MESH inguinal hernia in the new era of patient

Incisional hernia prevention
An Jairam
REPAIR research group
15th
of June 2018

Disclosure
No conflict of interest

Introduction
Incisional hernia
 Most frequent postoperative complication
 Incidence general population: 10-20%
 Incidence high risk groups: > 30%
>>> Prevention

Prevention of incisional hernia
Prophylactic mesh reinforcement – PRIMA trial
Small bites technique – STITCH trial

Profylactic mesh reinforcement
 1995, first study
 Studies 1998 - 2015
 Small patient numbers
 Mesh position: unclear
 Postoperative complications: unclear

Current guidelines
‘Larger trials are needed to make a strong recommendation to perform prophylactic
mesh augmentation for all patients within a certain risk group’

Randomization
1) Primary Suture
 Hechten van de fascie
2) Onlay mesh reinforcement
3) Sublay mesh reinforcement

Endpoints
 Primary endpoint
 Incisional hernia incidence after 2 years follow-up
 Secondary endpoints
 Postoperative complications
 Quality of Life (EuroQoL-5D, SF-36)
 Pain
 Cost-effectiveness

Methods
 Inclusion criteria
 Presence AAA and/or BMI ≥ 27
 Midline laparotomy
 Follow up
 Physical examination
 Radiological examination
 Statistical analysis
 Bonferroni correction: p=0.05/3 = 0.017

PRISMA Flow diagram
Included patients, n = 480
- AAA, n = 150
- BMI ≥ 27, n = 330
Total # of patients excluded, n = 18
- No midline incision, n = 8
- Withdrew informed consent, n = 3
- Already incisional hernia present, n = 3
- Other, n = 4
Total number of included patients
(n = 498)
PS, n = 107
-AAA, n = 37
-BMI ≥ 27 = 70
Lost to FU/missing: 13
OMA, n = 188
-AAA, n = 61
-BMI ≥ 27 = 127
SMA, n = 185
- AAA, n = 52
- BMI ≥ 27 = 133

Long-term results
 Incidence incisional hernia
 In total: 92 (19%)
 Per group:
 Mean FU: 21 months (SD ± 9)
No incisional hernia Incisional hernia %
PS 62 32 30%
Onlay 145 25 13%
Sublay 130 34 18%

Long-term results
Incidence (%) Odds ratio (95% CI) P-value
OMR vs. PS 13 vs. 30 0.37 (0.20-0.69) <0.001
SMR vs. PS 18 vs. 30 0.55 (0.30-1.00) 0.05

Postoperative complications
PS OMR SMR p-value
SSI (%)
Deep
Superficial
Intra-abdominal
4
2
8
7
7
4
5
4
2
NS
NS
NS
Seroma (%) 5 18 7 0.002 *
Mesh infections (%) - 3 1 NS
Mesh removal
Complete
Partial
Re-implantation
-
-
-
4
2
2
3
1
3
NS
NS
NS
Hematomas (%) 1 6 5 NS
Ileus (%) 3 6 6 NS
Re-intervention (%) 11 18 16 NS
Re-admission (%) 11 20 15 NS
* p-value: OMA vs. PS and OMA vs. SMA

Type of mesh?
Permanent vs. Absorbable

Surgical technique
In general
 (light-weight) polypropylene mesh
 Overlap: 3 centimetres
 Fixation mesh with fibrin sealant or rapid absorbable sutures
 Closure of midline fascia with running, slowly absorbable suture
 SL: WL 4:1

Mesh prophylaxis
 When?
 Elective procedures
 High risk groups: AAA, morbid obesity
 How?
 Polypropylene mesh
 Onlay vs. sublay

Small bites technique - Background

STITCH trial
Suture Techniques to reduce the Incidence of The inCisional Hernia
 Multicenter RCT
 The Netherlands
 10 hospitals
First inclusion: October 2009
Last inclusion: February 2012

Randomization
Continuous running suture; SL:WL ≥ 4:1
2 sutures knot middle
Large bites:
 Mass closure technique, PDS plus loop 1
 Stitch every 1 centimeter
 Tissue bite >1cm
Small bites:
 Approximation fascia, PDS plus 2-0
 Stitch every 0.5 cm
 Tissue bite 0.5-1cm

Methods
 Inclusion criteria:
 Age > 18 years
 Elective surgery
 Follow up:
 1 month and 1 year post-operative
 Physical and radiological examination

Outcome
Primary outcome:
 Incisional hernia after 1 year follow-up
Secondary outcomes:
 Surgical Site Infection
 Burst Abdomen
 Post operative pain (VAS)
 Quality of life (SF-36 and EuroQol-5D)

PRISMA Flow diagram
Randomized (n=560)
Exclusion (n=49)
- Not meeting inclusion criteria (n=20)
- Withdraw consent (n=3)
- Perioperative death (n=2)
- Other (n=24)
Assessed for eligibility (n=609)
Large bites
N=284
Small bites
N = 276

Suture technique
Large bites Small bites p
Length incision (cm) 22 22 0.98
Number sutures 25 45 <0.001
Length used sutures (cm) 95 110 <0.001
Suture length /
Wound length (SL:WL
ratio)
4.37 5.03 <0.001
Closure time (min) 10 14 <0.001
Skin closure
 Staples
 Intracutaneous suture
36
64
40
60
0.49

Postoperative complications
Large bites Small bites p
Admission (days) 14 15 0.58
Overall complications
(%)
45 45 1.00
 Pneumonia (%) 14 12 0.71
 Ileus (%) 11 10 0.59
 SSI (%) 23 20 0.20
 Burst abdomen (%) 0.7 1.4 0.746

Long-term results
Follow-up: median 12 months (range 1-36 months)
Incidence of incisional hernia:
 Large bites group: 23% (95% CI 17-30%)
 Small bites group: 14% (95% CI 9-20%) p=0.01

Small bites technique
 When?
 Elective procedures
 How?
 Single layer suture
 Small needle
 Continuous small bites suture technique: stitch every 5 mm
 Aponeurosis only

Conclusion
How to prevent incisional hernia?
 Place of incision
 Closing may need closure team
 Suture technique SL:WL ratio > 4:1
 Suture technique: small bites
 Do not use rapidly absorbable sutures
 Continuous suturing technique
 Single layer aponeurotic closure
 OMR: potential to become the standard treatment in high-risk groups

Future perspectives
 Adapt current EHS guidelines
 Implementation in daily surgical practice
 Randomized controlled trial: small bites technique and prophylactic
mesh reinforcement

MESH inguinal hernia in the new era of patient

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