Outcome of and risk factors for incisional hernia after partial hepatectomy

Postoperative Pain and Incisional Hernia of Specimen Extraction Sites for Minimally Invasive Rectal Cancer Surgery: Comparison of Periumbilical Midline Incision Versus Pfannenstiel Incision

Background: Recent studies indicate that minimally invasive surgery is widely accepted as the optimal procedure for colorectal cancer. However, the ideal location of the specimen extraction site remains unclear. This study aimed to compare the conventional periumbilical midline incision with the Pfannenstiel incision for specimen extraction during minimally invasive surgery for rectal cancer. Methods: This retrospective cohort study included 76 patients who underwent minimally invasive surgery (double-stapling technique anastomosis) for rectal cancer between January 2022 and June 2023. The postoperative short- and mid-term outcomes were compared between the periumbilical midline incision and Pfannenstiel incision groups. Results: The patients' backgrounds were comparable between the two groups. There were no significant differences in the surgical outcomes or short-term postoperative complications. The Pfannenstiel incision demonstrated advantages, including reduced postoperative pain at rest and during movement, and a lower incidence of incisional hernia (p = 0.038). Conclusions: The Pfannenstiel incision is a safe and effective option associated with reduced postoperative pain and a lower risk of incisional hernia. Therefore, it can serve as a useful alternative for specimen extraction during minimally invasive rectal cancer surgery.

Clinical importance of incisional hernia in patients resected for colorectal liver metastases: quality of life and abdominal wall symptoms

PURPOSE

Incisional hernia (IH) after open liver surgery is a well-recognized complication. The clinical importance of IH detected on computed tomography in terms of objective abdominal wall discomfort and impairment of quality of life (QoL) is less well known.

METHODS

Patients who underwent curative surgery for colorectal liver metastases between 2010 and 2015 at a single center and were alive in February 2017 were asked to complete a ventral hernia pain questionnaire and the EORTC QLQ-C30 QoL questionnaire.

RESULTS

A total of 105 patients (80%) completed the questionnaires. Forty-three patients (42%) developed IH. The majority (77%) of IHs were < 2.5 cm. Patients who had an IH before liver surgery developed a new IH to a greater extent (P = 0.001). There were no significant differences regarding abdominal wall symptoms and QoL between patients with and without IH. However, about half (48%) of all patients had abdominal wall symptoms after a median follow-up of 34 months.

CONCLUSION

Radiologically detected IH after open liver surgery has low clinical importance. About half of all patients who underwent liver surgery experienced abdominal wall symptoms a long after surgery, but these symptoms were not related to IH.

Incidence of incisional hernia following liver surgery for colorectal liver metastases. Does the laparoscopic approach reduce the risk? A comparative study

Backgrounds/Aims

No reports to compare incisional hernia (IH) incidence between laparoscopic and open colorectal liver metastases (CRLM) resections have previously been made. This is the first comparative study.

Methods

Single-center retrospective review of patients who underwent CRLM surgery between January 2011 and December 2018. IH relating to liver surgery was confirmed by computed tomography. Patients were divided into laparoscopic liver resection (LLR) and open liver resection (OLR) groups. Data collection included age, sex, presence of diabetes mellitus, steroid intake, history of previous hernia or liver resection, subcutaneous and peri-renal fat thickness, preoperative creatinine and albumin, American Society of Anesthesiologists (ASA) score, major liver resection, surgical site infection, synchronous presentation, and preoperative chemotherapy.

Results

Two hundred and forty-seven patients were included with a mean follow-up period of 41 ± 29 months (mean ± standard deviation). Eighty seven (35%) patients had LLR and 160 patients had OLR. No significant difference in the incidence of IH between LLR and OLR was found at 1 and 3 years, respectively ([10%, 19%] vs. [10%, 19%], p = 0.95). On multivariate analysis, previous hernia history (hazard ratio [HR], 2.22; 95% confidence interval [CI], 1.56-4.86) and subcutaneous fat thickness (HR, 2.22; 95% CI, 1.19-4.13) were independent risk factors. Length of hospital stay was shorter in LLR (6 ± 4 days vs. 10 ± 8 days, p < 0.001), in comparison to OLR.

Conclusions

In CRLM, no difference in the incidence of IH between LLR and OLR was found. Previous hernia and subcutaneous fat thickness were risk factors. Further studies are needed to assess modifiable risk factors to develop IH in LLR.

Small bites versus large bites during fascial closure of midline laparotomies: a systematic review and meta-analysis

PURPOSE

Incisional ventral hernias (IVH) are common after laparotomies, with up to 20% incidence in 12 months, increasing up to 60% at 3-5 years. Although Small Bites (SB) is the standard technique for fascial closure in laparotomies, its adoption in the United States is limited, and Large Bites (LB) is still commonly performed. We aim to assess the effectiveness of SB regarding IVH.

METHODS

We searched for RCTs and observational studies on Cochrane, EMBASE, and PubMed from inception to May 2023. We selected patients ≥ 18 years old, undergoing midline laparotomies, comparing SB and LB for IVH, surgical site infections (SSI), fascial dehiscence, hospital stay, and closure duration. We used RevMan 5.4. and RStudio for statistics. Heterogeneity was assessed with I2 statistics, and random effect was used if I2 > 25%.

RESULTS

1687 studies were screened, 45 reviewed, and 6 studies selected, including 3 RCTs and 3351 patients (49% received SB and 51% LB). SB showed fewer IVH (RR 0.54; 95% CI 0.39-0.74; P < 0.001) and SSI (RR 0.68; 95% CI 0.53-0.86; P = 0.002), shorter hospital stay (MD -1.36 days; 95% CI -2.35, -0.38; P = 0.007), and longer closure duration (MD 4.78 min; 95% CI 3.21-6.35; P < 0.001). No differences were seen regarding fascial dehiscence.

CONCLUSION

SB technique has lower incidence of IVH at 1-year follow-up, less SSI, shorter hospital stay, and longer fascial closure duration when compared to the LB. SB should be the technique of choice during midline laparotomies.

Incidence of and Risk Factors for Incisional Hernia After Hepatectomy for Colorectal Liver Metastases

BACKGROUND

Incisional hernia (IH) is common after major abdominal surgery; however, the incidence after hepatectomy for cancer has not been described. We analyzed incidence of and risk factors for IH after hepatectomy for colorectal liver metastases (CLM).

METHODS

Patients who underwent open hepatectomy with midline or reverse-L incision for CLM at a single institution between 2010 and 2018 were retrospectively analyzed. Postoperative CT scans were reviewed to identify IH and the time from hepatectomy to hernia. Cumulative IH incidence was calculated using competing risk analysis. Risk factors were assessed using Cox proportional hazards model analysis. The relationship between IH incidence and preoperative body mass index (BMI) was estimated using a generalized additive model.

RESULTS

Among 470 patients (median follow-up: 16.9 months), IH rates at 12, 24, and 60 months were 41.5%, 51.0%, and 59.2%, respectively. Factors independently associated with IH were surgical site infection (HR: 1.54, 95% CI 1.16-2.06, P = 0.003) and BMI > 25 kg/m2 (HR: 1.94, 95% CI 1.45-2.61, P < 0.001). IH incidence was similar in patients undergoing midline and reverse-L incisions and patients who received and did not receive a bevacizumab-containing regimen. The 1-year IH rate increased with increasing number of risk factors (zero: 22.2%; one: 46.8%; two: 60.3%; P < 0.001). Estimated IH incidence was 10% for BMI of 15 kg/m2 and 80% for BMI of 40 kg/m2.

CONCLUSION

IH is common after open hepatectomy for CLM, particularly in obese patients and patients with surgical site infection. Surgeons should consider risk-mitigation strategies, including alternative fascial closure techniques.

Corticosteroid Dose in Kidney Transplantation and Its Effect on Surgical Complication: A Systematic Review

OBJECTIVES

Although several studies have explored the connection between corticosteroids and renal transplant surgical complications, these studies have overlooked several factors. In addition, no review of the literature, to our knowledge, has been conducted to evaluate corticosteroid dose and incidence of posttransplant surgical complications in these patients. Thus, our objective was to carry out a systematic investigation ofthe correlationbetween corticosteroids and surgical complications in renaltransplant patients.

MATERIALS AND METHODS

A systematic search was conducted on the PubMed and Embase databases from their inception until April 2023. Retrospective and prospective cohort studies were included if they met the association between corticosteroids and surgical complications. The search strategy was performed using MeSH and non-MeSH key words. Terms used in the electronic search included kidney transplant* OR kidney transplant(mesh) AND steroid* OR steroids(mesh) AND complication* OR intraoperative complications(mesh).

RESULTS

From 3274 articles, 8 articles were included in the systematic review. Six studies were conducted as retrospective cohorts and 2 studies as prospective cohorts. The mean age of patients included in the studies was 42.1 years. The studies were conducted between 1981 and 2023. Findings suggested that decreasing the postoperative corticosteroid dosage was associated with a lower incidence of various postoperative surgical complications.

CONCLUSIONS

We investigated the potential benefits of reducing the dose of corticosteroids following kidney transplant. Findings suggested thatreducing the dose of corticosteroids following kidney transplant might be a viable strategy for minimizing the risk of surgical complications. However, it is essential to note that the optimal dosage and duration of corticosteroid therapy after kidney transplant may vary for each patient and should be carefully determined by the health care provider.

Incisions in Hepatobiliopancreatic Surgery: Surgical Anatomy and its Influence to Open and Close the Abdomen

Incisions performed for hepato-pancreatic-biliary (HPB) surgery are diverse, and can be a challenge both to perform correctly as well as to be properly closed. The anatomy of the region overlaps muscular layers and has a rich vascular and nervous supply. These structures are fundamental for the correct functionality of the abdominal wall. When performing certain types of incisions, damage to the muscular or neurovascular component of the abdominal wall, as well as an inadequate closure technique may influence in the development of long-term complications as incisional hernias (IH) or bulging. Considering that both may impair quality of life and that are complex to repair, prevention becomes essential during these procedures. With the currently available evidence, there is no clear recommendation on which is the better incision or what is the best method of closure. Despite the lack of sufficient data, the following review aims to correlate the anatomical knowledge learned from posterior component separation with the incisions performed in hepato-pancreatic-biliary (HPB) surgery and their consequences on incisional hernia formation. Overall, there is data that suggests some key points to perform these incisions: avoid vertical components and very lateral extensions, subcostal should be incised at least 2 cm from costal margin, multilayered suturing using small bites technique and consider the use of a prophylactic mesh in high-risk patients. Nevertheless, the lack of evidence prevents from the possibility of making any strong recommendations.

Intramuscular Adipose Tissue Content as a Predictor of Incisional Hernia after Hepatic Resection

BACKGROUND

Incisional hernia (IH) is a common surgical complication, with an incidence of 6-31% following major abdominal surgery. This study aimed to investigate the impact of intramuscular adipose tissue content (IMAC) on the incidence of IH in patients who underwent hepatic resection.

METHODS

Data of 205 patients who underwent open hepatic resection between 2007 and 2019 at Ehime University Hospital were retrospectively analyzed. Patient characteristics, perioperative findings, and body composition were compared between patients with IH and those without IH. The quantity and quality of skeletal muscle, calculated as skeletal muscle index and IMAC, were evaluated using preoperative computerized tomography images.

RESULTS

Forty (19.5%) patients were diagnosed with IH. The cumulative incidence rates were 15.6% at 1 year and 19.6% at 3 years. On univariate analysis, body mass index, areas of subcutaneous and visceral fat, and IMAC were significantly higher in the IH group than in the non-IH group (p = 0.0023, 0.0070, 0.0047, and 0.0080, respectively). No significant difference in skeletal muscle index was found between the groups (p = 0.3548). The incidence of diabetes mellitus, intraoperative transfusion, and postoperative wound infection was significantly higher in the IH group than in the non-IH group (p = 0.0361, 0.0078, and 0.0299, respectively). On multivariate analysis, a high IMAC and wound infection were independent risk factors for IH (adjusted odds ratio, 2.83 and 4.52, respectively; p = 0.0152 and 0.0164, respectively).

CONCLUSION

IMAC can predict the incidence of IH in patients undergoing hepatic resection.

Preoperative Computed Tomography Morphological Features Indicative of Incisional Hernia Formation After Abdominal Surgery

OBJECTIVE

To investigate key morphometric features identifiable on routine preoperative computed tomography (CT) imaging indicative of incisional hernia (IH) formation following abdominal surgery.

BACKGROUND

IH is a pervasive surgical disease that impacts all surgical disciplines operating in the abdominopelvic region and affecting 13% of patients undergoing abdominal surgery. Despite the significant costs and disability associated with IH, there is an incomplete understanding of the pathophysiology of hernia.

METHODS

A cohort of patients (n=21,501) that underwent colorectal surgery was identified, and clinical data and demographics were extracted, with a primary outcome of IH. Two datasets of case-control matched pairs were created for feature measurement, classification, and testing. Morphometric linear and volumetric measurements were extracted as features from anonymized preoperative abdominopelvic CT scans. Multivariate Pearson testing was performed to assess correlations among features. Each feature's ability to discriminate between classes was evaluated using 2-sided paired t testing. A support vector machine was implemented to determine the predictive accuracy of the features individually and in combination.

RESULTS

Two hundred and twelve patients were analyzed (106 matched pairs). Of 117 features measured, 21 features were capable of discriminating between IH and non-IH patients. These features are categorized into three key pathophysiologic domains: 1) structural widening of the rectus complex, 2) increased visceral volume, 3) atrophy of abdominopelvic skeletal muscle. Individual prediction accuracy ranged from 0.69 to 0.78 for the top 3 features among 117.

CONCLUSIONS

Three morphometric domains identifiable on routine preoperative CT imaging were associated with hernia: widening of the rectus complex, increased visceral volume, and body wall skeletal muscle atrophy. This work highlights an innovative pathophysiologic mechanism for IH formation hallmarked by increased intra-abdominal pressure and compromise of the rectus complex and abdominopelvic skeletal musculature.

Stoma creation is associated with a low incidence of midline incisional hernia after colorectal surgery: the "fighting over the fascia" theory concerning the incision and stoma hole

PURPOSE

Parastomal hernia (PH) develops more frequently than incisional hernia (IH) after colorectal surgery with stoma. This study evaluated our hypothesis that inward traction of the fascia when closing a midline incision widens the stoma hole and increases the incidence of PH.

METHODS

A total of 795 patients who underwent colorectal resection between 2006 and 2016 were retrospectively analyzed. The risk classification was constructed from IH risk factors extracted from the non-stoma group. Then, the classification was extrapolated to the stoma group for predicting midline IH and PH.

RESULTS

The incidence of IH was 5.3% in the stoma group and 12.5% in the non-stoma group (p = 0.005). PH developed in 19.6% of 97 patients with permanent stoma. The risk classification was able to predict PH without a significant difference but was well balanced in patients with permanent stoma; however, it failed to predict IH in the stoma group.

CONCLUSION

The risk classification constructed from the non-stoma group was useful for predicting not midline IH but PH, suggesting that the stoma site was the most vulnerable for herniation. The "fighting over the fascia" theory between the midline incision and stoma hole may explain the causal relationship between the midline IH and PH.

Limited upper midline incision for major hepatectomy in adults: safety and feasibility

Objective: Optimal incision for major hepatectomy remains controversial. In this study, we described our experience with a limited upper midline incision (UMI) for major hepatectomy. The objective was to analyze the feasibility and safety of UMI in major hepatectomy.

Material and Methods: Fifty-seven consecutive patients who underwent major hepatectomies performed via an UMI were compared to a control group of 36 patients who underwent major hepatectomies with a conventional incision (CI).

Results: In 85% of the patients, the indication was malignancy, with a median tumor size of 6 cm. Fifty-three percent of the patients had underlying chronic liver disease, and liver fibrosis was found in 61% of the patients. Ninteen percent of the patients had previous upper abdominal surgery. Twenty- six patients underwent left hepatectomy, 20 patients had right hepatectomy and 11 patients trisegmentectomy. Additional combined surgical proce- dures were performed in 42% of the patients. Median operative time was 323 minutes, estimated blood loss was 500 ml, and median post-operative hospital stay was seven days. Surgical complications occurred in 22 patients (39%). 5-year overall survival was 67%. When compared with the control group with CI, patients with UMI had no statistical difference on operative time, estimated blood loss, length of hospital stay, complication rate, and overall survival.

Conclusion: Major hepatectomies can be safely performed through UMI. This approach should be considered as a reasonable option in addition to conventional and laparoscopic approaches for major hepatectomies.

Incisional Surgical Site Infections After Mass and Layered Closure of Upper Abdominal Transverse Incisions: First Results of a Randomized Controlled Trial

OBJECTIVE

To compare the early results of mass and layered closure of upper abdominal transverse incisions.

SUMMARY OF BACKGROUND DATA

Contrary to midline incisions, data on closure of transverse abdominal incisions are lacking.

METHODS

This is the first analysis of a randomized controlled trial primarily designed to compare mass with layered closure of transverse incisions with respect to incisional hernias. Patients undergoing laparotomy through upper abdominal transverse incisions were randomized to either mass or layered closure with continuous sutures. Incisional surgical site infection (incisional-SSI) was the primary end-point. Secondary end-points comprised suture-to-wound length ratio (SWLR), closure duration, and fascial dehiscence (clinicatrials.gov NCT03561727).

RESULTS

A total of 268 patients were randomized to either mass (n=134) or layered (n=134) closure. Incisional-SSIs occurred in 24 (17.9%) and 8 (6.0%) patients after mass and layered closure, respectively (P =0.004), with crude odds ratio (OR) of 0.29 [95% confidence interval (95% CI) 0.13-0.67; P =0.004]. Layered technique was independently associated with fewer incisional-SSIs (OR: 0.29; 95% CI 0.12-0.69; P =0.005). The number needed to treat, absolute, and relative risk reduction for layered technique in reducing incisional-SSIs were 8.4 patients, 11.9%, and 66.5%, respectively. Dehiscence occurred in one (0.8%) patient after layered closure and in two (1.5%) patients after mass closure (P >0.999). Median SWLR were 8.1 and 5.6 (P <0.001) with median closure times of 27.5 and 25.0 minutes (P =0.044) for layered and mass closures, respectively.

CONCLUSIONS

Layered closure of upper abdominal transverse incisions should be preferred due to lower risk of incisional-SSIs and higher SWLR, despite clinically irrelevant longer duration.

Is the incision type important for the development of hernia in liver transplant patients?

OBJECTIVE

In this study, we aimed to investigate the rates and causes of incisional hernia that developed in the postoperative follow-up of patients who underwent liver transplantation.

MATERIAL AND METHOD

The results of patients who underwent LT by using three different incisions at the İstanbul Yeni Yüzyıl University Gaziosmanpaşa Hospital organ transplant center between January 2015 and December 2019 were retrospectively analyzed. Patients were divided into Chevron (group-1), reverse T (group-2), and J incisions (group-3) and hernia development rates were examined.

RESULTS

There was no significant difference in terms of incisional hernia in groups 1 and 2 according to the incision type (p = .723). Incisional hernia rate was significantly lower in the J incision group (p < .001). When the factors that increase the development of hernia in all LT patients were examined, it was seen that male gender (p = .021), high BMI rate (p = .003), postoperative bleeding (p = .018), and wound infection (p = .039) caused a significant increase in risk.

CONCLUSION

The incision, which is made during liver transplant, is important for the development of hernia. The J incision has a low hernia development rate without causing access problems. Regardless of the incision, high BMI index, male gender, postoperative bleeding, and wound infection increase the development of incisional hernia in liver transplant patients.

Risk factors for incisional hernia according to different wound sites after open hepatectomy using combinations of vertical and horizontal incisions: A multicenter cohort study

Background: Although several risk factors for incisional hernia after hepatectomy have been reported, their relationship to different wound sites has not been investigated. Therefore, this study aimed to examine the risk factors for incisional hernia according to various wound sites after hepatectomy. Methods: Patients from the Osaka Liver Surgery Study Group who underwent open hepatectomy using combinations of vertical and horizontal incisions (J-shaped incision, reversed L-shaped incision, reversed T-shaped incision, Mercedes incision) between January 2012 and December 2015 were included. Incisional hernia was defined as a hernia occurring within 3 y after surgery. Abdominal incisional hernia was classified into midline incisional hernia and transverse incisional hernia. The risk factors for each posthepatectomy incisional hernia type were identified. Results: A total of 1057 patients met the inclusion criteria. The overall posthepatectomy incisional hernia incidence rate was 5.9% (62 patients). In the multivariate analysis, the presence of diabetes mellitus and albumin levels <3.5 g/dL were identified as independent risk factors. Moreover, incidence rates of midline and transverse incisional hernias were 2.4% (25 patients), and 2.3% (24 patients), respectively. In multivariate analysis, the independent risk factor for transverse incisional hernia was the occurrence of superficial or deep incisional surgical site infection, and interrupted suturing for midline incisional hernia. Conclusions: Risk factors for incisional hernia after hepatectomy depend on the wound site. To prevent incisional hernia, running suture use might be better for midline wound closure. The prevention of postoperative wound infection is important for transverse wounds, under the presumption of preoperative nutrition and normoglycemia.

Wound complications after primary and repeated midline, transverse and modified Makuuchi incision: A single-center experience in 696 patients

There are 3 main types of incisions in major open, elective abdominal surgery: the midline incision (MI), the transverse incision (TI) and the modified Makuuchi incision (MMI). This study aimed to compare these approaches regarding wound complications and hernias, with a special focus on suture material and previous laparotomies.Patients who underwent elective abdominal surgery between 2015 and 2016 were retrospectively analyzed. Uni- and multivariate analyses were computed using stepwise binary and multifactorial regression models.In total, 696 patients (406 MI, 137 TI and 153 MMI) were included. No relevant differences were observed for patient characteristics (e.g., sex, age, body mass index [BMI], American Society of Anesthesiologists [ASA] score). Fewer wound complications (TI 22.6% vs MI 33.5% vs MMI 32.7%, P = .04) occurred in the TI group. However, regarding the endpoints surgical site infection (SSI), fascial dehiscence and incisional hernia, no risk factor after MI, TI, and MMI could be detected in statistical analysis. There was no difference regarding the occurrence of fascial dehiscence (P = .58) or incisional hernia (P = .97) between MI, TI, and MMI. In cases of relaparotomies, the incidence of fascial dehiscence (P = .2) or incisional hernia (P = .58) did not significantly differ between the MI, TI, or MMI as well as between primary and reincision of each type. On the other hand, the time to first appearance of a hernia after MMI is significantly shorter (P = .03) than after MI or TI, even after previous laparotomy (P = .003).In comparing the 3 most common types of abdominal incisions and ignoring the type of operative procedure performed, TI seems to be the least complicated approach. However, because the incidence of fascial dehiscence and incisional hernia is not relevantly increased, the stability of the abdominal wall is apparently not affected by relaparotomy, even by repeated MIs, TIs, and MMIs. Therefore, the type of laparotomy, especially a relaparotomy, can be chosen based on the surgeon's preference and planned procedure without worrying about increased wound complications.

Preventing incisional ventral hernias: important for patients but ignored by surgical specialities? A critical review

PURPOSE

Incisional ventral hernias (IHs) are a common complication across all surgical specialities requiring access to the abdomen, pelvis, and retroperitoneum. This public health issue continues to be widely ignored, resulting in appreciable morbidity and expenses. In this critical review, the issue is explored by an interdisciplinary group.

METHODS

A group of European surgeons encompassing representatives from abdominal wall, vascular, urological, gynecological, colorectal and hepato-pancreatico-biliary surgery have reviewed the occurrence of His in these disciplines.

RESULTS

Incisional hernias are a major public health issue with appreciable morbidity and cost implications. General surgeons are commonly called upon to repair IHs following an initial operation by others. Measures that may collectively reduce the frequency of IH across specialities include better planning and preparation (e.g. a fit patient, no time pressure, an experienced operator). A minimally invasive technique should be employed where appropriate. Our main recommendations in midline incisions include using the 'small bites' suture technique with a ≥ 4:1 suture-to-wound length, and adding prophylactic mesh augmentation in patients more likely to suffer herniation. For off-midline incisions, more research of this problem is essential.

CONCLUSION

Meticulous closure of the incision is significant for every patient. Raising awareness of the His is necessary in all surgical disciplines that work withing the abdomen or retroperitoneum. Across all specialties, surgeons should aim for a < 10% IH rate.

Incisional hernia formation in hepatobiliary surgery using transverse and hybrid incisions: a systematic review and meta-analysis

INTRODUCTION

Evidence suggests that midline incisions should be closed with the small-bite technique to reduce IH formation. No recommendations exist for the closure of transverse incisions used in hepatobiliary surgery. This work systematically summarises rates of IH formation and associated technical factors for these transverse incisions.

METHODS

A systematic search was undertaken. Studies describing the incidence of IH were included. Incisions were classified as transverse (two incision types) or hybrid (transverse with midline extension, comprising five incision types). The primary outcome measure was the pooled proportion of IH. Subgroup analysis based on minimum follow-up of two years and a priori definition of IH with clinical and radiological diagnosis was undertaken.

FINDINGS

Thirteen studies were identified and included 5,427 patients; 1,427 patients (26.3%) underwent surgery for benign conditions, 3,465 (63.8%) for malignancy and 535 (9.9%) for conditions that were not stated or classified as 'other'. The pooled incidence of IH was 6.0% (2.0-10.0%) at a weighted mean follow-up of 17.5 months in the transverse group, compared with 15.0% (11.0-19.0%) at a weighted mean follow-up of 42.0 months in the hybrid group (p = 0.045). Subgroup analysis did not demonstrate a statistical difference in IH formation between the hybrid versus transverse groups.

CONCLUSION

Owing to the limitations in study design and heterogeneity, there is limited evidence to guide incision choice and methods of closure in hepatopancreatobiliary surgery. There is an urgent need for a high-quality prospective cohort study to understand the techniques used and their outcomes, to inform future research.

[Analysis of the causes of recurrent postoperative ventral hernias]

OBJECTIVE

To study the causes of recurrent postoperative ventral hernias and methods for their prevention.

MATERIAL AND METHODS

There were 58 patients with recurrent postoperative ventral hernias after various methods of abdominal wall repair for the period 2005-2017.

RESULTS

The main causes of recurrent postoperative ventral hernias were identified. Local tissue rearrangement resulted recurrent hernia in 21 (36.2%) patients, that was observed even in patients with small hernia. Size discrepancy between endoprosthesis and hernial orifice caused a recurrence in 20 (34.5%) patients. In 11 (19%) patients, implant detachment followed by recurrent hernia occurred. Postoperative wound complications followed by recurrent hernia were diagnosed in 6 (10.3%) patients. Non-compliance with recommendations for wearing a bandage and restricting physical exertion also contributed to the development of recurrent hernia. Moreover, recurrent hernia occurred mainly in obese patients. Mean body mass index was 34.27±2.2 kg/m². Recurrent hernia was again detected in 12 out of 35 patients in long-term period after surgical treatment.

CONCLUSION

It is necessary to abandon local tissue rearrangement and to select a correct size of synthetic material for prevention of recurrent postoperative hernia. Preoperative body weight control is essential in patients with obesity. Wearing a bandage and restricting physical exertion are obligatory in postoperative period. Annual examination during 3-5 years after surgery is essential for timely diagnosis of recurrent hernia.

Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations

BACKGROUND

Enhanced Recovery After Surgery (ERAS) is a multimodal pathway developed to overcome the deleterious effect of perioperative stress after major surgery. In colorectal surgery, ERAS pathways reduced perioperative morbidity, hospital stay and costs. Similar concept should be applied for liver surgery. This study presents the specific ERAS Society recommendations for liver surgery based on the best available evidence and on expert consensus.

METHODS

A systematic review was performed on ERAS for liver surgery by searching EMBASE and Medline. Five independent reviewers selected relevant articles. Quality of randomized trials was assessed according to the Jadad score and CONSORT statement. The level of evidence for each item was determined using the GRADE system. The Delphi method was used to validate the final recommendations.

RESULTS

A total of 157 full texts were screened. Thirty-seven articles were included in the systematic review, and 16 of the 23 standard ERAS items were studied specifically for liver surgery. Consensus was reached among experts after 3 rounds. Prophylactic nasogastric intubation and prophylactic abdominal drainage should be omitted. The use of postoperative oral laxatives and minimally invasive surgery results in a quicker bowel recovery and shorter hospital stay. Goal-directed fluid therapy with maintenance of a low intraoperative central venous pressure induces faster recovery. Early oral intake and mobilization are recommended. There is no evidence to prefer epidural to other types of analgesia.

CONCLUSIONS

The current ERAS recommendations were elaborated based on the best available evidence and endorsed by the Delphi method. Nevertheless, prospective studies need to confirm the clinical use of the suggested protocol.

Prevention of incisional hernia with prophylactic onlay and sublay mesh reinforcement versus primary suture only in midline laparotomies (PRIMA): 2-year follow-up of a multicentre, double-blind, randomised controlled trial

BACKGROUND

Incisional hernia is a frequent long-term complication after abdominal surgery, with a prevalence greater than 30% in high-risk groups. The aim of the PRIMA trial was to evaluate the effectiveness of mesh reinforcement in high-risk patients, to prevent incisional hernia.

METHODS

We did a multicentre, double-blind, randomised controlled trial at 11 hospitals in Austria, Germany, and the Netherlands. We included patients aged 18 years or older who were undergoing elective midline laparotomy and had either an abdominal aortic aneurysm or a body-mass index (BMI) of 27 kg/m² or higher. We randomly assigned participants using a computer-generated randomisation sequence to one of three treatment groups: primary suture; onlay mesh reinforcement; or sublay mesh reinforcement. The primary endpoint was incidence of incisional hernia during 2 years of follow-up, analysed by intention to treat. Adjusted odds ratios (ORs) were estimated by logistic regression. This trial is registered at ClinicalTrials.gov, number NCT00761475.

FINDINGS

Between March, 2009, and December, 2012, 498 patients were enrolled to the study, of whom 18 were excluded before randomisation. Therefore, we included 480 patients in the primary analysis: 107 were assigned primary suture only, 188 were allocated onlay mesh reinforcement, and 185 were assigned sublay mesh reinforcement. 92 patients were identified with an incisional hernia, 33 (30%) who were allocated primary suture only, 25 (13%) who were assigned onlay mesh reinforcement, and 34 (18%) who were assigned sublay mesh reinforcement (onlay mesh reinforcement vs primary suture, OR 0·37, 95% CI 0·20-0·69; p=0·0016; sublay mesh reinforcement vs primary suture, 0·55, 0·30-1·00; p=0·05). Seromas were more frequent in patients allocated onlay mesh reinforcement (34 of 188) than in those assigned primary suture (five of 107; p=0·002) or sublay mesh reinforcement (13 of 185; p=0·002). The incidence of wound infection did not differ between treatment groups (14 of 107 primary suture; 25 of 188 onlay mesh reinforcement; and 19 of 185 sublay mesh reinforcement).

INTERPRETATION

A significant reduction in incidence of incisional hernia was achieved with onlay mesh reinforcement compared with sublay mesh reinforcement and primary suture only. Onlay mesh reinforcement has the potential to become the standard treatment for high-risk patients undergoing midline laparotomy.

FUNDING

Baxter; B Braun Surgical SA.

Long-Term Nononcologic Outcomes for Laparoscopic Liver Resection: Improvement over Open Hepatectomy?

Prior studies of laparoscopic liver resection (LLR) have evaluated long-term outcomes in terms of cancer survival, but few have evaluated nononcologic outcomes. This study analyzes long-term nondisease-specific complications associated with LLR and open liver resection (OLR). We performed a retrospective single-institution review of patients undergoing liver resection for any reason from January 2005 to December 2014. Long-term complication was defined as any complication not related to the primary disease process, and occurring more than 90 days after surgery, emphasizing incisional hernia (IH) and small bowel obstruction (SBO). A total of 208 patients were included in the OLR group and 79 patients in the LLR group. Forty-one patients (19.6%) developed IH after OLR, whereas only six patients (7.5%) developed IH after LLR ( P = 0.01). About 3.8 per cent of patients developed IH requiring surgical repair in both groups. Seven patients developed SBO (3.4%) after OLR; no patient developed SBO after LLR. Median time to development of complications was 13.8 months (range 3–54 months) after OLR compared with 8.5 months after LLR (range 6–36 months). Male gender, body mass index, prior abdominal surgery, and OLR were independent risk factors for development of long-term complications. There is a higher incidence of nondisease-specific complications after OLR than LLR.

Mass Continuous Suture versus Layered Interrupted Suture in Transverse Abdominal Incision Closure after Liver Resection

BACKGROUND

Abdominal incision closure technique seriously influences patient prognosis. Most studies have focused on the different suture techniques and materials on midline incision, while little data are available in wide transverse or oblique incisions after liver resection (LR). The aim of the present study is to compare the two major incision suture methods after LR in our institute: Mass continuous suture (group P) and layered interrupted suture (group S).

STUDY DESIGN

258 patients undergoing LR with abdominal transverse or oblique incisions were prospectively enrolled. They were divided into two groups according to different abdominal incision suture methods and compared with the preoperative, intraoperative parameters, and postoperative wound complications.

RESULTS

There were 118 patients in group P and 140 patients in group S, which was similar in general condition, primary disease, liver, and renal function. Incision length, total operation time, intraoperative blood loss, or perioperative antibiotics use were not different between the two groups. However, abdominal incision closure time and interval time for stitches removing after operation was significantly shorter in group P than group S (both p < 0.001). After a median follow-up of 16 months, the incidence of wound infection and fat liquefaction was more than two times higher in group S than group P, which, however, was not statistically different. Moreover, there was no difference in wound disruption or incisional hernia between the two groups.

CONCLUSIONS

Although similar in occurrence of postoperative wound complications, mass continuous suture with polydioxanone seemed to be more timesaving in incision closure and motivated in wound healing.

Incisional hernia after open resections for colorectal liver metastases - incidence and risk factors

BACKGROUND

Incisional hernia is one of the most common complications after laparotomy. The aim of this retrospective study was to investigate incidence, location and risk factors for incisional hernia after open resection for colorectal liver metastases including the use of perioperative chemotherapy and targeted therapy evaluated by computed tomography.

METHODS

Patients operated for colorectal liver metastases between 2010 and 2013 were included. Incisional hernia was defined as a discontinuity in the abdominal fascia observed on computed tomography.

RESULTS

A total of 256 patients were analyzed in regard to incisional hernia. Seventy-eight patients (30.5%) developed incisional hernia. Hernia locations were midline alone in 66 patients (84.6%) and involving the midline in another 8 patients (10.3%). In multivariate analysis, preoperative chemotherapy >6 cycles (hazard ratio 2.12, 95% confidence interval 1.14-3.94), preoperative bevacizumab (hazard ratio 3.63, 95% confidence interval 1.86-7.08) and incisional hernia from previous surgery (hazard ratio 3.50, 95% confidence interval 1.98-6.18) were found to be independent risk factors.

CONCLUSIONS

Prolonged preoperative chemotherapy and also preoperative bevacizumab were strong predictors for developing an incisional hernia. After an extended right subcostal incision, the hernia location was almost exclusively in the midline.

Systematic Review and Meta-Regression of Factors Affecting Midline Incisional Hernia Rates: Analysis of 14,618 Patients

BACKGROUND

The incidence of incisional hernias (IHs) following midline abdominal incisions is difficult to estimate. Furthermore recent analyses have reported inconsistent findings on the superiority of absorbable versus non-absorbable sutures.

OBJECTIVE

To estimate the mean IH rate following midline laparotomy from the published literature, to identify variables that predict IH rates and to analyse whether the type of suture (absorbable versus non-absorbable) affects IH rates.

METHODS

We undertook a systematic review according to PRISMA guidelines. We sought randomised trials and observational studies including patients undergoing midline incisions with standard suture closure. Papers describing two or more arms suitable for inclusion had data abstracted independently for each arm.

RESULTS

Fifty-six papers, describing 83 separate groups comprising 14,618 patients, met the inclusion criteria. The prevalence of IHs after midline incision was 12.8% (range: 0 to 35.6%) at a weighted mean of 23.7 months. The estimated risk of undergoing IH repair after midline laparotomy was 5.2%. Two meta-regression analyses (A and B) each identified seven characteristics associated with increased IH rate: one patient variable (higher age), two surgical variables (surgery for AAA and either surgery for obesity surgery (model A) or using an upper midline incision (model B)), two inclusion criteria (including patients with previous laparotomies and those with previous IHs), and two circumstantial variables (later year of publication and specifying an exact significance level). There was no significant difference in IH rate between absorbable and non-absorbable sutures either alone or in conjunction with either regression analysis.

CONCLUSIONS

The IH rate estimated by pooling the published literature is 12.8% after about two years. Seven factors account for the large variation in IH rates across groups. However there is no evidence that suture type has an intrinsic effect on IH rates.

Risk factors for incisional hernia after hepatic resection for hepatocellular carcinoma in patients with liver cirrhosis

BACKGROUND

The risk factors for incisional hernia (IH) and the association between liver fibrosis and IH after hepatic resection in patients with hepatocellular carcinoma (HCC) with liver cirrhosis (LC) are still unclear. We aimed to evaluate the rate of IH and to assess the effect of perioperative factors, including serum markers for liver fibrosis, on the risk of IH.

METHODS

A total of 192 patients with HCC with LC who received hepatectomy were retrospectively analyzed. The primary end point was the incidence rate of IH and the secondary end points were associations between IH and 22 clinical factors.

RESULTS

IH was diagnosed in 60 (31.3%) patients. The estimated incidence rates were 19.8% at 12 months, 32.5% at 36 months, and 38.8% at 60 months. In multivariable analysis, the presence of postoperative intractable ascites (odds ratio 24.83, P = .0003), abdominal wall closure by a single-layer mass closure with a continuous running suture (odds ratio 4.59, P = .0143), preoperative body mass index ≥ 25 kg/m(2) (odds ratio 3.36, P = .0025), and preoperative serum N-terminal pro-peptide of type IV collagen 7S domain (P4NP 7S) levels ≥ 5 ng/mL (odds ratio 3.13, P = .0234) were independent risk factors.

CONCLUSION

There are several risk factors for IH after hepatic resection in HCC patients with LC. Preoperative serum P4NP 7S levels ≥ 5 ng/mL are a useful predictive marker, and abdominal wall closure with a continuous running suture by a single-layer mass closure should be avoided.

Visceral obesity, not elevated BMI, is strongly associated with incisional hernia after colorectal surgery

BACKGROUND

High BMI is often used as a proxy for obesity and has been considered a risk factor for the development of an incisional hernia after abdominal surgery. However, BMI does not accurately reflect fat distribution.

OBJECTIVE

The purpose of this work was to investigate the relationship among different obesity measurements and the risk of incisional hernia.

DESIGN

This was a retrospective cohort study.

SETTINGS

The study included a single academic institution in New York from 2003 to 2010.

PATIENTS

The study consists of 193 patients who underwent colorectal cancer resection.

MAIN OUTCOME MEASURES

Preoperative CT scans were used to measure visceral fat volume, subcutaneous fat volume, total fat volume, and waist circumference. A diagnosis of incisional hernia was made either through physical examination in medical chart documentation or CT scan.

RESULTS

Forty-one patients (21.2%) developed an incisional hernia. The median time to hernia was 12.4 months. After adjusting for patient and surgical characteristics using Cox regression analysis, visceral obesity (HR 2.04, 95% CI 1.07-3.91) and history of an inguinal hernia (HR 2.40, 95% CI 1.09-5.25) were significant risk factors for incisional hernia. Laparoscopic resection using a transverse extraction site led to a >75% reduction in the risk of incisional hernia (HR 0.23, 95% CI 0.07-0.76). BMI > 30 kg/m was not significantly associated with incisional hernia development.

LIMITATIONS

Limitations include the retrospective design without standardized follow-up to detect hernias and the small sample size attributed to inadequate or unavailable CT scans.

CONCLUSIONS

Visceral obesity, history of inguinal hernia, and location of specimen extraction site are significantly associated with the development of an incisional hernia, whereas BMI is poorly associated with hernia development. These findings suggest that a lateral transverse location is the incision site of choice and that new strategies, such as prophylactic mesh placement, should be considered in viscerally obese patients.

Incidence of and risk factors for incisional hernia after abdominal surgery

BACKGROUND

Few larger studies have estimated the incidence of incisional hernia (IH) after abdominal surgery.

METHODS

Patients who had abdominal surgery between November 2009 and February 2011 were included in the study. The incidence rate and risk factors for IH were monitored for at least 180  days.

RESULTS

A total of 4305 consecutive patients were registered. Of these, 378 were excluded because of failure to complete follow-up and 3927 patients were analysed. IH was diagnosed in 318 patients. The estimated incidence rates for IH were 5·2 per cent at 12  months and 10·3 per cent at 24 months. In multivariable analysis, wound classification III and IV (hazard ratio (HR) 2·26, 95 per cent confidence interval 1·52 to 3·35), body mass index of 25 kg/m(2) or higher (HR 1·76, 1·35 to 2·30), midline incision (HR 1·74, 1·28 to 2·38), incisional surgical-site infection (I-SSI) (HR 1·68, 1·24 to 2·28), preoperative chemotherapy (HR 1·61, 1·08 to 2·37), blood transfusion (HR 1·46, 1·04 to 2·05), increasing age by 10-year interval (HR 1·30, 1·16 to 1·45), female sex (HR 1·26, 1·01 to 1·59) and thickness of subcutaneous tissue for every 1-cm increase (HR 1·18, 1·03 to 1·35) were identified as independent risk factors. Compared with superficial I-SSI, deep I-SSI was more strongly associated with the development of IH.

CONCLUSION

Although there are several risk factors for IH, reducing I-SSI is an important step in the prevention of IH.

REGISTRATION NUMBER

UMIN000004723 (University Hospital Medical Information Network, http://www.umin.ac.jp/ctr/index.htm).

Upper midline incision for liver resection

OBJECTIVES

The optimal incision for liver resection in living donors or patients with small tumours should be revisited. This study introduces the upper midline incision (UMI) above the umbilicus for various liver resections using a conventional open-surgery technique.

METHODS

A retrospective study based on a prospectively collected database of 308 liver resections performed by a single surgeon was conducted to evaluate the feasibility, safety and applicability of the UMI.

RESULTS

From September 2006 to September 2010, this incision was used successfully in 308 consecutive liver resections in all patients with tumours measuring ≤ 5 cm and all living donors without any extension of the incision. The median length of the incision was 16.4 cm (range: 12-20 cm).The median operating time was 189 min (range: 54-305 min). The median postoperative hospital stay was 8 days (range: 6-17 days). One patient died in the postoperative period from heart failure. All other patients fully recovered and returned to their previous level of activity. Over a median follow-up of 31 months (range: 20-68 months), 25 complications (8.1%) developed. Seven wound infections (2.3%) occurred with no incisional hernia.

CONCLUSIONS

The UMI can be used safely and effectively in conventional open surgery in various liver resections and should therefore be given priority as the first-line technique in living liver donors and patients with tumours measuring ≤ 5 cm.

Open versus laparoscopic left lateral hepatic sectionectomy within an enhanced recovery ERAS® programme (ORANGE II-trial): study protocol for a randomised controlled trial

Background

The use of lLaparoscopic liver resection in terms of time to functional recovery, length of hospital stay (LOS), long-term abdominal wall hernias, costs and quality of life (QOL) has never been studied in a randomised controlled trial. Therefore, this is the subject of the international multicentre randomised controlled ORANGE II trial.

Methods

Patients eligible for left lateral sectionectomy (LLS) of the liver will be recruited and randomised at the outpatient clinic. All randomised patients will undergo surgery in the setting of an ERAS programme. The experimental design produces two randomised arms (open and laparoscopic LLS) and a prospective registry. The prospective registry will be based on patients that cannot be randomised because of the explicit treatment preference of the patient or surgeon, or because of ineligibility (not meeting the in- and exclusion criteria) for randomisation in this trial. Therefore, all non-randomised patients undergoing LLS will be approached to participate in the prospective registry, thereby allowing acquisition of an uninterrupted prospective series of patients. The primary endpoint of the ORANGE II trial is time to functional recovery. Secondary endpoints are postoperative LOS, percentage readmission, (liver-specific) morbidity, QOL, body image and cosmetic result, hospital and societal costs over 1 year, and long-term incidence of incisional hernias. It will be assumed that in patients undergoing laparoscopic LLS, length of hospital stay can be reduced by two days. A sample size of 55 patients in each randomisation arm has been calculated to detect a 2-day reduction in LOS (90% power and α = 0.05 (two-tailed)).

The ORANGE II trial is a multicenter randomised controlled trial that will provide evidence on the merits of laparoscopic surgery in patients undergoing LLS within an enhanced recovery ERAS programme.

Trial registration

ClinicalTrials.gov NCT00874224.

Elastic fibers in the anterior abdominal wall

PURPOSE

The aim of this study was to substantiate the hypothesis as to whether an altered amount of elastic fibers in the linea alba aponeurosis occurs or not in anterior abdominal wall hernias (epigastric, incisional and umbilical), comparing the findings with those of a control group of cadavers without hernias.

METHODS

Thirty patients (15 males and 15 females) with anterior abdominal wall hernias were evaluated for analysis of the elastin content in samples from the linea alba aponeurosis, with immunohistochemistry and orcein staining using videomorphometry.

RESULTS

The results showed a greater amount of elastin in patients with abdominal wall hernias compared to the control group of cadavers without hernias (P < 0.05). The elastic fibers were greatly thickened, tortuous and fragmented in the patients.

CONCLUSION

It is essential to analyze the anterior abdominal wall concerning its anatomical condition and histological components. Altered collagen and elastic fibers play an important role in hernia formation, indicating that the main factor may be biological.