Abstract
BackgroundPrevention of incisional hernias with a prophylactic mesh in emergency surgery is controversial. The present study aimed to analyze the long-term results of prophylactic mesh used for preventing incisional hernia after emergency midline laparotomies.MethodsThis study was a registered (NCT04578561) retrospective analysis of patients who underwent an emergency midline laparotomy between January 2009 and July 2010 with a follow-up period of longer than 2 years. Long-term outcomes and risk factors for the development of incisional hernias between patients who received a prophylactic reinforcement mesh (Group M) and suture (Group S) were compared.ResultsFrom an initial 266 emergency midline laparotomies, 187 patients were included. The median follow-up time was 64.4 months (SD 35). Both groups had similar characteristics, except for a higher rate of previous operations (62 vs. 43.2%; P = 0.01) and operation due to a revision laparotomy (32.5 vs.13%; P = 0.02) in the M group. During follow-up, 29.9% of patients developed an incisional hernia (Group S 36.6% vs. Group M 14.3%; P = 0.002). Chronic mesh infections were diagnosed in 2 patients, but no mesh explants were needed, and no patient in the M group developed chronic pain. Long-term risk factors for incisional hernia were as follows: smoking (HR = 2.47; 95% CI 1.318–4.624; P = 0.05), contaminated surgery (HR = 2.98; 95% CI 1.142–7.8; P = 0.02), surgical site infection (SSI; HR = 3.83; 95% CI 1.86–7.86; P = 0.001), and no use of prophylactic mesh (HR = 5.09; 95% CI 2.1–12.2; P = 0.001).ConclusionIncidence of incisional hernias after emergency midline laparotomies is high and increases with time. High-risk patients, contaminated surgery, and surgical site infection (SSI) benefit from mesh reinforcement. Prophylactic mesh use is safe and feasible in emergencies with a low long-term complication rate.Trial registration: NCT04578561. www.clinicaltrials.gov
Highlights
Prevention of incisional hernias with a prophylactic mesh in emergency surgery is controversial
A recent metaanalysis concluded that there was inadequate evidence to recommend its use in a standardized approach [17]; on the other hand, a randomized control trial demonstrated that prophylactic mesh in emergency midline laparotomy (EML) reduced the incidence of dehiscence fascia when analyzing short-term outcomes, but with a higher incidence of surgical site infection (SSI) in the mesh group [18]
The eligibility criteria were as follows: undergoing emergency midline laparotomy excluding those with concomitant hernia repair, those who received incisions outside the midline, those with delayed abdominal closure, those who died in the immediate postoperative period, and a minimum 2 years of follow-up
Summary
Prevention of incisional hernias with a prophylactic mesh in emergency surgery is controversial. It has been demonstrated that prophylactic mesh reinforcement after midline elective laparotomy is useful in reducing IH, especially in high-risk patients [8,9,10,11,12,13]. Surgical site occurrences (SSO) and acute and chronic infection are the main concerns for surgeons when implementing a prophylactic mesh, especially in the emergency setting, apart from other complications such as chronic pain and intestinal fistulas [19] Despite these concerns, there have been no studies evaluating the long-term complications of mesh reinforcement in EMLs, some recent long-term studies in elective cases have demonstrated its safety and efficacy in reducing the incidence of IHs with a long-term follow up [20]. We hypothesize that prophylactic mesh may be useful in EMLs to prevent IHs
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