Prophylactic Mesh Reinforcement Research Articles

Prophylactic placement of permanent synthetic mesh at the time of ostomy closure prevents formation of incisional hernias

BackgroundReversal of an enterostomy results in a high rate of incisional hernia at the ostomy site. Prophylactic mesh reinforcement of the fascial defect is typically not considered due to the contaminated nature of the case. We present the outcomes of a series of prophylactic mesh reinforcements with retromuscular, large-pore polypropylene at the time of enterostomy reversal. MethodsRetrospective review of all ostomy reversals was performed. All cases with placement of synthetic mesh reinforcement were identified from a prospectively maintained, hernia database. Primary end points were surgical site occurrence, surgical site infection, and hernia occurrence. ResultsOstomy reversal was performed in 359 patients; 91 were reinforced with mesh and 268 without mesh. Colostomy reversal was performed in 56.5% and ileostomy in 43.5%. The mesh group had a greater body mass index and a greater incidence of chronic obstructive pulmonary disease, but groups were otherwise similar. A midline incisional hernia was present in 45% of the mesh group vs 4.5% in the controls. Incidence of surgical site occurrence and surgical site infection were similar for mesh and control groups (21 vs 22.8%; P = .82 and 20 vs 19.8%; P = 1.000, respectively). Superficial surgical site infection was less with mesh (8 vs 16.4%; P = .039). Incidence of a hernia developing at the stoma site was decreased markedly with mesh (1% vs 17.2%; P < .001), as was the occurrence of a midline hernia (6% vs 19%; P = .004). Mesh was placed across the midline prophylactically in 29.7% of cases, which decreased midline hernia formation from 24.1% to 4% (P = .019). ConclusionRetromuscular placement of permanent synthetic mesh at the time of enterostomy reversal is effective in preventing development of incisional hernia without increased risk of surgical site occurrence or surgical site infection.

Prevention of a Parastomal Hernia by Biological Mesh Reinforcement.

In the field of hernia prevention, the prophylactic mesh-reinforcement of stoma-sites is one of the most controversially discussed issues. The incidence of parastomal hernias in the literature reported to be up to 48.1% after end colostomy and up to 30.8% after loop of colostomy, but still remains uncertain due to diagnostic variety of clinical or radiological methods, heterogeneous patient groups and variable follow-up intervals. Anyway, the published data regarding the use of synthetic or bio-prostethic meshes in the prevention of parastomal hernia at the primary operation are very scarce. A literature search of the Medline database in terms of biological prophylactic mesh implantation in stoma creation identified six systematic reviews, two randomized controlled trials (RCT), two case-controlled studies, and one technical report. In a systematic review focusing on the prevention of parastomal hernia including only RCTs encompassing one RCT using bio-prosthetic mesh the incidence of herniation was 12.5% compared to 53% in the control group (p < 0.0001). In one RCT and two case-control studies, respectively, there was a significant smaller incidence of parastomal herniation as well as a similar complication rate compared to the control group. Only in one RCT, no significant difference regarding the incidence of parastomal hernia was reported with comparable complication rates. Thus, so far two RCT and two case-control studies are published with prophylactic bio-prosthetic reinforcement in stoma sites. The majority revealed significant better results in terms of parastomal herniation and without any mesh-related complications in comparison to the non mesh group. Further, multicenter RCT are required to achieve a sufficient level of recommendation.

PTU-218 Prophylactic mesh repair for the prevention of parastomal herniation: a case controlled comparative study between the prophylactic mesh and non-mesh group

Introduction To ascertain whether prophylactic mesh reinforcement at the time of stoma formation with a composite synthetic mesh reduces the incidence of parastomal herniation. Method Data was prospectively collected over 5 years from 1 st January 2009 to 31 st December 2013 for patients undergoing a prophylactic re-enforcement of the para-stomal abdominal wall with a Dynamesh-IPOM mesh, using a laparoscopic intra-peritoneal onlay technique. A case controlled comparison was carried out with a cohort of matched patients undergoing stoma-forming procedures in the same time duration, without the use of a prophylactic mesh. The primary outcome was the development of a parastomal hernia on clinical or radiological examination. Statistical analysis was carried out on IBM SPSS v21 in order to compare age, gender, BMI, ASA, operative time, length of stay, length of follow-up and incidence of hernias in between groups using a single-centre, single-surgeon case-control study design. Results Eleven patients underwent prophylactic mesh reinforcement of their colostomy using a keyhole mesh configuration (mean age 67 ± 11.9, M:F 8:3, median BMI 29 [95% CI 23–34]. Median operative time was 300 mins [95% CI 205–337]. This group included 8 APER and 3 Hartmann’s procedures; there was one conversion to an open procedure. After a median follow-up of 20 months [95% CI 6–27] none developed a parastomal hernia. There were 19 patients in the control group (Mean age 72.4 ± 14.0, M:F 12:7, median BMI 27.1 [95% CI 21.8–37.3]. The median operative time was 300 [95% CI 230–435]. This group included 13 APER, 5 Hartmann’s and one left hemicolectomy with end colostomy. There was one conversion to an open procedure. After a median follow-up 15 months [95% CI 6–29] six patients (31.6%) developed a parastomal hernia (two detected on CT scanning and 4 evident on clinical examinations). Two of these went on to have subsequent repair of the hernia (one elective, one emergency). There were no significant differences in between groups for age, gender, ASA, BMI, operative time, rate of conversion and length of follow-up. The likelihood ratio for developing a parastomal hernia was 6.33 ( p .05) and a Chi-square test demonstrated a significant association of herniation without mesh reinforcement; x 2 (1) = 4.34, p .05. Conclusion Prophylactic mesh reinforcement of stomas with a composite synthetic mesh using an intraperitoneal onlay technique caused a significant reduction in the risk of parastomal herniation. Furthermore, the use of this particular synthetic mesh does not confer any additional infective complications. Disclosure of interest None Declared.

Prophylactic Mesh Reinforcement Reduces Stomal Site Incisional Hernia after Ileostomy Closure

Stomal site incisional hernia is a common complication following ileostomy closure. The effectiveness of prophylactic mesh placement at the time of stomal closure is unknown because of fear of mesh infection and subsequent wound complications. The present study investigated whether prophylactic mesh placement reduces the rate of incisional hernia after ileostomy closure without increasing wound complications. The study was based on retrospective review of consecutive ileostomy closures undertaken at a tertiary referral center between January 2007 and December 2011. Hernias were identified through clinical examination and computed tomography. Eighty-three cases of ileostomy closure were reviewed; 47 patients received mesh reinforcement, and 36 underwent non-mesh closure (controls). In total, 16 (19.3 %) patients developed incisional hernia, 13 (36.1 %) of which occurred in the control group; 3 (6.4 %), in the mesh group [odds ratio (OR): 8.29; 95 % confidence interval (CI) 2.14-32.08; p = 0.001]. Incisional hernia repair was performed in 3 (23 %) patients in the control group; no hernias in the mesh group required surgery. There was no significant difference in wound infection rates between mesh (2 patients, 4.3 %) and control (1 patient, 2.8 %) groups. No mesh infection was found. Multivariate analysis demonstrated that malignancy (OR: 21.93, 95 % CI 1.58-303.95; p = 0.021) and diabetes (OR: 20.98, 95 % CI 3.23-136.31; p = 0.001) independently predicted incisional herniation, while mesh reinforcement prevented hernia development (OR: 0.06, 95 % CI 0.01-0.36; p = 0.002). Mesh placement significantly reduced the incidence of incisional hernia following ileostomy closure, but without increasing complication rates. This technique should be strongly considered in patients at high risk of hernia development.

Systematic review and meta-analysis of prophylactic mesh placement for prevention of incisional hernia following midline laparotomy

Incisional hernia is a common long-term complication after laparotomy. This study investigated whether prophylactic mesh reinforcement of laparotomy reduced the rate of incisional hernia, with emphasis on trial design and quality. A systematic review of published literature was performed for studies comparing incisional hernia presence following conventional closure or prophylactic mesh reinforcement. Studies were assessed using the Cochrane Risk of Bias Tool, the Jadad score and the Newcastle Ottawa Scale (NOS). The primary endpoint was incisional hernia, assessed by meta-analysis. Seven studies [four randomised controlled trials (RCTs) and three prospective trials] included 588 patients; 262 received mesh reinforcement. All studies included elective patients at high risk of incisional hernia. Six incorporated a polypropylene mesh and one a biologic mesh. Four studies were judged high quality by NOS and two of four RCTs were at low risk of bias, although overall outcome assessment from all studies was either poor or mediocre. Mesh significantly reduced the rate of incisional hernia [odds ratio (OR) 0.15, p < 0.001]; the same effect was seen in RCTs only (OR 0.17, p < 0.001). A borderline increase of seroma seen with a fixed effect model (OR 1.82, p = 0.050) was not seen with a random effect model (OR 1.86, p = 0.210, I (2) = 45 %). Mesh reinforcement of laparotomy significantly reduced the rate of incisional hernia in high-risk patients. However, poor assessment of secondary outcomes limits applicability; routine placement in all patients cannot yet be recommended. More evidence regarding the rates of adverse events, cost-benefits and quality of life are needed.

The persistent challenge of parastomal herniation: a review of the literature and future developments

The aim of this review article was to outline current evidence relating to the treatment and prevention of parastomal herniation with a view to guide surgeons dealing with patients potentially affected by this complication. Medline and PubMed databases were searched using the keywords 'parastomal hernia/herniation', 'stoma hernia/herniation' and 'stoma complications'. Evidence was obtained from randomized and non-randomized studies. Case reports and articles not written in English were excluded. Qualitative assessment of all included studies was performed using the Oxford Centre for Evidence-Based Medicine 2011 levels of evidence. The search revealed a total of 228 publications of which 115 fulfilled the selection criteria. Stoma formation through the rectus muscle is complicated by parastomal herniation in up to 50% of cases. There is no conclusive evidence that alternative techniques (e.g. extraperitoneal, lateral rectus abdominis positioned stoma) are superior. Open and laparoscopic parastomal hernia repair have similar recurrence rates up to 50%. The 'Sugarbaker' technique appears to be superior to the 'keyhole' technique when a laparoscopic approach is used. Prophylactic mesh reinforcement of the stoma trephine appears to reduce the herniation rate to approximately 15% and is accompanied by a decrease in symptomatic hernias requiring repair without any difference in stoma-related morbidity. Large prospective controlled trials are required to compare surgical techniques of stoma formation in reducing the incidence of parastomal herniation. Despite limited evidence, routine prophylactic mesh reinforcement of the stoma trephine should be offered to all patients undergoing permanent stoma formation.