RESUMO
BACKGROUND: Ventral hernia repair (VHR) is often performed in patients with obesity. While panniculectomy improves cosmetic outcomes, it may increase complications, particularly wound-related adverse events. Despite its widespread use, the impact of concurrent panniculectomy on postoperative complications in VHR remains unclear. This study aimed to assess whether concurrent panniculectomy increases postoperative complications in VHR. METHODS: We searched PubMed, Scopus, Web of Science, and Cochrane databases for studies published up to April 2024 comparing surgical outcomes in patients undergoing VHR with and without concurrent panniculectomy. We assessed recurrence, seroma, hematoma, surgical site infections (SSI), wound dehiscence, skin necrosis, chronic wound, length of stay (LOS), readmissions, duration of surgery, and deep venous thromboembolism (DVT). Risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were pooled for dichotomous and continuous endpoints, respectively. We used RStudio for statistics and heterogeneity was assessed with I2 statistics. RESULTS: We screened 890 studies, fully reviewed 40, and included 11 observational studies and 2 randomized controlled trials, comprising 23,354 patients. Of these, 2,972 (13%) patients underwent VHR with concurrent panniculectomy (VHR-PAN). The mean age ranged from 37 to 59 years, and 73% of the sample were women. The mean BMI varied from 29 to 45 kg/m2, and 75% of the patients underwent mesh repair. The mean defect area ranged from 36 to 389 cm2. Most repairs were performed using mesh (75%) in an underlay position (68%) and 24% underwent component separation. VHR-PAN was associated with a decrease in recurrence rates (RR 0.74; 95% CI 0.62 to 0.89; p < 0.001; I2 = 1%) with a follow-up ranging from 1 to 36 months. Furthermore, subgroup analysis of recurrence in studies with a mean follow-up of at least one year also showed a reduction in recurrence (RR 0.72; 95% CI 0.60 to 0.88; p < 0.001; I2 = 12%), with a follow-up ranging from 12 to 36 months. Moreover, concurrent panniculectomy was associated with increased SSI (RR 1.31; 95% CI 1.13 to 1.51; p < 0.001; I2 = 0%), SSO (RR 1.49; 95% CI 1.26 to 1.77; p < 0.001; I2 = 11%), skin necrosis (RR 2.94; 95% CI 1.26 to 6.85; p = 0.012; I2 = 0%) and reoperation (RR 1.73; 95% CI 1.32 to 2.28; p < 0.001; I2 = 0%), and longer LOS (MD 0.90 day; 95%CI 0.40 to 1.40; p < 0.001; I2 = 56%). There was no significant difference in ocurrence of DVT, enterocutaneous fistula, hematoma, seroma, or wound dehiscence, neither on operative time or readmission rates. CONCLUSION: VHR-PAN is associated with lower recurrence rates. However, it increases the risk of wound morbidity and reoperation and prolongs hospital stay. Surgeons should carefully weigh the risks and benefits of performing VHR-PAN. STUDY REGISTRATION: A review protocol for this systematic review and meta-analysis was registered at PROSPERO (CRD42024542721).
RESUMO
INTRODUCTION: Open abdomen (OA) therapy is used in the management of patients who require surgery for severe abdominal conditions. This meta-analysis aims to evaluate the VAWCM technique regarding short and long-term outcomes. METHODS: PubMed, Embase, and Cochrane Central were systematically searched for studies that analyzed VAWCM therapy in OA. Primary outcomes were the complete fascial closure rate and mean duration of OA treatment. Statistical analyses were performed using R statistical software. RESULTS: Seven studies comprising 535 patients were included. We found a complete fascial closure rate of 77.3 per 100 patients (80.1%; 95% CI 59.6-88.7; I2 = 76%), with an overall mortality of 30.3 per 100 (33.5%; 95% CI 9.3-19.4; I2 = 78%). The pooled mean duration of OA treatment was 14.6 days (95% CI 10.7-18.6; I2 = 93%), while the mean length of hospital stay was 43.3 days (95% CI 21.2-65.3; I2 = 96%). As additional outcomes, we found an enteroatmospheric fistula rate of 5.6 per 100 patients (5.4%; 95% CI 2.3-13.3; I2 = 45%) and incisional hernia rate of 34.7 per 100 (34.6%; 95% CI 28.9-41.1; I2 = 0%). The subgroup analysis of mesh materials (polypropylene or polyglactin) showed a higher complete fascial closure rate for the polyglactin (89.1% vs. 66.6%; p = 0.02). CONCLUSION: Our findings showed that VAWCM is a viable option for OA treatment, successfully reaching complete fascial closure, with a low duration of the technique, even though it presented a high heterogeneity between the studies.
RESUMO
Aim: Hernia registries report that guidelines are not always implemented by general surgeons and suggest that the success rate of this procedure is higher in hernia specialty centers. There are many definitions of hernia centers, but their objectives consist of improving healthcare by homogenizing the clinical practice. We performed a systematic review and meta-analysis to analyze hernia centers' definitions and compare hernia centers with non-specialized centers. Material and Methods: Cochrane Central, Scopus, Scielo, and PubMed were systematically searched for studies defining a hernia center or comparing hernia centers and non-specialized centers. Outcomes assessed were recurrence, surgical site events, hospital length of stay (LOS), and operative time. We performed subgroup analyses of hernia type. Statistical analysis was performed with R Studio. Results: 3,260 studies were screened and 88 were thoroughly reviewed. Thirteen studies were included. Five studies defined a hernia center and eight studies, comprising 141,366 patients, compared a hernia center with a non-specialized center. Generally, the definitions were similar in decision-making and educational requirements but differed in structural aspects and the steps required for the certification. We found lower recurrence rates for hernia centers for both inguinal (1.08% versus 5.11%; RR 0.21; 95% CI 0.19 to 0.23; p < 0.001) and ventral hernia (3.2% vs. 8.9%; RR 0.425; 95% CI 0.28 to 0.64; p < 0.001). Hernia centers also presented lower surgical site infection for both ventral (4.3% vs. 11.9%; RR 0.435; 95% CI 0.21 to 0.90; p = 0.026) and inguinal (0.1% vs. 0.52%; RR 0.15; 95% CI 0.02 to 0.99; p = 0.49) repair. Conclusion: Our systematic review and meta-analysis support that a hernia center establishment improves postoperative outcomes data. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024522263, PROSPERO CRD42024522263.
RESUMO
PURPOSE: Individual studies indicate poorer outcomes for smokers after hernia repair. Previous meta-analyses have examined the impact of smoking on specific outcomes such as recurrence and surgical site infection, but there has been a lack of comprehensive consensus or systematic review on this subject. Addressing this gap, our study undertakes a systematic review and meta-analysis to assess the impact of smoking on the outcomes of ventral hernia repair (VHR) and inguinal hernia repair. SOURCE: A thorough search of Cochrane Central, Scopus, SciELO, and PubMed/MEDLINE, focusing on studies that examined the effect of smoking on inguinal and VHR outcomes was conducted. Key outcomes evaluated included recurrence, reoperation, surgical site occurrences (SSO), surgical site infection (SSI), and seroma. PRINCIPAL FINDINGS: Out of 3296 screened studies, 42 met the inclusion criteria. These comprised 25 studies (69,295 patients) on VHR and 17 studies (204,337 patients) on inguinal hernia repair. The analysis revealed that smokers had significantly higher rates of recurrence (10.4% vs. 9.1%; RR 1.48; 95% CI [1.15; 1.90]; P < 0.01), SSO (13.6% vs. 12.7%; RR 1.44; 95% CI [1.12; 1.86]; P < 0.01) and SSI (6.6% vs. 4.2%; RR 1.64; 95% CI [1.38; 1.94]; P < 0.01) following VHR. Additionally, smokers undergoing inguinal hernia repair showed higher recurrence (9% vs. 8.7%; RR 1.91; 95% CI [1.21; 3.01]; P < 0.01), SSI (0.6% vs. 0.3%; RR 1.6; 95% CI [1.21; 2.0]; P < 0.001), and chronic pain (9.9% vs. 10%; RR 1.24; 95% CI [1.06; 1.45]; P < 0.01) rates. No significant differences were observed in seroma (RR 2.63; 95% CI [0.88; 7.91]; P = 0.084) and reoperation rates (RR 1.48; 95% CI [0.77; 2.85]; P = 0.236) for VHR, and in reoperation rates (RR 0.99; 95% CI [0.51; 1.91]; P = 0.978) for inguinal hernias between smokers and non-smokers. Analysis using funnel plots and Egger's test showed the absence of publication bias in the study outcomes. CONCLUSION: This comprehensive meta-analysis found statistically significant increases in recurrence rates, and immediate postoperative complications, such as SSO and SSI following inguinal and VHR. Also, our subgroup analysis suggests that the MIS approach seems to be protective of adverse outcomes in the smokers group. However, our findings suggest that these findings are not of clinical relevance, so our data do not support the necessity of smoking cessation before hernia surgery. More studies are needed to elucidate the specific consequences of smoking in both inguinal and ventral hernia repair. PROSPERO REGISTRATION: ID CRD42024517640.
RESUMO
PURPOSE: Recent guidelines indicate the use of mesh in UHR for defects > 1 cm, as it reduces recurrence, with 10% recurrence rate compared to up to 54.5% with primary closure. However, Nguyen et al. shows that primary closure is still widely performed in UHR, especially for small defects (1-2 cm), for which there is no published data to determine the optimal approach. In addition, previous meta-analysis by Madsen et al. comparing mesh repair with primary closure in UHR didn't exclude emergency conditions and recurrent hernias; also, didn't report subgroup analysis on hernia defect size. Thus, we aimed to perform a systematic review and meta-analysis comparing the mesh repairs vs. primary closure of the defect in an open elective primary UHR. METHODS: We searched for studies comparing mesh with suture in open UHR in PubMed, Scopus, Cochrane, Scielo, and Lilacs from inception until October 2023. Studies with patients ≤ 18 years old, with recurrent or emergency conditions were excluded. Outcomes were recurrence, seroma, hematoma, wound infection, and hospital length of stay. Subgroup analysis was performed for: (1) RCTs only, and (2) hernia defects smaller than 2 cm. We used RevMan 5.4. for statistical analysis. Heterogeneity was assessed with I² statistics, and random effect was used if I² > 25%. RESULTS: 2895 studies were screened and 56 were reviewed. 12 studies, including 4 RCTs, 1 prospective cohort, and 7 retrospective cohorts were included, comprising 2926 patients in total (47.6% in mesh group and 52.4% in the suture group). Mesh repair showed lower rates of recurrence in the overall analysis (RR 0.50; 95% CI 0.31 to 0.79; P = 0.003; I2 = 24%) and for hernia defects smaller than 2 cm (RR 0.56; 95% CI 0.34 to 0.93; P = 0.03; I2 = 0%). Suture repair showed lower rates of seroma (RR 1.88; 95% CI 1.07 to 3.32; P = 0.03; I2 = 0%) and wound infection (RR 1.65; 95%CI 1.12 to 2.43; P = 0.01; I2 = 15%) in the overall analysis, with no differences after performing subgroup analysis of RCTs. No differences were seen regarding hematoma and hospital length of stay. CONCLUSION: The use of mesh during UHR is associated with significantly lower incidence of recurrence in a long-term follow-up compared to the suture repair, reinforcing the previous indications of the guidelines. Additionally, despite the overall analysis showing higher risk of seroma and wound infection for the mesh repair, no differences were seen after subgroup analysis of RCTs. STUDY REGISTRATION: A review protocol for this systematic review and meta-analysis was registered at PROSPERO (CRD42024476854).
RESUMO
PURPOSE: The transinguinal preperitoneal (TIPP) technique is an open approach to groin hernia repair with posteriorly positioned mesh supposed to reduce recurrence rates. However, transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) techniques have similar mesh positioning with the advantages of minimally invasive surgery (MIS). Hence, we performed a systematic review and meta-analysis comparing TIPP and MIS for groin hernia repair. SOURCE: Cochrane, Embase, Scopus, Scielo, and PubMed were systematically searched for studies comparing TIPP and MIS techniques for groin hernia repair. Outcomes assessed were recurrence, chronic pain, surgical site infection (SSI), seroma, and hematoma. We performed a subgroup analysis of TAPP and TEP techniques separately. Statistical analysis was performed with R Studio. PRINCIPAL FINDINGS: 81 studies were screened and 19 were thoroughly reviewed. Six studies were included, of which two compared TIPP with TEP technique, two compared TIPP with TAPP, and two compared TIPP with both TEP and TAPP techniques. We found lower recurrence rates for the TEP technique compared to TIPP (0.38% versus 1.19%; RR 2.68; 95% CI 1.01 to 7.11; P = 0.04). Also, we found lower seroma rates for TIPP group on the overall analysis (RR 0.21; P = 0.002). We did not find statistically significant differences regarding overall recurrence (RR 1.6; P = 0.19), chronic pain (RR 1.53; P = 0.2), SSI (RR 2.51; P = 0.47), and hematoma (RR 1.29; P = 0.76) between MIS and TIPP. No statistically significant differences were found in the subgroup analysis of TAPP technique for all the outcomes. CONCLUSION: Our systematic review and meta-analysis found no differences between TIPP and MIS approaches in the overall analysis of recurrence, SSI, and chronic pain rates. Further research is needed to analyze individual techniques and draw a more precise conclusion on this subject. PROSPERO REGISTRATION: ID CRD42024530107, April 8, 2024.
Assuntos
Hérnia Inguinal , Herniorrafia , Procedimentos Cirúrgicos Minimamente Invasivos , Telas Cirúrgicas , Humanos , Hérnia Inguinal/cirurgia , Herniorrafia/métodos , Herniorrafia/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Recidiva , Seroma/etiologia , Infecção da Ferida Cirúrgica/etiologia , Dor Crônica/etiologia , Hematoma/etiologiaRESUMO
PURPOSE: Incisional ventral hernias (IVH) are common after laparotomies, with up to 20% incidence in 12 months, increasing up to 60% at 3-5 years. Although Small Bites (SB) is the standard technique for fascial closure in laparotomies, its adoption in the United States is limited, and Large Bites (LB) is still commonly performed. We aim to assess the effectiveness of SB regarding IVH. METHODS: We searched for RCTs and observational studies on Cochrane, EMBASE, and PubMed from inception to May 2023. We selected patients ≥ 18 years old, undergoing midline laparotomies, comparing SB and LB for IVH, surgical site infections (SSI), fascial dehiscence, hospital stay, and closure duration. We used RevMan 5.4. and RStudio for statistics. Heterogeneity was assessed with I2 statistics, and random effect was used if I2 > 25%. RESULTS: 1687 studies were screened, 45 reviewed, and 6 studies selected, including 3 RCTs and 3351 patients (49% received SB and 51% LB). SB showed fewer IVH (RR 0.54; 95% CI 0.39-0.74; P < 0.001) and SSI (RR 0.68; 95% CI 0.53-0.86; P = 0.002), shorter hospital stay (MD -1.36 days; 95% CI -2.35, -0.38; P = 0.007), and longer closure duration (MD 4.78 min; 95% CI 3.21-6.35; P < 0.001). No differences were seen regarding fascial dehiscence. CONCLUSION: SB technique has lower incidence of IVH at 1-year follow-up, less SSI, shorter hospital stay, and longer fascial closure duration when compared to the LB. SB should be the technique of choice during midline laparotomies.