A Commentary on “Prophylactic negative pressure wound therapy for closed laparotomy incision after ventral hernia repair: A systematic review and meta-analysis” (Int J Surg 2022; 97:106216)

Abstract

Abbreviations: NPWT: Negative Pressure Wound Therapy. Dear Editor, We read the interesting paper on efficacy of negative pressure wound therapy (NPWT) for closed laparotomy incisions in the primary treatment of ventral hernia repair [1]. This surgical repair procedure has significantly high morbidity and mortality rates, especially in high-risk patients. The overall perioperative complication rate reported in literature is around 35.8% and the mortality rate is 3.7%. In addition to systemic morbidity, wound complications and surgical site infection are especially common [1]. Wound infection occurs in around 13% of patients, with even higher incidences of seromas and dehiscence rates of 11–20% [2–4]. Patients affected by ventral hernia are often obese or associated with COPD, and they are more prone to post-operative morbidity. There is a need in these patients to receive improved post-operative management. NPWT was found by the authors in the recently published study to be useful in high risk patients [1]. In our experience, high BMI and COPD patients are prone to develop wound complications because of high wound tension due to cough and hypoperfusion due to excessive abdominal fat. Our results with NPWT in these patients were promising. Applying NPWT onto a wound removes fluid collection, allows formation of granulation tissues, promotes angiogenesis, and helps wound edge approximation. In addition, NPWT stabilizes the wound environment, decreases wound oedema and bacterial bioburden [3,5]. All these mechanisms are effective in promoting healing. The favorable use of NPWT in closed wound healing has been shown in orthopedic, plastic, gynecology and cardiac operations, with increasing evidence on complex abdominal wall reconstructive operations [6]. The present meta-analysis showed that incisional NPWT significantly reduced wound dehiscence and superficial surgical site infection [1]. These results are concordant with the largest trial reported by Galiano et al. [7], who found a significant decrease in wound dehiscence after breast surgery. In some studies, incisional NPWT used on primary wound closure not only decreased wound complications, but also unpredictably resulted in decreased recurrent hernia which might be indirectly related to less wound complications. As surgical site infection after hernioplasty often requires mesh removal, relapse of the original hernia can follow [8]. Although there is no evidence to support effectiveness of the use of NPWT in preventing seromas or hematomas, we noted a reduction of seroma incidence in our patients, which has also been reported in some studies [1,9]. We routinely treat our patients with open or septic abdomen, and those patients with a high risk of abdominal compartment syndrome with NPWT (Fig. 1). We also found that NPWT is useful as a tool in primary wound closure in elective and uncomplicated abdominal wall repair. We treated our patients undergoing elective complex abdominal wall reconstruction using a mesh (either biosynthetic, biological or synthetic), primary wound closure, skin approximating stitches, no surgical drainage and prolonged (at least 10 days) NPWT. The results in these patients were promising. The treatment was well tolerated, and the patients could be mobilized early and discharged home with the NPWT device applied. The dressings were renewed once every four days.Fig. 1.: A. Patient undergoing surgery at another hospital with evisceration due to total dehiscence of the laparotomy incision. B. Abdominal wall repair with intraperitoneal placement of a dual-mesh prosthesis (Ventrio™ Hernia Patch, Bard Davol, Inc., USA) and lateral incisions extending to the anterior fascia of the rectus abdominis to avoid abdominal compartment syndrome. C. Intervention at the end of operation, and D. Dressing with NPWT.Reported retrospective studies showed a significant difference in favor of the use of NPWT when compared to standard surgical dressings in wound healing and surgical site infection rates, especially in patients at high risks for these complications [4]. This treatment is cost-effective [1] even for the higher price of the device when compared to standard dressings. The higher price is more than off-balanced by early hospital discharge and a low complications rate of these patients. The device is easy to use and easily managed by patients and nurses. We are confident that this device will find more novel applications in the future. We believe that patients who are treated prophylactically with incisional NPWT for primary wound closure following surgery are more likely to experience fewer surgical site infection than those patients treated with standard dressings. We support the conclusions of the study by Guo et al. [1] and we believe that incisional NPWT is an effective procedure in preventing postoperative complications after ventral hernia repair. Provenance and peer review Commentary, internally reviewed. Ethical approval The study was a Letter of opinion in which we did not modify the usual treatment of this disease, so disclosures about human research (in the sense of clinical trial) are not applicable. Sources of funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author contribution Chiarello MM and Brisinda G conceived the original idea, meet the criteria for authorship established by the International Committee of Medical Journal Editors and verify the validity of the results reported. All authors read and approved the final manuscript. Research registration unique identifying number (UIN) The paper is a Letter to the Editor. Name of the registry: Unique Identifying number or registration ID: Hyperlink to your specific registration (must be publicly accessible and will be checked): Guarantor All authors read and approved the final manuscript. Declaration of competing interest The authors declare no competing interests.