Drain tube use in incisional hernia repair: a national survey

Systematic review and meta-analysis on robotic assisted ventral hernia repair: the ROVER review

INTRODUCTION

Robotic surgery for ventral hernia repair (VHR) is gaining attention for its potential advantages over laparoscopic and open techniques. This approach combines the advantages of minimally invasive surgery with the ability to perform technically challenging procedures, often required in open surgery but difficult with conventional laparoscopy. We aim to evaluate the efficacy and safety of robotic VHR compared to other surgical approaches, focusing on postoperative complications, operative time, and costs.

MATERIAL AND METHODS

A systematic review with meta-analysis were conducted, including 67 studies from January 2010 to May 2023 on Robotic VHR compared with other techniques. Primary outcome was 30-days postoperative complications; SSI, SSO, seroma, mortality, recurrence, length of hospital stay, operative time and costs were analysed as secondary outcomes.

RESULTS

Robotic surgery was associated with longer operative times compared to both laparoscopic (MD 64.67 min; p < 0.001) and open repairs (MD 69.69 min; p < 0.001). However, it resulted, compared to open surgery, in fewer SSIs (OR 0.62; p 0.05), mortality (OR 0.44; p 0.04) and shorter hospital stay (MD -3.77 days; p < 0.001). No differences were found in overall complications or length of stay between robotic and laparoscopic approaches but higher costs and longer operative times were reported in robotic VHR.

CONCLUSIONS

Based on the currently available low-quality evidence, robotic VHR appears to offer limited advantages compared to laparoscopic techniques. However, when compared to open approaches, robotic VHR may demonstrate reduced postoperative complications and shorter hospital stays even if an higher rate of seroma formation was retrieved probably related to technical details. Nevertheless, longer operative times and higher costs remain significant limitations. Further high-quality comparative studies are warranted to assess long-term outcomes and cost-effectiveness.

Do surgical drains reduce the postoperative surgical complications following incisional hernia repair? A systematic meta-analysis

PURPOSE

Abdominal surgeries are common surgical procedures worldwide. Incisional hernias commonly develop after abdominal wall surgery. Surgery is the definite treatment for most incisional hernias but carries a higher rate of complications. Although frequently used, the real benefit of using drain tubes to reduce surgical complications after incisional hernia repair is uncertain.

METHODS

PubMed and Embase databases were searched for studies that compared the outcomes of drain vs. no-drain placement and the risk of complications in patients undergoing incisional hernia repair. Primary endpoints were infection, seroma formation, length of hospital stay, and readmission rate.

RESULTS

From a total of 771 studies, we included 2 RCTs and 4 non-RCTs. A total of 40,325 patients were included, of which 28 497 (71%) patients used drain tubes, and 11 828 (29%) had no drains. The drain group had a significantly higher infection rate (OR 1.89; CI 1.13-3.16; P = 0.01) and mean length of hospital stay (Mean Difference-MD 2.66; 95% CI 0.81-4.52; P = 0.005). There was no difference in seroma formation and the readmission rate.

CONCLUSION

This comprehensive systematic meta-analysis concluded that drain tube placement after incisional hernia repair is associated with increased infection rate and length of hospital stay without affecting the rate of seroma formation and readmission rate. Prospective randomized studies are required to confirm these findings.

ONLAY VERSUS RIVES-STOPPA TECHNIQUES IN THE TREATMENT OF INCISIONAL HERNIAS

BACKGROUND

In the surgical correction of large incisional hernias, the use of a prosthesis is essential in most cases regardless of the technique chosen. The preference is for the polypropylene prosthesis.

AIMS

To compare the onlay and Rives-Stoppa techniques in the correction of incisional hernias, their immediate results, complications, advantages, and disadvantages.

METHODS

Two groups of patients with incisional hernias were analyzed, submitted to the onlay (19 patients) and Rives-Stoppa (17 patients) techniques, and that used polypropylene prostheses. General epidemiological variables, perioperative data variables, and postoperative complications were assessed.

RESULTS

The patients' epidemiologic profile was similar between both groups. The majority were women (58.4%), with a mean age of 65.5 years and a previous mean body mass index of 41.5 kg/m². The Rives-Stoppa technique was employed in most patients (52.7%). Those submitted to the onlay technique had longer abdominal drainage time and longer hospital stay, as well as a higher incidence of seromas and surgical wound infection.

CONCLUSIONS

The incisional herniorrhaphy technique with the placement of a pre-peritoneal polypropylene mesh by the Rives-Stoppa technique was superior to the onlay due to lower rates of drain use, hospital stay, and postoperative complications.

Short-Term Outcomes and Quality-of-Life Assessment Following Rives-Stoppa and Transversus Abdominis Release Procedures of Open Ventral Hernia Repair

INTRODUCTION

Ventral hernia is one of the common surgical conditions that can significantly impact a patient's quality of life (QoL). Open ventral hernia repair using the Rives-Stoppa (RS) and Transversus Abdominis Release (TAR) procedures has gained recognition for its effectiveness in achieving hernia repair and reducing the risk of further recurrence. However, limited research has been performed to explore the short-term outcomes and QoL assessment following these two surgical techniques. The aim of this study was to know the result after RS and TAR methods of hernia repair in terms of short-term recurrences, pain, postoperative complications, and QoL.

METHODS

This was a prospective, interventional study, which included 30 patients fulfilling the inclusion criteria. The study group was subjected to posterior component separation (PCS)-TAR and RS repair as per surgical indication (RS if defect size 4-10cm; PCS-TAR if defect size >10cm and

RESULTS

Not a single recurrence was observed till POD 180 in either of the repair methods. The mean operative time for RS repair was 170.47 ± 15.08 minutes while for TAR repair was 188.8 ± 22.04 (p-value= 0.013). Surgical site infection (SSI) was reported in 14.28% of RS repair cases and 11.11% of TAR repair cases. Seroma formation was observed in 9.5% of RS repair cases. RS repair has less mean CCS score than TAR. The one-way ANOVA showed f-ratio=421.43 and p-value=0.00001 for RS repair while f-ratio= 298.05 and p-value=0 .00001 for TAR repair at POD seven, POD 30, and POD 90. Both RS and TAR repair markedly reduced mean scores in all three domains on POD 90.

CONCLUSION

Both RS and TAR had no recurrence in a short period of six months. The intraoperative time taken in TAR was less than in earlier studies. QoL improved postoperatively in both the repairs with RS repair having better QoL than TAR repair.

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Key Words

• carolina comfort scale
• quality of life
• recurrence
• rives-stoppa
• tar
• ventral hernia

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Affiliation(s)

Rajiv Kumar General Surgery, Indira Gandhi Institute of Medical Sciences, Patna, IND
Prem Prakash General Surgery, Indira Gandhi Institute of Medical Sciences, Patna, IND
Seema R Sinha Biochemistry, Indira Gandhi Institute of Medical Sciences, Patna, IND
Nadeem Ahmad General Surgery, Indira Gandhi Institute of Medical Sciences, Patna, IND
Kanchan S Baitha General Surgery, Indira Gandhi Institute of Medical Sciences, Patna, IND

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Drain placement in retromuscular ventral hernia repair: a systematic review and meta-analysis

PURPOSE

Drain placement in retromuscular ventral hernia repair is controversial. Although it may reduce seroma formation, there is a concern regarding an increase in infectious complications. We aimed to perform a meta-analysis on retromuscular drain placement in retromuscular ventral hernia repair.

METHODS

We performed a literature search of Cochrane, Scopus and PubMed databases to identify studies comparing drain placement and the absence of drain in patients undergoing retromuscular ventral hernia repair. Postoperative outcomes were assessed by pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I² statistics.

RESULTS

3808 studies were screened and 48 were thoroughly reviewed. Four studies comprising 1724 patients were included in the analysis. We found that drain placement was significantly associated with a decrease in seroma (OR 0.34; 95% CI 0.12-0.96; P = 0.04; I² = 78%). Moreover, no differences were noted in surgical site infection, hematoma, surgical site occurrences or surgical site occurrences requiring procedural intervention.

CONCLUSIONS

Based on the analysis of short-term outcomes, retromuscular drain placement after retromuscular ventral hernia repair significantly reduces seroma and does not increase infectious complications. Further prospective randomized studies are necessary to confirm our findings, evaluate the optimal duration of drain placement, and report longer-term outcomes.

Do surgical drains reduce surgical site occurrence and infection after incisional hernia repair with sublay mesh? A non-randomised pilot study

INTRODUCTION

Surgical site occurrence (SSO) and surgical site infection (SSI) are common concerns with incisional hernia repair. Intraoperative drain placement is a common practice aiming to reduce SSO and SSI rates. However, literature on the matter is very poor. The aim of this study is to investigate the role of subcutaneous and periprosthetic drain placement on postoperative outcomes and SSO and SSI rates with incisional hernia repair.

METHODS

A non-randomised pilot study was performed between January 2018 and December 2020 and included patients with elective midline or lateral incisional hernia repair with sublay mesh placement. Patients were prospectively included, followed for 1 month and divided into three groups: group 1 without drainage, group 2 with subcutaneous drainage, and group 3 with subcutaneous and periprosthetic drains. Drains were placed at surgeon's discretion. All patients were included in the enhanced recovery program.

RESULTS

One hundred and four patients were included. Twenty-four patients (23.1%) did not have drains (group 1), 60 patients (57.7%) had a subcutaneous drain (group 2) and 20 patients (19.2%) had both a subcutaneous and a periprosthetic drains (group 3). SSO rates were significantly different between the 3 groups: 20.8% in group 1, 20.7% in group 2 and 50% in group 3 (p = 0.03). There was no significant difference in deep and superficial SSI rates between the 3 groups. Subgroup analysis revealed that adding a drain in direct contact with the mesh significantly increased SSO rate but did not influence SSI rate. Length of stay was also significantly increased by the presence of a drain, 3.1 ± 1.9 days for group 1; 5.9 ± 4.8 for group 2 and 5.9 ± 2.5 days for group 3 (p < 0.005).

CONCLUSION

Drain placement in direct contact with the mesh might increase SSO rate. More studies are necessary to evaluate the actual benefits of drainage after incisional hernia repair.

Patient-performed at-home surgical drain removal is safe and feasible following hernia repair and abdominal wall reconstruction

BACKGROUND

Traditionally, surgical drains are considered a relative contraindication to telemedicine-based postoperative care. We sought to assess the safety, feasibility, and outcomes of an at-home patient-performed surgical drain removal pilot program.

METHODS

A prospective cohort study among patients who were discharged with surgical drains was performed. Patients discharged with drains were given the option for in-clinic, provider-performed removal, or at-home, patient-performed drain removal. Patient demographics, health characteristics, perioperative metrics, and operative outcomes were compared and analyzed.

RESULTS

A total of 68 encounters with drain removal were included (at-home: 28%, n = 19; in-clinic: 72%, n = 49), with both groups having similar demographics, except for age (median age of telemedicine-based at-home: 50 vs in-clinic: 62 years, p = 0.03). Patients who opted into at-home, patient-performed drain removal were more likely to have drain removal occur earlier (9 vs 13 days for in-clinic, p < 0.001). In-clinic removal resulted in increased encounters with surgical nursing staff and increased travel time, with no significant difference in complication burden.

CONCLUSIONS

Patient-performed at-home drain removal is safe and allows for more timely drain removal.

Drain Versus No Drain in Open Mesh Repair for Incisional Hernia, Results of a Prospective Randomized Controlled Trial

BACKGROUND

Open mesh repair of incisional hernia is associated with different local complications, particularly bleeding and seroma formation. Traditionally, drains have been placed perioperatively to prevent these complications, despite the lack of scientific evidence or expert consensus. We formulated the hypothesis that the absence of drainage would reduce number of patients presenting collections or complications. The present study aimed to compare postoperative complication rates after open mesh repair for incisional hernia with or without prophylactic wound drainage.

METHODS

Prospective randomized study using standardized surgical technique and drain placement. The primary endpoint was the evaluation of residual fluid collection with ultrasound on postoperative day 30. Other complications, subdivided into medical and surgical, were analyzed as secondary endpoints.

RESULTS

There were 144 patients randomized (70 with drain, 74 without drain). No difference was identified between both groups for fluid collection at 30 days (60.3% vs. 62%, p = 0.844). However, less surgical complications were identified in the drain group (21.7% vs. 42.7%, p = 0.007), with a lower wound dehiscence rate (1.5% vs. 9.3%, p = 0.041).

CONCLUSIONS

Prophylactic drainage in open incisional hernia repair does not objectively reduce the rate of postoperative fluid collections. Therefore, our results do not support the use of routine drainage in incisional hernia repair.

TRIAL REGISTRATION

Trial registration on clinicaltrials.gov (NCT00478348).

ONLAY VERSUS SUBLAY TECHNIQUES FOR INCISIONAL HERNIA REPAIR: 30-DAY POSTOPERATIVE OUTCOMES

ABSTRACT BACKGROUND: The development of an incisional hernia is a common complication following laparotomy. It also has an important economic impact on healthcare systems and social security budget. The mesh reinforcement of the abdominal wall was an important advancement to increase the success of the repairs and reduce its long-term recurrence. The two most common locations for mesh placement in ventral hernia repairs include the premuscular (onlay technique) and retromuscular planes (sublay technique). However, until now, there is no consensus in the literature about the ideal location of the mesh. AIM: The aim of this study was to compare the two most common incisional hernia repair techniques (onlay and sublay) with regard to the complication rate within the first 30 days of postoperative care. METHOD: This study analyzes 115 patients who underwent either onlay or sublay incisional hernia repairs and evaluates the 30-day postoperative surgical site occurrences and hernia recurrence for each technique. RESULTS: We found no difference in the results between the groups, except in seroma formation, which was higher in patients submitted to the sublay technique, probably due to the lower rate of drain placement in this group. CONCLUSION: Both techniques of mesh placement seem to be adequate in the repair of incisional hernias, with no major difference in surgical site occurrences.

Risks and Prevention of Surgical Site Infection After Hernia Mesh Repair and the Predictive Utility of ACS-NSQIP

AIM

The aim of this paper was to provide a narrative review of surgical site infection after hernia surgery and the influence of perioperative preventative interventions.

METHODS

The review was based on current national and international guidelines and a literature search.

RESULTS

Mesh infection is a highly morbid complication after hernia surgery, and is associated with hospital re-admission, increased health care costs, re-operation, hernia recurrence, impaired quality of life and plaintiff litigation. The American College of Surgeons National Surgical Quality Improvement Program is a particularly useful resource for the study and evidence-based practise of abdominal wall hernia repair.

DISCUSSION

The three major modifiable patient comorbidities significantly associated with postoperative surgical site infection in hernia surgery are obesity, tobacco smoking and diabetes mellitus. Preoperative optimization includes weight loss, cessation of smoking, and control of diabetes. Intraoperative interventions relate, in particular, to the control of fomite mediated transmission in the operating theatre and prevention of mesh contamination with S. aureus CFUs. Risk management strategies should also target the niche ecological conditions which enable bacterial survival and subsequent biofilm formation on an implanted mesh. Outcomes of mesh infection after hernia surgery are closely related to mesh type and porosity, patient smoking status, presence of MRSA, bacterial adhesion and biofilm production. The use of suction drains and the timing of drain removal are controversial and discussed in detail. Finally, the utility of the ACS-NSQIP Surgical Risk Calculator in predicting complications and outcomes in individual patients and the importance of quality improvement initiatives in surgical units are emphasized.

Do drain tubes help reduce risks of post-operative complications in complex incisional hernia repair (as defined by a recent court ruling)?

BACKGROUND

A recent legal case described in the ANZ Journal of Surgery has sparked significant topical interest in drain tube use in incisional hernia repairs in Australia. This study reviews a single centre experience of drain tube use in incisional hernia repair.

METHODS

Data from online clinical records was collected retrospectively from patients that underwent incisional hernia repair from 1 January 2013 to 31 December 2017. 'Complexity' factors of smoking, obesity and lower midline incision (as identified by the legal case) were also used to stratify groups.

RESULTS

A total of 410 incisional hernia repair cases were identified during the 5-year period. Median length of stay of the non-drain placement group was significantly shorter than that of the drain placement group (2 versus 6 days, P < 0.001). In total, 10.8% of patients with drain suffered from post-op wound infection compared to 3.6% in patients without a drain tube in-situ (P = 0.005). Seroma rates were no different with or without a drain (15.7% versus 16.9% P = 0.78). When stratified by 'complexity', there was a trend towards increased complications when drains were used.

CONCLUSION

Drain tubes were placed in only a small proportion of patients during incisional hernia repairs and were associated with a higher post-operative wound infection rate. When stratified by the 'complexity' factors outlined by the recent legal case, complications in more 'complex' patients may actually increase when a drain tube is used.