Incisional hernia repair by synthetic mesh prosthesis in patients with inflammatory bowel disease: a comparative analysis

Investigation of optimal hernia repair techniques in patients with inflammatory bowel disease

INTRODUCTION

Multiple laparotomies, immunosuppressive therapy, wound infection, and malnutrition are risk factors for incisional hernia development, which places inflammatory bowel disease (IBD) patients at high risk. With advances in minimally invasive techniques, this study assesses incisional hernia repair techniques and complications in the IBD population.

METHODS

A single-center, retrospective review of adults with IBD who underwent incisional hernia repair from 2008 to 2022. Complications relative to operative approach and mesh placement location were assessed using descriptive and univariate statistics.

RESULTS

Eighty-eight IBD patients underwent incisional hernia repair. Fifty-two (59.1%) were on immunomodulators and 30 (34.1%) were repaired primarily. Thirty-five (39.7%) hernias recurred, of whom 19 (33%) had mesh placed. Three (30%) occurred in onlay repairs and 16 (33%) occurred in underlay repairs. Subdivision of underlay repairs into intraperitoneal, preperitoneal and retrorectus mesh placement revealed recurrence rates of 35.1%, 50%, and 14.3%, respectively. Patients with open repair were more likely to have intraoperative bowel injury (28.6% vs 9.7%, p = 0.041) and develop postoperative seromas/abscesses (12.5% vs 0%, p = 0.001) and wound complications (17.9% vs 0%, p = 0.012) compared to laparoscopic. Seromas/abscesses developed more frequently in onlay repairs compared to underlay (40% vs 2.13%, p = 0.001). Twelve (13.6%) patients presented with postoperative small bowel obstruction (SBO), 7 (58.3%) of whom had mesh placed, and 6 (85.7%) were underlay. All SBO after underlay repair had intraperitoneally placed mesh. When comparing surgeons, hernias were more likely to recur performed by colorectal surgeons compared to hernia surgeons (63.3% vs 21.3%, p < 0.001).

CONCLUSION

In IBD patients, minimally invasive approaches lead to fewer perioperative complications compared to open. Underlay mesh placement demonstrated decreased incidence of seroma/abscess formation compared to onlay. When sub-grouped, underlay placements were similar in terms of complications. Retrorectus placement, however, had fewer recurrences and no readmissions for SBO. This suggests a minimally invasive approach or placement of retrorectus mesh may provide the optimal repair in this patient population.

Risk of incisional hernia repair in patients with inflammatory bowel disease

AIM

Patients with inflammatory bowel disease (IBD) may undergo several abdominal surgeries with a risk of incisional hernia repair (IHR). The objectives of this study were to establish the risk of IHR and to analyse predictors of IHR after a first-time abdominal surgery for IBD.

METHOD

This Danish nationwide register-based cohort study (1996-2018) followed IBD patients from index operation until the date of IHR. The absolute risk was calculated as the cumulative incidence proportion treating death as a competing risk. Cox proportional hazard regression was used to compare the risk of IHR among different subtypes of IBD and to explore predictors of IHR. IBD subtypes were classified as ulcerative colitis (UC), Crohn's disease (CD) or unclassified IBD (IBD-U).

RESULTS

In total, 10 130 patients with IBD (UC 3911 [39%]; CD 4210 [41%]; IBD-U 2009 [20%]) underwent either an open or a laparoscopic index operation. The 10-year cumulative incidence of IHR varied between 5.0% and 6.3%, with a significantly higher risk in patients with UC and IBD-U. Patients with UC (75.9%) and IBD-U (91.9%) had more (two or more) abdominal surgeries in the follow-up period compared with CD (51.9%). The risk of IHR increased dramatically with the number of surgeries, although not as markedly if a laparoscopic approach was used. Male sex, age, comorbidity, fascial dehiscence, wound infection and presence of stoma were predictors of IHR for patients with IBD.

CONCLUSION

The long-term risk of IHR was roughly 5%-6%, with a higher risk in patients with UC and IBD-U. Open surgical approach and number of previous surgeries were, among other things, important predictors of IHR.

Abdominal hernia mesh repair in patients with inflammatory bowel disease: A systematic review

Background

Postoperative hernia-repair complications are frequent in patients with inflammatory bowel disease (IBD). This fact challenges surgeons’ decision about hernia mesh management in these patients. Therefore, we systematically reviewed the hernia mesh repair in IBD patients with emphasis on risk factors for postoperative complications.

Method

A systematic review was done in compliance with the PRISMA guidelines. A search was carried out on PubMed and ScienceDirect databases. English language articles published from inception to October 2021 were included in this study. MERSQI scores were applied along with evidence grades in agreement with GRADE’s recommendations. The research protocol was registered with PROSPERO (CRD42021247185).

Results

The present systematic search resulted in 11,243 citations with a final inclusion of 10 citations. One paper reached high and 4 moderate quality. Patients with IBD exhibit about 27% recurrence after hernia repair. Risk factors for overall abdominal septic morbidity in Crohn’s disease comprised enteroprosthetic fistula, mesh withdrawals, surgery duration, malnutrition biological mesh, and gastrointestinal concomitant procedure.

Conclusion

Patients with IBD were subject, more so than controls to postoperative complications and hernia recurrence. The use of a diversity of mesh types, a variety of position techniques, and several surgical choices in the citations left room for less explicit and more implicit inferences as regards best surgical option for hernia repair in patients with IBD.