Abstract
BackgroundThe surgical treatment of patients with complex ventral hernias is challenging. The aim of this study was to present an international overview of expert opinions on current practice.MethodsA survey questionnaire was designed to investigate preoperative risk management, surgical approach and mesh choice in patients undergoing complex hernias repair, and treatment strategies for infected meshes. Geographical location of practice, experience and annual volumes of the surgeons were compared.ResultsOf 408 surgeons, 234 (57.4 per cent) were practising in the USA, 116 (28.4 per cent) in Europe, and 58 (14.2 per cent) in other countries. Some 412 of 418 surgeons (98.6 per cent) performed open repair and 322 of 416 (77.4 per cent) performed laparoscopic repair. Most recommended preoperative work-up/lifestyle changes such as smoking cessation (319 of 398, 80.2 per cent) and weight loss (254 of 399, 63.7 per cent), but the consequences of these strategies varied. American surgeons and less experienced surgeons were stricter. Antibiotics were given at least 1 h before surgery by 295 of 414 respondents (71.3 per cent). Synthetic and biological meshes were used equally in contaminated primary hernia repair, whereas for recurrent hernia repair synthetic mesh was used in a clean environment and biological or no mesh in a contaminated environment. American surgeons and surgeons with less experience preferred biological mesh in contaminated environments significantly more often. Percutaneous drainage and antibiotics were the first steps recommended in treating mesh infection. In the presence of sepsis, most surgeons favoured synthetic mesh explantation and further repair with biological mesh.ConclusionThere remains a paucity of good-quality evidence in dealing with these hernias, leading to variations in management. Patient optimization and issues related to mesh choice and infections require well designed prospective studies.
Highlights
The surgical treatment of patients with complex ventral hernias is challenging
Synthetic and biological meshes were used in contaminated primary hernia repair, whereas for recurrent hernia repair synthetic mesh was used in a clean environment and biological or no mesh in a contaminated environment
Percutaneous drainage and antibiotics were the first steps recommended in treating mesh infection
Summary
The surgical treatment of patients with complex ventral hernias is challenging. Complexity is defined according to the criteria proposed by Slater et al.[1], and depends on the variables of size and location, contamination and soft tissue condition, patient history and risk factors, and the clinical scenario. Preoperative risk management, surgical technique, choice of mesh for contaminated wound conditions, and treatment of an infected mesh are the main topics addressed by guidelines designed to establish best clinical practice[2,3,4]. Rates of surgical-site infection and mesh infection range from 6 to 10 per cent for clean repair and up to 36 per cent in (potentially) contaminated fields[6]. Mesh infection in clinical practice seems to be widely treated by longterm antibiotic regimens with or without percutaneous drainage, or by mesh removal, again without strong evidence for superiority of a specific approach[7]. Methods: A survey questionnaire was designed to investigate preoperative risk management, surgical approach and mesh choice in patients undergoing complex hernias repair, and treatment strategies for infected meshes. Patient optimization and issues related to mesh choice and infections require well designed prospective studies
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