Open preperitoneal vs. open anterior repair for the treatment of emergency femoral hernia: a bicentric retrospective study

PURPOSE

The aim of this study is to compare the postoperative results, in terms of complications and recurrence, between the anterior and open preperitoneal approaches in emergency femoral hernia.

METHODS

This bi-centric retrospective cohort study included patients who underwent emergency femoral hernia repair between January 2010 and December 2018. Postoperative complications and recurrence were analyzed comparing anterior and open preperitoneal approaches. The predictors of complications, mortality and recurrence were investigated using multivariate logistic regression.

RESULTS

A total of 204 patients met the inclusion criteria. Open anterior approach was performed in 128 (62.7%) patients and open preperitoneal was performed in 76 (37.3%). Open preperitoneal approach was associated with lower rates of recurrence (P = 0.033) and associated midline laparotomies (P = 0.006). Multivariable analysis identified patients with chronic nephropathy (OR, 3.801; 95%CI, 1.034-13.974; P = 0.044), preoperative bowel obstruction (OR, 2.376; 95%CI, 1.118-5.047; P = 0.024) and required midline laparotomy (OR, 12.467; 95%CI, 11.392-102.372; P = 0.030) as risk factors for complications and ASA ≥ III (OR, 7.820; 95%CI, 1.279-47.804; P = 0.026), COPD (OR, 5.064; 95%CI, 1.188-21.585; P = 0.028), necrotic contents (OR, 36.968; 95%CI, 4.640-294.543; P = 0.001), and required midline laparotomy (OR, 11.047; 95%CI, 1.943-62.809; P = 0.007). as risk factors for 90-day mortality. Male gender (OR, 4.718; 95%CI, 1.668-13.347; P = 0.003) and anterior approach (OR, 5.292; 95%CI, 1.114-25.149; P = 0.036) were risk factors for recurrence.

CONCLUSION

Open preperitoneal approach may be superior to anterior approach in the emergency setting because it can avoid the morbidity of associated midline laparotomies, with a lower long-term recurrence rate.

Open Emergent Groin Hernia Repair: Anterior or Posterior Approach?

Introduction: The current literature has not yet provided a definitive conclusion on the best emergency groin hernia repair. The aim of this study was first to compare the short and long-term outcomes between open preperitoneal and anterior approach in emergency groin hernia repair and second to identify risk factors for postoperative complications, mortality, and recurrence. Materials and Methods: This retrospective cohort study included patients who underwent emergency groin hernia repair between January 2010 and December 2018. Short and long-term outcomes were analyzed comparing approach and repair techniques. The predictors of complications and mortality were investigated using multivariate logistic regression. Cox regression multivariate analysis were used to explore risk factors of recurrence. Results: A total of 316 patients met the inclusion criteria. The most widely used surgical techniques were open preperitoneal mesh repair (34%) and mesh plug (34%), followed by Lichtenstein (19%), plug and patch (7%) and tissue repair (6%). Open preperitoneal mesh repair was associated with lower rates of recurrence (p = 0.02) and associated laparotomies (p < 0.001). Complication and 90-day mortality rate was similar between the techniques. Multivariable analysis identified patients aged 75 years or older (OR, 2.08; 95% CI, 1.14-3.80; p = 0.016) and preoperative bowel obstruction (OR, 2.11; 95% CI, 1.20-3.70; p = 0.010) as risk factors for complications and Comprehensive Complication Index ≥26.2 as risk factor for 90-day mortality (OR, 44.76; 95% CI, 4.51-444.59; p = 0.01). Female gender was the only risk factor for recurrence. Conclusion: Open preperitoneal mesh repair may be superior to other techniques in the emergency setting, because it can avoid the morbidity of associated laparotomies, with a lower long-term recurrence rate.

Understanding patient-reported knowledge of hernia surgery: a quantitative study

PURPOSE

The objective of this study was to gather information on patient-reported knowledge (PRK) in the field of hernia surgery.

METHODS

A prospective quantitative study was designed to explore different aspects of PRK and opinions regarding hernia surgery. Patients referred for the first time to a surgical service with a presumed diagnosis of hernia and eventual hernia repair were eligible, and those who gave consent completed a simple self-assessment questionnaire before the clinical visit.

RESULTS

The study population included 449 patients (72.8% men, mean age 61.5). Twenty (4.5%) patients did not have hernia on physical examination. The patient's perceived health status was "neither bad nor good" or "good" in 56.6% of cases. Also, more patients considered that hernia repair would be an easy procedure (35.1%) rather than a difficult one (9.8%). Although patients were referred by their family physicians, 32 (7.1%) answered negatively to the question of coming to the visit to assess the presence of a hernia. The most important reason of the medical visit was to receive medical advice (77.7%), to be operated on as soon as possible (40.1%) or to be included in the surgical waiting list (35.9%). Also, 46.1% of the patients considered that they should undergo a hernia repair and 56.8% that surgery will be a definitive solution.

CONCLUSION

PRK of patients referred for the first time to an abdominal wall surgery unit with a presumed diagnosis of hernia was quite limited and there is still a long way towards improving knowledge of hernia surgery.

Closure of Iterative Laparotomy in Patients With Previous Mesh Reinforcement a Cohorts' Study. Short-Term Results

Purpose: Due to extension of prophylactic mesh indications use will become more common to find patients receiving an iterative laparotomy (IL) over a previous reinforced abdominal wall. The aim of this study was to analyze outcomes after IL in patients with previous mesh reinforcement. Methods: This study was a prospective secondary analysis of midline laparotomy closure performed from July 2017 to July 2018 registered in PHACPA study (NCT02658955). IL were included and surgery characteristics and outcomes analyzed. We compared two groups: with (PreM) or without previous prophylactic onlay mesh reinforcement (PreS) Subgroups' analysis, risk factors for complications and survival free hernia analysis were performed. Results: 121 IL were analyzed. Only obesity was associated with higher SSO (OR 2.6; CI 95% 1.02-6.90; p = 0.04) There were 15 incisional hernias (IH) (14.4%). Group with previous mesh reinforcement (pre M) had a higher statistically significative incidence of IH (OR = 1.21; CI 95% 1.05-1.39; p = 0.015). Use of slowly absorbable suture (OR = 0.74; CI 95% 0.60-0.91; p = 0.001), USP 2/0 suture (OR, 0.31; 95% CI, 0.10-0.94; p = 0.033), and small bites technique (OR = 0.81; CI 95% 0.72-0.90; p = 0.011) were associated with less IH. Conclusion: IL has a high percentage of complications and IH. In case of IL without previous reinforcement, a mesh can help to reduce IH. Our data cannot clearly support any technique to close an IL with previous mesh.

Implementing a protocol to prevent incisional hernia in high-risk patients: a mesh is a powerful tool

PURPOSE

The small bites (SB) technique for closure of elective midline laparotomies (EMLs) and a prophylactic mesh (PM) in high-risk patients are suggested by the guidelines to prevent incisional hernias (IHs) and fascial dehiscence (FD). Our aim was to implement a protocol combining both the techniques and to analyze its outcomes.

METHODS

Prospective data of all EMLs were collected for 2 years. Results were analyzed at 1 month and during follow-up. The incidence of HI and FD was compared by groups (M = Mesh vs. S = suture) and by subgroups depending on using SB.

RESULTS

A lower number of FD appeared in the M group (OR 0.0692; 95% CI 0.008-0.56; P = 0.01) in 197 operations. After a mean follow-up of 29.23 months (N = 163; min. 6 months), with a lower frequency of IH in M group (OR 0.769; 95% CI 0.65-0.91; P < 0.0001). (33) The observed differences persisted after a propensity matching score: FD (OR 0.355; 95% CI 0.255-0.494; P < 0.0001) and IH (OR 0.394; 95% CI 0.24-0.61; P < 0.0001). On comparing suturing techniques by subgroups, both mesh subgroups had better outcomes. PM was the main factor related to the reduction of IH (HR 11.794; 95% CI 4.29-32.39; P < 0.0001).

CONCLUSION

Following the protocol using PM and SB showed a lower rate of FD and HI. A PM is safe and effective for the prevention of both HI and FD after MLE, regardless of the closure technique used.

Early outcomes of component separation techniques: an analysis of the Spanish registry of incisional Hernia (EVEREG)

AIM

To analyze the outcomes of component separation techniques (CST) to treat incisional hernias (IH) in a large multicenter cohort of patients.

METHODS

All IH repair using CST, registered in EVEREG from July 2012 to December 2019, were included. Data on the pre-operative patient characteristics and comorbidities, IH characteristics, surgical technique, complications, and recurrence were collected. Outcomes between anterior (ACS) and posterior component separation (PCS) techniques were compared. Risk factors for complications and recurrences were analyzed.

RESULTS

During the study period, 1536 patients underwent CST (45.5% females) with a median age of 64.0 years and median body mass index (BMI) of 29.7 kg/m². ACS was the most common technique (77.7%). Overall complications were frequent in both ACS and PCS techniques (36.5%), with a higher frequency of wound infection (10.6% vs. 7.0%; P = 0.05) and skin necrosis (4.4% vs. 0.1%; P < 0.0001) with the ACS technique. Main factors leading to major complications were mesh explant (OR 1.72; P = 0.001), previous repair (OR 0.75; P = 0.038), morbid obesity (OR 0.67; P = 0.015), ASA grade (OR 0.62; P < 0.0001), COPD (OR 0.52; P < 0.0001), and longitudinal diameter larger than 10 cm (OR 0.58; P = 0.001). After a minimum follow-up of 6 months (median 15 months; N = 590), 59 (10.0%) recurrences were diagnosed. Operations performed in a non-specialized unit were significantly associated with recurrences (HR 4.903, CI 1.64-14.65; P = 0.004).

CONCLUSION

CST is a complex procedure with a high rate of complications. Both ACS and PCS techniques have similar complication and recurrence rates. Operations performed in a specialized unit have better outcomes.

Long-term follow-up of prophylactic mesh reinforcement after emergency laparotomy. A retrospective controlled study

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.

Incidence of Incisional Hernia After Emergency Subcostal Unilateral Laparotomy: Does Augmentation Prophylaxis Play a Role?

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.

Incisional hernia recurrence after open elective repair: expertise in abdominal wall surgery matters

BACKGROUND

Recurrence after incisional hernia repair is one of the major problems related with this operation. Our objective is to analyze the influence of abdominal wall surgery expertise in the results of the open elective repair of incisional hernia.

METHODS

We have compiled the data of a cohort of patients who received surgery for an incisional hernia from July 2012 to December 2015 in a University Hospital. Data were collected prospectively and registered in the Spanish Register of Incisional Hernia (EVEREG). The short- and long-term complications between the groups of patients operated on by the Abdominal Wall Surgery (AWS) unit and groups operated on by surgeons outside of the specialized abdominal wall group (GS) were compared.

RESULTS

During the study period, a total of 237 patients were operated on by the open approach (114 AWS; 123 GS). One hundred seventy-five patients completed a median follow-up of 36.6 months [standard deviation (SD) = 6]. Groups were comparable in terms of age, sex, body mass index (BMI), comorbidities, and complexity of hernia. Complications were similar in both groups. Patients in the AWS group presented fewer recurrences (12.0% vs. 28.9%; P = 0.005). The cumulative incidence of recurrence was higher in the GS group [log rank 13.370; P < 0.001; odds ratio (OR) = 37.8; 95% confidence interval (CI) = 30.3-45.4]. In the multivariate analysis, surgery performed by the AWS unit was related to fewer recurrences (OR = 0.19; 95%CI = 0.07-0.58; P < 0.001).

CONCLUSION

Incisional hernia surgery is associated with better results in terms of recurrence when it is performed in a specialized abdominal wall unit.