Prophylactic Mesh Augmentation Research Articles

INDEPENDENT PATIENT DATA META-ANALYSIS OF PROPHYLACTIC MESH PLACEMENT FOR INCISIONAL HERNIA PREVENTION (AFTER ABDOMINAL AORTIC ANEURYSM SURGERY): A COLLABORATIVE EUROPEAN HERNIA SOCIETY PROJECT (I-PREVENT-AAA)

Abstract Introduction Incisional hernia (IH) is a prevalent and potentially dangerous complication after abdominal surgery, especially in high-risk groups. Prophylactic mesh augmentation (PMA) of the abdominal wall has been studied as a preventive measure for IH-formation, but strong recommendations are lacking. Our primary aim was to evaluate the effectiveness of the use of PMA after open abdominal aortic aneurysm (AAA)-surgery for the prevention of IH by performing an individual patient-data meta-analysis (IPDMA). Secondary aims include evaluation of postoperative complications, and identification of subgroups that benefit most from PMA. Methods A systematic literature search to identify Randomized-Controlled Trials (RCTs) that compare PMA after open AAA surgery to primary suturing (PS), was conducted. Lead authors of eligible studies were asked to share individual participant-data. A one-stage analysis was performed and Cox-regression analyses were used to assess time-to-event outcomes. Results Five RCTs were included in our IPDMA, which resulted in 488 analysed patients. PMA resulted in a Hazard Ratio (HR) of 0.25 (95%CI 0.12–0.50) for the reduction of IH occurrence. No significant differences were present when comparing onlay with sublay mesh (HR 0.56, 95%CI 0.24–1.28). Patients treated with an onlay mesh had significantly more seroma formation in comparison to PS (OR 22.1,95%CI 1.88–259.58) and patients with a sublay mesh had fewer re-operations than those treated with PS (OR 0.47,95%CI 0.43–0.51). Subgroup analyses showed the effectiveness of PMA in various subgroups (e.g., high BMI patients). Conclusion PMA after open AAA surgery is an effective measure to reduce IH formation in a wide variety of patients.

Prophylactic mesh augmentation in emergency laparotomy closure: a meta-analysis of randomized controlled trials with trial sequential analysis.

Prophylactic mesh augmentation in emergency laparotomy closure is controversial. We aimed to perform a meta-analysis of randomized controlled trials (RCT) evaluating the placement of prophylactic mesh during emergency laparotomy. We performed a systematic review of Cochrane, Scopus, and PubMed databases to identify RCT comparing prophylactic mesh augmentation and no mesh augmentation in patients undergoing emergency laparotomy. We excluded observational studies, conference abstracts, elective surgeries, overlapping populations, and trial protocols. Postoperative outcomes were assessed by pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I2 statistics. Risk of bias was assessed using the revised Cochrane risk-of-bias tool (RoB 2). The review protocol was registered at PROSPERO (CRD42023412934). We screened 1312 studies and 33 were thoroughly reviewed. Four studies comprising 464 patients were included in the analysis. Mesh reinforcement was significantly associated with a decrease in incisional hernia incidence (OR 0.18; 95% CI 0.07-0.44; p < 0.001; I2 = 0%), and synthetic mesh placement reduced fascial dehiscence (OR 0.07; 95% CI 0.01-0.53; p = 0.01; I2 = 0%). Mesh augmentation was associated with an increase in operative time (MD 32.09min; 95% CI 6.39-57.78; p = 0.01; I2 = 49%) and seroma (OR 3.89; 95% CI 1.54-9.84; p = 0.004; I2 = 0%), but there was no difference in surgical-site infection or surgical-site occurrences requiring procedural intervention or reoperation. Mesh augmentation in emergency laparotomy decreases incisional hernia and fascial dehiscence incidence. Despite the risk of seroma, prophylactic mesh augmentation appears to be safe and might be considered for emergency laparotomy closure. Further studies evaluating long-term outcomes are still needed.

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Incisional hernias: epidemiology, evidence and guidelines

From an epidemiological point of view, one third of the population in industrialized countries will undergo abdominal surgery during their lifetime. Depending on the degree of patient-related and procedure-related risks, the occurrence of incisional hernias is associated in arange of up to 30% at 2‑year follow-up and even up to 60% at 5years. In addition to influencing comorbidities, the type of surgical approach and closure technique are of critical importance. To present adescriptive evidence-based recommendation for abdominal wall closure and prophylactic mesh augmentation. Aconcise summary was prepared incorporating the current literature and existing guidelines. According to recent studies the recognized risk for the occurrence of incisional hernias in the presence of obesity and abdominal aortic diseases also applies to patients undergoing colorectal surgery and the presence of diastasis recti abdominis. Based on high-level published data, the short stitch technique for midline laparotomy in the elective setting has a high level of evidence to be astandard procedure. Patients with an increased risk profile should receive prophylactic mesh reinforcement, either onlay or sublay, in addition to the short stitch technique. In emergency laparotomy, the individual risk of infection with respect to the closure technique used must be included. The avoidance of incisional hernias is primarily achieved by the minimally invasive access for laparoscopy. For closure of the most commonly used midline approach, the short stitch technique and, in the case of existing risk factors, additionally mesh augmentation are recommended.

P-084 INDEPENDENT PATIENT DATA META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS ON PROPHYLACTIC MESH PLACEMENT FOR INCISIONAL HERNIA PREVENTION: STUDY PROTOCOL

Abstract Aim In high risk groups such as patients undergoing open abdominal aortic aneurysm (AAA) surgery, the risk of incisional hernia (IH) formation is up to 69%. IH can be prevented through prophylactic mesh augmentation (PMA). Several randomized controlled trials (RCT) have shown a significant decrease in IH formation after PMA. However, due to study design and sample size issues, implementation of PMA into daily practice is lacking. Methods International collaboration will be initiated under the guidance of the European Hernia Society. RCTs studying PMA after open AAA surgery will be identified through a literature search. Corresponding authors of the selected studies will be approached for participation by e-mail, telephone or other means. Where independent patient data (IPD) are available, a suitable data delivery agreement (DDA) will be drafted and signed upon agreement. Pseudonymised or anonymised data sets will be securely transferred and stored, and relevant study parameters will be harmonized. A 1-stage IPD meta-analysis (IPDMA) will be performed, stratified per centre, assessing PMA effectivity according to the intention-to-treat principle. If a 1-stage IPDMA is not feasible, a 2-step IPDMA will be performed, analysing each RCT separately and pooling outcomes. Results will be published in internationally recognized, peer-reviewed journals. This study protocol was registered under PROSPERO number CRD42022347881. Conclusions Gathering IPD across relevant RCTs and performing an IPDMA on the combined data will help to better establish effectiveness of PMA in preventing IH after open AAA surgery. Secondarily, subgroup analyses will allow identification of patients who will benefit from PMA most.

Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies.

Incisional hernia is a frequent complication of abdominal wall incision. Surgical technique is an important risk factor for the development of incisional hernia. The aim of these updated guidelines was to provide recommendations to decrease the incidence of incisional hernia. A systematic literature search of MEDLINE, Embase, and Cochrane CENTRAL was performed on 22 January 2022. The Scottish Intercollegiate Guidelines Network instrument was used to evaluate systematic reviews and meta-analyses, RCTs, and cohort studies. The GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation) was used to appraise the certainty of the evidence. The guidelines group consisted of surgical specialists, a biomedical information specialist, certified guideline methodologist, and patient representative. Thirty-nine papers were included covering seven key questions, and weak recommendations were made for all of these. Laparoscopic surgery and non-midline incisions are suggested to be preferred when safe and feasible. In laparoscopic surgery, suturing the fascial defect of trocar sites of 10 mm and larger is advised, especially after single-incision laparoscopic surgery and at the umbilicus. For closure of an elective midline laparotomy, a continuous small-bites suturing technique with a slowly absorbable suture is suggested. Prophylactic mesh augmentation after elective midline laparotomy can be considered to reduce the risk of incisional hernia; a permanent synthetic mesh in either the onlay or retromuscular position is advised. These updated guidelines may help surgeons in selecting the optimal approach and location of abdominal wall incisions.

Abdominal incision defect following AAA-surgery (AIDA): 2-year results of prophylactic onlay-mesh augmentation in a multicentre, double-blind, randomised controlled trial

The reported incidence of incisional hernia following repair of abdominal aortic aneurysm (AAA) via midline laparotomy is up to 69%. This prospective, multicenter, double-blind, randomised controlled trial was conducted at eleven hospitals in Germany. Patients aged 18 years or older undergoing elective AAA-repair via midline incision were randomly assigned using a computer-generated randomisation sequence to one of three groups for fascial closure: with long-term absorbable suture (MonoPlus®, group I), long-term absorbable suture and onlay mesh reinforcement (group II) or extra long-term absorbable suture (MonoMax®, group III). The primary endpoint was the incidence of incisional hernia within 24 months of follow-up, analysed by intention to treat. Physicians conducting the postoperative visits and the patients were blinded. Between February 2011 and July 2013, 104 patients (69.8 ± 7.7 years) were randomised, 99 of them received a study intervention. The rate of incisional hernia within 24 months was not significantly reduced with onlay mesh augmentation compared to primary suture (p = 0.290). Furthermore, the rate of incisional hernia did not differ significantly between fascial closure with slow and extra long-term absorbable suture (p = 0.111). Serious adverse events related to study intervention occurred in five patients (5.1%) from treatment groups II and III. Wound healing disorders were more frequently seen after onlay mesh implantation on the day of discharge (p = 0.010) and three (p = 0.009) and six (p = 0.023) months postoperatively. The existing evidence on prophylactic mesh augmentation in patients undergoing AAA-repair via midline laparotomy probably needs critical review. As the implementation of new RCTs is considered difficult due to the increasing number of endovascular AAA treated, registry studies could help to collect and evaluate data in cases of open AAA-repair. Comparisons between prophylactic mesh implantation and the small bite technique are also required. Trial registration: ClinicalTrials.gov Identifier: NCT01353443. Funding Sources: Aesculap AG, Tuttlingen, Germany.

Evaluation of Absorbable Mesh for Prophylactic Mesh Augmentation in High-Risk Patients

Purpose: Hernia prevention following abdominal surgery has become a subject of growing interest in general surgery. Prophylactic mesh augmentation (PMA) is an emerging technique to prevent incisional hernia in high-risk populations. The aim of this study was to determine the efficacy and safety of PMA using an absorbable mesh. Methods: A retrospective review was performed on patients who underwent PMA between July 2014 and March 2020. A prophylactic synthetic absorbable mesh (Phasix™; Becton Dickinson, Franklin Lakes, NJ) was placed at the surgeon’s discretion according to the indication for the primary operation. The primary outcome was the incisional hernia rate. Secondary outcomes included mesh-related or other complications. Results: Fifty patients underwent PMA following cystectomy with ileal conduit, open aortic surgery, or colostomy creation/takedown. Overall, 10 patients (20%) developed hernia at a median follow-up of 2.2 years. Six of these 10 hernias occurred at incisions where mesh was not placed. There were no documented mesh infections. One mesh (2%) in the AAA group was explanted due to an infected endograft, but there was no evidence of mesh complication. Two patients (4%) developed seroma. Two (4%) patients developed superficial surgical site infections (SSI). There were no documented deep-space SSI. Conclusion: PMA is an emerging technique with a low rate of incisional hernia in high-risk patients, such as those undergoing stoma creation or open aortic intervention. The use of an absorbable mesh seems promising, however more and longer-term research is needed.

Prophylactic sublay non-absorbable mesh positioning following midline laparotomy in a clean-contaminated field: randomized clinical trial (PROMETHEUS)

Incisional hernia is a frequent postoperative complication after midline laparotomy. Prophylactic mesh augmentation in abdominal wall closure after elective surgery is recommended, but its role in emergency surgery is less well defined. This prospective randomized trial evaluated the incidence of incisional hernia in patients undergoing urgent midline laparotomy for clean-contaminated surgery. Closure using a slowly absorbable running suture was compared with closure using an additional sublay mesh (Parietex ProGrip™). Patients were randomized just before abdominal wall closure using computer-generated permuted blocks. Patients, care providers, staff collecting data, and those assessing the endpoints were all blinded to the group allocation. Patients were followed up for 24 months by means of clinical and ultrasonographic evaluations. From January 2015 to June 2018, 200 patients were randomized: 100 to primary closure (control group) and 100 to Parietex ProGrip™ mesh-supported closure (mesh group). Eight patients in the control group and six in the mesh group were lost to follow-up. By 24 months after surgery, 21 patients in the control group and six in the mesh group had developed incisional hernia (P = 0.002). There was no difference between groups in the incidence of haematoma (2 versus 5; P = 0.248) and superficial wound infection (4 versus 5; P = 0.733). Multivariable analysis confirmed the role of mesh in preventing incisional hernia (odds ratio 0.11, 95 per cent c.i. 0.03 to 0.37; P < 0.001). One patient in the mesh group required mesh removal because of deep infection. Prophylactic mesh-augmented abdominal wall closure after urgent laparotomy in clean-contaminated wounds is safe and effective in reducing the incidence of incisional hernia. Registration number: NCT04436887 (http://www.clinicaltrials.gov).

Preventing incisional ventral hernias: important for patients but ignored by surgical specialities? A critical review.

Incisional ventral hernias (IHs) are a common complication across all surgical specialities requiring access to the abdomen, pelvis, and retroperitoneum. This public health issue continues to be widely ignored, resulting in appreciable morbidity and expenses. In this critical review, the issue is explored by an interdisciplinary group. A group of European surgeons encompassing representatives from abdominal wall, vascular, urological, gynecological, colorectal and hepato-pancreatico-biliary surgery have reviewed the occurrence of His in these disciplines. Incisional hernias are a major public health issue with appreciable morbidity and cost implications. General surgeons are commonly called upon to repair IHs following an initial operation by others. Measures that may collectively reduce the frequency of IH across specialities include better planning and preparation (e.g. a fit patient, no time pressure, an experienced operator). A minimally invasive technique should be employed where appropriate. Our main recommendations in midline incisions include using the 'small bites' suture technique with a ≥ 4:1 suture-to-wound length, and adding prophylactic mesh augmentation in patients more likely to suffer herniation. For off-midline incisions, more research of this problem is essential. Meticulous closure of the incision is significant for every patient. Raising awareness of the His is necessary in all surgical disciplines that work withing the abdomen or retroperitoneum. Across all specialties, surgeons should aim for a < 10% IH rate.

Prophylactic mesh augmentation using permanent synthetic mesh: outcomes of keyhole and Stapled Ostomy Reinforcement with Retromuscular Mesh techniques.

Parastomal hernias (PSH) are the most common complication of stoma creation and can cause significant morbidity. We present a consecutive series of patients receiving prophylactic mesh augmentation (PMA) for prevention of PSH. This retrospective review evaluates the efficacy and outcomes of PMA for PSH prevention, and retrospectively compares traditional keyhole PMA (tPMA) (n = 28) with a prophylactic Stapled Ostomy Reinforcement with Retromuscular Mesh technique (pSTORRM) (n = 24). PMA was performed in 52 cases between January 2015 and July 2018. All cases used a large-pore, non-coated, mid-weight polypropylene mesh placed in the retrorectus space. With a median follow-up of 16 mos, parastomal hernia was confirmed in 11.5% (n = 6), 5 of whom were symptomatic. patient-reported outcomes (PRO) indicated 6 additional patients with symptoms associated with PSH without clinical or radiographic confirmation. Patients had similar comorbidities and operative characteristics between tPMA and pSTORRM techniques, and no difference in a median follow-up. pSTORRM patients had fewer surgical site infections (8.3 vs 32.1%; p = 0.046) and occurrences (12.5 vs 46.4%; p = 0.015), and lower rate of PSH, though not statistically significant (4.2 vs 17.9%; p = 0.195). Permanent synthetic mesh placed as a sublay in the retromuscular space is safe and appears to decrease the risk of PSH formation after the creation of permanent stomas. A stapled technique may provide advantages over a traditional keyhole technique.

Mesh salvage following deep surgical site infection

BACKGROUND: Following herniorrhaphy, deep surgical site infections with mesh involvement (dSSI-MI) traditionally necessitate mesh removal, putting patients at risk for hernia recurrence. There is no consensus about managing infected mesh, as salvage strategies are poorly reported. We describe our outcomes following dSSI-MI at two high-volume hernia centers. MATERIALS AND METHODS: A retrospective review of hernia repairs complicated by dSSI-MI with subsequent salvage attempt was undertaken. Outcome measures included duration of antibiotic use, recurrent dSSI-MI, need for mesh excision, postoperative complications, and hernia recurrence. RESULTS: Thirteen patients underwent attempted mesh salvage (female = 8, median age = 64, and median body mass index = 30.6). 62% had an average of 1.5 prior mesh repairs, and 23% had prior surgical site infection. Twelve underwent open ventral or parastomal hernia repairs, while one patient had a prophylactic mesh augmentation. Three cases required concomitant bowel surgery. Eight dSSI-MIs resulted from gastrointestinal tract complications. All patients received antibiotics for median of 17 days. 92% required operative management of dSSI-MI (100% incision and drainage, 66% debridement of soft tissue). Negative-pressure wound therapy (NPWT) was utilized in 92% for an average of 26 days. One patient was successfully managed without an operation. With a median follow-up of 34 months, there were two recurrent hernias, only one requiring repair. CONCLUSIONS: Despite requiring significant postoperative care (reoperations, prolonged antibiotics, and NPWT), mesh salvage without complete explantation is feasible following dSSI-MI, with a low rate of recurrent hernia formation or long-term infections. Salvage attempts were undertaken primarily in patients with retromuscular macroporous polypropylene, suggesting that repair type and mesh choice influence the decision-making for salvage.

Incidence of Incisional Hernia After Emergency Subcostal Unilateral Laparotomy: Does Augmentation Prophylaxis Play a Role?

Few data are available about the frequency of incisional hernia in an emergency subcostal laparotomy. Our objective is to analyze the incidence of incisional hernia after emergency subcostal laparotomy and evaluate if prophylactic mesh could help prevent it. This study is a monocentric retrospective analysis following STROBE guideline statements of all patients who underwent an emergency subcostal laparotomy between January 2011 and July 2017 in our University Hospital. We compared complications and incidence of incisional hernia between patients who received sutures (Group S; N = 203) and patients with prophylactic onlay mesh (Group M; N = 80). A multivariate risk factor analysis of incisional hernia was performed. An incisional hernia-estimated risk calculator equation was created. A total of 283 patients were analyzed. There were 80 patients in Group M and 203 in Group S. In short-term outcomes, length of surgery (213 ± 115min vs 165 ± 73.3min, P = 0.001) and hospital stay (16.4 ± 18.7 vs 11.6days ± 13.4, P = 0.038) were longer in Group M. Long-term follow-up was conducted in 207 patients with a mean follow-up time of 39.3 ± 23months. Incisional hernia was detected in 29 (19.1%) patients in Group S but in only two (3.8%) patients in Group M (P = 0.008). In the multivariate analysis, a risk factor analysis included wound infection (4.91 HR (2.12-11.4); P < 0.001), previous hernia repair (2.86 HR (1.24-6.61); P = 0.014), and shock (2.64 HR (1.01-6.93); P = 0.048). The incidence of incisional hernia after emergency subcostal laparotomy is high. Risk factors are wound infection, shock, and previous hernia surgery. The use of prophylactic mesh augmentation was safe and reduced the incidence of incisional hernia.

Prophylactic Mesh Augmentation: Patient Selection, Techniques, and Early Outcomes

Abstract Background Incisional hernias (IH) following abdominal surgery are frequent and morbid. Prophylactic mesh augmentation (PMA) has emerged as a technique to reduce IH formation. We aim to report patient selection, techniques and early outcomes after PMA. Methods Retrospective chart review identified descriptive characteristics, risk factors, operative technique, and early post-operative outcomes for PMA patients and matched non-PMA patients between January 1, 2016 and October 31, 2017. Results 18 consecutive PMA cases were performed (55.6% female, mean age 54.3 years and mean BMI = 29.5 kg/m2). 88.9% of patients had at least two high-risk features for IH. Zero PMA patients developed IH compared to 5.3% non-PMA patients (p = 0.314) (6-months mean follow-up). No difference in surgical site occurrences (SSO) were identified between the two groups. Conclusions Early results are encouraging, demonstrating PMA is safe with equivocal SSO. Further studies are needed to assess if the reduction in IH formation is statistically significant with longer follow-up.

Prophylactic Mesh for Hernia Prevention: Has the Time Arrived?

Incisional and parastomal hernias continue to be vexing problems for patients and surgeons. Risk factors are generally patient-related and/or technical in nature, and in some cases, can be altered, resulting in improved outcomes. Improved fascial closure techniques can only partly reduce the risk of incisional hernia formation. Even under optimal circumstances, using time tested closure techniques and materials, the rate remains high, due primarily to factors that are not modifiable or are unidentifiable. In such cases, there may be a beneficial role for prophylactic mesh augmentation (PMA), wherein mesh is implanted at the time of initial surgery or stoma formation. Several high-risk groups that might benefit from PMA have been identified, including patients undergoing open abdominal aneurysm repair or colorectal procedures, obese patients, and patients requiring creation of permanent gastrointestinal or urological stomas. Although the initial results of PMA are promising, the benefits of this strategy must be weighed against potential risks. Outcome measures to assess efficacy should include not only hernia recurrence but also quality of life, surgical-site occurrences, and cost. Further studies are warranted to predict which specific patient populations might benefit most from PMA and to identify ideal mesh materials as well as preferred implantation sites and methods of mesh fixation.

Abdominal Wall Closure in Elective Midline Laparotomy: The Current Recommendations

IntroductionThe risk of developing an incisional hernia after primary elective median laparotomy is reported in the literature as being between 5 and 20 percent. The goal of this systematic review was to evaluate different closure techniques for midline laparotomies and the use of additional prophylactic mesh augmentation for midline closure in high risk patients. MethodA systematic literature search was performed until September 2017. The quality of the RCTs was evaluated and analysed. The data are reported in accordance with the Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.ResultsIn the systematic review for closure techniques a total of 23 RCTs and 9 RCTs for the use of prophylactic mesh were included. In elective midline closure the use of a slowly absorbable suture material for continuous closure using the small bites technique results in significantly less incisional hernias than a large bites technique (OR 0.41; 95% CI 0.19, 0.86). The use of prophylactic mesh versus the suture closure of the midline achieved a significant reduction of the incisional hernia rate [OR 0.14 (95% CI 0.07–0.27)]. ConclusionsBased on the currently evidence in midline closure after elective laparotomy in the small bites technique can be recommended to reduce significantly the rate of incisional hernia. The additional use of a prophylactic mesh in high risk patients can significantly reduce the occurrence of incisional hernia.

Prophylactic mesh augmentation: Patient selection, techniques, and early outcomes

BackgroundIncisional hernias (IH) following abdominal surgery are frequent and morbid. Prophylactic mesh augmentation (PMA) has emerged as a technique to reduce IH formation. We aim to report patient selection, techniques and early outcomes after PMA. MethodsRetrospective chart review identified descriptive characteristics, risk factors, operative technique, and early post-operative outcomes for PMA patients and matched non-PMA patients between January 1, 2016 and October 31, 2017. Results18 consecutive PMA cases were performed (55.6% female, mean age 54.3 years and mean BMI = 29.5 kg/m2). 88.9% of patients had at least two high-risk features for IH. Zero PMA patients developed IH compared to 5.3% non-PMA patients (p = 0.314) (6-months mean follow-up). No difference in surgical site occurrences (SSO) were identified between the two groups. ConclusionsEarly results are encouraging, demonstrating PMA is safe with equivocal SSO. Further studies are needed to assess if the reduction in IH formation is statistically significant with longer follow-up.

The State of Prophylactic Mesh Augmentation

Prophylactic mesh augmentation (PMA) is the implantation of mesh during closure of an index laparotomy to decrease a patient's risk for developing incisional hernia (IH). The current body of evidence lacks refined guidelines for patient selection, mesh placement, and material choice. The purpose of this study is to summarize the literature and identify areas of research needed to foster responsible and appropriate use of PMA as an emerging technique. We conducted a comprehensive review of Scopus, Cochrane, PubMed, and <ext-link ext-link-type="uri" xlink:href="http://clinicaltrials.gov">clinicaltrials.gov</ext-link> for articles and trials related to using PMA for IH risk reduction. We further supplemented our review by including select papers on patient-reported outcomes, cost utility, risk modeling, surgical techniques, and available materials highly relevant to PMA. Five-hundred-fifty-one unique articles and 357 trials were reviewed. Multiple studies note a significant decrease in IH incidence with PMA compared with primary suture-only-based closure. No multicenter randomized control trial has been conducted in the United States, and only two such trials are currently active worldwide. Evidence exists supporting the use of PMA, with practical cost utility and models for selecting high-risk patients, but standard PMA guidelines are lacking. Although Europe has progressed with this technique, widespread adoption of PMA requires large-scale pragmatic randomized control trial research, strong evidence-based guidelines, current procedural terminology coding, and resolution of several barriers.

Impact of incisional hernia development following abdominal operations on total healthcare cost.

Introduction of the category III CPT code (0437T) for prophylactic mesh augmentation (PMA) highlights efforts to reduce incisional hernia (IH). PMA's value in the context of value-based care requires understanding both the cost of IH development and the savings from prevention. We hypothesized large healthcare costs with IH development. Appreciating which subsets of patients are at highest risk for IH, and the subsets who have the costliest care is essential in targeting interventions for hernia prevention. Retrospective cohort study utilizing data from Truven Health Analytic MarketScan Commercial Claims and Encounters Database from calendar years 2011-2014. Adults undergoing open abdominal operations with continued enrollment 3-year post-surgery were included. Inpatient and outpatient claims were tracked over 3 years to identify IH. Quantile regression estimated the association between conditional distribution of total cost and IH. A generalized linear model with gamma distribution estimated the association of conditional mean of total cost and IH. Models were adjusted for confounding cost covariates (e.g., age, gender, obesity, smoking, cancer). 14,290 patients were identified, 1294 (9.1%) developed IH, 48% within 1-year, 33% at 1-2years, and 19% at 2-3years post-surgery. 515 underwent stoma creation, 4579 colon resection, 2263 liver/kidney, 3890 peritoneal, 3043 other (foregut, appendectomy, cholecystectomy). Rate of IH formation was 25, 13, 5.9, 6.3, and 6.3%, respectively. The difference in median expenditures for IH development versus no IH was ostomies: $26,098, colorectal: $21,211, liver/kidney: $23,811, peritoneal: $25,554, others: $28,870 (p < 0.0.01). IH within 1 year was more expensive than within 3 years in the following categories: colorectal ($16,034, p = 0.0385), liver/kidney ($27,145, p = 0.0004), and ostomy ($18,992, p = 0.0035). IH is a common occurrence imposing significant healthcare burden. Higher costs occur when IH occurs within 1 year versus 3 years from theindex-procedure. This highlights the importance of hernia prevention techniques and the question of whether temporizing closure adjuncts are appropriate in high-risk patients.