Incidence and Prevention - Copy

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Journal of Visceral Surgery (2012) 149, e3e14

Available online at

www.sciencedirect.com

ORIGINAL ARTICLE

Incidence and prevention ofventral incisional hernia

R. Le Huu Nhoa,b,c,1, D. Mege a,b,c,1, M. Ouassia,b,c,,I. Sielezneffa,b,c, B. Sastre a,b,c

a Aix-Marseille, UMR 911, Campus sant Timone, 13005 Marseille, Franceb APHM, Hpital Timone, Service de chirurgie digestive et oncologique, Ple doncologie et

spcialits mdico-chirurgicales, 13385 Marseille, Francec Atelierdcriture mdicaleprovencale, 13005 Marseille, France

KEYWORDS

Incidence;Prevention;Incisional hernia

Summary

Objective: Ventral incisional hernia is a common complication of abdominal surgery. The inci-

dence ranges from 2% to 20% and varies greatly from one series to another. The goal ofthis study

was to determine the incidence, risk factors, and preventive measures for ventral incisional

hernia.

Materials andmethods: An analysis of the surgical literature was performed using the search

engines EMBASE, Cochrane Library, and PubMed with the keywords: abdominal hernia, wound

dehiscence, incisional hernia, incidence, trocar site hernia, and hernia prevention.

Results: The overall incidence of incisional hernia after laparotomy was 9.9%. The incidencewas significantly higher for midline incisions compared with transverse incisions (11% vs. 4.7%;

P= 0.006). In contrast, the incidence ofventral hernia was only 0.7% after laparoscopy. A compi-

lation of all the studies comparing laparotomy to laparoscopy showed a significantly higher

incidence of incisional hernia after laparotomy (P= 0.001). Independent risk factors for inci-

sional hernia included age and infectious complications. Only two meta-analyses were able to

show a significant decrease in risk-related to the use of non absorbable or slowly absorbable

suture material. No difference in incisional hernia risk was shown with different suture tech-

niques (11.1% for running suture, 9.8% for interrupted sutures: NS).

Conclusion: A review ofthe literature shows that only the choice ofincisional approach (trans-

verse incision or laparotomy vs. midline laparotomy) allows a significant decrease in the

incidence of ventral incisional hernia.

2012 Published by Elsevier Masson SAS.

Introduction

Ventral incisional hernia is a common complication of gastrointestinal surgery. The inci-dence varies from 2 to 20% [1], with extreme values ranging from 0 to 91% [2,3]. Severalfactors may explain this wide variability, such as:

Corresponding author. Service de chirurgie digestive et viscrale, hpital Timone, 264, rue Saint-Pierre, 13385 Marseille cedex 05,France. Tel.: +04 91 38 58 52; fax: +04 91 38 53 55.

E-mail address: [email protected] (M. Ouassi).1 These two authors contributed equally to this study.

1878-7886/$ see front matter 2012 Published by Elsevier Masson SAS.doi:10.1016/j.jviscsurg.2012.05.004
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e4 R. Le Huu Nho et al.

Table 1 Incidence of incisional hernia after laparotomy.

Authors (ref.) Year Study type Surgery Mean lengthincision (cm)

Follow-up(months)a

Number ofpatientsb

Incidence ofincisionalhernia n (%)

Gomez et al.[13]

2002 Retrospective LT NR 42 465 54 (11.6)

Piazzese et al.[9]

2004 Retrospective LT NR 29 623 31 (4.9)

Sorensenet al. [6]

2005 Cohort Various gas-trointestinal

NR 45 310 81 (26)

Burger et al.[15]

2005 Retrospective Various gas-trointestinal

NR 12 53 25 (47.1)

Vardanianet al. [11]

2006 Retrospective LT NR NR 959 44 (4.6)

Heisterkampet al. [20]

2008 Cohortprospective

LT NR 36 118 18 (15)

Engledowet al. [7]


Various gas-trointestinal

6 25 80 6 (7.5)

Veljkovicet al. [8]


Various gas-trointestinal

18 6 603 81 (13.4)

Gastaca et al.[10]

2010 Retrospective LT NR NR 626 11 (1.7)

Moussavianet al. [12]

2010 Retrospective Secondaryperitonitis

24.3 72 92 50 (54.3)

Al-Azzawiet al. [14]

2010 Retrospective Acutepancreatitis

NR 29 149 63 (42)

Total 4078 464 (11.3)

NR: not recorded; LT: liver transplantation.a Mean or median follow-up.b Number of patients examined at the end of follow-up to allow diagnosis of incisional hernia.

failure of the operating surgeon to report incisionalhernias or reparative surgery performed by a differentsurgeon;

too short a period offollow-up: while most incisional her-nias are diagnosed within the first 3 years after initiallaparotomy [4], some may not become evident for up to10 years after the initial surgery [5].

This wide variation in the reported rates of incisionalhernia is not unexpected, given the heterogeneity of thereported series with regard to the types ofpatients included,the types ofsurgery performed, and the duration offollow-up. Nonetheless, this complication necessitated 34,000ventral hernia repairs in France, based on the findings ofthe

Programme de mdicalisation des systmes dinformation(PMSI) study of 2009, consisting of either direct sutureherniorraphy or ofmesh implantation. Numerous risk factorshave been identified in the effort to limit the incidence ofventral incisional hernia, and numerous studies have beenperformed to determine surgical approaches and types offascial closure with the best results and lowest incidence ofincisional hernia. From this viewpoint, even the prophylacticplacement ofmesh has been proposed. The objective ofthisliterature review was to determine the incidence and riskfactors for ventral incisional hernia and to identify measuresthat might decrease the incidence ofthis complication.

Review of the literature

A search of Evidence-based medicine articles publishedbetween 1998 and 2011 was carried out by cross-referencing

the keyword descriptors: abdominal hernia, wound dehis-cence, incidence, trocar site hernia, hernia prevention. Thesearch engines of EMBASE, Cochrane Library, and PubMedwere used. The search was limited to articles publishedin French or English and dealing with human popula-tions. For research concerning preventive measures, thesearch was enlarged to include articles from 1981 to 2011because of technical improvements of surgical suture dur-ing these last two decades and because there were veryfew randomized studies published during the last 8 years.Studies concerning the treatment of ventral incisional her-nia and recurrence after repair as well as case reports wereexcluded.

The studies included consisted ofprospective, compara-

tive and retrospective series dealing with gastrointestinalor urologic abdominal surgery in adults and children.This search identified 88 references that were suffi-cient to select the studies necessary for analysis of thisproblem.

Incidence and risk factors

The literature review identified 17 original articlesconcerning ventral incisional hernia after laparotomy[2,621], 17 original articles concerning ventral inci-sional hernia after laparoscopy [2237,39] and 17

comparative studies of laparotomy vs. laparoscopy[3,38,4054]. A total of30,603 patients from the combinedseries, the incidence of ventral incisional hernia was3,7%.


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Table 2 Prospective randomized studies of incisional hernia incidence as a function of surgical incision.

Authors Year Studytype

Type ofsurgery

Incisionallength (cm)

Follow-up(months)

Number ofpatients included

Laparotomy Laparotomy

Midline Transverse Midline TransveInaba et al. [16] 2004 PR Upper abdominal 20.4 23.3 > 12 199 196Fassiadis et al. [2] 2005 PR Vascular NR NR 53 22 15Proske et al. [17] 2005 PR Upper abdominal 17.6 26.3 NR 47 47Seiler et al. [21] 2009 PR Various gastrointestinal NR NR 12 79 69Halm et al. [18] 2009 PR Upper abdominal 16.4 14 12 63 60

Total 410 387

PR: prospective randomized study; NR: not recorded; NS: not statistically significant.

Table 3 Incidence of incisional hernia after laparoscopy.Authors Year Study type Surgery Follow-up (months) Number ofpatients Inci

Glo

Bowrey et al. [22] 2001 Retrospective Gastric 12 320 9Duca et al. [23] 2003 Prospective Biliary 15 9542 12Montgomery et al. [24] 2005 Retrospective Urology NR 424 15Chiu et al. [25] 2006 Retrospective Bariatric 29 752 2Johnson et al. [26] 2006 Retrospective Bariatric 20 747 9Neri et al. [27] 2008 Prospective Biliairy NR 48 2Balakrishnan et al. [28] 2008 Prospective Biliary NR 1332 5Sexton et al. [29] 2008 Retrospective Gastric 12 61 1Singh et al. [30] 2008 Prospective Colorectal 20.2 166 13

Ferrari et al. [31] 2009 Prospective Vascular 37.9 271 34Hussain et al. [32] 2009 Retrospective All types 43 5541 8Cost et al. [33] 2010 Retrospective Urology 5.7 218 7Skipworth et al. [34] 2010 Prospective Colorectal 36 167 12Lin et al. [35] 2011 Retrospective Urology 33.9 308 1Gangl et al. [36] 2011 Prospective Biliary 21.5 134 2Fuller et al. [37] 2011 Prospective Urology 35 250 12

Total 20281 144

NR: not recorded.


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0

20

40

60

80

100

%

SEX

AGE

BMI

Tobacco

Diabetes

Previous surgery

CorcosteroidtherapySepc complicaons

Size of incision

Risk factors

Figure 1. Percentage of each independent risk factor in the 18studies evaluating risk factors for incisional hernia.

0

5

10

15

20

%

9,8% 11,1%

Rapidly absorbable

Slowly absorbable

Non Absorbable

Running sutureInterrupted sutures

Figure2. Overall incidence of incisional hernia by type of closureand suture material.

Ventral incisional hernia after laparotomy

Despite the increasing acceptance of laparoscopic surgery,laparotomy still remains the most common surgical approachfor abdominal surgery; in 2009 in the French Programmede mdicalisation des systmes d information (PMSI)database, 361,004 laparotomies were performed versus288,224 laparoscopies. From the 17 original articles pub-lished between 2002 and 2008, 11 articles that includedmore than 50 patients and had a follow-up period longerthan 6 months were selected for further analysis; (Table 1)evaluation showed an overall incidence of incisional herniaof 11.3% [615,20]. Sixty percent of these incisional her-nias occurred within 1 year ofthe initial laparotomy [4,15].The overall incidence of incisional hernia after laparotomy

was about 9.9%. This result exceeds the global incidenceof 3.7% is explained by a longer follow-up averaging 2.5years with an extreme range of 72 months [12]. The cumu-lative incidence of incisional hernia increases with time[4].

Influence ofthe type oflaparotomy incision

The choice of incision depends largely on the anatomicregion to be exposed, the type ofsurgery, and the surgeonscustomary practice. While the midline incision is adaptableto all surgical eventualities, but the incidence of incisionalhernia is increased as was shown by the meta-analysis ofGrantcharov et al. with an incisional hernia rate of8.1% vs.

a 5.1% rate for transverse incisions (P= 0.023) [19]. Afterthis study, two out of five randomized prospective trials[2,1618,21] showed a statistically significant incidence ofventral incisional hernia for midline vs. transverse incision

(Table 2). The combination of patients from the five seriesreported between 2004 and 2009 included a total of 410midline incisions and 387 transverse incisions; the incidenceof incisional hernia was higher for the midline incisions11% vs. 4.7%; P= 0.006) [2,1618,21]. A recent study fromthe Cochrane Library confirms the statistically significantincrease in the incidence of incisional hernia after mid-line incision compared with transverse laparotomy [55]. Astudy by Fassiadis concerning surgery for abdominal aorticaneurysm showed a higher rate ofincisional hernia for mid-line incision (91% vs. 40%; P= 0.01 [2]. However, the 91% rateof incisional hernia in this series is higher than any otherreported series.

Because of anatomical constraints, hepatic surgeryrequires unusual incisions (bilateral subcostal, J-shapedincisions, or stellate Mercedes incision). In hepatictransplantation series that used a Mercedes type inci-sion [911,13], the reported incidence of incisional herniaranged from 1.7% to 11.6%. In comparison with a J-shapedincision, the Mercedes incision for liver transplantationseemed to be more likely to result in incisional hernia as was

shown in the prospective comparative study ofHeisterkampet al. (24% vs. 6%; P= 0.002) [20]. In their retrospectivestudy, Piazzese et al. showed that three-quarters of inci-sional hernias were associated with a Mercedes incisionwhile the other quarter occurred after a J-shaped incision[9]. Bilateral subcostal incision was associated with a 1.7%incidence ofincisional hernia in the series ofGastaca et al.,significantly lower than that observed with J-shaped inci-sion 96%; P= 0.03) and Mercedes incision (24%; P= 0.003)[10]. The advent oflaparoscopy has made some ofthese sur-gical approaches obsolete such as the transverse subcostalincision for cholecystectomy.

Ventral incisional hernia after laparoscopyWhile the rise in laparoscopic surgery has permitted amarked decrease in the rate of incisional hernia, even thisapproach is not immune to this complication. Incisional her-nia can develop either at the incisional site through whichthe specimen is extracted, or even at trocar sites. In acompilation of 16 published reports (Table 3) over the last10 years and including 20,281 patients, the reported rateofincisional hernia from all sites is 0.7%; 0.4% occur at tro-car sites and 0.3% at the incision for specimen extraction[2237,39]. The risk seems to be less for upper abdomi-nal surgery with a minimum rate of 0.1% reported by Ducaet al. in a prospective study of 9542 cholecystectomies

[23].The highest rates of incisional hernia occur after colo-

rectal or vascular surgery; the incidence of hernia after

0

5

10

15

20

25

%

*

*

Parietal Wound

s

Control

Incisional Hernias

(*) P=0,001

Figure 3. Overall rate of incisional hernia as a function of pros-thetic mesh placement.


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Table 4 Comparison of incisional hernia rate after laparotomy vs. laparoscopy.

Authors Year Study type Surgery Follow-up(months)

Number ofpatients

Laparotomy Laparosco

Milsom et al. [40] 1998 Prospective randomised Colorectal 19 54 55Sanz-Lopez et al. [41] 1999 Retrospective Upper abdominal 66 84 123Winslow et al. [42] 2002 Prospective randomised Colorectal 30.1 46 37Lujan et al. [3] 2004 Prospective randomised Upper abdominal (b) 23 51 53Puzziferri et al. [43] 2006 Prospective randomised Upper abdominal (b) 39 57 59Laurent et al. [44] 2007 Retrospective Colorectal 51 165 155Stocchi et al. [45] 2008 Prospective randomised Colorectal 126 29 27Holst Andersen et al. [46] 2008 Retrospective Colorectal 57 143 58

Ihedioha et al. [47] 2008 Prospective Colorectal 22 63 32Ito et al. [48] 2009 Retrospective Hepatic NR 65 65Llaguna et al. [49] 2010 Retrospective Colorectal 26 109 109Veenhof et al. [50] 2010 Prospective Colorectal 20 28 25Eshuis et al. [51] 2010 Prospective randomised Colorectal 80.4 26 29Schouten et al. [52] 2010 Prospective Upper abdominal (b) 84 50 50Swank et al. [53] 2011 Retrospective Appendix 106 545 210Braga et al. [54] 2011 Prospective randomised Colorectal 96 201 190De Souza et al. [38] 2011 Retrospective Colorectal 17.5 142 370

Total 1858 1647

NR: not reported; (b): bariatric; NS: not statistically significant.


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Table 5 Type ofsuture material and absorption time.

Suture material Absorption time (days)

Rapidlyabsorbable (RA)

Polygalactin 910 (Vicryl) 6090Polyglycolic acid (Dexon) 20

Slowlyabsorbable (SA)

Polydioxane (PDS) 180Polyglyconate (Maxon) 180

Non absorbable (NA)Nylon (Nurolon)Polypropylene (Prolene)Polyethylene (Ethibond)Polyanide (Ethilon)

surgery for repair of infra-renal aortic aneurysm is 12.5%[31]. The site ofincision for extraction ofthe surgical spec-imen also influenced the rate of incisional hernia. In thestudy by Singh et al., the rate of incisional hernia wassignificantly higher with a vertical midline incision thanwith a Pfannenstiel incision (17.6% vs. 0%; P= 0.0002) [30].These findings were confirmed by Souza et al. in 2011; theyfound an incisional hernia rate of 16% for vertical mid-line incision vs. 0% for Pfannenstiel incision (P< 0.001) [38].The incidence was not modified by a hand-assisted laparo-scopic approach where the incisional hernia rate was 3.5%despite an 8 cm long Pfannenstiel incision [24]. In a compar-ative study, Sonoda confirmed this result with in incisionalrate of 4.8% after standard laparoscopic surgery vs 6% forhand-assisted laparoscopy [39]. The risk of incisional her-nia does not seem to be decreased in robotic laparoscopicsurgery; a prospective cohort study of 250 laparoscopic

prostatectomies found a 4.8% rate of incisional hernia[37]; this is comparable to results after classical laparo-scopic prostatectomy. Other approaches such as singletrocar laparoscopy have identical rates of incisional her-nia (1.9%) compared to classical laparoscopy (2.1%) [36].However, this is still a recent innovation and no long-termresults are yet available. The development of hernia-tion at trocar sites was first described in 1968 by Fearet al. [56]. This type of incisional hernia is under-reportedin the literature, mostly being described in individualcase reports. However, in our compilation of 17 seriesin the literature, the rate of trocar-site hernia was0.3%.

Incisional hernias after laparotomy and afterlaparoscopy

Seventeen series published between 1998 and 2011compare the incidence of incisional hernia after laparo-tomy versus laparoscopy (Table 4). For a combinedtotal of 1858 laparotomies and 1647 laparoscopies, theincidence of incisional hernia was 12% vs. 6.3%, a sta-tistically significant difference (P= 0.001) [3,38,4054].Three prospective randomized studies and two retrospec-tive comparative studies have reported a higher incidenceof incisional hernia after laparotomy [3,4348]. Two ofthese series involved bariatric surgery [3,43] and two

others involved colorectal surgery [44,46]. For hepaticsurgery, the laparoscopic approach has also resulted in asignificant decrease in the incidence of incisional hernia[48].

Risk factors for incisional hernia

Eighteen series published between 2002 and 2011 have ana-lyzed risk factors for the development ofpostoperative inci-sional hernia [4,6,8,1215,18,24,33,38,39,42,49,53,5759](Fig. 1). Anemia, the use of vasopressor agents [59], emer-gency surgery [57], coronary artery disease, postoperativeperitonitis due to intestinal rupture [12], and preoperativeuremia are all acknowledged risk factors. Thus, emergencysurgery may increase the risk by 42 to 50% due to localand systemic effects of infection [1214]. The two fac-tors that emerge from multivariate analysis in over halfof the selected series are age and parietal surgical siteinfection. Obesity, gender, and the length of the incisionare three other independent risk factors that have beenfound in 17 to 35% ofthe 18 series we studied. Preoperativemedical factors such as chronic pulmonary disease, benignprostatic hypertrophy, constipation and ascites that resultin increased abdominal pressure also increase the risk ofincisional hernia, but have not been shown to be indepen-dent risk factors. Some authors have studied factors that

can be determined by imaging; Berger et al. showed thatthe distance between the two bellies of the rectus muscleas measured by CT postoperatively are directly related tothe risk of incisional hernia: 92% of patients with incisionalhernia had a diastasis recti ofmore than 25 mm [1].

Influence of the type ofsuture used for fascialclosure

Sixteen articles published between 1982 and 2010 wereselected that compared different techniques of fascial clo-sure as a function of the type of suture material: nonabsorbable suture (NA), rapidly absorbable suture (RA),and slowly absorbable suture (SA) [21,6074]. The dif-ferent absorption characteristics of the suture materialsare detailed in Table 5. The majority of these articleswere prospective randomized studies with a follow-upof 12 months (range: 0.53 years) (Table 6). Thirteenstudies showed no difference in the rate of incisional her-nia as a function of the type of suture material used[21,6062,6469,72,73]. Two of the 16 studies reportedcontradictory results: Wissing et al. reported a significantlyhigher incisional hernia rate for rapidly absorbable suture(RA 20.6% vs. SA 10.4%; P< 0.009) [63], while Gislasonreported a higher rate with slowly absorbable suture (SA12% vs. RA 4.3%; P= 0.02) [70]. The combined total of

patients in these series (Table 6) included 8516 random-ized patients, but only 6914 (81%) could be evaluated forincidence of incisional hernia during their follow-up. Theoverall incidence of incisional hernia was 10.8%, and therewas no significant difference in incidence based on thesuture material used for fascial closure: NA 11.2%, RA 10.2%,and SA 11%. However, two meta-analyses demonstrated asignificantly lower incisional hernia incidence when fascialclosure was performed with NA or SA suture [75,76]. In con-trast, a recent multicentric prospective randomized studyof 625 cases did not detect any difference in hernia inci-dence based on the type of suture [21] RA 15.9%, SA 8.4%with PDS or 15.9% with MonoPlus. With regard to fas-cial wound infection, Van tRiets meta-analysis reported

a significantly increased rate of suture sinus and chronicpain with NA suture [76]. This is confirmed by Krukowskisstudy [64], which shows a lower infection rate with the useof SA suture (3.5% vs. 7%). In view of these results, it is


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Table 6 Prospective randomized studies analyzing incisional hernia incidence as a function offascial closure technique and type o

Authors year (ref.) Patients included Patientsa Suture technique Type ofsuture Inc

N

Corman et al., 1981 [60] 161 161 IS NA 49b 4 (IS NA 53c 2 (IS RA 59 (vicryl) 0 (

Richards et al., 1983 [61] 473 385d IS RA 184 1 (RS NA 201 4 (

Mc Neil et al., 1986 [62] 105 105 IS NA 54 5 (RS RA 51 5 (

Wissing et al., 1987 [63] 1539 1156 IS RA 286 48RS RA 290 60RS SA 281 37RS NA 299 31

Kukowski et al., 1987 [64] 757 580 RS SA 285 22RS NA 295 28

Gys et al., 1989 [65] 167 129 RS SA 65 4 (RS NA 64 4 (

Trimbos et al., 1992 [66] 340 240 IS RA 122 7 (RS SA 118 5 (

Sahlin et al., 1993 [67] 988 684 RS SA 345 28IS RA 339 21

Israelsson et al., 1994 [68] 813 643 RS NA 318 50RS SA 325 49

Carlson et al., 1995 [69] 225 171 RS NA 91 4 (

RS SA 80 7 (

Gislason et al., 1995 [70] 599 491 RS SA 164 19RS RA 163 9 (IS RA 164 7 (

Brolin 1996 [71] 229 229 RS SA 120 11IS NA 109 20


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Table 6 (Continued)

Authors year (ref.) Patients included Patientsa Suture technique Type ofsuture Incisional hernia

N (%)

Colombo et al., 1997 [72] 632 614 IS RA 306 45(14.7)RS SA 308 32 (10.4)

Hsiao et al., 2000 [73] 340 340 RS RA 184 7 (3.8)RS SA 156 3 (1.9)

Seiler et al., 2009 [21] 625 530 IS RA 176 28 (15.9)

RS SA 178 15 (8.4)RS SA 176 22 (12.5)

Bloemen et al., 2011 [74] 523 456 RS NA 223 45 (20.2)RS SA 233 58 (24.9)d dehisce

Total 8516 6914 747 (10.8)

RS: running suture; IS: interrupted suture; NA: non absorbable; SA: slowly absorbable; RA: rapidly absorbable; NS: non significanta Number of patients with data concerning incisional hernia incidence.b Multifilament braided.c Monofilament.d Only midline closures are included in this table.e Significative difference between rapidly absorbable with running suture and non absorbable with running suture.


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Table 7 Comparative studies of incisional rate after suture closure vs. prosthetic mesh abdominal wall closure.

Authors Year (ref.) Type ofstudy n Position ofprosthesisplacement

Type ofsurgery Type ofprosthesis

Parietalinfectio

n (%) P n

Gutierrez de la penaC. et al., 2003 [81]

Prospectiverandomized

Prosthesis n = 44 Pre-fascial Gastrointestinal Polypropylene 1 (2.3) NS 0

Control (nonabsorbable runningsuture) n = 44

1 (2.3) 5

Rogers M. et al., 2003[82]

Prospectivenonrandomised

Prosthesis n = 26 Pre-peritonealspace

Abdominal aorticaneurysm

Polypropylene 4 (15.4) 0

El-Khadrawy et al.,2009[83]

Prospectiverandomised

Prosthesis n = 20 Sub-fascial All midlinelaparotomies

Polypropylene 2 (10) NS 1

Control n = 20 4 (20) 3

Herbert et al.,2009[84] Prospective Prosthesis n = 16 ? Bariatric Polypropyleneor absorbable 3 (19) - 1

Hidalgo M.P. et al.,2010 [85]

Prospective Prosthesis n = 72 Pre-peritoneal Colorectal Polypropylene 0 0

Curro G. et al., 2010[86]

Prospectivecomparative

Prosthesis n = 25 Retromuscular Bariatric Polypropylene 1 (4) NS 1

Control n = 25 1 (4) 8

Bevis P. et al.,2010[87]

Prospectiverandomised

Prosthesis n = 37 Pre-peritoneal Abdominal aorticaneurysm

Polypropylene 2 (5,4) NS 5

Control (nonabsorbable suture)n = 43

2 (4,6) 16

Llaguna O et al., 2011[88]

Prospectivecomparative

Prosthesis n = 44 Sub-fascial Biologic 4 (9) NS 1

Control n = 62 1 (1.6) 1

NS: non significant; NC: not communicated.


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recommended that fascial closure be performed with SAsuture such as PDS. But the fascial suture techniquesvary widely and the definitions of parietal abnormalitiesare imprecise (dehiscence, incisional hernia) in thesestudies, which explain the heterogeneity ofresults.

Influence ofsuture technique on the

development ofincisional herniaStudies have been done to evaluate the influence on the inci-dence ofincisional hernia ofnot only the type ofsuture butalso the suture technique used for fascial closure, i.e., inter-rupted suture (IS) versus running suture (RS) (Table 6). Onlyone study showed a significant decrease in the incidenceof incisional hernia associated with RS closure but the typeof suture differed between the two techniques (RS with SAsuture [10%] vs. IS with NA suture 18%; P< 0.04) [71]. In thisliterature review, 5013 patients underwent RS closure and1901 underwent IS closure. Ofthe patients with RS closure,559 developed incisional hernia (11.1%), vs. 188 (9.8%) ofthose with IS closure (P= 0.13) (Fig. 2). The meta-analysis by

Van tRiet shows no difference in the incidence ofincisionalhernia as a function of running or IS technique [76]. Therecently published meta-analysis by Gupta reviewed 10,900patients and showed no difference in incidence ofincisionalhernia related to RS or IS closure [77]. Some surgeons havesuggested mass sutures ofthe full thickness ofthe abdominalwall including the skin. A prospective study published manyyears ago reported similar incisional hernia rates regardlessofwhether classical or full thickness abdominal wall closurewas performed (4.2% vs. 5.2%) [78]. In a retrospective study,Ausobski et al. reported a significantly lower rate of inci-sional hernia with classical closure than with full thicknessmass sutures (3% vs. 10%; P= 0.01) [79], but the two types ofclosures were applied to different incisions (paramedian andmidline, and their mass suture did not include the skin. Thewidely variable definition of full thickness abdominal wallsuture and the small numbers included in these older seriesdo not permit us to propose this closure technique for anyparticular type ofsurgery or degree ofobesity. With regardto trocar site closure, a recent literature review of studiesof trocar site herniation concluded that all trocar incisionslarger than 10 mm should be closed under direct vision aswell as all 5 mm trocar sites that were subjected to vigorousmanipulation [80].

Influence ofprosthetic material on theincidence ofincisional hernia

We selected eight prospective studies published between2003 and 2011, three ofwhich were randomized, that com-pared conventional fascial closure with the use ofprostheticmesh [8186,88] (Table 7). Most commonly, polypropylenemesh was used. Operative duration was not statistically dif-ferent between the control group and the prosthetic groupin any of the comparative studies. For all the comparativestudies (five out of eight) there was a significantly lowerincidence of incisional hernia in the prosthetic group withno increase in septic complications and no need to explantthe prosthesis (Fig. 3).

Conclusion

The overall incidence of postoperative incisional herniawas 3.7% in this literature review, essentially the same as

that noted in France in 2009 based on the PMSI database.This incidence varied from 0.7% after laparoscopy to 9.9%after laparotomy. Laparotomy clearly increases the risk ofincisional hernia compared with laparoscopy. The patientsgeneral condition, advanced age, and parietal wound infec-tion are the risk factors most commonly reported. Fascialclosure using slowly absorbable suture, whether by runningor IS, seems to be the technique that results in the low-est risk of incisional hernia. Systematic use of prostheticmaterial seems to be an interesting approach to minimiz-ing the risk of postoperative ventral hernia, but its actualeffectiveness must be confirmed in studies of larger num-bers of patients, with a longer follow-up period before wecan conclude the actual benefit ofthis as a routine practice.

Disclosure of interest

The authors declare that they have no conflicts of interestconcerning this article.

Acknowledgements

We wish to thank Professeur Huber Johanet and ProfesseurBertrand Millat for providing the PMSI data for the year 2009.

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