The use of mesh in acute hernia: frequency and outcome in 99 cases

The safety of polypropylene mesh in repairing incarcerated or strangulated hernias with organ resection

BACKGROUND

Organ resection is often required in incarcerated or strangulated hernias, which makes the surgical field more contaminated, and increased contamination makes it possible to elevate the risk of surgical site infections and increase the likelihood of hernia recurrence. The safety of polypropylene mesh for repair in such contaminated conditions is equivocal, leading to controversy concerning its application. This study aims to elucidate this matter by comparing the complications between mesh repair and primary repair specifically in strangulated or incarcerated hernias with organ resection. At the same time, the study contributed to assessing the safety of polypropylene mesh in repairing hernias under conditions where infection is a significant concern.

METHODS

This meta-analysis was reported following PRISMA 2020 guidelines, all studies were searched and retrieved from major databases (PubMed, and Web of Science), and were included if they reported complications between mesh repair and primary repair in incarcerated or strangulated ventral or groin hernias with or without organ resection. Meta-analyses were conducted when possible, and subgroup analyses were made for the severity of complications (major vs minor) and hernia type (ventral vs. groin). According to the study design, the risk of bias was assessed using the Newcastle-Ottawa Scale. All related articles and reference lists in these original studies were also obtained from the above databases.

RESULTS

Nine observational studies containing 1287 patients with incarcerated or strangulated hernias were included. Three findings were found: (1) Overall complications in the mesh repair group were more than those in the primary repair group in incarcerated or strangulated hernias with organ resection (OR = 4.93; 95% CI: 2.54, 9.56; P < 0.00001). (2) There was a slight tendency for more complications to occur in the organ resection group than in the non-resection group with mesh repair, although the difference was subtle (OR = 3.36; 95% CI: 0.86, 13.15; P = 0.08). (3) There was a trend that more complications occurred when mesh was used in emergent ventral hernia repair than in primary repair (OR = 3.33; 95% CI: 0.91, 12.26; P = 0.07), while, this trend was not observed in emergent groin hernia repair.

CONCLUSION

In cases of incarcerated or strangulated hernias requiring organ resection, the use of polypropylene mesh has been correlated with a higher incidence of complications compared to primary repair. Additionally, a trend was observed toward greater complication rates when ventral hernia repair was performed. Therefore, polypropylene mesh should be used cautiously in strangulated hernias with organ resection or in the repair of the ventral hernia.

Mapping the therapeutic landscape in emergency incisional hernia: a scoping review

PURPOSE

Incisional hernias (IH) represent common complications following abdominal surgeries, with emergency repair associated with increased morbidity and mortality. This scoping review aimed to map the existing literature on emergency incisional hernia repair, identify research gaps, and inform future guideline development.

METHODS

A comprehensive literature search was conducted in PubMed MEDLINE and SCOPUS for studies published between January 2000 and August 2024. Articles addressing any aspect of emergency incisional hernia repair in adults were included. Data extraction focused on study characteristics, patient demographics, surgical approaches, and outcomes.

RESULTS

Of 801 unique articles identified, 73 met the inclusion criteria. Most were cohort studies (73.97%), with only one randomized trial. The primary areas of interest were repair methods (47.95%), operative outcomes (31.51%), risk assessment (16.44%), and diagnosis (5.48%). Pooled analysis revealed a predominantly female (63%), elderly (mean age 62.3 years), and comorbid patient population. The most frequent study endpoints were readmission (18%), surgical site infection (12%), reoperation (8%), and mortality (4%). Significant heterogeneity was observed in defect characterization and surgical techniques.

CONCLUSION

This review highlights a paucity of randomized studies guiding emergency incisional hernia management. Key issues identified include inconsistent definitions of emergency presentation, limited data on hernia characteristics, and a lack of standardized outcome reporting. Future research should focus on developing a unified classification system for emergency incisional hernias, evaluating the role of imaging in decision-making, and conducting comparative studies on various treatment strategies across different clinical scenarios.

Characteristics of abdominal herniation and its associations among patients operated in a Sudanese tertiary hospital: a retrospective review

BACKGROUND & AIMS

Hernia is a very common surgical condition affecting all ages and both sexes. Data regarding abdominal wall hernias is essential to hernia management in an institution. With the absence of data regarding the prevalence, characteristics, and associations of abdominal wall hernias in Sudanese patients, we aimed to describe and find the possible differences in the spectrum of abdominal hernias, their rates, and associated predisposing factors.

METHODOLOGY

This was a retrospective cross-sectional chart review of surgical patients admitted at a Sudanese tertiary teaching Hospital, Department of Surgery, from January 2019-December 2021. Data were collected from the medical records using a checklist. The data obtained included age, gender, occupation, chronic medical conditions, past medical history (PMH), and year of admission. Data were analyzed using SPSS 22.

RESULTS

Results showed that between January 2019 and December 2021, a total of 1158 patients were admitted to the department of surgery, and abdominal hernia had a frequency of 16.23% (n = 188). There was a male predominance (55.3%), ages below 20 years constituted the majority of cases (45.2%), and those between (50-60 years) were the least. The most frequent subtype was the inguinal hernia. The association between sociodemographic variables, PMH, chronic medical conditions, and the diagnosis was found to be statistically significant. The rate of recurrence was found to be 10.1%.

CONCLUSION

There was a high rate of abdominal Herniation, and a difference between subtypes of abdominal herniation regarding demographic data, past medical history, and comorbidities.

Chevrel's procedure for midline incisional hernia repair-not to be abandoned or forgotten

The Chevrel technique is a well-established procedure for open repair of midline incisional hernia. This retrospective single-center case series aims to present the outcome of patients with midline incisional hernia treated with a modified Chevrel technique. The modification itself comprehended the use of a single-layer continuous suture for the inverted anterior rectus abdominis muscle sheet for the creation of the "new linea alba" without overlapping. Between January 2017 and December 2023, 40 patients were operated. The overall postoperative morbidity rate was 65%. Hernia recurrence occurred in three patients (7.5%). When the basic principles of the Chevrel technique are respected and conducted, this leads to satisfactory results. The postoperative outcome of this case series showed rates of complications and recurrences in concordance with the already published literature. Therefore, this technique should always be considered for the open approach for midline incisional hernia repair.

Incisional hernia after major pancreatic resection: long term risk assessment from two distinct sources - A large multi-institutional network and a single high-volume center

BACKGROUND

Post-operative incisional hernia (IH) is a common complication following abdominal surgery. Data regarding IH after major pancreatic surgery are limited. We aim to evaluate the long-term risk of IH following major pancreatic resection.

METHODS

A dual-approach study: a large multi-institutional research network (RN) was investigated for IH incidence and risk factors in propensity-score matched survivors after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP), was complemented by a patient-reported questionnaire.

RESULTS

RN analysis identified 22,113 patients that underwent pancreatic surgery. 11.0% of PD patients and 8.6% of DP patients developed IH (P < 0.0001). IH rates were higher with open surgery compared with minimally invasive approaches in PD (OR = 1.56, P = 0.03) and DP (OR = 1.94, P = 0.003). BMI>35 was found to correlate with increased IH rates for PD and DP (OR = 1.87, and OR = 1.86, respectively, P < 0.0001 each), as did postoperative intraabdominal infections (P < 0.0001). Patient-based survey of 104 patients, revealed that 16 patients (15%) reported post-operative IH during the follow-up period. BMI≥30, SSI and intra-abdominal abscesses were associated with increased IH risk (P < 0.05).

CONCLUSION

Improved survival after pancreatic resection has led to an increased prevalence of long-term surgical sequela. In this study, we demonstrate significant rates of IH among long-term survivors and assess potential risk factors.

Complicated Spigelian hernia presenting with sigmoid colon strangulation: A unique clinical report

INTRODUCTION AND IMPORTANCE

Spigelian hernias are rare, constituting about 1-2 % of all abdominal wall hernias. They present clinically significant challenges due to their potential for incarceration and strangulation. This case report highlights a unique presentation of a Spigelian hernia involving sigmoid colon strangulation, emphasizing the critical need for awareness and timely intervention.

CASE PRESENTATION

A 60-year-old female with hypertension and diabetes presented with severe left abdominal pain, nausea, and vomiting. Examination revealed leukocytosis, neutrophilia, and signs of acute abdomen. CT imaging showed a complicated left lateral abdominal wall hernia containing the sigmoid colon. Surgical intervention included sigmoidectomy with colorectal anastomosis and hernia repair. Postoperative recovery was successful with subsequent elective ileostomy reversal.

CLINICAL DISCUSSION

The rarity of Spigelian hernias and their atypical presentations can complicate diagnosis and management. This case was particularly challenging due to the strangulation of the sigmoid colon within the hernial sac. Surgical management was necessary to address the incarcerated bowel segment and prevent further complications. This case underscores the utility of CT scans in diagnosing complex cases and guiding surgical strategy.

CONCLUSION

Despite their rarity, Spigelian hernias carry significant risks of strangulation. Prompt diagnosis and treatment are essential to avoid severe complications. This case highlights the importance of including Spigelian hernia in the differential diagnosis for acute abdominal symptoms, especially when they are nonspecific.

Primary Uncomplicated Ventral Hernia Repair: Guidelines and Practice Patterns for Routine Hernia Repairs

Surgical repair of primary umbilical and epigastric hernias are among the most common abdominal operations in the world. The hernia defects range from small (<1 cm) to large and complex even in the absence of prior incision or repair. Mesh has generally been shown to decrease recurrence rates, and its use and location of placement should be individualized for each patient. Open, laparoscopic, and robotic approaches provide unique considerations for the technical aspects of primary repair with or without mesh augmentation.

Effect of N-acetyl-L-cysteine on inflammation after intraperitoneal mesh placement in a potentially contaminated environment: An experimental study in the rat

BACKGROUND

The use of prosthetic meshes in abdominal wall reconstruction is a well-established approach; however, in certain cases where a bowel resection coexists its application is disputed. Any underlying inflammatory process may augment adhesion formation which is a major postoperative complication. In this animal study, our aim was to investigate the effect of N-acetyl-l-cysteine (NAC) on adhesion formation and the expression of inflammatory markers when a mesh was used in a clean or a potentially contaminated environment.

METHODS

Sixty male Wistar rats were randomly and equally allocated in 3 groups: A, B and C. Animals in all groups underwent laparotomy, a prosthetic mesh was placed and chemoprophylaxis with ciprofloxacin was administered. In groups B and C an enterectomy was also performed. NAC was injected intraperitoneally in group C. Adhesion formation, IL-1a, IL-6, TNF-a and histological data including fibrosis, neutrophils' infiltration and neovascularization were assessed. Mesh samples were sent for cultivation.

RESULTS

Adhesion formation was significantly less and inflammation markers were also lower in group C compared to group B (p<0.05). Histological findings were significant for greater fibrosis, neutrophils' infiltration and neovascularization in group B compared to both group A and C. Regarding mesh cultures, more specimens were tested positive in group B (p <0.05). Outcomes between group A and C did not differ.

CONCLUSION

NAC effectively ameliorated adhesion formation and inflammation in a potentially septic environment where a prosthetic mesh was placed.

An Evaluation of the Evidence Guiding Adult Midline Ventral Hernia Repair

Purpose:  Several guidelines have been published in recent years to guide the clinician in ventral hernia repair. This review distils this advice, critically assesses their evidence base, and proposes avenues for future study. Methods:  A PUBMED search identified four guidelines addressing midline ventral hernia repair published by major surgical societies between 2016 and 2020. The studies used to inform the advice have been critically appraised, including 20 systematic reviews/meta-analyses, 10 randomized controlled trials, 32 cohort studies, and 14 case series. Results:  Despite a lack of randomized controlled trials, case heterogeneity, and variation in outcome reporting, key themes have emerged. Preoperative computed tomography scan assesses defect size, loss of domain, and the likely need for component separation. Prehabilitation, frailty assessment, and risk stratification are beneficial in complex cases. Minimally invasive component separation techniques, Botox injection, and progressive pneumoperitoneum represent novel techniques to promote closure of large fascial defects. Rives-Stoppa sublay mesh repair has become the "gold" standard for open and minimally invasive repairs. Laparoscopic repair promotes early return to functional status. The enhanced-view totally extraperitoneal approach facilitates laparoscopic sublay mesh placement, avoiding mesh contact with viscera. Robotic techniques continue to evolve, although the evidence at present remains immature. Synthetic mesh is recommended for use in clean and clean-contaminated cases. However, optimism regarding the use of biologic and biosynthetic meshes in the contaminated setting has waned. Conclusions:  Surgical techniques in ventral hernia repair have advanced in recent years. High-quality data has struggled to keep pace; rigorous clinical trials are required to support the surgical innovation.

Outcomes of Emergency Abdominal Wall Hernia Repair: Experience Over a Decade

Background Abdominal wall hernias are a common surgical entity encountered by the general surgeon. Approximately 10% of abdominal wall hernia patients require emergency surgery. However, these surgeries are associated with a high rate of postoperative morbidity and mortality. This study aimed to analyze the morbidity and mortality in patients undergoing emergency abdominal wall hernia repair and to determine the factors associated with surgical site infection (SSI) and recurrence in these patients attending a tertiary care hospital in south India. Methodology Our study was a single-centered, 10-year retrospective and a one-year prospective study conducted in a tertiary care center in India. All patients who underwent emergency abdominal wall hernia repair between April 2009 and May 2020 were included. Patients' demographic details, comorbidities, intraoperative findings, 30-day surgical outcomes including SSI, and recurrence were studied. Results Out of 383 patients in our study, 63.9% had an inguinal hernia, and 54% of the patients underwent tissue repair. SSI was the most common morbidity (21.9%). Postoperative sepsis was the only independent factor associated with perioperative mortality according to the logistic regression analysis (odds ratio = 22.73, p = 0.022). Conclusions Tissue repair for emergency hernia surgery has better outcomes than mesh repair in clean-contaminated cases.

Laparoscopic approach as a safe and effective option for incarcerated femoral hernias

INTRODUCTION

The laparoscopic approach for elective femoral herniorrhaphy is well established. However, femoral hernias often present as incarcerations and require emergency repair surgery, mainly using the open approach. This study aimed to retrospectively analyze the efficacy of the laparoscopic approach for incarcerated femoral hernias.

METHODS

Data of patients who underwent emergency surgery for incarcerated femoral hernia between April 2016 and August 2021 were retrospectively analyzed. Laparoscopy was performed whenever possible; however, conversion to an open approach remained a fallback option for when laparoscopic repair was not possible. In laparoscopic repair, incarcerated femoral hernias reduced using traction, water pressure, and preperitoneal methods. Data of patients who underwent open repair and laparoscopy were then compared.

RESULTS

During the observation period, 20 patients underwent emergency surgery for incarcerated femoral hernia. Eleven patients subsequently underwent repair using a laparoscopic approach, and eight underwent repair using an open approach. Only one patient underwent intestinal resection without hernia repair due to perforated bowel. Operative time for laparoscopic repair was longer. Mesh repair was performed in 18 patients. Four patients each in the laparoscopic repair and open group required intestinal resection.

CONCLUSION

Incarcerated femoral hernias can be safely repaired using the laparoscopic approach.

Enhanced-view totally extraperitoneal repair in a patient with incisional hernia after robot-assisted laparoscopic radical prostatectomy: a case report

BACKGROUND

Although laparoscopic incisional hernia repair, especially laparoscopic intraperitoneal onlay mesh, is a widely used technique, it can cause serious complications, including mesh erosion, adhesive bowel obstruction, and chronic pain. The enhanced-view totally extraperitoneal (eTEP) technique has been reported to prevent such complications by placing the mesh in the retrorectus space. Here, we report the case of a patient with post-robot-assisted laparoscopic radical prostatectomy (RARP) incisional hernia repaired using the eTEP technique.

CASE PRESENTATION

A 67-year-old man, who underwent RARP for prostate cancer 4 years ago developed an incisional hernia. Abdominal computed tomography showed the presence of an epigastric incisional hernia measuring 4 cm long and 3.7 cm wide. We performed an eTEP repair. We closed the hernia defect using a 0 barbed suture and placed a self-gripping mesh measuring 20 cm long and 15 cm wide in the developed retrorectus space with no fixation. There were no postoperative complications, and the patient was discharged on postoperative day 2.

CONCLUSIONS

eTEP repair is considered an extremely effective surgical treatment option for incisional hernias because of its few resulting postoperative mesh-and-tacker-related complications.

Analysis of risk factors for surgical site infection and postoperative recurrence following inguinal and femoral hernia surgery in adults

OBJECTIVE

We aimed to evaluate the causes of complications following surgery for inguinal and femoral hernia, using surgical site infection (SSI) and recurrence rate as indicators of outcomes to consider appropriate treatments.

METHODS

We retrospectively assessed the medical histories of 1,098 patients with adult inguinal and femoral hernias who underwent herniorrhaphy between July 2010 and March 2019. Using SSI and recurrence rate as indicators of outcomes, we statistically assessed the influence of preoperative and operative conditions on surgical outcomes.

RESULTS

The occurrence of postoperative SSI was significantly more frequent in patients who experienced a long surgical duration, excessive blood loss, and incarceration; underwent emergency surgery and bowel resection; and in whom no mesh sheet insertion was performed. There was no correlation between mesh use and SSI in cases that did not require emergency incarceration repair. For cases involving hernia incarceration, the use of a mesh sheet was avoided to prevent potential infection, which could explain the high incidence of SSI in cases where mesh was not used. The hernia may have recurred due to technical issues during the procedure, as well as failure to ligate the hernia sac.

CONCLUSIONS

Selecting the appropriate surgical method for hernia repair may reduce the incidence of SSI. If manual reduction of inguinal hernias is not possible, an appropriate surgical procedure should be determined based on laparoscopic findings in facilities where laparoscopic hernia surgeries are frequently performed. Moreover, in cases without infection and bowel resection, mesh use may be beneficial. Recurrence can be prevented by ligating the hernia sac during surgery and solving relevant technical problems.

In vivo Analysis of the Resistance of the Meshes to Escherichia coli Infection

Background: The mesh infection is mostly related to the gram-negative bacteria, such as Escherichia coli (E. coli) for emergency surgery of incarcerated hernia. However, few study investigated the effects of E. coli concentration, mesh materials and antibiotic prophylaxis on mesh infection after hernioplasty. The aim of this study was to evaluate the bacterial resistance to E. coli for three different materials of mesh, and to measure the minimum E. coli concentration for mesh infection with and without antibiotic prophylaxis in a rat model.

Methods: Three types of mesh (polytetrafluoroethylene, polypropylene, and biologic meshes) were used in the repair of an acute ventral hernia rat model in the setting of different concentrations of E. coli loads and antibiotics. At the 8th day after surgery, mesh samples were sent for microbiologic and histologic analyses.

Results: The positive rates of bacterial culture increased with E. coli concentration. The biologic mesh showed better bacterial resistance compared to polytetrafluoroethylene mesh and polypropylene mesh when the concentration of E. coli ranges from 10⁶ CFU/ml to 10⁸ CFU/ml (P = 0.002 and P = 0.029, respectively). Prophylactical ceftriaxone treatment could not decrease the colonization rate of E. coli at 10⁶ CFU/ml or 10⁸ CFU/ml in each group (P > 0.05). The scores of neovascularization in polypropylene mesh and biologic mesh were similar, which was higher than that of polytetrafluoroethylene mesh (P < 0.05). Compared with other meshes, biologic mesh showed better tolerance to 10⁶ CFU/ml E. coli with respect to inflammation, depth of inflammation, neovascularization, cellular repopulation and foreign body giant cells.

Conclusion: The biologic mesh had better E. coli resistance compared to polytetrafluoroethylene mesh and polypropylene mesh when the E. coli concentration is higher than 10⁶ CFU/ml in rats. Antibiotic prophylaxis was useful when the contamination was not particularly severe.

Comparison of postoperative infection after emergency inguinal hernia surgery with enterectomy between mesh repair and non-mesh repair: a national database analysis

PURPOSE

Synthetic non-absorbable mesh is used for elective inguinal hernia repair but is not commonly used for incarcerated or strangulated inguinal hernia requiring enterectomy to reduce the risk of surgical-site infection. This study aimed to evaluate the safety of synthetic non-absorbable mesh repair in patients with incarcerated or strangulated inguinal hernia requiring enterectomy versus non-mesh repair.

METHODS

We analyzed patients with incarcerated or strangulated inguinal hernia with enterectomy from April 2012 to March 2017 using a nationwide inpatient database in Japan. We conducted overlap propensity score-weighted analyses to compare surgical-site infection (SSI), duration of anesthesia, antibiotic use at > 3 days after surgery, postoperative hospital stay, and 30 day readmission. Two sensitivity analyses were performed. First, we compared the proportions of patients requiring wound culture at ≥ 3 days after surgery. Second, we performed overlap propensity score-weighted logistic regression analyses for surgical-site infection.

RESULTS

We identified 668 eligible patients, comprising 223 patients with mesh repair and 445 with non-mesh repair. Overlap propensity score-weighted analyses showed no significant differences between the mesh repair and non-mesh repair groups for SSI (2.5 vs. 2.8%, P = 0.79). Secondary outcomes did not differ significantly between the groups. Proportion of wound culture at ≥ 3 days after surgery was similar in the two groups (11.1 vs. 14.6%, P = 0.18). Logistic regression analysis showed no significant association between mesh repair and SSI (odds ratio, 0.93; 95% confidence interval, 0.34-2.57).

CONCLUSION

Synthetic non-absorbable mesh use may be safe for incarcerated or strangulated inguinal hernia requiring enterectomy.

Prosthetic mesh hernioplasty versus primary repair in incarcerated and strangulated groin and abdominal wall hernias with or without organ resection. Retrospective study

PURPOSE

The use of synthetic materials in emergency surgery for abdominal wall hernia in a potentially infected operating field has long been debated. In the present study, we evaluated the outcome of mesh prostheses in the management of incarcerated and strangulated abdominal wall hernias with or without organ resection.

METHODS

Between March 2012 and January 2020, medical records of 301 patients who underwent emergency surgery for incarcerated and strangulated abdominal wall hernias were retrospectively evaluated. The interventions were exclusively realized by two surgical teams, one of which used polypropylene mesh prostheses (group I), whereas the second team performed primary hernia repair (group II). The outcome of patients was observed for a mean follow-up period of 18.2 months. Categorical data were analyzed with the χ2 test or likelihood ratio. Logistic regression was used for adjustments in multivariate analysis. Statistical analyses were realized with SPSS, version 18. P values < 0.05 were considered statistically significant. For multiple comparisons between types of hernia, the significance level was set to P < 0.0083 according to Bonferroni adjustment.

RESULTS

Of the 301 patients, 190 were men (63.1%), and 111 were women (36.9%). The mean age was 59,98 years (range 17-92). Overall, 226 (75.1%) patients were treated with synthetic mesh replacement. One hundred two organ resections (34%) were performed involving the omentum, small intestine, colon, and appendix. No significant difference was identified in terms of postoperative complications, between the two groups both in patients who underwent organ resection and in patients who did not.

CONCLUSION

Synthetic materials may safely be used in the emergency management of incarcerated and strangulated groin and abdominal wall hernias in patients with or without organ resection, although they cannot formally be recommended due to the limited number of cases of the present study.

Surgical site infection in mesh repair for ventral hernia in contaminated field: A systematic review and meta-analysis

BACKGROUND

Given the risk of surgical site infection (SSI), the use of mesh in contaminated ventral hernia repair (VHR) is not standardized and still a clinical dilemma. This meta-analysis aimed to assess whether mesh use increased the risk of SSI in patients following VHR in contaminated field.

METHODS

We performed a systematic review of published literature. Studies comparing the mesh repair and anatomic repair, the use of mesh in different Center for Disease Control and Prevention (CDC) wound classes and mesh repair with synthetic mesh or other type of meshes to treat complicated and contaminated VHR were considered for analysis. The main outcome was SSI incidence.

RESULTS

Six studies compared mesh and suture repairs. No significant difference in SSI incidence was observed between patients with complicated VHR in the mesh and suture repair groups.Five studies analyzed mesh repair in patients by field contamination level. There was no significant difference between the use of mesh in clean-contaminated, contaminated and dirty field versus clean wound class. Moreover, there was no significant difference between the use of mesh in clean-contaminated and contaminated cases.Four studies compared mesh repair technique with synthetic mesh or other type of meshes were included. The incidence of SSI was significantly lower in the synthetic mesh group.

CONCLUSIONS

The use of mesh repair in the management of complicated VHR compared to suture repair is not associated with an increased incidence of SSI even in potentially contaminated fields.

Effectiveness and Safety of Mesh Repair for Incarcerated or Strangulated Hernias: A Systematic Review and Meta-Analysis

BACKGROUND

Hernia repair with mesh in patients with incarcerated or strangulated hernias is controversial. Moreover, the use of mesh for hernia repair with concomitant bowel resection poses a great dilemma. This study compared the outcomes of mesh and anatomic repairs in patients with acutely incarcerated or strangulated hernias.

METHODS

PubMed, Embase, and Cochrane databases were searched for studies published before November 2019. Randomized controlled trials (RCTs) and prospective studies were included. We conducted meta-analyses using a random-effects model. The treatment outcome was measured by the incidence of surgical site infection (SSI), seroma formation, and hernia recurrence postoperatively.

RESULTS

Two RCTs and six prospective studies with 978 patients were included. No significant difference in SSI incidence was observed between patients with incarcerated hernia from the mesh and anatomic repair groups. Recurrence was significantly lower in mesh repair group than in anatomic repair group (odds ratio, 0.08; 95% confidence interval, 0.01-0.45). Only two patients needed to have mesh explantation due to mesh infection. In the setting of hernia repair with concomitant bowel resection, the SSI rate with mesh repair was slightly higher, but most cases of infections were well controlled with conservative antibiotic therapy.

CONCLUSIONS

Mesh repair for incarcerated or strangulated hernias was feasible with a great benefit of lower recurrence rates. However, due to limited data, drawing conclusions regarding the use of mesh for hernia repair with concomitant bowel resection was difficult. Further studies with preset criteria for evaluating patients undergoing concomitant bowel resection may help elucidate this issue.

Emergency surgery of the abdominal wall hernias: risk factors that increase morbidity and mortality-a single-center experience

PURPOSE

Morbidity and mortality are higher in urgently operated abdominal hernia cases compared to elective surgeries. The present study aims to investigate the factors that cause increased morbidity and mortality in emergency surgical operations.

METHODS

The files of a total of 426 patients who were operated for non-reducible abdominal hernia between 2015 and 2020 were reviewed retrospectively. Patients' ages, genders, comorbidities, Charlson Comorbidity Index (CCI), ASA score, BMI, hernia types, duration of symptom, laboratory values, intestinal strangulations or necroses, whether intestinal resection was performed, whether mesh was preferred for hernia repair, and rates of morbidity and mortality were recorded. Factors affecting morbidity and mortality rates were analyzed.

RESULTS

Factors such as gender, BMI (> 30), duration of symptom (> 24 h), presence of bowel necrosis and resection, type of hernia and prolonged operation time were found to cause an increase in morbidity. In the multivariate analysis, however, gender, duration of symptom and BMI (> 30) were statistically significant factors causing increased morbidity (p = 0.009, p < 0.001, p = 0.032, respectively). Advanced age, high ASA scores, CCI and duration of symptom were determined as factors affecting the increase in mortality. In the multivariate analysis, the effect of high ASA scores and advanced age on high mortality rate was statistically significant (p < 0.023, p = 0.039, respectively).

CONCLUSIONS

The mortality rate is higher, especially in elderly patients with high comorbidity. Therefore, we argue that the cases of abdominal wall hernia should be operated under elective conditions even if they do not give any clinical findings to prevent problems in older ages.

Early outcomes of emergency ventral hernia repair in a cohort of poorly optimized patients

BACKGROUND

Strangulated and obstructed ventral hernias require emergent repair to mitigate the risk of life-threatening complications. Emergency ventral hernia repairs are associated with a higher rate of surgical complications and recurrence compared to elective repairs. The purpose of this study was to explore the impact of patient factors, hernia and operative characteristics on post-operative outcomes in patients requiring emergency ventral hernia repairs.

METHODS

Data were collected from a prospectively held database on 86 consecutive patients undergoing emergency ventral hernia repairs between January 2016 and January 2019 at Logan Hospital. Patient, hernia and operative characteristics were collected for reporting and analysis.

RESULTS

Of the 86 patients, 29 (34%) developed a surgical complication, of which 17 patients (59%) had surgical site infections. We identified obesity (P = 0.017), history of smoking (P = 0.008), American Society of Anesthesiologists class of III-IV (P = 0.008), hernia defect size ≥3 cm (P = 0.048) and concomitant small bowel resection (P = 0.028) to be associated with post-operative surgical complication. Multivariate analysis identified smoking (P = 0.005) and concomitant small bowel resection (P = 0.026) as independent predictors for developing surgical complications. Seven patients (8%) recurred at a median of 221 days. Incisional hernias (P = 0.001), recurrent hernias (P < 0.001), greater than one defect (P < 0.001) and bowel involvement (P = 0.049) were associated with higher rates of hernia recurrence.

CONCLUSION

Patient factors significantly influence outcomes in the emergency setting. Given that this is not modifiable at the time of surgery, greater emphasis needs to be placed on optimizing the physical and behavioural factors of patients with early symptomatic hernias for an elective repair.

Incarcerated Spigelian hernia: A rare cause of abdominal wall tender mass

In this study, we aimed to present that incarcerated Spigelian hernia is an important cause of acute abdomen although it is rare and accounts for 1–2% of all abdominal wall hernias. Spigelian hernia arises from a defect in the aponeurosis of the transversus abdominis muscle, also known as the Spiegel fascia. This case analysis aims to present a Spigelian hernia case in which the sigmoid colon is incarcerated. The patient was referred to our emergency surgery clinic complaining of severe abdominal pain and a palpable mass in the left quadrant of the abdomen, presenting tenderness on the front abdominal wall. The symptoms suddenly emerged approximately eight hours ago before the patient was admitted to the hospital. The patient was taken into surgery after the ultrasonography (US) and computed tomography (CT) results suggested a preliminary diagnosis of incarcerated Spigelian hernia for which polypropylene mesh repair was performed. No recurrence was identified in the patient’s control examination performed 22 months later. Incarcerated Speigel hernia should be considered as a cause for patients developing sudden stomach ache and mass, causing tenderness on the front abdominal wall for which mesh repair should be performed.

Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society

BACKGROUND

Umbilical and epigastric hernia repairs are frequently performed surgical procedures with an expected low complication rate. Nevertheless, the optimal method of repair with best short- and long-term outcomes remains debatable. The aim was to develop guidelines for the treatment of umbilical and epigastric hernias.

METHODS

The guideline group consisted of surgeons from Europe and North America including members from the European Hernia Society and the Americas Hernia Society. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, the Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklists, and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument were used. A systematic literature search was done on 1 May 2018, and updated on 1 February 2019.

RESULTS

Literature reporting specifically on umbilical and epigastric hernias was limited in quantity and quality, resulting in a majority of the recommendations being graded as weak, based on low-quality evidence. The main recommendation was to use mesh for repair of umbilical and epigastric hernias to reduce the recurrence rate. Most umbilical and epigastric hernias may be repaired by an open approach with a preperitoneal flat mesh. A laparoscopic approach may be considered if the hernia defect is large, or if the patient has an increased risk of wound morbidity.

CONCLUSION

This is the first European and American guideline on the treatment of umbilical and epigastric hernias. It is recommended that symptomatic umbilical and epigastric hernias are repaired by an open approach with a preperitoneal flat mesh.

Emergency repair of complicated abdominal wall hernias: WSES guidelines

PURPOSE

In July 2013, the World Society of Emergency Surgery (WSES) held the first Consensus Conference on emergency repair of abdominal wall hernias in adult patients with the intention of producing evidence-based guidelines to assist surgeons in the management of complicated abdominal wall hernias. Guidelines were updated in 2017 in keeping with varying clinical practice: benefits resulting from the increased use of biological prosthesis in the emergency setting were highlighted, as previously published in the World Journal of Emergency Surgery. This executive summary is intended to consolidate knowledge on the emergency management of complicated hernias by providing the broad readership with a practical and concise version of the original guidelines.

METHODS

This executive manuscript summarizes the WSES guidelines reporting on the emergency management of complicated abdominal wall hernias; statements are highlighted focusing the readers' attention on the main concepts presented in the original guidelines.

CONCLUSIONS

Emergency repair of complicated abdominal hernias remains one of the most common and challenging surgical emergencies worldwide. WSES aims to provide an essential version of the evidence-based guidelines focusing on the timing of intervention, laparoscopic approach, surgical repair following the Centers for Disease Control and Prevention (CDC) wound classification, antimicrobial prophylaxis and anesthesia in the emergency setting.

The results of open preperitoneal prosthetic mesh repair for acutely incarcerated or strangulated inguinal hernia: a retrospective study of 146 cases

BACKGROUND

Tension-free hernia repair has been regarded as the gold-standard treatment for selected inguinal hernias, but the use of prosthetic mesh in acutely incarcerated or strangulated inguinal hernias is controversial. Our aim was to evaluate the safety and efficacy of open prosthetic mesh repairs for emergency inguinal hernias.

METHODS

Patients with acutely incarcerated or strangulated inguinal hernias who underwent open preperitoneal prosthetic mesh repairs during 2013 to 2016 at our department were included. Patients' characteristics, operative details, results, and complications were retrospectively analyzed.

RESULTS

During a 4-year period, 146 cases who met the inclusion criteria were enrolled in our study. There were 127 males and 19 females of median age 75 years (range 19-95 years). The hernia was indirect inguinal in 104 (71.2%) patients, direct inguinal in 18 (12.3%), and femoral hernia in 24 (16.5%). Bowel resection was necessary in 20 patients (13.7%). Complications occurred in 15 (10.3%) patients, including wound infection in 6 (4.1%), scrotal hematoma in 2 (1.4%), bleeding in 1 (0.7%), deep vein thrombosis (DVT) in 2 (1.4%), and chest infection in 4 (2.7%). No mesh-related infections were detected. There were 2 mortalities. During the median follow-up of 26 months (range 6-53 months) 2 recurrences occurred, but there were no deaths or further infections.

CONCLUSION

Open preperitoneal prosthetic mesh repair can be safely performed in patients with incarcerated or strangulated inguinal hernia without contaminated hernia content. Mesh repair is not contraindicated in patients with bowel resection.

The Use of Prosthetic Mesh in the Emergency Management of Acute Incarcerated Inguinal Hernias

INTRODUCTION

Tension-free hernia repair has been regarded as a gold standard treatment for selected inguinal hernias, but the use of prosthetic mesh in acute incarcerated inguinal hernias is controversial. Our study focused on evaluating the safety and efficacy of the prosthetic mesh repair for emergency cases.

METHODS

Patients with acute incarcerated inguinal hernias who underwent emergency prosthetic mesh repair during 2009 to 2014 at our department were included. Patient characteristics, operative approaches and results, and complications were retrospectively analyzed.

RESULTS

A total of 167 patients were included in our study. One hundred and twenty-two patients underwent open surgery while the remaining 45 patients underwent transabdominal preperitoneal laparoscopic approach. The hernia was indirect inguinal in 133 patients (79.6%), direct inguinal in 15 patients (9.0%), and femoral in 19 patients (11.4%). The overall wound infection rate of these patients was 3%. Nonviable intestinal resection was performed in 25 patients (8.4%), only 2 of whom underwent wound infection. Another 3 patients who developed wound infection had viable hernia content. There was no mesh-related infection. There was no statistically significant difference in wound infection rates between patients with viable hernia contents and those with nonviable contents ( P < .05).

CONCLUSION

The use of the prosthetic mesh in the treatment of acute incarcerated inguinal hernia is safe and effective. Nonviable intestinal resection cannot be regarded as a contradiction of the mesh repair.

Midline preperitoneal repair for incarcerated and strangulated femoral hernia

OBJECTIVE

Femoral hernias constantly present as incarceration or strangulation and require emergency surgery. Incarcerated and strangulated femoral hernia repair remains challenging and controversial. The aim of our study was to analyze the efficacy of preperitoneal tension-free hernioplasty via lower abdominal midline incision for incarcerated and strangulated femoral hernia.

METHODS

Data of 47 patients who underwent emergency surgery for incarcerated or strangulated femoral hernias from January 2009 to December 2017 were retrospectively analyzed. According to the surgical incisions, they were divided into two groups: the observation group (21 cases) had a lower abdominal midline incision, and the control group (26 cases) had a traditional inguinal incision. General data of patients, intraoperative findings, operative time and postoperative complications were compared.

RESULTS

Patient characteristics showed that the two groups were comparable.15 cases (31.9%) underwent intestinal resection, and 32 cases (68.1%) underwent first-stage tension-free repair in total. The rate of first-stage tension-free hernioplasty was significantly higher in the observation group (18/21, 85.7% vs 14/26 53.8%, P = 0.020). No additional incision was required in the observation group, while six cases of the control group (23.1%) had an additional incision for intestinal resection and anastomosis (P = 0.026). Mean operative time (53.6 ± 24.7 min vs 77.9 ± 36.5 min, P = 0.012) and the length of hospital stay (6.3 ± 4.2 days vs 10.3 ± 6.9 days, P = 0.020) were significantly shorter in the observation group. The time of return to normal physical activity resulted significantly reduced compared to the control group (9.2 ± 4.1 days vs 13.3 ± 6.6 days, P = 0.017). The total incidence of postoperative complication (including chronic pain, foreign body sensation, hernia recurrence, wound infection and seroma/hematomas) in the observation group was lower (14.3% vs 42.3% P = 0.037). There were two recurrences in the control group. No mesh-related infection and no mortalities in two groups.

CONCLUSIONS

Midline preperitoneal approach for incarcerated and strangulated femoral hernia is a convenient and effective technique. It can improve the rate of first-stage tension-free repair of incarcerated femoral hernia and allow intestinal resection through the same incision, and with lower rate of postoperative complications.

Femoral Hernias: Analysis of Preoperative Risk Factors and 30-Day Outcomes of Initial Groin Hernias Using ACS-NSQIP

Femoral hernias are infrequently encountered groin hernias. The purpose of this study was to describe the natural history of femoral hernias by evaluating patient demographics, comorbidities, operative details, 30-day mortality, and risk factors for postoperative complications compared with inguinal hernias and in reducible versus incarcerated hernias. Overall 5360 femoral hernia repairs and 183,173 inguinal hernia repairs were identified using the 2005 to 2015 American College of Surgeon-National Surgical Quality Improvement Program's database. Univariate analysis was used to compare patient characteristics between femoral and inguinal hernias and between reducible and nonreducible femoral hernias. Multivariable logistic regression analyses were used to identify risk factors for 30-day postoperative complications after repair. Femoral hernias accounted for 2.8 per cent of initial groin hernias and 18.9 per cent of all groin hernias in females. A total of 56.5 per cent of initial femoral hernias were nonreducible and these patients were significantly older. Rates of small bowel resection (5.7 vs 0.3%, P < 0.0001), exploratory laparotomy (2.5% vs 0.4%, P < 0.0001), and diagnostic laparoscopy (2.0% vs 0.7%, P < 0.0001) were significantly higher in incarcerated femoral hernias compared with reducible femoral hernias. There were significantly higher rates of unplanned return to the OR, postoperative sepsis, and 30-day mortality in incarcerated femoral hernias versus reducible femoral hernias. Most femoral hernias present incarcerated in older, female patients. Femoral hernias present more commonly incarcerated in patients with significant comorbid diseases and are associated with significantly increased rates of systemic, local, major, and minor complications, return to OR, and mortality. Careful consideration should be given for the evaluation of intestinal viability in the acute setting.

Prosthetic Mesh Repair in the Emergency Management of Acutely Strangulated Groin Hernias with Grade I Bowel Necrosis: A Rational Choice

The aim of this study was to determine the feasibility of prosthetic mesh repair according to the degree of bowel necrosis in the emergency management of acutely strangulated groin hernias. Emergency prosthetic mesh repair versus primary suture repair was randomly performed in 208 consecutive strangulated groin hernia patients with bowel necrosis between January 2005 and August 2016. The degree of bowel necrosis of each patient was determined according to a modified three-grade classification system. Patient characteristics sorted by repair method were analyzed by using Pearson's chi-squared tests. Correlations between mortality and wound-related morbidity with bowel necrosis grade and repair method were analyzed. There was no difference in gender, age, body mass index, comorbid diseases, hernia type (left or right, primary or recurrent), necrosis grade, and mortality between the mesh repair and suture repair groups (all P > 0.05). However, with regard to wound-related morbidity, there was significant difference between the two groups ( P < 0.05). Mortality and wound-related morbidity showed significant relationship with necrosis grade, especially with regard to postoperative wound infection ( P < 0.001). The wound infection rate with mesh repair was significantly higher than that with primary suture in Grade II and III necrosis patients ( P < 0.05), but there was no difference in Grade I patients ( P > 0.05). The use of prosthetic mesh in the emergency repair of acutely strangulated groin hernias seems to be as safe as suture-only repair in patients with noninfected strangulated bowel (Grade I necrosis). The use of prosthetic mesh repair is a rational choice made based on the degree of bowel necrosis in the emergency management of acutely strangulated hernias.

Computed tomography evidence of fluid in the hernia sac predicts surgical site infection following mesh repair of acutely incarcerated ventral and groin hernias

BACKGROUND

Mesh placement during repair of acutely incarcerated ventral and groin hernias is associated with high rates of surgical site infection (SSI). The utility of preoperative computed tomography (CT) in this setting is unclear. We hypothesized that CT evidence of bowel wall compromise would predict SSI while accounting for physiologic parameters.

METHODS

We performed a 4-year retrospective cohort analysis of 50 consecutive patients who underwent mesh repair of acutely incarcerated ventral or groin hernias. We analyzed chronic disease burden, acute illness severity, CT findings, operative management, and herniorrhaphy-specific outcomes within 180 days. The primary outcome was SSI by the Centers for Disease Control and Prevention criteria. Multiple logistic regression was performed to identify independent predictors of SSI.

RESULTS

Eighty-four percent of all patients were American Society of Anesthesiologists class III or IV, 28% were active smokers, and mean body mass index (BMI) was 35 kg/m. Fifty-four percent had ventral hernias, 40% had inguinal hernias, and 6% had femoral or combined inguinal/ femoral hernias. Seventy percent of preoperative CT scans had features suggesting bowel compromise, abdominal free fluid, or fluid in the hernia sac. Surgical site infection occurred in 32% of all patients (8% superficial, 24% deep or organ/space). The strongest predictors of SSI were CT evidence of fluid in the hernia sac (odds ratio [OR], 8.3; 95% confidence interval [CI], 1.7-41), initial heart rate 90 beats/min or greater (OR, 6.3; 95% CI, 1.1-34), and BMI 35 kg/m or greater (OR, 5.8; 95% CI, 1.2-28). Surgical site infection rates were significantly higher among patients who had CT evidence of fluid in the hernia sac (56% vs. 19%, p = 0.012).

CONCLUSIONS

More than half of all patients with CT scan evidence of fluid in the hernia sac developed an SSI. Computed tomography evidence of fluid in the hernia sac was the strongest predictor of SSI, followed by heart rate and BMI. Together, these parameters identify high-risk patients for whom better strategies are needed to avoid SSI without sacrificing durability.

LEVEL OF EVIDENCE

Prognostic study, level III; Therapeutic, level IV.

2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias

Emergency repair of complicated abdominal wall hernias may be associated with worsen outcome and a significant rate of postoperative complications. There is no consensus on management of complicated abdominal hernias. The main matter of debate is about the use of mesh in case of intestinal resection and the type of mesh to be used. Wound infection is the most common complication encountered and represents an immense burden especially in the presence of a mesh. The recurrence rate is an important topic that influences the final outcome. A World Society of Emergency Surgery (WSES) Consensus Conference was held in Bergamo in July 2013 with the aim to define recommendations for emergency repair of abdominal wall hernias in adults. This document represents the executive summary of the consensus conference approved by a WSES expert panel. In 2016, the guidelines have been revised and updated according to the most recent available literature.

Outcomes following repair of incarcerated and strangulated ventral hernias with or without synthetic mesh

BACKGROUND

The use of synthetic mesh for ventral hernia repair under contaminated conditions is a controversial issue due to the considerable risk of surgical site infection (SSI). This study aimed to review the outcomes of repair of incarcerated and strangulated ventral hernias with or without synthetic mesh in compliance with established clinical guidelines regarding the incidence of SSI and hernia recurrence.

METHODS

The records of patients with complicated ventral hernias who were treated with or without synthetic mesh repair were reviewed. Variables collected included the characteristics of patients and of ventral hernias, type of repair, and incidence of SSI and recurrence.

RESULTS

One hundred twenty-two patients (56 males) of a mean age of 56 years were included. Fifty-two (42.6%) and 70 (57.4%) patients presented with incarcerated and strangulated ventral hernias, respectively. Sixty-six (54%) patients were treated with on-lay mesh repair, and 56 (46%) were managed with suture repair. Twenty-one patients required bowel resection. SSI was detected in eight (6.5%) patients. There was no significant difference between both groups regarding the incidence of SSI (7.5% for mesh group vs 5.3% for suture group). Recurrence occurred in seven patients. Median follow-up period was 24 months. The suture repair group had a significantly higher incidence of recurrence than the mesh group. Diabetes mellitus, previous recurrence, and intestinal resection were significant predictors for SSI.

CONCLUSION

Following established guidelines, synthetic mesh repair of incarcerated and strangulated ventral hernias attained lower recurrence rate, comparable incidence of SSI, and higher rate of seroma formation than suture repair.

TRIAL REGISTRATION

Research Registry, researchregistry1891.

Polypropylene-based composite mesh versus standard polypropylene mesh in the reconstruction of complicated large abdominal wall hernias: a prospective randomized study

PURPOSE

To compare polypropylene mesh positioned onlay supported by omentum and/or peritoneum versus inlay implantation of polypropylene-based composite mesh in patients with complicated wide-defect ventral hernias.

METHODS

This was a prospective randomized study carried out on 60 patients presenting with complicated large ventral hernia in the period from January 2012 to January 2016 in the department of Gastrointestinal Surgery unit and Surgical Emergency of the Main Alexandria University Hospital, Egypt. Large hernia had an abdominal wall defect that could not be closed. Patients were divided into two groups of 30 patients according to the type of mesh used to deal with the large abdominal wall defect.

RESULTS

The study included 38 women (63.3 %) and 22 men (37.7 %); their mean age was 46.5 years (range, 25-70). Complicated incisional hernia was the commonest presentation (56.7 %).The operative and mesh fixation times were longer in the polypropylene group. Seven wound infections and two recurrences were encountered in the propylene group. Mean follow-up was 28.7 months (2-48 months).

CONCLUSIONS

Composite mesh provided, in one session, satisfactory results in patients with complicated large ventral hernia. The procedure is safe and effective in lowering operative time with a trend of low wound complication and recurrence rates.

Prosthetic Mesh Repair for Incarcerated Inguinal Hernia

BACKGROUND

Incarcerated inguinal hernia is a commonly encountered urgent surgical condition, and tension-free repair is a well-established method for the treatment of non-complicated cases. However, due to the risk of prosthetic material-related infections, the use of mesh in the repair of strangulated or incarcerated hernia has often been subject to debate. Recent studies have demonstrated that biomaterials represent suitable materials for performing urgent hernia repair. Certain studies recommend mesh repair only for cases where no bowel resection is required; other studies, however, recommend mesh repair for patients requiring bowel resection as well.

AIM

The aim of this study was to compare the outcomes of different surgical techniques performed for strangulated hernia, and to evaluate the effect of mesh use on postoperative complications.

STUDY DESIGN

Retrospective cross-sectional study.

METHODS

This retrospective study was performed with 151 patients who had been admitted to our hospital's emergency department to undergo surgery for a diagnosis of incarcerated inguinal hernia. The patients were divided into two groups based on the applied surgical technique. Group 1 consisted of 112 patients treated with mesh-based repair techniques, while Group 2 consisted of 39 patients treated with tissue repair techniques. Patients in Group 1 were further divided into two sub-groups: one consisting of patients undergoing bowel resection (Group 3), and the other consisting of patients not undergoing bowel resection (Group 4).

RESULTS

In Group 1, it was observed that eight (7.14%) of the patients had wound infections, while two (1.78%) had hematomas, four (3.57%) had seromas, and one (0.89%) had relapse. In Group 2, one (2.56%) of the patients had a wound infection, while three (7.69%) had hematomas, one (2.56%) had seroma, and none had relapses. There were no statistically significant differences between the two groups with respect to wound infection, seroma, hematoma, or relapse (p>0.05). In Group 3, it was observed that one (6.7%) of the patients had wound infections, while one (6.7%) had a hematoma, one patient (6.7%) had seroma, and none had relapses. In Group 4, seven (7.2%) of the patients had wound infections, while one (1%) had a hematoma, three (3%) had seromas, and one (1%) had a relapse. There were no significant differences between the two groups with respect to wound infection, seroma, hematoma, or relapse (p>0.05).

CONCLUSION

In urgent groin hernia repair surgeries, polypropylene mesh can be safely used even in the patients undergoing bowel resection.

Stratification of surgical site infection by operative factors and comparison of infection rates after hernia repair

OBJECTIVE

To investigate whether operative factors are associated with risk of surgical site infection (SSI) after hernia repair.

DESIGN

Retrospective cohort study. Patients Commercially insured enrollees aged 6 months-64 years with International Classification of Diseases, Ninth Revision, Clinical Modification procedure or Current Procedural Terminology, fourth edition, codes for inguinal/femoral, umbilical, and incisional/ventral hernia repair procedures from January 1, 2004, through December 31, 2010.

METHODS

SSIs within 90 days after hernia repair were identified by diagnosis codes. The χ2 and Fisher exact tests were used to compare SSI incidence by operative factors.

RESULTS

A total of 119,973 hernia repair procedures were analyzed. The incidence of SSI differed significantly by anatomic site, with rates of 0.45% (352/77,666) for inguinal/femoral, 1.16% (288/24,917) for umbilical, and 4.11% (715/17,390) for incisional/ventral hernia repair. Within anatomic sites, the incidence of SSI was significantly higher for open versus laparoscopic inguinal/femoral (0.48% [295/61,142] vs 0.34% [57/16,524], P=.020) and incisional/ventral (4.20% [701/16,699] vs 2.03% [14/691], P=.005) hernia repairs. The rate of SSI was higher following procedures with bowel obstruction/necrosis than procedures without obstruction/necrosis for open inguinal/femoral (0.89% [48/5,422] vs 0.44% [247/55,720], P<.001) and umbilical (1.57% [131/8,355] vs 0.95% [157/16,562], P<.001), but not incisional/ventral hernia repair (4.01% [224/5,585] vs 4.16% [491/11,805], P=.645).

CONCLUSIONS

The incidence of SSI was highest after open procedures, incisional/ventral repairs, and hernia repairs with bowel obstruction/necrosis. Stratification of hernia repair SSI rates by some operative factors may facilitate accurate comparison of SSI rates between facilities.

Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial

BACKGROUND

Incisional hernia is a frequent complication of midline laparotomy and is associated with high morbidity, decreased quality of life, and high costs. We aimed to compare the large bites suture technique with the small bites technique for fascial closure of midline laparotomy incisions.

METHODS

We did this prospective, multicentre, double-blind, randomised controlled trial at surgical and gynaecological departments in ten hospitals in the Netherlands. Patients aged 18 years or older who were scheduled to undergo elective abdominal surgery with midline laparotomy were randomly assigned (1:1), via a computer-generated randomisation sequence, to receive small tissue bites of 5 mm every 5 mm or large bites of 1 cm every 1 cm. Randomisation was stratified by centre and between surgeons and residents with a minimisation procedure to ensure balanced allocation. Patients and study investigators were masked to group allocation. The primary outcome was the occurrence of incisional hernia; we postulated a reduced incidence in the small bites group. We analysed patients by intention to treat. This trial is registered at Clinicaltrials.gov, number NCT01132209 and with the Nederlands Trial Register, number NTR2052.

FINDINGS

Between Oct 20, 2009, and March 12, 2012, we randomly assigned 560 patients to the large bites group (n=284) or the small bites group (n=276). Follow-up ended on Aug 30, 2013; 545 (97%) patients completed follow-up and were included in the primary outcome analysis. Patients in the small bites group had fascial closures sutured with more stitches than those in the large bites group (mean number of stitches 45 [SD 12] vs 25 [10]; p<0·0001), a higher ratio of suture length to wound length (5·0 [1·5] vs 4·3 [1·4]; p<0·0001) and a longer closure time (14 [6] vs 10 [4] min; p<0·0001). At 1 year follow-up, 57 (21%) of 277 patients in the large bites group and 35 (13%) of 268 patients in the small bites group had incisional hernia (p=0·0220, covariate adjusted odds ratio 0·52, 95% CI 0·31-0·87; p=0·0131). Rates of adverse events did not differ significantly between groups.

INTERPRETATION

Our findings show that the small bites suture technique is more effective than the traditional large bites technique for prevention of incisional hernia in midline incisions and is not associated with a higher rate of adverse events. The small bites technique should become the standard closure technique for midline incisions.

FUNDING

Erasmus University Medical Center and Ethicon.

Obstructing ventral hernias are not independently associated with surgical site infections

BACKGROUND

Delayed operative intervention in the setting of adhesive bowel obstruction has been recently shown to increase the rate of surgical site infection (SSI), raising the concern for bacterial translocation. The effect of obstruction on SSI rate in patients with ventral hernia is unknown. The aim of this study was to assess the association between bowel obstruction and SSI in patients undergoing ventral hernia repair (VHR).

MATERIALS AND METHODS

This study is a retrospective database review. Patients undergoing isolated VHR from 2005-2011 were identified from the American College of Surgeons' National Surgical Quality Improvement Program database. Demographics, comorbidities, and 30-d outcomes were analyzed. Multivariate logistic regression was used for variables with a P value of <0.1.

RESULTS

A total of 68,811 patients underwent isolated VHR; 53.1% were male with mean age of 53 ± 15 y and body mass index of 32 ± 8. Hernia-related obstruction was found in 17,058 (24.8%). In patients with obstruction, SSI was more frequent (3.2% versus 2.6%, P < 0.001). Obesity, advanced age, vascular, pulmonary, hepatic, renal disease, and diabetes were more prevalent. After controlling for confounding baseline variables, bowel obstruction was not independently associated with SSI (odds ratio, 0.983, 95% confidence interval, 0.872-1.107). Subgroup analysis of clean classified cases also demonstrated the lack of independent association between obstruction and SSI.

CONCLUSIONS

Obstruction in patients undergoing VHR is not independently associated with SSI. Our results suggest that mesh implantation remains a viable option in this setting. Other confounding comorbid conditions should be assessed at the time of surgical intervention to identify patients appropriate for mesh repair.

Management of strangulated abdominal wall hernias with mesh; early results

OBJECTIVE

Surgery for abdominal wall hernias is a common procedure in general surgery practice. The main causes of delay for the operation are comorbid problems and patient unwillingness, which eventually, means that some patients are admitted to emergency clinics with strangulated hernias. In this report, patients who admitted to the emergency department with strangulated adominal wall hernias are presented together with their clinical management.

METHODS

Patients who admitted to our clinic between January 2009 and November 2011 and underwent emergency operation were included in the study retrospectively. Demographic characteristics, hernia type, length of hospital stay, surgical treatment and complications were assessed.

RESULTS

A total 81 patients (37 female, 44 male) with a mean age of 52.1±17.64 years were included in the study. Inguinal, femoral, umbilical and incisional hernias were detected in 40, 26, 9 and 6 patients respectively. Polypropylene mesh was used in 75 patients for repair. Primary repair without mesh was used in six patients. Small bowel (n=10; 12.34%), omentum (n=19; 23.45%), appendix (n=1; 1.2%) and Meckel's diverticulum (n=1; 1.2%) were resected. Median length of hospital stay was 2 (1-7) days. Surgical site infection was detected in five (6.2%) patients. No significant difference was detected for length of hospital stay and surgical site infection in patients who had mesh repair (p=0.232 and 0.326 respectively).

CONCLUSION

The need for bowel resection is common in strangulated abdominal wall hernias which undergo emergency operation. In the present study, an increase of morbidity was seen in patients who underwent bowel resection. No morbidity was detected related to the usage of prosthetic materials in repair of hernias. Hence, we believe that prosthetic materials can be used safely in emergency cases.

Bacteria in hernia sac: an important risk fact for surgical site infection after incarcerated hernia repair

BACKGROUND

Although some recent reports have proven that incarcerated and/or strangulated hernia is not contraindication to mesh repair, there is still a common concern owing to increased rate of postoperative surgical site infection (SSI). The aim of this clinical study was to evaluate factors that increase the risk of SSI after incarcerated hernia repair, and to identify the pathogens related to SSI.

METHODS

A retrospective analysis was performed on data collected prospectively over a 4-year interval from January 2007 to December 2011. A total of 121 patients who underwent emergency surgery for incarcerated hernias were analyzed.

RESULTS

107 hernias were repaired using mesh versus 14 primary suture repairs. SSIs were observed in 9 of the 121 patients. Of 15 preoperative and intraoperative variables studied, duration of symptoms, diabetes mellitus, present of ileus, bowel resection or mesh repair performed, bacteria present in hernia sac and cloudy fluid in hernia sac were found to be significant factors predicting SSI. On multivariate analysis only bowel resection, duration of symptoms and bacteria present in hernia sac were independent variables. The most common pathogen found in hernia sac and cultured from wound drainage or swab was Escherichia coli. The strains of bacteria cultured from wound drainage or swab were same as those cultured from fluid in hernia sac in six of nine patients.

CONCLUSION

Gut-sourced E. coli is an important common organisms associated with SSI after incarcerated hernia repair. Prosthetic mesh could be used when no bowel resection is performed, duration of symptoms less than 24 h and fluid hernia sac is clear.

Visceral organ resection during femoral hernia surgery is a predictor of morbidity

Reports on the outcomes of emergency and elective femoral hernia surgery are scarce. Most studies do not distinguish femoral hernia from other types of groin hernia; studies of femoral hernia alone are few in number. The main objective of the present study was to identify factors affecting morbidity of femoral hernia patients. We retrospectively analyzed data on 80 patients who underwent femoral hernia surgery between June 2009 and June 2013. Patients who did and did not experience morbidity were compared in terms of age, sex, hernia location, the presence of any comorbid disease, the type of anesthesia employed, the operative technique used, the type of surgical intervention, and performance of small bowel resection. Forty-three patients (53.8%) underwent emergency surgery because of incarceration. Of these, 18 (41.9%) experienced strangulation and underwent resection. Postoperative complications developed in 11 patients (13.8%). Upon multiple logistic regression analysis, visceral organ resection (of the small bowel and/or omentum) was the only independent predictor of significant morbidity (P < 0.05; odds ratio [OR]: 14.010, 95% confidence interval [CI]: 1.001-196.143). When diagnosed, femoral hernias should be electively repaired as soon as possible. The cumulative probability of strangulation rises over time. A requirement for bowel resection seems to significantly increase morbidity.

Endometriosis in a spigelian hernia sac: an unexpected finding

Describes the existence of endometrioma in a spigelian hernia sac. Spigelian Hernia is a rare ventral hernia, presenting difficulties in diagnosis and carrying a high incarceration and obstruction risk. Endometriomas occur due to implantation of endometrial cells into a surgical wound, most often after a cesarean delivery. A 37-year-old woman presented to our department with persistent abdominal pain, exacerbating during menses, and vomiting for 2 days. Physical examination revealed a mass-like lesion in the border between the left-upper and left-lower quadrant. Ultrasound examination was inconclusive and a computed tomography scan of the abdomen revealed an abdominal wall mass. During surgery, a spigelian hernia was found 5 to 7 cm above a previous cesarean incision. Tissue like "chocolate cysts" was present at the hernia sac. Hernia was repaired while tissue was excised and sent for histological examination that confirmed the diagnosis. Spigelian hernia is a hernia presenting difficulties in diagnosis and treatment. Endometrioma in a spigelian hernia sac is a rare diagnosis, confirmed only histologically. Clinical suspicion can be posed only through symptoms and thorough investigation.

Factors affecting morbidity and mortality in patients who underwent emergency operation for incarcerated abdominal wall hernia

Patients with incarcerated abdominal wall hernias (AWHs) are often encountered in emergency care units. Despite advances in anesthesia, antisepsis, antibiotic therapy, and fluid therapy, the morbidity and mortality rates for these patients remain high. Between 2006 and 2011, we retrospectively analyzed the cases of 131 patients who underwent emergency surgery for incarcerated abdominal wall hernias. Of these, there were 70 women (53.4%) and 61 men (46.6%) with an average age of 63.3 ± 17.4 years (range, 17-91 years). Morbidity was observed in 28 patients (21.4%), and the mortality rate was 2.3%. Intestinal resection, presence of concomitant disease, and general anesthesia were the independent variants that affected morbidity of patients with incarcerated abdominal wall hernias.

Two-stage laparoscopic treatment for strangulated inguinal, femoral and obturator hernias: totally extraperitoneal repair followed by intestinal resection assisted by intraperitoneal laparoscopic exploration

PURPOSE

Total extraperitoneal preperitoneal (TEP) repair is widely used for inguinal, femoral, or obturator hernia treatment. However, mesh repair is not often used for strangulated hernia treatment if intestinal resection is required because of the risk of postoperative mesh infection. Complete mesh repair is required for hernia treatment to prevent postoperative recurrence, particularly in patients with femoral or obturator hernia.

CASES

We treated four patients with inguinocrural and obturator hernias (a 72-year-old male with a right indirect inguinal hernia; an 83-year-old female with a right obturator hernia; and 86- and 82-year-old females with femoral hernias) via a two-stage laparoscopic surgery. All patients were diagnosed with intestinal obstruction due to strangulated hernia. First, the incarcerated small intestine was released and then laparoscopically resected. Further, 8-24 days after the first surgery, bilateral TEP repairs were performed in all patients; the postoperative course was uneventful in all patients, and they were discharged 5-10 days after TEP repair. At present, no hernia recurrence has been reported in any patient.

CONCLUSION

The two-stage laparoscopic treatment is safe for treatment of strangulated inguinal, femoral, and obturator hernias, and complete mesh repair via the TEP method can be performed in elderly patients to minimize the occurrence of mesh infection.

Use of a Bioprosthetic Mesh in Complex Hernia Repair

Background. Implantation of synthetic meshes for reinforcement of abdominal wall hernias can be complicated by mesh infection, which often requires mesh explantation. The risk of mesh infection is increased in a contaminated environment or in patients who have comorbidities such as diabetes or smoking. The use of biological prostheses has been advocated because of their ability to resist infection. Initial results, however, have shown high hernia recurrence rates and wound occurrences. The objective of the present study is to evaluate early and mid-term outcomes in the largest French series that included 43 consecutive complex abdominal hernias repaired with biological prostheses. Materials and methods. Retrospective observational study of a prospective collected data bank. Patient demographics, history of previous repairs, intraoperative findings and degree of contamination, associated procedures, postoperative prosthetic-related complications, and long-term results were retrospectively reviewed. Results. There were 25 (58%) incisional, 14 parastomal, and 4 midline hernia repairs. Hernias were considered “clean” (n = 5), “clean-contaminated” (n = 19), “contaminated” (n = 12), or “dirty” (n = 7). Wound-related morbidity occurred in 17 patients; 4 patients needed reoperation for cutaneous necrosis or abscess. Smoking was the only risk factor associated with wound complication ( P = .022). No postoperative wound events required removal of the prosthesis. There were 4 hernia recurrences (9%). A previous attempt at repair ( P = .018) and no complete fascia closure ( P = .033) were associated with hernia recurrence. Conclusions. This study demonstrated that the use of bioprothesis in complex hernia repair allowed successful single-stage reconstruction. Wound-related complications were frequent. Cost-benefit analyses are important to establish the validity of these findings.