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

Systematic review and meta-analysis of the incidence of incisional hernia in urological surgery

PURPOSE

To evaluate the incidence of incisional hernia in patients undergoing direct access to the abdominal cavity in urological surgery.

METHODS

We conducted a systematic review in Pubmed, Embase, and Cochrane Central from 1980 to the present according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Eighty-four studies were selected for inclusion in this analysis, and meta-analysis and meta-regression were performed.

RESULTS

The total incidence in the 84 studies was 4.8% (95% CI 3.7% - 6.2%) I2 93.84%. Depending on the type of incision, it was higher in the open medial approach: 7.1% (95% CI 4.3%-11.8%) I2 92.45% and lower in laparoscopic surgery: 1.9% (95% CI 1%-3.4%) I2 71, 85% According to access, it was lower in retroperitoneal: 0.9% (95% CI 0.2%-4.8%) I2 76.96% and off-midline: 4.7% (95% CI 3.5%-6.4%) I2 91.59%. Regarding the location of the hernia, parastomal hernias were more frequent: 15.1% (95% CI 9.6% - 23%) I2 77.39%. Meta-regression shows a significant effect in reducing the proportion of hernias in open lateral, laparoscopic and hand-assisted compared to medial open access.

CONCLUSION

The present review finds the access through the midline and stomas as the ones with the highest incidence of incisional hernia. The use of the lateral approach or minimally invasive techniques is preferable. More prospective studies are warranted to obtain the real incidence of incisional hernias and evaluate the role of better techniques to close the abdomen.

Three-year follow-up of the grip concept: an open, prospective, observational registry study on biomechanically calculated abdominal wall repair for complex incisional hernias

PURPOSE

We studied the effectiveness of biomechanically calculated abdominal wall reconstructions for incisional hernias of varying complexity in an open, prospective observational registry trial.

METHODS

From July 1st, 2017 to December 31st, 2020, four hospitals affiliated with the University of Heidelberg recruited 198 patients with complex incisional hernias. Hernias were repaired using biomechanically calculated reconstructions and materials classified on their gripping force towards cyclic load. This approach determines the required strength preoperatively based on the hernia size, using the Critical Resistance to Impacts related to Pressure. The surgeon is supported in reliably determining the Gained Resistance, which is based on the mesh-defect-area-ratio, as well as other mesh and suture factors, and the tissue stability. Tissue stability is defined as a maximum distension of 1.5 cm upon a Valsalva maneuver. In complex cases, a CT scan of the abdomen can be used to assess unstable tissue areas both at rest and during Valsalva's maneuver.

RESULTS

Larger and stronger gripping meshes were required for more complex cases to achieve a durable repair, especially for larger hernia sizes. To achieve durable repairs, the number of fixation points increased while the mesh-defect area ratio decreased. Performing these repairs required more operating room time. The complication rate remained low. Less than 1% of recurrences and low pain levels were observed after 3 years.

CONCLUSIONS

Biomechanical stability, defined as the resistance to cyclic load, is crucial in preventing postoperative complications, including recurrences and chronic pain.

Superiority trial for the development of an ideal method for the closure of midline abdominal wall incisions to reduce the incidence of wound complications after elective gastroenterological surgery: study protocol for a randomized controlled trial

BACKGROUND

The recent guidelines from the European and American Hernia Societies recommend a continuous small-bite suturing technique with slowly absorbable sutures for fascial closure of midline abdominal wall incisions to reduce the incidence of wound complications, especially for incisional hernia. However, this is based on low-certainty evidence. We could not find any recommendations for skin closure. The wound closure technique is an important determinant of the risk of wound complications, and a comprehensive approach to prevent wound complications should be developed.

METHODS

We propose a single-institute, prospective, randomized, blinded-endpoint trial to assess the superiority of the combination of continuous suturing of the fascia without peritoneal closure and continuous suturing of the subcuticular tissue (study group) over that of interrupted suturing of the fascia together with the peritoneum and interrupted suturing of the subcuticular tissue (control group) for reducing the incidence of midline abdominal wall incision wound complications after elective gastroenterological surgery with a clean-contaminated wound. Permuted-block randomization with an allocation ratio of 1:1 and blocking will be used. We hypothesize that the study group will show a 50% reduction in the incidence of wound complications. The target number of cases is set at 284. The primary outcome is the incidence of wound complications, including incisional surgical site infection, hemorrhage, seroma, wound dehiscence within 30 days after surgery, and incisional hernia at approximately 1 year after surgery.

DISCUSSION

This trial will provide initial evidence on the ideal combination of fascial and skin closure for midline abdominal wall incision to reduce the incidence of overall postoperative wound complications after gastroenterological surgery with a clean-contaminated wound. This trial is expected to generate high-quality evidence that supports the current guidelines for the closure of abdominal wall incisions from the European and American Hernia Societies and to contribute to their next updates.

TRIAL REGISTRATION

UMIN-CTR UMIN000048442. Registered on 1 August 2022. https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000055205.

Systematic review and meta-analysis comparing surgical site infection in abdominal surgery between triclosan-coated and uncoated sutures

PURPOSE

Surgical site infection (SSI) is a frequent complication after abdominal surgery and impacts morbidity, mortality and medical costs. This systematic review evaluates whether the use of triclosan-coated sutures for closing the fascia during abdominal surgery reduces the rate of SSI compared to uncoated sutures.

METHODS

A systematic review and meta-analysis were conducted using the PRISMA guidelines. On February 17, 2024, a literature search was performed in Medline ALL, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Embase. Randomized controlled trials (RCTs) on abdominal fascial closure in human adults, comparing triclosan-coated and uncoated sutures, were included. The risk of bias was assessed using the Cochrane RoB 2 tool. Pooled meta-analysis was performed using RevMan.

RESULTS

Out of 1523 records, eleven RCTs were included, with a total of 10,234 patients: 5159 in the triclosan-coated group and 5075 in the uncoated group. The incidence of SSI was statistically significantly lower in the triclosan-coated group (14.8% vs. 17.3%) with an odds ratio (OR) of 0.84 (95% CI [0.75, 0.93], p = 0.001). When polydioxanone was evaluated separately (coated N = 3999, uncoated N = 3900), triclosan-coating reduced SSI; 17.5% vs. 20.1%, OR 0.86 (95% CI [0.77; 0.96], p = 0.008). When polyglactin 910 was evaluated (coated N = 1160, uncoated N = 1175), triclosan-coating reduced the incidence of SSI; 5.4% vs. 7.8%, OR 0.67 (95% CI [0.48; 0.94], p = 0.02).

CONCLUSION

According to the results of this meta-analysis the use of triclosan-coated sutures for fascial closure statistically significantly reduces the incidence of SSI after abdominal surgery with a risk difference of about 2%.

Abdominal wall surgery units accreditation. The Spanish model

The Spanish Association of Surgeons (AEC) deems it essential to define and regulate the acquisition of high-specialization competencies within General Surgery and Gastrointestinal Surgery and proposes the Regulation for the accreditation of specialized surgical units. The AEC aims to define specialized surgical units as those functional elements of the health system that meet the defined requirements regarding their provision, solvency, and specialization in care, teaching, and research. In this paper we present the proposed accreditation model for Abdominal Wall Surgery Units, as well as the results of a survey conducted to assess the status of such units in our country. The model presented represents one of the pioneering initiatives worldwide concerning the accreditation of Abdominal Wall Surgery Units.

Suture-Needle Management Device and Novel Port Configuration for Robotic Sacrocolpopexy

IMPORTANCE

Robot-assisted sacrocolpopexy (SCP) is a commonly performed procedure for the repair of apical pelvic organ prolapse; therefore, novel devices and techniques to improve safety and efficacy of this procedure should be explored.

OBJECTIVE

The objective of this study was to assess safety and efficacy of 8-mm trocar site for use of a disposable suture/needle management device (StitchKit; Origami Surgical, Madison, NJ) for robot-assisted SCP with a 4-arm configuration and no assistant port.

STUDY DESIGN

This is a retrospective case series of patients undergoing robot-assisted SCP at a tertiary center from 2018 to 2021. All surgical procedures were performed using four 8-mm robotic trocars and StitchKit device. Our objective was to review all cases in which this technique was used to determine whether the approach resulted in a safely completed procedure and any complications or adverse events. Secondary objectives were to describe patient and operative characteristics.

RESULTS

In total, 422 patients underwent robot-assisted SCP for pelvic organ prolapse. The mean age was 60 ± 10 years, and mean body mass index was 27 ± 6 (calculated as weight in kilograms divided by height in meters squared). Most patients had stage 3 prolapse (73%) and underwent concomitant hysterectomy (70%). Ninety-nine percent (n = 416) of cases were completed robotically. StitchKit was successfully inserted and removed in all robotic cases with correct needle counts. All patients had postoperative visits, and 80% followed up at 3 months. No umbilical/port site hernias, operative site infections, or adverse events were reported.

CONCLUSIONS

Robot-assisted SCP can be performed safely using a 4-arm robotic configuration and suture kit device. This setup eliminates incisions greater than 8 mm and an assistant port, allowing for surgical efficiency without compromising patient outcomes.

Short-term outcomes of a multicentre prospective study using a "visible" polyvinylidene fluoride onlay mesh for the prevention of midline incisional hernia

INTRODUCTION

Prophylactic meshes in high-risk patients prevent incisional hernias, although there are still some concerns about the best layer to place them in, the type of fixation, the mesh material, the significance of the level of contamination, and surgical complications. We aimed to provide answers to these questions and information about how the implanted material behaves based on its visibility under magnetic resonance imaging (MRI).

METHOD

This is a prospective multicentre observational cohort study. Preliminary results from the first 3 months are presented. We included general surgical patients who had at least two risk factors for developing an incisional hernia. Multivariate logistic regression was used. A polyvinylidene fluoride (PVDF) mesh loaded with iron particles was used in an onlay position. MRIs were performed 6 weeks after treatment.

RESULTS

Between July 2016 and June 2022, 185 patients were enrolled in the study. Surgery was emergent in 30.3% of cases, contaminated in 10.7% and dirty in 11.8%. A total of 5.6% of cases had postoperative wound infections, with the requirement of stoma being the only significant risk factor (OR = 7.59, p = 0.03). The formation of a seroma at 6 weeks detected by MRI, was associated with body mass index (OR = 1.13, p = 0.02).

CONCLUSIONS

The prophylactic use of onlay PVDF mesh in midline laparotomies in high-risk patients was safe and effective in the short term, regardless of the type of surgery or the level of contamination. MRI allowed us to detect asymptomatic seromas during the early process of integration.

STUDY REGISTRATION

 This protocol was registered at ClinicalTrials.gov (NCT03105895).

Small bite fascial closure technique reduces incisional hernia rates in gynecologic oncology patients

BACKGROUND

The potential for the technique of small bite fascial closure in mitigating incisional hernias in gynecologic oncology patients still needs to be investigated.

OBJECTIVE

To evaluate the impact of closure of small fascial bites compared with prior standard closure on incisional hernia rates in gynecologic oncology patients.

METHODS

This is a retrospective cohort study comparing patient outcomes before and after the intervention at a single institution at a comprehensive cancer center. Patients who underwent laparotomy with a vertical midline incision for a suspected or known gynecologic malignancy with a 1-year follow-up were included. The pre-intervention cohort (large bites) had 'mass' or modified running Smead-Jones closure. In contrast, the post-intervention cohort had fascial bites taken 5-8 mm laterally with no more than 5 mm travel (small bites) closure using a 2-0 polydioxanone suture.The primary outcome was the incisional hernias rate determined by imaging or clinical examination within the first year of follow-up. Patient factors and peri-operative variates of interest were investigated for their association with hernia formation through univariate and multivariate analyses. These included age, body mass index (BMI), smoking history, estimated blood loss, pre-operative albumin, American Society of Anesthesia (ASA) physical status classification, or treatment with chemotherapy post-operatively.

RESULTS

Of the 255 patients included, the total hernia rate was 12.5% (32/255 patients). Patient characteristics were similar in both cohorts. Small bite closure led to a significant reduction in hernia rates from 17.2% (22/128 patients) to 7.9% (10/127 patients), p=0.025. According to logistic regression modeling, small bite closure (OR=0.40, 95% CI 0.17 to 0.94, p=0.036) was independently associated with lower odds of hernia formation. Other factors associated with increased hernia rates were chemotherapy (OR=3.22, 95% CI 1.22 to 8.51, p=0.019) and obesity (OR=23.4, 95% CI 3.09 to 177, p=0.002). In obese patients, small bite closures led to maximal hernia rate reduction compared with large bites.

CONCLUSIONS

The small bite closure technique effectively reduces hernia rates in gynecologic oncology patients undergoing midline laparotomy.

Protocol for an independent patient data meta-analysis of prophylactic mesh placement for incisional hernia prevention after abdominal aortic aneurysm surgery: a collaborative European Hernia Society project (I-PREVENT-AAA)

INTRODUCTION

Incisional hernia (IH) is a prevalent and potentially dangerous complication of abdominal surgery, especially in high-risk groups. Mesh reinforcement of the abdominal wall has been studied as a potential intervention to prevent IHs. Randomised controlled trials (RCTs) have demonstrated that prophylactic mesh reinforcement after abdominal surgery, in general, is effective and safe. In patients with abdominal aortic aneurysm (AAA), prophylactic mesh reinforcement after open repair has not yet been recommended in official guidelines, because of relatively small sample sizes in individual trials. Furthermore, the identification of subgroups that benefit most from prophylactic mesh placement requires larger patient numbers. Our primary aim is to evaluate the efficacy and effectiveness of the use of a prophylactic mesh after open AAA surgery to prevent IH by performing an individual patient data meta-analysis (IPDMA). Secondary aims include the evaluation of postoperative complications, pain and quality of life, and the identification of potential subgroups that benefit most from prophylactic mesh reinforcement.

METHODS AND ANALYSIS

We will conduct a systematic review to identify RCTs that study prophylactic mesh placement after open AAA surgery. Cochrane Central Register of Controlled Trials, MEDLINE Ovid, Embase, Web of Science Core Collection and Google Scholar will be searched from the date of inception onwards. RCTs must directly compare primary sutured closure with mesh closure in adult patients who undergo open AAA surgery. Lead authors of eligible studies will be asked to share individual participant data (IPD). The risk of bias (ROB) for each included study will be assessed using the Cochrane ROB tool. An IPDMA will be performed to evaluate the efficacy, with the IH rate as the primary outcome. Any signs of heterogeneity will be evaluated by Forest plots. Time-to-event analyses are performed using Cox regression analysis to evaluate risk factors.

ETHICS AND DISSEMINATION

No new data will be collected in this study. We will adhere to institutional, national and international regulations regarding the secure and confidential sharing of IPD, addressing ethics as indicated. We will disseminate findings via international conferences, open-source publications in peer-reviewed journals and summaries posted online.

PROSPERO REGISTRATION NUMBER

CRD42022347881.

Meshing around: high-risk hernias and infected mesh

Open laparotomy carries a risk up to 20% for an incisional hernia, making repair one of the most common operations performed by general surgeons in the USA. Despite a multitude of mesh appliances and techniques, no size fits all, and there is continued debate on what is the best mesh type, especially in high-risk patients with contaminated hernias. Infected mesh carries a significant burden to the patient, the surgeon and overall healthcare costs with medical legal implications. A stepwise approach that involves optimization of patient comorbidities, patient selective choice of mesh and technique is imperative in mitigating outcomes and recurrence rates. This review will focus on the avoidance of mesh infection and the selection of mesh in patients with contaminated wounds.

Robotic 8-mm trocar fascial wounds: To close or not to close?

BACKGROUND

The aim of this study was to investigate 8-mm robotic trocar site hernia (TSH) rate over the short and long term, providing aids to manage the related fascial wounds.

METHODS

A retrospective analysis of 320 patients undergoing robotic surgery was conducted. The primary outcome was 8-mm TSH rate with a minimum follow-up of 12 months. The secondary outcome was the rate of haematomas and infections related to 8-mm wounds and their association with patient comorbidities and trocar position.

RESULTS

One case of TSH was observed (0.31%). There were 15 cases of wound infection (4.68%) and 22 cases of wound haematoma (6.87%). Trocar related complications were significantly associated with patient comorbidities, not with trocar position.

CONCLUSIONS

Our results do not justify the 8-mm fascial wound closure. Data concerning the association between trocar-related complications and patient comorbidities strengthen the need to implement the control of metabolic state and correct administration of perioperative therapy in high-risk patients.

Strength of small-bites abdominal wall closure using different suturing methods and materials in an experimental animal model

PURPOSE

Using small instead of large bites for laparotomy closure results in lower incidence of incisional hernia, but no consensus exists on which suture material to use. This study aimed to compare five different closure strategies in a standardized experimental setting.

METHODS

Fifty porcine abdominal walls were arranged into 5 groups: (A) running 2/0 polydioxanone; (B) interlocking 2/0 polydioxanone; (C) running size 0 barbed polydioxanone; (D) running size 0 barbed glycolic acid and trimethylene carbonate; (E) running size 0 suturable polypropylene mesh. The small-bites technique was used for linea alba closure in all. The abdominal walls were divided into a supra- and infra-umbilical half, resulting in 20 specimens per group that were pulled apart in a tensile testing machine. Maximum tensile force and types of suture failure were registered.

RESULTS

The highest tensile force was measured when using barbed polydioxanone (334.8 N ± 157.0), but differences did not reach statistical significance. Infra-umbilical abdominal walls endured a significantly higher maximum tensile force compared to supra-umbilical (397 N vs 271 N, p < 0.001). Barbed glycolic acid and trimethylene carbonate failed significantly more often (25% vs 0%, p = 0.008).

CONCLUSION

Based on tensile force, both interlocking and running suture techniques using polydioxanone, and running sutures using barbed polydioxanone or suturable mesh, seem to be suitable for abdominal wall closure. Tensile strength was significantly higher in infra-umbilical abdominal walls compared to supra-umbilical. Barbed glycolic acid and trimethylene carbonate should probably be discouraged for fascial closure, because of increased risk of suture failure.

The enigma of incisional hernia prediction unraveled: external validation of a prognostic model in colorectal cancer patients

PURPOSE

Accurate prediction of hernia occurrence is vital for surgical decision-making and patient management, particularly in colorectal surgery patients. While a hernia prediction model has been developed, its performance in external populations remain to be investigated. This study aims to validate the existing model on an external dataset of patients who underwent colorectal surgery.

METHODS

The "Penn Hernia Calculator" model was externally validated using the Hughes Abdominal Repair Trial (HART) data, a randomized trial comparing colorectal cancer surgery closure techniques. The data encompassed demographics, comorbidities, and surgical specifics. Patients without complete follow-up were omitted. Model performance was assessed using key metrics, including area under the curve (AUC-ROC and AUC-PR) and Brier score. Reporting followed the TRIPOD consensus.

RESULTS

An external international dataset consisting of 802 colorectal surgery patients were identified, of which 674 patients with up to 2 years follow-up were included. Average patient age was 68 years, with 63.8% male. The average BMI was 28.1. Prevalence of diabetes, hypertension, and smoking were 15.7%, 16.3%, and 36.5%, respectively. Additionally, 7.9% of patients had a previous hernia. The most common operation types were low anterior resection (35.3%) and right hemicolectomy (34.4%). Hernia were observed in 24% of cases by 2-year follow-up. The external validation model revealed an AUC-ROC of 0.66, AUC-PR of 0.72, and a Brier score of 0.2.

CONCLUSION

The hernia prediction model demonstrated moderate performance in the external validation. Its potential generalizability, specifically in those undergoing colorectal surgery, may suggest utility in identifying and managing high-risk hernia candidates.

The effectiveness of fascial closure with antimicrobial-coated sutures in preventing incisional surgical site infections in gastrointestinal surgery: a systematic review and meta-analysis

The aim of this study was to conduct a systematic review and meta-analysis of the efficacy of fascial closure using antimicrobial-sutures specifically for the prevention of surgical site infections (SSIs) in gastrointestinal surgery, as part of the revision of the SSI prevention guidelines of the Japanese Society of Surgical Infectious Diseases (JSSI). We searched CENTRAL, PubMed and ICHUSHI-Web in May 2023, and included randomized controlled trials (RCTs) comparing antimicrobial-coated and non-coated sutures for fascial closure in gastrointestinal surgery (PROSPERO No. CRD42023430377). Three authors independently screened the RCTs. We assessed the risk of bias and the GRADE criteria for the extracted data. The primary outcome was incisional SSI and the secondary outcomes were abdominal wall dehiscence and the length of postoperative hospital stay. This study was supported partially by the JSSI. A total of 10 RCTs and 5396 patients were included. The use of antimicrobial-coated sutures significantly lowered the risk of incisional SSIs compared with non-coated suture (risk ratio: 0.79, 95% confidence intervals: 0.64-0.98). In subgroup analyses, antimicrobial-coated sutures reduced the risk of SSIs for open surgeries, and when monofilament sutures were used. Antimicrobial-coated sutures did not reduce the incidence of abdominal wall dehiscence and the length of hospital stay compared with non-coated sutures. The certainty of the evidence was rated as moderate according to the GRADE criteria, because of risk of bias. In conclusion, the use of antimicrobial-coated sutures for fascial closure in gastrointestinal surgery is associated with a significantly lower risk of SSI than non-coated sutures.

A Case of Abdominal Incisional Bladder Hernia

The case is a woman in her 60s. She had been aware of lower abdominal distention and pain for six months but was under observation. Gradually, the patient experienced worsening pain during distention and became aware of distention, especially before urination. She visited our clinic. Ultrasound (US) and computed tomography (CT) revealed an abdominal incisional hernia. The hernia was in the bladder. We decided on surgical treatment and made a skin incision of about 3 cm just above the hernia portal. Since the size of the hernia portal was approximately 1.3 cm, the patient underwent direct suture closure to repair the hernia portal, and the surgery was completed. The postoperative course was good. The patient was discharged on the second postoperative day. Four months have passed since the surgery, and the patient is under observation without recurrence.

Laparoscopic Trocars: Marketed Versus True Dimensions-A Descriptive Study

STUDY OBJECTIVE

To establish true dimensions of single-use laparoscopic trocars compared with marketed dimensions, calculate corresponding incision sizes, examine what trocar size categories are based on, and outline accessibility of information regarding true dimensions.

DESIGN

Descriptive study.

SETTING

Laparoscopic disposable trocars available in North America and Europe are marketed in several distinct categories. In practice, trocars in the same-size category exhibit different functionality (ability to introduce instruments/needles and retrieve specimens) and warrant different incision lengths.

PATIENTS

Not applicable.

INTERVENTIONS

Not applicable.

MEASUREMENTS AND MAIN RESULTS

True dimensions for 125 trocars (bladeless, optical, and balloon) were obtained from 9 vendors covering 8 marketed size categories (3-, 3.5-, 5-, 8-, 10-, 11-, 12-, and 15-mm trocars). On average, true inner cannula diameter was 0.92 mm wider (SD, 0.41 mm; range, 0-2.4 mm) than the marketed size category, with the widest range in the 5 mm category. For 5-mm trocars, mean true inner diameter was 6.1 mm (SD, 0.45; range, 5.5-7.4) and true outer diameter 8.3 mm (SD, 0.71; range, 8.0-10.7). For 12-mm trocars, mean true inner diameter was 13.0 mm (SD, 0.21; range, 12-13.3) and outer diameter 15.3 mm (SD, 0.48; range, 14.4-16.8). Five-mm trocars necessitate a mean incision size of 13.0 mm (SD, 1.1; range, 12.1-16.8) and 12-mm trocars a mean incision of 24.0 mm (SD, 0.75; range, 22.6-26.4). No vendors stated actual diameters on company website or catalog. In one instance the Instructions For Use document contained the true inner diameter.

CONCLUSION

Trocar size categories give a false sense of standardization when in actuality there are considerable within-category differences in both inner and outer diameters, corresponding to differences in functionality and required incision sizes. There is no universally applied definition for trocar size categories. Accessibility of information on true dimensions is limited.

Advances in Hernia Care State of the Art

The field of hernia surgery has seen many recent advances and continues to evolve. Care of the hernia patient begins preoperatively by ensuring adequate preparation for surgery with surgeons now having the opportunity to accurately predict risk which can aid with informed consent. Imaging studies can now help surgeons diagnose and plan hernia surgery on an individual level based on hernia characteristics as well as abdominal wall musculature. In the operating room, new technology and surgical techniques have allowed surgeons to become increasingly sophisticated with goals of reducing tension on midline closures, utilizing minimally invasive and robotic techniques, and availability of new and varied mesh prosthetics. While modest improvements in outcomes have been witnessed by these advances, there is still opportunity for improvement which will be realized by continued research, use of registries, and education and training. Hernia prevention strategies focusing on minimally invasive surgery, laparotomy closure, and the use of prophylactic mesh will also help with the burden of incisional hernias. These advances in hernia surgery have led to the new field of Abdominal Core Health which helps represent this evolving and growing new subspecialty of general surgery.

The changes in abdominal wall muscles following incisional hernia wall reconstruction

PURPOSE

The objective of incisional hernia surgery is to achieve the restoration of abdominal wall anatomical and physiological functions. This study aims to investigate the impact of abdominal wall reconstruction on abdominal muscle alterations by measuring the preoperative and postoperative changes in abdominal wall muscles in patients undergoing incisional hernia repair.

METHODS

For patients undergoing open incisional hernia abdominal wall reconstruction, preoperative and postoperative abdominal CT scans were analyzed at a minimum of 3 months post-surgery. 3D Slicer software was utilized for measuring preoperative and postoperative changes in abdominal cavity volume, abdominal muscle volume, as well as muscle volume, cross-sectional area, and abdominal circumference at specific levels. The acquired data were subjected to statistical analysis using SPSS software.

RESULTS

A total of 40 patients meeting the inclusion criteria underwent open incisional hernia repair surgery. Some of these patients required component separation technique (CST) due to the larger size of the hernia sac. The abdominal muscles surrounding the hernia ring were defined as the "damaged group," while the remaining abdominal muscles were defined as the "undamaged group." Measurements revealed a significant increase in the volume of rectus abdominis, external oblique, internal oblique, and transversus abdominis muscles in the damaged group. Similarly, there was a corresponding increase in the volume of rectus abdominis, external oblique, internal oblique, and transversus abdominis muscles in the undamaged group.

CONCLUSIONS

After abdominal wall reconstruction in incisional hernia patients, not only is their anatomical structure restored, but the overall biomechanical integrity of the abdominal wall is also repaired. The damaged muscles are subjected to renewed loading, leading to the reversal of disuse atrophy and an increase in muscle volume.

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.

Effect of Functionalization of Texturized Polypropylene Surface by Silanization and HBII-RGD Attachment on Response of Primary Abdominal and Vaginal Fibroblasts

Soft tissue defects, such as incisional hernia or pelvic organ prolapse, are prevalent pathologies characterized by a tissue microenvironment rich in fragile and dysfunctional fibroblasts. Precision medicine could improve their surgical repair, currently based on polymeric materials. Nonetheless, biomaterial-triggered interventions need first a better understanding of the cell-material interfaces that truly consider the patients' biology. Few tools are available to study the interactions between polymers and dysfunctional soft tissue cells in vitro. Here, we propose polypropylene (PP) as a matrix to create microscale surfaces w/wo functionalization with an HBII-RGD molecule, a fibronectin fragment modified to include an RGD sequence for promoting cell attachment and differentiation. Metal mold surfaces were roughened by shot blasting with aluminum oxide, and polypropylene plates were obtained by injection molding. HBII-RGD was covalently attached by silanization. As a proof of concept, primary abdominal and vaginal wall fasciae fibroblasts from control patients were grown on the new surfaces. Tissue-specific significant differences in cell morphology, early adhesion and cytoskeletal structure were observed. Roughness and biofunctionalization parameters exerted unique and combinatorial effects that need further investigation. We conclude that the proposed model is effective and provides a new framework to inform the design of smart materials for the treatment of clinically compromised tissues.

A virtual simulation approach to assess the effect of trocar-site placement and scar characteristics on the abdominal wall biomechanics

Analyses of registries and medical imaging suggest that laparoscopic surgery may be penalized with a high incidence of trocar-site hernias (TSH). In addition to trocar diameter, the location of the surgical wound (SW) may affect TSH incidence. The intra-abdominal pressure (IAP) exerted on the abdominal wall (AW) might also influence the appearance of TSH. In the present study, we used finite element (FE) simulations to predict the influence of trocar location and SW characteristics (stiffness) on the mechanical behavior of the AW subject to an IAP. Two models of laparoscopy patterns on the AW, with trocars in the 5-12 mm range, were generated. FE simulations for IAP values within the 4 kPa-20 kPa range were carried out using the Code Aster open-source software. Different stiffness levels of the SW tissue were considered. We found that midline-located surgical wounds barely deformed, even though they moved outwards along with the regular LA tissue. Laterally located SWs hardly changed their location but they experienced significant variations in their volume and shape. The amount of deformation of lateral SWs was found to strongly depend on their stiffness. Trocar incisions placed in a LA with non-diastatic dimensions do not compromise its mechanical integrity. The more lateral the trocars are placed, the greater is their deformation, regardless of their size. Thus, to prevent TSH it might be advisable to close lateral trocars with a suture, or even use a prosthetic reinforcement depending on the patient's risk factors (e.g., obesity).

Are Surgeons Going to Be Left Holding the Bag? Incisional Hernia Repair and Intra-Peritoneal Non-Absorbable Mesh Implant Complications

Ventral incisional hernias are common indications for elective repair and frequently complicated by recurrence. Surgical meshes, which may be synthetic, bio-synthetic, or biological, decrease recurrence and, resultingly, their use has become standard. While most patients are greatly benefited, mesh represents a permanently implanted foreign body. Mesh may be implanted within the intra-peritoneal, preperitoneal, retrorectus, inlay, or onlay anatomic positions. Meshes may be associated with complications that may be early or late and range from minor to severe. Long-term complications with intra-peritoneal synthetic mesh (IPSM) in apposition to the viscera are particularly at risk for adhesions and potential enteric fistula formation. The overall rate of such complications is difficult to appreciate due to poor long-term follow-up data, although it behooves surgeons to understand these risks as they are the ones who implant these devices. All surgeons need to be aware that meshes are commercial devices that are delivered into their operating room without scientific evidence of efficacy or even safety due to the unique regulatory practices that distinguish medical devices from medications. Thus, surgeons must continue to advocate for more stringent oversight and improved scientific evaluation to serve our patients properly and protect the patient-surgeon relationship as the only rationale long-term strategy to avoid ongoing complications.

STRONGHOLD first-year results of biomechanically calculated abdominal wall repair: a propensity score matching

PURPOSE

Every year around 70,000 people in Germany suffer from an abdominal incisional hernia that requires surgical treatment. Five years after reconstruction about 25% reoccur. Incisional hernias are usually closed with mesh using various reconstruction techniques, summarized here as standard reconstruction (SR). To improve hernia repair, we established a concept for biomechanically calculated reconstructions (BCR). In the BCR, two formulas enable customized patient care through standardized biomechanical measures. This study aims to compare the clinical outcomes of SR and BCR of incisional hernias after 1 year of follow-up based on the Herniamed registry.

METHODS

SR includes open retromuscular mesh augmented incisional hernia repair according to clinical guidelines. BCR determines the required strength (Critical Resistance to Impacts related to Pressure = CRIP) preoperatively depending on the hernia size. It supports the surgeon in reliably determining the Gained Resistance, based on the mesh-defect-area-ratio, further mesh and suture factors, and the tissue stability. To compare SR and BCR repair outcomes in incisional hernias at 1 year, propensity score matching was performed on 15 variables. Included were 301 patients with BCR surgery and 23,220 with standard repair.

RESULTS

BCR surgeries show a significant reduction in recurrences (1.7% vs. 5.2%, p = 0.0041), pain requiring treatment (4.1% vs. 12.0%, p = 0.001), and pain at rest (6.9% vs. 12.7%, p = 0.033) when comparing matched pairs. Complication rates, complication-related reoperations, and stress-related pain showed no systematic difference.

CONCLUSION

Biomechanically calculated repairs improve patient care. BCR shows a significant reduction in recurrence rates, pain at rest, and pain requiring treatment at 1-year follow-up compared to SR.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prophylactic mesh augmentation in emergency laparotomy closure: a meta-analysis of randomized controlled trials with trial sequential analysis

BACKGROUND

Prophylactic mesh augmentation in emergency laparotomy closure is controversial. We aimed to perform a meta-analysis of randomized controlled trials (RCT) evaluating the placement of prophylactic mesh during emergency laparotomy.

METHODS

We performed a systematic review of Cochrane, Scopus, and PubMed databases to identify RCT comparing prophylactic mesh augmentation and no mesh augmentation in patients undergoing emergency laparotomy. We excluded observational studies, conference abstracts, elective surgeries, overlapping populations, and trial protocols. Postoperative outcomes were assessed by pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I2 statistics. Risk of bias was assessed using the revised Cochrane risk-of-bias tool (RoB 2). The review protocol was registered at PROSPERO (CRD42023412934).

RESULTS

We screened 1312 studies and 33 were thoroughly reviewed. Four studies comprising 464 patients were included in the analysis. Mesh reinforcement was significantly associated with a decrease in incisional hernia incidence (OR 0.18; 95% CI 0.07-0.44; p < 0.001; I2 = 0%), and synthetic mesh placement reduced fascial dehiscence (OR 0.07; 95% CI 0.01-0.53; p = 0.01; I2 = 0%). Mesh augmentation was associated with an increase in operative time (MD 32.09 min; 95% CI 6.39-57.78; p = 0.01; I2 = 49%) and seroma (OR 3.89; 95% CI 1.54-9.84; p = 0.004; I2 = 0%), but there was no difference in surgical-site infection or surgical-site occurrences requiring procedural intervention or reoperation.

CONCLUSIONS

Mesh augmentation in emergency laparotomy decreases incisional hernia and fascial dehiscence incidence. Despite the risk of seroma, prophylactic mesh augmentation appears to be safe and might be considered for emergency laparotomy closure. Further studies evaluating long-term outcomes are still needed.

The Original Rutherford Morison Incision: A Case Report

In recent years, the Rutherford Morison incision has become synonymous with renal transplant surgery. However, this incision was originally intended for access to the sigmoid colon and pelvis, particularly in the case of a midline previously scarred from operation. We present a case of a middle-aged female with a caecal tumour, requiring resection. Upon examination, this patient was found to have large concomitant diastasis of the recti. A right-sided Rutherford Morison incision was utilized in performing a right hemicolectomy. Although the advantages of a minimally invasive approach to colonic resections are well described, laparoscopy was not utilized in the case discussed. Due to the wide area of anterior abdominal wall laxity, herniation is likely to develop at both port placement and specimen delivery sites. A similar outcome would result from a midline incision. However, a paramedian is an acceptable alternative to a Rutherford Morison incision in a case like this, as it is known to have very low rates of post-operative incisional herniation. While in modern times, its use may have become repurposed, the Rutherford Morison incision is one which should be remembered and used in the surgeons' armamentarium to improve clinical outcomes when necessary.

[Incisional hernias: epidemiology, evidence and guidelines]

BACKGROUND

From an epidemiological point of view, one third of the population in industrialized countries will undergo abdominal surgery during their lifetime. Depending on the degree of patient-related and procedure-related risks, the occurrence of incisional hernias is associated in a range of up to 30% at 2‑year follow-up and even up to 60% at 5 years. In addition to influencing comorbidities, the type of surgical approach and closure technique are of critical importance.

OBJECTIVE

To present a descriptive evidence-based recommendation for abdominal wall closure and prophylactic mesh augmentation.

MATERIAL AND METHODS

A concise summary was prepared incorporating the current literature and existing guidelines.

RESULTS

According to recent studies the recognized risk for the occurrence of incisional hernias in the presence of obesity and abdominal aortic diseases also applies to patients undergoing colorectal surgery and the presence of diastasis recti abdominis. Based on high-level published data, the short stitch technique for midline laparotomy in the elective setting has a high level of evidence to be a standard procedure. Patients with an increased risk profile should receive prophylactic mesh reinforcement, either onlay or sublay, in addition to the short stitch technique. In emergency laparotomy, the individual risk of infection with respect to the closure technique used must be included.

CONCLUSION

The avoidance of incisional hernias is primarily achieved by the minimally invasive access for laparoscopy. For closure of the most commonly used midline approach, the short stitch technique and, in the case of existing risk factors, additionally mesh augmentation are recommended.

A Prospective Randomized Controlled Trial Comparing Clinical Equivalence of PD Synth and PDS Polydioxanone Sutures

Introduction Incisional hernia is a common complication of midline laparotomy that may develop even after several years of surgery. Abdominal fascia closure with ideal suture material reduces the incidence of incisional hernia. This study compared the clinical equivalence of PD Synth (Healthium Medtech Limited) and PDS (Ethicon, Johnson & Johnson) slowly absorbed polydioxanone suture with respect to the occurrence of incisional hernia, following elective/emergency midline laparotomy. Methods Eighty-eight subjects undergoing elective/emergency midline laparotomy were randomized to PD Synth (n=45) and PDS (n=43) groups of this prospective, multicenter, randomized (1:1), single-blind, two-arm, parallel-group study (December 2020-May 2023). Primary endpoint was incidence of incisional hernia, occurring within six and 12 months of surgery. Secondary endpoints included incidence of fascial dehiscence, surgical site infection (SSI), suture sinus, seroma, hematoma, scar tenderness, and re-suturing, and evaluation of operative data, hospital stay, intra-operative suture handling, pain, time to return to normal day-to-day activities and work, overall patient satisfaction score, and adverse events. Results One subject in both PD Synth and PDS groups (p>0.05) developed incisional hernia at umbilicus 12 months post-laparotomy. In PDS group, one subject each had incidences of SSI on day 2, day 7, and one month, two subjects developed seroma on day seven, and one subject had readmission on one month; two subjects in PD Synth group developed superficial SSI (one month). Findings of other secondary endpoints were comparable between the groups. Conclusion Primary and secondary outcomes manifested that PD Synth and PDS slowly absorbed polydioxanone sutures are clinically equivalent, and can be used for abdominal fascial closure following midline laparotomy.

Contemporary Approaches to Hernia Repair: A Narrative Review in General Surgery

This narrative review offers a thorough and inclusive examination of modern techniques for hernia repair in general surgery. This exploration spans the development of new methods, substances, and technology, providing insight into the significant changes in hernia treatment in recent years. An extensive examination of peer-reviewed literature, encompassing historical advancements, conventional approaches, and the rise of contemporary surgical tactics, was undertaken. Key focus areas include integrating mesh technology, minimally invasive procedures, biological meshes, and 3D printing improvements. The overview explains the historical development from traditional open surgeries to the introduction of laparoscopic procedures, providing detailed information on several modern approaches. The presentation includes information on the utilization of mesh, concerns particular to individual patients, and the increasing importance of robots. An extensive analysis examines complications, obstacles, and current trends, thoroughly assessing safety profiles and patient outcomes. This review aims to consolidate existing information, highlight areas lacking research, and provide future paths to enhance outcomes for patients undergoing general surgery. At the same time, the field of hernia repair experiences significant changes. The integration of classic and contemporary approaches illustrates the changing character of hernia repair, enabling a nuanced understanding among physicians and academics alike.

Educating Residents in Abdominal Wall Closure: An Overview

Background and Aims: Incisional hernia prevention has become an important concept for surgeons operating on the abdominal wall. Several techniques have been proposed to help decrease incisional hernia formation with suture closure of the abdominal wall being one of the cornerstones. Technical details that have been reported to decrease incisional hernia rates include achieving a 4:1 Suture to Wound length ratio and the use of a small bites technique. Despite evidence to support many of these techniques there appears to be a gap in practice patterns amongst practicing surgeons. Introducing and promoting these principles in surgical residency may help to close this gap. This paper reviews our experience with surgical training for abdominal wall closures at our institution. Materials and Methods: Programs and projects related to abdominal wall closure were reviewed from our institution from 2010-Present. Type of project, intervention, and impact on education was evaluated and summarized. Results: Seven projects were identified relating to surgical training and abdominal wall closure. Three projects dealt with skills training using an abdominal wall simulation model and related to suturing techniques. Two projects were clinical studies focused on suture to wound length ratios and improving outcomes with this variable in a residency training program. Two projects dealt with models relating to abdominal wall closure and education. Conclusion: Implementation of educational programs in surgical residency programs can lead to improvements in technique and knowledge around abdominal wall closure and help in research endeavors.

A postoperative body weight increase is a novel risk factor for incisional hernia of midline abdominal incision after elective gastroenterological surgery

PURPOSE

Midline abdominal incisions (MAIs) are widely used in both open and minimally invasive surgery. Incisional hernia (IH) accounts for most long-term postoperative wound complications. This study explored the risk factors for IH due to MAI in patients with clean-contaminated wounds after elective gastroenterological surgery.

METHODS

The present study targeted patients enrolled in 2 randomized controlled trials to evaluate the efficacy of intraoperative interventions for incisional SSI prevention after gastroenterological surgery for clean-contaminated wounds. The patients were reassessed, and pre- and intraoperative variables and postoperative outcomes were collected. IH was defined as any abdominal wall gap, regardless of bulge, in the area of a postoperative scar that was perceptible or palpable on clinical examination or computed tomography according to the European Hernia Society guidelines. The risk factors for IH were identified using univariate and multivariate analyses.

RESULTS

The study population included 1,281 patients, of whom 273 (21.3%) developed IH. Seventy-four (5.8%) patients developed incisional SSI. Multivariate logistic regression analysis revealed that female sex (odds ratio [OR], 1.39; 95% confidence interval [CI] 1.03-1.86, p = 0.031), high preoperative body mass index (OR, 1.81; 95% CI 1.19-2.77, p = 0.006), incisional SSI (OR, 2.29; 95% CI 1.34-3.93, p = 0.003), and postoperative body weight increase (OR, 1.49; 95% CI 1.09-2.04, p = 0.012) were independent risk factors for IH due to MAI in patients who underwent elective gastroenterological surgery.

CONCLUSION

We identified postoperative body weight increase at one year as a novel risk factor for IH in patients with MAI after elective gastroenterological surgery.

Trocar Entry Site Hernias in Laparoscopic Sleeve Gastrectomy Patients: A Retrospective Cross-Sectional Study

Introduction There is insufficient data regarding trocar access site hernias (TSH) in laparoscopic sleeve gastrectomy (LSG). This retrospective study aimed to identify the incidence and risk factors for hernia development in patients who did not undergo fascia repair at trocar entry sites. Materials and methods We retrospectively reviewed the records of 284 patients with morbid obesity who underwent LSG between January 2016 and December 2021. The fascia of the trocar entry site was not closed in any of the patients. Weight, body mass index (BMI), percentage of excess weight loss (%EWL), percentage of total weight loss (%TWL), comorbidities, and the occurrence of complications were recorded at one, six, 12, 18, and 24 months after surgery. Ultrasonography (USG) was performed and supplemented with computed tomography (CT) when necessary. Results All patients underwent a 24-month follow-up, during which four patients developed trocar site hernias, resulting in an overall prevalence of 1.4%. Of the total hernias, two occurred within the first 30 days. A single patient required surgical intervention for an incarcerated hernia on the 18th day. Before undergoing laparoscopic sleeve gastrectomy (LSG), the mean weight and body mass index (BMI) of the participants were 124.2 ± 16.7 kg and 43.4 ± 5.7 kg/m², respectively. After one year, the participants experienced a mean percentage of excess weight loss (EWL) of 77.1 ± 12.2% and a mean total weight loss (TWL) of 33.2 ± 6.2%. Hernia formation has been found to be associated with both type 2 diabetes (T2D) and female gender. Conclusion In laparoscopic sleeve gastrectomy (LSG), repair of the trocar port closure is not always necessary. The rates of hernia at port entry sites were similar between cases with and without fascial repair.

Laparoscopic rectal cancer resection yields comparable clinical and oncological results with shorter hospital stay compared to open access: a 5-year national cohort

PURPOSE

Although widely applied, the results following laparoscopic rectal resection (LRR) compared to open rectal resection (ORR) are still debated. The aim of this study was to assess clinical short- and long-term results as well as oncological resection quality following LRR or ORR for cancer in a 5-year national cohort.

METHODS

Data from the Norwegian Registry for Gastrointestinal Surgery and the Norwegian Colorectal Cancer Registry were retrieved from January 2014 to December 2018 for patients who underwent elective resection for rectal cancer. Primary end point was 5-year overall survival. Secondary end points were local recurrence rates within 5 years, oncological resection quality, and short-term outcome measures.

RESULTS

A total of 1796 patients were included, of whom 1284 had undergone LRR and 512 ORR. There was no difference in 5-year survival rates between the groups after adjusting for relevant covariates with Cox regression analyses. Crude 5-year survival was 77.1% following LRR compared to 74.8% following ORR (p = 0.015). The 5-year local recurrence rates were 3.1% following LRR and 4.1% following ORR (p = 0.249). Length of hospital stay was median 8.0 days (quartiles 7.0-13.0) after ORR compared to 6.0 (quartiles 4.0-8.0) days after LRR. After adjusting for relevant covariates, estimated additional length of stay after ORR was 3.1 days (p < 0.001, 95% CI 2.3-3.9). Rates of positive resection margins and number of harvested lymph nodes were similar. There were no other significant differences in short-term outcomes between the groups.

CONCLUSION

LRR was performed with clinical and oncological outcomes similar to ORR, but with shorter hospital stay.

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

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

Outcome of incisional hernia repair in patients 80 years and older: results from the Herniamed-Registry

INTRODUCTION

More and more often complex abdominal surgeries are performed in the elderly. Together with the ageing population these patients are at risk for incisional hernias. We aimed on assessing outcomes following incisional hernia surgery in patients 80 years and older.

MATERIAL AND METHODS

Using the Herniamed-Registry, a prospective multi-institutional database, data on patients undergoing surgery for incisional hernias were retrospectively assessed. 46,040 patients were included and divided by age. Intraoperative-, general-, and postoperative complications as well as 1-year follow-up outcomes were assessed and compared between patients 80 years and older vs younger than 80 years.

RESULTS

Intra- (2.3% vs 1.5%; p < 0.001) and postoperative (8.6% vs 7.2%; p = 0.001) complications, general complications (5.5% vs 3.0%; p < 0.001), as well as reoperations (3.8% vs 3.0%; p = 0.007) were more likely to occur in elderly patients. By contrast, recurrences (3.6% vs 4.5%; p = 0.007), pain at rest (7.3% vs 10.1%; p < 0.001) and on exertion (11.3% vs 18.3%; p < 0.001), as well as pain requiring treatment (5.4% vs 7.7%; p < 0.001) was less likely in the group of patients aged ≥ 80 years.

CONCLUSION

Incisional hernia repair in patients 80 years and older is associated with a slightly higher complication risk but is quite acceptable and also have improved pain scores. The recurrence difference is also clinically unimportant.

Decellularization of Dense Regular Connective Tissue-Cellular and Molecular Modification with Applications in Regenerative Medicine

Healing of dense regular connective tissue, due to a high fiber-to-cell ratio and low metabolic activity and regeneration potential, frequently requires surgical implantation or reconstruction with high risk of reinjury. An alternative to synthetic implants is using bioscaffolds obtained through decellularization, a process where the aim is to extract cells from the tissue while preserving the tissue-specific native molecular structure of the ECM. Proteins, lipids, nucleic acids and other various extracellular molecules are largely involved in differentiation, proliferation, vascularization and collagen fibers deposit, making them the crucial processes in tissue regeneration. Because of the multiple possible forms of cell extraction, there is no standardized protocol in dense regular connective tissue (DRCT). Many modifications of the structure, shape and composition of the bioscaffold have also been described to improve the therapeutic result following the implantation of decellularized connective tissue. The available data provide a valuable source of crucial information. However, the wide spectrum of decellularization makes it important to understand the key aspects of bioscaffolds relative to their potential use in tissue regeneration.

Real-world accuracy of computed tomography in patients admitted with small bowel obstruction: a multicentre prospective cohort study

PURPOSE

Small bowel obstruction (SBO) is a common surgical emergency. Previous studies have shown the value computed tomography (CT) scanning in both confirming this diagnosis and identifying indications for urgent surgical intervention, such as strangulated bowel or closed loop obstructions. However, most of the literature is based on retrospective expert review of previous imaging and little data regarding the real-time accuracy of CT reporting is available. Here, we investigated the real-world accuracy of CT reporting in patients admitted with SBO.

METHODS

This was a multicentre prospective study including consecutive patients admitted with SBO. The primary outcomes were the sensitivity and specificity of CT scanning for bowel obstruction with ischaemia and closed loop obstruction. Data were retrieved from the original CT reports written by on-call radiologists and compared with operative findings.

RESULTS

One hundred seventy-six patients were included, all of whom underwent CT scanning with intravenous contrast followed by operative management of SBO. Bowel obstruction with ischaemia was noted in 20 patients, with a sensitivity and specificity of CT scanning of 40.0% and 85.5%, respectively. Closed loop obstructions were noted in 26 patients, with a sensitivity and specificity of CT scanning of 23.1% and 98.0%, respectively.

CONCLUSIONS

The real-world accuracy of CT scanning appears to be lower than previously reported in the literature. Strategies to address this could include the development of standardised reporting schemas and to increase the surgeon's own familiarity with relevant CT features in patients admitted with SBO.

ECLAPTE: Effective Closure of LAParoTomy in Emergency-2023 World Society of Emergency Surgery guidelines for the closure of laparotomy in emergency settings

Laparotomy incisions provide easy and rapid access to the peritoneal cavity in case of emergency surgery. Incisional hernia (IH) is a late manifestation of the failure of abdominal wall closure and represents frequent complication of any abdominal incision: IHs can cause pain and discomfort to the patients but also clinical serious sequelae like bowel obstruction, incarceration, strangulation, and necessity of reoperation. Previous guidelines and indications in the literature consider elective settings and evidence about laparotomy closure in emergency settings is lacking. This paper aims to present the World Society of Emergency Surgery (WSES) project called ECLAPTE (Effective Closure of LAParoTomy in Emergency): the final manuscript includes guidelines on the closure of emergency laparotomy.

Abdominal wound dehiscence and incisional hernia prevention in midline laparotomy: a systematic review and network meta-analysis

BACKGROUND

Incisional hernia (IH) is the main complication after laparotomy. In an attempt to reduce this complication, mesh techniques and studies in which the closure technique is modified have been proposed. Both types are characterized by comparison with the closure described as standard or conventional: 1 × 1, mass, and continuous closure. For this study, modified closure techniques (MCTs) were considered as those techniques in which an extra suture is placed (reinforced tension line (RTL), retention), the closure point is modified in distance (small bites) or shape (CLDC, Smead Jones, interrupted, Cardiff point) and which aim to reduce these complications. The objective of this network meta-analysis (NMA) was to evaluate the effectiveness of MCTs for reducing the incidence of IH and abdominal wound dehiscence (AWD) to provide objective support for their recommendation.

METHODS

An NMA was performed according to the PRISMA-NMA guidelines. The primary objective was to determine the incidence of IH and AWD, and the secondary objective was to determine the incidence of postoperative complications. Only published clinical trials were included. The risk of bias was analyzed, and the random-effects model was used to determine statistical significance.

RESULTS

Twelve studies comparing 3540 patients were included. The incidence of HI was lower in RTL, retention suture, and small bites, these techniques showed statistical differences with pooled ORs (95% CI) of 0.28 (0.09-0.83), 0.28 (0.13-0.62), and 0.44 (0.31-0.62), respectively. Associated complications, including hematoma, seroma, and postoperative pain, could not be analyzed; however, MCTs did not increase the risk of surgical site infection.

CONCLUSION

Small bites, RTL, and retention sutures decreased the prevalence of IH. RTL and retention suture decreased the prevalence of AWD. RTL was the best technique as it reduced both complications (IH and AWD) and had the best SUCRA and P-scores, and the number needed to treat (NNT) for net effect was 3.

REGISTRATION

This study was prospectively registered in the PROSPERO database under registration number CRD42021231107.

Update of risk factors for surgical site infection in clean-contaminated wounds after gastroenterological surgery: An analysis of 1,878 participants enrolled in 2 recent randomized control trials for the prevention of surgical site infection

BACKGROUND

Clean-contaminated wounds should be the main target for reducing the burden of harm caused by surgical site infection after gastroenterological surgery.

METHODS

The present study targeted 1,973 patients enrolled in 2 randomized controlled trials to evaluate the efficacy of intraoperative interventions for incisional surgical site infection prevention after gastroenterological surgery with clean-contaminated wounds. Patients were reassessed, and preoperative and postoperative variables were collected. Risk factors for surgical site infection were identified by univariate and multivariate analyses.

RESULTS

The study population included 1,878 patients, among whom 213 (11.3%) developed overall surgical site infection and 119 (6.3%) developed incisional surgical site infection. A multivariate analysis revealed that steroid or immunosuppressant use (odds ratio 3.03; 95% confidence interval 1.37-6.73, P = .0064), open surgery (odds ratio 1.77; 95% confidence interval 1.11-2.83, P = .0167), and long operative time (odds ratio 2.31; 95% confidence interval 1.5-3.56, P < .001) were independent risk factors for incisional surgical site infection. Steroid or immunosuppressant use (odds ratio 2.62; 95% confidence interval 1.29-5.33, P = .0078), open surgery (odds ratio 2.13; 95% confidence interval 1.44-3.16, P < .001), and long operative time (odds ratio 2.92; 95% confidence interval 2.08-4.10, P < .001) were also independent risk factors for overall surgical site infection in the multivariate analysis. Furthermore, a multivariate analysis revealed that a long operative time (odds ratio 3.21; 95% confidence interval 1.69-6.1, P = .00378) was an independent risk factor for incisional surgical site infection in patients who underwent laparoscopic surgery.

CONCLUSION

Even under current measures for surgical site infection prevention, surgeons should continue to make efforts to appropriately expand the indication of laparoscopic surgery and to reduce operative times even when performing laparoscopic surgery.