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Fabregó B, Miralpeix E, Sole-Sedeno JM, Pereira JA, Mancebo G. Prophylactic mesh to prevent incisional hernia in laparotomy for ovarian tumors. Int J Gynecol Cancer 2024:ijgc-2024-005427. [PMID: 38909993 DOI: 10.1136/ijgc-2024-005427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2024] Open
Abstract
OBJECTIVE Incisional hernias are a common complication of midline laparotomies. The aim of this study was to determine the impact of prophylactic mesh placement after midline laparotomy for ovarian tumors on the incidence of incisional hernia. METHODS We collected retrospective data from patients undergoing midline laparotomy for borderline or ovarian cancer with at least 12 months of follow-up, including those with and without mesh. Patient demographics, preoperative characteristics and risk factors for hernia were reported and grouped according to prophylactic mesh placement. A multivariate analysis was conducted to identify independent risk factors for incisional hernia. Kaplan-Meier curves illustrating the cumulative incidence of incisional hernia based on mesh placement were performed. RESULTS A total of 139 consecutive patients with available data were included, 58 in the non-mesh group and 81 in the mesh group, with high body mass index (BMI) as the most common reason for mesh placement. The mean (SD)) age was 60 years (13.97). A total of 11 patients (7.9%) had borderline tumors while 128 (92.1%) had invasive cancer. After clinical and radiological examination, 18.7% (26/139) of patients developed incisional hernia at a median follow-up of 35.8 months (IQR) 43.8): 31% (18/58) were detected in the non-mesh group, and 9.9% (8/81) in the mesh group (p<0.002). Multivariate analysis showed no-mesh placement (OR) 10; 95% CI) 2.8 to 35.919; p<0.001) as a significant risk factor for incisional hernia. Age ≥70 (OR 4.3; 95% CI 1.24 to 15; p=0.02) and BMI ≥29 (OR 4.4; 95% CI 1.27 to 14.93; p=0.019) were also identified as independent risk factors for hernia development. According to Kaplan-Meier curves, the cumulative incidence of incisional hernia was higher in the non-mesh group (p=0.002). CONCLUSION The incidence of incisional hernia was high in patients undergoing midline laparotomy for ovarian tumors. The addition of a prophylactic mesh may reduce this incidence, therefore there is a need to consider it as an option for high-risk patients, particularly those aged over 70 years or with a BMI ≥29 kg/m2.
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Affiliation(s)
- Berta Fabregó
- Department of Obstetrics and Gynecology, Hospital del Mar, Hospital del Mar, Barcelona, Catalunya, Spain
| | - Ester Miralpeix
- Department of Obstetrics and Gynecology, Hospital del Mar, Hospital del Mar, Barcelona, Catalunya, Spain
| | - Josep-Maria Sole-Sedeno
- Department of Obstetrics and Gynecology, Hospital del Mar, Hospital del Mar, Barcelona, Catalunya, Spain
| | - José-Antonio Pereira
- Department of Surgery, Hospital del Mar, Barcelona, Spain
- Pompeu Fabra University, Barcelona, Spain
| | - Gemma Mancebo
- Department of Obstetrics and Gynecology, Hospital del Mar, Hospital del Mar, Barcelona, Catalunya, Spain
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Rodicio Miravalles JL, Méndez CSM, Lopez-Monclus J, Moreno Gijón M, López Quindós P, Amoza Pais S, López López A, García Bear I, Menendez de Llano Ortega R, Díez Pérez de Las Vacas MI, Garcia-Urena MA. Short-term outcomes of a multicentre prospective study using a "visible" polyvinylidene fluoride onlay mesh for the prevention of midline incisional hernia. Langenbecks Arch Surg 2024; 409:136. [PMID: 38652308 DOI: 10.1007/s00423-024-03307-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 04/03/2024] [Indexed: 04/25/2024]
Abstract
INTRODUCTION Prophylactic meshes in high-risk patients prevent incisional hernias, although there are still some concerns about the best layer to place them in, the type of fixation, the mesh material, the significance of the level of contamination, and surgical complications. We aimed to provide answers to these questions and information about how the implanted material behaves based on its visibility under magnetic resonance imaging (MRI). METHOD This is a prospective multicentre observational cohort study. Preliminary results from the first 3 months are presented. We included general surgical patients who had at least two risk factors for developing an incisional hernia. Multivariate logistic regression was used. A polyvinylidene fluoride (PVDF) mesh loaded with iron particles was used in an onlay position. MRIs were performed 6 weeks after treatment. RESULTS Between July 2016 and June 2022, 185 patients were enrolled in the study. Surgery was emergent in 30.3% of cases, contaminated in 10.7% and dirty in 11.8%. A total of 5.6% of cases had postoperative wound infections, with the requirement of stoma being the only significant risk factor (OR = 7.59, p = 0.03). The formation of a seroma at 6 weeks detected by MRI, was associated with body mass index (OR = 1.13, p = 0.02). CONCLUSIONS The prophylactic use of onlay PVDF mesh in midline laparotomies in high-risk patients was safe and effective in the short term, regardless of the type of surgery or the level of contamination. MRI allowed us to detect asymptomatic seromas during the early process of integration. STUDY REGISTRATION This protocol was registered at ClinicalTrials.gov (NCT03105895).
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Affiliation(s)
- José Luis Rodicio Miravalles
- Division of General Surgery, Hospital Universitario Central de Asturias (HUCA), Avda de Roma, s/n, Oviedo, Asturias, 33011, Spain.
| | - Carlos San Miguel Méndez
- Division of General Surgery, Grupo de Investigación de Pared Abdominal Compleja, Universidad Francisco de Vitoria, Hospital Universitario del Henares, Madrid, Spain
| | - Javier Lopez-Monclus
- Division of General Surgery, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - María Moreno Gijón
- Division of General Surgery, Hospital Universitario Central de Asturias (HUCA), Avda de Roma, s/n, Oviedo, Asturias, 33011, Spain
| | - Patricia López Quindós
- Division of General Surgery, Grupo de Investigación de Pared Abdominal Compleja, Universidad Francisco de Vitoria, Hospital Universitario del Henares, Madrid, Spain
| | - Sonia Amoza Pais
- Division of General Surgery, Hospital Universitario Central de Asturias (HUCA), Avda de Roma, s/n, Oviedo, Asturias, 33011, Spain
| | - Antonio López López
- Division of General Surgery, Hospital Universitario Nuestra Señora del Prado, Toledo, Spain
| | - Isabel García Bear
- Division of General Surgery, Hospital Universitario San Agustin, Avilés, Spain
| | | | | | - Miguel Angel Garcia-Urena
- Division of General Surgery, Grupo de Investigación de Pared Abdominal Compleja, Universidad Francisco de Vitoria, Hospital Universitario del Henares, Madrid, Spain
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Fortelny RH, Dietz U. [Incisional hernias: epidemiology, evidence and guidelines]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:3-9. [PMID: 38078933 PMCID: PMC10781829 DOI: 10.1007/s00104-023-01999-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/06/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND From an epidemiological point of view, one third of the population in industrialized countries will undergo abdominal surgery during their lifetime. Depending on the degree of patient-related and procedure-related risks, the occurrence of incisional hernias is associated in a range of up to 30% at 2‑year follow-up and even up to 60% at 5 years. In addition to influencing comorbidities, the type of surgical approach and closure technique are of critical importance. OBJECTIVE To present a descriptive evidence-based recommendation for abdominal wall closure and prophylactic mesh augmentation. MATERIAL AND METHODS A concise summary was prepared incorporating the current literature and existing guidelines. RESULTS According to recent studies the recognized risk for the occurrence of incisional hernias in the presence of obesity and abdominal aortic diseases also applies to patients undergoing colorectal surgery and the presence of diastasis recti abdominis. Based on high-level published data, the short stitch technique for midline laparotomy in the elective setting has a high level of evidence to be a standard procedure. Patients with an increased risk profile should receive prophylactic mesh reinforcement, either onlay or sublay, in addition to the short stitch technique. In emergency laparotomy, the individual risk of infection with respect to the closure technique used must be included. CONCLUSION The avoidance of incisional hernias is primarily achieved by the minimally invasive access for laparoscopy. For closure of the most commonly used midline approach, the short stitch technique and, in the case of existing risk factors, additionally mesh augmentation are recommended.
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Affiliation(s)
- R H Fortelny
- Lehrstuhl für Allgemeinchirurgie, Medizinische Fakultät, Sigmund Freud PrivatUniversität Wien, Freudplatz 3, 1020, Wien, Österreich.
| | - U Dietz
- Chirurgie, Kantonsspital Olten, Olten, Schweiz
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Stephens I, Conroy J, Winter D, Simms C, Bucholc M, Sugrue M. Prophylactic onlay mesh placement techniques for optimal abdominal wall closure: randomized controlled trial in an ex vivo biomechanical model. Br J Surg 2023; 110:568-575. [PMID: 36918293 PMCID: PMC10683942 DOI: 10.1093/bjs/znad062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/10/2022] [Accepted: 02/01/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Incisional hernias occur after up to 40 per cent of laparotomies. Recent RCTs have demonstrated the role of prophylactic mesh placement in reducing the risk of developing an incisional hernia. An onlay approach is relatively straightforward; however, a variety of techniques have been described for mesh fixation. The biomechanical properties have not been interrogated extensively to date. METHODS This ex vivo randomized controlled trial using porcine abdominal wall investigated the biomechanical properties of three techniques for prophylactic onlay mesh placement at laparotomy closure. A classical onlay, anchoring onlay, and novel bifid onlay approach were compared with small-bite primary closure. A biomechanical abdominal wall model and ball burst test were used to assess transverse stretch, bursting force, and loading characteristics. RESULTS Mesh placement took an additional 7-15 min compared with standard primary closure. All techniques performed similarly, with no clearly superior approach. The minimum burst force was 493 N, and the maximum 1053 N. The classical approach had the highest mean burst force (mean(s.d.) 853(152) N). Failure patterns fell into either suture-line or tissue failures. Classical and anchoring techniques provided a second line of defence in the event of primary suture failure, whereas the bifid method demonstrated a more compliant loading curve. All mesh approaches held up at extreme quasistatic loads. CONCLUSION Subtle differences in biomechanical properties highlight the strengths of each closure type and suggest possible uses. The failure mechanisms seen here support the known hypotheses for early fascial dehiscence. The influence of dynamic loading needs to be investigated further in future studies.
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Affiliation(s)
- Ian Stephens
- Department of Surgery, Letterkenny University Hospital, Letterkenny, Ireland
| | - Jack Conroy
- Donegal Clinical Research Academy, Letterkenny University Hospital, Letterkenny, Ireland
- Trinity Centre for Bioengineering, Department of Mechanical, Manufacturing and Biomedical Engineering, Trinity College Dublin, Dublin, Ireland
| | - Des Winter
- Department of Surgery, St Vincent’s University Hospital, Dublin, Ireland
| | - Ciaran Simms
- Trinity Centre for Bioengineering, Department of Mechanical, Manufacturing and Biomedical Engineering, Trinity College Dublin, Dublin, Ireland
| | - Magda Bucholc
- EU INTERREG Centre for Personalized Medicine, Intelligent Systems Research Centre, School of Computing, Engineering and Intelligent Systems, Ulster University, Derry-Londonderry, UK
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital, Letterkenny, Ireland
- Donegal Clinical Research Academy, Letterkenny University Hospital, Letterkenny, Ireland
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Ulutas ME, Sahin A, Simsek G, Sekmenli N, Kilinc A, Arslan K, Eryilmaz MA, Kartal A. Does onlay mesh placement in emergency laparotomy prevent incisional hernia? A prospective randomized double-blind study. Hernia 2023:10.1007/s10029-023-02770-7. [PMID: 36967415 DOI: 10.1007/s10029-023-02770-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 03/09/2023] [Indexed: 03/28/2023]
Abstract
PURPOSE The objective of this study is to assess the effectiveness and safety of onlay mesh closure of emergency midline laparotomy to prevent incisional hernia. METHODS This is a prospective randomized double-blind study and was carried out in the General Surgery Clinic, Konya City Hospital, from August 1, 2020 to August, 1, 2021. The study included 108 patients who were randomly grouped in 2 groups: patients with conventional abdominal closure and closure using additional onlay mesh (1:1). The follow-up period was for a year. The primary outcome was the incidence of incisional hernia and secondary outcomes were clinical data like complications, hospital length of stay, re-operations. RESULTS It was observed that incisional hernia was present in 14 patients (27.4%) in conventional abdominal closure group and was in 2 patients using mesh (4%), (p = 0.001). Clavien-Dindo 3B complications were in rise in conventional closure group (p = 0.02). Of all complications, burst abdomen was significantly more common in conventional closure group (p = 0.04). The rate of surgically treated complications were higher in conventional closure group (p = 0.02). Clavien-Dindo 3A complications were more common in patients with contaminated wound in mesh group (p = 0.02). CONCLUSION The use of mesh while closing the abdomen in emergency midline laparotomy reduces the risk of incisional hernia. Thus, to lower the risks of incisional hernia and its complications, prophylactic mesh can be used in high-risk patients.
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Pereira-Rodríguez JA, Bravo-Salva A, Argudo-Aguirre N, Amador-Gil S, Pera-Román M. Defining High-Risk Patients Suitable for Incisional Hernia Prevention. JOURNAL OF ABDOMINAL WALL SURGERY : JAWS 2023; 2:10899. [PMID: 38312422 PMCID: PMC10831640 DOI: 10.3389/jaws.2023.10899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 01/19/2023] [Indexed: 02/06/2024]
Affiliation(s)
- Jose Antonio Pereira-Rodríguez
- General and Digestive Surgery Department, Parc de Salut Mar, Hospital del Mar, Barcelona, Spain
- Department of Medicine and Life Sciences, Pompeu Fabra University, Barcelona, Spain
| | - Alejandro Bravo-Salva
- General and Digestive Surgery Department, Parc de Salut Mar, Hospital del Mar, Barcelona, Spain
- Department of Medicine and Life Sciences, Pompeu Fabra University, Barcelona, Spain
| | - Núria Argudo-Aguirre
- General and Digestive Surgery Department, Parc de Salut Mar, Hospital del Mar, Barcelona, Spain
- Department of Medicine and Life Sciences, Pompeu Fabra University, Barcelona, Spain
| | - Sara Amador-Gil
- General and Digestive Surgery Department, Hospital de Granollers, Granollers, Spain
| | - Miguel Pera-Román
- General and Digestive Surgery Department, Parc de Salut Mar, Hospital del Mar, Barcelona, Spain
- Department of Medicine and Life Sciences, Pompeu Fabra University, Barcelona, Spain
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Kumar VV, Verma A, Thakur DS, Somashekar U, Kothari R, Sharma D. Prophylactic mesh placement in emergency midline laparotomy for intestinal perforation peritonitis: An appeal for caution. Trop Doct 2022; 52:522-525. [PMID: 35747937 DOI: 10.1177/00494755221110831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Prophylactic mesh placement (PMP) is increasingly being used to reduce the incidence of incisional hernia after routine and emergency midline laparotomy (EML). However, such studies are not available for EMLs done solely for intestinal perforation. Patients who underwent non-absorbable PMP during EML for intestinal perforation (Group A, 15 patients) were compared with those who had a conventional abdominal wall closure (Group B, 20 patients). The incidence of wound dehiscence was significantly higher in Group A, while surgical site infection (SSI), and incisional hernia were similar in both groups. Mesh explantation was needed in half the cases. A prophylactically placed non-absorbable mesh in patients undergoing EML for intestinal perforation is associated with significantly higher rates of wound dehiscence and of mesh explantation and therefore, routine use of such a mesh appears not to be justified.
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Affiliation(s)
- Vivek Vijay Kumar
- Department of Surgery, 534313NSCB Government Medical College, Jabalpur, India
| | - Amrendra Verma
- Department of Surgery, 534313NSCB Government Medical College, Jabalpur, India
| | - Dileep Singh Thakur
- Department of Surgery, 534313NSCB Government Medical College, Jabalpur, India
| | - Uday Somashekar
- Department of Surgery, 534313NSCB Government Medical College, Jabalpur, India
| | - Reena Kothari
- Department of Surgery, 534313NSCB Government Medical College, Jabalpur, India
| | - Dhananjaya Sharma
- Department of Surgery, 534313NSCB Government Medical College, Jabalpur, India
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Ciscar Belles A, Makhoukhi T, López-Cano M, Hernández Granados P, Pereira Rodríguez JA. Umbilical incisional hernias (M3): are trocar-site hernias different? Comparative analysis of the EVEREG registry⋆. Cir Esp 2022; 100:336-344. [PMID: 35618203 DOI: 10.1016/j.cireng.2022.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 01/24/2021] [Indexed: 06/15/2023]
Abstract
BACKGROUND Incisional hernia (HI), in open and laparoscopic surgery, is a very frequent complication. HI located in the umbilical region are called M3. The main aim of this study is to compare HI produced by the placement of an umbilical laparoscopic trocar (M3T) with those located in M3 in open surgery (M3O) in terms of basal characteristics, complications and recurrences; and secondarily the identification of risk factors. METHOD Cross-sectional observational study based on the national prospective registry EVEREG during the period of July 2012-June 2018. The main variables were recurrences and postoperative complications. Both groups (M3T and M3O) were compared. Multiple logistic regression was performed to identify the risk factors of the entire cohort. RESULTS 882 had a follow-up time longer than 12 months. M3O group presented superior ASA-Class, more complex HI and previous repair. It also presented a higher recurrence rate at 12 and 24 months (8.6% vs. 2.5%; P < 0,0001 and 9.3% vs. 2.9%; P < 0.0001) and higher postoperative complications rate (21.9% vs. 14.6 %; P = 0.02). Previous repair, intervention length and associated procedures requirement were identified as risk factors for postoperative complications. Absence of a specialist present during surgery, previous repair, and the absence of complications were identified as risk factors for recurrence. In the PSM analysis no differences were detected in of complications and recurrences. CONCLUSIONS HI M3O is more complex than M3T. The complexity is not related to the origin of the hernia but to its characteristics and those of the patient.
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Affiliation(s)
- Ana Ciscar Belles
- Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, Spain; Servicio de Cirugía General, Hospital de Mataró, Barcelona, Spain
| | - Touria Makhoukhi
- Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, Spain
| | - Manuel López-Cano
- Servicio de Cirugía General, Hospital Vall d'Hebron, Barcelona, Spain; Departament de Cirurgia, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - José Antonio Pereira Rodríguez
- Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, Spain; Servicio de Cirugía General, Hospital Universitari del Mar, Barcelona, Spain.
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Albendary M, Mohamedahmed AYY, Alamin A, Rout S, George A, Zaman S. Efficacy and safety of mesh closure in preventing wound failure following emergency laparotomy: a systematic review and meta-analysis. Langenbecks Arch Surg 2022; 407:1333-1344. [PMID: 35020082 DOI: 10.1007/s00423-021-02421-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 12/20/2021] [Indexed: 11/29/2022]
Abstract
AIMS To evaluate comparative outcomes of emergency laparotomy closure with and without prophylactic mesh. METHODS A systematic review was performed via literature databases: PubMed, Cochrane Library, Science Direct, and Google Scholar. Studies were examined for eligibility and included if they compared prophylactic mesh closure to the conventional laparotomy closure following emergency abdominal surgery. Both acute wound failure and incisional hernia (IH) occurence were our primary outcomes. Secondary outcomes included surgical site infection (SSI), seroma/hematoma formation, Clavien-Dindo complications (score ≥ 3), total operative time, and length of hospital stay (LOS). RESULTS Two randomised controlled trials (RCTs) and four comparative studies with a total of 817 patients met the inclusion criteria. Overall acute wound failure and incisional hernia rate was significantly lower in the mesh group compared to non-mesh group (odd ratio (OR) 0.23, p = 0.002) and (OR 0.21, p = 0.00001), respectively. There was no significant difference between the two groups regarding the following outcomes: total operative time (mean difference (MD) 21.44, p = 0.15), SSI (OR 1.47, p = 0.06), seroma/haematoma formation (OR 2.74, p = 0.07), grade ≥ 3 Clavien-Dindo complications (OR 2.39, p = 0.28), and LOS (MD 0.26, p = 0.84). CONCLUSION The current evidence for the use of prophylactic mesh in emergency laparotomy is diverse and obscure. Although the data trends towards a reduction in the incidence of IH, a reliable conclusion requires further high-quality RCTs to fully assess the efficacy and safety of mesh use in an emergency setting.
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Affiliation(s)
- Mohamed Albendary
- Department of General Surgery, Sandwell and West, Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Ali Yasen Y Mohamedahmed
- Department of General Surgery, Sandwell and West, Birmingham Hospitals NHS Trust, Birmingham, UK.
| | | | - Shantanu Rout
- Department of General Surgery, Sandwell and West, Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Anil George
- Department of General Surgery, Sandwell and West, Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Shafquat Zaman
- Department of General Surgery, Sandwell and West, Birmingham Hospitals NHS Trust, Birmingham, UK
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Mäkäräinen E, Tolonen M, Sallinen V, Mentula P, Leppäniemi A, Ahonen-Siirtola M, Saarnio J, Ohtonen P, Muysoms F, Rautio T. OUP accepted manuscript. BJS Open 2022; 6:6526454. [PMID: 35143628 PMCID: PMC8830749 DOI: 10.1093/bjsopen/zrab142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Despite the fact that emergency midline laparotomy is a risk factor for an incisional hernia, active research on hernia prevention in emergency settings is lacking. Different kinds of meshes and mesh positions have been studied in elective abdominal surgery, but no randomized controlled trials in emergency settings have been published thus far. Method The PREEMER trial (registration number NCT04311788) is a multicentre, patient- and assessor-blinded, randomized controlled trial to be conducted in six hospitals in Finland. A total of 244 patients will be randomized at a 1 : 1 ratio to either the retrorectus mesh group, featuring a self-gripping prophylactic mesh, or to the no mesh (control) group, both closed by small-stitch 4 : 1 closure with continuous slowly absorbable monofilament suturing. The primary outcome of the PREEMER trial is the incidence of incisional hernia 2 years after surgery, which will be detected clinically and/or radiologically. Secondary outcomes are the Comprehensive Complication Index score, incidence of surgical-site infections and fascial dehiscence within 30 days of surgery; the incisional hernia repair rate and mesh- or hernia-related reoperations within the 2- and 5-year follow-ups; the incidence of incisional hernia within the 5-year follow-up; and quality of life measured by RAND-36, the Activities Assessment Scale and the PROMIS questionnaire within 30 days and 2 and 5 years from surgery. Additionally, health–economic explorative measures will be explored. Conclusion The PREEMER trial will provide level 1 evidence on incisional hernia prevention in an emergency setting. Registration number NCT04311788 (http://www.clinicaltrials.gov). Registered 7 March 2020.
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Affiliation(s)
- Elisa Mäkäräinen
- Correspondence to: Elisa Mäkäräinen, Oulu University Hospital, PL 29, 90029 OYS, Oulu, Finland (e-mail: )
| | - Matti Tolonen
- Department of Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Ville Sallinen
- Department of Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Panu Mentula
- Department of Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Ari Leppäniemi
- Department of Surgery, Helsinki University Hospital, Helsinki, Finland
| | | | - Juha Saarnio
- Department of Surgery, Medical Research Center, Oulu University Hospital, Oulu, Finland
| | - Pasi Ohtonen
- Department of Surgery, Medical Research Center, Oulu University Hospital, Oulu, Finland
| | | | - Tero Rautio
- Department of Surgery, Medical Research Center, Oulu University Hospital, Oulu, Finland
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Tansawet A, Numthavaj P, Sumritpradit P, Techapongsatorn S, McKay G, Attia J, Thakkinstian A. Midline incisional hernia prophylaxis using synthetic mesh in an emergency or urgent gastrointestinal tract surgery: a protocol for multicentre randomised clinical trial. BMJ Open 2021; 11:e045541. [PMID: 34479930 PMCID: PMC8420735 DOI: 10.1136/bmjopen-2020-045541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 08/13/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Between 5% and 30% of abdominal incisions eventually result in incisional hernias (IHs) that can lead to severe complications and impaired quality of life. Unfortunately, IH repair is often unsuccessful; therefore, hernia prophylaxis is an important issue. The efficacy of mesh augmentation has been proven for hernia prophylaxis in high-risk patients, but no randomised clinical trial has evaluated prophylactic mesh placement in emergency/urgent gastrointestinal operations. METHODS AND ANALYSIS A multicentre, prospective randomised, open and patient-assessor blinded endpoint design will be conducted. A total of 470 patients will be enrolled and randomly allocated to retrorectus mesh augmentation with lightweight polypropylene mesh or primary suture closure. The primary outcome is IH occurrence within 24 months of follow-up, while other clinical outcomes are secondary endpoints. A cost-effectiveness analysis will be conducted from the societal and provider perspectives. ETHICS AND DISSEMINATION Ethics approval was obtained from Ramathibodi Hospital (MURA2020/1478) and Vajira Hospital (COA164/2563). The protocol is on the process of submission to the local ethics committee of the other study sites. Results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER TCTR20200924002.
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Affiliation(s)
- Amarit Tansawet
- Surgery, Navamindradhiraj University, Bangkok, Thailand
- Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pawin Numthavaj
- Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Preeda Sumritpradit
- Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Gareth McKay
- Centre for Public Health, Faculty of Medicine Health and Life Sciences, Queen's University Belfast, Belfast, UK
| | - John Attia
- Centre for Clinical Epidemiology and Biostatistics, Hunter Medical Research Institute, School of Medicine and Public Health, The University of Newcastle, New Lambton, New South Wales, Australia
| | - Ammarin Thakkinstian
- Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Cerdán-Santacruz C, Ambrona-Zafra D, Villalobos-Mori R, Mestres Petit N, Sierra Grañón JE, Olsina-Kissler JJ. Laparoscopic repair of perineal hernia without suture fixation - a video vignette. Colorectal Dis 2021; 23:1989-1990. [PMID: 33964105 DOI: 10.1111/codi.15704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/11/2021] [Accepted: 04/22/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Carlos Cerdán-Santacruz
- Colorectal Surgery Department, Clínica Santa Elena, Madrid, Spain.,Colorectal Surgery Department, Hospital Universitario de La Princesa, Madrid, Spain
| | - David Ambrona-Zafra
- Colorectal Surgery Unit, General and Digestive Surgery Department, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Rafael Villalobos-Mori
- Abdominal Wall Surgery Unit, General and Digestive Surgery Department, Hospital Universitari Arnau de Vilanova, Lleida, Spain.,Universitat de Lleida, Lleida, Spain.,Centre de Reserca Experimental Biomèdica Aplicada (CREBA), IRBLleida, Lleida, Spain
| | - Núria Mestres Petit
- Colorectal Surgery Unit, General and Digestive Surgery Department, Hospital Universitari Arnau de Vilanova, Lleida, Spain.,Universitat de Lleida, Lleida, Spain
| | - José Enrique Sierra Grañón
- Colorectal Surgery Unit, General and Digestive Surgery Department, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Jorge Juan Olsina-Kissler
- Universitat de Lleida, Lleida, Spain.,General and Digestive Surgery Department, Hospital Universitari Arnau de Vilanova, Lleida, Spain.,Centre de Reserca Experimental Biomèdica Aplicada (CREBA), IRBLleida, Lleida, Spain
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13
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Bravo-Salva A, Argudo-Aguirre N, González-Castillo AM, Membrilla-Fernandez E, Sancho-Insenser JJ, Grande-Posa L, Pera-Román M, Pereira-Rodríguez JA. Long-term follow-up of prophylactic mesh reinforcement after emergency laparotomy. A retrospective controlled study. BMC Surg 2021; 21:243. [PMID: 34006282 PMCID: PMC8130379 DOI: 10.1186/s12893-021-01243-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 05/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prevention of incisional hernias with a prophylactic mesh in emergency surgery is controversial. The present study aimed to analyze the long-term results of prophylactic mesh used for preventing incisional hernia after emergency midline laparotomies. METHODS This study was a registered (NCT04578561) retrospective analysis of patients who underwent an emergency midline laparotomy between January 2009 and July 2010 with a follow-up period of longer than 2 years. Long-term outcomes and risk factors for the development of incisional hernias between patients who received a prophylactic reinforcement mesh (Group M) and suture (Group S) were compared. RESULTS From an initial 266 emergency midline laparotomies, 187 patients were included. The median follow-up time was 64.4 months (SD 35). Both groups had similar characteristics, except for a higher rate of previous operations (62 vs. 43.2%; P = 0.01) and operation due to a revision laparotomy (32.5 vs.13%; P = 0.02) in the M group. During follow-up, 29.9% of patients developed an incisional hernia (Group S 36.6% vs. Group M 14.3%; P = 0.002). Chronic mesh infections were diagnosed in 2 patients, but no mesh explants were needed, and no patient in the M group developed chronic pain. Long-term risk factors for incisional hernia were as follows: smoking (HR = 2.47; 95% CI 1.318-4.624; P = 0.05), contaminated surgery (HR = 2.98; 95% CI 1.142-7.8; P = 0.02), surgical site infection (SSI; HR = 3.83; 95% CI 1.86-7.86; P = 0.001), and no use of prophylactic mesh (HR = 5.09; 95% CI 2.1-12.2; P = 0.001). CONCLUSION Incidence of incisional hernias after emergency midline laparotomies is high and increases with time. High-risk patients, contaminated surgery, and surgical site infection (SSI) benefit from mesh reinforcement. Prophylactic mesh use is safe and feasible in emergencies with a low long-term complication rate. TRIAL REGISTRATION NCT04578561. www.clinicaltrials.gov.
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Affiliation(s)
- A Bravo-Salva
- Servicio de Cirugía General Y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, P. Marítim 23-25, 08003, Barcelona, Spain.,Departament de Ciències, Experimentals I de La Salut, Universitat Pompeu Fabra, Dr. Aiguader 88, 08003, Barcelona, Spain
| | - N Argudo-Aguirre
- Servicio de Cirugía General Y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, P. Marítim 23-25, 08003, Barcelona, Spain.,Departament de Ciències, Experimentals I de La Salut, Universitat Pompeu Fabra, Dr. Aiguader 88, 08003, Barcelona, Spain
| | - A M González-Castillo
- Servicio de Cirugía General Y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, P. Marítim 23-25, 08003, Barcelona, Spain.,Departament de Ciències Morfològiques, Universitat Autónoma de Barcelona, Campus Bellaterra, 08193, Cerdanyola del Vallès - Barcelona, Spain
| | - E Membrilla-Fernandez
- Servicio de Cirugía General Y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, P. Marítim 23-25, 08003, Barcelona, Spain.,Departament de Cirurgia, Vall d'Hebrón, Unitat Departamental Parc de Salut Mar, Universitat Autónoma de Barcelona, Passeig Vall d'Hebrón 119-129, 08035, Barcelona, Spain
| | - J J Sancho-Insenser
- Servicio de Cirugía General Y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, P. Marítim 23-25, 08003, Barcelona, Spain.,Departament de Cirurgia, Vall d'Hebrón, Unitat Departamental Parc de Salut Mar, Universitat Autónoma de Barcelona, Passeig Vall d'Hebrón 119-129, 08035, Barcelona, Spain
| | - L Grande-Posa
- Servicio de Cirugía General Y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, P. Marítim 23-25, 08003, Barcelona, Spain.,Departament de Cirurgia, Vall d'Hebrón, Unitat Departamental Parc de Salut Mar, Universitat Autónoma de Barcelona, Passeig Vall d'Hebrón 119-129, 08035, Barcelona, Spain
| | - M Pera-Román
- Servicio de Cirugía General Y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, P. Marítim 23-25, 08003, Barcelona, Spain.,Departament de Cirurgia, Vall d'Hebrón, Unitat Departamental Parc de Salut Mar, Universitat Autónoma de Barcelona, Passeig Vall d'Hebrón 119-129, 08035, Barcelona, Spain
| | - J A Pereira-Rodríguez
- Servicio de Cirugía General Y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, P. Marítim 23-25, 08003, Barcelona, Spain. .,Departament de Ciències, Experimentals I de La Salut, Universitat Pompeu Fabra, Dr. Aiguader 88, 08003, Barcelona, Spain.
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14
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Pizza F, D'Antonio D, Ronchi A, Lucido FS, Brusciano L, Marvaso A, Dell'Isola C, Gambardella C. Prophylactic sublay non-absorbable mesh positioning following midline laparotomy in a clean-contaminated field: randomized clinical trial (PROMETHEUS). Br J Surg 2021; 108:638-643. [PMID: 33907800 DOI: 10.1093/bjs/znab068] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/11/2020] [Accepted: 01/31/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Incisional hernia is a frequent postoperative complication after midline laparotomy. Prophylactic mesh augmentation in abdominal wall closure after elective surgery is recommended, but its role in emergency surgery is less well defined. METHODS This prospective randomized trial evaluated the incidence of incisional hernia in patients undergoing urgent midline laparotomy for clean-contaminated surgery. Closure using a slowly absorbable running suture was compared with closure using an additional sublay mesh (Parietex ProGrip™). Patients were randomized just before abdominal wall closure using computer-generated permuted blocks. Patients, care providers, staff collecting data, and those assessing the endpoints were all blinded to the group allocation. Patients were followed up for 24 months by means of clinical and ultrasonographic evaluations. RESULTS From January 2015 to June 2018, 200 patients were randomized: 100 to primary closure (control group) and 100 to Parietex ProGrip™ mesh-supported closure (mesh group). Eight patients in the control group and six in the mesh group were lost to follow-up. By 24 months after surgery, 21 patients in the control group and six in the mesh group had developed incisional hernia (P = 0.002). There was no difference between groups in the incidence of haematoma (2 versus 5; P = 0.248) and superficial wound infection (4 versus 5; P = 0.733). Multivariable analysis confirmed the role of mesh in preventing incisional hernia (odds ratio 0.11, 95 per cent c.i. 0.03 to 0.37; P < 0.001). One patient in the mesh group required mesh removal because of deep infection. CONCLUSION Prophylactic mesh-augmented abdominal wall closure after urgent laparotomy in clean-contaminated wounds is safe and effective in reducing the incidence of incisional hernia. Registration number: NCT04436887 (http://www.clinicaltrials.gov). GRAPHICAL ABSTRACT An RCT was conducted to compare the widely recommended midline laparotomy closure using a slowly absorbable running suture with closure using a sublay mesh (Parietex ProGrip™), in patients undergoing urgent midline laparotomy for clean-contaminated surgery. Patients were followed up for 24 months with clinical and ultrasonographic evaluation during outpatient visits. Prophylactic reinforcement of the midline abdominal wall, using a ProGrip™ Parietex mesh in the retromuscular position, at the time of urgent laparotomy in clean-contaminated wounds was safe and effective in reducing the incidence of incisional hernia, although larger studies with longer follow-up are required.
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Affiliation(s)
- F Pizza
- Department of Surgery, Hospital 'Rizzoli', Naples, Italy
| | - D D'Antonio
- Department of Surgery, Hospital 'Rizzoli', Naples, Italy
| | - A Ronchi
- Pathology Unit, Department of Mental and Physical Health and Preventive Medicine, Naples University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - F S Lucido
- Division of General, Mininvasive and Bariatric Surgery, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - L Brusciano
- Division of General, Mininvasive and Bariatric Surgery, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - A Marvaso
- Department of Surgery, Hospital 'Rizzoli', Naples, Italy
| | - C Dell'Isola
- Department of Infectious Diseases, AORN 'dei Colli' Monaldi-Cotugno - CTO, Naples, Italy
| | - C Gambardella
- Division of General, Mininvasive and Bariatric Surgery, University of Campania 'Luigi Vanvitelli', Naples, Italy
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15
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Counting stitches does not save time. Surgery 2021; 169:1561. [PMID: 33773823 DOI: 10.1016/j.surg.2021.02.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 02/12/2021] [Indexed: 11/24/2022]
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16
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Biologic mesh implantation is associated with serious abdominal wall complications in patients undergoing emergency abdominal surgery: A randomized-controlled clinical trial. J Trauma Acute Care Surg 2021; 89:1149-1155. [PMID: 32649617 DOI: 10.1097/ta.0000000000002877] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Open, emergency abdominal surgery is associated with a high incidence of fascial dehiscence and incisional hernia. Implantation of biologic meshes potentially reinforces the abdominal wall and therefore decreases such complications. The aim of this prospective randomized study was to compare the outcome after prophylactic intraperitoneal implantation of a biologic Strattice mesh (Allergan, Dublin, Ireland) with standard abdominal closure in patients undergoing emergency abdominal surgery. METHODS A two-arm randomized clinical trial was performed in patients undergoing emergency abdominal surgery at Bern University Hospital, University of Bern, Switzerland, from April 2016 to March 2019. Patients were randomly assigned to prophylactic implantation of a biological intraperitoneal mesh using Strattice, Allergan (mesh group), or standard abdominal closure using a single, continuous running suture (no-mesh group). Because of safety concerns, patient enrollment was closed prematurely. RESULTS Eligibility for inclusion was assessed in 61 patients. A total of 48 patients were randomized (21 in the mesh group, 28 in the no-mesh group). No differences in baseline characteristics were found. Abdominal wall complications requiring reoperations were more frequent in the mesh group compared to the no-mesh group (5 [83.3%] of 13 vs. 1 [14.3%] of 13 patients, p = 0.026). Mesh-associated abdominal wall complications included nonintegration of the mesh into the abdominal wall, dissolution of the mesh, and mesh-related infections. CONCLUSION In patients undergoing emergency abdominal surgery, intraperitoneal biologic Strattice mesh implantation is associated with significantly more frequent abdominal wall complications requiring reoperation. Therefore, the use of such meshes cannot be recommended in the contaminated environment of emergency abdominal surgery. LEVEL OF EVIDENCE Therapeutic, level I.
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17
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Ciscar Belles A, Makhoukhi T, López-Cano M, Hernández Granados P, Pereira Rodríguez JA. Umbilical incisional hernia (M3) Are trocar hernia differents? Comparative analysis of the EVEREG Registry. Cir Esp 2021; 100:S0009-739X(21)00041-5. [PMID: 33640141 DOI: 10.1016/j.ciresp.2021.01.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/21/2021] [Accepted: 01/24/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Incisional hernia (HI), in open and laparoscopic surgery, is a very frequent complication. HI located in the umbilical region are called M3. The main aim of this study is to compare HI produced by the placement of an umbilical laparoscopic trocar (M3T) with those located in M3 in open surgery (M3O) in terms of basal characteristics, complications and recurrences; and secondarily the identification of risk factors. METHOD Cross-sectional observational study based on the national prospective registry EVEREG during the period of July 2012 - June 2018. The main variables were recurrences and postoperative complications. Both groups (M3T and M3O) were compared. Multiple logistic regression was performed to identify the risk factors of the entire cohort. RESULTS 882 had a follow-up time longer than 12 months. M3O group presented superior ASA-Class, more complex HI and previous repair. It also presented a higher recurrence rate at 12 and 24 months (8.6 vs. 2.5%; p < 0,0001 and 9.3 vs. 2.9%; p < 0.0001) and higher postoperative complications rate (21.9 vs. 14.6%; p = 0.02). Previous repair, intervention length and associated procedures requirement were identified as risk factors for postoperative complications. Absence of a specialist present during surgery, previous repair, and the absence of complications were identified as risk factors for recurrence. In the PSM analysis no differences were detected in of complications and recurrences. CONCLUSIONS HI M3O is more complex than M3T. The complexity is not related to the origin of the hernia but to its characteristics and those of the patient.
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Affiliation(s)
- Ana Ciscar Belles
- Departament de Ciències Experimentals i de la Salut. Universitat Pompeu Fabra, Barcelona, España; Servicio de Cirugía General. Hospital de Mataró, Barcelona, España
| | - Touria Makhoukhi
- Departament de Ciències Experimentals i de la Salut. Universitat Pompeu Fabra, Barcelona, España
| | - Manuel López-Cano
- Servicio de Cirugía General. Hospital Vall d'Hebron, Barcelona, España; Departament de Cirurgia. Universitat Autònoma de Barcelona, Barcelona, España
| | | | - José Antonio Pereira Rodríguez
- Departament de Ciències Experimentals i de la Salut. Universitat Pompeu Fabra, Barcelona, España; Servicio de Cirugía General. Hospital Universitari del Mar, Barcelona, España.
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18
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Prophylactic Mesh After Midline Laparotomy: Evidence is out There, but why do Surgeons Hesitate? World J Surg 2021; 45:1349-1361. [PMID: 33558998 DOI: 10.1007/s00268-020-05898-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Incisional hernias have an impact on patients' quality of life and on health care finances. Because of high recurrence rates despite mesh repair, the prevention of incisional hernias with prophylactic mesh reinforcement is currently a topic of interest. But only 15% of surgeons are implementing it, mainly because of fear for mesh complications and disbelief in the benefits. The goal of this systematic review is to evaluate the effectiveness and safety of prophylactic mesh in adult patients after midline laparotomy. METHODS An extensive literature search was performed in PubMed, Embase and CENTRAL until 9/5/2020 for RCTs and cohort studies regarding mesh reinforcement versus primary suture closure of a midline laparotomy. The quality of the articles was analyzed using the Scottish Intercollegiate Guidelines Network checklists. Revman 5 was used to perform a meta-analysis. RESULTS Twenty-three articles were found with a total of 1633 patients in the mesh reinforcement group and 1533 in the primary suture group. An odds ratio for incisional hernia incidence of 0.37 (95% CI = [0.30, 0.46], p < 0.01) with RCTs and of 0.15 (95% CI = [0.09,0.25], p < 0.01) in cohort studies was calculated. Seroma rate shows a significant odds ratio of 2.18 (95% CI = [1.45, 3.29], p < 0.01) in favor of primary suture. No increase was found regarding other complications. CONCLUSION The evidence for the use of prophylactic mesh reinforcement is overwhelming with a significant reduction in incisional hernia rate, but implementation in daily clinical practice remains limited. Instead of putting patients at risk for incisional hernia formation and subsequent complications, surgeons should question their arguments why not to use mesh reinforcement, specifically in high-risk patients.
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19
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Incisional hernia incidence following laparotomy for combat trauma: Investigating 15 years of US war surgery. J Trauma Acute Care Surg 2021; 89:S200-S206. [PMID: 32345894 DOI: 10.1097/ta.0000000000002769] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND While the incidence of incisional hernia (IH) following elective laparotomy has been well described, incidence following emergent laparotomy for combat trauma has been much less studied. This retrospective cohort investigates the latter to better describe the burden IH represents for the injured warfighter. METHODS Data were obtained from the Expeditionary Medical Encounter Database for service members who survived a combat-related injury between January 2002 and December 2016 and underwent abdominal surgery in the first 30 days after injury. Incisional hernia diagnosis at least 30 days after injury was determined from inpatient and outpatient records in the Military Health System's Medical Data Repository.Means and SDs were reported for age and continuous Injury Severity Score, and frequency and percentages were reported for sex, branch of service, paygrade, mechanism of injury, Injury Severity Score, and maximum abdominal Abbreviated Injury Scale. Service members with and without a hernia diagnosis were compared using t test for continuous variables and χ or Fisher exact test (depending on cell size) for categorical variables.Multivariate logistic regression models were used to examine relationships between IH diagnosis and the covariates previously mentioned. Data analysis was completed using SAS software version 9.4 (SAS Institute Inc., Cary, NC). RESULTS Of the 570 laparotomy patients, 109 (19.1%) developed IH. Of these, 58 (53%) were diagnosed within the first year after injury. An additional 21 (19%) were diagnosed within the following year, and 30 (28%) were diagnosed more than 2 years after injury. Presence of gastrointestinal injury, Abbreviated Injury Scale score of 4 and 5, and 5-year increments of age were positively associated with hernia formation. CONCLUSION The incidence of postlaparotomy IH in combat trauma is 19.1%, a considerable source of disability for injured warfighters. Further investigation into hernia-preventive closure strategies is warranted. LEVEL OF EVIDENCE Therapeutic study, level IV.
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20
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Mesh position for hernia prophylaxis after midline laparotomy: A systematic review and network meta-analysis of randomized clinical trials. Int J Surg 2020; 83:144-151. [DOI: 10.1016/j.ijsu.2020.08.059] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/23/2020] [Accepted: 08/26/2020] [Indexed: 12/11/2022]
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21
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Goldwag JL, Wilson LR, Ivatury SJ, Pauli EM, Tsapakos MJ, Wilson MZ. Stoma closure and reinforcement (SCAR): A study protocol for a pilot trial. Contemp Clin Trials Commun 2020; 19:100582. [PMID: 32577580 PMCID: PMC7300121 DOI: 10.1016/j.conctc.2020.100582] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 05/21/2020] [Accepted: 06/07/2020] [Indexed: 12/21/2022] Open
Abstract
A quality metric for centers performing rectal cancer surgery is a high percentage of sphincter sparing procedures. These procedures often involve temporary bowel diversion to minimize the complications of an anastomotic leak. The most common strategy is a diverting loop ileostomy which is then closed after completion of adjuvant therapy or the patient recovers from surgery. Loop ileostomy is not without complications and the closure is complicated by a one in three chance of incisional hernia development. Strategies to prevent this problem have been designed using a variety of techniques with and without mesh placement. This proposed pilot study will test the safety and efficacy of a novel stoma closure technique involving permanent mesh in the retro rectus position during ileostomy closure. The study will prospectively follow 20 patients undergoing ileostomy closure using this technique and evaluate for safety of the procedure, quality of life, and feasibility for a larger randomized controlled trial. Patients will be followed post procedurally and evaluated for 30-day complications, as well as followed up with routine cancer surveillance computed tomography every 6 months in which the presence of stoma site incisional hernias will be evaluated. The results of this pilot study will inform the design of a multiple center, blinded randomized controlled trial to evaluate the utility of permanent mesh placement to decrease the incidence of prior stoma site incisional hernias.
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Affiliation(s)
- Jenaya L Goldwag
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Lauren R Wilson
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Srinivas J Ivatury
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Eric M Pauli
- Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Michael J Tsapakos
- Department of Radiology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Matthew Z Wilson
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
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22
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Burns FA, Heywood EG, Challand CP, Lee MJ. Is there a role for prophylactic mesh in abdominal wall closure after emergency laparotomy? A systematic review and meta-analysis. Hernia 2020; 24:441-447. [PMID: 31641872 PMCID: PMC7210219 DOI: 10.1007/s10029-019-02060-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 09/27/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Incisional hernias are a common complication of emergency laparotomy and are associated with significant morbidity. Recent studies have found a reduction in incisional hernias when mesh is placed prophylactically during abdominal closure in elective laparotomies. This systematic review will assess the safety and efficacy of prophylactic mesh placement in emergency laparotomy. METHODS A systematic review was performed according to the PROSPERO registered protocol (CRD42018109283). Papers were dual screened for eligibility, and included when a comparison was made between closure with prophylactic mesh and closure with a standard technique, reported using a comparative design (i.e. case-control, cohort or randomised trial), where the primary outcome was incisional hernia. Bias was assessed using the Cochrane risk of bias in non-randomised studies tool. A meta-analysis of incisional hernia rate was performed to estimate risk ratio using a random effects model (Mantel-Haenszel approach). RESULTS 332 studies were screened for eligibility, 29 full texts were reviewed and 2 non-randomised studies were included. Both studies were biased due to confounding factors, as closure technique was based on patient risk factors for incisional hernia. Both studies found significantly fewer incisional hernias in the mesh groups [3.2% vs 28.6% (p < 0.001) and 5.9% vs 33.3% (p = 0.0001)]. A meta-analysis of incisional hernia risk favoured prophylactic mesh closure [risk ratio 0.15 (95% CI 0.6-0.35, p < 0.001)]. Neither study found an association between mesh and infection or enterocutaneous fistula. CONCLUSION This review found that there are limited data to assess the effect or safety profile of prophylactic mesh in the emergency laparotomy setting. The current data cannot reliably assess the use of mesh due to confounding factors, and a randomised controlled trial is required to address this important clinical question.
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Affiliation(s)
- F A Burns
- Academic Department of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S5 7AU, UK
| | - E G Heywood
- Academic Department of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S5 7AU, UK
| | - C P Challand
- Academic Department of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S5 7AU, UK
| | - Matthew J Lee
- Academic Department of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S5 7AU, UK.
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, S10 2RX, UK.
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23
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Luo XG, Lu C, Wang WL, Zhou F, Yu CZ. Giant ventral hernia simultaneously containing the spleen, a portion of the pancreas and the left hepatic lobe: A case report. World J Clin Cases 2020; 8:1721-1728. [PMID: 32432146 PMCID: PMC7211533 DOI: 10.12998/wjcc.v8.i9.1721] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 03/27/2020] [Accepted: 04/16/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Ventral hernia, also known as incisional hernia, is a common complication of previous surgery. The contents of ventral hernia may include omentum, preperitoneal fat, small intestine or colon. However, ventral hernia with protrusion of more than two parenchymal organs simultaneously is extremely rare, and its repair is very complex and difficult. Surgeons should make a comprehensive assessment based on their own experience and the individual characteristics of the hernia. In addition, psychological therapy should be emphasized in the whole treatment process.
CASE SUMMARY We report a rare case of asymptomatic giant ventral hernia for 15 years in a 21-year-old female. The patient underwent umbilical hernia repair at the age of 1 year. Approximately 5 years later, ventral hernia recurred and repair with Mesh was performed, but the operation failed due to postoperative infection, and a huge mass appeared in the left abdominal wall. The mass increased gradually with the development and maturity of the body. Computerized tomography scan demonstrated that the patient's total spleen, part of the pancreas and left lobe of the liver were simultaneously herniated through the abdominal incisional hernia. As the patient was unable to endure the inconvenience of life and the potential risk of spleen or liver rupture, she underwent a ventral hernia repair with Mesh at our hospital. The operation was successful and the patient had a good recovery. During a 3-mo follow-up, the patient remained asymptomatic and the appearance of the surgical incision was greatly improved.
CONCLUSION Ventral hernia is a common complication of abdominal surgery. Ventral hernia with protrusion of more than two parenchymal organs simultaneously is extremely rare. Surgeons should pay attention to the psychological treatment while restoring the abdominal physiological function in ventral hernia patients.
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Affiliation(s)
- Xia-Gang Luo
- Department of General Surgery, the Second Affiliated Hospital of Nanjing Medical University, Nanjing 2l0011, Jiangsu Province, China
| | - Chen Lu
- Department of General Surgery, the Second Affiliated Hospital of Nanjing Medical University, Nanjing 2l0011, Jiangsu Province, China
| | - Wu-Lin Wang
- Department of General Surgery, the Second Affiliated Hospital of Nanjing Medical University, Nanjing 2l0011, Jiangsu Province, China
| | - Fei Zhou
- Department of General Surgery, the Second Affiliated Hospital of Nanjing Medical University, Nanjing 2l0011, Jiangsu Province, China
| | - Chun-Zhao Yu
- Department of General Surgery, the Second Affiliated Hospital of Nanjing Medical University, Nanjing 2l0011, Jiangsu Province, China
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Safety and Efficacy of Synthetic Mesh for Ventral Hernia Repair in a Contaminated Field. J Am Coll Surg 2020; 230:405-413. [DOI: 10.1016/j.jamcollsurg.2019.12.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 11/17/2022]
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25
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Lima HV, Rasslan R, Novo FC, Lima TM, Damous SH, Bernini CO, Montero EF, Utiyama EM. Prevention of Fascial Dehiscence with Onlay Prophylactic Mesh in Emergency Laparotomy: A Randomized Clinical Trial. J Am Coll Surg 2020; 230:76-87. [DOI: 10.1016/j.jamcollsurg.2019.09.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 07/29/2019] [Accepted: 09/16/2019] [Indexed: 12/13/2022]
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26
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Bravo-Salva A, González-Castillo AM, Vela-Polanco FF, Membrilla-Fernández E, Vila-Domenech J, Pera-Román M, Sancho-Insenser JJ, Pereira-Rodríguez JA. Incidence of Incisional Hernia After Emergency Subcostal Unilateral Laparotomy: Does Augmentation Prophylaxis Play a Role? World J Surg 2019; 44:741-748. [PMID: 31741074 DOI: 10.1007/s00268-019-05282-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Few data are available about the frequency of incisional hernia in an emergency subcostal laparotomy. Our objective is to analyze the incidence of incisional hernia after emergency subcostal laparotomy and evaluate if prophylactic mesh could help prevent it. METHODS This study is a monocentric retrospective analysis following STROBE guideline statements of all patients who underwent an emergency subcostal laparotomy between January 2011 and July 2017 in our University Hospital. We compared complications and incidence of incisional hernia between patients who received sutures (Group S; N = 203) and patients with prophylactic onlay mesh (Group M; N = 80). A multivariate risk factor analysis of incisional hernia was performed. An incisional hernia-estimated risk calculator equation was created. RESULTS A total of 283 patients were analyzed. There were 80 patients in Group M and 203 in Group S. In short-term outcomes, length of surgery (213 ± 115 min vs 165 ± 73.3 min, P = 0.001) and hospital stay (16.4 ± 18.7 vs 11.6 days ± 13.4, P = 0.038) were longer in Group M. Long-term follow-up was conducted in 207 patients with a mean follow-up time of 39.3 ± 23 months. Incisional hernia was detected in 29 (19.1%) patients in Group S but in only two (3.8%) patients in Group M (P = 0.008). In the multivariate analysis, a risk factor analysis included wound infection (4.91 HR (2.12-11.4); P < 0.001), previous hernia repair (2.86 HR (1.24-6.61); P = 0.014), and shock (2.64 HR (1.01-6.93); P = 0.048). CONCLUSIONS The incidence of incisional hernia after emergency subcostal laparotomy is high. Risk factors are wound infection, shock, and previous hernia surgery. The use of prophylactic mesh augmentation was safe and reduced the incidence of incisional hernia.
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Affiliation(s)
- A Bravo-Salva
- Servicio de Cirugía General y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, Passeig Marítim 25-29, 08003, Barcelona, Spain. .,Departament de Ciències, Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, Spain.
| | - A M González-Castillo
- Servicio de Cirugía General y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, Passeig Marítim 25-29, 08003, Barcelona, Spain
| | - F F Vela-Polanco
- Servicio de Cirugía General y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, Passeig Marítim 25-29, 08003, Barcelona, Spain
| | - E Membrilla-Fernández
- Servicio de Cirugía General y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, Passeig Marítim 25-29, 08003, Barcelona, Spain.,Departament de Cirurgia, Universitat Autònoma de Barcelona, Hospital del Mar, Barcelona, Spain
| | - J Vila-Domenech
- IMIM-Institut de Recerca Hospital del Mar, Barcelona, Spain.,CIBER Epidemiology and Public Health (CIBERESP), Barcelona, Spain
| | - M Pera-Román
- Servicio de Cirugía General y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, Passeig Marítim 25-29, 08003, Barcelona, Spain.,Departament de Cirurgia, Universitat Autònoma de Barcelona, Hospital del Mar, Barcelona, Spain
| | - J J Sancho-Insenser
- Servicio de Cirugía General y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, Passeig Marítim 25-29, 08003, Barcelona, Spain.,Departament de Cirurgia, Universitat Autònoma de Barcelona, Hospital del Mar, Barcelona, Spain
| | - J A Pereira-Rodríguez
- Servicio de Cirugía General y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, Passeig Marítim 25-29, 08003, Barcelona, Spain.,Departament de Ciències, Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, Spain
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Aicher BO, Woodall J, Tolaymat B, Calvert C, Monahan TS, Toursavadkohi S. Does perfusion matter? Preoperative prediction of incisional hernia development. Hernia 2019; 25:419-425. [PMID: 31375948 DOI: 10.1007/s10029-019-02018-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Accepted: 07/20/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Incisional hernias complicate 12-15% of general surgery cases with higher rates reported after laparotomy for aortoiliac occlusive disease (10-17%) and aneurysmal disease (17-38%). We hypothesize that inadequate perfusion of the abdominal wall promotes future hernia development. METHODS Thirty-eight patients undergoing midline laparotomy or thoracoabdominal approach for aortic disease with at least 2 years of follow-up were included in the study. Preoperative imaging was reviewed to assess vessel patency, contributing to the abdominal wall perfusion. Patency of the superior epigastric artery was determined at the T10 level, the inferior epigastric artery at the L4 level, and the deep circumflex iliac artery at the anterior superior iliac spine. Lumbar arteries were considered patent if they were seen branching from the aorta. Clinic notes and hospital medical records were reviewed to evaluate the hernia development post-procedure. RESULTS Thirteen patients (34%) developed an incisional hernia. Absent flow from bilateral superior epigastric arteries or absent flow from ipsilateral superior and inferior epigastric arteries was found to be predictive of hernia development (P = 0.013, 0.011, respectively). There was no association identified with perfusion from the lumbar or deep circumflex iliac arteries. CONCLUSIONS Absent patency of the abdominal wall vasculature is a novel risk factor for incisional hernia development in the setting of aortic disease. Preoperative assessment of perfusion may convey the risk of hernia development and may be a tool to guide measures such as prophylactic mesh placement to reduce the future risk of incisional hernia.
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Affiliation(s)
- B O Aicher
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, 22 South Greene Street, S8B02, Baltimore, MD, 21201, USA.
| | - J Woodall
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, 22 South Greene Street, S8B02, Baltimore, MD, 21201, USA
| | - B Tolaymat
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, 22 South Greene Street, S8B02, Baltimore, MD, 21201, USA
| | - C Calvert
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, 22 South Greene Street, S8B02, Baltimore, MD, 21201, USA
| | - T S Monahan
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, 22 South Greene Street, S8B02, Baltimore, MD, 21201, USA.,Center for Aortic Disease, University of Maryland Medical Center, 22 South Greene Street, S8B02, Baltimore, MD, 21201, USA
| | - S Toursavadkohi
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, 22 South Greene Street, S8B02, Baltimore, MD, 21201, USA.,Center for Aortic Disease, University of Maryland Medical Center, 22 South Greene Street, S8B02, Baltimore, MD, 21201, USA
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Abstract
Incisional and parastomal hernias continue to be vexing problems for patients and surgeons. Risk factors are generally patient-related and/or technical in nature, and in some cases, can be altered, resulting in improved outcomes. Improved fascial closure techniques can only partly reduce the risk of incisional hernia formation. Even under optimal circumstances, using time tested closure techniques and materials, the rate remains high, due primarily to factors that are not modifiable or are unidentifiable. In such cases, there may be a beneficial role for prophylactic mesh augmentation (PMA), wherein mesh is implanted at the time of initial surgery or stoma formation. Several high-risk groups that might benefit from PMA have been identified, including patients undergoing open abdominal aneurysm repair or colorectal procedures, obese patients, and patients requiring creation of permanent gastrointestinal or urological stomas. Although the initial results of PMA are promising, the benefits of this strategy must be weighed against potential risks. Outcome measures to assess efficacy should include not only hernia recurrence but also quality of life, surgical-site occurrences, and cost. Further studies are warranted to predict which specific patient populations might benefit most from PMA and to identify ideal mesh materials as well as preferred implantation sites and methods of mesh fixation.
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29
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Reduced rate of incisional hernia after standardized fascial closure in emergency laparotomy. Hernia 2019; 23:341-346. [DOI: 10.1007/s10029-019-01893-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 01/15/2019] [Indexed: 10/27/2022]
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30
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Long-term outcomes after prophylactic use of onlay mesh in midline laparotomy. Hernia 2018; 22:1113-1122. [DOI: 10.1007/s10029-018-1833-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 09/24/2018] [Indexed: 10/28/2022]
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31
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Piccoli M, Agresta F, Attinà GM, Amabile D, Marchi D. "Complex abdominal wall" management: evidence-based guidelines of the Italian Consensus Conference. Updates Surg 2018; 71:255-272. [PMID: 30255435 PMCID: PMC6647889 DOI: 10.1007/s13304-018-0577-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 08/03/2018] [Indexed: 11/29/2022]
Abstract
To date, there is no shared consensus on a definition of a complex abdominal wall in elective surgery and in the emergency, on indications, technical details, complications, and follow-up. The purpose of the conference was to lay the foundations for a homogeneous approach to the complex abdominal wall with the primary intent being to attain the following objectives: (1) to develop evidence-based recommendations to define “complex abdominal wall”; (2) indications in emergency and in elective cases; (3) management of “complex abdominal wall”; (4) techniques for temporary abdominal closure. The decompressive laparostomy should be considered in a case of abdominal compartment syndrome in patients with critical conditions or after the failure of a medical treatment or less invasive methods. In the second one, beyond different mechanism, patients with surgical emergency diseases might reach the same pathophysiological end point of trauma patients where a preventive “open abdomen” might be indicated (a temporary abdominal closure: in the case of a non-infected field, the Wittmann patch and the NPWT had the best outcome followed by meshes; in the case of an infected field, NPWT techniques seem to be the preferred). The second priority is to create optimal both general as local conditions for healing: the right antimicrobial management, feeding—preferably by the enteral route—and managing correctly the open abdomen wall. The use of a mesh appears to be—if and when possible—the gold standard. There is a lot of enthusiasm about biological meshes. But the actual evidence supports their use only in contaminated or potentially contaminated fields but above all, to reduce the higher rate of recurrences, the wall anatomy and function should be restored in the midline, with or without component separation technique. On the other site has not to be neglected that the use of monofilament and macroporous non-absorbable meshes, in extraperitoneal position, in the setting of the complex abdomen with contamination, seems to have a cost effective role too. The idea of this consensus conference was mainly to try to bring order in the so copious, but not always so “evident” literature utilizing and exchanging the expertise of different specialists.
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Affiliation(s)
- Micaela Piccoli
- Department of General Surgery, General Surgery Unit, New Sant'Agostino Hospital, Via Pietro Giardini, 1355, 41126, Modena, Italy
| | - Ferdinando Agresta
- Department of General Surgery, ULSS19 Veneto, Piazzale degli Etruschi 9, 45011, Adria, Italy
| | - Grazia Maria Attinà
- Department of General Surgery, General Surgery Unit, S. Camillo-Forlanini Hospital, Circonvallazione Gianicolense, 87, 00152, Rome, Italy.
| | - Dalia Amabile
- Department of General Surgery, General Surgery 1, Saint Chiara Hospital, Largo Medaglie D'oro, 9, 38122, Trento, Italy
| | - Domenico Marchi
- Department of General Surgery, General Surgery Unit, New Sant'Agostino Hospital, Via Pietro Giardini, 1355, 41126, Modena, Italy
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32
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Harris HW, Hope WH, Adrales G, Andersen DK, Deerenberg EB, Diener H, Dumanian G, East B, Fischer JP, Ureña MAG, Gibeily GJ, Hansson BM, Hernández- Granados P, Hiles MC, Jeekel J, Levinson H, Lopez-Cano M, Muysoms F, Pereira JA, Prudhomme M, Ramaswamy A, Stabilini C, Torkington J, Valverde S, Young DM. Contemporary concepts in hernia prevention: Selected proceedings from the 2017 International Symposium on Prevention of Incisional Hernias. Surgery 2018; 164:319-326. [DOI: 10.1016/j.surg.2018.02.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 02/28/2018] [Indexed: 12/27/2022]
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33
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Jakob MO, Schwarz C, Haltmeier T, Zindel J, Pinworasarn T, Candinas D, Starlinger P, Beldi G. Mesh-augmented versus direct abdominal closure in patients undergoing open abdomen treatment. Hernia 2018; 22:785-792. [PMID: 30027445 PMCID: PMC6153946 DOI: 10.1007/s10029-018-1798-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 07/13/2018] [Indexed: 01/29/2023]
Abstract
Background Open abdomen (OA) may be required in patients with abdominal trauma, sepsis or compartment syndrome. Vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) is a widely used approach for temporary abdominal closure to close the abdominal wall. However, this method is associated with a high incidence of re-operations in short term and late sequelae such as incisional hernia. The current study aims to compare the results of surgical strategies of OA with versus without permanent mesh augmentation. Methods Patients with OA treatment undergoing vacuum-assisted wound closure and an intraperitoneal onlay mesh (VAC-IPOM) implantation were compared to VAWCM with direct fascial closure which represents the current standard of care. Outcomes of patients from two tertiary referral centers that performed the different strategies for abdominal closure after OA treatment were compared in univariate and multivariate regression analysis. Results A total of 139 patients were included in the study. Of these, 50 (36.0%) patients underwent VAC-IPOM and 89 (64.0%) patients VAWCM. VAC-IPOM was associated with reduced re-operations (adjusted incidence risk ratio 0.48 per 10-person days; CI 95% = 0.39–0.58, p < 0.001), reduced duration of stay on intensive care unit (ICU) [adjusted hazard ratio (aHR) 0.53; CI 95% = 0.36–0.79, p = 0.002] and reduced hospital stay (aHR 0.61; CI 95% = 0.040–0.94; p = 0.024). In-hospital mortality [22.5 vs 18.0%, risk difference − 4.5; confidence interval (CI) 95% = − 18.2 to 9.3; p = 0.665] and the incidence of intestinal fistula (18.0 vs 22.0%, risk difference 4.0; CI 95% = −10.0 to 18.0; p = 0.656) did not differ between the two groups. In Kaplan–Meier analysis, hernia-free survival was significantly increased after VAC-IPOM (p = 0.041). Conclusions In patients undergoing OA treatment, intraperitoneal mesh augmentation is associated with a significantly decreased number of re-operations, duration of hospital and ICU stay and incidence of incisional hernias when compared to VAWCM. Electronic supplementary material The online version of this article (10.1007/s10029-018-1798-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- M O Jakob
- Department of Visceral Surgery and Medicine, University Hospital, Bern, Switzerland
| | - C Schwarz
- Department of Surgery, General Hospital, Medical University of Vienna, Vienna, Austria
| | - T Haltmeier
- Department of Visceral Surgery and Medicine, University Hospital, Bern, Switzerland
| | - J Zindel
- Department of Visceral Surgery and Medicine, University Hospital, Bern, Switzerland
| | - T Pinworasarn
- Department of Visceral Surgery and Medicine, University Hospital, Bern, Switzerland
| | - D Candinas
- Department of Visceral Surgery and Medicine, University Hospital, Bern, Switzerland
| | - P Starlinger
- Department of Surgery, General Hospital, Medical University of Vienna, Vienna, Austria
| | - G Beldi
- Department of Visceral Surgery and Medicine, University Hospital, Bern, Switzerland.
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34
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Argudo N, Pera M, López-Cano M, Hernández L, Sancho JJ, Grande L, Pereira JA. Selective Mesh Augmentation to Prevent Incisional Hernias in Open Colorectal Surgery Is Safe and Cost-Effective. Front Surg 2018; 5:8. [PMID: 29503821 PMCID: PMC5820344 DOI: 10.3389/fsurg.2018.00008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 01/30/2018] [Indexed: 12/15/2022] Open
Affiliation(s)
- Núria Argudo
- Department of General and Digestive Surgery, Parc de Salut Mar, Barcelona, Spain.,Department de Cirurgia, Universitat Autònoma de Barcelona, Barcelona, Spain.,Department de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, Spain
| | - Miguel Pera
- Department of General and Digestive Surgery, Parc de Salut Mar, Barcelona, Spain.,Department de Cirurgia, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Manuel López-Cano
- Department de Cirurgia, Universitat Autònoma de Barcelona, Barcelona, Spain.,Department of General Surgery, Hospital Universitari Vall d'Hebrón, Barcelona, Spain
| | - Lourdes Hernández
- Department of General and Digestive Surgery, Parc de Salut Mar, Barcelona, Spain
| | - Juan José Sancho
- Department of General and Digestive Surgery, Parc de Salut Mar, Barcelona, Spain.,Department de Cirurgia, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Luis Grande
- Department of General and Digestive Surgery, Parc de Salut Mar, Barcelona, Spain.,Department de Cirurgia, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - José Antonio Pereira
- Department of General and Digestive Surgery, Parc de Salut Mar, Barcelona, Spain.,Department de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, Spain
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35
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Hernández-Granados P, López-Cano M, Morales-Conde S, Muysoms F, García-Alamino J, Pereira-Rodríguez JA. Incisional hernia prevention and use of mesh. A narrative review. Cir Esp 2018; 96:76-87. [PMID: 29454636 DOI: 10.1016/j.ciresp.2018.01.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Revised: 12/21/2017] [Accepted: 01/08/2018] [Indexed: 12/11/2022]
Abstract
Incisional hernias are a very common problem, with an estimated incidence around 15-20% of all laparotomies. Evisceration is another important problem, with a lower rate (2.5-3%) but severe consequences for patients. Prevention of both complications is an essential objective of correct patient treatment due to the improved quality of life and cost savings. This narrative review intends to provide an update on incisional hernia and evisceration prevention. We analyze the current criteria for proper abdominal wall closure and the possibility to add prosthetic reinforcement in certain cases requiring it. Parastomal, trocar-site hernias and hernias developed after stoma closure are included in this review.
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Affiliation(s)
- Pilar Hernández-Granados
- Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España; Sección de Pared Abdominal de la Asociación Española de Cirujanos, España.
| | - Manuel López-Cano
- Sección de Pared Abdominal de la Asociación Española de Cirujanos, España; Unidad de Pared Abdominal, Hospital Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
| | - Salvador Morales-Conde
- Unidad de Innovación en Cirugía Mínimamente Invasiva, Hospital Universitario Virgen del Rocío, Sevilla, España; Secretaría General, European Hernia Society
| | - Filip Muysoms
- Servicio de Cirugía, Hospital Maria Middelares, Ghent, Bélgica
| | - Josep García-Alamino
- Department of Primary Care Health Sciencies, University of Oxford, Oxford, Reino Unido
| | - José Antonio Pereira-Rodríguez
- Servicio de Cirugía General y Digestiva, Parc de Salut Mar, Hospital del Mar. Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, España
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36
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Lanni MA, Tecce MG, Shubinets V, Mirzabeigi MN, Fischer JP. The State of Prophylactic Mesh Augmentation. Am Surg 2018. [DOI: 10.1177/000313481808400129] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Prophylactic mesh augmentation (PMA) is the implantation of mesh during closure of an index laparotomy to decrease a patient's risk for developing incisional hernia (IH). The current body of evidence lacks refined guidelines for patient selection, mesh placement, and material choice. The purpose of this study is to summarize the literature and identify areas of research needed to foster responsible and appropriate use of PMA as an emerging technique. We conducted a comprehensive review of Scopus, Cochrane, PubMed, and clinicaltrials.gov for articles and trials related to using PMA for IH risk reduction. We further supplemented our review by including select papers on patient-reported outcomes, cost utility, risk modeling, surgical techniques, and available materials highly relevant to PMA. Five-hundred-fifty-one unique articles and 357 trials were reviewed. Multiple studies note a significant decrease in IH incidence with PMA compared with primary suture-only–based closure. No multicenter randomized control trial has been conducted in the United States, and only two such trials are currently active worldwide. Evidence exists supporting the use of PMA, with practical cost utility and models for selecting high-risk patients, but standard PMA guidelines are lacking. Although Europe has progressed with this technique, widespread adoption of PMA requires large-scale pragmatic randomized control trial research, strong evidence-based guidelines, current procedural terminology coding, and resolution of several barriers.
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Affiliation(s)
- Michael A. Lanni
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Michael G. Tecce
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Valeriy Shubinets
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Michael N. Mirzabeigi
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - John P. Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
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37
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Jakob MO, Spari D, Zindel J, Pinworasarn T, Candinas D, Beldi G. Prophylactic, Synthetic Intraperitoneal Mesh Versus No Mesh Implantation in Patients with Fascial Dehiscence. J Gastrointest Surg 2018; 22:2158-2166. [PMID: 30039450 PMCID: PMC6244924 DOI: 10.1007/s11605-018-3873-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 07/03/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Primary closure of post-operative facial dehiscence (FD) is associated with a high incidence of recurrence, revisional surgery, and incisional hernia. This retrospective study compares outcomes of implantation of non-absorbable intra-abdominal meshes with primary closure of FD. The outcomes of different mesh materials were assessed in subgroup analysis. METHODS A total of 119 consecutive patients with FD were operated (70 mesh group and 49 no mesh group) between 2001 and 2015. Primary outcome parameter was hernia-free survival. Secondary outcome parameters include re-operations of the abdominal wall, intestinal fistula, surgical site infections (SSI), and mortality. Kaplan-Meier analysis for hernia-free survival, adjusted Poisson regression analysis for re-operations and adjusted regression analysis for chronic SSI was performed. RESULTS Hernia-free survival was significantly higher in the mesh group compared to the no mesh group (P = 0.005). Fewer re-operations were necessary in the mesh group compared to the no mesh group (adjusted incidence risk ratio 0.44, 95% confidence interval [CI] 0.20-0.93, P = 0.032). No difference in SSI, intestinal fistula, and mortality was observed between groups. Chronic SSI was observed in 7 (10%) patients in the mesh group (n = 3 [6.7%] with polypropylene mesh and 4 [28.6%] with polyester mesh). The risk for chronic SSI was significantly higher if a polyester mesh was used when compared to a polypropylene mesh (adjusted odds ratio 8.69, 95% CI 1.30-58.05, P = 0.026). CONCLUSION Implantation of a polypropylene but not polyester-based mesh in patients with FD decreases incisional hernia with a low rate of mesh-related morbidity.
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Affiliation(s)
- Manuel O Jakob
- Department of Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland
| | - Daniel Spari
- Department of Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland
| | - Joel Zindel
- Department of Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland
| | - Tawan Pinworasarn
- Department of Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland
| | - Daniel Candinas
- Department of Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland
| | - Guido Beldi
- Department of Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland.
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38
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Hoyuela C, Juvany M, Trias M, Ardid J, Martrat A. Incisional hernia prevention using a cyanoacrilate-fixed retrofascial mesh. Cir Esp 2017; 96:35-40. [PMID: 29249278 DOI: 10.1016/j.ciresp.2017.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 10/24/2017] [Accepted: 10/28/2017] [Indexed: 01/15/2023]
Abstract
INTRODUCTION The rate of incisional hernia in high-risk patients (obesity, cancer, etc.) is high, even in laparoscopic surgery. The aim of this study is to evaluate the safety of the use of cyanoacrylate fixed prophylactic meshes in the assistance incision in overweight or obese patients undergoing laparoscopic colorectal surgery. METHODS A prospective, non-randomized cohort study of patients undergoing elective laparoscopic resection for colorectal cancer between January 2013 and March 2016 was performed. Those with a body mass index greater than 25kg / m2 were evaluated to implant a prophylactic meshes fixed with cyanoacrylate (Histoacryl®) as reinforcement of the assistance incision. RESULTS 52 patients were analyzed (mean body mass index: 28.4±2kg / m 2). Prophylactic meshes was implanted in 15 patients. The time to put the mesh in place was always less than 5minutes. There was no significant difference in wound infection rate (12% vs. 10%). No mesh had to be explanted. Although the mean follow-up was shorter (14.1±4 vs. 22.3±9 months), there were no incisional hernia in the mesh group. On the other hand, in the non-mesh group, 1 acute evisceration (2.7%) and 4 incisional hernia of the assistance incision were observed (10.8%). There were no significant differences between groups regarding trocar incisional hernia (6.6 vs. 5.4%). CONCLUSIONS The implantation of a reinforcement prophylactic mesh in overweight or obese patients undergoing laparoscopic colorectal surgery is safe and seems to reduce the short-term rate of incisional hernia. Fixation with cyanoacrylate is a rapid method that facilitates the procedure without additional complications.
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Affiliation(s)
- Carlos Hoyuela
- Servicio de Cirugía Digestiva, Hospital Platón Barcelona, Universitat Autònoma de Barcelona, Barcelona, España.
| | - Montserrat Juvany
- Servicio de Cirugía Digestiva, Hospital Platón Barcelona, Universitat Autònoma de Barcelona, Barcelona, España
| | - Miquel Trias
- Servicio de Cirugía Digestiva, Hospital Platón Barcelona, Universitat Autònoma de Barcelona, Barcelona, España
| | - Jordi Ardid
- Servicio de Cirugía Digestiva, Hospital Platón Barcelona, Universitat Autònoma de Barcelona, Barcelona, España
| | - Antoni Martrat
- Servicio de Cirugía Digestiva, Hospital Platón Barcelona, Universitat Autònoma de Barcelona, Barcelona, España
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Clay L, Stark B, Gunnarsson U, Strigård K. Full-thickness skin graft vs. synthetic mesh in the repair of giant incisional hernia: a randomized controlled multicenter study. Hernia 2017; 22:325-332. [PMID: 29247365 PMCID: PMC5937886 DOI: 10.1007/s10029-017-1712-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 12/09/2017] [Indexed: 12/15/2022]
Abstract
PURPOSE Repair of large incisional hernias includes the implantation of a synthetic mesh, but this may lead to pain, stiffness, infection and enterocutaneous fistulae. Autologous full-thickness skin graft as on-lay reinforcement has been tested in eight high-risk patients in a proof-of-concept study, with satisfactory results. In this multicenter randomized study, the use of skin graft was compared to synthetic mesh in giant ventral hernia repair. METHODS Non-smoking patients with a ventral hernia > 10 cm wide were randomized to repair using an on-lay autologous full-thickness skin graft or a synthetic mesh. The primary endpoint was surgical site complications during the first 3 months. A secondary endpoint was patient comfort. Fifty-three patients were included. Clinical evaluation was performed at a 3-month follow-up appointment. RESULTS There were fewer patients in the skin graft group reporting discomfort: 3 (13%) vs. 12 (43%) (p = 0.016). Skin graft patients had less pain and a better general improvement. No difference was seen regarding seroma; 13 (54%) vs. 13 (46%), or subcutaneous wound infection; 5 (20%) vs. 7 (25%). One recurrence appeared in each group. Three patients in the skin graft group and two in the synthetic mesh group were admitted to the intensive care unit. CONCLUSION No difference was seen for the primary endpoint short-term surgical complication. Full-thickness skin graft appears to be a reliable material for ventral hernia repair producing no more complications than when using synthetic mesh. Patients repaired with a skin graft have less subjective abdominal wall symptoms.
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Affiliation(s)
- L Clay
- Department of Clinical Science, Intervention and Technology (CLINTEC), H9, Karolinska Institutet, 171 64, Stockholm, Sweden
| | - B Stark
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 64, Stockholm, Sweden
| | - U Gunnarsson
- Department of Surgical and Perioperative Sciences, Umeå University, 907 85, Umeå, Sweden
| | - K Strigård
- Department of Surgical and Perioperative Sciences, Umeå University, 907 85, Umeå, Sweden.
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Warren JA, Beffa LR, Carbonell AM, Cull J, Sinopoli B, Ewing JA, McFadden C, Crockett J, Cobb WS. Prophylactic placement of permanent synthetic mesh at the time of ostomy closure prevents formation of incisional hernias. Surgery 2017; 163:839-846. [PMID: 29224706 DOI: 10.1016/j.surg.2017.09.041] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 08/22/2017] [Accepted: 09/13/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Reversal of an enterostomy results in a high rate of incisional hernia at the ostomy site. Prophylactic mesh reinforcement of the fascial defect is typically not considered due to the contaminated nature of the case. We present the outcomes of a series of prophylactic mesh reinforcements with retromuscular, large-pore polypropylene at the time of enterostomy reversal. METHODS Retrospective review of all ostomy reversals was performed. All cases with placement of synthetic mesh reinforcement were identified from a prospectively maintained, hernia database. Primary end points were surgical site occurrence, surgical site infection, and hernia occurrence. RESULTS Ostomy reversal was performed in 359 patients; 91 were reinforced with mesh and 268 without mesh. Colostomy reversal was performed in 56.5% and ileostomy in 43.5%. The mesh group had a greater body mass index and a greater incidence of chronic obstructive pulmonary disease, but groups were otherwise similar. A midline incisional hernia was present in 45% of the mesh group vs 4.5% in the controls. Incidence of surgical site occurrence and surgical site infection were similar for mesh and control groups (21 vs 22.8%; P = .82 and 20 vs 19.8%; P = 1.000, respectively). Superficial surgical site infection was less with mesh (8 vs 16.4%; P = .039). Incidence of a hernia developing at the stoma site was decreased markedly with mesh (1% vs 17.2%; P < .001), as was the occurrence of a midline hernia (6% vs 19%; P = .004). Mesh was placed across the midline prophylactically in 29.7% of cases, which decreased midline hernia formation from 24.1% to 4% (P = .019). CONCLUSION Retromuscular placement of permanent synthetic mesh at the time of enterostomy reversal is effective in preventing development of incisional hernia without increased risk of surgical site occurrence or surgical site infection.
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Affiliation(s)
- Jeremy A Warren
- Department of Surgery, Division of Minimally Invasive and Bariatric Surgery, Greenville Health System, University of South Carolina School of Medicine Greenville, Greenville, SC.
| | - Lucas R Beffa
- Department of Surgery, Division of Minimally Invasive and Bariatric Surgery, Greenville Health System, University of South Carolina School of Medicine Greenville, Greenville, SC
| | - Alfredo M Carbonell
- Department of Surgery, Division of Minimally Invasive and Bariatric Surgery, Greenville Health System, University of South Carolina School of Medicine Greenville, Greenville, SC
| | - Jennifer Cull
- University of South Carolina School of Medicine Greenville, Greenville, SC
| | - Brent Sinopoli
- Department of Surgery, Division of Minimally Invasive and Bariatric Surgery, Greenville Health System, University of South Carolina School of Medicine Greenville, Greenville, SC
| | - Joseph A Ewing
- Greenville Health System, Department of Quality Management, Greenville, SC
| | - Cedrek McFadden
- Department of Surgery, Division of Colorectal Surgery, Greenville Health System, Greenville, SC
| | - Jay Crockett
- Department of Surgery, Division of Colorectal Surgery, Greenville Health System, Greenville, SC
| | - William S Cobb
- Department of Surgery, Division of Minimally Invasive and Bariatric Surgery, Greenville Health System, University of South Carolina School of Medicine Greenville, Greenville, SC
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Carney MJ, Weissler JM, Fox JP, Tecce MG, Hsu JY, Fischer JP. Trends in open abdominal surgery in the United States—Observations from 9,950,759 discharges using the 2009–2013 National Inpatient Sample (NIS) datasets. Am J Surg 2017; 214:287-292. [DOI: 10.1016/j.amjsurg.2017.01.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 12/05/2016] [Accepted: 01/05/2017] [Indexed: 01/31/2023]
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The use of an algorithm for prophylactic mesh use in high risk patients reduces the incidence of incisional hernia following laparotomy for colorectal cancer resection. Cir Esp 2017; 95:222-228. [PMID: 28400141 DOI: 10.1016/j.ciresp.2017.03.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 02/10/2017] [Accepted: 03/26/2017] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Incisional hernia (IH) after colorectal surgery is highly prevalent. The objective of this study is to assess the utility of an algorithm to decide on mesh augmentation after a midline laparotomy for colorectal resection to prevent IH in high-risk patients. METHODS A prospective study was conducted including all patients undergoing a midline laparotomy for colorectal resection between January 2011 and June 2014, after the implementation of a decision algorithm for prophylactic mesh augmentation in selected high-risk patients. Intention-to-treat analyses were conducted between patients in which the algorithm was correctly applied and those in which it was not. RESULTS From the 235 patients analysed, the algorithm was followed in 166 patients, the resting 69 cases were used as a control group. From an initial adherence to the algorithm of 40% in the first semester, a 90.3% adherence was achieved in the seventh semester. The incidence of IH decreased as the adherence to the algorithm increased (from 28 to 0%) with a time-related correlation (R2=0.781). A statistically significant reduction in IH incidence was demonstrated in high-risk groups in which the algorithm was correctly applied (10,2 vs. 46,3%; p=0,0001; OR: 7,58;95%; CI: 3,8-15). Survival analysis showed that the differences remained constant during follow-up. CONCLUSION The implementation of the algorithm reduces the incidence of IH in high-risk patients. The adherence to the algorithm also correlates with a decrease in the incidence of IH.
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Wang XC, Zhang D, Yang ZX, Gan JX, Yin LN. Mesh reinforcement for the prevention of incisional hernia formation: a systematic review and meta-analysis of randomized controlled trials. J Surg Res 2017; 209:17-29. [DOI: 10.1016/j.jss.2016.09.055] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 09/04/2016] [Accepted: 09/27/2016] [Indexed: 02/07/2023]
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Borab ZM, Shakir S, Lanni MA, Tecce MG, MacDonald J, Hope WW, Fischer JP. Does prophylactic mesh placement in elective, midline laparotomy reduce the incidence of incisional hernia? A systematic review and meta-analysis. Surgery 2016; 161:1149-1163. [PMID: 28040255 DOI: 10.1016/j.surg.2016.09.036] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 09/12/2016] [Accepted: 09/12/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Operative intervention to correct incisional hernia affects 150,000 patients annually, with 1 in 3 repairs recurring within 9 years. The aim of this study was to compare the incidence of incisional hernia and postoperative complications in elective midline laparotomy patients after the use of prophylactic mesh placement and primary suture closure. METHODS A systematic review was performed to identify studies comparing prophylactic mesh placement to primary suture closure in elective, midline laparotomy at index abdominal aponeurosis closure. The primary outcome was incisional hernia. Secondary outcomes included postoperative complications. RESULTS Fourteen studies were included (2,114 patients), with 1,152 receiving prophylactic mesh placement. Prophylactic mesh placement decreased the risk of incisional hernia overall when compared to primary suture closure (relative risk = 0.15; P < .00001) and in trials using only polypropylene mesh versus 4:1 primary suture closure (relative risk = 0.15; P = .003). Prophylactic mesh placement reduced the risk of incisional hernia regardless of mesh location or composition: onlay (relative risk = 0.07; P < .0001), retrorectus (relative risk = 0.04; P = .002), and preperitoneal (relative risk = 0.18; P = .02). Prophylactic mesh placement increased risk of seroma overall (relative risk = 1.95; P < .0001), onlay (relative risk = 2.43; P = .01) and preperitoneal (relative risk = 1.47; P = .01) but not retrorectus plane (relative risk = 1.55; P = .26). Polypropylene mesh increased seroma risk only in the onlay position (relative risk = 2.77; P = .04). Prophylactic mesh placement patients are at increased risk for chronic wound pain compared to primary suture closure (relative risk = 1.70; P = .03). CONCLUSION Prophylactic mesh placement is associated with an 85% postoperative incisional hernia risk reduction when compared to primary suture closure in at-risk patients undergoing elective, midline laparotomy closure. This technique appears to be safe with comparable complication profiles, barring an increased risk of seroma, especially with the onlay technique, and the possibility for an increased risk of chronic pain. Despite this verification, evidence from large domestic trials that sufficiently addresses major knowledge gaps is simply lacking.
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Affiliation(s)
| | - Sameer Shakir
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Michael A Lanni
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Michael G Tecce
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - John MacDonald
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - William W Hope
- Department of Surgery, New Hanover Regional Medical Center, Wilmington, NC
| | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA.
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Prophylactic mesh can be used safely in the prevention of incisional hernia after bilateral subcostal laparotomies. Surgery 2016; 160:1358-1366. [DOI: 10.1016/j.surg.2016.05.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 05/07/2016] [Accepted: 05/13/2016] [Indexed: 02/07/2023]
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Port-site transversus abdominis fascia closure reduced the incidence of incisional hernia following retroperitoneal laparoscopic nephrectomy. Hernia 2016; 20:735-40. [DOI: 10.1007/s10029-016-1508-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 05/09/2016] [Indexed: 01/22/2023]
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López-Cano M, Pereira JA, Feliu X, Hernández L, Andrada D, Gil E, Villanueva B, Armengol-Carrasco M. Outcome of the Use of a Synthetic Mesh in the Repair of Burst Abdomen as Compared with Simple Suture. ACTA ACUST UNITED AC 2015. [DOI: 10.4236/ijcm.2015.63016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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