The impact of incisional hernia on mortality after colonic cancer resection

Retrospective study of an incisional hernia after laparoscopic colectomy for colorectal cancer

PURPOSE

This study aimed to examine the incidence of incisional hernia (IH) in elective laparoscopic colorectal surgery (LC) using regulated computed tomography (CT) images at intervals every 6 months.

METHODS

We retrospectively examined the diagnosis of IH in patients who underwent LC for colorectal cancer at Kansai Medical University Hospital from January 2014 to August 2018. The diagnosis of IH was defined as loss of continuity of the fascia in the axial CT images.

RESULTS

470 patients were included in the analysis. IH was diagnosed in 47 cases at 1 year after LC. The IH size was 7.8 cm2 [1.3-55.6]. In total, 38 patients with IH underwent CT examination 6 months after LC, and 37 were already diagnosed with IH. The IH size was 4.1 cm2 [0-58.9]. The IH size increased in 17 cases between 6 months and 1 year postoperatively, and in 1 case, a new IH occurred. 47%(18/38) of them continued to grow until 1 year after LC. A multivariate analysis was performed on the risk of IH occurrence. SSI was most significantly associated with IH occurrence (OR:5.28 [2.14-13.05], p = 0.0003).

CONCLUSION

IH occurred in 10% and 7.9% at 1 year and 6 months after LC. By examining CT images taken for the postoperative surveillance of colorectal cancer, we were able to investigate the occurrence of IH in detail.

Less postoperative pain and shorter length of stay after robot-assisted retrorectus hernia repair (rRetrorectus) compared with laparoscopic intraperitoneal onlay mesh repair (IPOM) for small or medium-sized ventral hernias

BACKGROUND

The optimal repair of ventral hernia remains unknown. We aimed to evaluate the results after robotic-assisted laparoscopic transabdominal repair with retrorectus mesh placement (rRetrorectus) compared with laparoscopic intraperitoneal onlay mesh repair (IPOM) for patients with small- or medium-sized ventral hernia.

METHODS

This was a retrospective cohort study of consecutive patients undergoing elective rRetrorectus or IPOM repair for small or medium-sized primary ventral or incisional hernias. The primary outcome was the postoperative need for transverse abdominis plane (TAP) block or epidural analgesia, secondary outcomes were length of stay and postoperative complications. All patients were followed for 30 days postoperatively.

RESULTS

A total of 59 patients were included undergoing rRetrorectus (n = 27) and IPOM (n = 32). Patients in the two groups were comparable in terms of age, sex, comorbidities, smoking status, body mass index (BMI), and type of hernia. The median fascial defect area was slightly larger in the rRetrorectus group (9 cm² vs. 6.2 cm², P = 0.031). The duration of surgery was longer for rRetrorectus (median 117.2 min. vs. 84.4, P = 0.003), whereas the postoperative need for TAP block or epidural analgesia was less after rRetrorectus compared with IPOM (3.7% versus 43.7%, P = 0.002). There were no severe complications or reoperations after either procedure. The length of stay was shorter after rRetrorectus (median 0 vs. 1 day, P < 0.001).

CONCLUSIONS

rRetrorectus was associated with reduced postoperative analgesic requirement and shorter length of stay compared with laparoscopic IPOM. Registration Clinicaltrial.gov: NCT05320055.

Is There Indication for the Use of Biological Mesh in Cancer Patients?

Up to 28% of all patients who undergo open surgery will develop a ventral hernia (VH) in the post-operative period. VH surgery is a debated topic in the literature, especially in oncological patients due to complex management. We searched in the surgical database of the Hepatobiliary Unit of the National Cancer Institute of Naples “G. Pascale Foundation” for all patients who underwent abdominal surgery for malignancy from January 2010 to December 2018. Our surgical approach and our choice of mesh for VH repair was planned case-by-case. We selected 57 patients that fulfilled our inclusion criteria, and we divided them into two groups: biological versus synthetic prosthesis. Anterior component separation was used in 31 patients (54.4%) vs. bridging procedure in 26 (45.6%). In 41 cases (71.9%), we used a biological mesh while a synthetic one was adopted in the remaining patients. Of our patients, 57% were male (33 male vs. 24 female) with a median age of 65 and a mean BMI of 30.8. We collected ventral hernia defects from 35 cm² to 600 cm² (mean 205.2 cm²); 30-day complications were present in 24 patients (42.1%), no 30-day mortality was reported, and 21 patients had a recurrence of pathology during study follow-up. This study confirms VH recurrence risk is not related with the type of mesh but is strongly related with BMI and type of surgery also in oncological patients.

Operative management of non-elective incisional hernia reduces readmission in a national database

PURPOSE

The aim of this project was to compare patient characteristics, overall efficacy, and readmission events following operative vs non-operative management modalities of non-elective patients presenting with symptomatic incisional hernias.

METHODS

This study is a retrospective study of patients and patient demographics that presented as non-elective hospitalizations with symptomatic incisional hernia. Analysis of patients and characteristics utilized the National Readmission Database from 2010 to Q3 of 2015, delineating patient factors and outcomes following operative or non-operative management of hernias.

RESULTS

A total of 14,137 patients met inclusion criteria for our study. The majority of patients were treated operatively rather than non-operatively (79 vs. 21%) on their non-elective admission for incisional hernia. Those undergoing surgical management were younger (56 vs 61 years, p < 0.01), we more often of male gender (69 vs 64%, p < 0.01), and had fewer comorbidities (1.92 vs 2.97, p < 0.01) and chronic conditions (0.45 vs 2.68, p < 0.01). Patients managed operatively had a significantly lower readmission rate when compared to patients managed non-operatively (6.6 vs 14.3%, p < 0.01). However, non-operative management was associated with a shorter length of stay (3 vs 4 days, p < 0.01). Of patients who were initially medically managed and had to be readmitted, a further 61% underwent surgical treatment on their readmission.

CONCLUSION

In this nationwide study, patients with non-elective admissions for incisional hernia were mostly managed surgically. Those managed operatively had lower rates of readmission when compared to non-operative management. Initial non-operative management was associated with a shorter length of stay and a lower cost to the patient. The results of this study support operative management of symptomatic incisional hernia.

The European Hernia Society Prehabilitation Project: a systematic review of patient prehabilitation prior to ventral hernia surgery

BACKGROUND

Ventral hernia repair is one of the most commonly performed surgical procedures worldwide. To reduce the risk of complications, patient prehabilitation has received increasing focus in recent years. To assess prehabilitation measures, this European Hernia Society endorsed project was launched. The aim of this systematic review was to evaluate the current literature on patient prehabilitation prior to ventral hernia repair.

METHODS

The strategies examined were optimization of renal disease, obesity, nutrition, physical exercise, COPD, diabetes and smoking cessation. For each topic, a separate literature search was conducted, allowing for seven different sub-reviews.

RESULTS

A limited amount of well-conducted research studies evaluating prehabilitation prior to ventral hernia surgery was found. The primary findings showed that smoking cessation and weight loss for obese patients led to reduced risks of complications after abdominal wall reconstruction.

CONCLUSION

Prehabilitation prior to ventral hernia repair may be widely used; however, the literature supporting its use is limited. Future studies evaluating the impact of prehabilitation before ventral hernia surgery are warranted.

Early peritoneal metastasis after laparoscopic incisional hernia repair secondary to colon cancer resection: A case report

INTRODUCTION

and importance: We report a case of a patient who developed early peritoneal metastasis after laparoscopic incisional hernia repair secondary to curative colon cancer resection.

CASE PRESENTATION

A 77-year-old woman underwent ileocecal resection with open laparotomy for locally advanced cecal cancer. The pathological diagnosis was adenocarcinoma with T3N2aM0. Three months after the surgery, she developed incisional hernia at the midline incision site. After the completion of adjuvant chemotherapy, surveillance computed tomography (CT) showed no cancer recurrence. Her abdominal discomfort persisted because of incisional hernia, and thus we performed laparoscopic incisional hernia repair using the intraperitoneal onlay mesh technique at 11 months after the initial surgery.Five months after incisional hernia repair, CT showed multiple liver and peritoneal metastases. She was started on systemic chemotherapy. Two days after the first therapeutic infusion, she developed small bowel obstruction. We decided to perform palliative surgery with intestinal bypass. Exploratory laparoscopy revealed that the implanted mesh for incisional hernia repair was completely covered with multiple nodules of peritoneal metastasis. Two months after the bypass surgery, she resumed her chemotherapy, but CT showed significant progression of all recurrent lesions. She did not wish to continue further chemotherapy and decided to receive the best supportive care.

CLINICAL DISCUSSION

This case may raise important clinical questions regarding the indication and timing of incisional hernia repair for patients who are at high risk of cancer recurrence.

CONCLUSION

Incisional hernia repair must be performed in the absence of any possibility of cancer recurrence, particularly in the earlier follow-up period.

Abdominal wound dehiscence is dangerous: a nationwide study of 14,169 patients undergoing elective open resection for colonic cancer

PURPOSE

The potential impact of abdominal wound dehiscence on long-term survival after elective abdominal surgery is largely unknown. The aim of this study was to examine the impact of abdominal wound dehiscence on survival and incisional hernia repair after elective, open colonic cancer resection.

METHODS

This was a nationwide cohort study based on merged data from Danish national registries, comprising patients subjected to elective, open resection for colonic cancer between May 1, 2001 and January 1, 2016. Multivariable Cox Regression analysis and propensity score matching was applied to adjust for confounding. The associations of abdominal wound dehiscence with 90-day mortality and subsequent incisional hernia repair were also examined.

RESULTS

A total of 14,169 patients were included in the cohort, of which 549 (3.9%) developed abdominal wound dehiscence. The 5-year survival was significantly decreased in patients with abdominal wound dehiscence (42.4%, 95% CI 38.1-46.7 vs. 53.4%, 52.6-54.3, P < 0.001), which was confirmed in the multivariable analysis (HR 1.22, CI 1.06-1.39, P = 0.004). Abdominal wound dehiscence was significantly associated with increased risk of 90-day mortality (OR 1.60, CI 1.12-2.27, P = 0.009) as well as subsequent incisional hernia repair (HR 1.80, CI 1.07-3.01, P = 0.026).

CONCLUSIONS

Abdominal wound dehiscence was significantly associated with decreased survival. Fascial closure after open colonic cancer resection should be given high priority to improve the long-term survival.

Increased risk of postoperative complications with retromuscular mesh placement in emergency incisional hernia repair: A nationwide register-based cohort study

INTRODUCTION

Incisional hernia is common after abdominal surgery. Watchful waiting carries the risk of incarceration and a need for emergency intervention. The aim of this study was to examine the risk of postoperative complications after emergency versus elective incisional hernia repair.

METHODS

Patients above 18 years of age undergoing open incisional hernia repair in Denmark in 2017-2018 were identified in the Danish Ventral Hernia Database. Patients were grouped according to elective or emergency hernia repair. The primary outcome was postoperative complications requiring operative intervention within 90 days, and the secondary outcome was postoperative length of stay.

RESULTS

We included 1050 patients, of whom 882 were admitted for elective and 168 for emergency operation. Patients undergoing emergency repair were older (64.7 years vs 59.2 years, p < 0.001), more often smokers (25.8% vs 13.6%, p = 0.003), and more often had a Charlson comorbidity score ⩾2 (26.8% vs 19.2%, p = 0.005) compared to patients undergoing elective repair. In a multivariate regression analysis, emergency compared to elective operation (OR = 2.71, 95% CI = 1.4-5.25, p = 0.003) and retromuscular compared to onlay mesh placement (OR = 2.14, 95% CI = 1.08-4.24, p = 0.013) were factors significantly associated with increased risk of postoperative complications. In a subgroup analysis including only emergency repairs, risk of complications after retromuscular mesh placement was even higher (OR = 10.12, 95% CI = 1.81-56.68, p = 0.008).

CONCLUSION

Emergency incisional hernia repair was associated with increased risk of postoperative complications and this risk was accentuated with retromuscular mesh placement. The use of retromuscular mesh in the emergency setting should be avoided, and the abdominal wall could either be closed by sutures or additional onlay mesh.

Functional outcomes in symptomatic versus asymptomatic patients undergoing incisional hernia repair: Replacing one problem with another? A prospective cohort study in 1312 patients

BACKGROUND

Incisional hernias can be associated with pain or discomfort. Surgical repair especially mesh reinforcement, may likewise induce pain. The primary objective was to assess the incidence of pain after hernia repair in patients with and without pre-operative pain or discomfort. The secondary objectives were to determine the preferred mesh type, mesh location and surgical technique in minimizing postoperative pain or discomfort.

MATERIALS AND METHODS

A registry-based prospective cohort study was performed, including patients undergoing incisional hernia repair between September 2011 and May 2019. Patients with a minimum follow-up of 3-6 months were included. The incidence of hernia related pain and discomfort was recorded perioperatively.

RESULTS

A total of 1312 patients were included. Pre-operatively, 1091 (83%) patients reported pain or discomfort. After hernia repair, 961 (73%) patients did not report pain or discomfort (mean follow-up = 11.1 months). Of the pre-operative asymptomatic patients (n = 221), 44 (20%, moderate or severe pain: n = 14, 32%) reported pain or discomfort after mean follow-up of 10.5 months. Of those patients initially reporting pain or discomfort (n = 1091), 307 (28%, moderate or severe pain: n = 80, 26%) still reported pain or discomfort after a mean follow-up of 11.3 months postoperatively.

CONCLUSION

In symptomatic incisional hernia patients, hernia related complaints may be resolved in the majority of cases undergoing surgical repair. In asymptomatic incisional hernia patients, pain or discomfort may be induced in a considerable number of patients due to surgical repair and one should be aware if this postoperative complication.

National trends in ventral hernia repairs for patients with intra-abdominal metastases

BACKGROUND

Ventral hernias in patients with intra-abdominal metastases may not be addressed owing to other oncologic priorities, but they can affect quality of life and lead to sequelae necessitating an emergency operation. We compared the national trends and perioperative outcomes for elective and nonelective ventral hernia repairs for patients with intra-abdominal metastases.

METHODS

Patients were identified from the National Inpatient Sample (2003-2015). Temporal trends were described using average annual percent change. Perioperative outcomes between elective and nonelective ventral hernia repairs were compared using multivariable regressions.

RESULTS

An estimated 947,112 ventral hernia repairs were performed nationally, including 5,602 (0.6%) in patients with intra-abdominal metastases. Among patients with intra-abdominal metastases, 40.1% had a nonelective ventral hernia repair, mean (standard deviation) age was 64 (12) years, and 65.1% were women. Between 2003 and 2015, the total number of ventral hernia repairs performed nationally did not change (average annual percent change 0.062, P = .84). For patients with intra-abdominal metastases, although there was no change in the number of elective ventral hernia repairs (average annual percent change 0.65, P = .59), the number of nonelective ventral hernia repairs increased significantly (average annual percent change 2.7, P = .025). By multivariable analyses, patients with intra-abdominal metastases who underwent a nonelective repair were more likely to experience complications (odds ratio 1.76, P = .001), nonroutine discharge (odds ratio 1.93, P < .001), and mortality (odds ratio 2.27, P = .035). Nonelective ventral hernia repairs was also associated with a 38.5% (P < .001) longer hospital stay and 24.4% (P < .001) higher charges.

CONCLUSION

The number of nonelective ventral hernia repairs, which is associated with substantial perioperative morbidity, has increased significantly among patients with intra-abdominal metastases. Surgeons should consider a nonemergency operation for select patients to mitigate the burden of nonelective ventral hernia repairs.

Histology and Function of the Rectus Abdominis Muscle in Patients With Incisional Hernia

BACKGROUND

The aim of the current study was to examine different features of the rectus abdominis muscle (RA) in patients with and without a midline incisional hernia to characterize the effects of a hernia on abdominal wall skeletal muscle.

MATERIAL AND METHODS

RA tissue from patients undergoing surgical repair of a large midline incisional hernia (n = 18) was compared with that from an intact abdominal wall in patients undergoing colorectal resection for benign or low-grade malignant disease (n = 18). In addition, needle biopsies were obtained from the vastus lateralis muscle (VL) of all subjects. Outcome measures were muscle fiber type and size, preoperative truncal flexion strength and leg extension power measured in strength-measure equipment, and RA cross-sectional area measured by computed tomography.

RESULTS

In both the RA and VL, the fiber cross-sectional area was greater in the patients with a hernia. The RA cross-sectional area correlated significantly with the truncal flexion strength (r = 0.44, P = 0.015). Patients in the hernia group had a significantly reduced ratio between truncal flexion strength and RA cross-sectional area compared with the control group (41.3 ± 11.5 N/cm²versus 51.2 ± 16.3 N/cm², P = 0.034).

CONCLUSIONS

Anatomical displacement of the RA and lack of medial insertion in the linea alba rather than dysfunction secondary to alteration of muscle fiber structure may contribute to impairment of abdominal wall function in patients with midline incisional hernias. The study was registered at http://www.clinicaltrials.gov/(NCT02011048).

Incidence of Incisional Hernia Repair After Laparoscopic Compared to Open Resection of Colonic Cancer: A Nationwide Analysis of 17,717 Patients

BACKGROUND

It remains unknown whether laparoscopic compared to open surgery translates into fewer incisional hernia repairs (IHR). The objectives of the current study were to compare the long-term incidence of IHR and the size of repaired hernias between patients subjected to laparoscopic or open resection of colonic cancer.

METHODS

This was a nationwide cohort study comprised of patients undergoing resection for colonic cancer between January 2007 and March 2016 according to the Danish Colorectal Cancer Group database. Patients who subsequently underwent IHR were identified in the Danish Ventral Hernia Database, from which information about the priority of the hernia repair and the size of the fascial defect was retrieved.

RESULTS

The study included 17,717 patients, of whom 482 (2.7%) underwent subsequent IHR during a median follow-up of 4.7 (interquartile range 2.8-6.9) years. There was no significant difference in the 5-year cumulative incidence of hernia repair after laparoscopic compared to open colonic resection (3.9%, CI 3.3-4.4% vs 4.1%, CI 3.5-4.6%). After adjustment for confounders, laparoscopic approach was associated with an increased rate of emergency IHR (HR 2.37, 95% CI 1.03-5.46, P = 0.042) as opposed to elective IHR (HR 0.91, 95% CI 0.73-1.14, P = 0.442). Laparoscopic surgery was significantly associated with a decreased fascial defect area compared to open surgery (mean difference -16.0 cm², 95% CI -29.4 to -2.5, P = 0.020).

CONCLUSIONS

There was no difference in the incidence of IHR after open compared to laparoscopic resection. Compared to the open approach, laparoscopic resection increased the rate of subsequent emergency IHR, suggesting that a more aggressive therapeutic approach may be warranted in this patient group upon diagnosis of an incisional hernia.

Risk Factors for Incarceration in Patients with Primary Abdominal Wall and Incisional Hernias: A Prospective Study in 4472 Patients

BACKGROUND

Incarceration of primary and incisional hernias often results in emergency surgery. The objective of this study was to evaluate the relation of defect size and location with incarceration. Secondary objectives comprised identification of additional patient factors associated with an incarcerated hernia.

METHODS

A registry-based prospective study was performed of all consecutive patients undergoing hernia surgery between September 2011 and February 2016. Multivariate logistic regression was performed to identify risk factors for incarceration.

RESULTS

In total, 83 (3.5%) of 2352 primary hernias and 79 (3.7%) of 2120 incisional hernias had a non-reducible incarceration. For primary hernias, a defect width of 3-4 cm compared to defects of 0-1 cm was significantly associated with an incarcerated hernia (OR 2.85, 95% CI 1.57-5.18, p = 0.0006). For incisional hernias, a defect width of 3-4 cm compared to defects of 0-2 cm was significantly associated with an incarceration (OR 2.14, 95% CI 1.07-4.31, p = 0.0324). For primary hernias, defects in the peri- and infra-umbilical region portrayed a significantly increased odds for incarceration as compared to supra-umbilical defects (OR 1.98, 95% CI 1.02-3.85, p = 0.043). Additionally, in primary hernias age, BMI, and constipation were associated with incarceration. In incisional hernias age, BMI, female sex, diabetes mellitus and ASA classification were associated with incarceration.

CONCLUSION

For primary and incisional hernias, mainly defects of 3-4 cm were associated with incarceration. For primary hernias, mainly defects located in the peri- and infra-umbilical region were associated with incarceration. Based on patient and hernia characteristics, patients with increased odds for incarceration may be selected and these patients may benefit from elective surgical treatment.

Hernia and Cancer: The Points Where the Roads Intersect

Introduction: This review aimed to present common points, intersections, and potential interactions or mutual effects for hernia and cancer. Besides direct relationships, indirect connections, and possible involvements were searched. Materials and Methods: A literature search of PubMed database was performed in July 2018 as well as a search of relevant journals and reference lists. The total number of screened articles was 1,422. Some articles were found in multiple different searches. A last PubMed search was performed during manuscript writing in December 2018 to update the knowledge. Eventually 427 articles with full text were evaluated, and 264 included, in this review. Results: There is no real evidence for a possible common etiology for abdominal wall hernias and any cancer type. The two different diseases had been found to have some common points in the studies on genes, integrins, and biomarkers, however, to date no meaningful relationship has been identified between these points. There is also some, albeit rather conflicting, evidence for inguinal hernia being a possible risk factor for testicular cancer. Neoadjuvant or adjuvant therapeutic modalities like chemotherapy and radiotherapy may cause postoperative herniation with their adverse effects on tissue repair. Certain specific substances like bevacizumab may cause more serious complications and interfere with hernia repair. There are only two articles in PubMed directly related to the topic of "hernia and cancer." In one of these the authors claimed that there was no association between cancer development and hernia repair with mesh. The other article reported two cases of squamous-cell carcinoma developed secondary to longstanding mesh infections. Conclusion: As expected, the relationship between abdominal wall hernias and cancer is weak. Hernia repair with mesh does not cause cancer, there is only one case report on cancer development following a longstanding prosthetic material infections. However, there are some intersection points between these two disease groups which are worthy of research in the future.