Long-term follow-up of prophylactic mesh reinforcement after emergency laparotomy. A retrospective controlled study

Abstract

Background Prevention of incisional hernias with a prophylactic mesh in emergency surgery is controversial. The present study aimed to analyze the long-term results of prophylactic mesh used for preventing incisional hernia after emergency midline laparotomies. Methods This study was a registered (NCT04578561) retrospective analysis of patients who underwent an emergency midline laparotomy between January 2009 and July 2010 with a follow-up period of longer than 2 years. Long-term outcomes and risk factors for the development of incisional hernias between patients who received a prophylactic reinforcement mesh (Group M) and suture (Group S) were compared. Results From an initial 266 emergency midline laparotomies, 187 patients were included. The median follow-up time was 64.4 months (SD 35). Both groups had similar characteristics, except for a higher rate of previous operations (62 vs. 43.2%; P = 0.01) and operation due to a revision laparotomy (32.5 vs.13%; P = 0.02) in the M group. During follow-up, 29.9% of patients developed an incisional hernia (Group S 36.6% vs. Group M 14.3%; P = 0.002). Chronic mesh infections were diagnosed in 2 patients, but no mesh explants were needed, and no patient in the M group developed chronic pain. Long-term risk factors for incisional hernia were as follows: smoking (HR = 2.47; 95% CI 1.318–4.624; P = 0.05), contaminated surgery (HR = 2.98; 95% CI 1.142–7.8; P = 0.02), surgical site infection (SSI; HR = 3.83; 95% CI 1.86–7.86; P = 0.001), and no use of prophylactic mesh (HR = 5.09; 95% CI 2.1–12.2; P = 0.001). Conclusion Incidence of incisional hernias after emergency midline laparotomies is high and increases with time. High-risk patients, contaminated surgery, and surgical site infection (SSI) benefit from mesh reinforcement. Prophylactic mesh use is safe and feasible in emergencies with a low long-term complication rate. Trial registration: NCT04578561. www.clinicaltrials.gov

Prophylactic mesh placement in emergency midline laparotomy for intestinal perforation peritonitis: An appeal for caution

“…13 The possibility of Zenker's degeneration, a prototype of coagulative necrosis of skeletal muscle such as the rectus abdominis, which can occur in severe toxaemia as in typhoid fever. 25 Previous observational studies & RCTs which have shown PMP effective in reducing incisional hernia after EML 5–9 have included a wide spectrum of aetiology (including cases without peritonitis), unlike our study which included only patients undergoing EML for intestinal perforation. Obesity is probably the most important risk factor for incisional hernia, and up to 73% of Western population are overweight. 26 Thus, Western trials which may have a large proportion of such patients may show a greater ‘benefit’ from PMP, unlike our cohort of patients which more accurately reflect the population of LMICs.…”

“…Previous observational studies & RCTs which have shown PMP effective in reducing incisional hernia after EML 5–9 have included a wide spectrum of aetiology (including cases without peritonitis), unlike our study which included only patients undergoing EML for intestinal perforation.…”

“…[1][2][3][4] A similar philosophy is driving the use of PMP in emergency cases including those with peritonitis. [5][6][7][8][9] However, objective evidence for its routine use, as synthesized by two recent meta-analyses, is limited. 10,11 Additionally, data are not available for the outcomes of PMP in patients undergoing EML for intestinal perforation peritonitis, prompting us to conduct this prospective observational study to assess its safety and efficacy in these cases.…”

Defining High-Risk Patients Suitable for Incisional Hernia Prevention

“…Systematic abdominal wall closure with small bites (SB) technique significantly reduces fascial dehiscence (FD) (6.6% vs. 3.8%) 6 and IH (27% vs. 15%) (18) in emergency laparotomy. Moreover, the use of PM in these situations, especially in the presence of other risk factors, reduces even more the incidence of FD and IH (19)(20)(21).…”

Incisional Hernia Depends on More Than Just Mesh Placement

“…These same long-term results were previously observed in other similar works [ 15 ]. Moreover, when it comes to preventing IH with non-absorbable synthetic mesh after emergency midline laparotomy, the scarce long-term follow-up data also show a similar phenomenon where the mesh only delays the onset of the hernia [ 16 ]. Finally, it is interesting to note that other studies concerning the closure of the abdominal wall, where the efficacy of meshes in the treatment or prevention of IH is not evaluated, reveal similar curves.…”