Analysis of Outcomes by Extraction Site following Subtotal Colectomy in Ulcerative Colitis: A Retrospective Cohort Study

Risk Factors for the Development of Parastomal Hernia: A Narrative Review

Parastomal hernia is one of the most common late complications after stoma formation, significantly decreasing patient's quality of life and negatively impacting body image and physical functioning. Progress has been made regarding the surgical technique of stoma creation in different categories of patients, but a better understanding of the risk factors is crucial in reducing the likeliness of parastomal hernia formation and in helping develop risk stratification strategies for pre-and post-operation management. However, currently there is limited consensus on the associated risk factors. Accordingly, for this narrative review, the authors conducted a literature review through three databases (PubMed, Web of Science, and Scopus) and categorized the identified risk factors into the following three categories: patient-, surgery-, and disease-related. Within these categories, the following 10 risk factors were identified and discussed: age, gender, waist circumference, type of ostomy, laparoscopic approach, aperture size >3 cm, stoma not passing through the middle of rectus abdominis muscle, BMI >25 kg/m2, altered collagen metabolism, and diabetes.

Extraction Site in Minimally Invasive Colorectal Surgery

The widespread adoption of minimally invasive colorectal surgery has led to improved patient recovery and outcomes. Specimen extraction sites remain a major source of pain and potential postoperative morbidity. Careful selection of the extraction site incision may allow surgeons to decrease postoperative pain, infectious complications, or rates of hernia formation. Options include midline, paramedian, transverse, Pfannenstiel, and natural orifice sites. Patient, disease, and surgeon-related factors should all be considered when choosing a site. This article will review different options for specimen extraction sites.

The incidence of extraction site incisional hernia after minimally invasive colorectal surgery: a systematic review and meta-analysis

AIM

Minimally invasive colorectal surgery reduces surgical trauma with better preservation of abdominal wall integrity, but the extraction site is still at risk of incisional hernia (IH). The aim of this study was to determine pooled incidence of IH for each type of extraction site and to compare rates of IH after midline, nonmidline and Pfannenstiel extraction.

METHOD

A systematic review and meta-analysis was conducted using the PRISMA guidelines. Single-armed and multiple-armed cohort studies and randomized controlled trials regarding minimally invasive colorectal surgery were searched from five databases. Outcomes were pooled and compared with random-effects, inverse-variance models. Risk of bias within the studies was assessed using the Cochrane ROBINS-I and RoB 2 tool.

RESULTS

Thirty six studies were included, with a total 11,788 patients. The pooled extraction site IH rate was 16.0% for midline (n = 4081), 9.3% for umbilical (n = 2425), 5.2% for transverse (n = 3213), 9.4% for paramedian (n = 134) and 2.1% for Pfannenstiel (n = 1449). Nonmidline extraction (transverse and paramedian) showed significantly lower odds ratios (ORs) for IH when compared with midline extraction (including umbilical). Pfannenstiel extraction resulted in a significantly lower OR for IH compared with midline [OR 0.12 (0.50-0.30)], transverse [OR 0.25 (0.13-0.50)] and umbilical (OR 0.072 [0.033-0.16]) extraction sites. The risks of surgical site infection, seroma/haematoma or wound dehiscence were not significantly different in any of the analyses.

CONCLUSION

Pfannenstiel extraction is the preferred method in minimally invasive colorectal surgery. In cases where Pfannenstiel extraction is not possible, surgeons should avoid specimen extraction in the midline.

Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies

BACKGROUND

Incisional hernia is a frequent complication of abdominal wall incision. Surgical technique is an important risk factor for the development of incisional hernia. The aim of these updated guidelines was to provide recommendations to decrease the incidence of incisional hernia.

METHODS

A systematic literature search of MEDLINE, Embase, and Cochrane CENTRAL was performed on 22 January 2022. The Scottish Intercollegiate Guidelines Network instrument was used to evaluate systematic reviews and meta-analyses, RCTs, and cohort studies. The GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation) was used to appraise the certainty of the evidence. The guidelines group consisted of surgical specialists, a biomedical information specialist, certified guideline methodologist, and patient representative.

RESULTS

Thirty-nine papers were included covering seven key questions, and weak recommendations were made for all of these. Laparoscopic surgery and non-midline incisions are suggested to be preferred when safe and feasible. In laparoscopic surgery, suturing the fascial defect of trocar sites of 10 mm and larger is advised, especially after single-incision laparoscopic surgery and at the umbilicus. For closure of an elective midline laparotomy, a continuous small-bites suturing technique with a slowly absorbable suture is suggested. Prophylactic mesh augmentation after elective midline laparotomy can be considered to reduce the risk of incisional hernia; a permanent synthetic mesh in either the onlay or retromuscular position is advised.

CONCLUSION

These updated guidelines may help surgeons in selecting the optimal approach and location of abdominal wall incisions.

An evidence map and synthesis review with meta-analysis on the risk of incisional hernia in colorectal surgery with standard closure

PURPOSE

To assess the incidence of incisional hernia (IH) across various type of incisions in colorectal surgery (CS) creating a map of evidence to define research trends, gaps and areas of future interest.

METHODS

Systematic review of PubMed and Scopus from 2010 onwards. Studies included both open (OS) and laparoscopic (LS). The primary outcome was incidence of IH 12 months after index procedure, secondary outcomes were the study features and their influence on reported proportion of IH. Random effects models were used to calculate pooled proportions. Meta-regression models were performed to explore heterogeneity.

RESULTS

Ninetyone studies were included reporting 6473 IH. The pooled proportions of IH for OS were 0.35 (95% CI 0.27-0.44) I² 0% in midline laparotomies and 0.02 (95% CI 0.00-0.07), I² 52% for off-midline. In case of LS the pooled proportion of IH for midline extraction sites were 0.10 (95% CI 0.07-0.16), I² 58% and 0.04 (95% CI 0.03-0.06), I² 86% in case of off-midline. In Port-site IH was 0.02 (95% CI 0.01-0.04), I² 82%, and for single incision surgery (SILS) of 0.06-95% CI 0.02-0.15, I² 81%. In case of stoma reversal sites was 0.20 (95% CI 0.16-0.24).

CONCLUSION

Midline laparotomies and stoma reversal sites are at high risk for IH and should be considered in research of preventive strategies of closure. After laparoscopic approach IH happens mainly by extraction sites incisions specially midline and also represent an important area of analysis.