Does prophylactic mesh placement in elective, midline laparotomy reduce the incidence of incisional hernia? A systematic review and meta-analysis

Borab, Zachary; Shakir, Sameer; Lanni, Michael A.; Tecce, Michael G.; MacDonald, John K; Hope, William W.; Fischer, John P.

doi:10.1016/j.surg.2016.09.036

Cited by 115 publications

(97 citation statements)

References 50 publications

(115 reference statements)

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“…However, the clinical significance of occult hernias remains unknown. No matter the reasoning, our detected high rate of radiographic hernias does align with some prior studies (20, 21). A study utilizing high- resolution ultrasound, for example, to determine the prevalence of paraumbilical hernias among adult patients in a tertiary care hospital presenting for non-abdominal wall complaints detected an approximately 25% rate (22).…”

Section: Discussionsupporting

confidence: 92%

External Validation of the HERNIAscore: An Observational Study

Cherla

Moses

Mueck

et al. 2017

Journal of the American College of Surgeons

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Background The HERNIAscore is a ventral incisional hernia (VIH) risk assessment tool that utilizes only preoperative variables and predictable intraoperative variables. The aim of this study was to validate and modify, if needed, the HERNIAscore in an external dataset. Study Design This was a retrospective observational study of all patients undergoing resection for gastrointestinal malignancy 2011–2015 at a safety-net hospital. Primary outcome was clinical postoperative VIH. Patients were stratified into low, medium, and high risk based on HERNIAscore. A Revised HERNIAscore was formed with the addition of prior abdominal surgery as a categorical variable. Cox regression of incisional hernia with stratification by risk class was performed. Incidence rates of clinical VIH formation within each risk class were also calculated. Results 247 patents were enrolled. On Cox regression, in addition to the three variables of the HERNIAscore (BMI, incision length, and COPD), prior abdominal surgery was also predictive of VIH. The Revised HERNIAscore demonstrated improved predictive accuracy for clinical VIH. While the original HERNIAscore effectively stratified the risk of developing an incisional radiographic VIH, the Revised HERNIAscore provided a statistically significant stratification for both clinical and radiographic VIHs in this patient cohort. Conclusion We have externally validated and improved the HERNIAscore. The Revised HERNIAscore utilizes BMI, incision length, COPD, and prior abdominal surgery to predict risk of post-operative incisional hernia. Future research should assess methods to prevent incisional hernias in moderate-to-high risk patients.

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Section: Discussionsupporting

confidence: 92%

External Validation of the HERNIAscore: An Observational Study

Cherla

Moses

Mueck

et al. 2017

Journal of the American College of Surgeons

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“…IH remains a significant complication of abdominal incision and carries a considerable morbidity [4]. A recent randomised control trial demonstrated a significant reduction in incidence of IH when mesh was used to close elective laparotomies [41], which is supported by a 2017 meta-analysis [6]. However, evidence suggests an increase in chronic pain, post-operative seroma formation and delayed wound healing with mesh closure of elective laparotomies [6,42].…”

Section: Discussionmentioning

confidence: 99%

“…Studies in elective settings show a significant reduction in IHs when there is prophylactic mesh placement [6,7]. A recent trial of alternate closure methods found that there was no effect on IHs when emergency laparotomies were closed with interrupted fascial sutures compared with continuous fascial sutures [5].…”

Section: Discussionmentioning

confidence: 99%

“…Implantable mesh has traditionally been used in the elective repair of IH, however, recent studies have focused on its potential prophylactic use. There have been promising results in the elective setting, with a significant reduction in IHs seen in multiple randomised studies [6,7]. However, these studies have focused solely on elective patients.…”

Section: Introductionmentioning

confidence: 99%

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Is there a role for prophylactic mesh in abdominal wall closure after emergency laparotomy? A systematic review and meta-analysis

Burns

Heywood

Challand

et al. 2019

Hernia

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Background Incisional hernias are a common complication of emergency laparotomy and are associated with significant morbidity. Recent studies have found a reduction in incisional hernias when mesh is placed prophylactically during abdominal closure in elective laparotomies. This systematic review will assess the safety and efficacy of prophylactic mesh placement in emergency laparotomy. Methods A systematic review was performed according to the PROSPERO registered protocol (CRD42018109283). Papers were dual screened for eligibility, and included when a comparison was made between closure with prophylactic mesh and closure with a standard technique, reported using a comparative design (i.e. case-control, cohort or randomised trial), where the primary outcome was incisional hernia. Bias was assessed using the Cochrane risk of bias in non-randomised studies tool. A meta-analysis of incisional hernia rate was performed to estimate risk ratio using a random effects model (Mantel-Haenszel approach). Results 332 studies were screened for eligibility, 29 full texts were reviewed and 2 non-randomised studies were included. Both studies were biased due to confounding factors, as closure technique was based on patient risk factors for incisional hernia. Both studies found significantly fewer incisional hernias in the mesh groups [3.2% vs 28.6% (p < 0.001) and 5.9% vs 33.3% (p = 0.0001)]. A meta-analysis of incisional hernia risk favoured prophylactic mesh closure [risk ratio 0.15 (95% CI 0.6-0.35, p < 0.001)]. Neither study found an association between mesh and infection or enterocutaneous fistula. Conclusion This review found that there are limited data to assess the effect or safety profile of prophylactic mesh in the emergency laparotomy setting. The current data cannot reliably assess the use of mesh due to confounding factors, and a randomised controlled trial is required to address this important clinical question.Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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“…The superiority of mesh in incisional hernia repair over suture repair in terms of hernia recurrence is well known. This has led to an active interest in using mesh at the same time as abdominal wall closure, especially in high‐risk groups such as those undergoing aortic aneurysm surgery and obese patients, with promising results. To date, however, mesh‐augmented closure has been compared with large‐stitch, large‐bite closure, so it remains to be seen what additional benefit mesh may have in abdominal wall closure over small‐stitch, small‐bite techniques.…”

mentioning

confidence: 99%