Surgical site infection: the "Achilles Heel" of all types of abdominal wall hernia reconstruction

The impact of simultaneous panniculectomy in ventral hernia repair: a systematic review and meta-analysis

BACKGROUND

Ventral hernia repair (VHR) is often performed in patients with obesity. While panniculectomy improves cosmetic outcomes, it may increase complications, particularly wound-related adverse events. Despite its widespread use, the impact of concurrent panniculectomy on postoperative complications in VHR remains unclear. This study aimed to assess whether concurrent panniculectomy increases postoperative complications in VHR.

METHODS

We searched PubMed, Scopus, Web of Science, and Cochrane databases for studies published up to April 2024 comparing surgical outcomes in patients undergoing VHR with and without concurrent panniculectomy. We assessed recurrence, seroma, hematoma, surgical site infections (SSI), wound dehiscence, skin necrosis, chronic wound, length of stay (LOS), readmissions, duration of surgery, and deep venous thromboembolism (DVT). Risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were pooled for dichotomous and continuous endpoints, respectively. We used RStudio for statistics and heterogeneity was assessed with I2 statistics.

RESULTS

We screened 890 studies, fully reviewed 40, and included 11 observational studies and 2 randomized controlled trials, comprising 23,354 patients. Of these, 2,972 (13%) patients underwent VHR with concurrent panniculectomy (VHR-PAN). The mean age ranged from 37 to 59 years, and 73% of the sample were women. The mean BMI varied from 29 to 45 kg/m2, and 75% of the patients underwent mesh repair. The mean defect area ranged from 36 to 389 cm2. Most repairs were performed using mesh (75%) in an underlay position (68%) and 24% underwent component separation. VHR-PAN was associated with a decrease in recurrence rates (RR 0.74; 95% CI 0.62 to 0.89; p < 0.001; I2 = 1%) with a follow-up ranging from 1 to 36 months. Furthermore, subgroup analysis of recurrence in studies with a mean follow-up of at least one year also showed a reduction in recurrence (RR 0.72; 95% CI 0.60 to 0.88; p < 0.001; I2 = 12%), with a follow-up ranging from 12 to 36 months. Moreover, concurrent panniculectomy was associated with increased SSI (RR 1.31; 95% CI 1.13 to 1.51; p < 0.001; I2 = 0%), SSO (RR 1.49; 95% CI 1.26 to 1.77; p < 0.001; I2 = 11%), skin necrosis (RR 2.94; 95% CI 1.26 to 6.85; p = 0.012; I2 = 0%) and reoperation (RR 1.73; 95% CI 1.32 to 2.28; p < 0.001; I2 = 0%), and longer LOS (MD 0.90 day; 95%CI 0.40 to 1.40; p < 0.001; I2 = 56%). There was no significant difference in ocurrence of DVT, enterocutaneous fistula, hematoma, seroma, or wound dehiscence, neither on operative time or readmission rates.

CONCLUSION

VHR-PAN is associated with lower recurrence rates. However, it increases the risk of wound morbidity and reoperation and prolongs hospital stay. Surgeons should carefully weigh the risks and benefits of performing VHR-PAN.

STUDY REGISTRATION

A review protocol for this systematic review and meta-analysis was registered at PROSPERO (CRD42024542721).

PROphylactic closed incision Negative-PRESSure treatment in open incisional hernia repair: Protocol for a multicenter randomized trial (PROPRESS study)

Background

Negative Pressure Therapy in closed incisions (ciNPT) after surgery has shown positive effects including reduction of Surgical Site Infection (SSI) incidence. In patients undergoing elective open incisional hernia repair, however, ciNPT is not standard care, perhaps due to high-quality evidence still not provided. This study hypothesizes that this patient group would benefit from ciNPT by reducing wound complications and improving postoperative quality of life.

Method

This is a multicenter Randomized Controlled Trial (RCT) including a total of 110 patients allocated in a 1:1 ratio with one intervention arm and one active control arm receiving ciNPT (i.e., Prevena™) and standard wound dressing, respectively. The primary outcome is the incidence of SSI at 30 days postoperatively and secondary outcomes are 1) pooled incidence of Surgical Site Occurrence (SSO), 2) patient-reported pain and satisfaction with the scar, and 3) hernia-related quality of life.

Conclusion

Patients undergoing elective open incisional hernia repair are fragile with a high risk of wound complication development. This multicenter RCT seeks to deliver the high-quality evidence needed to establish the role ciNPT must play for exactly this group with the aim of reducing SSI incidence and health economic costs, and finally improving quality of life. There are no theoretical or clinical experience of unwanted consequences of this treatment.

Incidence, Healthcare Resource Use and Costs Associated With Incisional Hernia Repair

Background: Incisional hernia (IH) is a common complication of abdominal surgery affecting between 12.8% and 30% of patients. In spite of this, rates of IH repair remain low, at around 5% in the literature. We aimed to assess the rate of IH repair in the UK across surgical specialties and the cost burden associated with IH repair. Methods: This is a retrospective observational study of patients undergoing abdominal surgery in England between 2012 and 2022 using the Hospital Episode Statistics (HES) database. Index abdominal surgery was identified between March 2014 and March 2017. Diagnostic and surgical procedure codes were used to identify pre-operative risk factors, index surgeries, IH repair and healthcare contact. Healthcare resource use (HCRU) costs were derived for index surgery and all post-index, non-elective inpatient admissions and outpatient visits using Healthcare Resource Group (HRG) codes within HES. Results: Of 297,134 patients undergoing abdominal surgery, 5.1% (n = 15,138) subsequently underwent incisional hernia repair. By specialty, rates were higher in Colorectal (10.0%), followed by Hepatobiliary (8.2%), Transplant (6.8%), Urological (4.0%), Bariatric (3.5%), Vascular (3.2%) and Gynaecological (2.6%) surgery. Patients undergoing IH repair had more healthcare contacts, longer length of inpatient stays and more A+E visits vs. those with no IH repair post index surgery (83% ≥ 1 A+E visit vs. 69%), as well as higher rates of referral to mental health services (19.8% vs. 11.5%). IH repair was associated with an average HCRU cost of £23,148 compared to £12,321 in patients with no IH repair. Conclusion: Patients undergoing IH repair have a greater morbidity than those not undergoing repair, shown by higher HCRU and more healthcare contacts. Despite this, rates of surgery for IH are low, suggesting that most patients with hernias are not undergoing repair. Emphasis must be placed squarely on primary prevention, rather than cure.

Next generation meshes for hernia repair: Polypropylene meshes coated with antimicrobial benzalkonium chloride induced proliferative activity of fibroblasts

Hernia repair is one of the most frequently performed world-wide surgical procedures in which hernia meshes are becoming increasingly used. Polypropylene (PP) mesh implants reduce the risk of recurrence and post-operative pain, although many other risks are associated with it, such as bacterial infection. In this study we developed PP meshes coated with the well-known antimicrobial compound, benzalkonium chloride (BAK) by dip-coating. Several dilutions (40, 20, 30, 10, 7.5, 5, 2.5, 1, 0.5, 0.1 and 0.05 % v/v) of commercial BAK solution (BAK diluted in 70 % ethyl alcohol at 0.1 % w/v) were used to produce antimicrobial meshes with different amounts of BAK. The dip-coating treatment with low concentrations of BAK (1, 0.5, 0.1 and 0.05 % v/v dilutions) was found to have biocompatible results in fibroblast. The use of 0.1 and 0.05 % v/v dilutions (PP meshes with up to ∼2 % w/w of BAK) showed proliferative activity on fibroblast cells, indicating that these novel antimicrobial meshes show great promise for hernia repair due to their ability to prevent infections while inducing fibroblast proliferation.

Hernia Prevention: The Role of Technique and Prophylactic Mesh to Prevent Incisional Hernias

Millions of laparotomies are performed annually, carrying up to a 41% risk of developing into a hernia. Incisional hernias are associated with morbidity, mortality, and costs; an estimated $9.6 billion is spent annually on repair of ventral hernias. Although repair is possible, surgeons must prevent incisional hernias from occurring. There is substantial evidence on surgical technique to reduce the risk of incisional hernia formation. This article aims to critically summarize the use of surgical technique and prophylactic mesh augmentation during fascial closure to inform decision-making and reduce incisional hernia formation.

Outcomes of Immediate Multistaged Abdominal Wall Reconstruction of Infected Mesh: Predictors of Surgical Site Complications and Hernia Recurrence

BACKGROUND

Mesh infection is one of the most devastating complications after ventral hernia repair. To date, no clear consensus exists on the optimal timing of definitive abdominal wall reconstruction (AWR) after excision of infected mesh. We evaluated outcomes of immediate multistaged AWR in patients with mesh infection.

METHODS

We performed a retrospective review of patients with mesh infection who underwent immediate, multistaged AWR, which consisted of exploratory laparotomy with debridement and mesh explantation, followed by definitive AWR during the same admission. Primary outcomes included hernia recurrence and surgical site occurrences, defined as wound dehiscence, surgical site infection, hematoma, and seroma.

RESULTS

Forty-seven patients with infected mesh were identified. At mean follow-up of 9.5 months, 5 patients (10.6%) experienced hernia recurrence. Higher body mass index (P = 0.006), bridge repair (P = 0.035), and postoperative surgical site infection (P = 0.005) were associated with hernia recurrence.

CONCLUSION

Immediate multistaged AWR is an effective surgical approach in patients with infected mesh.

Does smoking influence the clinical outcomes of robotic ventral hernia repair? A propensity score matching analysis study

The purpose of this study is to compare the clinical outcomes of robotic ventral hernia repair (RVHR) between smokers and non-smokers. Data for patients undergoing RVHR between 2012 and 2022 were collected. Patients were assigned to either smoking (+) or smoking (-) groups, according to their smoking status in the last 3 months prior to their procedure. Pre-, intra- and postoperative variables including surgical site occurrences (SSO) and infections (SSI), and hernia recurrence were analyzed after a propensity score matching analysis based on the patients' demographics and hernia's characteristics. Each group consisted of 143 patients matched according to their preoperative characteristics. There were no differences in terms of demographics and hernia characteristics. Intraoperative complications occurred at a comparable rate between both groups (p = 0.498). Comprehensive Complication Index® and all complication grades of the Clavien-Dindo classification were similar between both groups. Surgical site occurrences and infections did not differ either [smoking (+) vs. smoking (-): 7.6% vs 5.4%, p = 0.472; 5 vs. 0, p = 0.060, respectively). Rates of SSOs and SSIs that required any intervention (SSOPI) were similar in both groups [smoking (+): 3.1% vs. smoking (-): 0.8%, p = 0.370]. With a mean follow-up of 50 months for the cohort, recurrences rates were also comparable with 7 recorded in the smoking (-) versus 5 in the smoking (+) group (p = 0.215). Our study showed comparable rates of SSOs, SSIs, SSOPIs, and recurrence between smokers and non-smokers following RVHR. Future studies should compare the open, laparoscopic, and robotic approaches in smokers.

Successful management of strangulated incisional hernia in pregnancy - A case report

INTRODUCTION

Abdominal hernias, including incisional hernias, can occur due to weakness in the abdominal wall. Incisional hernias commonly occur following surgical incisions, and factors such as poor closure technique and patient-related factors can contribute to their development.

CASE PRESENTATION

In this case, the patient was presented with a painful, irreducible lump over a previous laparotomy scar, along with bowel obstruction symptoms. The diagnosis was supported by ultrasound findings showing obstructed bowel loop in the hernial sac. Emergency open surgical reduction and mesh repair were performed to treat the strangulated hernia and ensure the mother and fetus's safety. The patient had an uneventful postoperative period and was discharged after three days.

DISCUSSION

Incisional hernias can be diagnosed through clinical evaluation, and imaging studies may be necessary in complex cases. However, imaging techniques such as X-rays and Computed Tomography scans are limited in pregnant women due to the radiation risks. Ultrasonography (USS) is preferred in pregnant women for its safety and non-invasiveness, although it may have reduced sensitivity in obese patients. Complicated hernias should be treated with emergency surgical repair, while elective surgery can be considered for asymptomatic or non-complicated hernias. Laparoscopic surgery offers advantages such as shorter hospital stays and fewer complications. Mesh repair reduces the recurrence risk in subsequent pregnancies (relate the discussion with the case).

CONCLUSION

Overall, surgical management of hernias in pregnancy requires careful consideration of individual circumstances and the use of appropriate techniques to ensure the safety of both the mother and fetus.

The impact of comorbidities on postoperative outcomes of ventral hernia repair: the patients' perspective

INTRODUCTION

Ventral hernia repair (VHR) outcomes can be adversely affected by modifiable patient co-morbidities, such as diabetes, obesity, and smoking. Although this concept is well accepted among surgeons, the extent to which patients understand the significance of their co-morbidities is unknown, and a few studies have sought to determine patient perspectives regarding the impact of their modifiable co-morbidities on their post-operative outcomes. We attempted to determine how accurately patients predict their surgical outcomes after VHR compared to a surgical risk calculator while considering their modifiable co-morbidities.

METHODS

This is a prospective, single-center, survey-based study evaluating patients' perceptions of how their modifiable risk factors affect outcomes after elective ventral hernia repair. Pre-operatively, after surgeon counseling, patients predicted the percentage of impact that they believed their modifiable co-morbidities (diabetes, obesity, and smoking) had on 30-day surgical site infections (SSI) and hospital readmissions. Their predictions were compared to the Outcomes Reporting App for CLinicians and Patient Engagement (ORACLE) surgical risk calculator. Results were analyzed using demographic information.

RESULTS

222 surveys were administered and 157 were included in the analysis after excluding for incomplete data. 21% had diabetes, 85% were either overweight with body mass index (BMI) 25-29.9 or obese (BMI ≥ 30), and 22% were smokers. The overall mean SSI rate was 10.8%, SSOPI rate was 12.7%, and 30-day readmission rate was 10.2%. ORACLE predictions correlated with observed SSI rates (OR 1.31, 95% CI 1.12-1.54, p < 0.001), but patient predictions did not (OR 1.00, 95% CI 0.98-1.03, p = 0.868). The correlation between patient predictions and ORACLE calculations was weak ([Formula: see text] = 0.17). Patient predictions were on average 10.1 ± 18.0% different than ORACLE, and 65% overestimated their SSI probability. Similarly, ORACLE predictions correlated with observed 30-day readmission rates (OR 1.10, 95% CI 1.00-1.21, p = 0.0459), but patient predictions did not (OR 1.00, 95% CI 0.975-1.03, p = 0.784). The correlation between patient predictions and ORACLE calculations for readmissions was weak ([Formula: see text] = 0.27). Patient predictions were on average 2.4 ± 14.6% different than ORACLE, and 56% underestimated their readmission probability. Additionally, a substantial proportion of the cohort believed that they had a 0% risk of SSI (28%) and a 0% risk of readmission (43%). Education, income and healthcare employment did not affect the accuracy of patient predictions.

CONCLUSIONS

Despite surgeon counseling, patients do not accurately estimate their risks after VHR when compared to ORACLE. Most patients overestimate their SSI risk and underestimate their 30-day readmission risk. Furthermore, several patients believed that they had a 0% risk of SSI and readmission. These findings persisted regardless of level of education, income level, or healthcare employment. Additional attention should be directed toward setting expectations prior to surgery and using applications such as ORACLE to assist in this process.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Microbiological epidemiology and antibiotic susceptibility of infected meshes after prosthetic abdominal wall repair

INTRODUCTION

Infectious complications of parietal mesh after prosthetic abdominal wall repair are rare. Their management is complex. Furthermore, the emergence of bacterial resistance, the presence of a foreign material, the need to continue an extended antibiotic therapy, and the choice of an appropriate treatment are crucial. The objective of this study is to access the microbiological epidemiology of infected parietal meshes in order to optimize the empirical antibiotic therapy.

METHODS

Between January 2016 and December 2021, a monocentric and retrospective study was performed in patients hospitalized for infected parietal meshes at Avicenne hospital, in Paris area. Clinical and microbiological data such as antibiotic susceptibility were collected.

RESULTS

Twenty-six patients with infected parietal meshes have been hospitalized during this period. Meshes were in preaponevrotic positions (n=10; 38%), retromuscular (n=6; 23%) and intraperitoneal (n=10; 38%). Among the 22 (84.6%) documented cases of infections, 17 (77.3%) were polymicrobial. A total of 54 bacteria were isolated, 48 of which had an antibiogram available. The most frequently isolated bacteria were: Enterobacterales (n=19), Enterococcus spp. (n=11) and Staphylococcus aureus (n=6), whereas anaerobes were poorly isolated (n=3). Concerning these isolated bacteria, amoxicillin-clavulanic acid, metronidazole-associated cefotaxime, piperacillin-tazobactam and meropenem were susceptible in 45.5%, 68.2%, 63.6%, 77.2%, of cases, respectively.

CONCLUSION

This work highlights that infections of abdominal parietal meshes may be polymicrobial and the association amoxicillin-clavulanic acid cannot be used as a probabilist antibiotic therapy because of the high resistance rate in isolated bacteria. The association piperacillin-tazobactam appears to be a more adapted empirical treatment to preserve carbapenems, a broad-spectrum antibiotic class.

Risk factors for recurrence in blunt traumatic abdominal wall hernias: A secondary analysis of a Western Trauma association multicenter study

BACKGROUND

Few studies have investigated risk factors for recurrence of blunt traumatic abdominal wall hernias (TAWH).

METHODS

Twenty trauma centers identified repaired TAWH from January 2012 to December 2018. Logistic regression was used to investigate risk factors for recurrence.

RESULTS

TAWH were repaired in 175 patients with 21 (12.0%) known recurrences. No difference was found in location, defect size, or median time to repair between the recurrence and non-recurrence groups. Mesh use was not protective of recurrence. Female sex, injury severity score (ISS), emergency laparotomy (EL), and bowel resection were associated with hernia recurrence. Bowel resection remained significant in a multivariable model.

CONCLUSION

Female sex, ISS, EL, and bowel resection were identified as risk factors for hernia recurrence. Mesh use and time to repair were not associated with recurrence. Surgeons should be mindful of these risk factors but could attempt acute repair in the setting of appropriate physiologic parameters.

Incisional hernia repair in rats: description of the sublay technique under videomagnification system

PURPOSE

To describe the technique of sublay correction of incisional hernia in Wistar rats under videomagnification system.

METHODS

Five male rats of the species Rattus norvegicus, of the Wistar lineage, with body weight between 250-350 g and 60 days old were used. Incisional hernia was inducted in all animals. After that, the incisional hernia was immediately corrected by the sublay method.

RESULTS

There were no cases of recurrence of the incisional hernia after placement of the polypropylene mesh using the sublay technique. No postoperative complications were observed.

CONCLUSIONS

The technique is suitable for execution in Wistar rats.

Changes in Number and Antibacterial Activity of Silver Nanoparticles on the Surface of Suture Materials during Cyclic Freezing

This article presents the results of the 10-fold cyclic freezing (−37.0 °C) and thawing (0.0 °C) effect on the number and size range of silver nanoparticles (AgNPs). AgNPs were obtained by the cavitation-diffusion photochemical reduction method and their sorption on the fiber surface of various suture materials, perlon, silk, and catgut, was studied. The distribution of nanoparticles of different diameters before and after the application of the cyclic freezing/thawing processes for each type of fibers studied was determined using electron microscopy. In general, the present study demonstrates the effectiveness of using the technique of 10-fold cyclic freezing. It is applicable to increase the absolute amount of AgNPs on the surface of the suture material with a simultaneous decrease in the size dispersion. It was also found that the application of the developed technique leads to the overwhelming predominance of nanoparticles with 1 to 15 nm diameter on all the investigated fibers. In addition, it was shown that after the application of the freeze/thaw method, the antibacterial activity of silk and catgut suture materials with AgNPs was significantly higher than before their treatment by cyclic freezing.

Risks and Prevention of Surgical Site Infection After Hernia Mesh Repair and the Predictive Utility of ACS-NSQIP

AIM

The aim of this paper was to provide a narrative review of surgical site infection after hernia surgery and the influence of perioperative preventative interventions.

METHODS

The review was based on current national and international guidelines and a literature search.

RESULTS

Mesh infection is a highly morbid complication after hernia surgery, and is associated with hospital re-admission, increased health care costs, re-operation, hernia recurrence, impaired quality of life and plaintiff litigation. The American College of Surgeons National Surgical Quality Improvement Program is a particularly useful resource for the study and evidence-based practise of abdominal wall hernia repair.

DISCUSSION

The three major modifiable patient comorbidities significantly associated with postoperative surgical site infection in hernia surgery are obesity, tobacco smoking and diabetes mellitus. Preoperative optimization includes weight loss, cessation of smoking, and control of diabetes. Intraoperative interventions relate, in particular, to the control of fomite mediated transmission in the operating theatre and prevention of mesh contamination with S. aureus CFUs. Risk management strategies should also target the niche ecological conditions which enable bacterial survival and subsequent biofilm formation on an implanted mesh. Outcomes of mesh infection after hernia surgery are closely related to mesh type and porosity, patient smoking status, presence of MRSA, bacterial adhesion and biofilm production. The use of suction drains and the timing of drain removal are controversial and discussed in detail. Finally, the utility of the ACS-NSQIP Surgical Risk Calculator in predicting complications and outcomes in individual patients and the importance of quality improvement initiatives in surgical units are emphasized.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Different etiopathogeneses in early-onset and late-onset inguinal hernia mesh infections in a prospectively evaluated cohort

INTRODUCTION

Inguinal hernia mesh infection (IHMI) is a rare but a significant problem. The aim of this study was to determine whether etiopathogeneses of early-onset and late-onset IHMIs differ in terms of the origin of infectious agents, and route of dissemination.

PATIENTS AND METHODS

This was a retrospective cohort study with prospective data collection of patients operated on from 2013 to 2015. Early-onset IHMI was defined as symptoms developed within one year after the index surgery, whereas late-onset IHMI was defined as infection developed later than a year after the index surgery. Age, gender, ASA score, BMI, time from index surgery, isolated infectious agents and possible pathogeneses were analyzed.

RESULTS

During the study period, 1438 patients underwent inguinal hernia repair. Sixteen patients (1.1%) had IHMI, of whom nine were early-onset and seven late-onset. The groups were comparable for age (p = .54), gender (p = 1.0), BMI (p = .79), and ASA score (p = 1.0). The most common infectious agent in early-onset IHMI was St. aureus, whereas Enterococci and Enterobacter prevailed in late-onset IHMI. The possible pathogenesis of IHMI in seven patients with early-onset IHMI was primary exogenous infection, whereas in patients with late-onset IHMI the pathogenesis might be hematogenous or contact spread. All patients with IHMI underwent mesh removal. In two patients (one from each group), partial mesh removal was performed previously and IHMI recurred.

CONCLUSIONS

Early-onset hernia mesh infection is mostly caused by St. aureus through exogenous contamination, whereas its late-onset counterpart might be a result of hematogenous or contact spread of intestinal flora.

Independent Predictors for Surgical Site Infections in Patients Undergoing Complex Abdominal Wall Reconstruction

INTRODUCTION

Complex abdominal wall reconstruction (CAWR) in patients with large abdominal defects have become a common procedure. The aim of this study was to identify independent predictors of surgical site infections (SSI) in patients undergoing CAWR.

MATERIALS AND METHODS

This was an ambidirectional cohort study of 240 patients who underwent CAWR with biologic mesh between 2012 and 2020 at an academic tertiary/quaternary care center. Prior superficial SSI, deep SSI, organ space infections, enterocutaneous fistulae, and combined abdominal infections were defined as prior abdominal infections. Univariable and multivariable logistic regression models were performed to determine independent risk factors for SSI.

RESULTS

There were a total of 39 wound infections, with an infection rate of 16.3%. Forty percent of patients who underwent CAWR in this study had a history of prior abdominal infections. In the multivariable regression models not weighted for length of stay (LOS), prior abdominal infection (odds ratio [OR]: 2.49, p=0.013) and higher body mass index (BMI) (OR: 1.05, p=0.023) were independent predictors of SSI. In the multivariable regression model weighted for LOS, prior abdominal infection (OR: 2.2, p=0.034), higher BMI (OR: 1.05, p=0.024), and LOS (OR: 1.04, p=0.043) were independent predictors of SSI.

CONCLUSION

The history of prior abdominal infections, higher BMI, and increased LOS are important independent predictor of SSI following CAWR.

Comparative study of biological versus synthetic prostheses in the treatment of ventral hernias classified as grade II/III by the Ventral Hernia Working Group

AIM OF THE STUDY

The implantation of biological prostheses in an at-risk environment has seen increasing use. Their markedly higher cost compared to synthetic prostheses makes it important to analyse their usefulness in terms of actual benefit and cost-effectiveness. This study aims to examine the relevance of bioprostheses during surgical repair of Grade II/III ventral hernias as classified by the Ventral hernia working group (VHWG).

MATERIALS AND METHODS

This study analysed the data of 119 patients requiring non-emergency repair of VHWG II/III grade hernias between 2010 and 2017. The results of patients who were treated with a bioprosthesis (n=59) were compared to those receiving a synthetic prosthesis (n=60). The primary outcome was surgical site infection (SSI) at 90 days. The secondary endpoints were hernia recurrence rate, cost of the prosthesis, duration of hospital stay and re-hospitalisation rate.

RESULTS

The two groups were shown to be comparable by analysis of demographic, pre- and intraoperative data. The SSI rate was significantly higher in the bioprosthesis group (20% vs. 7%; P=0.010), as was the recurrence rate (56% vs. 28%; P=0.003) with a median follow-up of 40 months. The cost of the bioprosthesis was significantly higher than that of the synthetic prosthesis (€3363 vs. €249; P<0.010).

CONCLUSION

In this retrospective study, the use of a bioprosthesis for repair of VHWG II/III ventral hernias was associated with a higher rate of both SSI and hernia recurrence at a cost 13 times greater than the use of a synthetic prosthesis.

Infectious Complication in Relation to the Prophylactic Mesh Position: The PRIMA Trial Revisited

BACKGROUND

Prophylactic mesh reinforcement has proven to reduce the incidence of incisional hernia (IH). Fear of infectious complications may withhold the widespread implementation of prophylactic mesh reinforcement, particularly in the onlay position.

STUDY DESIGN

Patients scheduled for elective midline surgery were randomly assigned to a suture closure group, onlay mesh group, or sublay mesh group. The incidence, treatment, and outcomes of patients with infectious complications were assessed through examining the adverse event forms. Data were collected prospectively for 2 years after the index procedure.

RESULTS

Overall, infectious complications occurred in 14/107 (13.3%) patients in the suture group and in 52/373 (13.9%) patients with prophylactic mesh reinforcement (p = 0.821). Infectious complications occurred in 17.6% of the onlay group and 10.3% of the sublay group (p = 0.042). Excluding anastomotic leakage as a cause, these incidences were 16% (onlay) and 9.7% (sublay), p = 0.073. The mesh could remain in-situ in 40/52 (77%) patients with an infectious complication. The 2-year IH incidence after onlay mesh reinforcement was 10 in 33 (30.3%) with infectious complications and 15 in 140 (9.7%) without infectious complications (p = 0.003). This difference was not statistically significant for the sublay group.

CONCLUSIONS

Prophylactic mesh placement was not associated with increased incidence, severity, or need for invasive treatment of infectious complications compared with suture closure. Patients with onlay mesh reinforcement and an infectious complication had a significantly higher risk of developing an incisional hernia, compared with those in the sublay group.

Management of complex ventral hernias: results of an international survey

Background

The surgical treatment of patients with complex ventral hernias is challenging. The aim of this study was to present an international overview of expert opinions on current practice.

Methods

A survey questionnaire was designed to investigate preoperative risk management, surgical approach and mesh choice in patients undergoing complex hernias repair, and treatment strategies for infected meshes. Geographical location of practice, experience and annual volumes of the surgeons were compared.

Results

Of 408 surgeons, 234 (57.4 per cent) were practising in the USA, 116 (28.4 per cent) in Europe, and 58 (14.2 per cent) in other countries. Some 412 of 418 surgeons (98.6 per cent) performed open repair and 322 of 416 (77.4 per cent) performed laparoscopic repair. Most recommended preoperative work-up/lifestyle changes such as smoking cessation (319 of 398, 80.2 per cent) and weight loss (254 of 399, 63.7 per cent), but the consequences of these strategies varied. American surgeons and less experienced surgeons were stricter. Antibiotics were given at least 1 h before surgery by 295 of 414 respondents (71.3 per cent). Synthetic and biological meshes were used equally in contaminated primary hernia repair, whereas for recurrent hernia repair synthetic mesh was used in a clean environment and biological or no mesh in a contaminated environment. American surgeons and surgeons with less experience preferred biological mesh in contaminated environments significantly more often. Percutaneous drainage and antibiotics were the first steps recommended in treating mesh infection. In the presence of sepsis, most surgeons favoured synthetic mesh explantation and further repair with biological mesh.

Conclusion

There remains a paucity of good-quality evidence in dealing with these hernias, leading to variations in management. Patient optimization and issues related to mesh choice and infections require well designed prospective studies.

Ventral hernia repair with synthetic mesh in a contaminated field: a systematic review and meta-analysis

PURPOSE

The use of mesh in ventral hernia repair becomes especially challenging when associated with a contaminated field. Permanent synthetic mesh use in this setting is currently debated and this discussion is yet to be resolved clinically or in the literature. We aim to systematically assess postoperative outcomes of non-absorbable synthetic mesh (NASM) used in ventral hernia repair in the setting of contamination.

METHODS

A literature search of PubMed, Embase, Scopus, Cinahl, and Cochrane Library identified all articles from 2000-2020 that examined the use of NASM for ventral hernia repair in a contaminated field. Postoperative outcomes were assessed by means of pooled analysis and meta-analysis. Qualitative analysis was completed for all included studies using a modified Newcastle-Ottawa scale.

RESULTS

Of 630 distinct publications and 104 requiring full review, this study included 17 articles published between 2007 and 2020. Meta-analysis demonstrated absorbable mesh was associated with more HR (OR 1.89, 1.15-3.12, p = 0.008), SSO (OR 1.43, 0.96-2.11, p = 0.087), SSI (OR 2.84, 1.85-4.35, p < 0.001), and unplanned reoperation (OR 1.99, 1.19-3.32, p = 0.009) compared to NASM.

CONCLUSION

The use of NASM for ventral hernia repair in a contaminated field may be a safe alternative to absorbable mesh, as evidenced by lower rates of postoperative complications. This review counters the current clinical paradigm, and additional prospective randomized controlled trials are warranted.

Open versus laparoscopic incisional hernia repair: nationwide database study

Background

Although laparoscopic repair of incisional hernias decreases the incidence of wound complications compared with open repair, there has been rising concern related to intraperitoneal mesh placement. The aim of this study was to examine outcomes after open or laparoscopic elective incisional hernia mesh repair on a nationwide basis.

Methods

This study analysed merged data from the Danish Hernia Database and the National Patient Registry on perioperative information, 90-day readmission, 90-day reoperation for complication, and long-term operation for hernia recurrence among patients who underwent primary repair of an incisional hernia between 2007 and 2018.

Results

A total of 3090 (57.5 per cent) and 2288 (42.5 per cent) patients had surgery by a laparoscopic and open approach respectively. The defect was closed in 865 of 3090 laparoscopic procedures (28.0 per cent). The median follow-up time was 4.0 (i.q.r. 1.8–6.8) years. Rates of readmission (502 of 3090 (16.2 per cent) versus 442 of 2288 (19.3 per cent); P = 0.003) and reoperation for complication (216 of 3090 (7.0 per cent) versus 288 of 2288 (12.5 per cent); P < 0.001) were significantly lower for laparoscopic than open repairs. Reoperation for bowel obstruction or bowel resection was twice as common after laparoscopic repair compared with open repair (20 of 3090 (0.6 per cent) versus 6 of 2288 (0.3 per cent); P = 0.044). Patients were significantly less likely to undergo repair of recurrence following laparoscopic compared with open repair of defect widths 2–6 cm (P = 0.002).

Conclusion

Laparoscopic intraperitoneal mesh repair for incisional hernia should still be considered for fascial defects between 2 and 6 cm, because of decreased rates of early complications and repair of hernia recurrence compared with open repair.

Chevrel technique for ventral incisional hernia. Is it still an effective procedure?

BACKGROUND

Incisional hernia still represents the most frequent late complication of abdominal surgery. After a direct repair, in literature is reported a recurrence rate ranging from 31 to 49%, meanwhile after a prosthetic repair such values were much lower, with a recurrence rate up to 10%. The sites of prosthetic placement in the abdominal wall are premusculo-aponeurotic (onlay, or Chevrel technique), retromuscular-prefascial and preperitoneal (Rives technique, Stoppa technique), whereas intraperitoneal insertion can be done with open or laparoscopic surgery. The aim of this study was to evaluate the immediate and late postoperative results in patients treated with a Chevrel technique for ventral incisional hernia.

METHODS

A retrospective review was conducted on the medical records of patients undergoing ventral hernia repair between January 2008 and December 2018 at the Emergency Surgery Unit of the Careggi University Hospital in Florence.

RESULTS

Between January 2008 and December 2018 at the Emergency Surgery Unit of the Careggi University Hospital in Florence, 461 patients (245 male, 216 female) with a mean age of 61,52 years were submitted to ventral incisional hernia repair with a Chevrel technique. The mean operatory time was 95.29 min (±50.48) and in 72 patients (15.61%) human fibrin glue was vaporized under the mesh using a spray device. Mean postoperative hospital stay was 5 days and all drain tubes were removed after 7.1 days as mean (±4.3). No intraoperative mortality nor postoperative mortality was reported. In our experience the Chevrel technique for ventral incisional hernia show a recurrence rate (3.2%). Parietal complications observed were seroma in 7.1% of patients, hematoma in 4.7%, localized skin necrosis in 5.2%, surgical site infection in 6.7%, data comparable with the results reported in the other studies.

CONCLUSIONS

Most of the objections to the Chevrel procedure focus on the parietal complications and risk of infection. Chevrel procedure cannot be considered an obsolete intervention, in our series, results were very satisfactory in both immediate and late follow-up; moreover this technique is safe and easy to perform.

What are the trends in incisional hernia repair? Real-world data over 10 years from the Herniamed registry

INTRODUCTION

There is an increasingly controversial debate about the best possible incisional hernia repair technique. Despite the good outcomes of laparoscopic IPOM, concerns about the intraperitoneal mesh placement and its potential intraabdominal complications have risen. Against that background, this paper now analyzes changes and trends in incisional hernia repair techniques in the recent decade.

METHODS

Between 2010 and 2019 a total of 61,627 patients with primary elective incisional hernia repair were enrolled in the Herniamed Registry. The outcome results were assigned to the year of repair and summarized as curves to visualize trends. The explorative Fisher's exact test was used for statistical calculation of significant differences. Since the number of cases entered into the Herniamed Registry for the years 2010-2012 was still relatively small, the years 2013 and 2019 were compared for statistical analysis.

RESULTS

In the analyzed time period, the proportion of incisional hernias repaired in open suture technique remained unchanged at about 10%. The proportion of laparoscopic IPOM repairs decreased significantly from 33.8% in 2013 to 21.0% (p < 0.001) in 2019. Conversely, the proportion of open sublay repairs increased significantly from 32.1% in 2013 to 41.4% (p < 0.001) in 2019. Starting in 2015, there has also been the introduction and increasing use (4.5% in 2013 vs. 10.0% in 2019; p < 0.001) of new minimally-invasive techniques with placement of a mesh into the sublay/retromuscular/preperitoneal abdominal wall layer (E/MILOS, eTEP, preperitoneal mesh technique).

CONCLUSION

Analysis of data from the Herniamed Registry shows a significant trend to the disadvantage of the laparoscopic IPOM and to the advantage of the open sublay operation and the new minimally-invasive techniques (E/MILOS, eTEP, preperitoneal mesh technique). Despite all the recommendations in the guidelines, 10% of incisional hernias continue to be treated by means of a suture technique.

Should simultaneous stoma closure and incisional hernia repair be avoided?

PURPOSE

Patients scheduled for stoma closure may also have an incisional hernia. Studies have reported acceptable outcomes after contaminated ventral hernia repair, but whether stoma closure and incisional hernia repair should be performed as a combined procedure is unknown. This study examined combined stoma closure and incisional hernia repair compared with incisional hernia repair only.

METHODS

This was a nationwide propensity-score matched study. Patients who underwent elective incisional hernia repair from 2007-2017 were identified in the Danish Hernia Database. All patients who underwent concurrent stoma closure were matched 1:3 with patients who underwent incisional hernia repair only. The primary outcome was reoperation for hernia recurrence, whereas secondary outcomes included anastomotic leakage, length of hospital stay, and 30-day reoperation and readmission rates.

RESULTS

In total, 516 patients were included. The risk of reoperation for recurrence was increased after concurrent stoma closure compared with incisional hernia repair only (hazard ratio 1.69, 95% confidence interval 1.01-2.82, p = 0.044). Seven (5.4%) patients who underwent incisional hernia repair concurrent to stoma closure were reoperated for anastomotic leakage. Length of hospital stay and reoperation rates within 30 days were increased after concurrent stoma closure compared with incisional hernia repair only (median 8 versus 3 days, p < 0.001 and 29.5% versus 18.6%, p = 0.013), whereas there was no difference in 30-day readmission rates (p = 0.251).

CONCLUSIONS

Stoma closure and incisional hernia repair should be performed as a dual-stage procedure to decrease the risk of hernia recurrence.

Staged complex abdominal wall hernia repair in morbidly obese patients

PURPOSE

The repair of complex abdominal wall hernias in morbidly obese patients is often associated with a higher risk of complications and hernia recurrences. Improvement in obesity and its associated metabolic complications are hypothesized to improve hernia repair outcomes. This study analyzes outcomes from morbidly obese patients who underwent bariatric surgery with staged complex abdominal wall reconstruction at Creighton University Medical Center (CUMC).

METHODS

This retrospective study included morbidly obese patients with complex abdominal wall hernia, who underwent bariatric surgery with staged abdominal wall reconstruction. Data points collected included patient demographics, obesity-related co-morbidities, pre-operative BMI, EBMIL at 12 months, hernia characteristics, postoperative complications, BMI at time of hernia repair, and hernia recurrence.

RESULTS

Twelve patients with an average BMI of 48 and complex abdominal wall hernias (mean width 14.0 cm) met inclusion criteria. Seven patients (58%) had significant loss of domain. Bariatric procedures included six laparoscopic sleeve gastrectomies (LSG), three laparoscopic Roux-en-Y gastric bypasses (LRNYGB), and three revisional procedures (2 vertical band gastroplasties to LRNYGB and 1 LRNYGB revision). At 12-month follow-up, the mean excess BMI loss (EBMIL) was 64.6%. The average time to staged complex abdominal wall reconstruction was 22.3 months. Two non-elective hernia repairs were performed due to one incarceration and one strangulation. There were no recurrences after an average follow-up of 21.9 months.

CONCLUSIONS

In this study, staged mesh repair of complex abdominal wall hernias after bariatric surgery in morbidly obese patients was associated with acceptable morbidity and no hernia recurrences at approximately 1.5 year follow-up.

Is there an advantage to laparoscopy over open repair of primary umbilical hernias in obese patients? An analysis of the Americas Hernia Society Quality Collaborative (AHSQC)

PURPOSE

The most common techniques used to repair umbilical hernias are open and laparoscopic. As the obesity epidemic in the United States is growing, it is essential to understand how this morbidity affects umbilical hernia repairs. This study compares laparoscopic versus open umbilical hernia repairs in obese patients.

METHODS

All patients with body mass index (BMI) ≥ 30 kg/m² who underwent elective, open or laparoscopic repair of a primary umbilical hernia with mesh were identified from the Americas Hernia Society Quality Collaborative (AHSQC). A retrospective review of the prospectively collected data was conducted. Outcomes of interest included surgical site infections (SSI), surgical site occurrences requiring procedural intervention (SSOPI), hernia-related quality-of-life survey (HerQles), and long-term recurrence. A logistic regression model was used to generate propensity scores.

RESULTS

Of 1507 patients who met the inclusion criteria, 322 were laparoscopic, and 1185 were open cases. The laparoscopic group had higher mean BMI (37 ± 6 vs. 35 ± 5 kg/m² , P < 0.001 ) and mean hernia width (3 cm ± 1 vs. 2 cm ± 2, P < 0.001). Using a propensity score model, we controlled for several clinically relevant covariates. Propensity score adjustment showed no differences in the 30-day HerQles score (OR 0.93, 95% CI 0.58-1.49), SSI (OR 1.57, 95% CI 0.52-4.77), SSOPI (OR 2.85, 95% CI 0.84-9.62) or hernia recurrence (hazard ratio 0.86, 95% CI 0.50-1.49).

CONCLUSION

In obese patients with primary umbilical hernias, there is likely no benefit to laparoscopy over open umbilical hernia repair with mesh with regard to wound morbidity. Although, the long-term recurrence also showed no difference between these two approaches, overall follow up was lacking.

Improving Shared Decision-making and Treatment Planning Through Predictive Modeling: Clinical Insights on Ventral Hernia Repair

Abdominal wall hernia repair, including ventral hernia repair, is one of the most common general surgical procedures. Nationally, at least 350 000 ventral hernia repairs are performed annually, and of those, 150 000 cases were identified as incisional hernias. Outcomes are reported to be poor, resulting in additional surgical repair rates of 12.3% at 5 years and as high as 23% at 10 years. Healthcare costs associated with ventral hernia repair are estimated to exceed $3 billion each year. Additionally, ventral hernia repair is often complex and unpredictable when there is a current infection or a history of infection and significant comorbidities. Accordingly, a predictive model was developed using a retrospectively collected dataset to associate the pre- and intra-operative characteristics of patients to their outcomes, with the primary goal of identifying patients at risk of developing complications a priori in the future. The benefits and implications of such a predictive model, however, extend beyond this primary goal. This predictive model can serve as an important tool for clinicians who may use it to support their clinical intuition and clarify patient need for lifestyle modification prior to abdominal wall reconstruction. This predictive model can also support shared decision-making so that a personalized plan of care may be developed. The outcomes associated with use of the predictive model may include surgical repair but may suggest lifestyle modification coupled with less invasive interventions.

What Do We Know About the Chevrel Technique in Ventral Incisional Hernia Repair?

Introduction: In publications on ventral incisional hernia repair, the Chevrel technique and the onlay operation are often equated. This present review now aims to present the difference between these surgical techniques and analyze the findings available on the Chevrel technique.

Materials and Methods: A systematic search of the available literature was performed in January 2019 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library, as well as a search of relevant journals, books, and reference lists. Thirty-four publications were identified as relevant for this review. For assessment of the Chevrel-technique with other surgical procedures there are no randomized controlled trials, prospective or retrospective comparative studies available but only case series. In the majority of case series the follow-up procedure is not reported.

Results: In the onlay technique the defect is closed with direct suture or it is omitted altogether. Whereas, in the Chevrel technique this is done with sliding myofascial flaps harvested from the rectus sheaths. In the few case series available this appears to result in a lower recurrence rate for the Chevrel technique compared with the onlay technique. However, the rates of postoperative complications, surgical site occurrences (SSOs), surgical site infections (SSIs), seroma, and skin necrosis are as high as in the onlay technique. The reason for this is that both techniques require subcutaneous undermining with severance of perforator vessels.

Conclusion: If mesh placement in onlay position has been chosen for specific reasons, preference can be given to the Chevrel technique over the standard onlay technique, although the study quality is limited.