Magnetic resonance imaging and abdominal wall hernias in aortic surgery

Assessment of Quality of Life after Endovascular and Open Abdominal Aortic Aneurysm Repair: A Retrospective Single-Center Study

Postoperative quality of life is an important outcome parameter after treatment of abdominal aortic aneurysms. The aim of this retrospective single-center study was to assess and compare the health-related quality of life (HRQoL) of patients after open repair (OR) or endovascular treatment (EVAR), and furthermore to investigate the effect of incisional hernia (IH) formation on HRQoL. Patients who underwent OR or EVAR for treatment of an abdominal aortic aneurysm between 2008 and 2016 at a University Medical Center were included. HRQoL was assessed using the SF-36 questionnaire. The incidence of IH was recorded from patient files and by telephone contact. SF-36 scores of 83 patients (OR: n = 36; EVAR: n = 47) were obtained. The mean follow-up period was 7.1 years. When comparing HRQoL between OR and EVAR, patients in both groups scored higher in one of the eight categories of the SF36 questionnaires. The incidence of IH after OR was 30.6%. In patients with postoperative IH, HRQoL was significantly reduced in the dimensions “physical functioning”, “role physical” and “role emotional” of the SF-36. Based on this data, it can be concluded that neither OR nor EVAR supply a significant advantage regarding HRQoL. In contrast, the occurrence of IH has a relevant impact on the HRQoL of patients after OR.

Abdominal incision defect following AAA-surgery (AIDA): 2-year results of prophylactic onlay-mesh augmentation in a multicentre, double-blind, randomised controlled trial

The reported incidence of incisional hernia following repair of abdominal aortic aneurysm (AAA) via midline laparotomy is up to 69%. This prospective, multicenter, double-blind, randomised controlled trial was conducted at eleven hospitals in Germany. Patients aged 18 years or older undergoing elective AAA-repair via midline incision were randomly assigned using a computer-generated randomisation sequence to one of three groups for fascial closure: with long-term absorbable suture (MonoPlus^®, group I), long-term absorbable suture and onlay mesh reinforcement (group II) or extra long-term absorbable suture (MonoMax^®, group III). The primary endpoint was the incidence of incisional hernia within 24 months of follow-up, analysed by intention to treat. Physicians conducting the postoperative visits and the patients were blinded. Between February 2011 and July 2013, 104 patients (69.8 ± 7.7 years) were randomised, 99 of them received a study intervention. The rate of incisional hernia within 24 months was not significantly reduced with onlay mesh augmentation compared to primary suture (p = 0.290). Furthermore, the rate of incisional hernia did not differ significantly between fascial closure with slow and extra long-term absorbable suture (p = 0.111). Serious adverse events related to study intervention occurred in five patients (5.1%) from treatment groups II and III. Wound healing disorders were more frequently seen after onlay mesh implantation on the day of discharge (p = 0.010) and three (p = 0.009) and six (p = 0.023) months postoperatively. The existing evidence on prophylactic mesh augmentation in patients undergoing AAA-repair via midline laparotomy probably needs critical review. As the implementation of new RCTs is considered difficult due to the increasing number of endovascular AAA treated, registry studies could help to collect and evaluate data in cases of open AAA-repair. Comparisons between prophylactic mesh implantation and the small bite technique are also required. Trial registration: ClinicalTrials.gov Identifier: NCT01353443. Funding Sources: Aesculap AG, Tuttlingen, Germany.

Do Hernias Contribute to Increased Severity of Aneurysmal Disease among Abdominal Aortic Aneurysm Patients?

Background  Connective tissue disorders could contribute to the pathogenesis of both abdominal aortic aneurysms (AAA) and hernias. We tested the hypothesis that hernias in AAA patients contribute to increased severity of the aneurysmal disease.

Methods  A questionnaire was used to collect information from 195 AAA patients divided into four groups: (1) survivors ( n  = 22) of ruptured AAA, (2) patients ( n  = 90) after elective open repair, (3) patients ( n  = 43) after elective endovascular repair (EVAR), and (4) patients ( n  = 40) under surveillance of AAA. The control group consisted of 100 patients without AAA whose abdominal computed tomography (CT) scans were examined for the presence of hernias. Mann–Whitney U -test, Chi-squared ( χ² ) test, or Fisher's exact test (as appropriate) were used for statistical analyses. Multivariate logistic regression was used to control for potential confounding variables such as sex and age.

Results  The prevalence of inguinal hernias was significantly higher in the AAA than the control group (25 vs. 9%, p  = 0.001) and did not differ between the AAA subgroups (9, 24, 35, and 23% in subgroups 1 through 4, respectively, p  = 0.15) based on univariate analysis. The prevalence of inguinal hernias did not differ ( p  = 0.15) between the two open surgery groups (groups 1 and 2), or when comparing all three operative procedures as a combined group to group 4 ( p  = 0.73). The prevalences of incisional hernias were 18 and 24% for groups 1 and 2, respectively, with no significant difference ( p  = 0.39). Inguinal hernia demonstrated a significant association with AAA on multivariate analysis ( p  = 0.006; odds ratio [OR] = 4.00; 95% confidence interval [CI] = 1.49–10.66).

Conclusions  Our study confirms previous observations that patients with AAA have a high prevalence of hernias. Our results suggest that hernias do not contribute to increased severity of the aneurysmal disease.

Abdominal aortic aneurysms and abdominal wall hernias - a systematic review and meta-analysis

Background: Abdominal wall hernias (AWHs) share common epidemiological characteristics with abdominal aortic aneurysms (AAAs), typically presenting in male population and older ages. Prior reports have associated those two disease entities. Our objective was to perform a systematic review and meta-analysis and examine whether AAA rates are higher among patients with AWH vs controls and whether the incidence of AWH was higher among patients with AAA vs patients without AAA. Methods: We performed a systematic review and meta-analysis according to the PRISMA guidelines. The Medline database was searched up to July 31, 2020. A random effects meta-analysis was performed. Results: In total, 17 articles and 738,972 participants were included in the systematic review, while 107,578 patients were eligible for the meta-analysis. Among four studies investigating the incidence of AAA in patients with hernias, AAA was more common in patients with hernias, compared to patients without hernias. [OR: 2.53, 95% CI: 1.24-5.16, I²=81.6%]. Among thirteen studies that compared patients with known AAA vs no AAA, the incidence of hernias was higher in patients with AAA, compared with patients without AAA [OR: 2.27, 95% CI: 1.66-3.09, I²=84.6%]. Conclusions: Our study findings indicate that a strong association between AWH and AAA exists. AWHs could therefore be used as an additional selection criterion for screening patients for AAA, apart from age, gender, family history and smoking.

Hernia reduction following laparotomy using small stitch abdominal wall closure with and without mesh augmentation (the HULC trial): study protocol for a randomized controlled trial

Background

Incisional hernias are among the most frequent complications following abdominal surgery and cause substantial morbidity, impaired health-related quality of life and costs. Despite improvements in abdominal wall closure techniques, the risk for developing an incisional hernia is reported to be between 10 and 30% following midline laparotomies. There have been two recent innovations with promising results to reduce hernia risks, namely the small stitches technique and the placement of a prophylactic mesh. So far, these two techniques have not been evaluated in combination.

Methods

The HULC trial is a multicentre, randomized controlled, observer- and patient-blinded surgical effectiveness trial with two parallel study groups. A total of 812 patients scheduled for elective abdominal surgery via a midline laparotomy will be randomized in 12 centres after informed consent. Patients will be randomly assigned to the control group receiving closure of the midline incision with a slowly absorbable monofilament suture in the small stitches technique or to the intervention group, who will receive a small stitches closure followed by augmentation with a light-weight polypropylene mesh in the onlay technique. The primary endpoint will be the occurrence of incisional hernias, as defined by the European Hernia Society, within 24 months after surgery. Further perioperative parameters, as well as patient-reported outcomes, will be analysed as secondary outcomes.

Discussion

The HULC trial will address the yet unanswered question of whether a combination of small stitched fascial closure and onlay mesh augmentation after elective midline laparotomies reduces the risk of incisional hernias. The HULC trial marks the logical and innovative next step in the development of a safe abdominal closure technique.

Trial registration

German Clinical Trials Register, DRKS00017517. Registered on 24th June 2019.

Does perfusion matter? Preoperative prediction of incisional hernia development

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.

Repair of a bowel-containing, scrotal hernia with incarceration contributed by femorofemoral bypass graft

The rising use of endovascular techniques utilizing femoral artery access may increase the frequency with which surgeons face the challenge of hernia repair in reoperative groins—which may or may not include a vascular graft. We present a case where a vascular graft contributed to an acute presentation and complicated dissection, and review the literature. A 67-year-old man who had undergone prior endovascular aneurysm repair via open bilateral femoral artery access and concomitant prosthetic femorofemoral bypass, presented with an incarcerated, scrotal inguinal hernia. The graft with its associated fibrosis contributed to the incarceration by compressing the inguinal ring. Repair was undertaken via an open, anterior approach with tension-free, Lichtenstein herniorraphy after releasing graft-associated fibrosis. Repair of groin hernias in this complex setting requires careful surgical planning, preparation for potential vascular reconstruction and meticulous technique to avoid bowel injury in the face of a vascular conduit and mesh.

Systematic Review and Meta-Regression of Factors Affecting Midline Incisional Hernia Rates: Analysis of 14,618 Patients

BACKGROUND

The incidence of incisional hernias (IHs) following midline abdominal incisions is difficult to estimate. Furthermore recent analyses have reported inconsistent findings on the superiority of absorbable versus non-absorbable sutures.

OBJECTIVE

To estimate the mean IH rate following midline laparotomy from the published literature, to identify variables that predict IH rates and to analyse whether the type of suture (absorbable versus non-absorbable) affects IH rates.

METHODS

We undertook a systematic review according to PRISMA guidelines. We sought randomised trials and observational studies including patients undergoing midline incisions with standard suture closure. Papers describing two or more arms suitable for inclusion had data abstracted independently for each arm.

RESULTS

Fifty-six papers, describing 83 separate groups comprising 14,618 patients, met the inclusion criteria. The prevalence of IHs after midline incision was 12.8% (range: 0 to 35.6%) at a weighted mean of 23.7 months. The estimated risk of undergoing IH repair after midline laparotomy was 5.2%. Two meta-regression analyses (A and B) each identified seven characteristics associated with increased IH rate: one patient variable (higher age), two surgical variables (surgery for AAA and either surgery for obesity surgery (model A) or using an upper midline incision (model B)), two inclusion criteria (including patients with previous laparotomies and those with previous IHs), and two circumstantial variables (later year of publication and specifying an exact significance level). There was no significant difference in IH rate between absorbable and non-absorbable sutures either alone or in conjunction with either regression analysis.

CONCLUSIONS

The IH rate estimated by pooling the published literature is 12.8% after about two years. Seven factors account for the large variation in IH rates across groups. However there is no evidence that suture type has an intrinsic effect on IH rates.

Dynamic ultrasound with postural change facilitated the detection of an incisional hernia in a case with negative MRI findings

Incisional hernias commonly develop after abdominal surgeries with a lower incidence in patients receiving laparoscopy. Diagnosis through a non-surgical approach is usually made by computed tomography or magnetic resonance images (MRI) but both image modalities require patients to be examined in a supine position. We reported a case noticing a mass over her right lower abdomen after a laparoscopic liver segmentectomy with negative findings of hernia on MRI. A hernia sac was found by ultrasound with the patient being standing, highlighting the utility of dynamic ultrasound with postural change in investigation of incisional hernias.

A double blind randomized controlled trial comparing primary suture closure with mesh augmented closure to reduce incisional hernia incidence

Background

Incisional hernia is the most frequently seen long term complication after laparotomy causing much morbidity and even mortality. The overall incidence remains 11-20%, despite studies attempting to optimize closing techniques. Two patient groups, patients with abdominal aortic aneurysm and obese patients, have a risk for incisional hernia after laparotomy of more than 30%. These patients might benefit from mesh augmented midline closure as a means to reduce incisional hernia incidence.

Methods/design

The PRImary Mesh Closure of Abdominal Midline Wound (PRIMA) trial is a double-blinded international multicenter randomized controlled trial comparing running slowly absorbable suture closure with the same closure augmented with a sublay or onlay mesh. Primary endpoint will be incisional hernia incidence 2 years postoperatively. Secondary outcomes will be postoperative complications, pain, quality of life and cost effectiveness.

A total of 460 patients will be included in three arms of the study and randomized between running suture closure, onlay mesh closure or sublay mesh closure. Follow-up will be at 1, 3, 12 and 24 months with ultrasound imaging performed at 6 and 24 months to objectify the presence of incisional hernia. Patients, investigators and radiologists will be blinded throughout the whole follow up.

Disccusion

The use of prosthetic mesh has proven effective and safe in incisional hernia surgery however its use in a prophylactic manner has yet to be properly investigated. The PRIMA trial will provide level 1b evidence whether mesh augmented midline abdominal closure reduces incisional hernia incidence in high risk groups.

Trial registration

Clinical trial.gov NCT00761475.

Lack of association between inguinal hernia and abdominal aortic aneurysm in a population-based male cohort

Background

Previous studies have reported a higher prevalence of inguinal hernia in patients with abdominal aortic aneurysm (AAA). The aim of this study was to explore the association between inguinal hernia and AAA in a large population-based cohort of men who had screening for AAA.

Methods

A total of 18 331 men aged 65–76 years had ultrasound screening for AAA in the Central Region of Denmark from 2008 to 2010. The Danish National Patient Registry was interrogated, and screened men registered with an inguinal hernia from 1977 to 2011 were identified. The association between inguinal hernia and AAA was assessed by multiple logistic regression analysis.

Results

The prevalence of AAA was 3.3 per cent (601 of 18 331). A total of 2936 (16.0 per cent) of the 18 331 patients were registered with a diagnosis of inguinal hernia or hernia repair. Inguinal hernia was not associated with AAA: crude odds ratio (OR) 0.86 (95 per cent confidence interval 0.68 to 1.09) and adjusted OR 0.94 (0.75 to 1.20).

Conclusion

In contrast to smaller patient-based studies, this large population-based study found no association between inguinal hernia and AAA.

Incisional hernia postrepair of abdominal aortic occlusive and aneurysmal disease: five-year incidence

The aim of this study was to report the five-year incidence of incisional hernia after vascular repair of abdominal aortic occlusive (AOD) and aneurysmal disease (AAA), and to determine the factors associated with the development of this complication. Consecutive patients who underwent AAA and AOD at the University of Manitoba, Canada, between January 1999 and December 2002, were recruited and evaluated by clinical examination one week, one month and six months after the surgery, and through medical records review thereafter. The development of postoperative incisional hernia was recorded and analyzed. Two-hundred four patients, with a mean age of 70.1 years, provided consent for the study. The overall five-year incidence of incisional hernia was 69.1% and the overall median failure time was 48 months. The median failure time was 48 months for AOD and 36 months for AAA (P < 0.01). The urgent and ruptured AAA repair had a higher five-year incidence of incisional hernia as compared with AOD or elective AAA repair (P < 0.01). A history of bilateral inguinal hernia was significantly associated with incisional hernia (P < 0.05). Men and patients who were 65 years and older had a higher five-year incidence of incisional hernia (P < 0.01). Age ≥65 years, male gender, hypertension and past bilateral inguinal hernia repair double the risk for the development of incisional hernia (hazard ratio = 2.1. 2.2, 1.7 and 2.8, respectively). In conclusion, the five-year incidence of incisional hernia after vascular repair of AOD or AAA is 69.1%, and tends to occur late after vascular repair.

Imaging and management of complications of open surgical repair of abdominal aortic aneurysms

Open repair is still considered the reference standard for long-term repair of abdominal aortic aneurysms (AAA). In contrast to endovascular aneurysm repair (EVAR), patients with open surgical repair of AAA are not routinely followed up with imaging. Although complications following EVAR are widely recognized and routinely identified on follow-up imaging, complications also do occur following open surgical repair. With frequent use of multi-slice computed tomography (CT) angiography (CTA) in vascular patients, there is now improved recognition of the potential complications following open surgical repair. Many of these complications are increasingly being managed using endovascular techniques. The aim of this review is to illustrate a variety of potential complications that may occur following open surgical repair and to demonstrate their management using both surgical and endovascular techniques.

Abdominal aortic aneurysm and abdominal wall hernia as manifestations of a connective tissue disorder

BACKGROUND

Abdominal aortic aneurysms (AAAs) and abdominal wall hernias represent chronic degenerative conditions. Both aortic aneurysms and inguinal hernias share common epidemiologic features, and several investigators have found an increased propensity for hernia development in patients treated for aortic aneurysms. Chronic inflammation and dysregulation in connective tissue metabolism constitute underlying biological processes, whereas genetic influences appear to be independently associated with both disease states. A literature review was conducted to identify all published evidence correlating aneurysms and hernias to a common pathology.

METHODS

PubMed/Medline was searched for studies investigating the clinical, biochemical, and genetic associations of AAAs and abdominal wall hernias. The literature was searched using the MeSH terms "aortic aneurysm, abdominal," "hernia, inguinal," "hernia, ventral," "collagen," "connective tissue," "matrix metalloproteinases," and "genetics" in all possible combinations. An evaluation, analysis, and critical overview of current clinical data and pathogenic mechanisms suggesting an association between aneurysms and hernias were undertaken.

RESULTS

Ample evidence lending support to the clinical correlation between AAAs and abdominal wall hernias exists. Pooled analysis demonstrated that patients undergoing aortic aneurysm repair through a midline abdominal incision have a 2.9-fold increased risk of developing a postoperative incisional hernia compared with patients treated for aortoiliac occlusive disease (odds ratio, 2.86; 95% confidence interval, 1.97-4.16; P < .00001), whereas the risk of inguinal hernia was 2.3 (odds ratio, 2.30; 95% confidence interval, 1.52-3.48; P < .0001). Emerging evidence has identified inguinal hernia as an independent risk factor for aneurysm development. Although mechanisms of extracellular matrix remodeling and the imbalance between connective tissue degrading enzymes and their inhibitors instigating inflammatory responses have separately been described for both disease states, comparative studies investigating these biological processes in aneurysm and hernia populations are scarce. A genetic predisposition has been documented in familial and observational segregation studies; however, the pertinent literature lacks sufficient supporting evidence for a common genetic basis for aneurysm and hernia.

CONCLUSIONS

Insufficient data are currently available to support a systemic connective tissue defect affecting the structural integrity of the aortic and abdominal wall. Future investigations may elucidate obscure aspects of aneurysm and hernia pathophysiology and create novel targets for pharmaceutical and gene strategies for disease prevention and treatment.

Prevalence of Abdominal Wall Hernia in Participants With Abdominal Aortic Aneurysm Versus Peripheral Arterial Disease—A Population-Based Study

Small studies suggest an association between abdominal aortic aneurysms (AAAs) and hernias, possibly related to connective tissue weakness. We evaluated the association between AAA and abdominal wall hernia (AWH), using peripheral arterial disease (PAD) patients as controls, in Olmsted County, Minnesota. In a retrospective cohort study we queried the electronic medical records for the diagnosis of AAA. The resulting data were then queried for prevalence of AWH. The same set of queries was repeated for PAD. Occurrence of AWH in the 2 groups was compared using the chi-square test. Of the 187 151 patient records queried, 939 had AAA and 3465 had PAD. Abdominal wall hernia occurred in 157 (16.7%) patients with AAA and in 343 (9.9%) patients with PAD. Abdominal wall hernia was 1.7 times more prevalent in those with AAA versus PAD ( P < .0001). A history of hernia may prompt screening for AAA in some patients.

Incisional hernia, midline versus low transverse incision: what is the ideal incision for specimen extraction and hand-assisted laparoscopy?

BACKGROUND

Minimally invasive surgery is associated with smaller surgical incisions than those of traditional midline laparotomy. However, most colorectal resections and all hand-assisted procedures require an incision either for specimen retrieval or insertion of the hand-assist device. The ideal site of this incision has not been evaluated with respect to the incidence of incisional hernia. This study compares the rates of incisional hernia associated with a standard midline laparotomy, a midline incision of reduced length, and a Pfannenstiel incision.

METHODS

From March 2004 to July 2007, 512 consecutive patients were identified from a prospectively maintained database according to predefined inclusion and exclusion criteria. Patients were divided into three groups depending on the type of incision (open, midline, and Pfannenstiel). Demographic variables, rate of incisional hernia, and risk factors for hernia were compared among the groups.

RESULTS

There were 142, 231, and 139 patients in the open, midline, and Pfannenstiel groups, respectively. All three groups were comparable with respect to age, gender, steroid use, diabetes, number of patients with malignancy, and duration of follow-up. The Pfannenstiel group had a higher mean BMI (p = 0.015) and the open group had a higher rate of wound infection (28.2%) compared to the other groups. Incidence of incisional hernia was similar for the open and midline groups (19.7 and 16%, p = 0.36). At a mean follow-up of 17.5 months, not a single patient with a Pfannenstiel incision developed an incisional hernia (p < 0.001). BMI (p = 0.019), follow-up (p < 0.001), and Pfannenstiel incision (p < 0.001) were found to be predictors (protectors) of incisional hernia on multivariate analysis.

CONCLUSION

A Pfannenstiel incision is associated with the lowest rate of incisional hernia and should be the incision of choice for hand assistance and specimen extraction in minimally invasive colorectal resections wherever applicable.

Randomized clinical trial of mesh versus sutured wound closure after open abdominal aortic aneurysm surgery

Background

Incisional herniation is a common complication of abdominal aortic aneurysm (AAA) repair. This study investigated whether prophylactic mesh placement could reduce the rate of postoperative incisional hernia after open repair of AAA.

Methods

This randomized clinical trial was undertaken in three hospitals. Patients undergoing elective open AAA repair were randomized to routine abdominal mass closure after AAA repair or to prophylactic placement of polypropylene mesh in the preperitoneal plane.

Results

Eighty-five patients with a mean age of 73 (range 59–89) years were recruited, 77 (91 per cent) of whom were men. There were five perioperative deaths (6 per cent), two in the control group and three in the mesh group (P = 0·663), none related to the mesh. Sixteen patients in the control group and five in the mesh group developed a postoperative incisional hernia (hazard ratio 4·10, 95 per cent confidence interval 1·72 to 9·82; P = 0·002). Hernias developed between 170 and 585 days after surgery in the control group, and between 336 and 1122 days in the mesh group. Four patients in the control group and one in the mesh group underwent incisional hernia repair (P = 0·375). No mesh became infected, but one was subsequently removed owing to seroma formation during laparotomy for small bowel obstruction.

Conclusion

Mesh placement significantly reduced the rate of postoperative incisional hernia after open AAA repair without increasing the rate of complications. Registration number: ISRCTN28485581 (http://www.controlled-trials.com).

Prevalence of abdominal aortic aneurysms in over 65-year-old men with inguinal hernias

INTRODUCTION

The aim of this study was to determine the prevalence of abdominal aortic aneurysms (AAAs) in over 65-year-old men who have inguinal hernias and discuss if pre-operative selective screening of this population is appropriate.

PATIENTS AND METHODS

A prospective study on 70 consecutive male patients with an age range of 65-88 years (mean, 74 years) who were referred to a single vascular consultant's out-patient clinic with an inguinal hernia were screened for the presence of an AAA with an ultrasound scan before hernia repair over a period of 3 years.

RESULTS

Two patients were found to have an AAA measuring 3.8 cm and 6.0 cm giving an AAA prevalence of 3% (exact 95% confidence interval = 0-10%).

CONCLUSIONS

This study does not demonstrate an increased AAA prevalence in over 65-year-old male patients with inguinal hernias, scanned pre-operatively when compared to screening programmes. Selective screening of this cohort cannot be justified on this evidence.

Comparison of ultrasonography with computed tomography in the diagnosis of incisional hernias

BACKGROUND

The objective of this study is to determine the reliability and validity of ultrasonography (US) in diagnosing incisional hernias in comparison with computed tomography (CT). The CT scans were assessed by two radiologists in order to estimate the inter-observer variation and twice by one radiologist to estimate the intra-observer variation. Patients were evaluated after reconstruction for an abdominal aortic aneurysm or an aortoiliac occlusion.

METHODS

Patients with a midline incision after undergoing reconstruction of an abdominal aortic aneurysm or aortoiliac occlusion were examined by CT scanning and US. Two radiologists evaluated the CT scans independently. One radiologist examined the CT scans twice. Discrepancies between the CT observations were resolved in a common evaluation session between the two radiologists.

RESULTS

After a mean follow-up of 3.4 years, 40 patients were imaged after a reconstructed abdominal aortic aneurysm (80% of the patients) or aortoiliac occlusion. The prevalence of incisional hernias was 24/40 = 60.0% with CT scanning as the diagnostic modality and 17/40 = 42.5% with US. The measure of agreement between CT scanning and US expressed as a Kappa statistic was 0.66 (95% confidence interval [CI] 0.45-0.88). The sensitivity of US examination when using CT as a comparison was 70.8%, the specificity was 100%, the predictive value of a positive US was 100%, and the predictive value of a negative US was 69.6%. The likelihood ratio of a positive US was infinite and that of a negative US was 0.29. The inter- and intra-observer Kappa statistics were 0.74 (CI 0.54-0.95) and 0.80 (CI 0.62-0.99), respectively.

CONCLUSIONS

US imaging has a moderate sensitivity and negative predictive value, and a very good specificity and positive predictive value. Consistency of diagnosis, as determined by calculating the inter- and intra-observer Kappa statistics, was good. The incidence of incisional hernias is high after aortic reconstructions.

[General surgery under discussion. From the viewpoint of vascular surgery]

Vascular diseases are common and their frequency is rising. Statistics show that 15% of the German population over 65 display some kind of peripheral arterial pathology. Even aneurysmatic degeneration and cardiac and visceral perfusion disorders are being observed more frequently, while peak age is dropping. Therapeutic surgical options are accordingly being continually advanced and refined. Additionally the range of interventional therapies and new conservative options has substantially increased vascular surgeons' armamentarium. Updates in surgical training have responded to this increase in such disorders, and the diversification of therapeutic modalities has resulted in the elevation of vascular surgery from specialized techniques to a fully accredited specialty equal in standing to the other seven surgical disciplines. Controversy exists however about the new accredition, beginning with the question of advancement from basic surgical training while excluding important elements of general surgery. Since those training for this specialty will branch off immediately after 2 years of basic surgical training, their final accreditation in the new classification would exclude essential skills that remain part of the training as general surgeons.

Postoperative Incision Hernia in Patients with Abdominal Aortic Aneurysm and Aortoiliac Occlusive Disease: A Systematic Review

OBJECTIVES

We conducted a systematic review to determine the incidence of postoperative incision hernia in patients with abdominal aortic aneurysm compared to those with aortoiliac occlusive disease.

METHODS

Studies which compared the incidence of postoperative incision hernia in patients with abdominal aortic aneurysm and aortoiliac occlusive disease undergoing midline incision for arterial reconstruction were identified. MEDLINE was searched for articles published between January 1966 and September 2005.

RESULTS

Our search identified seven studies including data on 1132 patients, 719 with abdominal aortic aneurysm and 413 with aortoiliac occlusive disease. Pooled analysis demonstrated that patients with abdominal aortic aneurysm had a 2.9-fold increased risk of inguinal hernia (odds ratio 2.85, 95% confidence interval 1.71-4.77, p<0.0001), and a 2.8-fold risk of incisional hernia (2.79, 1.88-4.13, p<0.0001). Adjusting for other known risk factors patients with aortic aneurysm had a 5-fold increased risk of incisional hernia (5.45, 2.48-11.94, p<0.0001).

CONCLUSIONS

Patients with abdominal aortic aneurysm appear to have an approximately 3-fold increased risk for both inguinal and postoperative incision hernia compared to patients with aortoiliac occlusive disease. A large multi-centre prospective study is needed to confirm the results of this review.

Preoperative and Intraoperative Determinants of Incisional Bulge following Retroperitoneal Aortic Repair

Although the left flank retroperitoneal incision is a useful approach for many patients undergoing major aortic reconstruction for aneurysmal and occlusive disease, it has been associated with weakening of the flank muscles, resulting in bulges varying from slight asymmetry to huge hernias. The purpose of this study was to determine if the incidence of this complication correlated with identifiable preoperative or intraoperative factors. Fifty consecutive patients undergoing aortic reconstruction via the retroperitoneal approach were followed for 1 year postoperatively for evidence of disfiguring bulges. Bulges were scored as follows: normal/mild, <1-inch protrusion; moderate, protrusion 1-2 inches; severe, protrusion >2 inches and/or pain or true herniation. Preoperatively, patients were administered a questionnaire to elicit demographic and comorbidity data. Fifty-six percent of patients developed a bulge at 1 year. In 43% of these, the bulge was deemed mild and in 54% moderate. One patient developed a severe bulge. Among preoperative comorbidities, no statistically significant correlations were found on bivariate analysis. However, likelihood ratios for bulge development of 5.5 for renal disease and 3.1 for cancer were demonstrated. Conversely, peripheral vascular disease had a likelihood ratio of 0.21 for bulge formation and emphysema, 0.28. On logistic analysis, incision >15 cm and body mass index (BMI) >23 mg/kg(2) were found to correlate strongly with bulge formation (p=0.003, odds ratio=9.1, and p=0.018, odds ratio=16.9, respectively). Together, these yielded a pseudo r (2) of 0.32. BMI >23 mg/kg(2 )was found to yield the greatest explanatory power. These same two variables were found to correlate with severity of bulge: p=0.02 for incision>5 cm and p=0.006 for BMI >23. Of note, gender, age, and extension of the incision into the interspace were not significant on logistic analysis. Preoperatively, surgeons should warn obese patients and those requiring large incisions for extensive disease of their increased risk for poor healing. Intraoperatively, surgeons should aim to minimize incision length.

Abdominal Wall Hernias: Imaging Features, Complications, and Diagnostic Pitfalls at Multi–Detector Row CT

Abdominal wall hernias are a common imaging finding in the abdomen and may be complicated by strangulation, incarceration, or trauma. Because of the risk of developing complications, most abdominal wall hernias are surgically repaired, even if asymptomatic. However, post-surgical complications are also common and include hernia recurrence, infected and noninfected fluid collections, and complications related to prosthetic material. Multi-detector row computed tomography (CT) with its multiplanar capabilities is particularly useful for the evaluation of unrepaired and surgically repaired abdominal wall hernias. Multi-detector row CT provides exquisite anatomic detail of the abdominal wall, thereby allowing accurate identification of wall hernias and their contents, differentiation of hernias from other abdominal masses (tumors, hematomas, abscesses), and detection of pre- or postoperative complications. These findings improve the communication of imaging results to clinicians and help optimize treatment planning. Knowledge of multi-detector row CT findings in unrepaired and surgically repaired abdominal wall hernias and their complications is essential for making the correct diagnosis and may help guide clinical management.

Minilaparotomy for Aortoiliac Aneurysmal Disease

Vascular surgery is evolving, as other specialities, toward minimally invasive techniques. Presently, 3 approaches to aortoiliac disease are suggested as minimally invasive. Besides the endovascular procedures, laparoscopic techniques and minilaparotomy are being advocated. Although for aneurysmal disease, we favor a totally laparoscopic approach, criticisms raised over laparoscopy-assisted techniques by those advocating minilaparotomy led us to investigate the benefits of the latter technique. We first evaluated the procedure in 7 patients with infrarenal abdominal aortic aneurysm (AAA). We found the procedure impossible to perform with an 8- to 10-cm incision in 6 of the 7 patients. This led us to evaluate causes of failure of the technique. It appeared to us that most of our complications were related to inadequate exposure. Fifty consecutive computed tomography scans from patients with AAA of surgical size were then reviewed to evaluate the aneurysm lengths and compare them to the reported lengths of skin incision for minilaparotomy. Results were expressed adding a total of 2 cm for proximal and distal clamping. Only 2% of patients would present with aneurysms suitable for treatment through an 8-cm midline incision and 30% through a 10-cm incision. We then reviewed the literature on minilaparotomy. We believe that minilaparotomy should be reserved for those patients with purely aortic disease and the appropriate body habitus.

Early and Mid-term Results of Totally Laparoscopic Surgery for Aortoiliac Disease

The present article is the first in the literature reporting short- and medium-term results using a totally laparoscopic technique for aortoiliac disease.Forty-nine patients, 6 having an associated small aneurysm, were scheduled for totally laparoscopic surgery (TLS) for aortoiliac occlusive disease and 2 for treatment of aortic aneurysmal disease (AAA). Patients' characteristics, intraoperative, postoperative data and mid-term data were recorded.TLS was successfully completed in 45 patients. Of those patients, 41 received an aortobifemoral bypass; three, an iliofemoral bypass; and one, an aortoaortic bypass. Five patients were converted from TLS to video-assisted laparoscopic surgery using incisions varying in size from 7 cm to 11 cm. One patient underwent conversion to standard open surgery. One death occurred unrelated to the technique. Major perioperative complications related to the technique were few and presented in the early phase of the study: One intraoperative embolization to the lower limbs that needed embolectomy, and one acute aortic false aneurysm. Midterm results were favorable, demonstrating two limb graft thromboses. Hernias at trocar sites occurred in only 3.9%. The patients benefited from this procedure, which is considered definitive like its standard open counterpart. The conversion rate is lower than that reported for acute cholecystitis. Selection of patients has been less stringent during the second half of the study in term of inclusion of patients with AAA and of more TASC IV patients. Surgeons willing to learn this technique should attend dedicated courses. In the future, as this surgical innovation matures, controlled randomized studies should be initiated.

Abdominal wall hernias after open abdominal aortic aneurysm repair: prospective radiographic detection and clinical implications

The purpose of this study was to evaluate the prevalence of radiographically detected abdominal wall defects (AWD) after open abdominal aortic aneurysm (AAA) repair and to correlate it with prospectively gathered clinical information. Fine collimation, high-resolution, serial follow-up computed tomography (CT) scans for 99 patients in the control group of the Guidant Ancure device trial were reviewed. CT scans were obtained at 12, 24, 36, 48, and 60 months. AWDs, defined as discontinuity of the fascial layer with protrusion of abdominal contents, were identified. Clinical information regarding AWDs was retrieved from the study registry. The prevalence of AWD exceeds 20% and plateaus at 24 months. Eight patients (8%) had clinical evidence of ventral incisional hernias. One patient underwent repair, but no other patient developed hernia incarceration or intestinal obstruction or required additional procedures related to the AWD. AWDs are radiographic findings occurring frequently after open AAA repair. Radiographic evaluation is more sensitive than clinical observation for detection of ventral hernias. Clinical events and reinterventions related to these radiographic abnormalities are rare.

Incidence of Incisional Hernias in Patients Operated on for Aneurysm or Occlusive Disease

The purpose of this study was to evaluate the incidence of postoperative incisional hernias after elective open abdominal aortic aneurysm (AAA) repair versus aortofemoral reconstruction. In this open prospective study, 281 patients who underwent elective open AAA or aortofemoral repair were included. All patients were evaluated by clinical examination 1 month after the operation, every 6 months for the next 5 years, and every year thereafter for the presence of an incisional hernia. Mean duration of follow-up was 63.7 months (range, 12–144 months). Seventeen patients (6.2%) were lost to follow-up. The development of a postoperative incisional hernia was recorded and analyzed with regard to the demographic data and the traditional risk factors for atherosclerosis. Statistical analysis was performed using the Kaplan-Meier method and the Cox regression analysis. The development of a postoperative incisional hernia after AAA surgical repair had an incidence of 16.2 per cent versus 7.4 per cent after aortofemoral reconstruction. Patients electively operated on for AAA have a 3.8-fold increase of developing a postoperative incisional hernia over patients operated on for peripheral occlusive disease (POD).

Laparoscopic incisional hernia repair in a porcine model: what do transfixion sutures add?

BACKGROUND

The aim of this study was to evaluate the need for transfixion sutures during laparoscopic ventral hernia repair with mesh.

METHODS

Incisional hernias were created in 14 Yucatan mini-pigs. Animals were randomized to undergo laparoscopic hernia repair either with spiral tacks alone (Tacks) or with tacks and 4 Prolene transfixion sutures (Sutured) using Composix E/X mesh (Davol Inc.). At 4 weeks, exploratory laparoscopy was performed to assess the repair and score adhesions. The abdominal wall was harvested for tensile strength analysis and histologic evaluation. Continuous variables were compared using a two-tailed nonpaired t-test. Results are presented as mean +/- standard deviation.

RESULTS

The mean hernia size was 8.5 +/- 0.5 cm by 5.5 +/- 0.7 cm, with no difference between groups. The operative time was significantly longer ( p = 0.006) for the Sutured group (62.1 +/- 16.8 min) than for the Tacks group (32.3 +/- 7.0 min). The number of tacks per repair was equivalent between groups. At necropsy, the mesh in all cases was well incorporated, reperitonealized, and without evidence of migration. No hernias recurred. However, the Sutured group had a significantly ( p < or = 0.05) higher adhesion score (5.4 +/- 3.3) than the Tacks group (2.0 +/- 2.7). The tensile strength of the repair zone was no different between groups (Sutured 4.8 +/- 1.5 N/cm, Tacks 3.8 +/- 1.4 N/cm). On histologic examination, the ratio of inflammatory cells to fibroblasts was similar between groups (Sutured 0.2 +/- 0.6, Tacks 0.2 +/- 0.3). Only 82% of tacks in each group penetrated the fascia, and the depth of tack penetration was similar between groups (Sutured 3.7 +/- 0.3 mm, Tacks 3.9 +/- 0.4 mm).

CONCLUSIONS

In a porcine model, the use of transfixion sutures was associated with longer operative times and more adhesions, without improvement in tensile strength or mesh incorporation. A human clinical trial is needed to determine the optimal method of securing abdominal wall mesh.

Prevention of incisional hernia after aortic aneurysm repair

BACKGROUND

Incisional hernia is a common late complication of elective abdominal aneurysm (AAA) repair. This paper describes a technique that could prevent the development of this condition.

METHODS

Since Jan 2001, a polypropylene mesh has been sutured prophylactically in the pre-peritoneal space during abdominal closure after elective AAA repair.

RESULTS

Twenty-eight consecutive elective procedures were performed. One patient died from a myocardial infarct 13 days after operation. Four patients (14%) had a wound infection (1 deep methicillin resistant Staphylococcus aureus (MRSA) infection and 3 superficial) that were treated successfully with antibiotics and dressings. One additional patient had a positive MRSA wound swab but required no treatment. Two patients required late re-operations. One, who was on warfarin, required an urgent laparotomy for a leaking false aneurysm of the distal anastomoses 3 months after elective repair. A second patient had an anterior resection 18 months after aneurysm repair. Both re-operations were uneventful. No patient has yet developed a clinically evident incisional hernia.

CONCLUSIONS

These early data suggest that this mesh technique is a simple, safe and potentially effective method to decrease the incidence of incisional hernia following aortic aneurysm repair.

Acute wound healing: the biology of acute wound failure

Acute wound healing failure is an important source of morbidity and mortality for surgical patients. Many incisional hernias, gastrointestinal anastomotic leaks, and vascular pseudoaneurysms occur despite patient optimization and standardized surgical technique. Modern surgical experience suggests that biologic and mechanical pathways overlap during "normal" acute wound healing. The cellular and molecular processes activated to repair tissue from the moment of injury are under the control of biologic and mechanical signals. Successful acute wound healing occurs when a dynamic balance is met between the loads placed across a provisional matrix and the feedback and feed-forward responses of repair cells.

Incision and abdominal wall hernias in patients with aneurysm or occlusive aortic disease

INTRODUCTION

Patients undergoing midline incision for abdominal aortic reconstruction appear to be at greater risk for postoperative incision hernia compared with patients undergoing celiotomy for general surgical procedures. Controversy exists as to whether incidence of abdominal wall hernia and increased risk for incision hernia is higher in patients with abdominal aortic aneurysm (AAA) than in patients operated on because of aortoiliac occlusive disease (AOD). We conducted a prospective multi-institutional study to assess frequency of incision hernia after aortic surgery through a midline laparotomy and of previous abdominal wall hernia.

METHODS

Patients with AAA (n = 177) or AOD (n = 82) from three major institutions were prospectively enrolled in the study and examined. Data collected included demographic data, cardiopulmonary risk factors, smoking status, history of previous or current abdominal wall hernia (incision, inguinal, umbilical, femoral), previous midline incision, suture type, and postoperative complications. At a minimum of 6 months after laparotomy, patients were evaluated clinically for a new incision hernia. Differences were tested with the unpaired t test, X(2) test, or Fisher exact test, and multiple logistic regression was used to control for confounding variables.

RESULTS

Mean follow-up of the cohort was 32.8 +/- 2.3 months. Rate of abdominal wall hernia and inguinal hernia in patients with AAA versus AOD was 38.4% versus 11% (P =.001) and 23.7% versus 6.1% (P =.003), respectively. Rate of postoperative incision hernia in patients with AAA was 28.2%, and in patients with AOD was 11.0% (P =.002). Adjusting for age, smoking, chronic obstructive pulmonary disease, body mass index, diabetes, bowel obstruction, and suture type, patients with AAA had almost a ninefold risk for postoperative incision hernia formation (odds ratio [OR], 8.8; P =.0049).

CONCLUSION

Compared with patients with AOD, patients with AAA have a higher frequency of abdominal wall hernia and inguinal hernia, and are at significant increased risk for development of incision hernia postoperatively. The higher frequency of hernia formation in patients with AAA suggests the presence of a structural defect within the fascia. Further studies are needed to delineate the molecular changes of the aorta and its relation to the abdominal wall fascia.