Enhanced recovery after abdominal wall reconstruction: a systematic review and meta-analysis.

BACKGROUND: Enhanced recovery after surgery (ERAS) are evidence-based protocols associated with improved patient outcomes. The use of ERAS pathways is well documented in various surgical specialties. The aim of this systematic review and meta-analysis was to examine the efficacy of ERAS protocols in patients undergoing abdominal wall reconstruction (AWR). METHODS: This systematic review and meta-analysis were reported according to PRISMA and MOOSE guidelines. The databases PubMed, EMBASE, CINAHL, Web of Science and Cochrane Library were searched for original studies comparing ERAS with standard care in patients undergoing AWR. The primary outcome was length of stay (LOS) and secondary outcomes were readmission and surgical site infection (SSI) and/or surgical site occurrences (SSO). RESULTS: Five studies were included in the meta-analysis. All were retrospective cohort studies including 453 patients treated according to ERAS protocols, and 494 patients treated according to standard care. The meta-analysis demonstrated that patients undergoing AWR managed with ERAS had a mean 0.89 days reduction in LOS compared with patients treated with standard care (95% CI - 1.70 to - 0.07 days, p = 0.03). There was no statistically significant difference in readmission rate (OR 1.00, 95% CI 0.53 to 1.87, p = 1.00) or SSI/SSO (OR 1.19, 95% CI 0.67 to 2.11, p = 0.56) between groups. CONCLUSIONS: The use of ERAS in patients undergoing AWR was found to significantly reduce LOS without increasing the readmission rate or SSI/SSO. Based on the existing literature, ERAS protocols should be implemented for patients undergoing AWR.

Association of Primary Ventral Hernia and Pregnancy.

OBJECTIVE: To determine the optimal timing of elective repair, the primary objective of this study was to assess if parity at the time of repair and subsequent pregnancy were associated with reoperation for recurrence. The secondary objective was to examine if parity was associated with hernia formation requiring surgical repair. SUMMARY BACKGROUND DATA: Women of childbearing age constitute 18% of patients operated on for a primary ventral hernia, but consensus is lacking on the management in women who might subsequently become pregnant. METHODS: In this nationwide retrospective cohort-study, all women born in Denmark from 1962 to 1971 were eligible for inclusion and followed from age 15 to 45 years. The follow-up rate was 100%. Data on pregnancies and surgical procedures were obtained from the Danish Medical Birth Registry and National Patient Registry. Extended Cox regression and Poisson regression were used for statistical analysis. RESULTS: In total, 470,646 women were included, of whom 2113 underwent repair of a primary ventral hernia. The 10-year cumulative incidence of reoperation for recurrence was 14.1% (95% CI 12.3%-16.0%). Parity at the time of repair was not associated with reoperation for recurrence, while a subsequent pregnancy was associated with a 1.6-fold increased risk (hazard ratio 1.58, 95% CI 1.08-2.31). Parous women had a 7-fold increased risk of undergoing hernia repair compared with nulliparous, in an age-adjusted model (incidence rate ratio 7.04, 95% CI 5.87-8.43). CONCLUSION: To reduce the risk of hernia recurrence, the optimal timing of elective repair is after the last pregnancy.

Histology and Function of the Rectus Abdominis Muscle in Patients With Incisional Hernia.

BACKGROUND: The aim of the current study was to examine different features of the rectus abdominis muscle (RA) in patients with and without a midline incisional hernia to characterize the effects of a hernia on abdominal wall skeletal muscle. MATERIAL AND METHODS: RA tissue from patients undergoing surgical repair of a large midline incisional hernia (n = 18) was compared with that from an intact abdominal wall in patients undergoing colorectal resection for benign or low-grade malignant disease (n = 18). In addition, needle biopsies were obtained from the vastus lateralis muscle (VL) of all subjects. Outcome measures were muscle fiber type and size, preoperative truncal flexion strength and leg extension power measured in strength-measure equipment, and RA cross-sectional area measured by computed tomography. RESULTS: In both the RA and VL, the fiber cross-sectional area was greater in the patients with a hernia. The RA cross-sectional area correlated significantly with the truncal flexion strength (r = 0.44, P = 0.015). Patients in the hernia group had a significantly reduced ratio between truncal flexion strength and RA cross-sectional area compared with the control group (41.3 ± 11.5 N/cm2versus 51.2 ± 16.3 N/cm2, P = 0.034). CONCLUSIONS: Anatomical displacement of the RA and lack of medial insertion in the linea alba rather than dysfunction secondary to alteration of muscle fiber structure may contribute to impairment of abdominal wall function in patients with midline incisional hernias. The study was registered at http://www.clinicaltrials.gov/(NCT02011048).

Nationwide Propensity-Score Matched Study of Mesh Versus Suture Repair of Primary Ventral Hernias in Women with a Subsequent Pregnancy.

BACKGROUND: Mesh reinforcement is recommended for repair of primary ventral hernias; however, this recommendation does not consider a potential subsequent pregnancy. The aim of this prospective cohort study was to compare mesh and suture repair of a primary ventral hernia in women with a subsequent pregnancy. METHODS: All women of childbearing age who underwent repair of a primary ventral hernia between 2007 and 2014 were identified in the Danish Ventral Hernia Database. Data were merged with the Danish Medical Birth Registry. Women with a subsequent pregnancy and a propensity-score matched control group of women without a subsequent pregnancy were included. A structured questionnaire was sent out, and the primary outcome was hernia recurrence, while the secondary outcome was chronic postoperative pain. RESULTS: In total, 632 women were included, of whom 441 (69.8%) responded to the questionnaire (195 and 246 with and without subsequent pregnancy, respectively). The 8-year cumulative incidence of recurrence was 24.8%. In women with a subsequent pregnancy, mesh repair was associated with a decreased risk of recurrence (hazard ratio 0.44, 95% CI 0.20-0.95, p = 0.038, number needed to treat = 5.1) and an increased risk of chronic pain (OR 5.07, 95% CI 1.20-23.38, p = 0.029, number needed to harm = 4.7) compared with suture repair, in multivariable analyses. CONCLUSIONS: Mesh repair was associated with a decreased risk of recurrence, but an increased risk of chronic pain, compared with suture repair in women with a subsequent pregnancy.

Type of incision does not predict abdominal wall outcome after emergency surgery for colonic anastomotic leakage.

PURPOSE: Most literature on abdominal incision is based on patients undergoing elective surgery. In a cohort of patients with anastomotic leakage after colonic cancer resection, we analyzed the association between type of incision, fascial dehiscence, and incisional hernia. METHODS: Data were extracted from the Danish Colorectal Cancer Group database and merged with information from the Danish National Patient Register. All patients with anastomotic leakage after colonic resection in Denmark from 2001 until 2008 were included and surgical records on re-operations were retrieved. The primary outcome of the study was incisional hernia formation, and the secondary outcome was fascial dehiscence. Multivariable logistic, Cox, and competing risks regression analysis, as well as propensity score matching were used for confounder control. RESULTS: A total of 363 patients undergoing reoperation for anastomotic leakage were included with a median follow-up of 5.4 years. Incisional hernia occurred in 41 of 227 (15.3%) patients undergoing midline incision compared with 14 of 81 (14.7%) following transverse incision, P = 1.00. After adjusting for confounders, there was no association between the type of incision and incisional hernia (transverse incision hazard ratio 1.36, 0.68-2.72, P = 0.390) or fascial dehiscence (transverse incision odds ratio 1.66, 0.57-4.49, P = 0.331). This conclusion was confirmed after propensity score matching, P = 0.507. CONCLUSIONS: In the current study, type of incision did not predict abdominal wall outcome after emergency surgery for colonic anastomotic leakage.

Ventral hernia and pregnancy: A systematic review.

BACKGROUND: Consensus lacks concerning management of ventral hernia in women who are, or might become pregnant. The aim of this systematic review was to examine the risk of recurrence following pre-pregnancy ventral hernia repair, and secondly the prevalence of ventral hernia during pregnancy and the risk of surgical repair pre- and post-partum. DATA SOURCES: PubMed, Embase, CINAHL, Cochrane Library and Web of Science were systematically searched for randomized controlled trials, case-control, cohort studies and larger case-series on ventral (umbilical, epigastric or incisional) hernia repair in relation to pregnancy. CONCLUSIONS: If possible, elective ventral repair should be postponed until after last pregnancy. A non-mesh repair seems appropriate for smaller primary ventral hernia in women who plan future pregnancies. Umbilical hernia during pregnancy seems very rare and seldom requires repair pre- and post-partum. Routine practice of umbilical hernia repair in combination with cesarean section cannot be recommended. PROSPERO: CRD42017073736.

The use of component separation during abdominal wall reconstruction in contaminated fields: A case-control analysis.

BACKGROUND: Component separation technique (CST) allows fascial medialization during abdominal wall reconstruction (AWR). Wound contamination increases the incidence of wound complications, which multiplies the incidence of repair failure. The aim of this study was to compare the impact of CST on AWR outcomes in contaminated fields in comparison to those operations without CST. METHODS: A prospective, single institution hernia database was queried for patients undergoing AWR with CST and contamination. A case control cohort was identified using propensity score matching. RESULTS: There were 286 CSTs performed in contaminated cases. After propensity score matching, 61 CSTs were compared to 61 No-CSTs. These groups were matched by defect area (CST:287.1 ±â€¯150.4 vs No-CST:277.6 ±â€¯218.4 cm2, p = 0.156), BMI (32.0 ±â€¯7.0 vs 32.2 ±â€¯6.0 kg/m2, p = 0.767), diabetes (26.2% vs 32.8%, p = 0.427), and panniculectomy (52.5% vs 36.1%, p = 0.068). Groups had similar rates of wound complications (42.6% vs 40.7%, p = 0.829) and recurrence (4.9% vs 13.1%, p = 0.114). CONCLUSIONS: The use of CST in the face of contamination is not associated with an increase in wound complications, mesh complications, or recurrence.

Recurrence After Operative Treatment of Adhesive Small-Bowel Obstruction.

BACKGROUND: Postoperative adhesions are a common cause of small-bowel obstruction, and up to 53% of patients operated on for adhesive small-bowel obstruction (ASBO) experience recurrence. The primary aim of this study was to identify predictors for recurrence of ASBO. METHODS: We reviewed medical records including operation descriptions from patients who underwent emergency surgery due to ASBO at our institution between 2004 and 2013. Information on the peri- and postoperative periods, including conservatively and surgically treated recurrent ASBO, were obtained from medical records. RESULTS: In total, 478 patients were included in the study. Of these, 58 (12.1%) patients experienced recurrence of ASBO during median 2.2 years follow-up. Female gender (hazard ratio [HR] 2.00, P = 0.023), multiple/matted adhesions (HR 1.72, P = 0.046), and fascial dehiscence (HR 3.26, P = 0.009) were associated with increased risk of recurrence. Conversely, intestinal resection decreased the risk of recurrence (HR 0.47, P = 0.036). CONCLUSIONS: The overall recurrence rate after surgically treated ASBO was 12.1%, and the risk of recurrence was persistent several years after index operation. Factors associated with an increased risk were female gender, multiple/matted adhesions, and fascial dehiscence.

Increased risk of ventral hernia recurrence after pregnancy: A nationwide register-based study.

BACKGROUND: Female patients of reproductive age constitute a substantial portion of patients undergoing ventral hernia repair, however the impact of pregnancy on the risk of recurrence is scarcely documented. The aim of the study was to evaluate if pregnancy following ventral hernia repair was associated with an increased risk of recurrence. METHODS: This nationwide cohort study included all female patients of reproductive age registered in the Danish Ventral Hernia Database with ventral hernia repair between 2007 and 2013. The primary outcome was ventral hernia recurrence. Multivariable extended Cox regression analysis was performed. RESULTS: A total of 3578 patients were included in the study, 267 (7.5%) of whom subsequently became pregnant during follow-up. The median follow-up was 3.1 years (range 0-8.4 years). Pregnancy was independently associated with recurrence (hazard ratio 1.56, 95% confidence interval 1.09-2.25, P = 0.016). CONCLUSIONS: Pregnancy after ventral hernia repair was independently associated with ventral hernia recurrence.

Recurrent umbilical or epigastric hernia during and after pregnancy: A nationwide cohort study.

BACKGROUND: Umbilical and epigastric (umb/epi) hernia repairs are performed commonly in fertile female patients. Recent studies suggest mesh repair to be superior to suture repair; however, evidence is lacking concerning the optimal treatment of umb/epi hernias in female patients who might wish future pregnancies. The aim of this study was to compare the cumulative recurrence rate after mesh versus suture repair of umb/epi hernia in female patients subsequently becoming pregnant. METHODS: This retrospective nationwide cohort study included female patients who underwent primary umb/epi hernia repair and subsequently became pregnant between 2007 and 2013. The follow-up began at first day of pregnancy and ended May 2015. Data were obtained from the Danish Ventral Hernia Database, Medical Birth Registry, and National Patient Registry. Patients with recurrence before pregnancy were excluded. RESULTS: In total, 224 patients were analyzed. The median follow-up was 3.8 years (range 0.1-8.1). The cumulative recurrence rate was 16.3% after mesh repair and 10.9% after suture repair, P = .299. Univariate Cox regression analysis (mesh repair hazard ratio 1.63, 95% confidence interval 0.71-3.72, P = .249) and multivariate analysis adjusted for body mass index and hernia defect size (mesh repair hazard ratio 2.77, confidence interval 0.98-7.85, P = .055) likewise showed no significant difference in the risk of recurrence when we compared mesh and suture repair. CONCLUSION: Contrary to findings in the general operative patient, mesh repair was not associated with a lesser risk of recurrence compared with suture repair for treatment of umb/epi hernia in female patients with subsequent pregnancy.