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Warren JA, Lucas C, Beffa LR, Petro CC, Prabhu AS, Krpata DM, Rosen MJ, Orenstein SB, Nikolian VC, Pauli EM, Horne CM, LaBelle M, Phillips S, Poulose BK, Carbonell AM. Reducing the incidence of surgical site infection after ventral hernia repair: Outcomes from the RINSE randomized control trial. Am J Surg 2024; 232:68-74. [PMID: 38199871 DOI: 10.1016/j.amjsurg.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/20/2023] [Accepted: 01/04/2024] [Indexed: 01/12/2024]
Abstract
BACKGROUND The clinical and financial impact of surgical site infection after ventral hernia repair is significant. Here we investigate the impact of dual antibiotic irrigation on SSI after VHR. METHODS This was a multicenter, prospective randomized control trial of open retromuscular VHR with mesh. Patients were randomized to gentamicin + clindamycin (G + C) (n = 125) vs saline (n = 125) irrigation at time of mesh placement. Primary outcome was 30-day SSI. RESULTS No significant difference was seen in SSI between control and antibiotic irrigation (9.91 vs 9.09 %; p = 0.836). No differences were seen in secondary outcomes: SSO (11.71 vs 13.64 %; p = 0.667); 90-day SSO (11.1 vs 13.9 %; p = 0.603); 90-day SSI (6.9 vs 3.8 %; p = 0.389); SSIPI (7.21 vs 7.27 %, p = 0.985); SSOPI (3.6 vs 3.64 %; p = 0.990); 30-day readmission (9.91 vs 6.36 %; p = 0.335); reoperation (5.41 vs 0.91 %; p = 0.056). CONCLUSION Dual antibiotic irrigation with G + C did not reduce the risk of surgical site infection during open retromuscular ventral hernia repair.
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Affiliation(s)
- Jeremy A Warren
- University of South Carolina School of Medicine Greenville and Prisma Health Upstate Department of Surgery, Greenville, SC, USA.
| | - Claiborne Lucas
- Prisma Health Upstate Department of Surgery, Greenville, SC, USA
| | | | | | | | | | | | | | | | - Eric M Pauli
- Penn State Health Milton S Hershey Medical Center Department of Surgery, Hershey, PA, USA
| | - Charlotte M Horne
- Penn State Health Milton S Hershey Medical Center Department of Surgery, Hershey, PA, USA
| | - Molly LaBelle
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | | | - Benjamin K Poulose
- The Ohio State University Wexner Department of Surgery and Center for Abdominal Core Health, Columbus, OH, USA
| | - Alfredo M Carbonell
- University of South Carolina School of Medicine Greenville and Prisma Health Upstate Department of Surgery, Greenville, SC, USA
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Bontekoning N, Huizing NJ, Timmer AS, Groenen H, de Jonge SW, Boermeester MA. Topical antimicrobial treatment of mesh for the reduction of surgical site infections after hernia repair: a systematic review and meta-analysis. Hernia 2024; 28:691-700. [PMID: 38722398 PMCID: PMC11249405 DOI: 10.1007/s10029-024-02987-0] [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: 12/05/2023] [Accepted: 02/08/2024] [Indexed: 07/16/2024]
Abstract
PURPOSE Use of mesh is essential in hernia repair. A common complication after hernia repair is surgical site infection (SSI), which poses a risk in spreading to the mesh, possibly causing mesh infection. Topical antimicrobial pretreatment of mesh may potentially reduce SSI risk in hernia repair and has shown promising results in in vitro and in vivo studies. Clinical evidence, however, is more important. This systematic review aims to provide an overview of available clinical evidence for antimicrobial pretreated mesh in hernia repair surgery to reduce SSI. METHODS We report in accordance with PRISMA guidelines. CENTRAL, EMBASE, CINAHL and PubMed were searched up to October 2023 for studies that investigated the use of antimicrobial pretreated mesh on SSI incidence in adults undergoing hernia repair. The primary outcome was SSI incidence. We also collected data on pathogen involvement, hernia recurrence, and mesh infection. A meta-analysis on SSI risk and GRADE-assessment was performed of eligible studies. RESULTS We identified 11 eligible studies (n = 2660 patients); 5 randomized trials and 6 cohort studies. Investigated interventions included pre-coated mesh, antibiotic carriers, mesh soaked or irrigated with antibiotic or antiseptic solution. Meta-analysis showed no significant reduction in SSI for antibiotic pretreated polypropylene mesh (RR 0.76 [95% CI 0.27; 2.09]; I2 50%). CONCLUSION Data on topical mesh pretreatment to reduce SSI risk after hernia repair is limited. Very low certainty evidence from randomized trials in hernia repair surgery shows no significant benefit for antibiotic mesh pretreatment for SSI reduction, but data are imprecise due to optimal information size not being met.
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Affiliation(s)
- Nathan Bontekoning
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, The Netherlands
| | - Nathalie J Huizing
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Allard S Timmer
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, The Netherlands
| | - Hannah Groenen
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, The Netherlands
| | - Stijn W de Jonge
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, The Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, The Netherlands.
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Schlosser KA, Warren JA. Hernia Mesh Complications: Management of Mesh Infections and Enteroprosthetic Fistula. Surg Clin North Am 2023; 103:1029-1042. [PMID: 37709388 DOI: 10.1016/j.suc.2023.04.011] [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] [Indexed: 09/16/2023]
Abstract
The potential consequences of mesh infection mandate careful consideration of surgical approach, mesh selection, and preoperative patient optimization when planning for ventral hernia repair. Intraperitoneal mesh, microporous or laminar mesh, and multifilament mesh typically require explantation, whereas macroporous, monofilament mesh in an extraperitoneal position is often salvageable. Delayed presentation of mesh infection should raise the suspicion for enteroprosthetic fistula when intraperitoneal mesh is present. When mesh excision is necessary, the surgeon must carefully consider both the risk of recurrent infection as well as hernia recurrence when deciding on single-stage definitive reconstruction versus primary closure with delayed reconstruction.
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Affiliation(s)
- Kathryn A Schlosser
- Department of Surgery, Prisma Health, 701 Grove Road, Support Tower 3, Greenville, SC 29605, USA. https://twitter.com/KT_Schlosser
| | - Jeremy A Warren
- Department of Surgery, Division of Minimal Access Surgery, University of South Carolina School of Medicine Greenville, Prisma Health, 701 Grove Road, Support Tower 3, Greenville, SC 29605, USA.
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Wouters D, Cavallaro G, Jensen KK, East B, Jíšová B, Jorgensen LN, López-Cano M, Rodrigues-Gonçalves V, Stabilini C, Berrevoet F. The European Hernia Society Prehabilitation Project: A Systematic Review of Intra-Operative Prevention Strategies for Surgical Site Occurrences in Ventral Hernia Surgery. Front Surg 2022; 9:847279. [PMID: 35910469 PMCID: PMC9326087 DOI: 10.3389/fsurg.2022.847279] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 06/06/2022] [Indexed: 11/29/2022] Open
Abstract
Background Ventral hernia repair is one of the most commonly performed surgical procedures worldwide. To reduce the risk of complications, pre- and intra-operative strategies have received increasing focus in recent years. To assess possible preventive surgical strategies, this European Hernia Society endorsed project was launched. The aim of this review was to evaluate the current literature focusing on pre- and intra-operative strategies for surgical site occurrences (SSO) and specifically surgical site infection (SSI) in ventral hernia repair. Methods A systematic review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Databases used were Pubmed and Web of Science. Original retrospective or prospective human adult studies describing at least one intra-operative intervention to reduce SSO after ventral hernia repair were considered eligible. Results From a total of 4775 results, a total of 18 papers were considered suitable after full text reading. Prehospital chlorhexidine gluconate (CHG) scrub appears to increase the risk of SSO in patients undergoing ventral hernia repair, while there is no association between any type of surgical hat worn and the incidence of postoperative wound events. Intraoperative measures as prophylactic negative pressure therapy, surgical drain placement and the use of quilt sutures seem beneficial for decreasing the incidence of SSO and/or SSI. No positive effect has been shown for antibiotic soaking of a synthetic mesh, nor for the use of fibrin sealants. Conclusion This review identified a limited amount of literature describing specific preventive measures and techniques during ventral hernia repair. An advantage of prophylactic negative pressure therapy in prevention of SSI was observed, but different tools to decrease SSIs and SSOs continuously further need our full attention to improve patient outcomes and to lower overall costs.
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Affiliation(s)
- D. Wouters
- Department for General and HPB Surgery and Liver Transplantation, University Hospital Gent, Gent, Belgium
| | - G. Cavallaro
- Department for General and HPB Surgery and Liver Transplantation, University Hospital Gent, Gent, Belgium
| | - Kristian K. Jensen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - B. East
- 3rd Department of Surgery and 1st Medical Faculty of Charles University, Motol University Hospital, Prague, Czech Republic
| | - B. Jíšová
- 3rd Department of Surgery and 1st Medical Faculty of Charles University, Motol University Hospital, Prague, Czech Republic
| | - L. N. Jorgensen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - M. López-Cano
- Abdominal Wall Surgery Unit, Department of General Surgery, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - V. Rodrigues-Gonçalves
- Abdominal Wall Surgery Unit, Department of General Surgery, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - C. Stabilini
- Department of Surgery, University of Genoa, Genoa, Italy
- European Hernia Society, Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - F. Berrevoet
- Department for General and HPB Surgery and Liver Transplantation, University Hospital Gent, Gent, Belgium
- Correspondence: Frederik Berrevoet
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Fu C, Meng L, Ma M, Li N, Zhang J. Effect of wound irrigation on the prevention of surgical site infections: A meta-analysis. Int Wound J 2022; 19:1878-1886. [PMID: 35293119 PMCID: PMC9615282 DOI: 10.1111/iwj.13794] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/05/2022] [Accepted: 03/08/2022] [Indexed: 11/29/2022] Open
Abstract
We performed a meta‐analysis to evaluate the effect of wound irrigation on the prevention of surgical site infections. A systematic literature search up to January 2022 was done and 24 studies included 4967 subjects under surgery at the start of the study; antibiotic irrigation was used with 1372 of them, 1261 were aqueous povidone‐iodine irrigation, and 2334 were saline irrigation or no irrigation for surgical site infections prevention in all surgical populations. We calculated the odds ratio (OR) with 95% confidence intervals (CIs) to evaluate the effect of different wound irrigation on the prevention of surgical site infections by the dichotomous method with a random or fixed‐influence model. Antibiotic irrigation had significantly lower surgical site infections in all surgical populations (OR, 0.48; 95% CI, 0.36‐0.62, P < .001) compared with saline irrigation or no irrigation for the subject under surgery. Aqueous povidone‐iodine irrigation had significantly lower surgical site infections in all surgical populations (OR, 0.40; 95% CI, 0.20‐0.81, P = .01) compared with saline irrigation or no irrigation for the subject under surgery. Antibiotic irrigation and aqueous povidone‐iodine irrigation significantly lowered surgical site infections in all surgical populations compared with saline irrigation or no irrigation for the subject under surgery. Further studies are required.
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Affiliation(s)
- Chunmei Fu
- Department of General Surgery, Hainan West Central Hospital, Danzhou, China
| | - Linghong Meng
- Endoscopy Room, Hainan Cancer Hospital, Haikou, China
| | - Miguo Ma
- Department of Renal Endocrinology, Qionghai People's Hospital, Qionghai, China
| | - Na Li
- Department of Renal Endocrinology, Qionghai People's Hospital, Qionghai, China
| | - Jingcen Zhang
- Department of Anesthesiology, Hainan West Central Hospital, Danzhou, China
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Risks and Prevention of Surgical Site Infection After Hernia Mesh Repair and the Predictive Utility of ACS-NSQIP. J Gastrointest Surg 2022; 26:950-964. [PMID: 35064459 PMCID: PMC9021144 DOI: 10.1007/s11605-022-05248-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/23/2021] [Indexed: 02/06/2023]
Abstract
AIM The aim of this paper was to provide a narrative review of surgical site infection after hernia surgery and the influence of perioperative preventative interventions. METHODS The review was based on current national and international guidelines and a literature search. RESULTS Mesh infection is a highly morbid complication after hernia surgery, and is associated with hospital re-admission, increased health care costs, re-operation, hernia recurrence, impaired quality of life and plaintiff litigation. The American College of Surgeons National Surgical Quality Improvement Program is a particularly useful resource for the study and evidence-based practise of abdominal wall hernia repair. DISCUSSION The three major modifiable patient comorbidities significantly associated with postoperative surgical site infection in hernia surgery are obesity, tobacco smoking and diabetes mellitus. Preoperative optimization includes weight loss, cessation of smoking, and control of diabetes. Intraoperative interventions relate, in particular, to the control of fomite mediated transmission in the operating theatre and prevention of mesh contamination with S. aureus CFUs. Risk management strategies should also target the niche ecological conditions which enable bacterial survival and subsequent biofilm formation on an implanted mesh. Outcomes of mesh infection after hernia surgery are closely related to mesh type and porosity, patient smoking status, presence of MRSA, bacterial adhesion and biofilm production. The use of suction drains and the timing of drain removal are controversial and discussed in detail. Finally, the utility of the ACS-NSQIP Surgical Risk Calculator in predicting complications and outcomes in individual patients and the importance of quality improvement initiatives in surgical units are emphasized.
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Synthetic Mesh in Contaminated Abdominal Wall Surgery: Friend or Foe? A Literature Review. J Gastrointest Surg 2022; 26:235-244. [PMID: 34590215 DOI: 10.1007/s11605-021-05155-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 09/17/2021] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The use of synthetic mesh in contaminated fields is controversial. In the last decade, published data have grown in this matter suggesting favorable outcomes. However, multiple variables and scenarios that influence the results still make difficult to obtain convincing recommendations. METHODS We performed a review of relevant available data in English regarding the use of synthetic meshes in contaminated abdominal wall surgery using the Medline database. Articles including patients undergoing ventral hernia in contaminated fields were included for analysis. RESULTS Most studies support the use of synthetic meshes for ventral hernia repair in contaminated fields, as they have shown lower recurrence rate and similar wound morbidity. Although no mesh seems ideal in this setting, most surgeons advocate for the use of reduced-in-weight polypropylene mesh. Sublay location of the prosthesis associated with complete fascial closure appears to offer better results in these patients. In addition, current evidence suggests that the use of prophylactic synthetic mesh when performing a stoma or for stoma reversal incisional hernias might be beneficial. CONCLUSION A better understanding of surgical site occurrences and its prevention, as well as the introduction of new reduced-in-weight meshes have allowed using synthetic meshes in a contaminated field. Although the use of mesh has indeed shown promising results in these patients, the surgical team should still balance pros and cons at the time of placing synthetics in contaminated fields.
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Issa M, Noureldin K, Elgadi A, Abdelaziz A, Badawi M, Makram M. Evaluation of the Sublay Mesh Repair Outcomes in Different Types of Ventral Hernia. Cureus 2021; 13:e20590. [PMID: 35103166 PMCID: PMC8777263 DOI: 10.7759/cureus.20590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction: Ventral hernia repair is one of the challenging surgical operations over time. Several surgical techniques for mesh repair have been described (onlay, inlay, sublay, and underlay repairs). It is suggested that sublay mesh repair has the lowest recurrence and surgical site infection in open anterior abdominal hernia repair. This study aimed to analyze the pros and cons of the sublay mesh in ventral hernia repair to evaluate the significance of this technique as a treatment modality. Hospital stay, acute postoperative complications, and the recurrence rate were the main areas of investigation. Methods: A retrospective study on 79 patients with ventral hernias who were operated on with sublay mesh repair between January 2015 and December 2018 was conducted. Patients were admitted through the elective route. The study included fit patients with first-time ventral hernias (primary and incisional). Recurrent hernia, patients with decompensated cardiopulmonary disorders, and bleeding disorders were excluded from the project. The project pro forma includes patient’s demographics, operative details, length of stay, postoperative complications, and follow-up up to 12 months. Results: All patients underwent open mesh repair using the sublay technique. The ventral hernia was five times more common in females than males. The mean age of presentation was 44.8 years old. The mean operating time was 67 minutes and a one-day hospital stay. Paraumblical and incisional hernias represented the majority of cases. The component separation approach was added in three cases (3.7%). Simultaneous cholecystectomy was performed in two cases (2.5%). Only six cases (6.3%) developed wound-related complications, while two cases (2.5%) had a recurrence. Conclusion: The sublay mesh repair is a perfect choice for the repair of ventral abdominal hernia. It is associated with a smooth and short hospital stay and the least incidence of complications and recurrence.
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Antibiotic irrigation during pancreatoduodenectomy to prevent infection and pancreatic fistula: A randomized controlled clinical trial. Surgery 2019; 166:469-475. [DOI: 10.1016/j.surg.2019.05.053] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 04/02/2019] [Accepted: 05/19/2019] [Indexed: 11/20/2022]
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