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Fortelny RH, Dietz U. [Incisional hernias: epidemiology, evidence and guidelines]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:3-9. [PMID: 38078933 PMCID: PMC10781829 DOI: 10.1007/s00104-023-01999-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/06/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND From an epidemiological point of view, one third of the population in industrialized countries will undergo abdominal surgery during their lifetime. Depending on the degree of patient-related and procedure-related risks, the occurrence of incisional hernias is associated in a range of up to 30% at 2‑year follow-up and even up to 60% at 5 years. In addition to influencing comorbidities, the type of surgical approach and closure technique are of critical importance. OBJECTIVE To present a descriptive evidence-based recommendation for abdominal wall closure and prophylactic mesh augmentation. MATERIAL AND METHODS A concise summary was prepared incorporating the current literature and existing guidelines. RESULTS According to recent studies the recognized risk for the occurrence of incisional hernias in the presence of obesity and abdominal aortic diseases also applies to patients undergoing colorectal surgery and the presence of diastasis recti abdominis. Based on high-level published data, the short stitch technique for midline laparotomy in the elective setting has a high level of evidence to be a standard procedure. Patients with an increased risk profile should receive prophylactic mesh reinforcement, either onlay or sublay, in addition to the short stitch technique. In emergency laparotomy, the individual risk of infection with respect to the closure technique used must be included. CONCLUSION The avoidance of incisional hernias is primarily achieved by the minimally invasive access for laparoscopy. For closure of the most commonly used midline approach, the short stitch technique and, in the case of existing risk factors, additionally mesh augmentation are recommended.
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Affiliation(s)
- R H Fortelny
- Lehrstuhl für Allgemeinchirurgie, Medizinische Fakultät, Sigmund Freud PrivatUniversität Wien, Freudplatz 3, 1020, Wien, Österreich.
| | - U Dietz
- Chirurgie, Kantonsspital Olten, Olten, Schweiz
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Kobayashi T, Miki H, Yamamoto N, Hori S, Hatta M, Hashimoto Y, Mukaide H, Yamasaki M, Inoue K, Sekimoto M. Retrospective study of an incisional hernia after laparoscopic colectomy for colorectal cancer. BMC Surg 2023; 23:314. [PMID: 37845691 PMCID: PMC10580507 DOI: 10.1186/s12893-023-02229-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 10/11/2023] [Indexed: 10/18/2023] Open
Abstract
PURPOSE This study aimed to examine the incidence of incisional hernia (IH) in elective laparoscopic colorectal surgery (LC) using regulated computed tomography (CT) images at intervals every 6 months. METHODS We retrospectively examined the diagnosis of IH in patients who underwent LC for colorectal cancer at Kansai Medical University Hospital from January 2014 to August 2018. The diagnosis of IH was defined as loss of continuity of the fascia in the axial CT images. RESULTS 470 patients were included in the analysis. IH was diagnosed in 47 cases at 1 year after LC. The IH size was 7.8 cm2 [1.3-55.6]. In total, 38 patients with IH underwent CT examination 6 months after LC, and 37 were already diagnosed with IH. The IH size was 4.1 cm2 [0-58.9]. The IH size increased in 17 cases between 6 months and 1 year postoperatively, and in 1 case, a new IH occurred. 47%(18/38) of them continued to grow until 1 year after LC. A multivariate analysis was performed on the risk of IH occurrence. SSI was most significantly associated with IH occurrence (OR:5.28 [2.14-13.05], p = 0.0003). CONCLUSION IH occurred in 10% and 7.9% at 1 year and 6 months after LC. By examining CT images taken for the postoperative surveillance of colorectal cancer, we were able to investigate the occurrence of IH in detail.
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Affiliation(s)
- Toshinori Kobayashi
- Department of Surgery, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Hisanori Miki
- Department of Surgery, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Nobuyuki Yamamoto
- Department of Surgery, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Soushi Hori
- Department of Surgery, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Masahiko Hatta
- Department of Surgery, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Yuki Hashimoto
- Department of Surgery, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Hiromi Mukaide
- Department of Surgery, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Makoto Yamasaki
- Department of Surgery, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Kentaro Inoue
- Department of Surgery, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Mitsugu Sekimoto
- Department of Surgery, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 573-1010, Japan.
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Jakob MO, Brüggemann A, Moser N, Candinas D, Beldi G, Haltmeier T. Predictors for surgical site infection in patients undergoing therapeutic or prophylactic intra-abdominal onlay mesh (IPOM) implantation in clean and contaminated surgical fields. Surg Endosc 2023; 37:6885-6894. [PMID: 37311892 PMCID: PMC10462502 DOI: 10.1007/s00464-023-10144-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 05/16/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Prophylactic intra-abdominal onlay mesh (IPOM) implantation has been shown to reduce the rate of fascial dehiscence and incisional hernia. However, surgical site infection (SSI) in presence of an IPOM remains a concern. The aim of this study was to assess predictors for SSI following IPOM placement in hernia and non-hernia abdominal surgery in clean and contaminated surgical fields. METHODS Observational study including patients undergoing IPOM placement at a Swiss tertiary care hospital 2007-2016. IPOM implantation was performed in hernia and non-hernia elective and emergency abdominal surgery, including contaminated and infected surgical fields. The incidence of SSI was prospectively assessed by Swissnoso according to CDC criteria. The effect of disease- and procedure-related factors on SSI was assessed in multivariable regression analysis, adjusting for patient-related factors. RESULTS A total of 1072 IPOM implantations were performed. Laparoscopy was performed in 415 patients (38.7%), laparotomy in 657 patients (61.3%). SSI occurred in 172 patients (16.0%). Superficial, deep, and organ space SSI were found in 77 (7.2%), 26 (2.4%), and 69 (6.4%) patients, respectively. Multivariable analysis revealed emergency hospitalization (OR 1.787, p = 0.006), previous laparotomy (1.745, p = 0.029), duration of operation (OR 1.193, p < 0.001), laparotomy (OR 6.167, p < 0.001), bariatric (OR 4.641, p < 0.001), colorectal (OR 1.941, p = 0.001), and emergency (OR 2.510, p < 0.001) surgery, wound class ≥ 3 (OR 3.878, p < 0.001), and non-polypropylene mesh (OR 1.818, p = 0.003) as independent predictors for SSI. Hernia surgery was independently associated with a lower risk for SSI (OR 0.165, p < 0.001). CONCLUSION This study revealed emergency hospitalization, previous laparotomy, duration of operation, laparotomy, as well as bariatric, colorectal, and emergency surgery, abdominal contamination or infection, and usage of non-polypropylene mesh as independent predictors for SSI. In contrast, hernia surgery was associated with a lower risk for SSI. The knowledge of these predictors will help to balance benefits of IPOM implantation against the risk for SSI.
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Affiliation(s)
- Manuel O Jakob
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Microbiology, Infectious Diseases and Immunology (I-MIDI), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Adriana Brüggemann
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nina Moser
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Candinas
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Guido Beldi
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Haltmeier
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Ulutas ME, Sahin A, Simsek G, Sekmenli N, Kilinc A, Arslan K, Eryilmaz MA, Kartal A. Does onlay mesh placement in emergency laparotomy prevent incisional hernia? A prospective randomized double-blind study. Hernia 2023:10.1007/s10029-023-02770-7. [PMID: 36967415 DOI: 10.1007/s10029-023-02770-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 03/09/2023] [Indexed: 03/28/2023]
Abstract
PURPOSE The objective of this study is to assess the effectiveness and safety of onlay mesh closure of emergency midline laparotomy to prevent incisional hernia. METHODS This is a prospective randomized double-blind study and was carried out in the General Surgery Clinic, Konya City Hospital, from August 1, 2020 to August, 1, 2021. The study included 108 patients who were randomly grouped in 2 groups: patients with conventional abdominal closure and closure using additional onlay mesh (1:1). The follow-up period was for a year. The primary outcome was the incidence of incisional hernia and secondary outcomes were clinical data like complications, hospital length of stay, re-operations. RESULTS It was observed that incisional hernia was present in 14 patients (27.4%) in conventional abdominal closure group and was in 2 patients using mesh (4%), (p = 0.001). Clavien-Dindo 3B complications were in rise in conventional closure group (p = 0.02). Of all complications, burst abdomen was significantly more common in conventional closure group (p = 0.04). The rate of surgically treated complications were higher in conventional closure group (p = 0.02). Clavien-Dindo 3A complications were more common in patients with contaminated wound in mesh group (p = 0.02). CONCLUSION The use of mesh while closing the abdomen in emergency midline laparotomy reduces the risk of incisional hernia. Thus, to lower the risks of incisional hernia and its complications, prophylactic mesh can be used in high-risk patients.
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Christopher AN, Sanchez J, Fischer JP. A Biomechanical Analysis of Prophylactic Mesh Reinforced Porcine Laparotomy Incisions. J Surg Res 2022; 278:196-205. [PMID: 35617785 PMCID: PMC9580392 DOI: 10.1016/j.jss.2022.04.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 03/10/2022] [Accepted: 04/08/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Research indicates that prophylactic mesh may help prevent incisional hernia after laparotomy, but best practice patterns in these situations are still evolving. Here, we compare the failure loads (FLs) and biomechanical stiffness (BMS) of 35 porcine abdominal wall laparotomy incisions reinforced with meshes of various widths and fixation distances using biomechanical testing. METHODS In each specimen, a 10-cm incision was made and closed using continuous 1-0 Maxon suture. Specimens were randomized to mesh width (none, 2.5 cm, 3 cm, 4 cm, 6 cm, 8 cm) and tack separation (1.5 cm, 2 cm apart) and the meshes secured in an onlay fashion. Cyclic loads oscillating from 15 N to 140 N were applied to simulate abdominal wall stress, and the specimens subsequently loaded to failure. FLs (N) and BMS (N/mm) were comparatively analyzed. RESULTS All specimens failed via suture pull-through. FLs and BMS were lowest in specimens with suture-only (421.43 N; 11.69 N/mm). FLs and BMS were significantly higher in 4-cm mesh specimens (567.51 N) than those with suture, 2.5-cm, and 3.0-cm mesh (all P < 0.05). FLs in specimens with a greater number of tacks were consistently higher in meshes of similar sizes, although these did not reach significance. CONCLUSIONS A 4-cm mesh reenforcement was superior to suture-only and smaller meshes at preserving strength in laparotomy closure in a porcine model but larger meshes (6 cm, 8 cm) did not provide an additional benefit. Meshes with more fixation points may be advantageous, but additional data are needed to make definitive conclusions.
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Affiliation(s)
- Adrienne N Christopher
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
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Clementi M, Pietroletti R, Carletti F, Sista F, Grasso A, Fiasca F, Cappelli S, Balla A, Rizza V, Ciarrocchi A, Guadagni S. Colostomy Reversal following Hartmann’s Procedure: The Importance of Timing in Short- and Long-Term Complications: A Retrospective Multicentric Study. J Clin Med 2022; 11:jcm11154388. [PMID: 35956003 PMCID: PMC9369122 DOI: 10.3390/jcm11154388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/23/2022] [Accepted: 07/23/2022] [Indexed: 01/19/2023] Open
Abstract
The restoration of bowel continuity following Hartmann’s Procedure (HP) has been reported hitherto with high morbidity and mortality rates. No clear guidelines exist about timing in Hartmann’s Reversal (HR), the literature data being conflicting. We have sought to investigate the effect of the interval time between HP and HR in short- and long-term HR outcomes through a retrospective study based on consecutive patients undergoing HR between 2009 and 2017 in two regional hospitals in Italy. Demographic characteristics, comorbidities, intra- and post-operative data, as well as early complications, were recorded. Long-term data were collected on the surgical site occurrences of Incisional Ventral Hernia (IVH). One hundred and five patients were recruited for the study. Late HR, female gender, and long operating time were related to the highest incidence of peri-operative complications. Patients who developed IVH had undergone HR at significantly shorter times and had a higher Body Mass Index (BMI). The timing of HR seems to be an important variable linked to the onset of early and late post-operative complications. The patients submitted to early HR show a significantly lower complication rate but, at the same time, a higher rate of IVH incidence after restorative surgery. These data, in our opinion, reflect the need for planning, where possible, an early restoration of bowel continuity after HP.
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Affiliation(s)
- Marco Clementi
- General Surgical Unit, San Salvatore Hospital, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Via Vetoio, 67100 Coppito, Italy; (F.C.); (A.G.); (S.G.)
- Correspondence: ; Tel.: +39-33-5538-6225
| | - Renato Pietroletti
- Unit of Proctology and Colorectal Surgery, Val Vibrata-Sant’Omero Hospital, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Via Vetoio, 67100 Coppito, Italy; (R.P.); (V.R.)
| | - Filippo Carletti
- General Surgical Unit, San Salvatore Hospital, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Via Vetoio, 67100 Coppito, Italy; (F.C.); (A.G.); (S.G.)
| | - Federico Sista
- Hepatic Pancreatic and Biliary Surgical Unit, San Salvatore Hospital, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Via Vetoio, 67100 Coppito, Italy;
| | - Antonella Grasso
- General Surgical Unit, San Salvatore Hospital, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Via Vetoio, 67100 Coppito, Italy; (F.C.); (A.G.); (S.G.)
| | - Fabiana Fiasca
- Public Health Unit, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Via Vetoio, 67100 Coppito, Italy;
| | - Sonia Cappelli
- Department of Surgery, IRCCS Regina Elena National Cancer Institute, 00144 Rome, Italy;
| | - Andrea Balla
- General and Minimally Invasive Surgical Unit, San Paolo Hospital, 00053 Civitavecchia, Italy;
| | - Vinicio Rizza
- Unit of Proctology and Colorectal Surgery, Val Vibrata-Sant’Omero Hospital, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Via Vetoio, 67100 Coppito, Italy; (R.P.); (V.R.)
| | - Andrea Ciarrocchi
- General Surgical Unit, Maria ss. dello Splendore Hospital, 67021 Giulianova, Italy;
| | - Stefano Guadagni
- General Surgical Unit, San Salvatore Hospital, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Via Vetoio, 67100 Coppito, Italy; (F.C.); (A.G.); (S.G.)
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7
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Kumar VV, Verma A, Thakur DS, Somashekar U, Kothari R, Sharma D. Prophylactic mesh placement in emergency midline laparotomy for intestinal perforation peritonitis: An appeal for caution. Trop Doct 2022; 52:522-525. [PMID: 35747937 DOI: 10.1177/00494755221110831] [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: 11/16/2022]
Abstract
Prophylactic mesh placement (PMP) is increasingly being used to reduce the incidence of incisional hernia after routine and emergency midline laparotomy (EML). However, such studies are not available for EMLs done solely for intestinal perforation. Patients who underwent non-absorbable PMP during EML for intestinal perforation (Group A, 15 patients) were compared with those who had a conventional abdominal wall closure (Group B, 20 patients). The incidence of wound dehiscence was significantly higher in Group A, while surgical site infection (SSI), and incisional hernia were similar in both groups. Mesh explantation was needed in half the cases. A prophylactically placed non-absorbable mesh in patients undergoing EML for intestinal perforation is associated with significantly higher rates of wound dehiscence and of mesh explantation and therefore, routine use of such a mesh appears not to be justified.
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Affiliation(s)
- Vivek Vijay Kumar
- Department of Surgery, 534313NSCB Government Medical College, Jabalpur, India
| | - Amrendra Verma
- Department of Surgery, 534313NSCB Government Medical College, Jabalpur, India
| | - Dileep Singh Thakur
- Department of Surgery, 534313NSCB Government Medical College, Jabalpur, India
| | - Uday Somashekar
- Department of Surgery, 534313NSCB Government Medical College, Jabalpur, India
| | - Reena Kothari
- Department of Surgery, 534313NSCB Government Medical College, Jabalpur, India
| | - Dhananjaya Sharma
- Department of Surgery, 534313NSCB Government Medical College, Jabalpur, India
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Coccolini F, Tarasconi A, Petracca GL, Perrone G, Giuffrida M, Disisto C, Sartelli M, Carcoforo P, Ansaloni L, Catena F. PROPHYlactic Implantation of BIOlogic Mesh in peritonitis (PROPHYBIOM): a prospective multicentric randomized controlled trial. Trials 2022; 23:198. [PMID: 35246206 PMCID: PMC8895107 DOI: 10.1186/s13063-022-06103-4] [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: 04/19/2021] [Accepted: 02/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients undergoing emergency surgery for peritonitis are at increased risk of abdominal wall-related complications. In patients with peritonitis, the risk of incisional hernia (IH) is extremely elevated. The evaluation of quality of life of patients with incisional hernia showed lower mean scores on physical components of health-related quality of life and body image. Furthermore, the arise of a post-operative abdominal wall complication (i.e., wound dehiscence, evisceration and IH) greatly increases morbidity and mortality rates and prolongs the hospitalization. METHODS The present study aims to evaluate the efficacy of the use of a swine dermal collagen prosthesis implanted preperitoneally as a prophylactic procedure in urgency/emergency setting against abdominal wall complications in patients operated with contaminated/infected field in peritonitis. The sample size was defined in 90 patients divided in two arms (prosthesis positioning versus normal wall abdominal closure). The follow-up will be performed at 3, 6, and 12 months after surgery. The percentage of incisional hernias, wound infections, and adverse events will be investigated by physical examination and ultrasound. DISCUSSION The objective is to evaluate the possibility to reduce the incisional hernia rate in patients undergoing urgent/emergent laparotomy in contaminated/infected field with peritonitis by using swine dermal collagen prosthesis preperitoneal positioning as a prophylactic procedure. TRIAL REGISTRATION ClinicalTrials.gov NCT04681326. Registered (retrospectively after first patient recruited) on 23 December 2020.
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Affiliation(s)
- F Coccolini
- General Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - A Tarasconi
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - G L Petracca
- Emergency Surgery Department, Parma University Hospital, Parma, Italy.
| | - G Perrone
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - M Giuffrida
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - C Disisto
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - M Sartelli
- Department of Surgery, Macerata Hospital, Macerata, Italy
| | - P Carcoforo
- Department of Surgery, S. Anna University Hospital and University of Ferrara, Ferrara, Italy
| | - L Ansaloni
- General Surgery, Pavia University Hospital, Pavia, Italy
| | - F Catena
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
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Albendary M, Mohamedahmed AYY, Alamin A, Rout S, George A, Zaman S. Efficacy and safety of mesh closure in preventing wound failure following emergency laparotomy: a systematic review and meta-analysis. Langenbecks Arch Surg 2022; 407:1333-1344. [PMID: 35020082 DOI: 10.1007/s00423-021-02421-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 12/20/2021] [Indexed: 11/29/2022]
Abstract
AIMS To evaluate comparative outcomes of emergency laparotomy closure with and without prophylactic mesh. METHODS A systematic review was performed via literature databases: PubMed, Cochrane Library, Science Direct, and Google Scholar. Studies were examined for eligibility and included if they compared prophylactic mesh closure to the conventional laparotomy closure following emergency abdominal surgery. Both acute wound failure and incisional hernia (IH) occurence were our primary outcomes. Secondary outcomes included surgical site infection (SSI), seroma/hematoma formation, Clavien-Dindo complications (score ≥ 3), total operative time, and length of hospital stay (LOS). RESULTS Two randomised controlled trials (RCTs) and four comparative studies with a total of 817 patients met the inclusion criteria. Overall acute wound failure and incisional hernia rate was significantly lower in the mesh group compared to non-mesh group (odd ratio (OR) 0.23, p = 0.002) and (OR 0.21, p = 0.00001), respectively. There was no significant difference between the two groups regarding the following outcomes: total operative time (mean difference (MD) 21.44, p = 0.15), SSI (OR 1.47, p = 0.06), seroma/haematoma formation (OR 2.74, p = 0.07), grade ≥ 3 Clavien-Dindo complications (OR 2.39, p = 0.28), and LOS (MD 0.26, p = 0.84). CONCLUSION The current evidence for the use of prophylactic mesh in emergency laparotomy is diverse and obscure. Although the data trends towards a reduction in the incidence of IH, a reliable conclusion requires further high-quality RCTs to fully assess the efficacy and safety of mesh use in an emergency setting.
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Affiliation(s)
- Mohamed Albendary
- Department of General Surgery, Sandwell and West, Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Ali Yasen Y Mohamedahmed
- Department of General Surgery, Sandwell and West, Birmingham Hospitals NHS Trust, Birmingham, UK.
| | | | - Shantanu Rout
- Department of General Surgery, Sandwell and West, Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Anil George
- Department of General Surgery, Sandwell and West, Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Shafquat Zaman
- Department of General Surgery, Sandwell and West, Birmingham Hospitals NHS Trust, Birmingham, UK
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Mäkäräinen E, Tolonen M, Sallinen V, Mentula P, Leppäniemi A, Ahonen-Siirtola M, Saarnio J, Ohtonen P, Muysoms F, Rautio T. OUP accepted manuscript. BJS Open 2022; 6:6526454. [PMID: 35143628 PMCID: PMC8830749 DOI: 10.1093/bjsopen/zrab142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Despite the fact that emergency midline laparotomy is a risk factor for an incisional hernia, active research on hernia prevention in emergency settings is lacking. Different kinds of meshes and mesh positions have been studied in elective abdominal surgery, but no randomized controlled trials in emergency settings have been published thus far. Method The PREEMER trial (registration number NCT04311788) is a multicentre, patient- and assessor-blinded, randomized controlled trial to be conducted in six hospitals in Finland. A total of 244 patients will be randomized at a 1 : 1 ratio to either the retrorectus mesh group, featuring a self-gripping prophylactic mesh, or to the no mesh (control) group, both closed by small-stitch 4 : 1 closure with continuous slowly absorbable monofilament suturing. The primary outcome of the PREEMER trial is the incidence of incisional hernia 2 years after surgery, which will be detected clinically and/or radiologically. Secondary outcomes are the Comprehensive Complication Index score, incidence of surgical-site infections and fascial dehiscence within 30 days of surgery; the incisional hernia repair rate and mesh- or hernia-related reoperations within the 2- and 5-year follow-ups; the incidence of incisional hernia within the 5-year follow-up; and quality of life measured by RAND-36, the Activities Assessment Scale and the PROMIS questionnaire within 30 days and 2 and 5 years from surgery. Additionally, health–economic explorative measures will be explored. Conclusion The PREEMER trial will provide level 1 evidence on incisional hernia prevention in an emergency setting. Registration number NCT04311788 (http://www.clinicaltrials.gov). Registered 7 March 2020.
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Affiliation(s)
- Elisa Mäkäräinen
- Correspondence to: Elisa Mäkäräinen, Oulu University Hospital, PL 29, 90029 OYS, Oulu, Finland (e-mail: )
| | - Matti Tolonen
- Department of Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Ville Sallinen
- Department of Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Panu Mentula
- Department of Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Ari Leppäniemi
- Department of Surgery, Helsinki University Hospital, Helsinki, Finland
| | | | - Juha Saarnio
- Department of Surgery, Medical Research Center, Oulu University Hospital, Oulu, Finland
| | - Pasi Ohtonen
- Department of Surgery, Medical Research Center, Oulu University Hospital, Oulu, Finland
| | | | - Tero Rautio
- Department of Surgery, Medical Research Center, Oulu University Hospital, Oulu, Finland
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Parpoudi S, Mantzoros I, Gkiouliava A, Kyziridis D, Makrantonakis A, Chatzakis C, Gekas C, Konstantaras D, Ioannidis O, Bitsianis S, Miliaras D, Aggelopoulos S. The effect of N-acetyl-l-cysteine on inflammation after intraperitoneal mesh placement in a potentially contaminated environment: Experimental study in the rat. Asian J Surg 2021; 45:2191-2196. [PMID: 34801356 DOI: 10.1016/j.asjsur.2021.11.001] [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: 07/22/2021] [Accepted: 11/05/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The use of prosthetic meshes in abdominal wall reconstruction is a well-established approach; however, in certain cases where a bowel resection coexists its application is disputed. Any underlying inflammatory process may augment adhesion formation which is a major postoperative complication. In this animal study, our aim was to investigate the effect of N-acetyl-l-cysteine (NAC) on adhesion formation and the expression of inflammatory markers when a mesh was used in a clean or a potentially contaminated environment. METHODS Sixty male Wistar rats were randomly and equally allocated in 3 groups: A, B and C. Animals in all groups underwent laparotomy, a prosthetic mesh was placed and chemoprophylaxis with ciprofloxacin was administered. In groups B and C an enterectomy was also performed. NAC was injected intraperitoneally in group C. Adhesion formation, IL-1a, IL-6, TNF-a and histological data including fibrosis, neutrophils' infiltration and neovascularization were assessed. Mesh samples were sent for cultivation. RESULTS Adhesion formation was significantly less and inflammation markers were also lower in group C compared to group B (p<0.05). Histological findings were significant for greater fibrosis, neutrophils' infiltration and neovascularization in group B compared to both group A and C. Regarding mesh cultures, more specimens were tested positive in group B (p <0.05). Outcomes between group A and C did not differ. CONCLUSION NAC effectively ameliorated adhesion formation and inflammation in a potentially septic environment where a prosthetic mesh was placed.
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Affiliation(s)
- Styliani Parpoudi
- 4th Surgical Clinic, School of Medicine, Faculty of Health Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Mantzoros
- 4th Surgical Clinic, School of Medicine, Faculty of Health Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anna Gkiouliava
- Anaesthesiology Department, Georgios Papanikolaou General Hospital, Thessaloniki, Greece.
| | - Dimitrios Kyziridis
- 4th Surgical Clinic, School of Medicine, Faculty of Health Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos Makrantonakis
- 4th Surgical Clinic, School of Medicine, Faculty of Health Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christos Chatzakis
- 4th Surgical Clinic, School of Medicine, Faculty of Health Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christos Gekas
- Orthopaedic Department, Ippokrateio Hospital, Thessaloniki, Greece
| | - Dimitrios Konstantaras
- 4th Surgical Clinic, School of Medicine, Faculty of Health Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Orestis Ioannidis
- 4th Surgical Clinic, School of Medicine, Faculty of Health Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stefanos Bitsianis
- 4th Surgical Clinic, School of Medicine, Faculty of Health Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimosthenis Miliaras
- Laboratory of Histology-Embryology, School of Medicine, Faculty of Health Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stamatios Aggelopoulos
- 4th Surgical Clinic, School of Medicine, Faculty of Health Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
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12
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Tansawet A, Numthavaj P, Sumritpradit P, Techapongsatorn S, McKay G, Attia J, Thakkinstian A. Midline incisional hernia prophylaxis using synthetic mesh in an emergency or urgent gastrointestinal tract surgery: a protocol for multicentre randomised clinical trial. BMJ Open 2021; 11:e045541. [PMID: 34479930 PMCID: PMC8420735 DOI: 10.1136/bmjopen-2020-045541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 08/13/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Between 5% and 30% of abdominal incisions eventually result in incisional hernias (IHs) that can lead to severe complications and impaired quality of life. Unfortunately, IH repair is often unsuccessful; therefore, hernia prophylaxis is an important issue. The efficacy of mesh augmentation has been proven for hernia prophylaxis in high-risk patients, but no randomised clinical trial has evaluated prophylactic mesh placement in emergency/urgent gastrointestinal operations. METHODS AND ANALYSIS A multicentre, prospective randomised, open and patient-assessor blinded endpoint design will be conducted. A total of 470 patients will be enrolled and randomly allocated to retrorectus mesh augmentation with lightweight polypropylene mesh or primary suture closure. The primary outcome is IH occurrence within 24 months of follow-up, while other clinical outcomes are secondary endpoints. A cost-effectiveness analysis will be conducted from the societal and provider perspectives. ETHICS AND DISSEMINATION Ethics approval was obtained from Ramathibodi Hospital (MURA2020/1478) and Vajira Hospital (COA164/2563). The protocol is on the process of submission to the local ethics committee of the other study sites. Results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER TCTR20200924002.
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Affiliation(s)
- Amarit Tansawet
- Surgery, Navamindradhiraj University, Bangkok, Thailand
- Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pawin Numthavaj
- Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Preeda Sumritpradit
- Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Gareth McKay
- Centre for Public Health, Faculty of Medicine Health and Life Sciences, Queen's University Belfast, Belfast, UK
| | - John Attia
- Centre for Clinical Epidemiology and Biostatistics, Hunter Medical Research Institute, School of Medicine and Public Health, The University of Newcastle, New Lambton, New South Wales, Australia
| | - Ammarin Thakkinstian
- Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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13
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Hassan MA, Yunus RM, Khan S, Memon MA. Prophylactic Onlay Mesh Repair (POMR) Versus Primary Suture Repair (PSR) for Prevention of Incisional Hernia (IH) After Abdominal Wall Surgery: A Systematic Review and Meta-analysis. World J Surg 2021; 45:3080-3091. [PMID: 34279690 DOI: 10.1007/s00268-021-06238-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND With many different operative techniques in use to reduce the incidence of incisional hernias (IH) following a midline laparotomy, there is no consensus among the clinicians on the efficacy and safety of any particular repair technique. This meta-analysis compares the prophylactic onlay mesh repair (POMR) and primary suture repair (PSR) for the incidence of IH. METHODS A meta-analysis and systematic review of MEDLINE, PubMed Central (via PubMed), Embase (via Ovid), SCOPUS, ScienceDirect, Google Scholar, SCI and Cochrane Library databases were undertaken. Seven randomized controlled trials assessing the outcomes of PSR and POMR were analyzed in accordance with the PRISMA statement. The risk of bias was assessed using the Rob2 tool. RESULTS According to the pooled analysis, POMR significantly reduced the incidence of IH compared to the PSR (OR 5.82 [95% CI 2.69, 12.58] P < 0.01) with a significantly higher seroma formation rate post-surgery (OR 0.35 [95% CI 0.18, 0.67] P < 0.01). Furthermore, the length of hospital stay (WMD -0.78 [95% CI -1.58, 0.02] P = 0.05) was significantly shorter for PSR compared to POMR group. Comparable effects were noted for reintervention, postoperative ileus, postoperative hematoma, postoperative mortality, long-term intervention and long-term deaths between the two groups. CONCLUSIONS POMR significantly reduces the risk of IH when compared to the PSR, with an increased risk of postoperative seroma formation and longer hospital stay. However, more RCTs with standardized protocols are needed for meaningful comparisons of the two interventions, along with longer duration of follow-up to assess the impact on the occurrence of IH.
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Affiliation(s)
- Maha Awaiz Hassan
- MAP Center for Urban Health Solutions, St. Michael's Hospital, 3rd floor, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada.
| | - Rossita Mohamad Yunus
- Institute of Mathematical Sciences, Faculty of Science, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Shahjahan Khan
- School of Sciences, Centre for Health Sciences Research, University of Southern Queensland, Toowoomba, QLD, Australia
| | - Muhammed Ashraf Memon
- School of Sciences, Centre for Health Sciences Research, University of Southern Queensland, Toowoomba, QLD, Australia.,South East Queensland Surgery (SEQS), Sunnybank Obesity Centre, Sunnybank, QLD, Australia.,Mayne Medical School, School of Medicine, University of Queensland, Brisbane, QLD, Australia.,Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia.,Faculty of Health and Social Science, Bolton University, Bolton, Lancashire, UK
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14
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Pizza F, D'Antonio D, Ronchi A, Lucido FS, Brusciano L, Marvaso A, Dell'Isola C, Gambardella C. Prophylactic sublay non-absorbable mesh positioning following midline laparotomy in a clean-contaminated field: randomized clinical trial (PROMETHEUS). Br J Surg 2021; 108:638-643. [PMID: 33907800 DOI: 10.1093/bjs/znab068] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/11/2020] [Accepted: 01/31/2021] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- F Pizza
- Department of Surgery, Hospital 'Rizzoli', Naples, Italy
| | - D D'Antonio
- Department of Surgery, Hospital 'Rizzoli', Naples, Italy
| | - A Ronchi
- Pathology Unit, Department of Mental and Physical Health and Preventive Medicine, Naples University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - F S Lucido
- Division of General, Mininvasive and Bariatric Surgery, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - L Brusciano
- Division of General, Mininvasive and Bariatric Surgery, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - A Marvaso
- Department of Surgery, Hospital 'Rizzoli', Naples, Italy
| | - C Dell'Isola
- Department of Infectious Diseases, AORN 'dei Colli' Monaldi-Cotugno - CTO, Naples, Italy
| | - C Gambardella
- Division of General, Mininvasive and Bariatric Surgery, University of Campania 'Luigi Vanvitelli', Naples, Italy
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15
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Prophylactic Mesh After Midline Laparotomy: Evidence is out There, but why do Surgeons Hesitate? World J Surg 2021; 45:1349-1361. [PMID: 33558998 DOI: 10.1007/s00268-020-05898-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Incisional hernias have an impact on patients' quality of life and on health care finances. Because of high recurrence rates despite mesh repair, the prevention of incisional hernias with prophylactic mesh reinforcement is currently a topic of interest. But only 15% of surgeons are implementing it, mainly because of fear for mesh complications and disbelief in the benefits. The goal of this systematic review is to evaluate the effectiveness and safety of prophylactic mesh in adult patients after midline laparotomy. METHODS An extensive literature search was performed in PubMed, Embase and CENTRAL until 9/5/2020 for RCTs and cohort studies regarding mesh reinforcement versus primary suture closure of a midline laparotomy. The quality of the articles was analyzed using the Scottish Intercollegiate Guidelines Network checklists. Revman 5 was used to perform a meta-analysis. RESULTS Twenty-three articles were found with a total of 1633 patients in the mesh reinforcement group and 1533 in the primary suture group. An odds ratio for incisional hernia incidence of 0.37 (95% CI = [0.30, 0.46], p < 0.01) with RCTs and of 0.15 (95% CI = [0.09,0.25], p < 0.01) in cohort studies was calculated. Seroma rate shows a significant odds ratio of 2.18 (95% CI = [1.45, 3.29], p < 0.01) in favor of primary suture. No increase was found regarding other complications. CONCLUSION The evidence for the use of prophylactic mesh reinforcement is overwhelming with a significant reduction in incisional hernia rate, but implementation in daily clinical practice remains limited. Instead of putting patients at risk for incisional hernia formation and subsequent complications, surgeons should question their arguments why not to use mesh reinforcement, specifically in high-risk patients.
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16
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Jakob MO, Haltmeier T, Beldi G. Authors' reply to letter to the editor by Robert Martindale. J Trauma Acute Care Surg 2021; 90:e55. [PMID: 33060541 DOI: 10.1097/ta.0000000000002993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Jakob MO, Beldi G. Authors' reply: Methodological biases may render a clinical study underpowered. J Trauma Acute Care Surg 2021; 90:e59-e60. [PMID: 33075027 DOI: 10.1097/ta.0000000000002992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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18
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Hernani BDL, Barros PHFD, Tastaldi L, Ladeira LN, Roll S, Ferreira FG, Garcia DPC. Biomechanical and adhesion comparison of linea alba prophylactic reinforcement with coated and uncoated three-dimensional T-shaped mesh in rabbits. Acta Cir Bras 2020; 35:e202001001. [PMID: 33206869 PMCID: PMC7671607 DOI: 10.1590/s0102-865020200100000001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 09/11/2020] [Indexed: 12/02/2022] Open
Abstract
Purpose: Incisional hernia (IH) is a frequent complication of median laparotomy. The use of prophylactic mesh to reduce IH incidence has gained increasing attention. We hypothesized that in an animal model, linea alba prophylactic reinforcement with a three-dimensional T-shaped polypropylene mesh results in greater abdominal wall resistance. Methods: Study was performed in 27 rabbits. After abdominal midline incision, animals were divided into three groups according to the laparotomy closure method used: (1)3D T-shaped coated mesh; (2)3D T-shaped uncoated mesh; and (3) closure without mesh. After 4 months, each animal’s abdominal wall was resected and tensiometric tests were applied. Results included IH occurrence, adhesions to the mesh, and wound complications. Results: There was no significant difference between the groups in maximum tensile strength (p=0.250) or abdominal wall elongation under maximum stress (p=0.839). One rabbit from the control group developed IH (p=1.00). Small intestine and colon adhesions occurred only in the uncoated mesh group (p<0.001) and the degree of adhesions was higher in this group compared to the coated mesh group (p<0.05). Conclusion: Use of the current 3D T-shaped prophylactic mesh model did not result in a significant difference in tensiometric measurements when compared with simple abdominal wall closure in rabbits.
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Affiliation(s)
| | | | | | | | - Sergio Roll
- Irmandade da Santa Casa de Misericórdia de São Paulo, and HAOC, Brazil
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19
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Burns FA, Heywood EG, Challand CP, Lee MJ. Is there a role for prophylactic mesh in abdominal wall closure after emergency laparotomy? A systematic review and meta-analysis. Hernia 2020; 24:441-447. [PMID: 31641872 PMCID: PMC7210219 DOI: 10.1007/s10029-019-02060-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 09/27/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Incisional hernias are a common complication of emergency laparotomy and are associated with significant morbidity. Recent studies have found a reduction in incisional hernias when mesh is placed prophylactically during abdominal closure in elective laparotomies. This systematic review will assess the safety and efficacy of prophylactic mesh placement in emergency laparotomy. METHODS A systematic review was performed according to the PROSPERO registered protocol (CRD42018109283). Papers were dual screened for eligibility, and included when a comparison was made between closure with prophylactic mesh and closure with a standard technique, reported using a comparative design (i.e. case-control, cohort or randomised trial), where the primary outcome was incisional hernia. Bias was assessed using the Cochrane risk of bias in non-randomised studies tool. A meta-analysis of incisional hernia rate was performed to estimate risk ratio using a random effects model (Mantel-Haenszel approach). RESULTS 332 studies were screened for eligibility, 29 full texts were reviewed and 2 non-randomised studies were included. Both studies were biased due to confounding factors, as closure technique was based on patient risk factors for incisional hernia. Both studies found significantly fewer incisional hernias in the mesh groups [3.2% vs 28.6% (p < 0.001) and 5.9% vs 33.3% (p = 0.0001)]. A meta-analysis of incisional hernia risk favoured prophylactic mesh closure [risk ratio 0.15 (95% CI 0.6-0.35, p < 0.001)]. Neither study found an association between mesh and infection or enterocutaneous fistula. CONCLUSION This review found that there are limited data to assess the effect or safety profile of prophylactic mesh in the emergency laparotomy setting. The current data cannot reliably assess the use of mesh due to confounding factors, and a randomised controlled trial is required to address this important clinical question.
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Affiliation(s)
- F A Burns
- Academic Department of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S5 7AU, UK
| | - E G Heywood
- Academic Department of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S5 7AU, UK
| | - C P Challand
- Academic Department of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S5 7AU, UK
| | - Matthew J Lee
- Academic Department of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S5 7AU, UK.
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, S10 2RX, UK.
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20
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Tsang CLN, O'Neill RS, Joseph CM, Palasovski T. Small Bowel Perforation Secondary to Biliary Stent Migration in an Incarcerated Inguinal Hernia. Cureus 2020; 12:e7268. [PMID: 32292679 PMCID: PMC7153812 DOI: 10.7759/cureus.7268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
We describe the case of a 90-year-old female who presented with signs of a strangulated inguinal hernia. Further history revealed a paired biliary-pancreatic stent insertion three years prior for ascending cholangitis and a long-standing asymptomatic right inguinal hernia. Biochemistry revealed a slightly elevated C-reactive protein level of 65 mmol/L, but was otherwise unremarkable. Abdominal CT demonstrated two plastic biliary stents within an incarcerated right inguinal hernia. At the time of surgery, a 3-mm perforation due to the stents was identified in the small bowel within the hernia. The stents were retrieved via an enterotomy that was subsequently repaired with full-thickness interrupted sutures. A tissue-suture repair of the inguinal hernia was performed due to significant contamination of enteric contents in the operative field. The patient had an unremarkable recovery and was discharged four days after her operation. This is a very rare acute presentation of stent migration with only a handful of such reported cases in the literature. With the rising number of endoscopic biliary stenting procedures, these complications are likely to increase, and clinicians need to be aware of this possibility in patients with pre-existing hernias.
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21
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Lima HV, Rasslan R, Novo FC, Lima TM, Damous SH, Bernini CO, Montero EF, Utiyama EM. Prevention of Fascial Dehiscence with Onlay Prophylactic Mesh in Emergency Laparotomy: A Randomized Clinical Trial. J Am Coll Surg 2020; 230:76-87. [DOI: 10.1016/j.jamcollsurg.2019.09.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 07/29/2019] [Accepted: 09/16/2019] [Indexed: 12/13/2022]
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22
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Kohler A, Lavanchy JL, Lenoir U, Kurmann A, Candinas D, Beldi G. Effectiveness of Prophylactic Intraperitoneal Mesh Implantation for Prevention of Incisional Hernia in Patients Undergoing Open Abdominal Surgery: A Randomized Clinical Trial. JAMA Surg 2019; 154:109-115. [PMID: 30476940 DOI: 10.1001/jamasurg.2018.4221] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Importance Incisional hernia is a frequent complication after open abdominal surgery. Prophylactic mesh implantation in the onlay or sublay position requires dissection of the abdominal wall, potentially leading to wound-associated complications. Objective To compare the incidence of incisional hernia among patients after prophylactic intraperitoneal mesh implantation with that among patients after standard abdominal closure. Design, Setting, and Participants An open-label randomized clinical trial was performed in 169 patients undergoing elective open abdominal surgery from January 1, 2011, to February 29, 2014. Follow-up examinations were performed 1 year and 3 years after surgery. The study was conducted at Bern University Hospital, Bern, Switzerland, a referral center that offers the whole spectrum of abdominal surgical interventions. Patients with 2 or more of the following risk factors were included: overweight or obesity, diagnosis of neoplastic disease, male sex, or history of previous laparotomy. Patients were randomly assigned to prophylactic intraperitoneal mesh implantation or standard abdominal closure. Data were analyzed in August 2017. Interventions Intraperitoneal implantation of a polypropylene-polyvinylidene fluoride mesh with circumferential fixation. Main Outcomes and Measures The primary end point was the incidence of incisional hernia 3 years after surgery. Secondary end points included mesh-related complications. Results After the exclusion of 19 patients, 150 patients (81 in the control group and 69 in the mesh group; mean [SD] age, 64.2 [11.1] years; 102 [68.0%] male) were studied. The cumulative incidence of incisional hernia was significantly lower in the mesh group compared with the control group (5 of 69 [7.2%] vs 15 of 81 [18.5%], log-rank test P = .03). Abdominal pain was observed in significantly more patients in the mesh group compared with the control group at 6 weeks (34 of 52 [65%] vs 26 of 59 [44%], P = .04) but not at 12 and 36 months postoperatively. No difference in surgical site infections was observed, but time to complete wound healing of surgical site infection was significantly longer in patients with mesh implantation (median [interquartile range], 8 [6-24] weeks compared with 5 [1-9] weeks; P = .03). Trunk extension was significantly decreased after mesh implantation compared with the control group (mean [SD], 1.73 [0.97] cm vs 2.40 [1.23] cm, P = .009). Conclusions and Relevance In patients at elevated risk for incisional hernia, prophylactic intraperitoneal mesh implantation reduces the incidence of hernia formation but with increased early postoperative pain and prolonged wound healing of surgical site infection. Trial Registration ClinicalTrials.gov Identifier: NCT01203553.
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Affiliation(s)
- Andreas Kohler
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Joel L Lavanchy
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ursina Lenoir
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anita Kurmann
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Candinas
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Guido Beldi
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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23
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Reduced rate of incisional hernia after standardized fascial closure in emergency laparotomy. Hernia 2019; 23:341-346. [DOI: 10.1007/s10029-019-01893-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 01/15/2019] [Indexed: 10/27/2022]
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24
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Schwab R, Germer CT, Lang H. Relevante Nebenerkrankungen zu Notfallindikationen und Notfalloperationen in der Viszeral- und Allgemeinchirurgie. NOTFÄLLE IN DER ALLGEMEIN- UND VISZERALCHIRURGIE 2019. [PMCID: PMC7121273 DOI: 10.1007/978-3-662-53557-8_28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Die Adipositas ist eine über das Normalmaß hinausgehende Vermehrung des Körperfetts und wird über den Body-Mass- Index (BMI = kg/m) bestimmt. Ab einem BMI von 30 kg/m liegt definitionsgemäß eine Adipositas vor. Der Krankheitswert ergibt sich aus der Assoziation von Folgeerkrankungen, deren Risiko mit der Prävalenzdauer und dem Schweregrad der Adipositas ansteigt (Tab. 28.1). Dabei korreliert das kardiovaskuläre Risiko besonders mit dem Vorliegen einer viszeralen Adipositas (>88/102 cm Taillenumfang bei Frauen/ Männern). Die Prävalenz der Adipositas steigt in Deutschland kontinuierlich an. Derzeit ist knapp ein Viertel der deutschen Bevölkerung als adipös einzustufen.
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Affiliation(s)
- Robert Schwab
- grid.493974.40000 0000 8974 8488BundeswehrZentralkrankenhaus Koblenz, Koblenz, Deutschland
| | | | - Hauke Lang
- grid.410607.4Universitätsmedizin Mainz, Mainz, Deutschland
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Prophylactic Intraperitoneal Onlay Mesh Reinforcement Reduces the Risk of Incisional Hernia, Two-Year Results of a Randomized Clinical Trial. World J Surg 2018; 42:1687-1694. [PMID: 29159603 DOI: 10.1007/s00268-017-4363-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Incisional hernias still are a major concern after laparotomy and are causing substantial morbidity. This study examines the feasibility, safety and incisional hernia rate of the use of a prophylactic intraperitoneal onlay mesh stripe (IPOM) to prevent incisional hernia following midline laparotomy. METHODS This prospective, randomized controlled trial randomly allocated patients undergoing median laparotomy either to mass closure of the abdominal wall with a PDS-loop running suture reinforced by an intraperitoneal composite mesh stripe (Group A) or to the same procedure without the additional mesh stripe (Group B). Primary endpoint was the incidence of incisional hernias at 2 years following midline laparotomy. Secondary endpoints are were the feasibility, the safety of the mesh stripe implantation including postoperative pain, and the incidence of incisional hernias at 5 years. RESULTS A total of 267 patients were included in this study. Follow-up data 2 years after surgery was available from 210 patients (Group A = 107; Group B = 103). An incisional hernia was diagnosed in 18/107 (17%) patients in Group A and in 40/103 (39%) patients in Group B (p < 0.001). A surgical operation due to an incisional hernia was conducted for 12/107 (11%) patients in Group A and for 24/103 (23%) patients in Group B (p = 0.039). In both groups, minor and major complications as well as postoperative pain are reported with no statistically significant difference between the groups, even in contaminated situations. CONCLUSIONS This first randomized clinical trial indicates that the placement of a non-absorbable IPOM-stripe with prophylactic intention may significantly reduce the risk for a midline incisional hernia. TRIAL REGISTRATION Ref. NCT01003067 (clinicaltrials.gov).
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Jakob MO, Schwarz C, Haltmeier T, Zindel J, Pinworasarn T, Candinas D, Starlinger P, Beldi G. Mesh-augmented versus direct abdominal closure in patients undergoing open abdomen treatment. Hernia 2018; 22:785-792. [PMID: 30027445 PMCID: PMC6153946 DOI: 10.1007/s10029-018-1798-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 07/13/2018] [Indexed: 01/29/2023]
Abstract
Background Open abdomen (OA) may be required in patients with abdominal trauma, sepsis or compartment syndrome. Vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) is a widely used approach for temporary abdominal closure to close the abdominal wall. However, this method is associated with a high incidence of re-operations in short term and late sequelae such as incisional hernia. The current study aims to compare the results of surgical strategies of OA with versus without permanent mesh augmentation. Methods Patients with OA treatment undergoing vacuum-assisted wound closure and an intraperitoneal onlay mesh (VAC-IPOM) implantation were compared to VAWCM with direct fascial closure which represents the current standard of care. Outcomes of patients from two tertiary referral centers that performed the different strategies for abdominal closure after OA treatment were compared in univariate and multivariate regression analysis. Results A total of 139 patients were included in the study. Of these, 50 (36.0%) patients underwent VAC-IPOM and 89 (64.0%) patients VAWCM. VAC-IPOM was associated with reduced re-operations (adjusted incidence risk ratio 0.48 per 10-person days; CI 95% = 0.39–0.58, p < 0.001), reduced duration of stay on intensive care unit (ICU) [adjusted hazard ratio (aHR) 0.53; CI 95% = 0.36–0.79, p = 0.002] and reduced hospital stay (aHR 0.61; CI 95% = 0.040–0.94; p = 0.024). In-hospital mortality [22.5 vs 18.0%, risk difference − 4.5; confidence interval (CI) 95% = − 18.2 to 9.3; p = 0.665] and the incidence of intestinal fistula (18.0 vs 22.0%, risk difference 4.0; CI 95% = −10.0 to 18.0; p = 0.656) did not differ between the two groups. In Kaplan–Meier analysis, hernia-free survival was significantly increased after VAC-IPOM (p = 0.041). Conclusions In patients undergoing OA treatment, intraperitoneal mesh augmentation is associated with a significantly decreased number of re-operations, duration of hospital and ICU stay and incidence of incisional hernias when compared to VAWCM. Electronic supplementary material The online version of this article (10.1007/s10029-018-1798-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- M O Jakob
- Department of Visceral Surgery and Medicine, University Hospital, Bern, Switzerland
| | - C Schwarz
- Department of Surgery, General Hospital, Medical University of Vienna, Vienna, Austria
| | - T Haltmeier
- Department of Visceral Surgery and Medicine, University Hospital, Bern, Switzerland
| | - J Zindel
- Department of Visceral Surgery and Medicine, University Hospital, Bern, Switzerland
| | - T Pinworasarn
- Department of Visceral Surgery and Medicine, University Hospital, Bern, Switzerland
| | - D Candinas
- Department of Visceral Surgery and Medicine, University Hospital, Bern, Switzerland
| | - P Starlinger
- Department of Surgery, General Hospital, Medical University of Vienna, Vienna, Austria
| | - G Beldi
- Department of Visceral Surgery and Medicine, University Hospital, Bern, Switzerland.
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Grainger JT, Maeda Y, Donnelly SC, Vaizey CJ. Assessment and management of patients with intestinal failure: a multidisciplinary approach. Clin Exp Gastroenterol 2018; 11:233-241. [PMID: 29928141 PMCID: PMC6003282 DOI: 10.2147/ceg.s122868] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Intestinal failure (IF) is a condition characterized by the inability to maintain a state of adequate nutrition, or fluid and electrolyte balance due to an anatomical or a physiological disorder of the gastrointestinal system. IF can be an extremely debilitating condition, significantly affecting the quality of life of those affected. The surgical management of patients with acute and chronic IF requires a specialist team who has the expertise in terms of technical challenges and decision-making. A dedicated IF unit will have the expertise in patient selection for surgery, investigative workup and planning, operative risk assessment with relevant anesthetic expertise, and a multidisciplinary team with support such as nutritional expertise and interventional radiology. This article covers the details of IF management, including the classification of IF, etiology, prevention of IF, and initial management of IF, focusing on sepsis treatment and nutritional support. It also covers the surgical aspects of IF such as intestinal reconstruction, abdominal wall reconstruction, and intestinal transplantation.
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Affiliation(s)
- Jennie T Grainger
- The Lennard Jones Intestinal Failure Unit, St. Mark's Hospital, Harrow, UK
| | - Yasuko Maeda
- The Lennard Jones Intestinal Failure Unit, St. Mark's Hospital, Harrow, UK.,Faculty of Medicine, Imperial College London, London, UK
| | - Suzanne C Donnelly
- The Lennard Jones Intestinal Failure Unit, St. Mark's Hospital, Harrow, UK
| | - Carolynne J Vaizey
- The Lennard Jones Intestinal Failure Unit, St. Mark's Hospital, Harrow, UK.,Faculty of Medicine, Imperial College London, London, UK
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Abstract
BACKGROUND There is a high incidence of incisional hernias in specific high-risk patient populations. For these patients, the prophylactic placement of mesh during closure of the abdominal wall incision has been investigated in several prospective studies. OBJECTIVE This article aims to summarize and synthetize the currently available evidence on prophylactic meshes in a narrative review. MATERIALS AND METHODS Systematic reviews were performed on the use of prophylactic meshes in different indications: midline laparotomies, stoma reversal wounds, and permanent stoma. RESULTS High-quality data from randomized trials shows that prophylactic synthetic non-absorbable mesh implantation is safe and effective, both in prevention of incisional hernias after midline laparotomies and during construction of an elective end colostomy. It should be considered in patients with a high risk for incisional hernia development, such as those receiving open abdominal aortic aneurysm, obesity, or colorectal cancer surgery. It is strongly recommended for construction of an elective permanent end colostomy. For midline laparotomies, both the retromuscular and onlay positions of a prophylactic mesh seem equally effective and safe. For parastomal hernia prevention, only the retromuscular prophylactic mesh and its use for end colostomies has been proven to be effective and safe. No data support the choice of a biological mesh or a synthetic absorbable mesh over a non-absorbable synthetic mesh, even in clean-contaminated surgical procedures. No data yet support the standard use of prophylactic mesh when closing the wound during closure of a temporary stoma. CONCLUSION Prophylactic mesh implantation should be standard of care during construction of an elective end colostomy and will become standard of care for midline laparotomies in patients at a high risk of incisional hernias.
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Affiliation(s)
- F E Muysoms
- Department for General, Thoracic and Cardiovascular Surgery, AZ Maria Middelares Dienst Algemene Heelkunde, Buitenring Sint-Denijs 30, 9000, Ghent, Belgium.
| | - U A Dietz
- Klinik und Poliklinik für Allgemein-, Viszeral-, Gefäß- und Kinderchirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Strasse 6, 97080, Würzburg, Germany
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Hernández-Granados P, López-Cano M, Morales-Conde S, Muysoms F, García-Alamino J, Pereira-Rodríguez JA. Incisional hernia prevention and use of mesh. A narrative review. Cir Esp 2018; 96:76-87. [PMID: 29454636 DOI: 10.1016/j.ciresp.2018.01.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Revised: 12/21/2017] [Accepted: 01/08/2018] [Indexed: 12/11/2022]
Abstract
Incisional hernias are a very common problem, with an estimated incidence around 15-20% of all laparotomies. Evisceration is another important problem, with a lower rate (2.5-3%) but severe consequences for patients. Prevention of both complications is an essential objective of correct patient treatment due to the improved quality of life and cost savings. This narrative review intends to provide an update on incisional hernia and evisceration prevention. We analyze the current criteria for proper abdominal wall closure and the possibility to add prosthetic reinforcement in certain cases requiring it. Parastomal, trocar-site hernias and hernias developed after stoma closure are included in this review.
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Affiliation(s)
- Pilar Hernández-Granados
- Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España; Sección de Pared Abdominal de la Asociación Española de Cirujanos, España.
| | - Manuel López-Cano
- Sección de Pared Abdominal de la Asociación Española de Cirujanos, España; Unidad de Pared Abdominal, Hospital Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
| | - Salvador Morales-Conde
- Unidad de Innovación en Cirugía Mínimamente Invasiva, Hospital Universitario Virgen del Rocío, Sevilla, España; Secretaría General, European Hernia Society
| | - Filip Muysoms
- Servicio de Cirugía, Hospital Maria Middelares, Ghent, Bélgica
| | - Josep García-Alamino
- Department of Primary Care Health Sciencies, University of Oxford, Oxford, Reino Unido
| | - José Antonio Pereira-Rodríguez
- Servicio de Cirugía General y Digestiva, Parc de Salut Mar, Hospital del Mar. Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, España
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Lanni MA, Tecce MG, Shubinets V, Mirzabeigi MN, Fischer JP. The State of Prophylactic Mesh Augmentation. Am Surg 2018. [DOI: 10.1177/000313481808400129] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Prophylactic mesh augmentation (PMA) is the implantation of mesh during closure of an index laparotomy to decrease a patient's risk for developing incisional hernia (IH). The current body of evidence lacks refined guidelines for patient selection, mesh placement, and material choice. The purpose of this study is to summarize the literature and identify areas of research needed to foster responsible and appropriate use of PMA as an emerging technique. We conducted a comprehensive review of Scopus, Cochrane, PubMed, and clinicaltrials.gov for articles and trials related to using PMA for IH risk reduction. We further supplemented our review by including select papers on patient-reported outcomes, cost utility, risk modeling, surgical techniques, and available materials highly relevant to PMA. Five-hundred-fifty-one unique articles and 357 trials were reviewed. Multiple studies note a significant decrease in IH incidence with PMA compared with primary suture-only–based closure. No multicenter randomized control trial has been conducted in the United States, and only two such trials are currently active worldwide. Evidence exists supporting the use of PMA, with practical cost utility and models for selecting high-risk patients, but standard PMA guidelines are lacking. Although Europe has progressed with this technique, widespread adoption of PMA requires large-scale pragmatic randomized control trial research, strong evidence-based guidelines, current procedural terminology coding, and resolution of several barriers.
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Affiliation(s)
- Michael A. Lanni
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Michael G. Tecce
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Valeriy Shubinets
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Michael N. Mirzabeigi
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - John P. Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
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Carney MJ, Weissler JM, Fox JP, Tecce MG, Hsu JY, Fischer JP. Trends in open abdominal surgery in the United States—Observations from 9,950,759 discharges using the 2009–2013 National Inpatient Sample (NIS) datasets. Am J Surg 2017; 214:287-292. [DOI: 10.1016/j.amjsurg.2017.01.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 12/05/2016] [Accepted: 01/05/2017] [Indexed: 01/31/2023]
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Treatments and other prognostic factors in the management of the open abdomen: A systematic review. J Trauma Acute Care Surg 2017; 82:407-418. [PMID: 27918375 DOI: 10.1097/ta.0000000000001314] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND The open abdomen (OA) is an important approach for managing intra-abdominal catastrophes and continues to be the standard of care. Despite this, challenges remain with it associated with a high incidence of complications and poor outcomes. The objective of this article is to perform a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify prognostic factors in OA patients in regard to definitive fascial closure (DFC), mortality and intra-abdominal complications. METHODS An electronic database search was conducted involving Medline, Excerpta Medica, Central Register of Controlled Trials, Cumulative Index to Nursing, and Allied Health Literature and Clinicaltrials.gov. All studies that described prognostic factors in regard to the above outcomes in OA patients were eligible for inclusion. Data collected were synthesized by each outcome of interest and assessed for methodological quality. RESULTS Thirty-one studies were included in the final synthesis. Enteral nutrition, organ dysfunction, local and systemic infection, number of reexplorations, worsening Injury Severity Score, and the development of a fistula appeared to significantly delay DFC. Age and Adult Physiology And Chronic Health Evaluation version II score were predictors for in-hospital mortality. Failed DFC, large bowel resection and >5 to 10 L of intravenous fluids in <48 hours were predictors of enteroatmospheric fistula. The source of infection (small bowel as opposed to colon) was a predictor for ventral hernia. Large bowel resection, >5 to 10 and >10 L of intravenous fluids in <48 hours were predictors of intra-abdominal abscess. Fascial closure on (or after) day 5 and having a bowel anastomosis were predictors for anastomotic leak. Overall methodological quality was of a moderate level. LIMITATIONS Overall methodological quality, high number of retrospective studies, low reporting of prognostic factors and the multitude of factors potentially affecting patient outcome that were not analyzed. CONCLUSION Careful selection and management of OA patients will avoid prolonged treatment and facilitate early DFC. Future research should focus on the development of a prognostic model. LEVEL OF EVIDENCE Systematic review, level III.
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Borab ZM, Shakir S, Lanni MA, Tecce MG, MacDonald J, Hope WW, Fischer JP. Does prophylactic mesh placement in elective, midline laparotomy reduce the incidence of incisional hernia? A systematic review and meta-analysis. Surgery 2016; 161:1149-1163. [PMID: 28040255 DOI: 10.1016/j.surg.2016.09.036] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 09/12/2016] [Accepted: 09/12/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Operative intervention to correct incisional hernia affects 150,000 patients annually, with 1 in 3 repairs recurring within 9 years. The aim of this study was to compare the incidence of incisional hernia and postoperative complications in elective midline laparotomy patients after the use of prophylactic mesh placement and primary suture closure. METHODS A systematic review was performed to identify studies comparing prophylactic mesh placement to primary suture closure in elective, midline laparotomy at index abdominal aponeurosis closure. The primary outcome was incisional hernia. Secondary outcomes included postoperative complications. RESULTS Fourteen studies were included (2,114 patients), with 1,152 receiving prophylactic mesh placement. Prophylactic mesh placement decreased the risk of incisional hernia overall when compared to primary suture closure (relative risk = 0.15; P < .00001) and in trials using only polypropylene mesh versus 4:1 primary suture closure (relative risk = 0.15; P = .003). Prophylactic mesh placement reduced the risk of incisional hernia regardless of mesh location or composition: onlay (relative risk = 0.07; P < .0001), retrorectus (relative risk = 0.04; P = .002), and preperitoneal (relative risk = 0.18; P = .02). Prophylactic mesh placement increased risk of seroma overall (relative risk = 1.95; P < .0001), onlay (relative risk = 2.43; P = .01) and preperitoneal (relative risk = 1.47; P = .01) but not retrorectus plane (relative risk = 1.55; P = .26). Polypropylene mesh increased seroma risk only in the onlay position (relative risk = 2.77; P = .04). Prophylactic mesh placement patients are at increased risk for chronic wound pain compared to primary suture closure (relative risk = 1.70; P = .03). CONCLUSION Prophylactic mesh placement is associated with an 85% postoperative incisional hernia risk reduction when compared to primary suture closure in at-risk patients undergoing elective, midline laparotomy closure. This technique appears to be safe with comparable complication profiles, barring an increased risk of seroma, especially with the onlay technique, and the possibility for an increased risk of chronic pain. Despite this verification, evidence from large domestic trials that sufficiently addresses major knowledge gaps is simply lacking.
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Affiliation(s)
| | - Sameer Shakir
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Michael A Lanni
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Michael G Tecce
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - John MacDonald
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - William W Hope
- Department of Surgery, New Hanover Regional Medical Center, Wilmington, NC
| | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA.
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Fischer JP, Basta MN, Mirzabeigi MN, Bauder AR, Fox JP, Drebin JA, Serletti JM, Kovach SJ. A Risk Model and Cost Analysis of Incisional Hernia After Elective, Abdominal Surgery Based Upon 12,373 Cases: The Case for Targeted Prophylactic Intervention. Ann Surg 2016; 263:1010-7. [PMID: 26465784 PMCID: PMC4825112 DOI: 10.1097/sla.0000000000001394] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objectives: Incisional hernia (IH) remains a common, highly morbid, and costly complication. Modest progress has been realized in surgical technique and mesh technology; however, few advances have been achieved toward understanding risk and prevention. In light of the increasing emphasis on prevention in today's health care environment and the billions in costs for surgically treated IH, greater focus on predictive risk models is needed. Methods: All patients undergoing gastrointestinal or gynecologic procedures from January 1, 2005 to June 1, 2013, within the University of Pennsylvania Health System were identified. Comorbidities and operative characteristics were assessed. The primary outcome was surgically treated IH after index procedures. Patients with prior hernia, less than 1-year follow-up, or emergency surgical procedures were excluded. Cox hazard regression modeling with bootstrapped validation, risk factor stratification, and assessment of model performance were conducted. Results: A total of 12,373 patients with a 3.5% incidence of surgically treated IH (follow-up 32.2 ± 26.6 months) were identified. The cost of surgical treatment of IH and management of associated complications exceeded $17.5 million. Notable independent risk factors for IH were ostomy reversal (HR = 2.76), recent chemotherapy (HR = 2.04), bariatric surgery (HR = 1.78), smoking history (HR = 1.74), liver disease (HR = 1.60), and obesity (HR = 1.96). High-risk patients (20.6%) developed IH compared with 0.5% of low-risk patients (C-statistic = 0.78). Conclusions: This study demonstrates an internally validated preoperative risk model of surgically treated IH after 12,000 elective, intra-abdominal procedures to provide more individualized risk counseling and to better inform evidence-based algorithms for the role of prophylactic mesh.
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Affiliation(s)
- John P Fischer
- *Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA †Division of Gastrointestinal Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA
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Vaizey CJ, Maeda Y, Barbosa E, Bozzetti F, Calvo J, Irtun Ø, Jeppesen PB, Klek S, Panisic-Sekeljic M, Papaconstantinou I, Pascher A, Panis Y, Wallace WD, Carlson G, Boermeester M. European Society of Coloproctology consensus on the surgical management of intestinal failure in adults. Colorectal Dis 2016; 18:535-48. [PMID: 26946219 DOI: 10.1111/codi.13321] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 01/22/2016] [Indexed: 12/19/2022]
Abstract
Intestinal failure (IF) is a debilitating condition of inadequate nutrition due to an anatomical and/or physiological deficit of the intestine. Surgical management of patients with acute and chronic IF requires expertise to deal with technical challenges and make correct decisions. Dedicated IF units have expertise in patient selection, operative risk assessment and multidisciplinary support such as nutritional input and interventional radiology, which dramatically improve the morbidity and mortality of this complex condition and can beneficially affect the continuing dependence on parenteral nutritional support. Currently there is little guidance to bridge the gap between general surgeons and specialist IF surgeons. Fifteen European experts took part in a consensus process to develop guidance to support surgeons in the management of patients with IF. Based on a systematic literature review, statements were prepared for a modified Delphi process. The evidence for each statement was graded using Oxford Centre for Evidence-Based Medicine Levels of Evidence. The current paper contains the statements reflecting the position and practice of leading European experts in IF encompassing the general definition of IF surgery and organization of an IF unit, strategies to prevent IF, management of acute IF, management of wound, fistula and stoma, rehabilitation, intestinal and abdominal reconstruction, criteria for referral to a specialist unit and intestinal transplantation.
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Affiliation(s)
| | - C J Vaizey
- The Lennard Jones Intestinal Failure Unit, St Mark's Hospital, Northwick Park, Harrow, UK.,Imperial College London, London, UK
| | - Y Maeda
- The Lennard Jones Intestinal Failure Unit, St Mark's Hospital, Northwick Park, Harrow, UK.,Imperial College London, London, UK
| | - E Barbosa
- Serviço de Cirurgia, Hospital Pedro Hispano, Senhora da Hora, Portugal
| | - F Bozzetti
- Faculty of Medicine, University of Milan, Milan, Italy
| | - J Calvo
- Department of General, Digestive, Hepato-Biliary-Pancreatic Surgery and Abdominal Organ Transplantation Unit, University Hospital 12 de Octubre, Madrid, Spain
| | - Ø Irtun
- Gastrosurgery Research Group, UiT the Arctic University of Norway, University Hospital North-Norway, Tromsø, Norway.,Department of Gastroenterologic Surgery, University Hospital North-Norway, Tromsø, Norway
| | - P B Jeppesen
- Department of Medical Gastroenterology CA-2121, Rigshospitalet, Copenhagen, Denmark
| | - S Klek
- General and Oncology Surgery, General and Oncology Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - M Panisic-Sekeljic
- Department for Perioperative Nutrition, Clinic for General Surgery, Military Medical Academy, Belgrade, Serbia
| | - I Papaconstantinou
- 2nd Department of Surgery, Areteion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - A Pascher
- Department of General, Visceral, Vascular, Thoracic and Transplant Surgery, Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - Y Panis
- Colorectal Department, Beaujon Hospital and University Paris VII, Clichy, France
| | - W D Wallace
- Northern Ireland Regional Intestinal Failure Service, Belfast City Hospital, Belfast, UK
| | - G Carlson
- National Intestinal Failure Centre, Salford Royal NHS Foundation Trust, University of Manchester, Salford, Manchester, UK
| | - M Boermeester
- Department of Surgery/Intestinal Failure Team, Academic Medical Center, Amsterdam, The Netherlands
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Randomized Controlled Trial of the Use of a Large-pore Polypropylene Mesh to Prevent Incisional Hernia in Colorectal Surgery. Ann Surg 2015; 261:876-81. [DOI: 10.1097/sla.0000000000001116] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Prophylactic synthetic mesh can be safely used to close emergency laparotomies, even in peritonitis. Surgery 2014; 156:1238-44. [DOI: 10.1016/j.surg.2014.04.035] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 04/16/2014] [Indexed: 12/18/2022]
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Lee L, Mata J, Landry T, Khwaja KA, Vassiliou MC, Fried GM, Feldman LS. A systematic review of synthetic and biologic materials for abdominal wall reinforcement in contaminated fields. Surg Endosc 2014; 28:2531-46. [PMID: 24619334 DOI: 10.1007/s00464-014-3499-5] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 02/17/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Guidelines recommend the use of bioprosthetics for abdominal wall reinforcement in contaminated fields, but the evidence supporting the use of biologic over synthetic non-absorbable prosthetics for this indication is poor. Therefore, the objective was to perform a systematic review of outcomes after synthetic non-absorbable and biologic prosthetics for ventral hernia repair or prophylaxis in contaminated fields. METHODS The systematic literature search identified all articles published up to 2013 that reported outcomes after abdominal wall reinforcement using synthetic non-absorbable or biologic prosthetics in contaminated fields. Studies were included if they included at least 10 cases (excluding inguinal and parastomal hernias). Quality assessment was performed using the MINORS instrument. The main outcomes measures were the incidence of wound infection and hernia at follow-up. Weighted pooled proportions were calculated using a random effects model. RESULTS A total of 32 studies met the inclusion criteria and were included for synthesis. Mean sample size was 41.4 (range 10-190), and duration of follow-up was >1 year in 72 % of studies. Overall quality was low (mean 6.2, range 1-12). Pooled wound infection rates were 31.6 % (95 % CI 14.5-48.7) with biologic and 6.4 % (95 % CI 3.4-9.4) with synthetic non-absorbable prosthetics in clean-contaminated cases, with similar hernia rates. In contaminated and/or dirty fields, wound infection rates were similar, but pooled hernia rates were 27.2 % (95 % CI 9.5-44.9) with biologic and 3.2 % (95 % CI 0.0-11.0) with synthetic non-absorbable. Other outcomes were comparable. CONCLUSIONS The available evidence is limited, but does not support the superiority of biologic over synthetic non-absorbable prosthetics in contaminated fields.
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Affiliation(s)
- Lawrence Lee
- Steinberg-Bernstein Centre for Minimally-Invasive Surgery and Innovation, McGill University Health Centre, 1650 Cedar Ave, E19-125, Montreal, QC, H3G 1A4, Canada,
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van Barneveld KWY, Vogels RRM, Beets GL, Breukink SO, Greve JWM, Bouvy ND, Schreinemacher MHF. Prophylactic intraperitoneal mesh placement to prevent incisional hernia after stoma reversal: a feasibility study. Surg Endosc 2013; 28:1522-7. [DOI: 10.1007/s00464-013-3346-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 11/18/2013] [Indexed: 12/31/2022]
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