Prophylactic Onlay Mesh Repair (POMR) Versus Primary Suture Repair (PSR) for Prevention of Incisional Hernia (IH) After Abdominal Wall Surgery: A Systematic Review and Meta-analysis

The MESH-RTL Project for prevention of abdominal wound dehiscence (AWD) in high-risk patients: noninferiority, randomized controlled trial

PURPOSE

To compare reinforced tension line (RTL) and mesh techniques in the onlay position for preventing abdominal wound dehiscence (AWD) in a noninferiority clinical trial.

METHODS

Patients > 18 years old who underwent midline laparotomy and who were considered at high risk on the modified Rotterdam risk scale were included. The outcomes analyzed were the incidence of AWD and surgical site occurrence (SSO).

RESULTS

239 patients were included: 121 mesh group and 118 RTL group. Five (4.1%) of the 121 patients in the mesh group and 7 (5.9%) of the 118 patients in the RTL group presented with AWD (p = 0.56, RR = 0.69, 95% CI = 0.22-2.13) in the per-protocol analysis. The median time of presentation was 6 days. The 95% CI (-0.0567, 0.0231) for the difference in incidence between the two groups was entirely within the predefined noninferiority margin of 5%. The incidence of complications did not significantly differ between the two groups: the mesh group (27, 22.3%) and the RTL group (16, 12.8%) (p = 0.09, RR (95% CI) = 1.64 (0.93-2.89)).

CONCLUSION

The use of the RTL technique for preventing AWD was not inferior to the use of mesh in the onlay position, nor did it increase the risk of complications. This study was registered on clinicaltrials.gov: Mesh-RTL Project (NCT04134455).

Surgical site occurrence after prophylactic use of mesh for prevention of incisional hernia in midline laparotomy: systematic review and meta-analysis of randomized clinical trials

BACKGROUND

The use of mesh is the standard for the prevention of incisional hernia (IH). However, the effect of surgical site occurrence (SSO) has never been compared. The aim of this meta-analysis was to evaluate the prevalence of SSO and measure its negative effect through the calculation of the number needed to treat for net effect (NNT net).

METHODS

A meta-analysis was performed according to the PRISMA guidelines. The primary objective was to determine the prevalence of SSO and IH, and the secondary objective was to determine the NNT net as a metric to measure the combined benefits and harms. Only published clinical trials were included. The risk of bias was analyzed, and the random effects model was used to determine statistical significance.

RESULTS

A total of 15 studies comparing 2344 patients were included. The incidence of IH was significantly lower in the mesh group than in the control group, with an OR of 0.29 (95% CI 0.16-0.49, p = 0.0001). The incidence of SSO was higher in the mesh group than in the control group, with an OR of 1.21 (95% CI 0.85-1.72, p = 0.0001) but without statistical significance. Therefore, the way to compare the benefits and risks of each of the studies was done with the calculation of the NNT net, which is the average number of patients who need to be treated to see the benefit exceeding the harm by one event, and the result was 5, which is the average number of patients who need to be treated to see the benefit exceeding the harm by one event.

CONCLUSION

The use of mesh reduces the prevalence of IH and it does not increases the prevalence of SSO, the NNT net determined that the use of mesh continues to be beneficial for the patient.

Hernia Prevention: The Role of Technique and Prophylactic Mesh to Prevent Incisional Hernias

Millions of laparotomies are performed annually, carrying up to a 41% risk of developing into a hernia. Incisional hernias are associated with morbidity, mortality, and costs; an estimated $9.6 billion is spent annually on repair of ventral hernias. Although repair is possible, surgeons must prevent incisional hernias from occurring. There is substantial evidence on surgical technique to reduce the risk of incisional hernia formation. This article aims to critically summarize the use of surgical technique and prophylactic mesh augmentation during fascial closure to inform decision-making and reduce incisional hernia formation.

Hernia Prevention Using Biologic Mesh and/or Small Bites: A Multispecialty 2 × 2 Factorial Randomized Controlled Trial

BACKGROUND

Ventral incisional hernias are the most common complication after abdominal operation. Randomized trials have shown efficacy of prophylactic synthetic mesh and small bites. Adoption of these practices has been limited due to concerns with placement of synthetic mesh in contaminated cases and small bites in an overweight population. We sought to assess the efficacy of prophylactic biologic mesh and small bites to prevent postoperative major complications: ventral incisional hernias, surgical site infection, reoperation, and death.

STUDY DESIGN

High-risk patients (overweight/obese, current smoker) undergoing abdominal operation with a midline incision (5 cm or greater) were randomized (2 × 2 factorial trial) to receive either sublay biologic mesh or no mesh and either small bites (0.5 × 0. 5cm) or large bites (1 × 1 cm) fascial closure. The primary outcome measure was major complications at 1 year postoperative. CONSORT guidelines were followed, and this study was registered on clinicaltrials.gov (NCT03148496). Assuming α = 0.05, β = 0.20, and Δ = 20%, it was estimated that 105 patients were needed. Primary outcome was assessed using Fisher's exact test.

RESULTS

A total of 107 patients were randomized: 52 (49%) to mesh, 55 (51%) to no mesh, 55 (51%) to small bites, and 52 (49%) to large bites. Of the patients, 16% were smokers, 31% were overweight, and 55% were obese. At 1 year postoperative, there were no differences in major complications between groups (mesh vs no mesh 21% vs 16%, p = 0.62; small vs large bites 18% vs 19%, p = 1.00).

CONCLUSIONS

In this trial, biologic mesh and small bites appear to have no benefit. Further randomized trials are needed among high-risk patients before widespread adoption of prophylactic biologic mesh or small bites.

Does onlay mesh placement in emergency laparotomy prevent incisional hernia? A prospective randomized double-blind study

PURPOSE

The objective of this study is to assess the effectiveness and safety of onlay mesh closure of emergency midline laparotomy to prevent incisional hernia.

METHODS

This is a prospective randomized double-blind study and was carried out in the General Surgery Clinic, Konya City Hospital, from August 1, 2020 to August, 1, 2021. The study included 108 patients who were randomly grouped in 2 groups: patients with conventional abdominal closure and closure using additional onlay mesh (1:1). The follow-up period was for a year. The primary outcome was the incidence of incisional hernia and secondary outcomes were clinical data like complications, hospital length of stay, re-operations.

RESULTS

It was observed that incisional hernia was present in 14 patients (27.4%) in conventional abdominal closure group and was in 2 patients using mesh (4%), (p = 0.001). Clavien-Dindo 3B complications were in rise in conventional closure group (p = 0.02). Of all complications, burst abdomen was significantly more common in conventional closure group (p = 0.04). The rate of surgically treated complications were higher in conventional closure group (p = 0.02). Clavien-Dindo 3A complications were more common in patients with contaminated wound in mesh group (p = 0.02).

CONCLUSION

The use of mesh while closing the abdomen in emergency midline laparotomy reduces the risk of incisional hernia. Thus, to lower the risks of incisional hernia and its complications, prophylactic mesh can be used in high-risk patients.

Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies

BACKGROUND

Incisional hernia is a frequent complication of abdominal wall incision. Surgical technique is an important risk factor for the development of incisional hernia. The aim of these updated guidelines was to provide recommendations to decrease the incidence of incisional hernia.

METHODS

A systematic literature search of MEDLINE, Embase, and Cochrane CENTRAL was performed on 22 January 2022. The Scottish Intercollegiate Guidelines Network instrument was used to evaluate systematic reviews and meta-analyses, RCTs, and cohort studies. The GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation) was used to appraise the certainty of the evidence. The guidelines group consisted of surgical specialists, a biomedical information specialist, certified guideline methodologist, and patient representative.

RESULTS

Thirty-nine papers were included covering seven key questions, and weak recommendations were made for all of these. Laparoscopic surgery and non-midline incisions are suggested to be preferred when safe and feasible. In laparoscopic surgery, suturing the fascial defect of trocar sites of 10 mm and larger is advised, especially after single-incision laparoscopic surgery and at the umbilicus. For closure of an elective midline laparotomy, a continuous small-bites suturing technique with a slowly absorbable suture is suggested. Prophylactic mesh augmentation after elective midline laparotomy can be considered to reduce the risk of incisional hernia; a permanent synthetic mesh in either the onlay or retromuscular position is advised.

CONCLUSION

These updated guidelines may help surgeons in selecting the optimal approach and location of abdominal wall incisions.

Umbilical hernia: could it be the 'canary in the coal mine' for a more significant abdominal wall problem?

BACKGROUND

A considerable proportion of incisional hernias presenting to this unit evolve following simple umbilical hernia repair. Our aim was to review our series of complex ventral hernia repairs and identify the frequency of this problem. Our secondary aim was to encourage surgeons to evaluate whether any of the factors that increase the risk of recurrent hernia may be present, prior to undertaking an umbilical hernia repair.

METHODS

Observational retrospective review of a prospectively maintained single-surgeon database of consecutive patients undergoing surgery for recurrent ventral hernia. Patients presenting with recurrence at the site of a previous umbilical hernia repair were identified and their demographic data collected and analysed. A review of the published literature was performed. Patient and surgeon factors contributing to recurrence were identified and discussed.

RESULTS

Of 386 patients undergoing surgery for a recurrent ventral hernial, 102 (26.4%) were initially managed as 'simple' umbilical hernias repaired with a mesh patch or primary suture repair. 71 (69.6%) patients had undergone one or more subsequent hernia repairs prior to referral to our unit with 16 (15.6%) having had three or more repairs prior to referral.

CONCLUSION

Recurrence rates after umbilical hernia repair are likely to be much higher than surgeons and patients appreciate. There are many aspects to consider in the repair of a 'simple' umbilical hernia and we seek promote a discussion amongst surgeons that umbilical hernias be assessed as a major abdominal wall condition and not relegated to minor surgery status.