Prophylactic synthetic mesh can be safely used to close emergency laparotomies, even in peritonitis

doi:10.1016/j.surg.2014.04.035

Surgery

Volume 156, Issue 5, November 2014, Pages 1238-1244

https://doi.org/10.1016/j.surg.2014.04.035 Get rights and content

Background

This study was conducted to determine the efficacy and safety of the use of a partially absorbable large pore synthetic prophylactic mesh in emergent midline laparotomies for the prevention of evisceration and incisional hernia.

Methods

Retrospective analysis of all patients who underwent an emergency midline laparotomy between January of 2009 and July of 2010 was performed. Patients with complicated ventral hernia repair, postoperative death, and lack of follow-up were excluded.

Results

A total of 266 patients were included. Laparotomies were closed with a running suture of slow-reabsorbable material in 190 patients (Group S), and 50 patients within this group (26.3%) received additional retention sutures. In 76 patients (Group M), an additional partially absorbable lightweight mesh was placed in the Supra-aponeurotic space. Both groups presented similar complication rates (71.1% Group S vs 80.3% Group M, P = .97). There were no differences regarding surgical-site infection rates (17.9% Group S vs 26.3% Group M; P = .13) or postoperative mortality (13.7% Group S vs 18.3% Group M; P = .346). A total of 150 patients completed the follow-up (99 Group S; 51 Group M) at a mean time of 16.7 months. During follow-up, 36 cases of incisional hernia (24%) were diagnosed: 33 (33%) in Group S, whereas there were only three cases (5.9%) in Group M (P = .0001). Mesh removal for chronic infection was not required in any case.

Conclusion

The use of a partially absorbable, lightweight large pore prophylactic mesh in the closure of emergency midline laparotomies is feasible for the prevention of incisional hernia without adding a substantial rate of morbidity to the procedure, even if high contamination or infections are present.

Section snippets

Patients and methods

We performed a retrospective analysis of the prospectively maintained database of the Emergency Surgery Unit of the Department of General Surgery in our university hospital, using FileMaker Pro v. 10 (Santa Clara, CA). The initial population included all consecutive patients undergoing emergency laparotomy in the period between January 2009 and July 2010.

The population was divided into Group S (suture closure) and Group M (suture + prophylactic mesh). We excluded patients who presented with

Results

Of the 266 midline laparotomies performed during the study period, a prophylactic mesh was placed in 76 cases (Group M). In the remaining 190 patients (Group S), the midline closure consisted of a running suture in 140 cases (73.7%), with added reinforcement with retention sutures in 50 cases (26.3%).

The Group M patients were significantly older (P = .04) and presented a greater frequency of obesity (P = .032) and previous laparotomies (P = .01). The most frequent diagnosis was peritonitis from

Discussion

In our series, the incidence of incisional hernia after use of a running suture for closure of midline laparotomy in emergency surgery was 33%. Most studies on the incidence of incisional hernia have been conducted in the context of elective surgery, reporting figures ranging between 9 and 20%.5, 20 Our findings confirm previous reports that had already detected an incidence greater than 30% of incisional hernia in patients undergoing surgery for peritonitis.6, 7

On the basis of this study, we

References (41)

A. Ceydeli et al.
Finding the best abdominal closure: an evidence-based review of the literature
Curr Surg
(2005)
M.R. Moussavian et al.
Long-term follow up for incisional hernia after severe secondary peritonitis—incidence and risk factors
Am J Surg
(2010)
Z. Khorgami et al.
Prophylactic retention sutures in midline laparotomy in high-risk patients for wound dehiscence: a randomized controlled trial
J Surg Res
(2013)
K. Breuing et al.
Incisional ventral hernias: review of the literature and recommendations regarding the grading and technique of repair
Surgery
(2010)
H.J. Sugerman et al.
Greater risk of incisional hernia with morbidly obese tan steroid-dependent patients and low recurrence with prefascial polypropylene mesh
Am J Surg
(1996)
B.W. Murray et al.
The impact of surgical site infection on the development of incisional hernia and small bowel obstruction in colorectal surgery
Am J Surg
(2011)
J.A. Pereira et al.
High incidence of incisional hernia following open and laparoscopic resection for colorectal cancer
Cir Esp
(2013)
C. Birolini et al.
Elective colonic operation and prosthetic repair of incisional hernia: does contamination contraindicate abdominal wall prosthesis use?
J Am Coll Surg
(2000)
M. Mudge et al.
Incisional hernia: a 10 year prospective study of incidence and attitudes
Br J Surg
(1985)
G.M. Fleischer et al.
Infected abdominal wall and burst abdomen
Chirurg
(2000)

L.T. Sørensen et al.

Risk factors for tissue and wound complications in gastrointestinal surgery

Ann Surg

(2005)

D.L. Sanders et al.

The modern management of incisional hernias

BMJ

(2012)

A. Mingoli et al.

Incidence of incisional hernia following emergency abdominal surgery

Ital J Gastroenterol Hepatol

(1999)

A.D. Rink et al.

Negative side effects of retention sutures for abdominal wound closure. A prospective randomised study

Eur J Surg

(2000)

P.M. Bevis et al.

Randomized clinical trial of mesh versus sutured wound closure after open abdominal aortic aneurysm surgery

Br J Surg

(2010)

A. Jänes et al.

Experiences with a prophylactic mesh in 93 consecutive ostomies

World J Surg

(2010)

M.H. Abo-Ryia et al.

Prophylactic preperitoneal mesh placement in open bariatric surgery: a guard against incisional hernia development

Obes Surg

(2013)

C.P. Brandt et al.

Polypropylene mesh closure after emergency laparotomy: morbidity and outcome

Surgery

(1995)

D.J. Geisler et al.

Safety and outcome of use of nonabsorbable mesh for repair of fascial defects in the presence of open bowel

Dis Colon Rectum

(2003)

M.E. Kelly et al.

The safety and efficacy of prosthetic hernia repair in clean-contaminated and contaminated wounds

Am Surg

(2002)

Cited by (55)

A Biomechanical Analysis of Prophylactic Mesh Reinforced Porcine Laparotomy Incisions
2022, Journal of Surgical Research
Citation Excerpt :
PMP of the initial suture closure reinforces the anterior fascia and has been found to increase biomechanical strength from 44 N to 57 N.8 With this knowledge, there has been a recent emphasis on clinically investigating the impact of prophylactically reinforcing laparotomy incisions with mesh, particularly in high risk patients. In patients presenting for emergency midline laparotomies,9,10 elective or emergent colorectal procedures,11 open bariatric surgery in the setting of morbid obesity,12 and abdominal aortic aneurysm (AAA) repair,13 PMP has resulted in lower rates of IH than patients repaired with suture-only, with similar complications rates. Results of the PRImary Mesh Closure of Abdominal Midline Wound trial, a multicenter double-blind randomized control trial, found that after randomizing 480 high-risk (body mass index >27 or open AAA) patients to primary suture repair, onlay, or retrorectus mesh placement, rates of IH at 2 y were 30% if repaired with suture alone, 18% if repaired with retrorectus mesh (P = 0.05), and 13% if repaired with onlay mesh (P = 0.0016).14
Research indicates that prophylactic mesh may help prevent incisional hernia after laparotomy, but best practice patterns in these situations are still evolving. Here, we compare the failure loads (FLs) and biomechanical stiffness (BMS) of 35 porcine abdominal wall laparotomy incisions reinforced with meshes of various widths and fixation distances using biomechanical testing.
In each specimen, a 10-cm incision was made and closed using continuous 1-0 Maxon suture. Specimens were randomized to mesh width (none, 2.5 cm, 3 cm, 4 cm, 6 cm, 8 cm) and tack separation (1.5 cm, 2 cm apart) and the meshes secured in an onlay fashion. Cyclic loads oscillating from 15 N to 140 N were applied to simulate abdominal wall stress, and the specimens subsequently loaded to failure. FLs (N) and BMS (N/mm) were comparatively analyzed.
All specimens failed via suture pull-through. FLs and BMS were lowest in specimens with suture-only (421.43 N; 11.69 N/mm). FLs and BMS were significantly higher in 4-cm mesh specimens (567.51 N) than those with suture, 2.5-cm, and 3.0-cm mesh (all P < 0.05). FLs in specimens with a greater number of tacks were consistently higher in meshes of similar sizes, although these did not reach significance.
A 4-cm mesh reenforcement was superior to suture-only and smaller meshes at preserving strength in laparotomy closure in a porcine model but larger meshes (6 cm, 8 cm) did not provide an additional benefit. Meshes with more fixation points may be advantageous, but additional data are needed to make definitive conclusions.
Umbilical incisional hernias (M3): Are trocar-site hernias different? Comparative analysis of the EVEREG Registry
2022, Cirugia Espanola
La hernia incisional (HI) es una complicación frecuente. El objetivo principal de este estudio es comparar características, complicaciones y recurrencias de las HI producidas por la colocación de un trócar laparoscópico umbilical (M3T) con las de misma localización tras cirugía abierta (M3O); y de forma secundaria, la identificación de factores de riesgo.
Estudio observacional transversal analizando al registro EVEREG durante el periodo entre julio del 2012 y junio del 2018. Las variables principales fueron recurrencias y complicaciones postoperatorias. Se compararon ambos grupos (M3T y M3O). Se realizó regresión logística múltiple para identificar los factores de riesgo de la cohorte completa.
Se incluyeron un total de 882 casos. El grupo M3O presentó un ASA superior, HI con criterios de mayor complejidad para la reparación, mayor número de recurrencias a los 12 y 24 meses (8,6 vs. 2,5%; p < 0,0001 y 9,3 vs. 2,9%; p < 0,0001, respectivamente) y complicaciones postoperatorias (21,9 vs. 14,6%; p = 0,02). Se identificaron como factores de riesgo para la aparición de complicaciones postoperatorias, la reparación previa, la duración de la intervención y el requerimiento de procedimientos asociados, y para las recidivas: la ausencia de especialista de pared abdominal, la reparación previa y la aparición de complicaciones. El análisis por puntuación de propensión no detectó diferencias significativas en complicaciones y recurrencias.
Las HI M3 de trócar umbilical son menos complejas que las originadas por cirugía abierta. La complejidad no se relaciona con el origen de la hernia, sino con sus características y las del paciente.
Incisional hernia (HI), in open and laparoscopic surgery, is a very frequent complication. HI located in the umbilical region are called M3. The main aim of this study is to compare HI produced by the placement of an umbilical laparoscopic trocar (M3T) with those located in M3 in open surgery (M3O) in terms of basal characteristics, complications and recurrences; and secondarily the identification of risk factors.
Cross-sectional observational study based on the national prospective registry EVEREG during the period of July 2012 - June 2018. The main variables were recurrences and postoperative complications. Both groups (M3T and M3O) were compared. Multiple logistic regression was performed to identify the risk factors of the entire cohort.
882 had a follow-up time longer than 12 months. M3O group presented superior ASA-Class, more complex HI and previous repair. It also presented a higher recurrence rate at 12 and 24 months (8.6 vs. 2.5%; p < 0,0001 and 9.3 vs. 2.9%; p < 0.0001) and higher postoperative complications rate (21.9 vs. 14.6%; p = 0.02).
Previous repair, intervention length and associated procedures requirement were identified as risk factors for postoperative complications. Absence of a specialist present during surgery, previous repair, and the absence of complications were identified as risk factors for recurrence. In the PSM analysis no differences were detected in of complications and recurrences.
HI M3O is more complex than M3T. The complexity is not related to the origin of the hernia but to its characteristics and those of the patient.
Counting stitches does not save time
2021, Surgery (United States)
Mesh position for hernia prophylaxis after midline laparotomy: A systematic review and network meta-analysis of randomized clinical trials
2020, International Journal of Surgery
Citation Excerpt :
However, laparotomy is still preferred in an emergency. A meta-analysis from Burns et al. [44], which included only two non-randomized studies [41,45], has found that there are limited data of prophylactic mesh in an emergency setting. RCT was required to assess the effect of prophylactic mesh in this particular group of patients.
Mesh can be used to prevent incisional hernia (IH) occurrence. However, the effect of various mesh positions has never been compared. This study aimed to compare and rank the effect and safety of various mesh-augmented fascia closure techniques on hernia prophylaxis in midline laparotomy.
MEDLINE and SCOPUS were searched from inception to December 2019. Randomized clinical trials (RCTs) were eligible if they met the following criteria: comparison of any of the following interventions: onlay (OM), retrorectus (RM), preperitoneal (PM), intraperitoneal mesh (IM) augmentation, and primary suture closure (PSC); and reporting on any of these outcomes: IH, wound infection, seroma, hematoma, and dehiscence. Two independent reviewers extracted data and assessed the risk of bias. A two-stage random-effect network meta-analysis was performed, then intervention effects were pooled and ranked accordingly.
A total of 20 RCTs were eligible. Only OM and RM showed a significantly lower risk of IH than PSC with pooled risk ratios (RRs), 95% confidence intervals (95%CI) of 0.24 (0.12, 0.46) and 0.32 (0.16, 0.66), and number needed to treat (NNTs) of 4 and 5, respectively. However, OM showed a significantly higher risk of seroma than PSC (RR 2.21 (1.44, 3.39) with a number needed to harm (NNH) of 14). Most mesh placements showed a higher risk of wound infection, except for RM, but none of these was significantly different. All mesh techniques, except RM, showed a reduction in dehiscence, but again these were not significantly different.
OM and RM provided the most effective IH prevention relative to PSC. However, OM had a higher rate of seroma than RM and PSC. Other complications, including wound infection, hematoma, and dehiscence, were not significantly observed among these fascia closure techniques.
Stoma closure and reinforcement (SCAR): A study protocol for a pilot trial
2020, Contemporary Clinical Trials Communications
A quality metric for centers performing rectal cancer surgery is a high percentage of sphincter sparing procedures. These procedures often involve temporary bowel diversion to minimize the complications of an anastomotic leak. The most common strategy is a diverting loop ileostomy which is then closed after completion of adjuvant therapy or the patient recovers from surgery. Loop ileostomy is not without complications and the closure is complicated by a one in three chance of incisional hernia development. Strategies to prevent this problem have been designed using a variety of techniques with and without mesh placement. This proposed pilot study will test the safety and efficacy of a novel stoma closure technique involving permanent mesh in the retro rectus position during ileostomy closure. The study will prospectively follow 20 patients undergoing ileostomy closure using this technique and evaluate for safety of the procedure, quality of life, and feasibility for a larger randomized controlled trial. Patients will be followed post procedurally and evaluated for 30-day complications, as well as followed up with routine cancer surveillance computed tomography every 6 months in which the presence of stoma site incisional hernias will be evaluated. The results of this pilot study will inform the design of a multiple center, blinded randomized controlled trial to evaluate the utility of permanent mesh placement to decrease the incidence of prior stoma site incisional hernias.
Safety and Efficacy of Synthetic Mesh for Ventral Hernia Repair in a Contaminated Field
2020, Journal of the American College of Surgeons
Controversy remains about appropriate mesh selection during ventral hernia repair (VHR) in a contaminated field. Fear of mesh infection has led to increased use of biologic and absorbable synthetic meshes rather than permanent synthetic mesh in these cases. We report the safety and efficacy of permanent synthetic mesh during contaminated VHR.
Retrospective review of our database identified all cases of contaminated VHR from July 2007 to May 2019. Student's t-test and Wilcoxon rank sum were used to analyze continuous variables, and discrete variables with Fisher's or Kruskal-Wallis test.
There were 541 contaminated cases: 245 clean-contaminated, 214 contaminated, and 82 dirty cases. Suture repair was performed in 46 patients, biologic mesh was used in 38, absorbable synthetic mesh in 55, and permanent synthetic mesh in 402. Mesh was extraperitoneal in 97% of cases. Incidence of surgical site infection in each group was 17.4%, 36.8%, 32.7%, and 14.2%, respectively (p < 0.001). Multivariate analysis showed no effect of mesh selection on risk of surgical site infection. Mesh was removed in 7 patients; 5 were permanent synthetic (1.2%), 1 was absorbable synthetic (1.8%), and 1 was biologic (2.6%). In 4 patients there was mesh-specific complication and the remaining meshes were removed during exploration for indications unrelated to the mesh. At a median follow-up of 30.2 months, recurrence occurred in 15.2% of patients and was significantly lower with permanent synthetic mesh.
Permanent synthetic mesh placed in an extraperitoneal position is not only safe for VHR in a contaminated field, but it confers a significantly lower rate of surgical site infection and recurrence compared with biologic or bioabsorbable meshes.

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Acute Care SurgeryProphylactic synthetic mesh can be safely used to close emergency laparotomies, even in peritonitis

Background

Methods

Results

Conclusion

Section snippets

Patients and methods

Results

Discussion

Curr Surg

Am J Surg

J Surg Res

Surgery

Am J Surg

Am J Surg

Cir Esp

J Am Coll Surg

Incisional hernia: a 10 year prospective study of incidence and attitudes

Br J Surg

Infected abdominal wall and burst abdomen

Chirurg

Risk factors for tissue and wound complications in gastrointestinal surgery

Ann Surg

The modern management of incisional hernias

BMJ

Incidence of incisional hernia following emergency abdominal surgery

Ital J Gastroenterol Hepatol

Negative side effects of retention sutures for abdominal wound closure. A prospective randomised study

Eur J Surg

Randomized clinical trial of mesh versus sutured wound closure after open abdominal aortic aneurysm surgery

Br J Surg

Experiences with a prophylactic mesh in 93 consecutive ostomies

World J Surg

Prophylactic preperitoneal mesh placement in open bariatric surgery: a guard against incisional hernia development

Obes Surg

Polypropylene mesh closure after emergency laparotomy: morbidity and outcome

Surgery

Safety and outcome of use of nonabsorbable mesh for repair of fascial defects in the presence of open bowel

Dis Colon Rectum

The safety and efficacy of prosthetic hernia repair in clean-contaminated and contaminated wounds

Am Surg

Acute Care Surgery
Prophylactic synthetic mesh can be safely used to close emergency laparotomies, even in peritonitis