective primary hernia surgery. Using the specific hernia code inguinal (T201-9), umbilical (T241-9), incisional (T251-9) and other abdominal wall hernia (T271-9), the use of mesh or suture repair was determined. Recurrent and emergency hernia surgery were excluded. All data were provided by NHS RightCare.

RESULTS

There are almost 100,000 hernia repairs performed annually in NHS England. For every four hernias, three are repaired with mesh. The percentage repaired by mesh varies by hernia type. Mesh repairs in inguinal, umbilical and incisional hernias accounted for 95%, 50% and 82%, respectively.

CONCLUSIONS

Mesh repair for all hernia types is more common than suture repair. However, for umbilical and other abdominal wall hernias, a significant proportion are repaired without the use of mesh.