Suture versus preperitoneal polypropylene mesh for elective umbilical hernia repairs

Mesh versus suture for elective primary umbilical hernia open repair: a systematic review and meta-analysis

PURPOSE

Recent guidelines indicate the use of mesh in UHR for defects > 1 cm, as it reduces recurrence, with 10% recurrence rate compared to up to 54.5% with primary closure. However, Nguyen et al. shows that primary closure is still widely performed in UHR, especially for small defects (1-2 cm), for which there is no published data to determine the optimal approach. In addition, previous meta-analysis by Madsen et al. comparing mesh repair with primary closure in UHR didn't exclude emergency conditions and recurrent hernias; also, didn't report subgroup analysis on hernia defect size. Thus, we aimed to perform a systematic review and meta-analysis comparing the mesh repairs vs. primary closure of the defect in an open elective primary UHR.

METHODS

We searched for studies comparing mesh with suture in open UHR in PubMed, Scopus, Cochrane, Scielo, and Lilacs from inception until October 2023. Studies with patients ≤ 18 years old, with recurrent or emergency conditions were excluded. Outcomes were recurrence, seroma, hematoma, wound infection, and hospital length of stay. Subgroup analysis was performed for: (1) RCTs only, and (2) hernia defects smaller than 2 cm. We used RevMan 5.4. for statistical analysis. Heterogeneity was assessed with I² statistics, and random effect was used if I² > 25%.

RESULTS

2895 studies were screened and 56 were reviewed. 12 studies, including 4 RCTs, 1 prospective cohort, and 7 retrospective cohorts were included, comprising 2926 patients in total (47.6% in mesh group and 52.4% in the suture group). Mesh repair showed lower rates of recurrence in the overall analysis (RR 0.50; 95% CI 0.31 to 0.79; P = 0.003; I2 = 24%) and for hernia defects smaller than 2 cm (RR 0.56; 95% CI 0.34 to 0.93; P = 0.03; I2 = 0%). Suture repair showed lower rates of seroma (RR 1.88; 95% CI 1.07 to 3.32; P = 0.03; I2 = 0%) and wound infection (RR 1.65; 95%CI 1.12 to 2.43; P = 0.01; I2 = 15%) in the overall analysis, with no differences after performing subgroup analysis of RCTs. No differences were seen regarding hematoma and hospital length of stay.

CONCLUSION

The use of mesh during UHR is associated with significantly lower incidence of recurrence in a long-term follow-up compared to the suture repair, reinforcing the previous indications of the guidelines. Additionally, despite the overall analysis showing higher risk of seroma and wound infection for the mesh repair, no differences were seen after subgroup analysis of RCTs.

STUDY REGISTRATION

A review protocol for this systematic review and meta-analysis was registered at PROSPERO (CRD42024476854).

Techniques of Concomitant Abdominoplasty and Umbilical Hernia Repair: A Review

BACKGROUND

Different methods of performing full abdominoplasty and umbilical hernia (UH) repair simultaneously have been proposed.

OBJECTIVES

The aim of this study was to review and compare UH repair outcomes and umbilical stalk survival.

METHODS

A literature research was performed through 28 December 2019. Other hernia repairs and mini-abdominoplasty (without umbilical transposition) were excluded. The primary outcomes analyzed were rates of UH recurrence, mesh infection, and umbilical necrosis.

RESULTS

Six studies were included (5 retrospectives series, 1 case report). Hernia was repaired by an open approach (3 studies, 28 patients) or a laparoscopic approach (3 studies, 67 patients). UH repair consisted of mesh placement in the intraperitoneal or retromuscular/preperitoneal plane, or suture technique in the intraperitoneal plane. No hernia recurrence, mesh infection, or umbilical necrosis was described.

CONCLUSIONS

Both open and laparoscopic approaches to simultaneous abdominoplasty and UH repair seem to be safe based on the rates of umbilical stalk vascularization, hernia recurrence, and mesh infection. However, more well-designed studies are needed to prove this hypothesis.

LEVEL OF EVIDENCE: 4

A case of diaphragmatic hernia incarceration after a heart transplant operation

We report a case of a diaphragmatic hernia after a heart transplant operation. A 43-year-old woman, who underwent orthotropic heart transplantation for hypertrophic cadiomyopathy two year earlier, presented with vomiting and epigastric pain. A computed tomography scan showed that the stomach and transverse colon were dislocated in the left thoracic cavity. We diagnosed left diaphragmatic hernia incarceration and performed laparoscopic repair of the diaphragmatic hernia. A 12 × 8 cm diaphragmatic defect was found intraoperatively on the ventrolateral aspect of the left diaphragm, and the stomach with volvulus had herniated into the thorax through the defect. The hernia was considered to be iatrogenic. The diaphragmatic defect was large, and the diaphragm was thinning. We closed the defect by mesh repair. Laparoscopic mesh repair of the diaphragmatic hernia could be performed safely and with minimal invasiveness.

Primary Umbilical Hernia Repair: A Large-Volume Single-Surgeon Study

There are conflicting views regarding techniques for repair of small umbilical hernias (UHs). Here, we compare the recurrence rate in primary repair with that reported for mesh repair by examining a single surgeon's practice at a large medical center with a comprehensive electronic medical record. A six-year retrospective review of primary UH repairs between January 2012 and December 2017 at Kaiser Permanente Los Angeles Medical Center was undertaken. Patients were identified through a database search of the electronic medical record. The primary endpoint of UH recurrence was examined; median follow-up was 3.4 years. Primary, elective UH repair was performed in 244 patients; 71 per cent of hernias were small (<2 cm). The total number of recurrences was seven (3%). The t test analysis showed significant differences in the average size of hernia defects between those with recurrences (2 cm) and those without (1.4 cm), P < 0.05. Primary repair affords low infection and recurrence rates, comparable to those reported for mesh repair. Our single-surgeon/large-volume study contributes to the evidence that primary UH repair is a safe and durable method, with low risk of recurrence. The use of absorbable monofilament suture, and selection for lower BMI and smaller hernia sizes proved to be effective.

Mesh versus suture in elective repair of umbilical hernia: systematic review and meta-analysis

BACKGROUND

Mesh repair of umbilical hernia has been associated with a reduced recurrence rate compared with suture closure, but potentially at the expense of increased postoperative complications and chronic pain. The objective of this systematic review and meta-analysis was to examine the outcomes after elective open mesh and suture repair for umbilical hernia in adults.

METHODS

A literature search was conducted to identify studies presenting original data on elective open mesh and suture repair of umbilical hernia. The primary outcome was hernia recurrence. Secondary outcomes included surgical-site infection (SSI), seroma, haematoma and chronic pain. Meta-analyses were undertaken.

RESULTS

The search resulted in 5353 hits and led to 14 studies being included (6 RCTs and 8 observational studies) describing a total of 2361 patients. Compared with suture, mesh repair was associated with a lower risk of recurrence (risk ratio (RR) 0·48, 95 per cent c.i. 0·30 to 0·77), with number needed to treat 19 (95 per cent c.i. 14 to 31). Mesh repair was associated with a higher risk of seroma (RR 2·37, 1·45 to 3·87), with number needed to harm 30 (17 to 86). There was no significant difference in the risk of SSI, haematoma or chronic pain.

CONCLUSION

The use of mesh in elective repair of umbilical hernia reduced the risk of recurrence compared with suture closure without altering the risk of chronic pain.

Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society

BACKGROUND

Umbilical and epigastric hernia repairs are frequently performed surgical procedures with an expected low complication rate. Nevertheless, the optimal method of repair with best short- and long-term outcomes remains debatable. The aim was to develop guidelines for the treatment of umbilical and epigastric hernias.

METHODS

The guideline group consisted of surgeons from Europe and North America including members from the European Hernia Society and the Americas Hernia Society. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, the Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklists, and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument were used. A systematic literature search was done on 1 May 2018, and updated on 1 February 2019.

RESULTS

Literature reporting specifically on umbilical and epigastric hernias was limited in quantity and quality, resulting in a majority of the recommendations being graded as weak, based on low-quality evidence. The main recommendation was to use mesh for repair of umbilical and epigastric hernias to reduce the recurrence rate. Most umbilical and epigastric hernias may be repaired by an open approach with a preperitoneal flat mesh. A laparoscopic approach may be considered if the hernia defect is large, or if the patient has an increased risk of wound morbidity.

CONCLUSION

This is the first European and American guideline on the treatment of umbilical and epigastric hernias. It is recommended that symptomatic umbilical and epigastric hernias are repaired by an open approach with a preperitoneal flat mesh.

Open mesh versus suture repair of umbilical hernia: Meta-analysis of randomized controlled trials

BACKGROUND

The optimal methodology of surgical treatment of umbilical hernia in adults remains controversial. Previously published randomized controlled trials (RCTs) and cohort studies have demonstrated advantage for open mesh over suture repair. Two published meta-analyses, including RCTs and retrospective cohort studies, have compared the outcomes of open mesh versus suture repair of umbilical hernia in adult, which were flawed since they included both elective and emergency repairs of umbilical hernias. The aim of this meta-analysis is to include RCTs to examine whether open mesh repair of umbilical hernia produces a better outcome than suture repair in adult patients.

METHODS

A literature search using Medline, Embase and Cochrane Database was performed, and meta-analysis was performed using RevMan 5.3.5 software. Outcomes evaluated incidence of hernia recurrence, wound infection, haematoma, seroma and patient death.

RESULTS

Of the 620 records identified, 4 RCTs, including 620 patients, were included in the meta-analysis. In the RCTS, when open mesh repair was compared with suture repair, open mesh repair was associated with significantly low incidence of recurrence (odds ratio (OR) 0.22, 95% confidence interval (CI) 0.10-0.48; P = 0.0001). The incidence of wound infection (OR 0.89, 95% CI 0.35-2.31; P = 0.82), haematoma (OR 0.83, 95% CI 0.28-2.41; P = 0.73), and seroma (OR 2.01, 95% CI 0.82-4.91; P = 0.13), were similar between the two groups.

CONCLUSIONS

Open mesh repair was associated with significant reduction in the recurrence rate in comparison to suture repair of umbilical hernia.

Abdominoplasty with simultaneous laparoscopic umbilical hernia repair: A practical approach to preserve the umbilical vascularization

BACKGROUND

Umbilical necrosis is a well-known complication of abdominoplasty, the risk of this complication can be increased when an associated umbilical hernia requires further dissection in peri-umbilical region, potentially leading to umbilical devascularisation. Multiple minimally invasive open techniques were described to avoid this problem. The combined approach of abdominoplasty with laparoscopic umbilical hernia repair is one promising solution to avoid devascularising the umbilicus.

METHODS

A retrospective evaluation of patients who underwent concomitant abdominoplasty with laparoscopic umbilical hernia repair from 2007 to 2017 was carried out. All patients were followed up and evaluated for complications, including the incidence of umbilical skin necrosis.

RESULTS

A total of 47 patients were included in this study. The average operative duration was 3.3hours with an average hospital stay of 2.5 days. No cases of postoperative umbilical necrosis were encountered. A mean follow-up period was 2.4 years showed no cases of hernia or rectus abdominis diastasis recurrence. Minor complications included 4 cases of dehiscence, one hematoma. There was no major complications.

CONCLUSION

The concomitant use of laparoscopic umbilical hernia repair and abdominoplasty is a feasible approach to reduce the risks of umbilical devascularization. Especially in larger hernias and in patients with higher risk of recurrence.

Use of imaging for pre- and post-operative characterisation of ventral hernia: systematic review

OBJECTIVE

Complex ventral hernia (CVH) repair is performed increasingly, exacerbated by the obesity epidemic. Imaging can characterise hernia morphology and diagnose recurrence. By systematic review we investigated the extent to which studies employ imaging.

METHODS

The PubMed database was searched for studies of ventral hernia repair from January 1995 to March 2016. Hernias of all size were eligible. Independent reviewers screened articles and extracted data from selected studies related to study design, use of pre- and post-operative hernia imaging and the proportion of subjects imaged. The review was registered: PROSPERO CRD42016043071.

RESULTS

15,771 records were identified initially. 174 full-texts were examined and 158 ultimately included in the systematic review [31 randomised controlled trials (RCTs); 32 cohort studies; 95 retrospective cohort studies]. 31,874 subjects were reported overall. Only 19 (12%) studies employed pre-operative imaging for hernia characterisation and 46 (29%) post-operatively [equating to 511 (2%) of all pre-operative subjects and 1123 (4%) post-operative]. Furthermore, most studies employing imaging did not do so in all subjects: Just 6 (4%) of the 158 studies used imaging in all subjects pre-operatively and just 4 (3%) post-operatively, i.e. imaging was usually applied to a proportion of patients only. Moreover, the exact proportion was frequently not specified. Studies using imaging frequently stated that "imaging", "radiography" or "radiology" was used but did not specify the modality precisely nor the proportion of subjects imaged.

CONCLUSION

Despite the ability to characterise ventral hernia morphology and recurrence with precision, most indexed studies do not employ imaging. Where imaging is used, data are often reported incompletely. Advances in knowledge: (1) This systematic review is the first to focus on the use of imaging in surgical studies of ventral hernia repair. (2) Studies of ventral hernia repair rarely use imaging, either to characterise hernias pre-operatively or to diagnose recurrence, despite the latter being the primary outcome of most studies. (3) Failure to use imaging will result in incomplete hernia characterisation and underestimate recurrence rates in studies of surgical repair.

Mesh repair of paraumblical hernia, outcome of 58 cases

Background

According to the literature, defects in para-umbilical hernias up to 2 cm in diameter could be sutured primarily. For defects larger than 2 cm in dimeters, mesh repair is recommended. The aim of this study is to evaluate the outcome of para-umbilical hernia repair with proline mesh regardless of its size.

Methods

In this retrospective study, patients with para-umbilical hernia, who were managed by onlay mesh placement were presented, and followed for 1–6 years. Several variables were studied including patients' socio-demographic data, post-operative complications, morbidity and mortality.

Results

The series includes 58 patients, the age ranged from 18 to 85 years with median age of 44 years and inter-quartile range of 13.5 years. Mean body mass index was (30.9 ± 4.2). From 49 female patients; 43 (87.8%) were multipara. Forty seven cases (81%) presented for the first time, and 11 cases (19%) had recurrent hernias. Twenty patients (34.5%) had hernia defect ≤2 cm, while 38 patients (65.5%) had hernia size >2 cm. Superficial surgical site infection was found in 6 patients (10.34%). Seroma was found in one female patient (1.72%). One patient (1.72%) had recurrent hernia after 19 months.

Conclusion

Mesh onlay repair by open surgery can be applied to all sizes of para umbilical hernias, it has low recurrence rate and the rates of morbidity and recurrence are comparable with international standard.

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Defect in para-umbilical hernias up to 2 cm in diameter may be sutured primarily. For defects larger than 2 cm, mesh repair is recommended.

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A retrospective study of 58 paraumblical hernias that were treated with onlay mesh.

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The aim of this study is to confirm the outcome of para-umbilical hernia repair with proline mesh regardless of its size.

Umbilical Hernia Repair: Overview of Approaches and Review of Literature

Umbilical hernias are ubiquitous, and surgery is indicated in symptomatic patients. Umbilical hernia defects can range from small (<1 cm) to very large/complex hernias, and treatment options should be tailored to the clinical situation. Open, laparoscopic, and robotic options exist for repair, with each having its advantages and disadvantages. In general, mesh should be used for repair, because it has been shown to decrease recurrence rates, even in small hernias. Although outcomes are generally favorable after umbilical hernia repairs, some patients have chronic complaints that are mostly related to recurrences.

Mesh versus suture repair of umbilical hernia in adults: a randomised, double-blind, controlled, multicentre trial

BACKGROUND

Both mesh and suture repair are used for the treatment of umbilical hernias, but for smaller umbilical hernias (diameter 1-4 cm) there is little evidence whether mesh repair would be beneficial. In this study we aimed to investigate whether use of a mesh was better in reducing recurrence compared with suture repair for smaller umbilical hernias.

METHODS

We did a randomised, double-blind, controlled multicentre trial in 12 hospitals (nine in the Netherlands, two in Germany, and one in Italy). Eligible participants were adults aged at least 18 years with a primary umbilical hernia of diameter 1-4 cm, and were randomly assigned (1:1) intraoperatively to either suture repair or mesh repair. In the first 3 years of the inclusion period, blocked randomisation (of non-specified size) was achieved by an envelope randomisation system; after this time computer-generated randomisation was introduced. Patients, investigators, and analysts were masked to the allocated treatment, and participants were stratified by hernia size (1-2 cm and >2-4 cm). At study initiation, all surgeons were invited to training sessions to ensure they used the same standardised techniques for suture repair or mesh repair. Patients underwent physical examinations at 2 weeks, and 3, 12, and 24-30 months after the operation. The primary outcome was the rate of recurrences of the umbilical hernia after 24 months assessed in the modified intention-to-treat population by physical examination and, in case of any doubt, abdominal ultrasound. This trial is registered with ClinicalTrials.gov, number NCT00789230.

FINDINGS

Between June 21, 2006, and April 16, 2014, we randomly assigned 300 patients, 150 to mesh repair and 150 to suture repair. The median follow-up was 25·1 months (IQR 15·5-33·4). After a maximum follow-up of 30 months, there were fewer recurrences in the mesh group than in the suture group (six [4%] in 146 patients vs 17 [12%] in 138 patients; 2-year actuarial estimates of recurrence 3·6% [95% CI 1·4-9·4] vs 11·4% (6·8-18·9); p=0·01, hazard ratio 0·31, 95% CI 0·12-0·80, corresponding to a number needed to treat of 12·8). The most common postoperative complications were seroma (one [<1%] in the suture group vs five [3%] in the mesh group), haematoma (two [1%] vs three [2%]), and wound infection (one [<1%] vs three [2%]). There were no anaesthetic complications or postoperative deaths.

INTERPRETATION

This is the first study showing high level evidence for mesh repair in patients with small hernias of diameter 1-4 cm. Hence we suggest mesh repair should be used for operations on all patients with an umbilical hernia of this size.

FUNDING

Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands.

Negative-Pressure Wound Therapy in the Management of High-Grade Ventral Hernia Repairs

BACKGROUND

Despite improved operative techniques, open ventral hernia repair (VHR) surgery in high-risk, potentially contaminated patients remains challenging. As previously reported by our group, the use of a modified negative-pressure wound therapy system (hybrid-VAC or HVAC) in patients with grade 2 hernias is associated with lower surgical site occurrence (SSO) and surgical site infection (SSI) rates. Accordingly, the authors aim to evaluate whether the HVAC would similarly improve surgical site outcomes following VHR in patients with grade 3 hernias.

METHODS

A 4-year retrospective review (2011-2014) was conducted of all consecutive, modified ventral hernia working group (VHWG) grade 3 hernia repairs with HVAC closure performed by a single surgeon (FEE) at a single institution. Operative data and 90-day outcomes were evaluated. Overall outcomes (e.g., recurrence, reoperation, mortality) were reviewed for the study group.

RESULTS

A total of 117 patients with an average age of 56.7 ± 11.9 years were classified as grade 3 hernias and underwent open VHR with subsequent HVAC closure. Fifty patients were male (42.7 %), the mean BMI was 35.2 (±9.5), and 60.7 % had a history of prior hernia repair. The average fascial defect size was 201.5 (±167.3) cm(2) and the mean length of stay was 14.2 (±9.3) days. Ninety-day outcomes showed an SSO rate of 20.7 % and an SSI rate of 5.2 %. The overall hernia recurrence rate was 4.2 % (n=6) with a mean follow-up of 11 ± 7.3 months.

CONCLUSION

Modified VHWG grade 3 ventral hernias are associated with significant morbidity. In our series utilizing the HVAC system after VHR, the observed rate of SSO and SSI compared favorably to reported series. Further prospective cost-effective studies are warranted to validate these findings.