A systematic review evaluating the influence of incisional Negative Pressure Wound Therapy on scarring.

Pathological scars can result in functional impairment, disfigurement, a psychological burden, itch, and even chronic pain. We conducted a systematic review to investigate the influence of incisional Negative Pressure Wound Therapy (iNPWT) on scarring. PubMed, EMBASE and CINAHL were searched for preclinical and clinical comparative studies that investigated the influence of iNPWT on scarring-related outcomes. Individual studies were assessed using the OHAT Risk of Bias Rating Tool for Human and Animal studies. The body of evidence was rated using OHAT methodology. Six preclinical studies and nine clinical studies (377 patients) were identified. Preclinical studies suggested that iNPWT reduced lateral tension on incisions, increased wound strength, and reduced scar width upon histological assessment. Two clinical studies reported improved patient-reported scar satisfaction as measured with the PSAS (1 year after surgery), POSAS, and a VAS (both 42, 90, and 180 days after surgery). Five clinical studies reported improved observer-reported scar satisfaction as measured with the VSS, SBSES, OSAS, MSS, VAS, and POSAS (7, 15, 30, 42, 90, 180, and 365 days after surgery). Three clinical studies did not detect significant differences at any point in time (POSAS, VAS, and NRS). Because of imprecision concerns, a moderate level of evidence was identified using OHAT methodology. Preclinical as well as clinical evidence indicates a beneficial influence of iNPWT on scarring. Moderate level evidence indicates that iNPWT decreases scar width and improves patient and observer-reported scar satisfaction.

Topical antimicrobial treatment of mesh for the reduction of surgical site infections after hernia repair: a systematic review and meta-analysis.

PURPOSE: Use of mesh is essential in hernia repair. A common complication after hernia repair is surgical site infection (SSI), which poses a risk in spreading to the mesh, possibly causing mesh infection. Topical antimicrobial pretreatment of mesh may potentially reduce SSI risk in hernia repair and has shown promising results in in vitro and in vivo studies. Clinical evidence, however, is more important. This systematic review aims to provide an overview of available clinical evidence for antimicrobial pretreated mesh in hernia repair surgery to reduce SSI. METHODS: We report in accordance with PRISMA guidelines. CENTRAL, EMBASE, CINAHL and PubMed were searched up to October 2023 for studies that investigated the use of antimicrobial pretreated mesh on SSI incidence in adults undergoing hernia repair. The primary outcome was SSI incidence. We also collected data on pathogen involvement, hernia recurrence, and mesh infection. A meta-analysis on SSI risk and GRADE-assessment was performed of eligible studies. RESULTS: We identified 11 eligible studies (n = 2660 patients); 5 randomized trials and 6 cohort studies. Investigated interventions included pre-coated mesh, antibiotic carriers, mesh soaked or irrigated with antibiotic or antiseptic solution. Meta-analysis showed no significant reduction in SSI for antibiotic pretreated polypropylene mesh (RR 0.76 [95% CI 0.27; 2.09]; I2 50%). CONCLUSION: Data on topical mesh pretreatment to reduce SSI risk after hernia repair is limited. Very low certainty evidence from randomized trials in hernia repair surgery shows no significant benefit for antibiotic mesh pretreatment for SSI reduction, but data are imprecise due to optimal information size not being met.

Comparison of Two Versus Three Bilateral Botulinum Toxin Injections Prior to Abdominal Wall Reconstruction.

Background: Intramuscular injection of botulinum toxin A (BTA) induces a temporary muscle paralysis. In patients with a ventral hernia, preoperative injection of BTA in the muscles of the lateral abdominal wall (LAW) leads to thinning and lengthening of these muscles, making fascial closure more likely. In many hernia centres, treatment with BTA prior to abdominal wall reconstruction has therefore become standard care. However, evidence on the optimal BTA strategy is lacking. Methods: In this single-centre retrospective study, we analysed a consecutive cohort of ventral hernia patients that underwent bilateral BTA injections prior to abdominal wall reconstruction with available CT before and after BTA. We only included patients that were treated with exactly 600 units of Dysport®, diluted into 120 mL of saline, via either two- or three injections on each side into all three LAW muscle layers. The primary outcome was the change in LAW muscle length and thickness, comparing CT measures from before BTA and 4-6 weeks after the injections. Results: We analysed 67 patients; 30 had received two injections bilaterally and 37 had received three injections bilaterally. Baseline data showed no significant differences in LAW muscle thickness or length between groups. In both groups, the median LAW muscle thickness decreased with 0.5 cm (p < 0.001). The LAW muscle length increased with 0.9 cm (p = 0.001) and 1.2 cm (p < 0.001) in the two- and three bilateral injection group, respectively. The BTA-induced changes in LAW thickness and length were not significantly different between both groups (p = 0.809 and p = 0.654, respectively). Discussion: When using the exact same dosage and distribution volume of BTA in patients with a complex abdominal wall defect, two injections bilaterally in the lateral abdominal wall muscles are as effective as three injections bilaterally.

Risk Factor-Driven Prehabilitation Prior to Abdominal Wall Reconstruction to Improve Postoperative Outcome. A Narrative Review.

All abdominal wall reconstructions find themselves on a scale, varying between simple to highly complex procedures. The level of complexity depends on many factors that are divided into patient comorbidities, hernia characteristics, and wound characteristics. Preoperative identification of modifiable risk factors provides the opportunity for patient optimization. Because this so called prehabilitation greatly improves postoperative outcome, reconstructive surgery should not be scheduled before all modifiable risk factors are optimized to a point where no further improvement can be expected. In this review, we discuss the importance of preoperative risk factor recognition, identify modifiable risk factors, and utilize options for patient prehabilitation, all aiming to improve postoperative outcome and therewith long-term success of the reconstruction.

The Effect of Negative-Pressure Wound Therapy with Instillation Compared to Current Standard Care on Wound Closure Time of Infected Wounds: A Systematic Review and Meta-Analysis.

BACKGROUND: Infected wounds extend healing time and are associated with higher treatment costs than noninfected wounds. Several observational studies indicate that negative-pressure wound therapy with instillation can effectively reduce bacterial bioburden and improve wound healing. Only a few randomized trials with small sample sizes have been published, and a meta-analysis directly comparing negative-pressure wound therapy with instillation to current standard care is lacking. It is therefore uncertain whether negative-pressure wound therapy with instillation actually improves wound healing. The authors performed a systematic review and hypothesized that negative-pressure wound therapy with instillation reduces wound closure time. METHODS: The PubMed, Embase, and CENTRAL databases were searched up to December of 2020 for English studies that compare negative-pressure wound therapy with instillation-to either negative-pressure wound therapy without instillation or to other types of wound care-for the treatment of acute or chronically infected wounds. Time to wound closure was analyzed using a random effects meta-analysis in predefined subgroups according to study design and comparative wound care. RESULTS: The authors identified 14 studies describing 1053 patients. Meta-analysis of three randomized trials shows no significant difference in time to wound closure between negative-pressure wound therapy with instillation and that without (mean difference, 0.48 day; 95 percent CI, -0.70 to 1.65; I ² = 0 percent). Data from eleven observational studies indicate that negative-pressure wound therapy with instillation reduces wound closure time (from 1.6 to 16.8 days; no pooled data). Because of imprecision and risk of bias, the available evidence provides only low-level certainty. CONCLUSIONS: There is currently insufficient evidence to support or discard the use of negative-pressure wound therapy with instillation for infected wounds. More randomized trials are needed to determine whether a beneficial effect can be substantiated.

Clinical outcomes of open abdominal wall reconstruction with the use of a polypropylene reinforced tissue matrix: a multicenter retrospective study.

OBJECTIVE: To assess mesh behaviour and clinical outcomes of open complex abdominal wall reconstruction (CAWR) with the use of a polypropylene reinforced tissue matrix. METHODS: A multicenter retrospective study of adult patients who underwent open CAWR with the use of a permanent polypropylene reinforced tissue matrix (OviTex®) between June 2019 and January 2021. RESULTS: Fifty-five consecutive patients from four hospitals in the Netherlands were analysed; 46 patients with a ventral hernia and 9 patients with an open abdomen. Most patients with a ventral hernia had one or more complicating comorbidities (91.3%) and one or more complicating hernia characteristics (95.7%). Most procedures were performed in a (clean) contaminated surgical field (69.6% CDC 2-4; 41.3% CDC 3-4). All nine patients with an open abdomen underwent semi-emergent surgery. Twelve out of 46 patients with a ventral hernia (26.1%) and 4 of 9 patients with an open abdomen (44.4%) developed a postoperative surgical site infection that made direct contact with the mesh as confirmed on computed tomography (CT), suspicious of mesh infection. No patient needed mesh explantation for persistent infection of the mesh. During a median follow-up of 13 months, 4 of 46 ventral hernia patients (8.7%) developed a CT confirmed hernia recurrence. CONCLUSION: Polypropylene reinforced tissue matrix can withstand infectious complications and provides acceptable mid-term recurrence rates in this retrospective study on open complex abdominal wall reconstructions. Longer follow-up data from prospective studies are required to determine further risk of hernia recurrence.

Effect of triclosan-coated sutures for abdominal wound closure on the incidence of abdominal wound dehiscence: a protocol for an individual participant data meta-analysis.

INTRODUCTION: Acute abdominal wound dehiscence (AWD) or burst abdomen is a severe complication after abdominal surgery with an incidence up to 3.8%. Surgical site infection (SSI) is the biggest risk factor for the development of AWD. It is strongly suggested that the use of triclosan-coated sutures (TCS) for wound closure reduces the risk of SSI. We hypothesise that the use of TCS for abdominal wound closure may reduce the risk of AWD. Current randomised controlled trials (RCTs) lack power to investigate this. Therefore, the purpose of this individual participant data meta-analysis is to evaluate the effect of TCS for abdominal wound closure on the incidence of AWD. METHODS AND ANALYSIS: We will conduct a systematic review of Medline, Embase and Cochrane Central Register of Controlled Trials for RCTs investigating the effect of TCS compared with non-coated sutures for abdominal wound closure in adult participants scheduled for open abdominal surgery. Two independent reviewers will assess eligible studies for inclusion and methodological quality. Authors of eligible studies will be invited to collaborate and share individual participant data. The primary outcome will be AWD within 30 days after surgery requiring reoperation. Secondary outcomes include SSI, all-cause reoperations, length of hospital stay and all-cause mortality within 30 days after surgery. Data will be analysed with a one-step approach, followed by a two-step approach. In the one-step approach, treatment effects will be estimated as a risk ratio with corresponding 95% CI in a generalised linear mixed model framework with a log link and binomial distribution assumption. The quality of evidence will be judged using the Grading of Recommendations Assessment Development and Evaluation approach. ETHICS AND DISSEMINATION: The medical ethics committee of the Amsterdam UMC, location AMC in the Netherlands waived the necessity for a formal approval of this study, as this research does not fall under the Medical Research involving Human Subjects Act. Collaborating investigators will deidentify data before sharing. The results will be submitted to a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42019121173.

[Botox preceding ventral hernia repair: it's not about esthetics]. / Botox voorafgaand aan littekenbreukcorrecties.

Ventral hernia is a common complication after laparotomy. The aim during ventral hernia repair is to close the abdomen through medialization of the rectus muscles. Particularly in patients with large ventral hernia, chronically retracted lateral muscles may preclude muscle medialization and therewith closure of the abdomen. A recent development in abdominal wall surgery is the injection of botulinum toxin (botox) in the lateral abdominal wall muscles a few weeks prior to surgery. These intramuscular injections cause a temporary partial paralysis resulting in elongation of the lateral muscles, compared to pre-botox contracted and retracted lateral muscles, and therewith facilitate closure of the abdomen. Despite positive first results only little is known about this new application of botox. In this article we discuss both the technical aspects as well as the current state of this new technique.