Endoscopic-assisted repair of combined ventral hernias and diastasis recti: minimizing seroma incidence by quilting.

BACKGROUND: To reduce the incidence of seromas, we have adapted the quilting procedure used in open abdominoplasty to the endoscopic-assisted repair of concomitant ventral hernia (VH) and diastasis recti (DR). The aim of this study was to describe the technique and assess its efficacy by comparing two groups of patients operated on with the same repair technique before and after introducing the quilting. METHODS: This retrospective study included data prospectively registered in the French Club Hernie database from 176 consecutive patients who underwent surgery for concomitant VH and DR via the double-layer suturing technique. Patients were categorized into two groups: Group 1 comprised 102 patients operated before introducing the quilting procedure and Group 2 comprised 74 operated after introducing the quilting. To carry out comparisons between groups, seromas were classified into two types: type A included spontaneously resorbable seromas and seromas drained by a single puncture and type B included seromas requiring two or more punctures and complicated cases requiring reoperation. RESULTS: The global percentage of seromas was 24.4%. The percentage of seromas of any type was greater in Group 1 (27.5%) than in Group 2 (20.3%). The percentage of Type B seromas was greater in Group 1 (19.6%) than in Group 2 (5.4%), when the percentage of Type A seromas was greater in Group 2 (14.9) than in Group 1 (7.9%). Differences were significant (p = 0.014). The operation duration was longer in Group 2 (83.9 min) than in Group 1 (69.9 min). Four complications requiring reoperation were observed in Group 1: three persistent seromas requiring surgical drainage under general anesthesia and one encapsulated seroma. CONCLUSION: Adapting the quilting technique to the endoscopic-assisted bilayer suturing technique for combined VH and DR repair can significantly reduce the incidence and severity of postoperative seromas.

Modified Approach for Extraperitoneal Colostomy Creation in Laparoscopic Abdominoperineal Resection.

BACKGROUND: Parastomal hernia is a major long-term complication after abdominoperineal resection. Extraperitoneal colostomy has been proposed as an effective step for parastomal hernia prevention, but it has not been widely used as it is technically demanding and time-consuming. We proposed a modified approach for extraperitoneal colostomy creation by entering the extraperitoneal space through the arcuate line of the posterior rectus sheath. OBJECTIVE: To evaluate the safety, difficulty, and efficacy of long-term parastomal hernia prevention of the modified approach for extraperitoneal colostomy creation compared with the conventional transperitoneal colostomy approach. DESIGN: This was a retrospective evaluation of a surgical and video database. SETTINGS: This was a single-institution retrospective study. PATIENTS: Clinical data of 74 patients who underwent laparoscopic abdominoperineal resection surgery from January 2019 to January 2020 in the Department of General Surgery, Qilu Hospital of Shandong University, were retrospectively reviewed. MAIN OUTCOME MEASURES: Baseline characteristics, time required for colostomy creation (from skin incision to colostomy maturation), perioperative complications, and long-term colostomy-related complications were compared. RESULTS: Baseline characteristics did not differ between the 2 approaches. The BMI level ranged from 19.5 to 29.4 for patients undergoing extraperitoneal approach. Time required for colostomy creation median [interquartile range], (22 [21-25] minutes for extraperitoneal vs 23 [21-25] minutes for transperitoneal, p = 0.861) were comparable between the 2 approaches. The cumulative incidence of parastomal hernia was significantly greater with transperitoneal colostomy than extraperitoneal colostomy at 2 and 3 years postoperatively (16.2% vs 0%, p = 0.025, and 21.6% vs 0%, p = 0.005). The remaining perioperative complications and long-term colostomy-related complications did not differ between the 2 approaches. LIMITATIONS: This study is limited by its retrospective design and small sample size. CONCLUSIONS: The modified approach for extraperitoneal colostomy creation is safe, technically simple, and effective for long-term parastomal hernia prevention in patients with a BMI of 19.5 to 29.4.

Quality of life measures and cost analysis of biologic versus synthetic mesh for ventral hernia repair: The Preventing Recurrence in Clean and Contaminated Hernias randomized clinical trial.

BACKGROUND: Although the most durable method for ventral hernia repairs involves using mesh, whether to use biologic mesh versus synthetic mesh remains controversial. This study aimed to compare synthetic and biologic meshes with respect to patient-reported quality of life scores and costs after ventral hernia repair surgeries. METHODS: This study is part of the Preventing Recurrence in Clean and Contaminated Hernias (PRICE) pragmatic randomized control trial conducted from March 2014 through October 2018. Patients were randomized 1:1 to undergo ventral hernia repair using either a biologic or synthetic mesh. The coprimary outcomes were 2-year changes in Visual Analog Scale, Activities Assessment Scale, Hernia-Related Quality-of-Life Survey, and Short-Form 36 Health Survey (SF-36) quality-of-life scores from repair. The secondary outcome was the overall cost per patient. RESULTS: Among the 165 patients included in the study, 82 were randomized to biologic meshes and 83 to synthetic meshes. There were no significant differences in the performance between the 2 mesh types with regard to quality-of-life measures using a mixed model approach. This result was consistent even when performing subgroup analysis based on wound contamination. However, nonparametric tests comparing the differences in quality-of-life measures from preoperative to 24-month postoperative timepoints revealed that the synthetic mesh group showed a greater reduction in disability than biologic mesh for the SF-36 (median [interquartile range] of 20 [5-30] vs 6 [1-20], P = .025). This difference was due to reductions in the physical role limitations (62 [0-100] vs 0 [0-50], P = .018) and the pain (38 [12-50] vs 12 [0-25], P = .012) domains of the SF-36. Overall cost per patient was greater for biologic meshes (mean [95% confidence interval] of $80,420 [$66,485-$94,355] vs $61,036 [$48,946-$73,125], P = .038), regardless of insurance type. CONCLUSION: In this randomized clinical trial, there were no differences in changes in quality-of-life scores at the 2-year timepoint except for the SF-36, where the synthetic mesh may be associated with less pain and physical role limitations than the biologic mesh. Overall costs per patient were less for synthetic than biologic mesh.

Risk Factors for Incisional Hernia After Open Abdominal Aortic Aneurysm Repair.

BACKGROUND/AIM: Incisional hernia is among the most prevalent complications associated with open abdominal aortic aneurysm repair. However, risk factors for incisional hernias in patients with abdominal aortic aneurysm are multifactorial. Therefore, this study evaluated the risk factors of incisional hernia after open abdominal aortic aneurysm repair, including surgical factors. PATIENTS AND METHODS: We retrospectively extracted data from patients with incisional hernias after abdominal aortic aneurysm repair between 2012 and 2019 and investigated their perioperative characteristics and wound closure techniques. RESULTS: The mean follow-up periods were 41.5±30.3 months, and 30 of 131 (22.9%) patients suffered an incisional hernia. Regarding the underlying disease, only diabetes mellitus was significantly more common in the incisional hernia group (11 of 30 patients, 36.6%), and no significant differences were found in the patients' perioperative data. Interrupted sutures were used in all 30 patients in the hernia group. Moreover, in 8 of the 101 remaining cases, barbed sutures were used, and no incisional hernia occurred in any of these cases. CONCLUSION: In addition to diabetes mellitus, abdominal aortic aneurysm is a significant risk factor for incisional hernia after abdominal aortic aneurysm repair. Therefore, employing the barbed suture technique may effectively prevent incisional hernias after abdominal aortic aneurysm repair.

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.

[Perioperative prevention of complications in surgery of ventral hernias]. / Perioperatsionnaya profilaktika oslozhnenii v khirurgii ventral'nykh gryzh.

OBJECTIVE: To improve perioperative algorithm of prevention of complications in patients with ventral and incisional hernias via differentiated choice of mesh implants and hernia repair technique. MATERIAL AND METHODS: The study included 144 patients with abdominal wall hernia, who were divided into two representative groups. RESULTS: Original algorithms for choosing the method of hernia repair depending on type and position of mesh implant, as well as methods of perioperative prevention of complications are proposed. CONCLUSION: These algorithms significantly reduced the incidence of postoperative wound complications after sublay hernia repair and posterior separation with TAR.

Hernia Prevention Using Biologic Mesh and/or Small Bites: A Multispecialty 2 × 2 Factorial Randomized Controlled Trial.

BACKGROUND: Ventral incisional hernias are the most common complication after abdominal operation. Randomized trials have shown efficacy of prophylactic synthetic mesh and small bites. Adoption of these practices has been limited due to concerns with placement of synthetic mesh in contaminated cases and small bites in an overweight population. We sought to assess the efficacy of prophylactic biologic mesh and small bites to prevent postoperative major complications: ventral incisional hernias, surgical site infection, reoperation, and death. STUDY DESIGN: High-risk patients (overweight/obese, current smoker) undergoing abdominal operation with a midline incision (5 cm or greater) were randomized (2 × 2 factorial trial) to receive either sublay biologic mesh or no mesh and either small bites (0.5 × 0. 5cm) or large bites (1 × 1 cm) fascial closure. The primary outcome measure was major complications at 1 year postoperative. CONSORT guidelines were followed, and this study was registered on clinicaltrials.gov (NCT03148496). Assuming α = 0.05, ß = 0.20, and Δ = 20%, it was estimated that 105 patients were needed. Primary outcome was assessed using Fisher's exact test. RESULTS: A total of 107 patients were randomized: 52 (49%) to mesh, 55 (51%) to no mesh, 55 (51%) to small bites, and 52 (49%) to large bites. Of the patients, 16% were smokers, 31% were overweight, and 55% were obese. At 1 year postoperative, there were no differences in major complications between groups (mesh vs no mesh 21% vs 16%, p = 0.62; small vs large bites 18% vs 19%, p = 1.00). CONCLUSIONS: In this trial, biologic mesh and small bites appear to have no benefit. Further randomized trials are needed among high-risk patients before widespread adoption of prophylactic biologic mesh or small bites.

The utilization of an absorbable mesh after ostomy reversal does not decrease incisional hernia rates.

BACKGROUND: Postoperative ostomy reversal hernias are common and can create strain on the healthcare system. There is little literature evaluating the utilization of absorbable mesh following ostomy reversal. The effect on subsequent hernia rates at our institution has not been evaluated. We examine if the addition of absorbable mesh decreases the postoperative hernia rate in our patient population. METHODS: We performed a retrospective review of all ileostomy and colostomy reversals. Patients were divided into two groups based on whether an absorbable mesh was used at ostomy closure or not. RESULTS: Hernia recurrence rates were lower in the group that had mesh reinforcement (8.96%) vs the group that did not receive a mesh (14.8%) though this was not statistically significant (p = 0.233). CONCLUSION: Prophylactic use of an absorbable biosynthetic mesh did not alter the rate of incisional hernia rates following ostomy reversal in our cohort of patients.

Predictors for surgical site infection in patients undergoing therapeutic or prophylactic intra-abdominal onlay mesh (IPOM) implantation in clean and contaminated surgical fields.

BACKGROUND: Prophylactic intra-abdominal onlay mesh (IPOM) implantation has been shown to reduce the rate of fascial dehiscence and incisional hernia. However, surgical site infection (SSI) in presence of an IPOM remains a concern. The aim of this study was to assess predictors for SSI following IPOM placement in hernia and non-hernia abdominal surgery in clean and contaminated surgical fields. METHODS: Observational study including patients undergoing IPOM placement at a Swiss tertiary care hospital 2007-2016. IPOM implantation was performed in hernia and non-hernia elective and emergency abdominal surgery, including contaminated and infected surgical fields. The incidence of SSI was prospectively assessed by Swissnoso according to CDC criteria. The effect of disease- and procedure-related factors on SSI was assessed in multivariable regression analysis, adjusting for patient-related factors. RESULTS: A total of 1072 IPOM implantations were performed. Laparoscopy was performed in 415 patients (38.7%), laparotomy in 657 patients (61.3%). SSI occurred in 172 patients (16.0%). Superficial, deep, and organ space SSI were found in 77 (7.2%), 26 (2.4%), and 69 (6.4%) patients, respectively. Multivariable analysis revealed emergency hospitalization (OR 1.787, p = 0.006), previous laparotomy (1.745, p = 0.029), duration of operation (OR 1.193, p < 0.001), laparotomy (OR 6.167, p < 0.001), bariatric (OR 4.641, p < 0.001), colorectal (OR 1.941, p = 0.001), and emergency (OR 2.510, p < 0.001) surgery, wound class ≥ 3 (OR 3.878, p < 0.001), and non-polypropylene mesh (OR 1.818, p = 0.003) as independent predictors for SSI. Hernia surgery was independently associated with a lower risk for SSI (OR 0.165, p < 0.001). CONCLUSION: This study revealed emergency hospitalization, previous laparotomy, duration of operation, laparotomy, as well as bariatric, colorectal, and emergency surgery, abdominal contamination or infection, and usage of non-polypropylene mesh as independent predictors for SSI. In contrast, hernia surgery was associated with a lower risk for SSI. The knowledge of these predictors will help to balance benefits of IPOM implantation against the risk for SSI.

[Clinical value of mesh prophylaxis for parastomal hernia based on evidence-based medicine].

The incidence of parastomal hernia is substantially high, significantly affecting the quality of life of patients with stoma. How to effectively solve the problem of parastomal hernia is a long-term focus of hernia and abdominal wall surgery and colorectal surgery. The European Hernia Society guidelines on prevention and treatment of parastomal hernia published in 2018 has recommended the use of a prophylactic mesh to prevent parastomal hernia for the first time. In the following 5 years, more randomized controlled trials of multi-center, large-sample, double-blind, long-term follow-up have been published, and no significant effect of mesh prophylaxis has been observed on the incidence of parastomal hernia. However, whether mesh could decrease surgical intervention by limiting the symptoms of parastomal hernias would become a potential value of prophylaxis, which requires further research to elucidate.

Parastomal hernia prevention with permanent mesh in end colostomy: failure with late follow-up of cohorts in three randomized trials.

PURPOSE: Short-term results have been reported regarding parastomal hernia (PH) prevention with a permanent mesh. Long-term results are scarce. The objective was to assess the long-term PH occurrence after a prophylactic synthetic non-absorbable mesh. METHODS: Long-term data of three randomized controlled trials (RCTs) were collected. The primary outcome was the detection of PH based exclusively on a radiological diagnosis by computed tomography (CT) performed during the long-term follow-up. The Kaplan-Meier method was used for the comparison of time to diagnosis of PH according to the presence of mesh vs. no-mesh and the technique of mesh insertion: open retromuscular, laparoscopic keyhole, and laparoscopic modified Sugarbaker. RESULTS: We studied 121 patients (87 men, median age 70 years), 82 (67.8%) of which developed a PH. The median overall length of follow-up was 48.5 months [interquartile range (IQR) 14.4-104.9], with a median time until PH diagnosis of 17.7 months (IQR 9.3-49.0). The survival analysis did not show significant differences in the time to development of a PH according to the presence or absence of a prophylactic mesh neither in the overall study population (log-rank, P = 0.094) nor in the groups of each technique of mesh insertion, although according to the surgical technique, a higher reduction in the appearance of PH for the open retromuscular technique was found (log-rank, P = 0.001). CONCLUSION: In the long-term follow-up placement of a non-absorbable synthetic prophylactic mesh in the context of an elective end colostomy does not seem effective for preventing PH.

Addressing parastomal herniation through biomechanical simulation.

PURPOSE: Parastomal hernia remains a significant source of post-operative morbidity. Existing surgical solutions have shown limited success while not addressing the biomechanics underpinning parastomal herniation. The primary objective was to examine the influence of stoma aperture shape on abdominal wall stress and tissue destruction. The secondary objective compared mesh designs with respect to abdominal wall stress. METHODS: Finite element analysis of an abdominal wall model was used to simulate various stoma and mesh designs. The outcome measures were abdominal wall (mmHg) pressure required to initiate tissue tearing, stress distribution and median and peak abdominal wall stress (N/m2). RESULTS: The simulation demonstrated that the cruciate stoma incision developed high stress concentration at the apices of the slit incisions. The circular stoma incision distributed stress uniformly. The circular stoma design was more resistant to tissue tearing. The Keyhole mesh design demonstrated the lowest median and peak stress at 17.32 and 28.01 N/m2. This was a statically significant reduction in stress compared to the Sugar Baker and no mesh designs (p < 0.001).There were no significant differences between the Keyhole mesh design and loose mesh designs as long as the loose mesh design aperture did not exceed 1.5 times the stoma aperture diameter (p = 0.223). CONCLUSIONS: This study has demonstrated that the shape of the fascia incision and mesh design have a significant impact on parastomal hernia formation. Novel designs can be used to optimise the stoma. The circular stoma and loose mesh designs are promising avenues for future research.

[Risk factors and prevent strategy of parastomal hernia].

Parastomal hernia is one of the common complications of stoma surgery with an incidence of more than 30%, which can be diagnosed by physical examination and abdominal CT. Risk factors of parastomal hernia might include stoma approaches including the selection of intestine, relationship between stoma and peritoneum, stoma location, aperture size, operation time and the patient's own conditions. It is essential to prevent parastomal hernia in order to improve patients' quality of life. Prophylactic mesh and perioperative care might prevent parastomal hernias. The mesh type might also influence the incidence of parastomal hernia. To reduce the incidence of recurrence of parastomal hernia, placement of mesh by the laparoscopic Sugarbaker technique was an effective surgical approach. How to prevent and repair parastomal hernia and cure parastomal hernia repair still needs further high-quality research to provide evidence.

Is the type of biomesh relevant in the prevention of recurrence following abdominal wall reconstruction? A randomized controlled trial.

BACKGROUND: Complex abdominal wall reconstruction technique remains controversial. The use of biologic mesh products is also debated in active infection, sepsis prophylaxis and high-risk patients. Differences in biologic mesh technology and cost remain significant. We aimed to compare the efficacy of 2 commonly used biologic meshes in regards to hernia recurrence at 1 year. METHODS: This study was a parallel, dual-arm, double-blind randomized controlled trial involving adult patients undergoing complex abdominal wall reconstruction with a biologic mesh at a quaternary care institution (2017-2020). Patients were randomly assigned to receive Permacol (cross-linked) compared with Strattice (not crosslinked). The main outcome measure was hernia recurrence at 1 or more years following the index repair. RESULTS: We included 94 patients randomized to undergo reconstruction with 1 of 2 commonly used biologic mesh products (mean age 59.4 yr, standard deviation [SD] 9.9; 51% female; body mass index 32.9, SD 6.8). We found no significant differences between the groups (patient comorbidities, hernia recurrence risk factors, hernia size or infection profiles). Hernia recurrence rates (15%) were similar between groups (median 783 days of follow up, interquartile range 119). We found there was significantly less of a need for a component separation technique in the Strattice group (69% v. 87%). All other secondary outcome measures were equivalent between study arms. Multivariate analysis identified hepatic transplantation (odds ratio [OR] 1.94, 95% confidence intervals [CI] 0.33-4.41), active abdominal wall infection (OR 2.01, 95% CI 0.50-7.01), and more than 1 previous hernia repair (OR 2.68, 95% CI 0.41-5.99) as risk factors for subsequent hernia recurrence; however, there was no difference in recurrence factors between patient study groups. CONCLUSION: Given similar clinical performance between the 2 most commonly used biologic mesh products, the most cost effective mesh should be used in cost-conscious health care systems.

Incidence and risk factors for parastomal hernia with a permanent colostomy.

AIM: This study aims to explore the incidence and risk factors for permanent colostomy complicated with a parastomal hernia (PSH) after rectal cancer resection. METHODS: This was a retrospective study of gastrointestinal surgery performed from January 2013 to December 2017 in patients with colorectal cancer treated at the Affiliated Hospital of Qingdao University. The relevant clinical variables of the patient were analyzed. Kaplan-Meier, univariate, and Cox multivariate analyses were used to evaluate the influencing factors and morbidity of PSH. RESULTS: Among the 211 patients, 65 developed PSH. The cumulative incidence reached 33.5% at 62 months. In the multivariate Cox survival analysis, the results showed that being a woman, aged ≥65 years, having a body mass index (BMI) ≥ 25 kg/m2 , diabetes, and Clavien-Dindo Grade III and IV complications were risk factors for the occurrence of PSH. CONCLUSION: In our study, the incidence of PSH increased annually and reached a maximum of 33.5% after 62 months. Among the patient-related factors, female sex, age ≥65 years, BMI ≥ 25 kg/m2 , diabetes, and postoperative Clavien-Dindo Grade III and IV complications were significantly associated with the development of PSH. Therefore, intervention measures to prevent patients with this risk factor are advisable.

A Biomechanical Analysis of Prophylactic Mesh Reinforced Porcine Laparotomy Incisions.

INTRODUCTION: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Use of prophylactic stoma mesh is a risk factor for developing rectus abdominis muscle atrophy.

PURPOSE: The aim of this study was to evaluate the possible risk factors for developing a parastomal hernia (PSH) in a cohort of rectal cancer patients with and without the application of a retro-muscular prophylactic mesh. The evaluated risk factors included the position of the stoma in the rectus abdominis muscle (RAM), RAM atrophy and shift of abdominal wall midline structures. METHODS: Rectal cancer patients treated with an abdominoperineal excision or Hartmann's procedure between 2002 and 2015 at Västmanland Hospital, Sweden was included. Postoperative CT examinations were retrospectively reviewed regarding the presence of PSH and RAM atrophy and for measurements such as position of the stoma in the RAM. RESULTS: 116 patients were included, with a median age of 71 years. 70 patients received a prophylactic stoma mesh. 55 patients (47%) had a parastomal hernia at three-year follow-up. Rectus abdominis muscle atrophy was significantly higher in the mesh group compared with the non-mesh group (37% vs 2%; P = 0.04). RAM atrophy was a significant independent protective factor for developing a PSH (P = 0.007; OR 0.15; 95% CI 0.03-0.55). CONCLUSION: Placement of a prophylactic retro-muscular stoma mesh resulted in a high frequency of RAM atrophy distal to the stomal aperture and patients with such atrophy had a lower risk of developing a PSH.

Risk factors for the development of a parastomal hernia in patients with enterostomy: a systematic review and meta-analysis.

PURPOSE: Parastomal hernia (PSH) is a common and serious complication in patients with enterostomy, but there is no current consensus for the risk factors for PSH from previous studies. Therefore, this study systematically analyzed the risk factors for PSH to provide a reference for prevention and treatment of this condition. METHODS: Seven databases and 3 registers were systematically searched from database inception to January, 2021. Study quality was assessed by Newcastle-Ottawa Scale. Review Manager 5.3 software was used for statistical analysis. The data that could not be combined quantitatively were only analyzed qualitatively. RESULTS: Sixteen studies with 2031 patients were included. Higher BMI (OR, 1.29; 95% CI,1.02-1.63), older age (OR, 1.04; 95% CI, 1.02-1.07), female (OR, 2.55; 95% CI,1.39-4.67), lager aperture size (OR, 2.8; 95%CI, 1.78-4.42), transperitoneal stoma creation (OR, 2.4; 95% CI, 1.33-4.35), and lager waist circumference (OR, 1.01; 95% CI,1.0-1.01) were significant risk factors for PSH. The laparoscopic approach was not a risk factor for PSH (OR, 2.09; 95% CI, 0.83-5.27). Other risk factors, including the thickness of abdominal subcutaneous fat, no mesh, a stoma not through the middle of the rectus abdominis, atrophy of left lower medial part of rectus abdominis, α1(III) procollagen expression level, emergency surgery, no preoperative stoma site marking, end colostomy, smoking, diabetes, peristomal infection, severe abdominal distention, severe cough, chronic obstructive pulmonary disease, operation time and hypertension, were significant on the multivariate analysis of each individual study. CONCLUSIONS: The current available evidence showed that higher BMI, older age, female, larger aperture size, the creation of a transperitoneal stoma, and a larger waist circumference were independent risk factors for PSH. For factors without exact cutoff value, further explorations are needed in the future. In addition, reference to the limited number of studies in the pooled analysis, these factors still need to be interpreted carefully.

Risks and Prevention of Surgical Site Infection After Hernia Mesh Repair and the Predictive Utility of ACS-NSQIP.

AIM: The aim of this paper was to provide a narrative review of surgical site infection after hernia surgery and the influence of perioperative preventative interventions. METHODS: The review was based on current national and international guidelines and a literature search. RESULTS: Mesh infection is a highly morbid complication after hernia surgery, and is associated with hospital re-admission, increased health care costs, re-operation, hernia recurrence, impaired quality of life and plaintiff litigation. The American College of Surgeons National Surgical Quality Improvement Program is a particularly useful resource for the study and evidence-based practise of abdominal wall hernia repair. DISCUSSION: The three major modifiable patient comorbidities significantly associated with postoperative surgical site infection in hernia surgery are obesity, tobacco smoking and diabetes mellitus. Preoperative optimization includes weight loss, cessation of smoking, and control of diabetes. Intraoperative interventions relate, in particular, to the control of fomite mediated transmission in the operating theatre and prevention of mesh contamination with S. aureus CFUs. Risk management strategies should also target the niche ecological conditions which enable bacterial survival and subsequent biofilm formation on an implanted mesh. Outcomes of mesh infection after hernia surgery are closely related to mesh type and porosity, patient smoking status, presence of MRSA, bacterial adhesion and biofilm production. The use of suction drains and the timing of drain removal are controversial and discussed in detail. Finally, the utility of the ACS-NSQIP Surgical Risk Calculator in predicting complications and outcomes in individual patients and the importance of quality improvement initiatives in surgical units are emphasized.