Incisional hernias post cytoreductive surgery/peritonectomy and hyperthermic intraperitoneal chemotherapy: a systematic review and meta-analysis.

PURPOSE: Cytoreductive surgery (CRS) is often combined with hyperthermic intraperitoneal chemotherapy (HIPEC) for the treatment of peritoneal tumour deposits. Considering CRS, the evidence relating the large incisions, local chemotherapy and abdominal wall trauma to incisional hernias (IH) has not been synthesized. This systematic review and meta-analysis was conducted to examine the proportion of IH present in patients post CRS and the effect HIPEC had on these rates. METHODS: PubMed, EMBASE, and Cochrane Central Registry of Trials were searched up to June 2023 to examine studies relating IH and CRS plus or minus HIPEC. The most up to date PRISMA guidelines were followed. Pertinent clinical information was synthesized in tabular form. A meta-analysis reporting the pooled proportions of IH post CRS plus or minus HIPEC, the odds of IH in HIPEC versus non-HIPEC CRS and the difference in follow-up time between groups was conducted. RESULTS: Nine studies comprising 1416 patients were included. The pooled proportion of IH post CRS was 12% (95% confidence interval (CI) 8-16%) in HIPEC and 7% (95% CI 4-10%) in non-HIPEC patients and 11% (95% CI 7-14%) overall. Previously reported rates of IH in midline laparotomy range from 10 to 30%. The odds of IH in the HIPEC was 1.9 times higher compared to non-HIPEC cohorts however this was not statistically significant (odds ratio (OR) 1.9, 95% 0.7-5.2; p = 0.21). There was no significant difference in average follow-up times between HIPEC and non-HIPEC cohorts. CONCLUSIONS: IH post CRS plus or minus HIPEC were in the expected range for midline laparotomies. IH in patients receiving HIPEC may occur at a greater proportion than in non-HIPEC patients, however, there were too few studies in our meta-analysis to determine this with statistical significance.

Increased risk for incisional hernia following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.

INTRODUCTION: The incidence of incisional hernias (IH) after midline laparotomy varies from 11% to 20%. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is potentially prone to hernias because a Xiphoid to pubis laparotomy incision performed on patients who have undergone previous abdominal surgeries with the addition of chemotherapy and its related adverse effects. METHODS: We performed a retrospective analysis on a prospectively maintained single institution database from March 2015 to July 2020. The inclusion criteria were patients who underwent CRS-HIPEC and had at least 6 months postoperative follow-up with post-operative cross-sectional imaging study. RESULTS: Two hundred and one patients were included in the study. All patients underwent CRS-HIPEC with resection of previous scar and umbilectomy. Fifty-four patients were diagnosed with IH (26.9%). The major risk factors for IH in multivariate analysis were higher American society of Anesthesiologists score (ASA) (OR 3.9, P = 0.012), increasing age (OR 1.06, P = 0.004) and increasing BMI (OR 1.1, P = 0.006). Most of the hernia sites were median (n = 43, 79.6%). Eleven (20.4%) patients had lateral hernias due to stoma incisions or drain sites. Most of the median hernias were at the level of the resected umbilicus 58.9% (n = 23). Five (9.3%) of the patients with IH necessitated an urgent surgical repair. CONCLUSION: We have demonstrated that more than a quarter of the patients after CRS-HIPEC suffer from IH and up to 10% of them may require surgical intervention. More research is needed to find the appropriate intraoperative interventions to minimize this sequela.

An Evaluation of Parastomal Hernia Repair Using the Americas Hernia Society Quality Collaborative.

The purpose of this review was to evaluate outcomes relating to parastomal hernia repair. Data from the Americas Hernia Society Quality Collaborative were used to identify patients undergoing parastomal hernia repair from 2013 to 2016. Parastomal hernia repairs were compared with other repairs using Pearson's test and Wilcoxon test with a P value <0.05 considered significant. Parastomal hernia repairs were performed in 311 patients. Techniques of repair include open in 85 per cent and laparoscopic in 15 per cent. Mesh was used in 92 per cent with keyhole in 34 per cent, flat mesh in 33 per cent, and Sugarbaker in 25 per cent. Mesh types were permanent synthetic in 79 per cent, biologic in 13 per cent, absorbable synthetic in 6 per cent, and hybrid synthetic/biologic in 2 per cent. Most common location for mesh was sublay in 84 per cent followed by onlay in 14 per cent and inlay in 2 per cent with 59 per cent of patients undergoing a myofascial release. Ostomy disposition included ostomy left in situ (47%), moved to a new site (18%), taken down (22%), and rematured in same location in (13%). Outcomes related to parastomal hernia repair included 10 per cent surgical site infection, 24 per cent surgical site occurrence, and 12 per cent surgical site occurrences requiring procedural interventions with a 13 per cent readmission rate and 6 per cent reoperation rate. When comparing parastomal hernias with other ventral hernia repairs, parastomal hernias had a significantly higher surgical site infection, surgical site occurrence, surgical site occurrences requiring procedural intervention, readmission, reoperation rate, and length of stay, and were less commonly performed laparoscopically (P < 0.05). Most parastomal hernias are being repaired open with synthetic mesh in the sublay position. Less favorable outcomes of parastomal hernia repair when compared with other ventral hernia repairs are likely related to the complexity of parastomal hernia repair.

Abdominal Wall Morbidity Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy.

BACKGROUND: Incisional hernia formation has been reported as high as 20% within 1 year following midline laparotomy. Since hyperthermic intraperitoneal chemotherapy is likely to impair wound healing, we sought to investigate the incidence of incisional hernia formation and abdominal wall rupture following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. METHODS: Consecutive patients with radiographic evidence of peritoneal metastases were scheduled for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy at the Comprehensive Cancer Center, University Hospital Tuebingen, Germany. Clinical data were retrospectively analyzed. RESULTS: Between May 2005 and May 2014, 271 patients underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Within follow-up, 19 (7%) incisional hernias and 11 (4%) abdominal wall ruptures were observed. Age ⩾70 years, cardio-pulmonary comorbidity, the presence of pseudomyxoma peritonei or mesothelioma, and postoperative abdominal wall rupture were detected as risk factors for hernia formation. However, Cox multivariate analysis only confirmed the presence of pseudomyxoma peritonei or mesothelioma and postoperative abdominal wall rupture as independent risk factors. CONCLUSION: Our data do not suggest that cytoreductive surgery and hyperthermic intraperitoneal chemotherapy is necessarily associated with a higher incidence of incisional hernia formation. However, patients suffering from pseudomyxoma peritonei or mesothelioma and patients with postoperative abdominal wall rupture seem to be at risk for developing incisional herniation.

Continuous local analgesia is effective in postoperative pain treatment after medium and large incisional hernia repair.

INTRODUCTION: Incisional hernias are a frequent complication of laparotomy. Open surgery is still an option for the treatment of incisional hernias with medium and large wall defects. Major opioids are routinely used in the treatment of postoperative pain, with several side effects. Continuous local analgesia can be effective in postoperative pain management after various surgical interventions. However, very few reports exist on its application in incisional hernias. PURPOSE: We assessed the effectiveness of ropivacaine in reducing the need for systemic analgesics in postoperative pain management related to these interventions. METHODS: We conducted an open-label, prospective, randomized design study. One hundred patients with medium and large incisional hernias were treated by open surgery. Thirty patients with abdominal defects > 8 cm received continuous postoperative local analgesia with ropivacaine 5 mg/ml. Thirty four and 36 patients (abdominal defects of more, and respectively less than 8 cm) received conventional analgesia. RESULTS: Continuous local anesthesia during the first 72 h after surgery reduced the number of patients needing analgesia with pethidine (17 vs 47% and 53%, p = 0.006), as well as the cumulative doses of pethidine (p < 0.05), tramadol (p < 0.001), and metamizole (p < 0.001) needed to control postoperative pain. Catheter installation for local anesthesia did not increase surgery time (p = 0.16) or the rate of local complications. CONCLUSION: Continuous local analgesia reduces the need for systemic opioids and can be successfully used in the postoperative pain management after medium and large incisional hernias treated by open surgery.

Influencing factors for port-site hernias after single-incision laparoscopy.

PURPOSE: Single-incision laparoscopic surgery (SILS) has been demonstrated to be a feasible alternative to multiport laparoscopy, but concerns over port-site incisional hernias have not been well addressed. A retrospective study was performed to determine the rate of port-site hernias as well as influencing risk factors for developing this complication. METHODS: A review of all consecutive patients who underwent SILS over 4 years was conducted using electronic medical records in a multi-specialty integrated healthcare system. Statistical evaluation included descriptive analysis of demographics in addition to bivariate and multivariate analyses of potential risk factors, which were age, gender, BMI, procedure, existing insertion-site hernia, wound infection, tobacco use, steroid use, and diabetes. RESULTS: 787 patients who underwent SILS without conversion to open were reviewed. There were 454 cholecystectomies, 189 appendectomies, 72 colectomies, 21 fundoplications, 15 transabdominal inguinal herniorrhaphies, and 36 other surgeries. Cases included 532 (67.6 %) women, and among all patients mean age was 44.65 (±19.05) years and mean BMI of 28.04 (±6). Of these, 50 (6.35 %) patients were documented as developing port-site incisional hernias by a health care provider or by incidental imaging. Of the risk factors analyzed, insertion-site hernia, age, and BMI were significant. Multivariate analysis indicated that both preexisting hernia and BMI were significant risk factors (p value = 0.00212; p value = 0.0307). Morbidly obese patients had the highest incidence of incisional hernias at 18.18 % (p value = 0.02). CONCLUSIONS: When selecting patients for SILS, surgeons should consider the presence of an umbilical hernia, increased age and obesity as risk factors for developing a port-site hernia.