VAC-instillation therapy in abdominal mesh exposure: a novel indication

Mesh Infection After Hernia Repair and Negative Pressure Wound Therapy. A Systematic Review

BACKGROUND

Surgical mesh infection (SMI) after abdominal wall hernia repair (AWHR) is a challenging and highly debated clinical problem with no current consensus. The purpose of this review was to analyze the literature about the use of negative pressure wound therapy (NPWT) in the management of the conservative treatment of SMI and report results about infected mesh salvage.

METHODS

A systematic review of EMBASE and PUBMED was performed describing the use of NPWT in patients with SMI following AWHR. Reviewed articles evaluating data about the association between clinical, demographic, analytic and surgical characteristics about SMI after AWHR were analyzed. The high heterogeneity of these studies did not allow a meta-analysis of outcomes.

RESULTS

The search strategy yielded 33 studies from PubMed, and 16 studies from EMBASE. NPWT was performed in 230 patients across 9 studies being achieved the mesh salvage in 196 (85.2%). Of these 230 cases, 46% were polypropylene (PPL), 9.9% polyester (PE), 16.8% polytetrafluoroethylene (PTFE), 4% biologic and 10.2% composite mesh (PPL and PTFE). Infected mesh location was onlay (43%), retromuscular (22%), preperitoneal (19%), intraperitoneal (10%) and between the oblique muscles (5%). The better option on salvageability with the use of NPWT was the combination of macroporous PPL mesh in an extraperitoneal position (19.2% onlay, 23.3% preperitoneal, 48.8% retromuscular).

CONCLUSION

NPWT is a sufficient approach to treat SMI following AWHR. In most cases, infected prostheses can be salvaged with this management. Further studies with a larger sample size are needed to confirm our analysis results.

Negative pressure therapy in abdominal wall surgery

Negative pressure wound therapy (NPWT) is widely known in surgical practice. The initial indications for NPWT were chronic wounds, especially diabetic foot, vascular and decubitus ulcers, and infected traumatic wounds. Nowadays, the use has been widely increased. Although in the field of abdominal wall surgery, it has mainly been used in the treatment of surgical wound complications after hernia repair, other indications have been added after years of experience in the management of NPWT. Therefore, the aim of this article is to analyze and review the main indications of NPWT in abdominal wall surgery, as well as the advantages obtained with its application.

The Effect of Negative-Pressure Wound Therapy with Instillation Compared to Current Standard Care on Wound Closure Time of Infected Wounds: A Systematic Review and Meta-Analysis

BACKGROUND

Infected wounds extend healing time and are associated with higher treatment costs than noninfected wounds. Several observational studies indicate that negative-pressure wound therapy with instillation can effectively reduce bacterial bioburden and improve wound healing. Only a few randomized trials with small sample sizes have been published, and a meta-analysis directly comparing negative-pressure wound therapy with instillation to current standard care is lacking. It is therefore uncertain whether negative-pressure wound therapy with instillation actually improves wound healing. The authors performed a systematic review and hypothesized that negative-pressure wound therapy with instillation reduces wound closure time.

METHODS

The PubMed, Embase, and CENTRAL databases were searched up to December of 2020 for English studies that compare negative-pressure wound therapy with instillation-to either negative-pressure wound therapy without instillation or to other types of wound care-for the treatment of acute or chronically infected wounds. Time to wound closure was analyzed using a random effects meta-analysis in predefined subgroups according to study design and comparative wound care.

RESULTS

The authors identified 14 studies describing 1053 patients. Meta-analysis of three randomized trials shows no significant difference in time to wound closure between negative-pressure wound therapy with instillation and that without (mean difference, 0.48 day; 95 percent CI, -0.70 to 1.65; I ² = 0 percent). Data from eleven observational studies indicate that negative-pressure wound therapy with instillation reduces wound closure time (from 1.6 to 16.8 days; no pooled data). Because of imprecision and risk of bias, the available evidence provides only low-level certainty.

CONCLUSIONS

There is currently insufficient evidence to support or discard the use of negative-pressure wound therapy with instillation for infected wounds. More randomized trials are needed to determine whether a beneficial effect can be substantiated.

Effects of Negative-Pressure Wound Therapy With Instillation versus Standard of Care in Multiple Wound Types: Systematic Literature Review and Meta-Analysis

BACKGROUND

Large randomized controlled trials that evaluate the effects of negative-pressure wound therapy with instillation of a topical solution and dwell time (NPWTi-d) are lacking. There is a need to synthesize existing data across multiple studies to provide a more precise estimate of the clinical effects of NPWTi-d.

METHODS

A systematic literature review and a meta-analysis of comparative studies were performed to determine the effects of NPWTi-d versus control therapy in the adjunctive management of complex wounds. Weighted standardized mean difference or odds ratios and 95% confidence intervals were calculated to pool study and control group results in each publication for analysis.

RESULTS

Thirteen studies comprising 720 patients were included in the analysis. Significantly fewer surgical debridements were performed in NPWTi-d patients versus control patients (P = 0.01). Wounds in the NPWTi-d group were ready for closure faster than control wounds (P = 0.03). The odds of reducing bacterial count from baseline in the NPWTi-d group was 4.4 times greater than control group wounds (P = 0.003), and percent reduction of bacterial count in NPWTi-d wounds was evident in all studies that captured that endpoint. There was a significantly shorter length of therapy in NPWTi-d patients versus control patients (P = 0.03). Wounds in NPWTi-d group were 2.39 times more likely to close than control group wounds (P = 0.01). Length of hospital stay was not significantly reduced for NPWTi-d patients compared with that for control patients (P = 0.06).

CONCLUSION

Results of this meta-analysis show a positive effect with use of NPWTi-d in various wound types.

The negative pressure wound therapy may salvage the infected mesh following open incisional hernia repair

Background

s: Incisional hernias may occur in 10–25% of patients undergoing laparotomy. In cases of a surgical site infection (SSI) after incisional hernia repair (IHR) secondary operative intervention with mesh removal are often needed. There is only minimal data available in the literature regarding the treatment of a wound infection with negative pressure wound therapy (NPWT). Conducting the study at hand, we aimed to provide more evidence on this topic.

Methods

From April to June 2020 a monocentric retrospective study has been performed. Patients who underwent NPWT due to a SSI with mesh involvement following open IHR from 2007 to 2020 were included. The primary endpoint was the mesh removal rate in the end of NPWT. Main secondary endpoints were the duration of NPWT and the amount of NPWT procedures.

Results

The data of 30 patients were extracted. The average age was 65.9 years (9.9). A total of 13 individuals were male and 17 females. The BMI was on average 31.1 kg/m² (4.9). All patients received a polypropylene mesh. The average duration of NPWT was 31.3 days (22.1). The first wound revision with initiation of a NPWT was conducted on average 31.1 days (34.0) after IHR. The average amount of NPWT procedures was 8.3 (7.2). In 5 of 30 patients (16.6%) the mesh was removed (Open sublay group n = 4 (36.34%) vs. open onlay group n = 1 (5.26%), p = 0.047).

Conclusion

In cases of SSI following IHR the NPWT may facilitate mesh selvage. Further trials with a larger sample size are mandatory to confirm our hypothesis.

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As one of a main complication SSI may occur in up to 30% of cases following incisional hernia repair.

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The mesh is often removed in cases of a SSI.

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NPWT may salvage mesh removal in cases of mesh infection.

Clinical application and efficacy of negative pressure wound therapy with instillation and dwell time (NPWTi-d): A systematic review and meta-analysis

This study evaluates the current clinical evidence of Negative Pressure Wound Therapy with Instillation and dwell time (NPWTi‐d) to establish its clinical application and efficacy. MEDLINE, EMBASE, and CENTRAL databases were searched from 1946 to July 2019 for studies reporting clinical outcomes on wounds treated with NPWTi‐d. The primary outcome was proportion of wounds with complete healing. The secondary outcomes were mean time for healing, NPWTi‐d settings, cost, length of stay, and adverse events. Thirteen articles were included with a total of 624 wounds in 542 patients involving wounds of various aetiology. The pooled proportion of wound that achieved complete healing was 93.65% (95%CI: 84.02‐99.04). Normal saline was the most commonly used instillation solution with the mean dwell time of 14.23 minutes (95%CI: 10.88‐17.59) and instillation cycle every 4.17 ± 2.32 hourly. The mean therapy duration was 10.69 days (95%CI: 10.46‐10.91) with daily cost of $194.80. The mean hospital stay was 18.1 days (95%CI: 17.20‐19.00). There were no severe adverse effects reported. NPWTi‐d is an adjuntive therapy to aid complete healing of the vast majority of wounds. However, the current data are limited by the lack of level 1 evidence.

Negative Pressure Wound Therapy with Instillation as Conservative Management for a Large Abdominal Wound Following Incarcerated Parastomal Hernia Repair

Parastomal herniation is a common complication following stoma creation, necessitating surgical repair in up to one-quarter of cases, including emergency cases of incarceration or strangulation. Following hernia repair with or without mesh placement, surgical sites are at risk of infection post-operatively and this is typically resolved by removing the mesh, which can be technically challenging. Few studies have assessed conservative management options for these types of cases. Here, we present a case where negative pressure wound therapy (NPWT) with instillation was utilized for secondary intention healing of a large abdominal wound (20 cm x 23 cm x 5 cm) following mesh infection post-parastomal hernia repair. The patient’s wound was completely healed after eight weeks and she had no long-term complications at the one-year follow-up. NPWT with instillation is an option for the conservative management of large abdominal wounds, which can be considered on a case-by-case basis.

Mesh trimming and suture reconstruction for wound dehiscence after huge abdominal intercostal hernia repair: A case report

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Large abdominal intercostal hernia in the thoracoabdominal region must be treated.

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Repair of abdominal intercostal hernia using mesh and surgical approach is controversial.

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With exposed mesh, partial mesh removal may be an option if conditions are met.

Introduction

Abdominal intercostal hernia repair for huge incisional hernia after thoracoabdominal surgery involves a complex anatomical structure. Hence, it is difficult to apply the laparoscopic approach to large hernias in the lateral upper abdomen. Further the optimal approach to mesh exposure without infection after incisional hernia repair is still controversial. Herein, we describe our experience of repairing a huge abdominal intercostal hernia by mesh trimming and suture reconstruction for wound dehiscence.

Presentation of case

A 73-year-old man presented with an incisional hernia in the left flank from just below the eight intercostal space to the transverse umbilical region 6 months after thoracoabdominal aortic aneurysm surgery. Computed tomography revealed an incisional hernia orifice of 17 × 13 cm located on the left flank around the ninth rib. We chose the open approach as treatment because the hernia orifice was large, and we created a mesh placement space in the extraperitoneal cavity and placed expanded polytetrafluoroethylene mesh there with 1–0 nonabsorbable monofilament suture. At postoperative day 26, we observed mesh exposure due to wound dehiscence. Mesh trimming and suture reconstruction for wound dehiscence was performed because there were no signs of wound infection. The postoperative course was uneventful including infection and dehiscence. The patient has been well without recurrence for 14 months since last operation.

Conclusions

Optimal treatment for repair of a large abdominal intercostal hernia with thoracoabdominal location is necessary. Moreover, partial mesh removal may be one of the treatment options for mesh exposure if conditions are met.

Negative pressure wound therapy with instillation, a cost-effective treatment for abdominal mesh exposure

PURPOSE

Negative pressure wound therapy with instillation (NPWTi) has been proved to be a safe and effective treatment option for abdominal wall wound dehiscence with mesh exposure. Our aim in this study is to examine whether it is also cost-effective.

METHODS

We performed a retrospective cohort study with 45 patients treated for postoperative abdominal wall wound dehiscence and exposed mesh: 34 were treated with conventional wound therapy (CWT) and 11 with NPWTi. We carried out a cost analysis for each treatment group using the Diagnosis-related group (DRG) system and a second evaluation using the calculated costs "per hospital stay". The differences between NPWTi and CWT were calculated with both evaluation systems. Comparative analysis was performed using the Mann-Whitney U test.

RESULTS

Mean costs using the DRG estimation were 29,613.71€ for the CWT group and 15,093.37€ for the NPWTi group, and according to the calculated expenses "per hospital stay", 17,322.88€ for the CWT group and 15,284.22€ for the NPWTi group. NPWTi showed a reduction in the total expense of treatment, related to a reduction in episodes of hospitalization and number of surgeries required to achieve wound closure. However, differences were not statistically significant in our sample.

CONCLUSIONS

NPWTi proves to be an efficient treatment option for abdominal wall wound dehiscence with mesh exposure, compared to CWT. More trials aimed to optimize treatment protocols will lead to an additional increase in NPWTi efficiency. In addition, to generalize our results, further studies with larger samples would be necessary.