Short-term outcomes of a multicentre prospective study using a "visible" polyvinylidene fluoride onlay mesh for the prevention of midline incisional hernia

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).

Prophylactic Mesh Reinforcement for Prevention of Midline Incisional Hernias: A Publication Bias Adjusted Meta-analysis

OBJECTIVE

To systematically review the published literature on the use of prophylactic mesh reinforcement of midline laparotomy closures for prevention of VIH.

SUMMARY OF BACKGROUND DATA

VIH are common complications of abdominal surgery. Prophylactic mesh has been proposed as an adjunct to prevent their occurrence.

METHODS

PubMed, Embase, Scopus, and Cochrane were reviewed for RCTs that compared prophylactic mesh reinforcement versus conventional suture closure of midline abdominal surgery. Primary outcome was the incidence of VIH at postoperative follow-up ≥24 months. Secondary outcomes included surgical site infection and surgical site occurrence (SSO). Pooled risk ratios were obtained through random effect meta-analyses and adjusted for publication bias. Network meta-analyses were performed to compare mesh types and locations.

RESULTS

Of 1969 screened articles, 12 RCTs were included. On meta-analysis there was a lower incidence of VIH with prophylactic mesh [11.1% vs 21.3%, Relative risk (RR) = 0.32; 95% confidence interval (CI) = 0.19-0.55, P < 0.001), however, publication bias was highly likely. When adjusted for this bias, prophylactic mesh had a more conservative effect (RR = 0.52; 95% CI = 0.39-0.70). There was no difference in risk of surgical site infection (9.1% vs 8.9%, RR = 1.08, 95% CI = 0.82-1.43; P = 0.118), however, prophylactic mesh increased the risk of SSO (14.2% vs 8.9%, RR = 1.57, 95% CI = 1.19-2.05; P < 0.001).

CONCLUSION

Current RCTs suggest that in mid-term follow-up prophylactic mesh prevents VIH with increased risk for SSO. There is limited long-term data and substantial publication bias.

Reoperation Through a Prosthetic-Reinforced Abdominal Wall and Its Association With Postoperative Outcomes and Longitudinal Health Care Utilization

Importance

Prosthetic reinforcement of critically sized incisional hernias is necessary to decrease hernia recurrence, but long-term prosthetic-mesh footprint may increase complication risk during subsequent abdominal operations.

Objective

To investigate the association of prior incisional hernia repair with mesh (IHRWM) with postoperative outcomes and health care utilization after common abdominal operations.

Design, Setting, and Participants

This was a population-based, retrospective cohort study of patients undergoing inpatient abdominal surgical procedures during the period of January 2009 to December 2016, with at least 1 year of follow-up within 5 geographically diverse statewide inpatient/ambulatory databases (Florida, Iowa, Nebraska, New York, Utah). History of an abdominal operation was ascertained within the 3-year period preceding the index operation. Patients admitted to the hospital with a history of an abdominal operation (ie, bariatric, cholecystectomy, small- or large-bowel resection, prostatectomy, gynecologic) were identified using the International Classification of Diseases, Ninth Revision and Tenth Revision, Clinical Modification procedure codes. Patients with prior IHRWM were propensity score matched (1:1) to controls both with and without a history of an abdominal surgical procedure based on clinical and operative characteristics. Data analysis was conducted from March 1 to November 27, 2021.

Main Outcomes and Measures

The primary outcome was a composite of adverse postoperative outcomes (surgical and nonsurgical). Secondary outcomes included health care utilization determined by length of hospital stay, hospital charges, and 1-year readmissions. Logistic and Cox regression determined the association of prior IHRWM with the outcomes of interest. Additional subanalyses matched and compared patients with prior IHR without mesh (IHRWOM) to those with a history of an abdominal operation.

Results

Of the 914 105 patients undergoing common abdominal surgical procedures (81 123 bariatric [8.9%], 284 450 small- or large-bowel resection [31.1%], 223 768 cholecystectomy [24.5%], 33 183 prostatectomy [3.6%], and 291 581 gynecologic [31.9%]), all 3517 patients (age group: 46-55 years, 1547 [44.0%]; 2396 majority sex [68.1%]) with prior IHRWM were matched to patients without a history of abdominal surgical procedures. After matching, prior IHRWM was associated with increased overall complications (odds ratio [OR], 1.43; 95% CI, 1.27-1.60), surgical complications (OR, 1.51; 95% CI, 1.34-1.70), length of hospital stay (mean increase of 1.03 days; 95% CI, 0.56-1.49 days; P < .001), index admission charges (predicted mean difference of $11 896.10; 95% CI, $6096.80-$17 695.40; P < .001), and 1-year unplanned readmissions (hazard ratio, 1.14; 95% CI, 1.05-1.25; P = .002). This trend persisted even when comparing matched patients with prior IHRWM to patients with a history of abdominal surgical procedures, and the treatment outcome disappeared when comparing patients with prior IHRWOM to those without a previous abdominal operation.

Conclusions and Relevance

Reoperation through a previously prosthetic-reinforced abdominal wall was associated with increased surgical complications and health care utilization. This risk appeared to be independent of a history of abdominal surgical procedures and was magnified by the presence of a prosthetic-mesh footprint in the abdominal wall.

Prophylactic Mesh After Midline Laparotomy: Evidence is out There, but why do Surgeons Hesitate?

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.

Preventing incisional ventral hernias: important for patients but ignored by surgical specialities? A critical review

PURPOSE

Incisional ventral hernias (IHs) are a common complication across all surgical specialities requiring access to the abdomen, pelvis, and retroperitoneum. This public health issue continues to be widely ignored, resulting in appreciable morbidity and expenses. In this critical review, the issue is explored by an interdisciplinary group.

METHODS

A group of European surgeons encompassing representatives from abdominal wall, vascular, urological, gynecological, colorectal and hepato-pancreatico-biliary surgery have reviewed the occurrence of His in these disciplines.

RESULTS

Incisional hernias are a major public health issue with appreciable morbidity and cost implications. General surgeons are commonly called upon to repair IHs following an initial operation by others. Measures that may collectively reduce the frequency of IH across specialities include better planning and preparation (e.g. a fit patient, no time pressure, an experienced operator). A minimally invasive technique should be employed where appropriate. Our main recommendations in midline incisions include using the 'small bites' suture technique with a ≥ 4:1 suture-to-wound length, and adding prophylactic mesh augmentation in patients more likely to suffer herniation. For off-midline incisions, more research of this problem is essential.

CONCLUSION

Meticulous closure of the incision is significant for every patient. Raising awareness of the His is necessary in all surgical disciplines that work withing the abdomen or retroperitoneum. Across all specialties, surgeons should aim for a < 10% IH rate.

Prophylactic mesh augmentation: Patient selection, techniques, and early outcomes

BACKGROUND

Incisional hernias (IH) following abdominal surgery are frequent and morbid. Prophylactic mesh augmentation (PMA) has emerged as a technique to reduce IH formation. We aim to report patient selection, techniques and early outcomes after PMA.

METHODS

Retrospective chart review identified descriptive characteristics, risk factors, operative technique, and early post-operative outcomes for PMA patients and matched non-PMA patients between January 1, 2016 and October 31, 2017.

RESULTS

18 consecutive PMA cases were performed (55.6% female, mean age 54.3 years and mean BMI = 29.5 kg/m²). 88.9% of patients had at least two high-risk features for IH. Zero PMA patients developed IH compared to 5.3% non-PMA patients (p = 0.314) (6-months mean follow-up). No difference in surgical site occurrences (SSO) were identified between the two groups.

CONCLUSIONS

Early results are encouraging, demonstrating PMA is safe with equivocal SSO. Further studies are needed to assess if the reduction in IH formation is statistically significant with longer follow-up.