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Medtronic / Clinical Solutions / Incisional Hernia - Reinforce and Prevent / Guideline Summaries

Guideline summaries

British Journal of Surgery (2022)

Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies1

Deerenberg E, et al., Department of Surgery, Franciscus Gasthuis en Vlietland, Rotterdam, the Netherlands

Background

Incisional hernia is a frequent complication of abdominal wall incision. Surgical technique is an important risk factor for the development of incisional hernia. The aim of these updated guidelines was to provide recommendations to decrease the incidence of incisional hernia.

Conclusion

These updated guidelines may help surgeons in selecting the optimal approach and location of abdominal wall incisions.

Hernia (2022)

Implementing a protocol to prevent incisional hernia in high‑risk patients: a mesh is a powerful tool2

J. A. Pereira‑Rodríguez et al., Department of General and Digestive Surgery, Hospital, Universitario del Mar. Parc de Salut Mar, Barcelona, Spain

Purpose

The small bites (SB) technique for closure of elective midline laparotomies (EMLs) and a prophylactic mesh (PM) in high-risk patients are suggested by the guidelines to prevent incisional hernias (IHs) and fascial dehiscence (FD). Our aim was to implement a protocol combining both the techniques and to analyze its outcomes.

Conclusion

Following the protocol using PM and SB showed a lower rate of FD and HI. A PM is safe and effective for the prevention of both HI and FD after MLE, regardless of the closure technique used.

Annals of Surgery (2022)

Prevention of Incisional Hernias by Prophylactic Meshaugmented Reinforcement of Midline Laparotomies for Abdominal Aortic Aneurysm Treatment3

Five-year Follow-up of a Randomized Controlled Trial

Maxime Dewulf MD, et al., Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands

Introduction

The incidence of incisional hernias (IHs) after open repair of an abdominal aortic aneurysm (AAA) is high. Several randomized controlled trials have reported favorable results with the use of prophylactic mesh to prevent IHs, without increasing complications. In this analysis, we report on the results of the 60-month follow-up of the PRIMAAT trial.

Conclusions

Prophylactic retrorectus mesh reinforcement after midline laparotomy for the treatment of AAAs safely and effectively decreases the rate of IHs. The cumulative incidence of IHs after open AAA repair, when no mesh is used, continues to increase during the first 5 years after surgery, which leads to a substantial rate of hernia repairs.

British Journal of Surgery (2021)

Prophylactic sublay non-absorbable mesh positioning following midline laparotomy in a clean-contaminated field: randomized clinical trial (PROMETHEUS)4

F. Pizza, et al., Department of Surgery, Hospital ‘Rizzoli’, Naples, Italy

Background

Incisional hernia is a frequent postoperative complication after midline laparotomy. Prophylactic mesh augmentation in abdominal wall closure after elective surgery is recommended, but its role in emergency surgery is less well defined.

Conclusion

Prophylactic mesh-augmented abdominal wall closure after urgent laparotomy in clean-contaminated wounds is safe and effective in reducing the incidence of incisional hernia. Registration number: NCT04436887 (http://www.clinicaltrials.gov).

Hernia (2020)

Preventing incisional ventral hernias: important for patients but ignored by surgical specialities? A critical review5

M. A. Garcia‑Urena, et al., Hospital Universitario del Henares, Faculty of Health Sciences. Universidad Francisco de Vitoria, Madrid, Spain

Purpose

Incisional ventral hernias (IHs) are a common complication across all surgical specialities requiring access to the abdomen, pelvis, and retroperitoneum. This public health issue continues to be widely ignored, resulting in appreciable morbidity and expenses. In this critical review, the issue is explored by an interdisciplinary group. 

Conclusion

Meticulous closure of the incision is significant for every patient. Raising awareness of the His is necessary in all surgical disciplines that work withing the abdomen or retroperitoneum. Across all specialties, surgeons should aim for a <10% IH rate.

Colorectal Disease (2020)

Incidence and risk factors for incisional hernia and recurrence: Retrospective analysis of the French national database6

Benoit Gignoux, et al., Clinique de la Sauvegarde, Lyon, France

Aim

The aim of this work was to determine the rate of incisional hernia (IH) repair and risk factors for IH repair after laparotomy.

Conclusion

From the PMSI database, the real rate of IH repair after laparotomy was 5%, increasing to 17% after digestive surgery. Obesity was the main risk factor, with an IH repair rate of 31% after digestive surgery. Because of the important medico-economic consequences, prevention of IH after laparotomy in high-risk patients should be considered.

Surgical Endoscopy (2019)

Update of Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS))7

R. Bittner, et al., Emeritus Director Marienhospital Stuttgart, Germany

Recommendations

Grade A:
A prophylactic mesh should be placed at the primary stoma operation

Grade B:
Prophylactic onlay mesh reinforcement has the potential to become the standard treatment for high-risk patients undergoing midline laparotomy

Conclude

“..prophylactic mesh placement reduces the rate of incisional hernia in high-risk groups with morbid obesity or aortic aneurysm, or colorectal surgery"

European Society for Vascular Surgery (ESVS) 2019

Clinical Practice Guidelines on the Managment of Abdominal Aortoiliac Artery Aneurysms8

Anders Wanhaineny, et al., Department of Surgical Sciences, Vascular Surgery, Uppsala University, Sweden

 

“A recent meta-analysis based on several RCTs showed that prophylactic use of mesh reinforcement of midline laparotomies significantly reduces the risk of incisional hernia after open AAA repair.”

Recommendation 

In patients treated for abdominal aortic aneurysm by open repair, prophylactic use of mesh reinforcement of midline laparotomies may be considered for patients at high risk of incisional hernia.

 

Surgery (2018)

Contemporary concepts in hernia prevention: Selected proceedings from the 2017 International Symposium on Prevention of Incisional Hernias9

Hobart W. Harris, et al., Department of Surgery, University of California, San Francisco, USA

Abstract

Incisional hernia is a frequent complication of midline laparotomy and enterostomal creation and is as- sociated with high morbidity, decreased quality of life, and high costs. The International Symposium on Incisional Hernia Prevention was held October 19 –20, 2017, at the InterContinental Hotel in San Francisco, CA, hosted by the Department of Surgery, University of California, San Francisco.

Recommendation

The Symposium was a combination of new information but also a comprehensive review of the existing data so as to assess the current state of the field and to set the stage for future research. Further, the Symposium sought to increase awareness and thus emphasize the importance of preventing the formation of incisional and enterostomal hernias.

Hernia 2015

European Hernia Society guidelines on the closure of abdominal wall incisions10

F. E. Muysoms, et al., Department of Surgery, AZ Maria Middelares, Ghent, Belgium

 

“Prophylactic mesh augmentation appears effective and safe and can be suggested in high-risk patients, like aortic aneurysm surgery and obese patients.”

Suggestion:

Prophylactic mesh augmentation for an elective midline laparotomy in a high-risk patient in order to reduce the risk of incisional hernia is suggested.

 
References:

  1. Deerenberg E, Henriksen N, et al. Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies. BJS (2022) https://doi.org/10.1093/bjs/znac302
  2. Pereira‑Rodríguez J.A., et al. Implementing a protocol to prevent incisional hernia in high‑risk patients: a mesh is a powerful tool, Hernia (2022) 26:457–466
  3. Dewulf M, et al. Prevention of Incisional Hernias by Prophylactic Meshaugmented Reinforcement of Midline Laparotomies for Abdominal Aortic Aneurysm Treatment Five-year Follow-up of a Randomized Controlled Trial, Ann Surg 2022;276:e217–e222, DOI: 10.1097/SLA.0000000000005545
  4. Pizza F, et al. Prophylactic sublay non-absorbable mesh positioning following midline laparotomy in a clean-contaminated field: randomized clinical trial (PROMETHEUS), BJS, 2021, 1–6, DOI: 10.1093/bjs/znab068
  5. Garcia‑Urena M.A., Preventing incisional ventral hernias: important for patients but ignored by surgical specialities? A critical review, Hernia 2020, https://doi.org/10.1007/s10029-020-02348-7
  6. Gignoux B., et al., Incidence and risk factors for incisional hernia and recurrence: Retrospective analysis of the French national database, Colorectal Disease. 2021;00:1–9. 
  7. Bittner R, Bain K, Bansal VK, et al. Update of Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS)) - Part A. Surg End (2019) 33:3069-3139
  8. Wanhainen A, Verzini F, Van Herzeele I, et al. European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. Eur J Vasc Endovasc Surg (2018) 1-97
  9. Harris H.W., Hope W.H., et al. Contemporary concepts in hernia prevention: Selected proceedings from the 2017 International Symposium on Prevention of Incisional Hernias, Surgery 164 (2018) 319–326, https://doi.org/10.1016/j.surg.2018.02.020
  10. Muysoms FE, Antoniou SA, Bury K, et al. European Hernia Society guidelines on the closure of abdominal wall incisions. Hernia 2015;19:1–24. DOI 10.1007/s10029-014-1342