NEW YORK (Reuters Health) – Onlay mesh reinforcement significantly reduced the incidence of incisional hernia compared with sublay mesh or primary suture in high-risk patients undergoing midline laparotomy, researchers say.
“Incisional hernia is one of the most frequently seen complications after abdominal surgery, with an incidence that can increase over 35% in high-risk groups,” such as obese patients and those with an abdominal aortic aneurysm, Dr. Ari Jairam of Erasmus University Medical Center in Rotterdam, Netherlands told Reuters Health.
To assess the effectiveness of mesh reinforcement in patients at high risk, Dr. Jairam and colleagues randomized patients undergoing elective midline laparotomy to primary suture only (107 patients), onlay mesh reinforcement (188) and sublay mesh reinforcement (185). A lightweight, large-pore polypropylene mesh was used in both mesh groups, which was fixated with fibrin glue.
Participants had either an abdominal aortic aneurysm or a BMI of 27 or higher.
As reported online June 19 in The Lancet, 92 patients had an incisional hernia during two years of followup: 31% in the primary suture group, 13% in the onlay mesh reinforcement group and 18% in the sublay mesh group.
The incidence of incisional hernia differed significantly between the primary suture and onlay mesh groups (OR, 0.37). However, there were no significant differences between the primary suture versus sublay mesh groups (OR, 1.8) or onlay versus sublay mesh (OR, 1.4).
Among the subgroup of 150 patients with abdominal aortic aneurysm, 36 (24%) had an incisional hernia: 16 in the primary suture group, 10 in the onlay mesh group, and 10 assigned to sublay mesh.
In the subgroup of 330 patients with a BMI of 27 or higher, 54 (16%) had an incisional hernia: 16 in the primary suture group, 15 allocated to onlay mesh and 23 assigned to sublay mesh.
Close to 25% of patients had a postoperative complication during two years of follow-up. At one month, seromas were seen most frequently in those who received onlay mesh reinforcement. “However, this finding did not have any further consequences for patients, i.e., the frequency of surgical-site infections, re-interventions or re-admissions with onlay mesh reinforcement was not different when compared with primary suture or sublay mesh reinforcement,” the authors note.
The risk of re-intervention (p=0.343) and re-admission (p=0.508) did not differ among the groups. None of the re-interventions or re-admissions were related to the mesh or the fibrin sealant.
“Closure of laparotomy with onlay mesh reinforcement has the potential to become the standard treatment in high-risk groups, which will reduce the socioeconomic burden of incisional hernia,” Dr. Jairam suggests.
Editorialist Dr. Lillian Kao of the University of Texas Health Science Center at Houston told Reuters Health, “Theoretically, onlay mesh is technically easier to perform. On the other hand, onlay mesh may predispose to increased seromas or surgical site infections, the latter of which may require the mesh to be explanted.”
“The increased risk (of seromas) is postulated to result from dissection of flaps for the onlay mesh placement,” she said by email. “In the trial, the mesh overlapped the fascia by 3 cm, so perhaps there was not as significant a need for creating flaps.”
“Given that approximately 50% of patients underwent gastrointestinal surgery, it is likely that there were a significant number of patients with clean-contaminated wounds,” she continued. “However, there is no description of what proportion of patients had contaminated wounds – and because only elective patients were included, there were likely also only a few patients with dirty wounds.”
“Therefore, one should be cautious about extrapolating the results to patients with contaminated or dirty wounds,” Dr. Kao said. “In addition, it is not known at what risk of incisional hernia formation prophylactic mesh should be used – i.e., should it be used in patients at low risk of hernia after exploratory laparotomy? What constitutes low or high risk?”
The study was funded by Baxter and B Braun Surgical SA. The authors declared no competing interests.
SOURCE: http://bit.ly/2sr5J47 and http://bit.ly/2sVOmfb
Lancet 2017.
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