Incisional hernia: early complication of abdominal surgery

Wound healing and hernia after abdominal aortic aneurysm repair: Onlay self-gripping polyester mesh reinforcement compared with small bite sutured closure

BACKGROUND

Prophylactic mesh implantation following open surgical repair of abdominal aortic aneurysm is a debatable subject.

OBJECTIVE

To assess the efficacy of a self-gripping polyester mesh used in on-lay technique to prevent incisional hernia after open abdominal aortic aneurysm repair.

METHODS

We retrospectively reviewed the records of 495 patients who underwent aortic surgery between May 2017 and May 2021. Patients included in the study underwent open surgical repair for infrarenal abdominal aortic aneurysm (AAA) with closure of the abdominal wall with either small bite suture technique or prophylactic mesh reinforcement. Primary endpoint of the study was the occurrence of incisional hernia during a two-year follow-up period. Secondary endpoints were mesh-related complications.

RESULTS

Mesh implantation with the on-lay technique was successful in all cases. No patient in the mesh group developed an incisional hernia during the 24-month follow-up period. Two patients in the non-mesh group developed a symptomatic incisional hernia during the follow-up period at 6 months. Three cases of post-operative access site complications were observed in the mesh group.

CONCLUSIONS

Application of a self-gripping polyester mesh using the on-lay technique demonstrates acceptable early-durability after open surgical repair of abdominal aortic aneurysms. However, it appears to be associated with a number of post-operative access site complications.

Patient-specific computational simulations of wound healing following midline laparotomy closure

In the current study, we developed a new computational methodology to simulate wound healing in soft tissues. We assumed that the injured tissue recovers partially its mechanical strength and stiffness by gradually increasing the volume fraction of collagen fibers. Following the principles of the constrained mixture theory, we assumed that new collagen fibers are deposited at homeostatic tension while the already existing tissue undergoes a permanent deformation due to the effects of remodeling. The model was implemented in the finite-element software Abaqus® through a VUMAT subroutine and applied to a complex and realistic case: simulating wound healing following midline laparotomy closure. The incidence of incisional hernia is still quite significant clinically, and our goal was to investigate different conditions hampering the success of these procedures. We simulated wound healing over periods of 6 months on a patient-specific geometry. One of the outcomes of the finite-element simulations was the width of the wound tissue, which was found to be clinically correlated with the development of incisional hernia after midline laparotomy closure. We studied the impact of different suturing modalities and the effects of situations inducing increased intra-abdominal pressure or its intermittent variations such as coughing. Eventually, the results showed that the main risks of developing an incisional hernia mostly depend on the elastic strains reached in the wound tissue after degradation of the suturing wires. Despite the need for clinical validation, these results are promising for establishing a digital twin of wound healing in midline laparotomy incision.

A Comparative Study on Outcomes and Quality of Life Changes Following Ventral Transabdominal Preperitoneal (Ventral-TAPP) and Laparoscopic Intraperitoneal Onlay Mesh (IPOM)-Plus Repair for Ventral Hernia

Background Ventral transabdominal preperitoneal (ventral-TAPP) repair and intraperitoneal onlay mesh (IPOM) plus repair are two options among the available techniques of laparoscopic ventral hernia repair (LVHR). We conducted a comparative study to evaluate the clinical and quality of life (QoL)-related outcomes between ventral-TAPP and IPOM-plus repair. It was hypothesized that both procedures offered similar outcomes and QoL. Materials and methods The study included 32 consecutive patients undergoing LVHR, divided equally between ventral-TAPP and IPOM-plus groups. In the ventral-TAPP procedure, a peritoneal flap was created around the defect, followed by defect approximation and polypropylene mesh placement in the pre-peritoneal pocket. For the IPOM-plus procedure, the defect was closed and a composite (dual-side) mesh was placed around the defect. The minimum overlap beyond the original defect margin in both groups was 5 cm. Data regarding pre-operative parameters and postoperative outcomes, including pain and QoL at one week, one month, and three months, were recorded. A p-value of less than or equal to 0.05 was considered to be statistically significant. Results While the mean duration of surgery was longer, the cost of treatment was lower in group 1 (ventral-TAPP) with a p-value of <0.05 for both parameters. The length of hospital stay was significantly shorter in group 1 (ventral-TAPP), while the return to normal activity was similar in both groups. The visual analog scale (VAS) score for overall pain perception and the European registry for abdominal wall hernias (EuraHS; hernia-related QoL) score for 'Pain at Site' and 'Restriction of Activity' domains were significantly higher in group 2 (IPOM-plus) at one week. Conclusion Although the ventral-TAPP procedure requires more time and expertise to perform, the EuraHS QoL assessment at one week was better in group 1 (ventral-TAPP). Ventral-TAPP group scored better in terms of length of hospital stay and cost-effectiveness as well.

Gastrointestinal procedures and anastomoses can be safely performed during complex abdominal wall reconstruction

INTRODUCTION

The literature regarding combined abdominal wall reconstruction and gastrointestinal surgery is limited and largely suggests staged procedures due to a reported increased incidence of surgical site infections (SSIs), hernia recurrence and anastomotic leak, but this exposes patients to the risks of two substantial procedures. This study evaluates the outcomes of single-stage GI surgery with complex abdominal wall reconstructions (CAWR) by a single surgeon.

METHODS

Analysis of 10 years of a prospectively maintained single surgeon CAWR database compared those who had CAWR-alone with those having concomitant gastrointestinal surgery (CAWR-GI) such as stoma reversal or bowel resection but excluding cholecystectomy, gynaecological surgery and adhesiolysis alone. Groups were compared using the paired t test (continuous data) and Fisher's exact test (nominal data).

RESULTS

Overall, 62 elective cases (42 CAWR-alone vs. 20 CAWR-GI) were analysed. Baseline demographics (age, BMI, co-morbidities, smoking status and hernia size) showed no differences; CAWR-GI mean operating time was significantly longer compared to the CAWR-alone group (5.4 h vs. 4.1 h) with an increased incidence of post-operative ileus in the intestinal group (40% vs. 11.9%, p < 0.05). Post-operative complications were common (chest infection (32.3%) and SSI (41.9%)), but similar between groups. There were no anastomotic leaks, and the hernia recurrence rate at almost 4 years median follow-up was 10% in both groups.

CONCLUSION

Performing simultaneous intestinal surgery during complex abdominal wall repair can be performed safely without increasing the risk of hernia recurrence, mesh infections or anastomotic leak. A careful choice of mesh implant is required.

Do surgical drains reduce surgical site occurrence and infection after incisional hernia repair with sublay mesh? A non-randomised pilot study

INTRODUCTION

Surgical site occurrence (SSO) and surgical site infection (SSI) are common concerns with incisional hernia repair. Intraoperative drain placement is a common practice aiming to reduce SSO and SSI rates. However, literature on the matter is very poor. The aim of this study is to investigate the role of subcutaneous and periprosthetic drain placement on postoperative outcomes and SSO and SSI rates with incisional hernia repair.

METHODS

A non-randomised pilot study was performed between January 2018 and December 2020 and included patients with elective midline or lateral incisional hernia repair with sublay mesh placement. Patients were prospectively included, followed for 1 month and divided into three groups: group 1 without drainage, group 2 with subcutaneous drainage, and group 3 with subcutaneous and periprosthetic drains. Drains were placed at surgeon's discretion. All patients were included in the enhanced recovery program.

RESULTS

One hundred and four patients were included. Twenty-four patients (23.1%) did not have drains (group 1), 60 patients (57.7%) had a subcutaneous drain (group 2) and 20 patients (19.2%) had both a subcutaneous and a periprosthetic drains (group 3). SSO rates were significantly different between the 3 groups: 20.8% in group 1, 20.7% in group 2 and 50% in group 3 (p = 0.03). There was no significant difference in deep and superficial SSI rates between the 3 groups. Subgroup analysis revealed that adding a drain in direct contact with the mesh significantly increased SSO rate but did not influence SSI rate. Length of stay was also significantly increased by the presence of a drain, 3.1 ± 1.9 days for group 1; 5.9 ± 4.8 for group 2 and 5.9 ± 2.5 days for group 3 (p < 0.005).

CONCLUSION

Drain placement in direct contact with the mesh might increase SSO rate. More studies are necessary to evaluate the actual benefits of drainage after incisional hernia repair.

Advantages of laparoscopic hepatic hemangioma surgery in quality of life: a prospective study

BACKGROUND

Surgical intervention is the most accurate method for the treatment of hepatic hemangioma. The advantages of laparoscopic surgery on quality of life should be clarified by prospective studies.

METHODS

The sample sizes of the laparoscopic and open surgery groups were calculated based on previous retrospective literature. Intraoperative and postoperative parameters were prospectively collected and analyzed. Quality of life in both groups was predicted by a mixed linear model.

RESULTS

Sixty patients were enrolled in the laparoscopic surgery group and open surgery group. The laparoscopic group had a longer operation time (P = 0.040) and more hospitalization expenses (P = 0.001); however, the Clavien-Dindo classification and comprehensive complication index suggested a lower incidence of surgical complications in the laparoscopic group, with P values of 0.049 and 0.002, respectively. After mixed linear model prediction, between-group analysis indicated that the laparoscopic group had little impact on role-physical functioning and role-emotional functioning; in addition, within-group analysis showed a rapid recovery time on role-physical functioning and role-emotional functioning in the laparoscopic group. Quality of life in both groups recovered to the preoperative level within 1 year after the operation.

CONCLUSION

The advantages of laparoscopic hepatectomy for hepatic hemangioma were fewer postoperative complications, lower impact on quality of life and faster recovery from affected quality of life.

Liquid resorbable nanofibrous surgical mesh: a proof of a concept

BACKGROUND

Surgical mesh is widely used not only to treat but also to prevent incisional hernia formation. Despite much effort by material engineers, the 'ideal' mesh mechanically, biologically and surgically easy to use remains elusive. Advances in tissue engineering and nanomedicine have allowed new concepts to be tested with promising results in both small and large animals. Abandoning the concept of a pre-formed mesh completely for a 'pour in liquid mesh' has never been tested before.

MATERIALS AND METHODS

Thirty rabbits underwent midline laparotomy with closure using an absorbable suture and small stitch small bites technique. In addition, their abdominal wall closure was reinforced by a liquid nanofibrous scaffold composed of a fibrin sealant and nanofibres of poly-ε-caprolactone with or without hyaluronic acid or the sealant alone, poured in as an 'onlay' over the closed abdominal wall. The animals were killed at 6 weeks and their abdominal wall was subjected to histological and biomechanical evaluations.

RESULTS

All the animals survived the study period with no major complication. Histological evaluation showed an eosinophilic infiltration in all groups and foreign body reaction more pronounced in the groups with nanofibres. Biomechanical testing demonstrated that groups treated with nanofibres developed a scar with higher tensile yield strength.

CONCLUSION

The use of nanofibres in a liquid form applied to the closed abdominal wall is easy to use and improves the biomechanical properties of healing fascia at 6 weeks after midline laparotomy in a rabbit model.

Report of novel application of T-line hernia mesh in ventral hernia repair

Introduction

Ventral hernia repair is one of the most common surgeries performed in the United States. Failure of hernia repairs can be attributed to sutures pulling through tissue or mesh (anchor point failure). T-Line Hernia Mesh is the first mesh designed to specifically prevent anchor point failure by distributing tension. This case study of two patients is the first clinical application of the novel T-Line Hernia Mesh.

Presentation of case

Two separate patients presented with symptomatic ventral hernia secondary to previous laparotomy. Patient 1 is a fifty-five year-old male who underwent open ventral hernia repair with T-Line Hernia Mesh onlay placement. Patient 2 is a fifty-eight year-old female with a symptomatic ventral hernia that underwent bilateral component separation and primary hernia repair with T-Line Hernia Mesh. Both patients postoperative course was uneventful with no reported surgical site occurrences or hernia recurrence.

Discussion

T-Line Hernia Mesh provides a new innovative approach to hernia surgery. This provides the first clinical outcomes. No complications were observed. In addition, this manuscript also demonstrates the surgical technique for the first time.

Conclusion

This cases and technical description provides the initial report for a new designed T-Line Hernia Mesh that could result in a paradigm shift in hernia surgery concepts.

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T-Line Hernia Mesh® is an innovative unique design with mesh extensions that provide 15x the surface area and 275% stronger repair to overcome hernia recurrence.

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This is the first clinical study that demonstrates open ventral hernia repair with the T-Line Hernia Mesh with onlay repair. No surgical site occurrences were observed.

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T-Line Hernia Mesh design and clinical outcomes advance may advance current paradigms in hernia repair surgery mesh fixation and tools

Use of a bioabsorbable mesh in midline laparotomy closure to prevent incisional hernia: randomized controlled trial

INTRODUCTION

The objective was to assess the effectiveness and safety of a bioabsorbable mesh at the time of closure of a midline laparotomy for IH prevention.

MATERIALS AND METHODS

A multicenter, randomized clinical trial including patients undergoing abdominal surgical procedures through a midline laparotomy incision was designed. In the group of mesh (n = 167) the incision was closed using a continuous polydioxanone suture (PDS) plus a bioabsorbable mesh. In the control group (n = 165) a continuous PDS single layer suture was only used. Patients were randomly assigned (1:1) to the two groups. The primary outcome was the incidence of IH at 6, 12 and 24 months. Assessment of IH was done using a CT scan.

RESULTS

At 6 months, the rates of IH were 15.2% and 24.8% in the experimental and control groups, respectively (relative risk [RR] 0.66, 95% confidence interval [CI] 0.38-0.98, P = 0.042). At 12 months, the rate of IH continued to be significantly lower in the experimental group (21.4% vs. 33.1%, P = 0.033), but at 24 months, there were no significant differences between the study groups with a follow-up rate of only 37.5%. The number needed to treat (NNT) was 11 and 9 at 6 and 12 months, respectively.

CONCLUSION

The bioabsorbable mesh significantly prevented IH during the first year. Not reliable conclusions can be drawn across the second year. This may suggest that the any of the closing technique assessed in this study would have a "palliative" transient effect for preventing IH in the long-term.

Complex giant incisional hernia repair with intraperitoneal mesh: A case report

Introduction and importance

An incisional hernia is one of the most frequent complications after abdominal surgery, with an estimated incidence of 2-20% after midline laparotomy. They are often caused by poor wound healing. We present the case of a complex giant incisional hernia that was repaired by implanting an intraperitoneal mesh.

Case presentation

A 63-year-old man with obesity, hypertension, and multiple previous laparotomies, who developed a complex giant incisional hernia (xipho-pubic > 10 cm wide). An open technique repair was decided with the introduction of a large mesh (Parietex ™ Composite) in an intraperitoneal position, covering a 25 × 16 cm hernial ring. After two years, the patient continues to be followed due to a low-output distal enterocutaneous fistula.

Clinical discussion

Currently, there is no technique or approach that has become a gold standard for ventral incisional hernia repair. The introduction of an intraperitoneal mesh with two surfaces by laparotomy is recommended when there are contraindications for laparoscopic surgery, for example in obese patients, and patients with multiple previous laparotomies. However, it has been reported to be a complex technique with an enterocutaneous fistula rate of 0.3-4%.

Conclusion

The introduction of a composite mesh represents an alternative surgical technique for the repair of giant incisional hernias.

Evaluation of the Ventral Hernia Working Group classification for long-term outcome using English Hospital Episode Statistics: a population study

Purpose

The Ventral Hernia Working Group (VHWG) classification of ventral/incisional hernia (IH) was developed by expert consensus in 2010. Subsequently, Kanters et al. have demonstrated the validity of a modified version of the system for predicting short-term outcomes. This study aims to evaluate the modified system for predicting hernia recurrence.

Methods

Patients undergoing IH surgery (defined by OPCS codes) in the England Hospital Episode Statistics (HES) database, from 1997 to 2012, were identified. Baseline demographics at index hernia operation and episodes of further hernia surgery (FHS) were recorded. Risk factors for FHS were identified using cox regression and evaluated against the modified-VHWG grade using receiver-operating characteristics (ROC).

Results

The final analysis included 214,082 index IH operations. Of these, 52.6% were female and mean age was 56.59 (SD15.9). An admission for FHS was found in 8.3% cases (17,714 patients).

Multi-variate cox regression revealed contaminated hernia (p < 0.0001), pre-existing IBD (p < 0.0001) and hernia comorbidity (p = 0.05) to be significantly related to long-term FHS. Classifying patients using these factors, according to the modified-VHWG classification, revealed that compared to Grade 1, the hazard ratio (HR) of FHS increased in Grade 2 (HR 1.19; p < 0.0001) and further increased in Grade 3 (HR 1.79; p < 0.0001). ROC analysis revealed the area under the curve to be 0.73 (95% CI 0.73–0.74).

Conclusion

This analysis demonstrates the broad validity of the modified-VHWG classification in discriminating risk for FHS. Inclusion of pre-existing IBD as a factor defining Grade 2 patients would be recommended. This analysis is limited by the absence of certain factors within the HES database, such as BMI.

Giant pedunculated incisional hernia

Ventral hernia is a common complication of abdominal surgeries, with the incidence of up to 20% in some series. Giant ventral hernia is that with a neck more than 10 cm wide. The loss of abdominal domain due to the shift of viscera into the hernia sac could lead to the complication after surgery. A 54-year-old female presented with a giant pedunculated ventral hernia. She had low tension mesh repair through a transverse suprapubic incision. The surgical repair of giant hernia with mesh has led to reduced complications. The sublay mesh repair method has further reduced the rate of underlay mesh recurrence.

Quantifying fascial tension in ventral hernia repair and component separation

BACKGROUND

Excessive fascial tension is a major cause of ventral hernia recurrence. Although hernias are commonly characterized by area, the tension experienced by fascia is directly proportional to the surrounding tissue stiffness. We demonstrate an accurate and simple technique for intra-operative measurement of fascial closing tension and quantify the decrease in tension following Component Separation (CS).

METHODS

A tensiometer was created using a spring with a known recoil constant (k) and a surgical clamp. Using Hooke's law (Force = kX; X = spring displacement), fascial tension was calculated. This method was first validated on a bench-top model and then applied to the anterior fascia of 4 fresh cadavers (8 hemi-abdomens) over a range of simulated hernia defect sizes. When fascia could no longer reach midline, CS was performed and measures repeated. Tissue stiffness was calculated by plotting defect size versus resulting tension.

RESULTS

Fascial defects ranged from 1- to 18-cm wide with average midline closing tension prior to release 36.1 N (range 17-48) and 8.2 N (range 5-11) after CS, a mean 76% decrease (range 70%-85%). Mean R2 values between defect size and tension for the synthetic and cadaver models were 0.99 (p < 0.01) and 0.91 (p = 0.01; all hemi-abdomen measurements significant). Inter-rater Pearson's correlation consistently found R² values > 0.95 (p < 0.01) for each hemi-abdomen, showing high precision and reproducibility.

CONCLUSION

We have applied a cheap, simple, and precise method to sterilely assess fascial tension during herniorrhaphy and also quantified the decrease in tension following component separation. This technique may be rapidly translated into the operating room with minimal equipment to provide objective data critical for intraoperative decision-making.

Poly-4-hydroxybutyrate (Phasix™) mesh onlay in complex abdominal wall repair

BACKGROUND

Poly-4-hydroxybutyric acid (P4HB, Phasix™) is a biosynthetic polymer that degrades by hydrolysis that can be woven into a mesh for use in soft tissue reinforcement. Herein, we describe our initial experience performing complex abdominal wall repair (CAWR) utilizing component separation and P4HB mesh as onlay reinforcement.

METHODS

All patients undergoing CAWR between June 2014 and May 2017 were followed prospectively for postoperative outcomes. Only those patients who underwent components separation with primary repair of the fascial edges followed by onlay of P4HB mesh were included in this study.

RESULTS

105 patients (52 male, 53 female; mean age 59.2 years, range 22-84) met inclusion criteria. Mean BMI was 29.1 (range 16-48); 52% patients had prior attempted hernia repair, most with multiple medical comorbidities (71% of patients with ASA 3 or greater). 30% of cases were not clean at the time of repair (CDC class 2 or greater). Median follow-up was 36 months (range 9-63). Eighteen patients (17%) developed a hernia recurrence ranging from 2 to 36 months postoperatively. Five (5%) patients developed a localized superficial infection treated with antibiotics, three (2.8%) required re-operation for non-healing wounds, and six (6%) patients developed seroma.

CONCLUSIONS

These data demonstrate a relatively low rate of hernia recurrence, seroma, and other common complications of CAWR in a highly morbid patient population. Importantly, the rate of mesh infection was low and no patients required complete mesh removal, even when placed into a contaminated or infected surgical field.

Do drain tubes help reduce risks of post-operative complications in complex incisional hernia repair (as defined by a recent court ruling)?

BACKGROUND

A recent legal case described in the ANZ Journal of Surgery has sparked significant topical interest in drain tube use in incisional hernia repairs in Australia. This study reviews a single centre experience of drain tube use in incisional hernia repair.

METHODS

Data from online clinical records was collected retrospectively from patients that underwent incisional hernia repair from 1 January 2013 to 31 December 2017. 'Complexity' factors of smoking, obesity and lower midline incision (as identified by the legal case) were also used to stratify groups.

RESULTS

A total of 410 incisional hernia repair cases were identified during the 5-year period. Median length of stay of the non-drain placement group was significantly shorter than that of the drain placement group (2 versus 6 days, P < 0.001). In total, 10.8% of patients with drain suffered from post-op wound infection compared to 3.6% in patients without a drain tube in-situ (P = 0.005). Seroma rates were no different with or without a drain (15.7% versus 16.9% P = 0.78). When stratified by 'complexity', there was a trend towards increased complications when drains were used.

CONCLUSION

Drain tubes were placed in only a small proportion of patients during incisional hernia repairs and were associated with a higher post-operative wound infection rate. When stratified by the 'complexity' factors outlined by the recent legal case, complications in more 'complex' patients may actually increase when a drain tube is used.

Incisional hernia and enterocutaneous fistula in patients with chronic intestinal failure: prevalence and risk factors in a cohort of patients referred to a tertiary centre

AIM

This study aims to determine the prevalence of incisional hernia (IH) and enterocutaneous fistula (ECF) in patients with intestinal failure (IF) referred to a tertiary centre and to identify factors associated with their development.

METHOD

A retrospective case note review was undertaken of a prospectively maintained database of all patients on home parenteral nutrition between 2011 and 2016 at a UK tertiary referral centre for IF. Risk factors were identified using binary logistic regression.

RESULTS

The database search identified 447 patients, of whom 349 (78.1%) had surgery prior to developing IF. Eighty-one (23.2%) patients had an IH and 123 (35.2%) had an ECF at the time of referral. Of these, 51 (14.6%) had both IH and ECF. IH was associated with a high body mass index (P = 0.05), a history of a major surgical complication resulting in IF (P = 0.01), previous emergency surgery (P = 0.04), increasing number of operations (P = 0.02) and surgical site infection (SSI; P = 0.01). ECF was associated with complications relating to earlier surgery. (P ≤ .001), previous treatment with an open abdomen (P = 0.03), SSI (P = 0.001), intra-abdominal collection (P ≤ 0.001) and anastomotic leak (P = 0.02).

CONCLUSION

In this series, patients with IF had a prevalence of IH which was more than double that expected following elective laparotomy (about 10%) and one in three had an ECF. Risk factors for IH and ECF are discussed.

Incidence of wound dehiscence after colorectal cancer surgery: results from a national population-based register for colorectal cancer

BACKGROUND

Patient-related risk factors for wound dehiscence after colorectal surgery remain obscure.

METHODS

All open abdominal procedures for colorectal cancer registered in the Swedish Colorectal Cancer Registry (SCRCR, 5) 2007-2013 were identified. Potential risk factors for wound dehiscence were identified by cross-matching between the SCRCR and the National Patient Register (NPR). The endpoint in this study was reoperation for wound dehiscence registered in either the SCRCR or NPR and patients not reoperated were considered controls.

RESULTS

A total of 30,050 patients were included in the study. In a multivariable regression analysis, age > 70 years, male gender, BMI > 30, history of chronic obstructive pulmonary disease, history of generalised inflammatory disease, and duration of surgery less than 180 min were independently and significantly associated with increased risk for wound dehiscence. A history of diabetes, chronic renal disease, liver cirrhosis, and distant metastases was not associated with wound dehiscence. The hazard ratio for postoperative death was 1.24 for patients who underwent reoperation for wound dehiscence compared with that for controls.

DISCUSSION

Patients reoperated for wound dehiscence face a significantly higher postoperative mortality than those without. Risk factors include male gender, age > 70 years, obesity, history of chronic obstructive pulmonary disease, and history of generalised inflammatory disease. Patients at high risk for developing wound dehiscence may, if identified preoperatively, benefit from active prevention measures implemented in routine surgical practice.

Implementation of the small bites closure of abdominal midline incisions in clinical practice is correlated with a reduction in surgical site infections

BACKGROUND

Small steps wound closure of midline laparotomy has been reported to decrease the incidence of incisional hernia development in two randomized controlled trials. The aim of the present study was to evaluate the effect of implementing the small steps wound closure technique in clinical practice with regards to the development of incisional ventral hernia (IVH) and surgical site infections (SSI) in clinical practice.

METHODS

Implementation of the small steps wound closure technique using the small tissue bites technique as the standard closure technique for abdominal midline incisions in our clinical practice was done in March 2015. For this study, all patients from June 2013 until June 2016 with a midline laparotomy, either long or small in case of specimen extraction in laparoscopic surgery, in either elective or emergency setting were included. Conventional large bite wound closure was compared to small steps wound closure with regards to the development of SSI, IVH as well as burst abdomen.

RESULTS

A total of 327 patients were included. The small steps suture technique was used in 136 (42%) of the patients, whereas the conventional large bites suture technique was used in 191 patients (58%). A total of 54 patients in the large bites group developed SSI (28%) compared to 23 (17%) patients in the small steps group (p = 0.02). A total number of 10 patients (7%) developed IVH in the small steps group compared to 27 patients (14%) in the large bites group (p = 0.08).

CONCLUSION

Implementation of small bites wound closure of abdominal midline incisions in clinical practice was correlated with a reduction in surgical site infections.

Elective and emergent laparotomy closure: The importance of protocolizing the technique

BACKGROUND

Incisional hernias are a frequent complication, and their prevention includes proper closure of the abdominal wall.

METHODS

A prospective study was conducted at a third-level hospital after the introduction of a midline laparotomy closure protocol. An objective measurement of the suture length to incision length ratio was made. and the postoperative results were analyzed.

RESULTS

127 patients were included and 34 of them (26.8%) had received a technically deficient closure. Incisional hernia was described in 20.5% of cases. An improvement in the quality of the abdominal wall closure was demonstrated over time.

CONCLUSION

The abdominal wall closure was deficient in nearly one- quarter of the laparotomies performed at a third-level medical center. A protocol improved the quality of the laparotomy closure.

Integration of Biomechanical and Biological Characterization in the Development of Porous Poly(caprolactone)-Based Membranes for Abdominal Wall Hernia Treatment

Aims. Synthetic meshes are the long-standing choice for the clinical treatment of abdominal wall hernias: the associated long-term complications have stimulated the development of a new generation of bioresorbable prostheses. In this work, polycaprolactone (PCL) porous membranes prepared by solvent casting/porogen leaching of PCL/poly(ethylene glycol) (PEG) blends with different compositions (different PCL/PEG weight ratios and PEG molecular weights) were investigated to be applied in the field. An optimal porous membrane structure was selected based on the evaluation of physicochemical, biomechanical, and in vitro biological properties, compared to a reference commercially available hernia mesh (CMC). Findings. Selected PCL7-2i membranes, derived from PCL/PEG 70/30 (PCL: Mw 70,000-90,000 Da; PEG: 35,000 Da), showed suitable pore size for the application, intermediate surface hydrophilicity, and biomimetic mechanical properties. In vitro cell tests performed on PCL7-2i membranes showed their cytocompatibility, high cell growth during 21 days, a reduced production of proinflammatory IL-6 with respect to CMC, and a significant secretion of collagen type I. Conclusions. PCL7-2i membranes showed biomimetic biomechanical properties and in vitro biological properties similar to or even better than - in the case of anti-inflammatory behavior and collagen production - CMC, a commercially available product, suggesting potentially improved integration in the host tissue.

Incidence of and risk factors for incisional hernia after closure of temporary ileostomy for colorectal malignancy

PURPOSE

Incisional hernia is a major complication after stoma closure and can cause uncomfortable symptoms. In this study, we evaluated the risk factors for hernia formation with the aim of reducing the incidence of incisional hernia.

METHODS

A total of 134 oncology patients underwent closure of a temporary loop ileostomy between May 2004 and December 2013. The incidence of incisional hernia was determined by routine follow-up computed tomography scanning every 6 months. The relationships between patients' characteristics, including age, sex, obesity, diabetes mellitus, surgical site infection, chronic obstructive pulmonary disease, hypertension, hypoalbuminemia, smoking, and presence of a midline hernia and the occurrence of incisional hernia were retrospectively evaluated.

RESULTS

The median follow-up time was 47 months (range 8-130). Hernias occurred in 23.9% of patients (32/134). The median time to detection of hernias was 8 months (range 2-39). The Chi-squared test revealed significant differences in obesity (P = 0.0003), hypertension (P = 0.0057), and incisional hernia history (P = 0.0000) between patients with and without incisional hernia. Multivariable analysis and univariate analysis revealed that hypertension and the presence of midline incisional hernia were risk factors for incisional hernia.

CONCLUSIONS

Hypertension and the presence of a midline incisional hernia were the major risk factors for incisional hernia after loop ileostomy closure. These risk factors can be addressed before planning surgery.

Visceral obesity is a significant risk factor for incisional hernia after laparoscopic colorectal surgery: A single-center review

INTRODUCTION

Although laparoscopic surgery uses relatively small incisions, incisional hernia after surgery is not uncommon. However, the incidence of incisional hernia and its risk factors are not well known. The purpose of our study was to investigate risk factors for incisional hernia after laparoscopic colorectal cancer surgery.

METHODS

The study group consisted of 212 patients who underwent laparoscopic colorectal cancer surgery at Hiroshima Prefectural Hospital between November 2008 and October 2013. Diagnosis of incisional hernia was performed by postoperative CT. The visceral fat area (VFA) and subcutaneous fat area at the level of the umbilicus were calculated using an image analysis system. For statistical analysis, Fisher's exact test or Student's t-test were used for univariate analysis, and logistic regression analysis was used for multivariate analysis. The cut-off value for risk factors was calculated from the receiver-operator curve.

RESULTS

Incisional hernia was observed in 18 patients (8.5%). On univariate analysis, female sex (P = 0.04), older age (P = 0.02), subcutaneous fat area (P < 0.01), VFA (P = 0.02), and BMI >25 kg/m² (P < 0.01) were significant risk factors for incisional hernia. The predictive cut-off values were as follows: age, 72 years; subcutaneous fat area, 110 cm² ; VFA, 110 cm² ; and albumin concentration, 3.9 g/dL. On multivariate analysis, a VFA >110 cm² (P < 0.01) and female sex (P = 0.01) were retained as independent risk factors for incisional hernia.

CONCLUSION

After laparoscopic colorectal cancer surgery, a higher VFA and female sex are independent risk factors for incisional hernia.

Long-term clinical experience with laparoscopic ventral hernia repair using a ParietexTM composite mesh in severely obese and non-severe obese patients: a single center cohort study

Background: The treatment of incisional and ventral hernias is associated with significant complications and recurrences, especially in severely obese patients. Recent studies have shown a reduced rate of surgical site infections and length of hospital stay in severely obese patients undergoing a laparoscopic ventral hernia repair.Aim: This study aims to describe the clinical experience in terms of efficacy and safety with laparoscopic ventral hernia repair using the ParietexTM Composite mesh (Covidien Sofradim Production, Trevoux, France) in severely obese patients (body mass index ≥35) compared with non-severe obese patients in a seven-year single-center cohort.Material and methods: All patients with a primary ventral or incisional hernia admitted to our hospital from 2006 until December 2012 who underwent a laparoscopic repair with the Parietex Composite mesh were included in this study. Pain scores using a numeric rating were collected prospectively 24-48 hours postoperatively. Patient data were retrospectively collected.Results: A total number of 210 patients were included; 173 with a BMI <35 and 37 with a BMI ≥35. Mean follow-up was 31 months. No statistically significant differences were found with regard to operation time, hospital stay, use of analgesics and postoperative complications. The long-term follow up recurrence rate in non-severely obese patients was 13% compared to 16% in severely obese patients (p = .60).Conclusion: Laparoscopic ventral and incisional hernia repair using the Parietex Composite mesh is feasible and safe in severely obese patients compared to non-severely obese patients.

Single-Institution Experience With Component Separation for Ventral Hernia Repair: A Retrospective Review

PURPOSE

In this study, we reviewed our institution's experience using component separation for repair of ventral hernias.

METHODS

This was a retrospective review of all component separations for ventral hernia between July 2009 and December 2015. Recorded data included body mass index (BMI), preoperative albumin, smoking history, comorbidities, additional procedures, length of surgery, hospitalization, recurrence, and postoperative complications.

RESULTS

One hundred ninety-six component separations were performed in the study period. The average patient age was 56 years, and 65.3% of patients were female. The average BMI was 32.6 kg/m; preoperative albumin was 3.59; 18.4% were current smokers; 28.1% were diabetic; and 14.3% had heart disease. Postoperative complications developed in 16.8% of patients. Recurrence developed in 8.7% of patients. Patients who developed a postoperative complication had a higher BMI (P = 0.025) and lower albumin (P = 0.047) compared with patients who did not develop complications. Current smokers were more likely to develop complications (P = 0.008). More than one third of patients had additional procedures at the time of the ventral hernia repair. The addition of a plastic surgery procedure was not associated with an increased risk of developing a complication (P = 0.25). Patients who developed complications had a significantly longer hospital course (P < 0.001) but no difference in total operative time (P = 0.975). Increased number of comorbidities did not statistically correlate with an increased complication rate (P = 0.65) or length of hospital stay (P = 0.43).

CONCLUSIONS

We identified risk factors that increase the likelihood of postoperative complications and length of hospital stay. In addition, this study suggests that more comorbidities and additional procedures at the time of the hernia repair may not have as large of impact on complication risk as previously thought.

The 'AbdoMAN': an artificial abdominal wall simulator for biomechanical studies on laparotomy closure techniques

Purpose

Incisional hernia remains a frequent complication after abdominal surgery associated with significant morbidity and high costs. Animal and clinical studies have exhibited some limitations. The purpose of this study was to develop an artificial human abdominal wall (AW) simulator in order to enable investigations on closure modalities. We hypothesized that a physical model of the human AW would give new insight into commonly used suture techniques representing a substantial complement or alternative to clinical and animal studies.

Methods

The ‘AbdoMAN’ was developed to simulate human AW biomechanics. The ‘AbdoMAN’ capacities include measurement and regulation of intra-abdominal pressure (IAP), generation of IAP peaks as a result of muscle contraction and measurements of AW strain patterns analyzed with 3D image stereo correlation software. Intact synthetic samples were used to test repeatability. A laparotomy closure was then performed on five samples to analyze strain patterns.

Results

The ‘AbdoMAN’ was capable of simulating physiological conditions. AbdoMAN lateral muscles contract at 660 N, leading the IAP to increase up to 74.9 mmHg (range 65.3–88.3). Two strain criteria were used to assess test repeatability. A test with laparotomy closure demonstrated closure testing repeatability.

Conclusions

The ‘AbdoMAN’ reveals as a promising enabling tool for investigating AW surgery-related biomechanics and could become an alternative to animal and clinical studies. 3D image correlation analysis should bring new insights on laparotomy closure research. The next step will consist in evaluating different closure modalities on synthetic, porcine and human AW.

Electronic supplementary material

The online version of this article (doi:10.1007/s10029-017-1615-x) contains supplementary material, which is available to authorized users.

The effect of thymoquinone coating on adhesive properties of polypropylene mesh

BACKGROUND

An incisional hernia is a common complication following abdominal surgery. Polypropylene mesh is frequently used in the repair of such defects and has nearly become the standard surgical treatment modality. Though they are very effective in reducing recurrence, mesh materials exhibit a strong stimulating effect for intraabdominal adhesion. The thymoquinone (TQ) extracted from Nigella sativa seeds has potential medical properties. TQ has anti-inflammatory, antioxidant and antibacterial properties. The aim of this study is to coat polypropylene mesh with TQ in order to investigate the effect of surface modification on intraabdominal adhesions.

METHODS

TQ-coated polypropylene mesh material was tested for cytotoxicity, contact angle, surface spectroscopy, TQ content, sterility, and electron microscopic surface properties. An experimental incisional hernia model was created in study groups, each consisting of 12 female Wistar rats. The defect was closed with uncoated mesh in control group, with polylactic acid (PLA) coated mesh and PLA-TQ coated mesh in study groups. Adhesion scores and histopathologic properties were evaluated after sacrifice on postoperative 21th day.

RESULTS

Granuloma formation, lymphocyte and polymorphonuclear leukocyte infiltration, histiocyte fibroblast and giant cell formation, capillary infiltration, collagen content were significantly reduced in the PLA-TQ coated mesh group (p < 0.05). Though not statistically significant, likely due to the limited number of study animals, adhesion formation was also reduced in the PLA-TQ coated mesh group (p: 0.067).

CONCLUSION

TQ coated mesh is shown to reduce adhesion formation and TQ is a promising coating material for mesh surface modification.

Development of incisional herniation after midline laparotomy

BACKGROUND

Incisional herniation is a common complication after abdominal surgery associated with considerable morbidity. The aim of this study was to determine whether incisional hernia is an early complication, in order to understand better the aetiology of incisional hernia formation.

METHODS

This study involved the secondary analysis of a subset of patients included in a large RCT comparing small and large tissue bites (5 mm every 5 mm, or 1 cm every 1 cm) in patients scheduled to undergo elective abdominal surgery by midline laparotomy. The distance between the rectus abdominis muscles (RAM distance) was measured by standardized ultrasound imaging 1 month and 1 year after surgery. The relationship between the 1-year incidence of incisional hernia and the RAM distance at 1 month was investigated.

RESULTS

Some 219 patients were investigated, 113 in the small-bites and 106 in the large-bites group. At 1 month after surgery the RAM distance was smaller for small bites than for large bites (mean(s.d.) 1·90(1·18) versus 2·39(1·34) cm respectively; P = 0·005). At 1 year, patients with incisional hernia had a longer RAM distance at 1 month than those with no incisional hernia (mean(s.d.) 2·43(1·48) versus 2·03(1·19) cm respectively; relative risk 1·14, 95 per cent c.i. 1·03 to 1·26, P = 0·015).

CONCLUSION

A RAM distance greater than 2 cm at 1 month after midline laparotomy is associated with incisional hernia. Closure with small bites results in a smaller distance between the muscles.

Surgical treatment of large incisional hernias with intraperitoneal composite mesh: a cohort study

PURPOSE

Patients with large incisional hernias have significant morbidity and their management is a challenge for the surgical team because of the large abdominal wall involvement. The choice of surgical technique is still controversial. The purpose of this study is to analyze the predictive factors for recurrence after intraperitoneal mesh repair in patients with large incisional hernias.

METHODS

A retrospective cohort observational study with a prospectively collected database was performed in the Hospital Clinico San Carlos (Madrid, Spain). All consecutive patients operated on from January 2009 to December 2014 with incisional hernia of 10 or more centimeters in its transverse diameter were included. An intraperitoneal repair with a composite mesh fixed with discontinuous absorbable suture and fibrin sealant was performed. Demographic data, comorbidities, and early and long term outcomes were analyzed. The primary outcome was the presence of recurrence.

RESULTS

One hundred and twenty patients were included. Mean age was 63.3 years (SD 12.9) and sex ratio was 1.4:1. Seventy-two patients (60%) were ASA III-IV. Forty-five patients (37.5%) had recurrent ventral hernias. Mean defect size was 14.7 cm (SD 3.21) of width. Overall postoperative morbidity rate was 25%. Median hospital stay was 6 days (IQR 4-8). Recurrence rate was 8.3%, after a median follow-up of 16 months (IQR 10-25). Multivariate analysis showed significant association between ASA III-IV, use of Composix Kugel™ mesh, superficial surgical site infection, and the presence of recurrence.

CONCLUSIONS

The recurrence rate after intraperitoneal mesh repair in patients with large incisional hernias might be associated with ASA III-IV, use of Composix Kugel™ mesh, and superficial surgical site infection.

Feasibility of selective non-operative management for penetrating abdominal trauma in France

INTRODUCTION

In France, non-operative management (NOM) is not the widely accepted treatment for penetrating wounds. The aim of our study was to evaluate the feasibility of NOM for the treatment of penetrating abdominal traumas at 3 hospitals in the Southeast of France.

METHODOLOGY

Our study was multicentric and retroprospective from January, 2010 to September, 2013. Patients presenting with a penetrating abdominal stab wound (SW) or gunshot wound (GSW) were included in the study. Those with signs of acute abdomen or hemodynamic instability had immediate surgery. Patients who were hemodynamically stable had a CT scan with contrast. If no intra-abdominal injury requiring surgery was evident, patients were observed. Criteria evaluated were failed NOM and its morbidity, rate of non-therapeutic procedures (NTP) and their morbidity, length of hospital stay and cost analysis.

RESULTS

One hundred patients were included in the study. One patient died at admission. Twenty-seven were selected for NOM (20 SW and 7 GSW). Morbidity rate was 18%. Failure rate was 7.4% (2 patients) and there were no mortality. Seventy-two patients required operation of which 22 were NTP. In this sub-group, the morbidity rate was 9%. There were no mortality. Median length of hospital stay was 4 days for the NOM group and 5.5 days for group requiring surgery. Cost analysis showed an economic advantage to NOM.

CONCLUSION

Implementation of NOM of penetrating trauma is feasible and safe in France. Indications may be extended even for some GSW. Clinical criteria are clearly defined but CT scan criteria should be better described to improve patient selection. NOM reduced costs and length of hospital stay.

Post-incisional ventral hernia repair in patients undergoing chemotherapy: improving outcomes with biological mesh

Background

Patients requiring ventral hernia (VH) repair during perioperative chemotherapy have a higher risk for post-operative complications. The aim of the study was to perform a case-controlled analysis in patients undergoing chemotherapy who underwent VH repair using biological mesh or synthetic mesh.

Methods

From January 2013 to December 2015, 32 patients, within 8 weeks from chemotherapy administration, were treated electively for VH repair using a biological mesh (BIOMESH). A control group (CG) receiving chemotherapy within the same time interval and treated with synthetic meshes was selected. There were no differences regarding sex, age, American Society of Anesthesiologists (ASA) score III, BMI, and size of the defect. Morbidity, type of complications, and recurrence rate were investigated and compared between the two groups.

Results

In the BIOMESH group, eight patients (25 %) experienced complications. Wound dehiscence occurred in four (12.5 %) patients and was treated conservatively. Only three small seromas not requiring treatment were observed. The CG presented a higher mean Clavien-Dindo complication grade (1.94 ± 0.44 vs 1.63 ± 0.52; p = 0.13) and a higher incidence of wound dehiscence (n = 9/32, 28.1 % vs n = 4/32, 12.5 %; p = 0.11). Five patients developed seroma treated by wound drainage. One patient experienced an intra-abdominal collection treated by percutaneous drainage. At the univariate and multivariate analysis use of traditional mesh, BMI and the ASA III were predictive factors of post-operative complications. Two patients (6.3 %) developed a VH recurrence only in the CG.

Conclusions

Biological meshes could be considered a valid option to improve post-operative short-term outcomes in selected high-risk patients undergoing chemotherapy treated for VH repair.

Physiopathology and clinical considerations of laparoscopic surgery in the elderly

OBJECTIVE

The marked improvements in medical technology and healthcare, lead an increasing number of elderly patients to take advantage of even complex surgical. Recently, laparoscopic surgery has been accepted as a minimally invasive treatment to reduce the morbidity after conventional surgery, and a number of studies have demonstrated the feasibility of laparoscopy with significant advantages also in the elderly. On the other side, the laparoscopic procedure has some drawbacks, including prolonged operation time and impact of carbon dioxide pneumoperitoneum on circulatory and respiratory dynamics. This paper will review the physiopathological implications of laparoscopy, as well as the current literature concerning the most common laparoscopic procedures that are increasingly performed in elderly patients.

MATERIALS AND METHODS

A systematic review of the current literature was performed using the search engines EMBASE and PubMed to identify all studies reporting the physiopathological implications of laparoscopy in the elderly. The MeSH search terms used were "laparoscopy in the elderly", "physiopathology of laparoscopy", and "pneumoperitoneum". Multiple combinations of the keywords and MeSH terms were used with particular reference to elderly patients.

RESULTS

Although laparoscopy is minimally invasive in its dissection techniques, the increased physiologic demands present particular challenges among elderly patients.

CONCLUSIONS

Laparoscopy and its safety in the elderly patients remains a challenge and the evaluation of this approach is therefore mandatory. Although many studies have demonstrated the applicability and advantages of the laparoscopy also in the geriatric population, with low rates of morbidity and mortality, in elderly patients undergoing general surgical procedures the physiologic demands of laparoscopy should be carefully considered.

Experimental study of the characteristics of a novel mesh suture

Background

The failure of sutures to maintain tissue in apposition is well characterized in hernia repairs. A mesh suture designed to facilitate tissue integration into and around the filaments may improve tissue hold and decrease suture pull‐through.

Methods

In vitro, the sutures were compared for resistance to pull‐through in ballistics gel. In vivo, closure of midline laparotomy incisions was done with both sutures in 11 female pigs. Tissue segments were subsequently subjected to mechanical and histological testing.

Results

The mesh suture had tensile characteristics nearly identical to those of 0‐polypropylene suture. Mesh suture demonstrated greater resistance to pull‐through than standard suture (mean(s.d.) 4·27(0·42) versus 2·23(0·48) N; P < 0·001) in vitro. In pigs, the ultimate tensile strength for repaired linea alba at 8 days was higher with mesh suture (320(57) versus 160(56) N; P < 0·001), as was the work to failure (24·6(14·2) versus 7·3(3·7) J; P < 0·001) and elasticity (128(9) versus 72(7) N/cm; P < 0·001) in comparison with 0‐polypropylene suture. Histological examination at 8 and 90 days showed complete tissue integration of the mesh suture.

Conclusion

The novel mesh suture structure increased the strength of early wound healing in an experimental model.

Contraction of abdominal wall muscles influences size and occurrence of incisional hernia

BACKGROUND

Incisional hernias are a complication in 10% of all open abdominal operations and can result in substantial morbidity. The purpose of this study was to determine whether inhibiting abdominal muscle contraction influences incisional hernia formation during the fascial healing after laparotomy. We hypothesized that decreasing the deformation of the abdominal musculature would decrease the size or occurrence of an incisional hernia.

METHODS

Using an established rat model for incisional hernia, a laparotomy through the linea alba was closed with 1 mid-incision, fast-absorbing suture. Three groups were compared: a sham group (sham; n = 6) received no laparotomy, and the saline hernia (SH; n = 6) and Botox hernia (BH; n = 6) groups were treated once with equal volumes of saline or botulinum toxin (Botox, Allergan) before the incomplete laparotomy closure. On postoperative day 14, the abdominal wall was examined for herniation and adhesions, and contractile forces were measured for abdominal wall muscles.

RESULTS

No hernias developed in the sham rats. Rostral hernias developed in all SH and BH rats. Caudal hernias developed in all SH rats, but in only 50% of the BH rats. Rostral hernias in the BH group were 35% shorter and 43% narrower compared with those in the SH group (P < .05). The BH group had weaker abdominal muscles compared with the sham and SH groups (P < .05).

CONCLUSION

In our rat model, partial paralysis of abdominal muscles decreases the number and size of incisional hernias. These results suggest that contractions of the abdominal wall muscle play a role in the pathophysiology of the formation of incisional hernias.

In vivo evaluation of a novel mesh suture design for abdominal wall closure

Supplemental Digital Content is available in the text.

Background:

The authors present a novel mesh suture design aimed at minimizing the early laparotomy dehiscence that drives ventral hernia formation. The authors hypothesized that modulation of the suture-tissue interface through use of a macroporous structure and increased aspect ratio (width-to-height ratio) would decrease the suture pull-through that leads to laparotomy dehiscence.

Methods:

Incisional hernias were produced in 30 rats according to an established hernia model. The rat hernias were randomized to repair with either two 5-0 polypropylene sutures or two midweight polypropylene mesh sutures. Standardized photographs were taken before repair and 1 month after repair. Edge-detection software was used to define the border of the hernia defect and calculate the defect area. Histologic analysis was performed on all mesh suture specimens.

Results:

Seventeen hernias were repaired with mesh sutures and 13 were repaired with conventional sutures. The mean area of the recurrent defects following repair with mesh suture was 177.8 ± 27.1 mm2, compared with 267.3 ± 34.1 mm2 following conventional suture repair. This correlated to a 57.4 percent reduction in defect area after mesh suture repair, compared with a 10.1 percent increase in defect area following conventional suture repair (p < 0.0007). None (zero of 34) of the mesh sutures pulled through the surrounding tissue, whereas 65 percent (17 of 26) of the conventional sutures demonstrated complete pull-through. Excellent fibrocollagenous ingrowth was observed in 13 of 17 mesh suture specimens.

Conclusions:

Mesh sutures better resisted suture pull-through than conventional polypropylene sutures. The design elements of mesh sutures may prevent early laparotomy dehiscence by more evenly distributing distracting forces at the suture-tissue interface and permitting tissue incorporation of the suture itself.

Age, Preoperative Subcutaneous Fat Area, and Open Laparotomy are Risk Factors for Incisional Hernia following Colorectal Cancer Surgery

BACKGROUND

Although incisional hernia (IH) is a common complication of abdominal surgery, the incidence rate and risk factors are not well known. The objectives of this study are to determine the incidence rate of IH following colorectal cancer surgery and to describe the associated risk factors.

METHODS

Between 2005 and 2010, patients who underwent surgery to treat colorectal cancer were examined. The diagnosis of IH was performed by CT scan, and the visceral fat area (VFA) and subcutaneous fat area (SFA) at the level of the umbilicus were calculated using a 3D-image analysis system. Survival analysis was used to assess the incidence and risk factors of IH.

RESULTS

A total of 626 patients (326 open, 300 laparoscopic) were included in this study, with median follow-up of 54 (range 2-97) months. Forty patients were diagnosed with postoperative IH, and the cumulative, 5-year incidence of IH was 7.3 %. Univariate analysis revealed that age, body mass index, waist circumference, hip circumference, open laparotomy, wound infection, VFA, and SFA were significantly associated with incidence of IH. Multivariate analysis revealed that age [hazard ratio (HR) 1.043 (1.005-1.083), p = 0.027], open laparotomy [HR 4.410 (1.018-19.095), p = 0.047], and SFA [HR 1.013 (1.004-1.022), p = 0.005] were significant risk factors for developing IH.

CONCLUSIONS

Higher age and SFA, along with open surgery, are risk factors for developing IH.

Chemotherapy does not adversely impact outcome following post-incisional hernia repair with biomaterial mesh

Background

Patients receiving chemotherapy are at increased risk for developing recurrent or post‐incisional hernias (PIH). Biological materials are an alternative to synthetic mesh in contaminated fields. The impact of chemotherapy on biomaterial tissue ingrowth and integration has not been well studied.

Methods

From 2008 to 2011 patients who underwent PIH repair with biomaterial mesh (Biodesign®) were selected. Patients were divided into two groups: those receiving chemotherapy (CT) and those not receiving chemotherapy (NCT).

Results

Forty‐five patients were identified, 28 (62%) in the NCT group and 17 (38%) in the CT group. Median follow up for NCT and CT groups were 27 and 17 months, respectively. A total of 9/45 (20%) surgical site infections (SSI) were diagnosed, with 6/28 (21%) in the NCT and 3/17 (18%) in the CT group (P = 0.53). Seroma formation was seen in 5/28 (18%) of NCT patients and 4/17 (23%) in CT group (P = 0.46). Overall hernia recurrence rate was 22%, and the rates of recurrence were similar among the CT 3/17 (18%) and NCT 7/28 (25%) groups (P = 0.42).

Conclusion

The use of perioperative chemotherapy did not increase the rate of wound complications following PIH repair with biologic mesh in this group of patients. J. Surg. Oncol. 2015 111:725–728. © 2015 The Authors. Journal of Surgical Oncology Published by Wiley Periodicals, Inc.

The effect of relaparotomy timing on wound healing in an animal model

BACKGROUND

The effect of the timing of the second laparotomy on wound healing is not clear. In an experimental study in rats, we aimed to investigate the effect of timing on wound healing after reoperations on the same surgical site.

MATERIAL AND METHODS

Forty-eight rats were divided into four groups. The control group (GC) didn't have another laparotomy whereas the relaparotomies on the same surgical site were performed either on the 3rd, 15th or the 30th postoperative days in the three study groups (G3, G15, G30 respectively). The midline tension pressure, collagen types I, III and, histological analysis were performed from the specimens in order to assess the wound healing and strength.

RESULTS

The tensile strength was the highest in GC and decreased gradually in G3, G15 and G30, the difference between the groups did not reach statistical significance. Higher collagen levels, increased fibrosis, and large defects were observed in relaparotomy groups than CG. The musculoaponeurotic gap was shortest in GC when compared to other three relaparotomy groups (P < 0.001) and, it was the longest in G30 (P = 0.004 between G3 and G30).

CONCLUSIONS

Although non-statistically significant the gradual decrease in the tensile strength and the statistically significant increase in the musculoaponeurotic gap with time point out the importance of the timing of relaparotomy in the healing process. Early relaparotomies do not disrupt the healing process as much as relaparotomy performed later.

Incisional reinforcement in high-risk patients

Hernia formation after surgical procedures continues to be an important cause of surgical morbidity. Incisional reinforcement at the time of the initial operation has been used in some patient populations to reduce the risk of subsequent hernia formation. In this article, reinforcement techniques in different surgical wounds are examined to identify situations in which hernia formation may be prevented. Mesh use for midline closure, pelvic floor reconstruction, and stoma site reinforcement is discussed. Additionally, the use of retention sutures, closure of the open abdomen, and reinforcement after component separation are examined using current literature. Although existing studies do not support the routine use of mesh reinforcement for all surgical incisions, certain patient populations appear to benefit from reinforcement with lower rates of subsequent hernia formation. The identification and characterization of these groups will guide the future use of mesh reinforcement in surgical incisions.

Effectiveness of porcine dermal collagen in giant hernia closure in patients with deleterious fascia constitution after orthotopic liver transplantation

Incisional hernias (IHs) occur universally after orthotopic liver transplantation (OLT). This study aimed to investigate the effectiveness of porcine dermal collagen (PDC) as a closing aid in giant hernias after OLT in a prospective trial. If direct closure (DC) was not feasible due to the hernia size and abdominal wall constitution, a PDC mesh was implanted. All patients from the PDC and DC groups were followed prospectively for 24 months. IH recurrence rates served as the primary endpoint, and the development of infections and wound healing disorders served as the secondary endpoints. Recurrence rate was 21% (4/19) in DC patients and 12% (2/16) in PDC patients (P = 0.045). Implant site infections occurred in five of PDC and one of DC patients (P < 0.05). All of them were managed with antibiotics; two of the PDC patients required surgical drainage. Histological analysis of PDC mesh biopsies indicated good angiogenesis and integration of the PDC into the abdominal wall. PDC was effective in our study for incisional hernia repair, and our results compared favourably with those of patients in whom direct hernia closure was feasible.

One-year follow-up after open abdomen therapy with vacuum-assisted wound closure and mesh-mediated fascial traction

BACKGROUND

Open abdomen (OA) therapy frequently results in a giant planned ventral hernia. Vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) enables delayed primary fascial closure in most patients, even after prolonged OA treatment. Our aim was to study the incidence of hernia and abdominal wall discomfort 1 year after abdominal closure.

METHODS

A prospective multicenter cohort study of 111 patients undergoing OA/VAWCM was performed during 2006-2009. Surviving patients underwent clinical examination, computed tomography (CT), and chart review at 1 year. Incisional and parastomal hernias and abdominal wall symptoms were noted.

RESULTS

The median age for the 70 surviving patients was 68 years, 77 % of whom were male. Indications for OA were visceral pathology (n = 40), vascular pathology (n = 22), or trauma (n = 8). Median length of OA therapy was 14 days. Among 64 survivors who had delayed primary fascial closure, 23 (36 %) had a clinically detectable hernia and another 19 (30 %) had hernias that were detected on CT (n = 18) or at laparotomy (n = 1). Symptomatic hernias were found in 14 (22 %), 7 of them underwent repair. The median hernia widths in symptomatic and asymptomatic patients were 7.3 and 4.8 cm, respectively (p = 0.031) with median areas of 81.0 and 42.9 cm(2), respectively (p = 0.025). Of 31 patients with a stoma, 18 (58 %) had a parastomal hernia. Parastomal hernia (odds ratio 8.9; 95 % confidence interval 1.2-68.8) was the only independent factor associated with an incisional hernia.

CONCLUSIONS

Incisional hernia incidence 1 year after OA therapy with VAWCM was high. Most hernias were small and asymptomatic, unlike the giant planned ventral hernias of the past.