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).

[Incisional hernias: epidemiology, evidence and guidelines]

BACKGROUND

From an epidemiological point of view, one third of the population in industrialized countries will undergo abdominal surgery during their lifetime. Depending on the degree of patient-related and procedure-related risks, the occurrence of incisional hernias is associated in a range of up to 30% at 2‑year follow-up and even up to 60% at 5 years. In addition to influencing comorbidities, the type of surgical approach and closure technique are of critical importance.

OBJECTIVE

To present a descriptive evidence-based recommendation for abdominal wall closure and prophylactic mesh augmentation.

MATERIAL AND METHODS

A concise summary was prepared incorporating the current literature and existing guidelines.

RESULTS

According to recent studies the recognized risk for the occurrence of incisional hernias in the presence of obesity and abdominal aortic diseases also applies to patients undergoing colorectal surgery and the presence of diastasis recti abdominis. Based on high-level published data, the short stitch technique for midline laparotomy in the elective setting has a high level of evidence to be a standard procedure. Patients with an increased risk profile should receive prophylactic mesh reinforcement, either onlay or sublay, in addition to the short stitch technique. In emergency laparotomy, the individual risk of infection with respect to the closure technique used must be included.

CONCLUSION

The avoidance of incisional hernias is primarily achieved by the minimally invasive access for laparoscopy. For closure of the most commonly used midline approach, the short stitch technique and, in the case of existing risk factors, additionally mesh augmentation are recommended.

Prevention of incisional hernia with prophylactic onlay and sublay mesh reinforcement vs. primary suture only in midline laparotomies (PRIMA): long-term outcomes of a multicentre, double-blind, randomised controlled trial

Background

Incisional hernia occurs approximately in 40% of high-risk patients after midline laparotomy. Prophylactic mesh placement has shown promising results, but long-term outcomes are needed. The present study aimed to assess the long-term incisional hernia rates of the previously conducted PRIMA trial with radiological follow-up.

Methods

In the PRIMA trial, patients with increased risk of incisional hernia formation (AAA or BMI ≥27 kg/m2) were randomised in a 1:2:2 ratio to primary suture, onlay mesh or sublay mesh closure in three different countries in eleven institutions. Incisional hernia during follow-up was diagnosed by any of: CT, ultrasound and physical examination, or during surgery. Assessors and patients were blinded until 2-year follow-up. Time-to-event analysis according to intention-to-treat principle was performed with the Kaplan-Meier method and Cox proportional hazard models. Trial registration: NCT00761475 (ClinicalTrials.gov).

Findings

Between 2009 and 2012, 480 patients were randomized: 107 primary suture, 188 onlay mesh and 185 sublay mesh. Five-year incisional hernia rates were 53.4% (95% CI: 40.4-64.8), 24.7% (95% CI: 12.7-38.8), 29.8% (95% CI: 17.9-42.6), respectively. Compared to primary suture, onlay mesh (HR: 0.390, 95% CI: 0.248-0.614, p < 0.001) and sublay mesh (HR: 0.485, 95% CI: 0.309-0.761, p = 0.002) were associated with a significantly lower risk of incisional hernia development.

Interpretation

Prophylactic mesh placement remained effective in reducing incisional hernia occurrence after midline laparotomy in high-risk patients during long-term follow-up. Hernia rates in the primary suture group were higher than previously anticipated.

Funding

B. Braun.

Prevention of incisional hernia after kidney transplantation: study protocol for a randomized controlled trial

BACKGROUND

Incisional hernia is a common complication after kidney transplantation with an incidence of 1.6-18%. Concerning non-transplant patients, a recently published meta-analysis describes a reduction of the incidence of incisional hernia of up to 85% due to prophylactic mesh replacement in elective, midline laparotomy. The aim of our study is to show a reduction of the incidence of incisional hernia after kidney transplantation with minimal risk for complication.

METHODS/DESIGN

This is a blinded, randomized controlled trial comparing time to incisional hernia over a period of 24 months between patients undergoing kidney transplantation and standardized abdominal closure with or without prophylactic placement of ProGrip™ (Medtronic, Fridley, MN, USA) mesh in an onlay position. As we believe that the mesh intervention is superior to the standard procedure in reducing the incidence of hernia, this is a superiority trial.

DISCUSSION

The high risk for developing incisional hernia following kidney transplantation might be reduced by prophylactic mesh placement. ProGrip™ mesh features polylactic acid (PLA) microgrips that provide immediate, strong and uniform fixation. The use of this mesh combines the effectiveness demonstrated by the macropore propylene meshes in the treatment of incisional hernias, a high simplicity of use provided by its capacity for self-fixation that does not increase significantly surgery time, and safety.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04794582. Registered on 08 March 2021. Protocol version 2.0. (02-18-2021).

National survey of colorectal surgery units on abdominal wall closure

INTRODUCTION

The purpose of this study is to assess the current status and knowledge of the Spanish colorectal surgeons on the wall closure.

METHODS

A single answer questionnaire of 25 closed questions was conducted using specific software for online surveys that was distributed to a cohort of colorectal surgeons.

RESULTS

53 surgeons replied to the survey. The vast majority prefer a closure of the midlaparotomy with a very slow absorbing monofilament (67.92%) continuous suture (96.23%) in a single plane (81.13%). Mass stitches, retention systems, and loop sutures continue to be used. The most commonly used suture gauge was USP 1 (United States Pharmacopeia) (58.49%). The most commonly used needle is with a cylindrical body and a trocar tip. Only 50%, routinely perform wall closure after placement of a trocar equal to or greater than 10 mm. Almost everyone knows the 4:1 rule and thinks it should be applied, but the small bites technique is not performed. 50% would never place a prophylactic prosthesis. The closure is usually performed by the same surgeon who has performed the entire procedure. One out of five confesses not knowing the rate of incisional hernias in his unit.

CONCLUSION

There is a lack of consensus and basic knowledge regarding the technical aspects of closure and the prevention of the appearance of incisional hernias. The use of slow absorbing monofilament continuous suture in a single plane seems well accepted.

Prophylactic mesh reinforcement for midline incisional hernia prevention: systematic review and updated meta-analysis of randomized controlled trials

BACKGROUND

Incisional hernia (IH) is a common complication after abdominal surgery. Prevention of IH is matter of intense research. Prophylactic mesh reinforcement (PMR) has been shown to be promising in the minimization of IH risk after elective midline laparotomy.

METHODS

Systematic review and meta-analysis of randomized controlled trials (RCTs) comparing PMR vs. primary suture closure (PSC). Risk ratio (RR) and standardized mean difference (MD) were used as pooled effect size measures whereas 95% confidence intervals (95%CI) were used to assess relative inference.

RESULTS

Fourteen RCTs (2332 patients) were included. Overall, 1280 (54.9%) underwent PMR while 1052 (45.1%) PSC. Postoperative follow-up ranged from 12 to 67 months. The incidence of IH was reduced for PMR vs. PSC (13.4% vs. 27.5%). The estimated pooled IH RR for PMR vs. PSC is 0.38 (95% CI 0.24-0.58; p < 0.001). Stratified subgroup analysis according to mesh location shows a risk reduction for intraperitoneal (RR = 0.65; 95% CI 0.48-0.89), preperitoneal (RR = 0.18; 95% CI 0.04-0.81), retromuscular (RR = 0.47; 95% CI 0.24-0.92) and onlay (RR = 0.24; 95% CI 0.12-0.51) compared to PSC. The seroma RR was higher for PMR (RR = 2.05; p = 0.0008). No differences were found for hematoma (RR = 1.49; p = 0.34), surgical site infection (SSI) (RR = 1.17; p = 0.38), operative time (OT) (MD = 0.27; p = 0.413), and hospital length of stay (HLOS) (MD = -0.03; p = 0.237).

CONCLUSIONS

PMR seems effective in reducing the risk of IH after elective midline laparotomy compared to PSC in the medium-term follow-up. While the risk of postoperative seroma appears higher for PMR, hematoma, SSI, HLOS and OT seems comparable.

Synthetic Mesh in Contaminated Abdominal Wall Surgery: Friend or Foe? A Literature Review

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.

Prevention of Incisional Hernia after Open Hepato-Pancreato-Biliary Surgery: A Systematic Review

INTRODUCTION

Most hepato-pancreato-biliary (HPB) procedures are still performed through open approach. Incisional hernia (IH) is one of the most common complications after open surgery. To date, published data on IH after HPB surgery are scarce; therefore, the aim of this study was to assess the current evidence regarding incidence, risk factors, and prevention.

METHODS

Medline/PubMed (1946-2020), EMBASE (1947-2020), and the Cochrane library (1995-2020) were searched for studies on IH in open HPB surgery. Animal studies, editorials, letters, reviews, comments, short case series and liver transplant, laparoscopic, or robotic procedures were excluded. The protocol was registered with PROSPERO (CRD42020163296).

RESULTS

A total of 5,079 articles were retrieved. Eight studies were finally included for the analysis. The incidence of IH after HPB surgery ranges from 7.7% to 38.8%. The identified risk factors were body mass index, surgical site infection, ascites, Mercedes or reversed T incisions, and previous IH. Prophylactic mesh might be safe and effective.

CONCLUSIONS

IH after open HPB surgery is still an important matter. Some of the risk factors are specific for the HPB operations and the incision type should be carefully considered. Randomized controlled trials are required to confirm the role of prophylactic mesh after HPB operations.

Controversies in Abdominal Wall Reconstruction

This article discuses current controversies in abdominal wall reconstruction, including the standardization of outcome reporting, mesh selection, the utility of robotic surgery in ventral hernia repair, and role for prophylactic stoma mesh at the time of permanent end colostomy formation. The current state of the literature pertaining to these topics is reviewed in detail.

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.

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.

Preventing Parastomal Hernia After Ileal Conduit by the Use of a Prophylactic Mesh: A Randomised Study

BACKGROUND

Parastomal hernia (PSH) after urinary diversion with ileal conduit is frequently a clinical problem.

OBJECTIVE

To investigate whether a prophylactic lightweight mesh in the sublay position can reduce the cumulative incidence of PSH after open cystectomy with ileal conduit.

DESIGN, SETTING, AND PARTICIPANTS

From 2012 to 2017, we randomised 242 patients 1:1 to conventional stoma construction (n = 124) or prophylactic mesh (n = 118) at three Swedish hospitals (ISRCTN 95093825).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was clinical PSH, and secondary endpoints were radiological PSH assessed in prone position with the stoma in the centre of a ring, parastomal bulging, and complications from the mesh.

RESULTS AND LIMITATIONS

Within 24 mo, 20/89 (23%) patients in the control arm and 10/92 (11%) in the intervention arm had developed a clinical PSH (p = 0.06) after a median follow-up of 3 yr, corresponding to a hazard ratio of 0.45 (confidence interval 0.24-0.86, p = 0.02) in the intervention arm. The proportions of radiological PSHs within 24 mo were 22/89 (25%) and 17/92 (19%) in the two study arms. During follow-up, five patients in the control arm and two in the intervention arm were operated for PSH. The median operating time was 50 min longer in patients receiving a mesh. No differences were noted in proportions of Clavien-Dindo complications at 90 d postoperatively or in complications related to the mesh during follow-up.

CONCLUSIONS

Prophylactic implantation of a lightweight mesh in the sublay position decreases the risk of PSH when constructing an ileal conduit without increasing the risk of complications related to the mesh. The median surgical time is prolonged by mesh implantation.

PATIENT SUMMARY

In this randomised report, we looked at the risk of parastomal hernia after cystectomy and urinary diversion with ileal conduit with or without the use of a prophylactic mesh. We conclude that such a prophylactic measure decreased the occurrence of parastomal hernias, with only a slight increase in operating time and no added risk of complications related to the mesh.

Closure of stoma site with or without prophylactic mesh reinforcement: a systematic review and meta-analysis

AIMS

To evaluate comparative outcomes of the closure of temporary stoma site with or without prophylactic mesh reinforcement METHODS: A systematic online search was conducted using the following databases: PubMed, Scopus, Cochrane database, The Virtual Health Library, Clinical trials.gov and Science Direct. Studies comparing the reversal of stoma with and without prophylactic mesh reinforcement were included. Stoma site incisional hernia (SSIH), surgical site infection (SSI), operative time, seroma formation, haematoma formation, bowel obstruction, anastomosis leak, length of hospital stay (LOS) and secondary operation to repair the SSIH were the evaluated outcome parameters.

RESULTS

Six comparative studies reporting a total of 1683 patients who underwent closure of stoma with (n = 669) or without (n = 1014) prophylactic mesh reinforcement were included. Use of mesh was associated with a significantly lower risk of SSIH (OR 0.22, P = 0.003) and need for surgical intervention to repair SSIH (OR 0.32, P = 0.04) compared with no use of mesh. However, it was associated with significantly longer operative time (MD 47.78, P = 0.02). There was no significant difference in SSI (OR 1.09, P = 0.59), bowel obstruction (OR 1.11, P = 0.74), seroma formation (OR 2.86, P = 0.19), anastomosis leak (OR 1.60, P = 0.15), haematoma formation (OR 1.25, P = 0.75) or LOS (MD - 0.45, P = 0.31) between two groups.

CONCLUSION

Prophylactic mesh reinforcement during the closure of temporary stoma may significantly reduce the risk of SSIH and surgical intervention to repair the hernia without increasing the risk of SSI or other morbidities. However, it may increase the procedure time. Future higher-quality randomised evidence is required.

Prophylactic mesh augmentation using permanent synthetic mesh: outcomes of keyhole and Stapled Ostomy Reinforcement with Retromuscular Mesh techniques

INTRODUCTION

Parastomal hernias (PSH) are the most common complication of stoma creation and can cause significant morbidity. We present a consecutive series of patients receiving prophylactic mesh augmentation (PMA) for prevention of PSH.

METHODS

This retrospective review evaluates the efficacy and outcomes of PMA for PSH prevention, and retrospectively compares traditional keyhole PMA (tPMA) (n = 28) with a prophylactic Stapled Ostomy Reinforcement with Retromuscular Mesh technique (pSTORRM) (n = 24).

RESULTS

PMA was performed in 52 cases between January 2015 and July 2018. All cases used a large-pore, non-coated, mid-weight polypropylene mesh placed in the retrorectus space. With a median follow-up of 16 mos, parastomal hernia was confirmed in 11.5% (n = 6), 5 of whom were symptomatic. patient-reported outcomes (PRO) indicated 6 additional patients with symptoms associated with PSH without clinical or radiographic confirmation. Patients had similar comorbidities and operative characteristics between tPMA and pSTORRM techniques, and no difference in a median follow-up. pSTORRM patients had fewer surgical site infections (8.3 vs 32.1%; p = 0.046) and occurrences (12.5 vs 46.4%; p = 0.015), and lower rate of PSH, though not statistically significant (4.2 vs 17.9%; p = 0.195).

CONCLUSION

Permanent synthetic mesh placed as a sublay in the retromuscular space is safe and appears to decrease the risk of PSH formation after the creation of permanent stomas. A stapled technique may provide advantages over a traditional keyhole technique.

Comments to "PRevention of INCisional hernia after liver transplantation (PRINC trial): study protocol for a randomized controlled trial."

Prophylactic augmentation of the wound with mesh proposed by Kniepeiss et al is the world's first attempt to significantly reduce the risk of postoperative hernia in liver transplantation. Similar technique have been described 17 years ago in bariatric patients and confirmed by many studies in various clinical settings. The results of mesh hernia repair in patients on immunosuppressive therapy are not inferior from the data obtained from non- transplant surgery registers.To reduce the risk of using the mesh in patients scheduled for liver transplantation authors chose absorbable mesh, that maintains the mechanical strength of the wound for up to 18 months. Half of the incisional hernias have been diagnoses more than 3 years from the original procedure.For prevention of incisional hernias, there is no evidence to support the use of biologic/biosynthetic meshes.

Prophylactic mesh placement to avoid incisional hernias after stoma reversal: a systematic review and meta-analysis

Purpose

To provide an overview of the available literature on prevention of incisional hernias after stoma reversal, with the use of prophylactic meshes.

Methods

A literature search of Pubmed, MEDLINE and EMBASE was performed. Search terms for stoma, enterostomy, mesh, prophylaxis and hernia were used. Search was updated to December 31th 2018. No time limitations were used, while English, Geman, Dutch and French were used as language restrictions. The primary outcome was the incidence of incisional hernia formation after stoma reversal. Secondary outcomes were mesh-related complications. Data on study design, sample size, patient characteristics, stoma and mesh characteristics, duration of follow-up and outcomes were extracted from the included articles.

Results

A number of 241 articles were identified and three studies with 536 patients were included. A prophylactic mesh was placed in 168 patients to prevent incisional hernias after stoma reversal. Follow-up ranged from 10 to 21 months. The risk of incisional hernia in case of prophylactic mesh placement was significantly lower in comparison to no mesh placement (OR 0.10, 95% CI 0.04–0.27, p < 0.001, I² = 0%, CI 0–91.40%). No differences in surgical site infections were detected between the groups.

Conclusions

The use of a prophylactic mesh seems to reduce the risk on incisional hernias after stoma reversal and therefore mesh reinforcement should be considered after stoma reversal.

Electronic supplementary material

The online version of this article (10.1007/s10029-019-01996-8) contains supplementary material, which is available to authorized users.

PRevention of INCisional hernia after liver transplantation (PRINC trial): study protocol for a randomized controlled trial

Background

Incisional hernia is a common complication after liver transplantation with an incidence of 5 to 46%. Concerning non-transplant patients, a recently published meta-analysis describes a reduction of the incidence of incisional hernia of up to 85% due to prophylactic mesh replacement in elective, midline laparotomy. The aim of our study is to show a reduction of the incidence of incisional hernia after liver transplantation with minimal risk for complication.

Methods/design

This is an unblinded, randomized controlled trial comparing time to incisional hernia over a period of 12 months between patients undergoing liver transplantation and standardized abdominal closure with or without prophylactic placement of Phasix™ (Bard – Davol Inc., Warwick, RI, USA) mesh in an onlay position. As we believe that the mesh intervention is superior to the standard procedure in reducing the incidence of hernia, this is a superiority trial.

Discussion

The high risk for developing incisional hernia following liver transplantation might be reduced by prophylactic mesh placement. Immunosuppressed patients are at high risk for developing surgical-site infections. We chose a mesh which has anti-inflammatory properties and is fully resorbed after 18 months.

Trial registration

ClinicalTrials.gov, ID: 03222102. Registered retrospectively on 17 July 2018. Protocol version 1.4, 7 October 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3477-2) contains supplementary material, which is available to authorized users.

Hernias at the extraction incision after laparoscopic colon and rectal resection: Influence of incision location and use of prophylactic mesh

OBJECTIVES

To determine the incidence of incisional hernia (IH) in the extraction incision (EI) in colorectal resection for cancer. To analyze whether the location of the incision has any relationship with the incidence of hernias and whether mesh could be useful for prevention in high-risk patients.

METHODS

Retrospective review of the colon and rectal surgery database from January 2015 to December 2016. Data were classified into 2groups, transverse (TI) and midline incision (MI), and the latter was divided into 2subgroups (mesh [MIM] and suture [MIS]). Patients were classified using the HERNIAscore. Hernias were diagnosed by clinical and/or CT examination.

RESULTS

A total of 182 out of 210 surgical patients were included. After a median follow-up of 13.0 months, 39 IH (21.9%) were detected, 23 of which (13.4%) were in the EI; their frequency was lower in the TI group (3.4%) and in the MIM group (5.9%) than in the MIS group (29.5%; p=0.007). The probability of developing IH in the MIS group showed an OR=11.7 (95%CI: 3.3-42.0) compared to the TI group and 4.3 (IC 95%: 1.1-16.3) versus the MIM group.

CONCLUSIONS

The location of the incision is relevant to avoid incisional hernias. Transverse incisions should be used as the first option. When a midline incision is needed, a prophylactic mesh could be considered in high risk patients because it is safe and associated with low morbidity.

New advances in prophylactic mesh placement in end colostomy

Patients with end colostomy often undergo multiple operations because of high incidence and recurrence rates of parastoml hernia. Therefore, it is particularly important to prevent the occurrence of parastomal hernia when undergoing an end colostomy. Using a prophylactic mesh, which is developed and gradually recognized in recent years, is one of the methods to prevent parastomal hernia. Here, we review the application and new advances in prophylactic mesh placement in end colostomy.

Incisional hernia prevention and use of mesh. A narrative review

Incisional hernias are a very common problem, with an estimated incidence around 15-20% of all laparotomies. Evisceration is another important problem, with a lower rate (2.5-3%) but severe consequences for patients. Prevention of both complications is an essential objective of correct patient treatment due to the improved quality of life and cost savings. This narrative review intends to provide an update on incisional hernia and evisceration prevention. We analyze the current criteria for proper abdominal wall closure and the possibility to add prosthetic reinforcement in certain cases requiring it. Parastomal, trocar-site hernias and hernias developed after stoma closure are included in this review.

The use of an algorithm for prophylactic mesh use in high risk patients reduces the incidence of incisional hernia following laparotomy for colorectal cancer resection

OBJECTIVE

Incisional hernia (IH) after colorectal surgery is highly prevalent. The objective of this study is to assess the utility of an algorithm to decide on mesh augmentation after a midline laparotomy for colorectal resection to prevent IH in high-risk patients.

METHODS

A prospective study was conducted including all patients undergoing a midline laparotomy for colorectal resection between January 2011 and June 2014, after the implementation of a decision algorithm for prophylactic mesh augmentation in selected high-risk patients. Intention-to-treat analyses were conducted between patients in which the algorithm was correctly applied and those in which it was not.

RESULTS

From the 235 patients analysed, the algorithm was followed in 166 patients, the resting 69 cases were used as a control group. From an initial adherence to the algorithm of 40% in the first semester, a 90.3% adherence was achieved in the seventh semester. The incidence of IH decreased as the adherence to the algorithm increased (from 28 to 0%) with a time-related correlation (R²=0.781). A statistically significant reduction in IH incidence was demonstrated in high-risk groups in which the algorithm was correctly applied (10,2 vs. 46,3%; p=0,0001; OR: 7,58;95%; CI: 3,8-15). Survival analysis showed that the differences remained constant during follow-up.

CONCLUSION

The implementation of the algorithm reduces the incidence of IH in high-risk patients. The adherence to the algorithm also correlates with a decrease in the incidence of IH.

Prophylactic mesh to prevent parastomal hernia: a meta-analysis of randomized controlled studies

The aim of the present meta-analysis was to determine whether prophylactic mesh decreases the odds of parastomal hernia formation. Randomized controlled trials referenced in MEDLINE or EMBASE between 1946 and 2016 comparing prophylactic mesh to standard stoma formation were included. The primary outcome was occurrence of parastomal hernia. Secondary outcomes were parastomal hernia requiring surgical intervention and complications. Odds ratios were calculated for the primary and secondary outcomes. Subgroup analyses were conducted based on mesh type, mesh location, laparoscopic versus open, and method of hernia diagnosis. Nine randomized controlled trials with 569 participants were included. There was a significant decrease in the odds of developing a parastomal hernia in the prophylactic mesh group [odds ratio (OR) 0.21, 95% confidence interval (CI) 0.11-0.38, p < 0.00001, I ² = 36%], as well as decreased odds of requiring surgical repair (OR 0.36, 95% CI 0.15-0.87, p = 0.02, I ² = 0%). There was no evidence that prophylactic mesh increased the odds of surgical complications (seven studies, OR 1.34, 95% CI 0.73-2.46, p = 0.34, I ² = 34%) or stoma-specific complications (eight studies, OR 0.65, 95% CI 0.40-1.05, p = 0.08, I ² = 0%). There was a subgroup effect with synthetic mesh associated with a lower incidence of parastomal hernias which was not appreciated in the biologic mesh group (test of subgroup effect p = 0.01). Five studies had a high risk of bias. The Grades of Recommendation, Assessment, Development and Evaluation quality of evidence was moderate. Prophylactic mesh is associated with decreased odds of parastomal hernia formation and the need for surgical repair. There is no evidence that mesh placement increases the odds of complications.

Prophylactic mesh placement for prevention of incisional hernia after open bariatric surgery: a systematic review and meta-analysis

BACKGROUND

Prophylactic mesh during laparotomy has been shown to be effective in preventing postoperative incisional hernia (IH) in high-risk patients. Since obesity is a risk factor for IH, we wished to determine whether mesh prevents IH in open and laparoscopic bariatric surgery patients.

METHODS

We conducted a systematic review of the literature with meta-analysis. Seven studies met inclusion criteria. We abstracted data regarding postoperative IH development, surgical site infection, and seroma or wound leakage and performed meta-analysis.

RESULTS

The prophylactic mesh group had significantly decreased odds of developing IH than the standard closure group (odds ratio, .30, 95% CI, .13 to .68, P = .004). No included studies evaluated outcomes after prophylactic mesh during laparoscopic bariatric surgery.

CONCLUSIONS

Prophylactic mesh during open bariatric surgery appears to be beneficial in reducing postoperative IH without significant increasing the odds of surgical site infection or seroma or wound leakage. Higher quality studies, including those in laparoscopic patients, and cost-utility analysis, are needed to support routine use of this intervention.

Long-term assessment of parastomal hernia prevention by intra-peritoneal mesh reinforcement according to the modified Sugarbaker technique

BACKGROUND

Parastomal hernia (PSH) is a very frequent complication after creation of a permanent colostomy. The aim of that study is to assess the safety and the long-term efficacy of an intra-peritoneal onlay mesh (IPOM) positioned at the time of primary stoma formation to prevent PSH occurrence.

MATERIALS AND METHODS

That multicentre prospective study concerned 29 consecutive patients operated for cancer of the low rectum between 2008 and 2014. There were 14 men and 15 women with a median age of 73 years (range 39-88) and a BMI of 28 (range 21-43). All the patients had potentially curative abdominoperineal excision associated with IPOM reinforcement of the abdominal wall with a round non-slit composite mesh centred on the stoma site and covering the lateralized colon according to the modified Sugarbaker technique. The major outcomes analysed were operative time, complications related to mesh and PSH incidence. Patients were evaluated at 6-month intervals for the first 2 years and thereafter annually with physical examination and CT scan control. For PSH evaluation, we used the classification of Moreno-Matias.

RESULTS

Surgery was performed by laparoscopy in 24 patients and by laparotomy in 5; 17 had a trans-peritoneal colostomy and 12 an extra-peritoneal colostomy. The median size of the mesh was 15 cm (range 12-20), the operative time 225 min. (range 123-311) and the specific time for mesh placement 15 min. (range 10-30). With a median follow-up of 48 months (range 6-88), no mesh infection or complication requiring mesh removal were recorded. No patient developed a true PSH; two of them had a type Ia PSH (only containing the bowel forming the colostomy with a sac < 5 cm) and were totally asymptomatic.

CONCLUSION

In our series, the incidence of PSH was 7 % and no specific mesh-related complication was noted. Prophylactic mesh reinforcement according to the modified Sugarbaker is an effective technique that addresses the issues related to the occurrence of PSH.