Reversal of stoma with biosynthetic mesh fascial reinforcement: a systematic review and meta-analysis.

AIM: Temporary stoma formation remains a common part of modern-day colorectal surgical operations. At the time of reversal, a second procedure is required when the bowel is anastomosed and the musculature is closed. The rate of incisional hernia at these sites is 30%-35% with conventional suture closure. Mesh placement at this site is therefore an attractive option to reduce hernia risk, particularly as new mesh types, such as biosynthetic meshes, are available. The aim of this work was to conduct a systematic review and meta-analysis assessing the use of mesh for prophylaxis of incisional hernia at stoma closure and to explore the outcome measures used by each of the included studies to establish whether they are genuinely patient-centred. METHOD: This is a systematic review and meta-analysis assessing the published literature regarding the use of mesh at stoma site closure operations. Comprehensive literature searches of major electronic databases were performed by an information specialist. Screening of search results was undertaken using standard systematic review principles. Data from selected studies were input into an Excel file. Meta-analysis of the results of included studies was conducted using RevMan software (v.5.4). Randomized controlled trial (RCT) and non-RCT data were analysed separately. RESULTS: Eleven studies with a total of 2008 patients were selected for inclusion, with various mesh types used. Of the included studies, one was a RCT, seven were nonrandomized comparative studies and three were case series. The meta-analysis of nonrandomized studies shows that the rate of incisional hernia was lower in the mesh reinforcement group compared with the suture closure group (OR 0.21, 95% CI 0.12-0.37) while rates of infection and haematoma/seroma were similar between groups (OR 0.7, 95% CI 0.41-1.21 and OR 1.05, 95% CI 0.63-1.80, respectively). The results of the RCT were in line with those of the nonrandomized studies. CONCLUSION: Current evidence indicates that mesh is safe and reduces incisional hernia. However, this is not commonly adopted into current clinical practice and the literature has minimal patient-reported outcome measures. Future work should explore the reasons for such slow adoption as well as the preferences of patients in terms of outcome measures that matter most to them.

Incisional hernias following robotic-assisted laparoscopic prostatectomy: does the extraction site matter?

The incidence of incisional hernia (IH) following robotic-assisted laparoscopic prostatectomy (RALP) varies widely within the literature (0.4-9.7%). Whilst small hernias may go unnoticed, the potential exists for bowel strangulation and subsequent emergency surgery. We suggest that the extraction site may influence the rate of IH. A retrospective chart review of a single surgeon RALP series was undertaken. One hundred charts were sampled, of which 69 had sufficient data to be analysed. Prior to July 2017, specimen extraction had been via the supra-umbilical port site. After this time, specimens were extracted via a Pfannenstiel incision. Of the 69 patients, 24 underwent RALP prior to July 2017. Three patients developed IH at the supra-umbilical port extended for extraction site in the pre-2017 group and three patients developed IH at the supra-umbilical port (not extraction) site in the post-2017 group. The rate of IH was almost double in the pre-July 2017 group (12.5% vs. 6.7%). No patient developed an incisional hernia at the Pfannenstiel site in the post-2017 group. In our series, no patient developed a hernia at the Pfannenstiel site. This is in keeping with the reported < 1% IH rate following Pfannenstiel specimen extraction. Given that incisional hernias are a known complication of robotic surgery, thought should be given to changing the site of specimen extraction site to lower the rate of incisional hernias and the morbidity associated with such.

Outcomes of posterior component separation with transversus abdominis release for repair of abdominally based breast reconstruction donor site hernias.

PURPOSE: Abdominally based autologous breast reconstruction (ABABR) is common after mastectomy, but carries a risk of complex abdominal wall hernias. We report experience with posterior component separation (PCS) and transversus abdominis release (TAR) with permanent synthetic mesh repair of ABABR-related hernias. METHODS: Patients at Cleveland Clinic Foundation and Penn State Health were identified retrospectively. Outcomes included postoperative complications, hernia recurrence, and patient-reported outcomes (PROs): Hernia Recurrence Inventory, HerQLes Summary Score, Patient-Reported Outcome Measurement Information System (PROMIS) Pain Intensity 3a Survey, and the Decision Regret Scale (DRS). RESULTS: Forty patients underwent PCS/TAR repair of hernias resulting from pedicled (35%), free (5%), muscle-sparing TRAMs (15%), and DIEPs (28%) from August 2014 to March 2021. Following PCS, 30-day complications included superficial surgical site infection (13%), seroma (8%), and superficial wound breakdown (5%). Five patients (20%) developed clinical hernia recurrence. At a minimum of 1 year, 17 (63%) reported a bulge, 12 (44%) reported pain, median HerQLes Quality Of Life Scores improved from 33 to 63/100 (p value < 0.01), PROMIS 3a Pain Intensity Scores improved from 52 to 38 (p value < 0.05), and DRS scores were consistent with low regret (20/100). CONCLUSION: ABABR-related hernias are complex and technically challenging due to missing abdominal wall components and denervation injury. After repair with PCS/TAR, patients had high rates of recurrence and bulge, but reported improved quality of life and pain and low regret. Surgeons should set realistic expectations regarding postoperative bulge and risk of hernia recurrence.

Do surgical drains reduce the postoperative surgical complications following incisional hernia repair? A systematic meta-analysis.

PURPOSE: Abdominal surgeries are common surgical procedures worldwide. Incisional hernias commonly develop after abdominal wall surgery. Surgery is the definite treatment for most incisional hernias but carries a higher rate of complications. Although frequently used, the real benefit of using drain tubes to reduce surgical complications after incisional hernia repair is uncertain. METHODS: PubMed and Embase databases were searched for studies that compared the outcomes of drain vs. no-drain placement and the risk of complications in patients undergoing incisional hernia repair. Primary endpoints were infection, seroma formation, length of hospital stay, and readmission rate. RESULTS: From a total of 771 studies, we included 2 RCTs and 4 non-RCTs. A total of 40,325 patients were included, of which 28 497 (71%) patients used drain tubes, and 11 828 (29%) had no drains. The drain group had a significantly higher infection rate (OR 1.89; CI 1.13-3.16; P = 0.01) and mean length of hospital stay (Mean Difference-MD 2.66; 95% CI 0.81-4.52; P = 0.005). There was no difference in seroma formation and the readmission rate. CONCLUSION: This comprehensive systematic meta-analysis concluded that drain tube placement after incisional hernia repair is associated with increased infection rate and length of hospital stay without affecting the rate of seroma formation and readmission rate. Prospective randomized studies are required to confirm these findings.

The PROPHER study: patient-reported outcomes after parastomal hernia treatment-a prospective international cohort study.

AIM: A significant proportion of stoma patients develop a parastomal hernia (PSH), with reported rates varying widely from 5% to 50% due to heterogeneity in the definition and mode of diagnosis. PSHs are symptomatic in 75% of these patients, causing a significant impact on quality of life due to issues with appliance fitting, leakage, skin excoriation and pain. They can also lead to emergency presentations with strangulation and obstruction. Evidence is lacking on how to select patients for surgical intervention or conservative treatment. In those who do undergo surgery, the best operation for a particular patient or PSH is not always clear and many options exist. The aim of this study is to assess the impact of an individual patient's PSH treatment on their subsequent self-reported outcomes including treatment success and quality of life. METHODS: This is a prospective international cohort study of PSH treatment, including both operative and non-operative interventions. A global network of clinicians and specialist nurses will recruit 1000-1500 patients and centralize detailed information, their individual background and their PSH treatment, as well as short-term outcomes up to 30 days. Patients will then provide their own outcomes data including quality of life and whether their treatment was successful, via a secure online system, at 3, 6 and 12 months. PROPHER will be run in two phases: an internal pilot phase of at least 10 hospitals from up to five countries, and a main phase of up to 200 hospitals from across the European Society of Coloproctology network. DISCUSSION: This study will provide a wealth of contemporaneous information which will improve our ability to counsel patients and facilitate improved selection of appropriate and personalized interventions for those with a PSH.

The enigma of incisional hernia prediction unraveled: external validation of a prognostic model in colorectal cancer patients.

PURPOSE: Accurate prediction of hernia occurrence is vital for surgical decision-making and patient management, particularly in colorectal surgery patients. While a hernia prediction model has been developed, its performance in external populations remain to be investigated. This study aims to validate the existing model on an external dataset of patients who underwent colorectal surgery. METHODS: The "Penn Hernia Calculator" model was externally validated using the Hughes Abdominal Repair Trial (HART) data, a randomized trial comparing colorectal cancer surgery closure techniques. The data encompassed demographics, comorbidities, and surgical specifics. Patients without complete follow-up were omitted. Model performance was assessed using key metrics, including area under the curve (AUC-ROC and AUC-PR) and Brier score. Reporting followed the TRIPOD consensus. RESULTS: An external international dataset consisting of 802 colorectal surgery patients were identified, of which 674 patients with up to 2 years follow-up were included. Average patient age was 68 years, with 63.8% male. The average BMI was 28.1. Prevalence of diabetes, hypertension, and smoking were 15.7%, 16.3%, and 36.5%, respectively. Additionally, 7.9% of patients had a previous hernia. The most common operation types were low anterior resection (35.3%) and right hemicolectomy (34.4%). Hernia were observed in 24% of cases by 2-year follow-up. The external validation model revealed an AUC-ROC of 0.66, AUC-PR of 0.72, and a Brier score of 0.2. CONCLUSION: The hernia prediction model demonstrated moderate performance in the external validation. Its potential generalizability, specifically in those undergoing colorectal surgery, may suggest utility in identifying and managing high-risk hernia candidates.

Development and preliminary evaluation of a novel procedure for creation of an ileal conduit stoma aimed at preventing parastomal hernia.

OBJECTIVES: Our previous study suggested that the operative procedure is critical for the development of parastomal hernia. We developed a novel procedure for the creation of an ileal conduit stoma to prevent parastomal hernia. Herein we evaluate the efficacy and safety of the procedure. METHODS: A total of 113 Japanese patients underwent radical cystectomy and ileal conduit diversion for bladder cancer from January 2017 through December 2021 at our institution. After excluding those with incomplete data, 103 patients consisting of 46 (44.7%) with the conventional procedure and 57 (55.3%) with the novel procedure were consecutively enrolled. The main points of the novel procedure are as follows: (1) the passage of the ileal conduit is ≤2.4 cm in diameter in principle; (2) the posterior rectus sheath and peritoneum are vertically incised 2 cm laterally from the middle of the stoma site to make an oblique passage for the ileal conduit; and (3) the anterior rectus sheath and posterior rectus sheath with peritoneum are fixed to the ileal conduit separately. RESULTS: Radiography-based parastomal hernia was observed in 11 patients (10.7%) with a median follow-up of 22.0 months. The incidences of parastomal hernia were 3.5% and 19.6% in the novel and the conventional procedure groups, respectively (p = 0.011). The former had a significantly lower cumulative incidence of parastomal hernia (p = 0.008, log-rank test). No specific complications associated with the procedure were observed. CONCLUSIONS: The results of the preliminary cohort study suggest that the novel procedure is safe and effective for the prevention of parastomal hernia.

Incisional Hernia After Laparoscopic Right Colectomy for Colorectal Cancer: A Prospective Study with Retrospective Control on Intracorporeal Versus Extracorporeal Anastomosis.

Background: Incisional hernias often occur after laparoscopic colorectal surgery, but the precise risk factors are not fully understood. This study's primary aim was to compare the incidence of incisional hernias following laparoscopic right colectomy with intracorporeal anastomotic reconstruction (ICA) versus extracorporeal anastomotic reconstruction (ECA). Materials and Methods: A cohort study compared two groups of patients who underwent elective laparoscopic right colectomy for colon cancer following a standardized perioperative enhanced recovery program (ERP): a prospective group underwent ICA from January 2018 to February 2020 and a retrospective group underwent ECA from January 2013 to December 2016. The presence of incisional hernias was assessed by reviewing patients' follow-up computed tomography scans or evaluating the patients by telephone interview or outpatient office visit and diagnostic imaging. Secondary objectives included the hospital length of stay, postoperative complications, 30-day readmission rate, reoperation, and mortality. Results: The study included 89 patients who had laparoscopic right colectomy for malignant colon neoplasms. Among these, 48 underwent ECA (ECA group), and 41 had ICA (ICA group). At a median follow-up of 36 months, incisional hernia was observed in 1 patient (2.4%) in the ICA group, in contrast to 11 (22.9%) confirmed cases in the ECA group (P = .010). The length of hospital stay was similar between the two groups (5 days versus 4 days; P = .064). The two groups showed similarities in terms of postoperative complications (P = .093), hospital readmission (P = .999), and the rate of reoperation within 30 days (P = .461). Conclusions: The ICA technique was associated with a reduced risk of incisional hernias compared with the ECA technique, with similar outcomes in short-term postoperative complications and overall patient recovery.

[Incisional hernias: epidemiology, evidence and guidelines]. / Narbenhernien: Epidemiologie, Evidenz und Leitlinien.

BACKGROUND: From an epidemiological point of view, one third of the population in industrialized countries will undergo abdominal surgery during their lifetime. Depending on the degree of patient-related and procedure-related risks, the occurrence of incisional hernias is associated in a range of up to 30% at 2­year follow-up and even up to 60% at 5 years. In addition to influencing comorbidities, the type of surgical approach and closure technique are of critical importance. OBJECTIVE: To present a descriptive evidence-based recommendation for abdominal wall closure and prophylactic mesh augmentation. MATERIAL AND METHODS: A concise summary was prepared incorporating the current literature and existing guidelines. RESULTS: According to recent studies the recognized risk for the occurrence of incisional hernias in the presence of obesity and abdominal aortic diseases also applies to patients undergoing colorectal surgery and the presence of diastasis recti abdominis. Based on high-level published data, the short stitch technique for midline laparotomy in the elective setting has a high level of evidence to be a standard procedure. Patients with an increased risk profile should receive prophylactic mesh reinforcement, either onlay or sublay, in addition to the short stitch technique. In emergency laparotomy, the individual risk of infection with respect to the closure technique used must be included. CONCLUSION: The avoidance of incisional hernias is primarily achieved by the minimally invasive access for laparoscopy. For closure of the most commonly used midline approach, the short stitch technique and, in the case of existing risk factors, additionally mesh augmentation are recommended.

Preoperative CT imaging as a tool to predict incisional hernia outcomes following abdominal wall reconstruction: A retrospective cohort analysis.

INTRODUCTION: Ventral wall hernia often causes significant morbidity and requires complex abdominal wall reconstruction (AWR). This study aims to determine whether subcutaneous abdominal fat thickness (AFT) measured with preoperative CT scans could predict postoperative outcomes in patients undergoing AWR. METHODS: A retrospective cohort study was conducted on all patients who underwent AWR at our institution between 2009 and 2021, with a minimum follow-up of 12 months. Using preoperative CT scans, AFT was measured at the xiphoid process, umbilicus, and pubic tubercle, as well as the hernia dimensions. Demographic, operative, and surgical outcome data were also collected and analyzed using statistical tests. RESULTS: The results showed that 9 of 101 patients (8.9%) experienced hernia recurrence. Smoking was associated with an increased risk of hernia recurrence (p < 0.001) with a predictive odds ratio (OR) of 18.27 (p = 0.041). Increased AFT at the xiphoid (p = 0.005), umbilicus (p < 0.001), and pubic tubercle (p < 0.001) were also associated with hernia recurrence and risk of infection. Only AFT at the pubic tubercle reached significance in the regression model predicting recurrence (OR=1.10; p = 0.030) and infection (OR=1.04; p = 0.021). A cut-off value of 67 mm was associated with a positive predictive value of 42.14% (sensitivity of 67% and specificity of 91%). Hernia defect area was not associated with risk of recurrence or infection. CONCLUSIONS: Smoking and increased AFT at the pubic tubercle are significant predictive factors for recurrence and infection in patients undergoing AWR, and preoperative optimization should focus on reducing these factors.

Prophylactic mesh does not prevent parastomal hernia in long-term: Meta-analysis and trial sequential analysis.

BACKGROUND: Previous randomized clinical trials, systematic reviews, and meta-analyses evaluating parastomal hernia prevention with mesh placement during end colostomy formation have reported contradictory results. This review aimed to assess the efficacy of this strategy in long-term follow-up according to the latest available data. METHODS: Medline, EMBASE, Cochrane Library, Web of Science, and Google Scholar were searched. Randomized clinical trials were included if they compared mesh with no mesh during initial end colostomy creation in adult patients to prevent parastomal hernia with a follow-up longer than 2 years. A meta-analysis was performed to evaluate parastomal hernia incidence (primary outcome), parastomal hernia repair rate, and mortality. Subgroup analysis included surgical approach and mesh position, and trial sequential analysis was performed. RESULTS: Eight randomized clinical trials involving 537 patients met the inclusion criteria. Based on long-term follow-up, the incidence of parastomal hernia was not reduced when a prophylactic mesh was placed (relative risk = 0.68 [95% confidence interval:0.46-1.02]; I2 = 81%, P =.06). The parastomal hernia repair rate was low; however, no difference was found between the groups (relative risk = 0.90 [95% confidence interval:0.51-1.56]; I2 = 0%; P = .70), and no difference was detected between the groups when mortality was assessed (relative risk = 1.03 [95% confidence interval: 0.77-1.39]; I2 = 21%; P = .83). Subgroup analyses did not show differences according to the surgical approach or mesh position used. Regarding trial sequential analysis, an optimal information size was not achieved. CONCLUSION: Prophylactic mesh placement during end colostomy formation does not prevent parastomal hernia in the long term. The parastomal hernia repair rate and mortality rate did not vary between the included groups. Heterogeneity among the included randomized clinical trials might restrict the reliability of the results.

Prevention of incisional hernia with retrorectus synthetic mesh versus biological mesh following loop ileostomy closure (Preloop trial).

BACKGROUND: The rate of incisional hernia after closure of a temporary loop ileostomy is significant. Synthetic meshes are still commonly avoided in contaminated wounds. The Preloop trial was a multicentre RCT designed to evaluate the benefits of synthetic mesh in incisional hernia prevention, and its safety for use in a contaminated surgical site compared with biological mesh. METHODS: Study patients who underwent closure of a loop ileostomy after anterior resection for rectal cancer were assigned to receive either retrorectus synthetic or biological mesh to prevent incisional hernia. The primary outcomes were surgical-site infections within 30 days, and clinical or radiological incisional hernia incidence at 10 months. Secondary outcomes were reoperation rate, operating time, duration of hospital stay, other complications within 30 days of surgery, 5-year quality of life measured by RAND-36, and incisional hernia incidence within 5 years of follow-up. RESULTS: Between November 2018 and September 2021, 102 patients were randomised, of whom 97 received the intended allocation. At 10-month follow-up, 90 patients had undergone clinical evaluation and 88 radiological evaluation. One patient in each group (2 per cent) had a clinical diagnosis of incisional hernia (P = 0.950) and one further patient in each group had a CT-confirmed incisional hernia (P = 0.949). The number of other complications, reoperation rate, operating time, and duration of hospital stay did not differ between the study groups. CONCLUSION: Synthetic mesh appeared comparable to biological mesh in efficacy and safety for incisional hernia prevention at the time of loop ileostomy closure. REGISTRATION NUMBER: NCT03445936 (http://www.clinicaltrials.gov).

Does intraperitoneal mesh increase the risk of bowel obstruction? A nationwide French analysis.

INTRODUCTION: Incisional hernias are associated with a reduced quality of life. Mesh reinforcement of the abdominal wall is the current standard for incisional hernia repair (IHR), since it reduces the risk of recurrence. The best position for the mesh remains controversial, and each position has advantages and disadvantages. OBJECTIVE: In this nationwide population-based study, we aimed to determine whether IHR with intraperitoneal mesh is associated with an increased risk of bowel obstruction. PATIENTS AND METHODS: Using the French hospital database (PMSI), which collects data from all public and private hospitals, two patient cohorts were created and compared. Patients having undergone a laparoscopic IHR with intraperitoneal mesh (IPOM) in 2013 or 2014 due to a laparotomy performed in the 4 previous years were the IPOM group. Patients hospitalized for any other acute disease (i.e., without IHR) in 2013 and 2014, but having a similar laparotomy in the 4 previous years were the control group. Both cohorts were followed until 2019 in search of any episode of bowel obstruction. RESULTS: A total of 815 patients were included in the IPOM group and matched to 1630 control patients. The 5 year bowel obstruction rate was 7.36% in the IPOM group and 4.42% in the control group (p < 0.01). In the multivariate analysis, after adjustment on age and obesity, incisional hernia repair with laparoscopic IPOM increased the risk of bowel obstruction in the 5 years following surgery (HR = 1.712; 95% CI 1.208-2.427; p = 0.0025). CONCLUSIONS: Patients having undergone laparoscopic IPOM have an increased risk of bowel obstruction compared with patients who have a similar surgical history but no IHR.

Incisional hernias post renal transplant: a systematic review and meta-analysis.

PURPOSE: Incisional hernia (IH) post renal transplant (RT) is relatively uncommon and can be challenging to manage clinically due to the presence of the kidney graft and patient immunosuppression. This systematic review and meta-analysis synthesises the current literature in relation to IH rates, risk factors and outcomes post RT. METHODS: PubMed, EMBASE, and Cochrane Central Registry of Controlled Trials (CENTRAL) were searched up to July 2023. The most up to date Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines were followed. Pertinent clinical information was synthesised. A meta-analysis of the pooled proportions of IH rates, the rates of patients requiring surgical repair and the rates of recurrence post RT are reported. RESULTS: Twenty studies comprising 16,018 patients were included in this analysis. The pooled rate of IH occurrence post RT was 4% (CI 3-5%). The pooled rate of IH repair post RT was 61% (CI 14-100%). The pooled rate of IH recurrence after repair was 16% (CI 9-23%). Risk factors identified for IH development post RT are BMI, immunosuppression, age, smoking, incision type, reoperation, concurrent abdominal wall hernia, lymphocele formation and pulmonary disease. CONCLUSIONS: IH post RT is uncommon and the majority of IH post RT are repaired surgically on an elective basis.

Optimal computed tomography-based biomarkers for prediction of incisional hernia formation.

PURPOSE: Unstructured data are an untapped source for surgical prediction. Modern image analysis and machine learning (ML) can harness unstructured data in medical imaging. Incisional hernia (IH) is a pervasive surgical disease, well-suited for prediction using image analysis. Our objective was to identify optimal biomarkers (OBMs) from preoperative abdominopelvic computed tomography (CT) imaging which are most predictive of IH development. METHODS: Two hundred and twelve rigorously matched colorectal surgery patients at our institution were included. Preoperative abdominopelvic CT scans were segmented to derive linear, volumetric, intensity-based, and textural features. These features were analyzed to find a small subset of OBMs, which are maximally predictive of IH. Three ML classifiers (Ensemble Boosting, Random Forest, SVM) trained on these OBMs were used for prediction of IH. RESULTS: Altogether, 279 features were extracted from each CT scan. The most predictive OBMs found were: (1) abdominopelvic visceral adipose tissue (VAT) volume, normalized for height; (2) abdominopelvic skeletal muscle tissue volume, normalized for height; and (3) pelvic VAT volume to pelvic outer aspect of body wall skeletal musculature (OAM) volume ratio. Among ML prediction models, Ensemble Boosting produced the best performance with an AUC of 0.85, accuracy of 0.83, sensitivity of 0.86, and specificity of 0.81. CONCLUSION: These OBMs suggest increased intra-abdominopelvic volume/pressure as the salient pathophysiologic driver and likely mechanism for IH formation. ML models using these OBMs are highly predictive for IH development. The next generation of surgical prediction will maximize the utility of unstructured data using advanced image analysis and ML.

External validation and revision of Penn incisional hernia prediction model: A large-scale retrospective cohort of abdominal operations.

BACKGROUND: Incisional hernia (IH) manifests in 10%-15% of abdominal surgeries and patients at elevated risk of this complication should be identified for prophylactic intervention. This study aimed to externally validate the Penn hernia risk calculator. METHODS: The Ramathibodi abdominal surgery cohort was constructed by linking relevant hospital databases from 2010 to 2021. Penn hernia risk scores were calculated according to the original model which was externally validated using a seven-step approach. An updated model which included four additional predictor variables (i.e., age, immunosuppressive medication, ostomy reversal, and transfusion) added to those of the three original predictors (i.e., body mass index, chronic liver disease, and open surgery) was also evaluated. The area under the receiver operating characteristic curve (AUC) was estimated, and calibration performance was compared using the Hosmer-Lemeshow goodness-of-fit method for the observed/expected (O/E) ratio. RESULTS: A total of 12,155 abdominal operations were assessed. The original Penn model yielded fair discrimination with an AUC (95% confidence interval (CI)) of 0.645 (0.607, 0.683). The updated model that included the additional predictor variables achieved an acceptable AUC (95% CI) of 0.733 (0.698, 0.768) with the O/E ratio of 0.968 (0.848, 1.088). CONCLUSION: The updated model achieved improved discrimination and calibration performance, and should be considered for the identification of high-risk patients for further hernia prevention strategy.

Incisional hernia repair following pancreatic surgery-open vs laparoscopic approach.

INTRODUCTION: For pancreatic procedures, transverse and midline or combined approaches are used. Having an increased morbidity after pancreatic surgery, these patients have an increased risk of developing an incisional hernia. In the following, we will analyze how the results of incisional hernia surgery after pancreatic surgery are presented in the Herniamed Registry. METHODS: Hospitals and surgeons from Germany, Austria and Switzerland can voluntarily enter all routinely performed hernia operations prospectively into the Herniamed Registry. All patients sign a special informed consent declaration that they agree to the documentation of their treatment in the Herniamed Registry. Perioperative complications (intraoperative complications, postoperative complications, complication-related reoperations and general complications) are recorded up to 30 days after surgery. After 1, 5, and 10 years, patients and primary care physicians are contacted and asked about any pain at rest, pain on exertion, chronic pain requiring treatment or recurrence. This retrospective analysis of prospectively collected data compares the outcomes of minimally invasive vs open techniques in incisional hernia repair after pancreatic surgery. RESULTS: Relative to the total number of all incisional hernia patients in the Herniamed Registry, the proportion after pancreatic surgery with 1-year follow-up was 0.64% (n = 461) patients. 95% of previous pancreatic surgeries were open. Minimally invasive incisional hernia repair was performed in 17.1% and open repair in 82.9% of cases. 23.2% of the defects were larger than 10 cm and 32.8% were located laterally or were a combination of lateral and medial defects. Among the few differences between the collectives, a significantly higher rate of defect closure (58.1% vs 25.3%; p < 0.001) and drainage (72.8% vs 13.9%; p < 0.001) was found in the open repairs, and larger meshes were seen in the minimally invasive procedures (340.6 cm2 vs 259.6 cm2; p < 0.001). No difference deemed a risk factor for chronic postoperative pain was seen in the rate of preoperative pain between the open and minimally invasive procedures (Appendix Table 4) No significant differences were found in either the perioperative complications or at 1-year follow-up. CONCLUSIONS: Incisional hernias after complex pancreatic surgery can be repaired safely and with a low recurrence rate in both open and minimally invasive techniques.

Risk factors for incisional hernia after gastrointestinal surgeries in non-tumor patients.

PURPOSE: Incisional hernia (IH) is a common secondary ventral hernia after abdominal incisions and there is still little reliable evidence to predict and prevent IH. This study aimed to estimate risk factors of its incidence, especially concentrating on blood results. METHODS: 96 patients received midline laparotomy for gastrointestinal benign diseases and suffered from IH were enrolled in the IH group. A control group of 192 patients were randomly selected from patients underwent midline laparotomy for gastrointestinal benign diseases without IH. RESULTS: Patients in the IH group exhibited higher age (P < 0.001), BMI (P < 0.001), hernia history (P = 0.001) and laparotomy history (P < 0.001). Rate of coronary heart disease (P = 0.046), hypertension (P < 0.001), diabetes (P = 0.008), incisional infection (P = 0.004) and emergency surgery (P = 0.041) were also higher in the IH group. Patients with IH had lower levels of Hb (P = 0.002), TP (P = 0.013), ALB (P < 0.001), A/G (P = 0.019), PA (P < 0.001), HDL-C (P = 0.008) and ApoA1 (P = 0.005). Meanwhile, patients in the control group bore lower levels of LDH (P = 0.008), GLU (P = 0.007), BUN (P = 0.048), UA (P = 0.021), TG (P = 0.011), TG/HDL-C (P = 0.002), TC/HDL-C (P = 0.013), ApoB/ApoA1 (P = 0.001) and Lp(a) (P = 0.001). A multivariate logistic regression revealed that high BMI, laparotomy history, incisional infection, decreased PA, elevated levels of UA, Lp(a) and ApoB/ApoA1 were independent risk factors of IH. CONCLUSION: This is the first study to reveal the relationship between IH and serum biochemical levels, and give a prediction through the nomograph model. These results will help surgeons identify high-risk patients, and take measures to prevent IH during the perioperative period.

Surgical site occurrence after prophylactic use of mesh for prevention of incisional hernia in midline laparotomy: systematic review and meta-analysis of randomized clinical trials.

BACKGROUND: The use of mesh is the standard for the prevention of incisional hernia (IH). However, the effect of surgical site occurrence (SSO) has never been compared. The aim of this meta-analysis was to evaluate the prevalence of SSO and measure its negative effect through the calculation of the number needed to treat for net effect (NNT net). METHODS: A meta-analysis was performed according to the PRISMA guidelines. The primary objective was to determine the prevalence of SSO and IH, and the secondary objective was to determine the NNT net as a metric to measure the combined benefits and harms. Only published clinical trials were included. The risk of bias was analyzed, and the random effects model was used to determine statistical significance. RESULTS: A total of 15 studies comparing 2344 patients were included. The incidence of IH was significantly lower in the mesh group than in the control group, with an OR of 0.29 (95% CI 0.16-0.49, p = 0.0001). The incidence of SSO was higher in the mesh group than in the control group, with an OR of 1.21 (95% CI 0.85-1.72, p = 0.0001) but without statistical significance. Therefore, the way to compare the benefits and risks of each of the studies was done with the calculation of the NNT net, which is the average number of patients who need to be treated to see the benefit exceeding the harm by one event, and the result was 5, which is the average number of patients who need to be treated to see the benefit exceeding the harm by one event. CONCLUSION: The use of mesh reduces the prevalence of IH and it does not increases the prevalence of SSO, the NNT net determined that the use of mesh continues to be beneficial for the patient.