Abstract
The incidence of incisional hernia after open repair of an abdominal aortic aneurysm (AAA) varies between 21% and 38% during the first two years of follow up, and up to 69% five years after surgery. 1 Indrakusuma R. Jalalzadeh H. van der Meij J. Balm R. Koelemay M. Prophylactic mesh reinforcement versus sutured closure to prevent incisional hernias after open abdominal aortic aneurysm repair via midline laparotomy: a systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2018; 56: 120-128 Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar ,2 Alnassar S. Bawahab M. Abdoh A. Guzman R. Al Tuwaijiri T. Louridas G. Incisional hernia postrepair of abdominal aortic occlusive and aneurysmal disease: five-year incidence. Vascular. 2012; 20: 273-277 Crossref PubMed Scopus (34) Google Scholar To date, there have been five randomised controlled trials (RCT) on the use of a prophylactic mesh after open AAA repair. 1 Indrakusuma R. Jalalzadeh H. van der Meij J. Balm R. Koelemay M. Prophylactic mesh reinforcement versus sutured closure to prevent incisional hernias after open abdominal aortic aneurysm repair via midline laparotomy: a systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2018; 56: 120-128 Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar ,3 Nicolajsen C. Eldrup N. Abdominal closure and the risk of incisional hernia in aneurysm surgery - a systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2020; 59: 227-236 Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Four of them have demonstrated a substantial reduction in incisional hernias at two to three years follow up, without increasing post-operative or mesh related complications. A fifth RCT did not report favourable effects of an onlay prophylactic mesh, but is subject to several limitations. 4 Honig S. Diener H. Kölbel T. Reinpold W. Zapf A. Bibiza-Freiwald E. et al. Abdominal incision defect following AAA-surgery (AIDA): 2-year results of prophylactic onlay-mesh augmentation in a multicentre, double-blind, randomised controlled trial. Updates Surg. 2021; ([Epub ahead of print])https://doi.org/10.1007/s13304-021-01125-0 Crossref Scopus (4) Google Scholar The most recent guidelines by the European Hernia Society (EHS) suggest the use of a prophylactic mesh in high risk patients (level of evidence: moderate, strength of recommendation: weak), and the use of a 4 to 1 suture to wound length ratio (4:1 SL/WL) for suture closure of the abdominal wall (level of evidence: low, strength of recommendation: weak). 5 Muysoms F. Antoniou S. Bury K. Campanelli G. Conze J. Cuccurullo D. et al. European Hernia Society guidelines on the closure of abdominal wall incisions. Hernia. 2015; 19: 1-24 Crossref PubMed Scopus (315) Google Scholar The European Society of Vascular and Endovascular Surgery (ESVS) guidelines (2019) state that prophylactic mesh augmentation of the midline may be considered after open AAA repair in patients at high risk of incisional hernia. 6 Wanhainen A. Verzini F. Van Herzeele I. Allaire I. Bown M. Cohnert T. et al. Editor's Choice - European Society for Vascular Surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms. Eur J Vasc Endovasc Surg. 2019; 57: 8-93 Abstract Full Text Full Text PDF PubMed Scopus (1094) Google Scholar A survey was designed aiming to monitor current practice among Belgian and Dutch vascular surgeons regarding techniques to prevent incisional hernias after midline laparotomy in AAA repair. Incisional Hernias After Open Abdominal Aortic Aneurysm Repair: More Attention Needed at Start and FinishEuropean Journal of Vascular and Endovascular SurgeryVol. 64Issues 2-3PreviewThe Research Letter by Dewulf et al.1 possibly indicates that practice limitations regarding mesh use after open surgical repair (OSR) of abdominal aortic aneurysms (AAAs) are widespread. The (not insignificant) minority who suggested mesh should be inserted by a hernia surgeon probably reflects training programmes lacking a broader generalist perspective. Recommendations that mesh should be used in “high risk” candidates are questionable as the literature indicates the risk of incisional hernia formation after OSR is near 30%,2 implying high risk by default. Full-Text PDF
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