Incisional Hernia Rate Research Articles

Incisional hernia after single-incision laparoscopic cholecystectomy: incidence and predictive factors.

To access the incidence and predictive factors of incisional hernia after single-incision laparoscopic cholecystectomy (SILC). Eighty-two consecutive patients operated on for uncomplicated cholelithiasis between 2009 and 2013 were eligible for the study. Clinical outcome was assessed by a combination of case notes review, office consultation and telephone interview. Long-term incisional hernia rate was the major outcome of the study. Secondary outcome was the evaluation of predictive factors. Univariate and multivariate statistical analyses were performed using the following variables: age, gender, ASA score, BMI, risk, or comorbidity factors and surgical site infection. Six patients (7%) were lost to follow-up after the 1-month office visit and excluded. The study group consisted of 16 men and 60 women with a median age of 42years (range 18-69) and a BMI of 25 (range 19-34). Eight patients had risk or comorbidity factors, 46 were classified ASA I, and 30 ASA II. Early postoperative course was uneventful in all cases but two patients developed a superficial wound abscess after hospital discharge. With a median follow-up of 44months (range 12-72), incisional hernia was noted in six patients (7.9%). Multivariate logistic analysis revealed that age (OR 1.08, 95% CI 1.00-1.16, p<0.038) and BMI (OR 1.37, 95% CI 1.03-1.82, p<0.029) were independent predictive factors of developing an incisional hernia. The incidence of hernia was, respectively, 15% in patients with an age≥50 and 33% in patients with a BMI≥30. After SILC, we noted an incisional hernia rate of 8%. To decrease the risk of developing that specific complication, SILC should only be proposed to young and non-obese patients.

Incisional hernias after open versus laparoscopic surgery for colonic cancer: a nationwide cohort study.

Laparoscopic surgery for colonic cancer decreases the incidence of postoperative complications and length of hospital stay as compared with open surgery, while the oncologic outcome remains equivalent. It is unknown whether the surgical approach impacts on the long-term rate of incisional hernia. Furthermore, risk factors for incisional hernia formation are not fully elucidated. The aim of this study was to evaluate the long-term effect of elective open versus laparoscopic surgery for colonic cancer on development of incisional hernia. This nationwide cohort study included patients operated on electively for colonic cancer with primary anastomosis in Denmark from 2001 to 2008. Patient data were obtained from the database of the Danish Colorectal Cancer Group and merged with data from the National Patient Registry. Multivariable Cox regression and competing risks analysis were performed. A total of 8489 patients were included, with a median follow-up of 8.8 (interquartile range 7.0-10.7)years. The incidence of incisional hernia was increased among patients operated on with open techniques compared with patients undergoing laparoscopic surgery (7.3 vs. 5.2%, p<0.001). After adjustment for confounders, laparoscopic approach was associated with a decreased risk of incisional hernia formation (hazard ratio [HR] 0.62, 95% confidence interval [CI] 0.44-0.89; p=0.009). Other factors associated with increased risk of incisional hernia were wound infection, fascial dehiscence, anastomotic leak, and body mass index >25kg/m(2). This nationwide analysis demonstrated that laparoscopic as compared with open access for curative resection of colonic cancer was associated with a decreased risk of incisional hernia formation.

When and How to “Open” in Laparoscopic or Robotic Surgery

Surgical training today is all about minimally invasive surgery. With little or no experience and/or confidence in rapid, emergent conversion to an open procedure, how does the surgeon expeditiously do so? The intent of this paper is to help those inexperienced in "open" techniques to quickly recognize the need for same and rapidly open and temporarily control an acute hemorrhage or significant problem requiring more than the tips of laparoscopic instruments. The left subcostal or high transverse incision has been used by this author and several others with an experience of several thousand open cases. The author's emergent technique includes a 3-cm mid-line incision from the xiphoid inferiorly, extending into a 135° left subcostal "hockey stick" approximately 12 cm in length, large enough for the surgeon's fist to rapidly apply a tamponading moist lap sponge. Extension of the incision and rectus muscle bleeding is then controlled before proceeding. This author has used the left subcostal incision in over 4000 bariatric cases over a 30-year career with an incisional hernia and major wound infection rates of less than 1%. Today, the laparoscope has virtually replaced all open GS visceral techniques which are de-emphasized in surgical training programs. This author's experience demonstrates a rapid fire technique, which will assist the inexperienced open surgeon in dealing with a very treatable acute complication and preventing a long-term disaster with a huge mid-line wound infection, dehiscence, and ultimate hernia.

What about vaginal extraction of the kidney? results of an online survey.

ABSTRACTPurpose We aimed to characterize surgeons opinion about the vaginal extraction of the kidney after transperitoneal laparoscopic nephrectomy.Matherial and Methods A 9-item questionnaire was published online (Survey Monkey TM) and publicized via email to a multidisciplinary pool of surgeons in Portugal. Data was collected and statistical analysis was performed using IBM SPSS Statistics, Version 21.0.Results Three hundred and fifty nine inquiries were sent, 154 surgeons completed the questionnaires (response rate of 43.0%). Fifty five point eight percent of the participants would choose the transvaginal approach for themselves or for a close relative. The most stated arguments were a better cosmesis (29.0%) expectancy of lower post operative pain (26.0%) and lower rate of incisional hernias (23.0%). Defenders of the transabdominal procedure justified with an expectancy of lower complication rate (39%), namely impairment of sexual function and fertility (22%). The female gender and the familiarity with transvaginal surgery were the stronger predictors of the option for this approach (70.6% vs 48.5%; p=0,016 and 85.3% vs 46.6%; p <0.001 respectively).Conclusions Contrasting with similar surveys published on transvaginal NOTES, the vaginal specimen extraction after conventional laparoscopic nephrectomy was fairly accepted by the inquired surgeons.

Rate of development of incisional hernia 1 year after urgent midline laparotomy

Objective The aim of the present study was to determine the rate of development of incisional hernia at 6 months and 1 year in patients suffering from peritonitis (potentially septic wounds) and other patients suffering from intraperitoneal hemorrhage (IPHge) (aseptic wounds) who had undergone urgent midline laparotomy. In addition, we aimed to evaluate different surgical techniques and suture materials used for abdominal closure and the prevalence of postoperative complications among the studied groups in the Emergency Department of Aswan University Hospital, Egypt. Patients and methods This observational and descriptive study included evaluation and assessment of interviews of 160 patients divided into two groups (A and B). Group A included 80 patients suffering from peritonitis and group B included 80 patients suffering from IPHge. All patients submitted to the surgical treatment in the form of emergency exploratory laparotomy and evaluation of their medical records, involving different surgical techniques and suture materials used for abdominal closure. Postoperative follow-up was set at 6 months and 1 year for the development of incisional hernia. Results Analyses of 160 patients in the two groups indicated that the incisional hernia rate increased significantly from 7.5% at 6 months to 17.5% at 1 year after urgent midline laparotomy in all studied patients (P=0.007). There was a significant increase in incisional hernia rate in group A in comparison with group B at 6 months (12.5 vs. 2.5%; P=0.02) and at 1 year (25 vs. 10%; P=0.01) follow-up after urgent midline laparotomy. Regarding the techniques of closure of urgent midline laparotomy and the used suture materials (Vicryl and Prolene), there was an insignificant deference as regards the development of incisional hernia between subgroups A1 and A2 at 6 months (P=0.50) and at 1 year (P=0.30), and also between subgroups B1 and B2 at 6 months (P=0.49) and at 1 year (P=1.0) follow-up after urgent midline laparotomy. Conclusion The incisional hernia remains the most common complication after midline laparotomy, representing 7.5% at 6 months and 17.5% at 1 year follow-up in the present study. Incisional hernia was significantly increased in patients suffering from peritonitis than in those patients suffering from IPHge at 6 months and at 1 year after urgent midline laparotomy. Regarding the surgical techniques and suture materials used for closure of urgent midline laparotomy, there was an insignificant difference as regards the development of incisional hernia between closure of urgent midline incision by continuous suture plus some interrupted sutures in between using slowly absorbable multifilamentous suture material [Vicryl (polyglactin)] and continuous suture only using nonabsorbable monofilamentous suture material [Prolene (polypropylene)] at 6 months and 1 year between subgroups A1 and A2, and between B1 and B2.

Single incision laparoscopic liver resection (SILL) - a systematic review.

Background: Today, minimally invasive liver resections for both benign and malignant tumors are routinely performed. Recently, some authors have described single incision laparoscopic liver resection (SILL) procedures. Since SILL is a relatively young branch of laparoscopy, we performed a systematic review of the current literature to collect data on feasibility, perioperative results and oncological outcome.Methods: A literature research was performed on Medline for all studies that met the eligibility criteria. Titles and abstracts were screened by two authors independently. A study was included for review if consensus was obtained by discussion between the authors on the basis of predefined inclusion criteria. A thorough quality assessment of all included studies was performed. Data were analyzed and tabulated according to predefined outcome measures. Synthesis of the results was achieved by narrative review. Results: A total of 15 eligible studies were identified among which there was one prospective cohort study and one randomized controlled trial comparing SILL to multi incision laparoscopic liver resection (MILL). The rest were retrospective case series with a maximum of 24 patients. All studies demonstrated convincing results with regards to feasibility, morbidity and mortality. The rate of wound complications and incisional hernia was low. The cosmetic results were good.Conclusions: This is the first systematic review on SILL including prospective trials. The results of the existing studies reporting on SILL are favorable. However, a large body of scientific evidence on the field of SILL is missing, further randomized controlled studies are urgently needed.

Incisional and port-site hernias following robotic colorectal surgery.

The association between extraction site location, robotic trocar size, and the incidence of incisional hernias in robotic colorectal surgery remain unclear. Laparoscopic literature reports variable rates of incisional hernias versus open surgery, and variable rates of trocar site hernias. However, conclusions from these studies are confusing due to heterogeneity in closure techniques and may not be generalized to robotic cases. This study evaluates the effect of extraction site location on incisional hernia rates, as well as trocar hernia rates in robotic colorectal surgery. A retrospective review of multiport and single incision robotic colorectal surgeries from a single institution was performed. Patients underwent subtotal, segmental, or proctocolectomies, and were compared based on the extraction site through either a muscle-splitting (MS) or midline (ML) incision. Hernias were identified by imaging and/or physical exam. Demographics and risk factors for hernias were assessed. Groups were compared using a multivariate logistic regression analysis. The study included 259 colorectal surgery patients comprising 146 with MS and 113 with ML extraction sites. Postoperative computed tomograms were performed on 155 patients (59.8%) with a mean follow-up of 16.5months. The overall incisional hernia rate was 5.8%. A significantly higher hernia rate was found among the ML group compared to the MS group (12.4 vs. 0.68%, p<0.0001). Of the known risk factors assessed, only increased BMI was associated with incisional hernias (OR 1.18). No trocar site hernias were found. Midline extraction sites are associated with a significantly increased rate of incisional hernias compared to muscle-splitting extraction sites. There is little evidence to recommend fascia closure of 8-mm trocar sites.

Systematic review and meta regression of factors affecting midline incisional hernia rates: An analysis of 14,618 patients

Systematic review and meta regression of factors affecting midline incisional hernia rates: An analysis of 14,618 patients

Minimizing the Access Trauma of Laparoscopic Sleeve Gastrectomy: the Transoral Specimen Extraction Technique

Laparoscopic sleeve gastrectomy has become a popular stand-alone procedure among bariatric surgeons. Recently, Natural Orifice Specimen Extraction laparoscopic surgery has been introduced to avoid minilaparotomy, possibly reducing postoperative pain, hospital stay, and improving QoL and cosmetics. Operative steps and preliminary results of NOSE sleeve gastrectomy are described and reported. Five patients underwent NOSE LSG from November 2014 to March 2015. Selection criteria were as follows: age <60 years, ASA score ≤III, BMI <50. Operative steps are the same of standard LSG, but the stomach transection that starts higher on the greater curvature. A 2–3 cm width opening is created on the exceeding antrum and the resected stomach sutured to the calibration probe tip, which is pull back allowing transoral specimen extraction. The exceeding antrum is stapler-trimmed, allowing breach closure and completion of tubulization. Mean age was 41.6 years (median 43), average weight was 123.6 Kg (median 114), mean BMI 43.6 Kg/m2 (median 44). Mean operation time was 72 min (median 75). Mean and median postoperative stay were 4.6 and 5. No intraoperative nor postoperative complications occurred. Postoperative day 1 mean and median VAS pain score at were 1.4 and 1, respectively. Follow-up ranged 1–5 months (mean and median 3), average weight loss was 19.8 Kg (median 19), and excess weight loss 36.2 % (median 32 %). NOSE LSG potential advantages are as follows: improved cosmetics, decreased postoperative pain, possible incisional hernia rate reduction. No objective data are available to confirm these theoretical benefits; larger observational studies and RCTs are mandatory before clinical validation.

Everolimus is safe within the first month after liver transplantation

Sirolimus should not be started within the first month after liver transplantation (LT) because of an increased risk of adverse outcomes. The evidence regarding everolimus is lacking but the manufacturer transposed the same warning. We aimed to evaluate the safety of everolimus started within the first month after LT. A consecutive cohort 187 LT patients (2009-2013) with a tacrolimus-based immunosuppression was evaluated. Patients starting everolimus within the first month after LT (n = 33; 17.6%) were compared with those starting everolimus thereafter (n = 25; 13.4%) or not receiving everolimus (n = 129; 69%). The median follow-up after LT was 21 months (IQR 7-36). Prospective outcomes were evaluated by using Kaplan-Meier curves and Cox's regression. The incidence of hepatic artery thrombosis was not significantly different in patients early treated with everolimus when compared with the remaining cohort (0% vs 9.1%; p = 0.12). Other vascular complications occurred in 9.1% of patients with early everolimus vs 7.3% in the remaining cohort (p = 0.72). No wound healing complications were detected with early everolimus. There were similar rates of incisional hernia (p = 0.31), infections (p = 0.15), renal impairment (p = 0.37), and histologically-proven acute rejection (p = 0.24) between groups. The rates of hyperlipidemia were increased with early everolimus (29.9% vs 16.5% at 3 years; p = 0.018). Graft loss and mortality rates were similar between groups (p = 0.34 and p = 0.94 respectively), after adjusting for possible confounding factors. Everolimus combined with reduced tacrolimus proved to be safe within the first month after LT. Future trials may be allowed to implement everolimus early after LT.

Bowel obstructions and incisional hernias following trauma laparotomy and the nonoperative therapy of solid organ injuries: A retrospective population-based analysis.

Small bowel obstruction (SBO) and incisional hernia (IH) represent the most common long-term complications of laparotomy. They may also be more common among injured patients than for elective/nontrauma emergency scenarios. Unfortunately, the population-based incidence of SBO and IH following trauma laparotomy is unknown. The aim of this study was to define the long-term, population-based incidence of SBO and IH following both trauma laparotomy as well as the nonoperative therapy of solid organ injuries. All injured patients admitted to a Level 1 trauma center (2002-2013) who underwent (1) a laparotomy or nonoperative care of (2) splenic and/or (3) hepatic injuries were linked with the Alberta Health Services Discharge Database to identify all readmissions for subsequent SBO and/or IH within the province. Standard statistical methodology was used (p < 0.05). Of 484 patients who underwent a trauma laparotomy, 29 (6%) and 42 (9%) required readmission for SBO and IH, respectively (0.13 SBO and 0.10 IH admissions per patient year). Patients who underwent nonoperative management of their liver and/or spleen injuries displayed long-term SBO rates of 1% (6 of 619) and 0.7% (4 of 606), respectively. The rate of SBO and IH in patients with unnecessary laparotomies was equivalent to therapeutic procedures (p = 0.183). Topical hemostatic agents, repeat laparotomies, and injury pattern did not alter SBO or IH rates (p > 0.05). The population-based, long-term rate of clinically relevant SBO and IH following trauma laparotomies is 15%. This increases to 19% on a per-admission basis. Nontherapeutic scenarios, injury pattern, topical hemostatics, and open abdomens did not alter complication rates. Therapeutic study, level IV.

Bioprosthetic mesh reinforcement during temporary stoma closure decreases the rate of incisional hernia: A blinded, case-matched study in 94 patients with rectal cancer

This case-matched study aimed to assess the feasibility and the potential benefits of placement of a prophylactic bioprosthetic collagen porcine mesh during closure of the temporary ileostomy after total mesorectal excision (TME) for rectal cancer. From September 2012 to March 2013, 30 consecutive patients underwent placement of a retromuscular bioprosthetic mesh in the abdominal wall during closure of a diverting ileostomy after sphincter-saving laparoscopic TME for rectal cancer (mesh group). These 30 patients were matched individually to all identical patients who underwent a closure of the ileostomy without mesh after laparoscopic TME extracted from our prospective database (control group). The matching process was performed according to sex, age, body mass index, medically treated diabetes mellitus, neoadjuvant radiotherapy, and the delay between TME and closure of the ileostomy. The primary endpoint was stoma site incisional hernia, assessed in a blinded fashion by CT 1 year later. Mesh placement was feasible in all mesh group patients. There was no postoperative mortality. Overall postoperative morbidity rates were similar between mesh and control groups (n = 5 [17%] vs n = 7 [11%], respectively; P = .512). On the 1-year CT, incisional hernia at the site of stomal closure was less in the mesh group (n = 1) compared with the control group (n = 12; P = .043). Reoperation for incisional hernia at the site of stomal closure was performed in 8 patients (13%) in the control group, whereas no patient from the mesh group required repair of the hernia (P = .052). Placement of a bioprosthetic collagen porcine mesh during closure of the temporary ileostomy after laparoscopic TME for rectal cancer seems to decrease the chance of hernia formation at the stoma site, at least at the 1-year follow-up.

Risk factors for incisional hernia after hepatic resection for hepatocellular carcinoma in patients with liver cirrhosis

The risk factors for incisional hernia (IH) and the association between liver fibrosis and IH after hepatic resection in patients with hepatocellular carcinoma (HCC) with liver cirrhosis (LC) are still unclear. We aimed to evaluate the rate of IH and to assess the effect of perioperative factors, including serum markers for liver fibrosis, on the risk of IH. A total of 192 patients with HCC with LC who received hepatectomy were retrospectively analyzed. The primary end point was the incidence rate of IH and the secondary end points were associations between IH and 22 clinical factors. IH was diagnosed in 60 (31.3%) patients. The estimated incidence rates were 19.8% at 12 months, 32.5% at 36 months, and 38.8% at 60 months. In multivariable analysis, the presence of postoperative intractable ascites (odds ratio 24.83, P = .0003), abdominal wall closure by a single-layer mass closure with a continuous running suture (odds ratio 4.59, P = .0143), preoperative body mass index ≥ 25 kg/m(2) (odds ratio 3.36, P = .0025), and preoperative serum N-terminal pro-peptide of type IV collagen 7S domain (P4NP 7S) levels ≥ 5 ng/mL (odds ratio 3.13, P = .0234) were independent risk factors. There are several risk factors for IH after hepatic resection in HCC patients with LC. Preoperative serum P4NP 7S levels ≥ 5 ng/mL are a useful predictive marker, and abdominal wall closure with a continuous running suture by a single-layer mass closure should be avoided.

Are women with advanced pelvic organ prolapse treated by open mesh sacrocolpopexy at risk of secondary incisional hernia?

Our purpose was to determine whether vaginal hernia is a predisposing factor for incisional hernia (IH) in a cohort of women with symptomatic pelvic organ prolapse (POP) who underwent corrective repair by open mesh sacrocolpopexy (MSC) and had long-term follow-up to determine their rate of subsequent IH. Following IRB approval, the charts of women entered into a longitudinal database and who underwent open MSC at a tertiary institution were reviewed. Data collected included demographics, MSC and IH details, and long-term outcome. Patients were excluded if the follow-up after MSC was < 1 year. Data were reviewed by a neutral investigator who was not involved in patient care (FA). From 1999 to 2012, 75 of 88 women met inclusion criteria, with mean follow-up of 65 (48-84) months. Thirteen were either lost to follow-up or had follow-up < 1 year. Seven women underwent symptomatic IH repair, with a mean onset of IH diagnosis after MSC at 18 (range 8-72) months. Five repairs were done via an open approach, and two were repaired laparoscopically. No IH recurrence was noted at a mean of 41 (range 14-75) months after IH repair. No risk factors were identified in the IH group compared with those who did not form a secondary IH. In this longitudinal series, IH after open MSC occurred in 9.3%, a rate comparable with that reported in women undergoing abdominal procedures through midline or Pfannenstiel incisions.

PTU-228 Abdominal fascial wound closure with 2–0 sutures does not lead to increased rates of dehiscence or incisional hernia

Introduction Emerging evidence has shown that using smaller more frequent sutures close to the fascial wound edge is associated with a lower incidence of incisional hernia, dehiscence and surgical site infection compared to conventional wound closure. 1 However in implementing this practice we have experienced difficulty due to concerns regarding sutures below 1–0 grade allowing increased rates of early dehiscence and incisional hernia. We sought to demonstrate the safety of this method of wound closure. Method Un-selected patients undergoing abdominal surgery (elective and emergency) were prospectively collected from within the practice of a single surgeon in a regional teaching hospital. All wounds greater than four centimetres (fascia defect length) were included. All patients underwent closure of abdominal fascial wounds using a suture to wound length ratio of at least 4:1. Suture material was 2–0 PDS. Risk of death from surgery was preoperatively calculated using the P-POSSUM score. Initial follow up period was 30 days from procedure. Study end points were length of stay, morbidity and mortality within 30 days, dehiscence and hernia formation rate. Results 34 patients underwent fascial closure as described above, 17 cases were patients undergoing emergency laparotomy. Average fascial defect length was 13.8 cm (median 14.5 cm); average length of suture used was 98.5 cm (median 82 cm). Average ratio of suture length to wound length was 7.5. Mean length of stay in this group was 5.4 days. Average BMI was 28.9; average calculated risk of death was 11.6%. A single patient died from overwhelming sepsis shortly after emergency laparotomy. Three patients developed chest sepsis post operatively (emergency group) and two elective patients were readmitted within 30 days with chest infection and hypocalcaemia respectively. Conclusion We have demonstrated that using a small, frequent suture does not give rise to increased rates of early dehiscence, incisional hernia or major wound complications in the early post operative period. Disclosure of interest None Declared. Reference Israelsson L, Millbourn D. Prevention of incisional hernias. How to close a midline incision. Surg Clin North Am. 2013;93:1027–1040

PWE-395 Patient and clinical risk factors for incisional hernia following reversal of loop ileostomy

<h3>Introduction</h3> Loop ileostomy reversal is commonly performed, with reported rates of ileostomy-site incisional hernia between 0–48%. Risk factors of patients developing post-reversal hernias are poorly understood. <h3>Method</h3> We performed a retrospective study of patients undergoing loop ileostomy reversal during five years 1^stJanuary 2009 to 31^stDecember 2013. The primary outcome was ileostomy-site incisional hernia, detected clinically and, as a gold standard, by computed tomography scans or ultrasonography. Data were extracted on preoperative factors (age, BMI, smoking, preoperative marking, surgical indication), intraoperative decisions (rectus sheath suture, skin suture, closure method) and postoperative events (complication (&lt;30days), followup duration). Data were analysed with SPSS version 21. Statistics are median (IQR) and correlations Spearman’s rho. P &lt; 0.05 was considered statistically significant. <h3>Results</h3> In total, 180 patients underwent loop ileostomy closure. Baseline demographics were as follows: age (66 years (26), BMI 25kg/m²(5.8) and 28 patients (16%) were smokers. Indication for ileostomy was rectal cancer (n = 98; 54.4%), followed by inflammatory bowel disease (n = 40; 22.2%), diverticulosis (n = 19; 10.6%), inflammatory fistulae (n = 4; 2.2%), and assorted indications (n = 16; 8.9%). Overall incidence of ileostomy-site incisional hernia was 19%, occurring at a median of 8 months (IQR 15). Overall duration of postoperative follow up was 20 months (IQR 28). Clinical detection of hernia compared to CT/US was 88% and all clinically-evident cases were identified radiologically. Four cases not evident clinically were detected by radiology alone. 64% of hernias required reoperation. Surgical indication was a significant hernia determinant (χ²p &lt; 0.001) with a higher incidence in cancer patients. 66% of patients were marked preoperatively. Post-closure complications occurred in 22% of patients and predicted higher hernia risk (χ²p &lt; 0.001). BMI was a major risk factor for ileostomy-site hernia (Mann Whitney P = 0.04; R=.236; P = 0.002). Patients with higher blood pressure at closure had a higher incidence of hernias (Mann Whitney P = 0.009). Age and smoking were not significant factors (R = -0.018 and 0.005 respectively; P &gt; 0.05 for both). Choice of suture material for rectus sheath (PDS vs. Prolene) or skin (Monocryl vs. Maxon) did not predict hernia (R=-0.113 and -0.041 respectively; both P &gt; 0.05). Healing by secondary intention was not associated with higher hernia incidence (R = 0.004; P &gt; 0.05). <h3>Conclusion</h3> Ileostomy-site hernia occurs in approximately one fifth of patients. Patient factors such as BMI and preoperative co-morbidity remain the greatest predictors of hernia. Variability in operative practice such as choice of suture material and the method of skin closure does not impact hernia risk. <h3>Disclosure of interest</h3> None Declared.

Laparoscopic hysterectomy with morcellation vs abdominal hysterectomy for presumed fibroid tumors in premenopausal women: a decision analysis

The purpose of this study was to model outcomes in laparoscopic hysterectomy with morcellation compared with abdominal hysterectomy for the presumed fibroid uterus and to examine short- and long-term complications and death. A decision tree was constructed to compare outcomes for a hypothetical cohort of 100,000 premenopausal women who underwent hysterectomy for presumed fibroid tumors over a 5-year time horizon. Parameter and quality-of-life utility estimates were determined from published literature for postoperative complications, leiomyosarcoma incidence, death related to leiomyosarcoma, and procedure-related death. The decision-tree analysis predicted fewer overall deaths with laparoscopic hysterectomy compared with abdominal hysterectomy (98 vs 103 per 100,000). Although there were more deaths fromleiomyosarcoma after laparoscopic hysterectomy (86 vs 71 per 100,000), there were more hysterectomy-related deaths with abdominal hysterectomy (32 vs 12 per 100,000). The laparoscopic group had lower rates of transfusion (2400 vs 4700 per 100,000), wound infection (1500 vs 6300 per 100,000), venous thromboembolism (690 vs 840 per 100,000) and incisional hernia (710 vs 8800 per 100,000), but a higher rate of vaginal cuff dehiscence (640 vs 290per 100,000). Laparoscopic hysterectomy resulted in more quality-adjusted life years (499,171 vs 490,711 over 5 years). The risk of leiomyosarcoma morcellation is balanced byprocedure-related complications that are associated with laparotomy, including death. This analysis provides patients and surgeons with estimates of risk and benefit on which patient-centered decisions can be made.

Acute appendicitis can be treated with single‐incision laparoscopy: a systematic review of randomized controlled trials

Single-incision laparoscopic surgery (SILS) has been proposed as the next step in minimally invasive surgery for appendicectomy. Previous reviews have summarized the results of low-evidence comparative studies, suggesting that the two approaches are comparable in terms of outcomes but showing the need for randomized controlled trials (RCTs). This review offers a meta-analyses of RCTs on this topic to evaluate the safety and efficacy of single-incision laparoscopic appendectomy (SILA). A comprehensive research of electronic databases was performed. Primary outcomes (overall and access-specific morbidity) were designated as safety issues. Secondary outcomes were pain, cosmesis, operative time, conversion rate and length of hospital stay. After exclusions, five RCTs satisfied the inclusion criteria. They included a total of 761 patients [379 SILA and 382 conventional three-port laparoscopic appendectomies (CLA)]. No significant differences were found in overall morbidity, early wound morbidity or length of stay between SILA and CLA. Cosmesis and pain were not comparable due to different scales and time records. Conclusions on the incisional hernia rate were not reliable due to short follow-up periods. SILA can be considered an acceptable alternative to CLA in the treatment of acute appendicitis, but an economic evaluation of the various techniques for single access must be performed before its widespread clinical introduction. Better-designed RCTs are necessary to define a population in which SILA could have major benefits.

Age, Preoperative Subcutaneous Fat Area, and Open Laparotomy are Risk Factors for Incisional Hernia following Colorectal Cancer Surgery.

Although incisional hernia (IH) is a common complication of abdominal surgery, the incidence rate and risk factors are not well known. The objectives of this study are to determine the incidence rate of IH following colorectal cancer surgery and to describe the associated risk factors. Between 2005 and 2010, patients who underwent surgery to treat colorectal cancer were examined. The diagnosis of IH was performed by CT scan, and the visceral fat area (VFA) and subcutaneous fat area (SFA) at the level of the umbilicus were calculated using a 3D-image analysis system. Survival analysis was used to assess the incidence and risk factors of IH. A total of 626 patients (326 open, 300 laparoscopic) were included in this study, with median follow-up of 54 (range 2-97) months. Forty patients were diagnosed with postoperative IH, and the cumulative, 5-year incidence of IH was 7.3 %. Univariate analysis revealed that age, body mass index, waist circumference, hip circumference, open laparotomy, wound infection, VFA, and SFA were significantly associated with incidence of IH. Multivariate analysis revealed that age [hazard ratio (HR) 1.043 (1.005-1.083), p = 0.027], open laparotomy [HR 4.410 (1.018-19.095), p = 0.047], and SFA [HR 1.013 (1.004-1.022), p = 0.005] were significant risk factors for developing IH. Higher age and SFA, along with open surgery, are risk factors for developing IH.

Effect of suture technique on the occurrence of incisional hernia after elective midline abdominal wall closure: study protocol for a randomized controlled trial.

BackgroundBased on a recent meta-analysis, a continuous suture technique with a suture to wound length ratio of at least 4:1, using a slowly absorbable monofilament suture material, is recommended for primary median laparotomy closure. Incisional hernia, which develops in 9 to 20% of patients, remains the major complication of abdominal wall closure. Current clinical data indicate that the incidence of incisional hernias increases by 60% between the first and the third year after median laparotomy, implicating that a follow-up period of 1 year postoperatively is too short with regard to this common complication. Trauma to the abdominal wall can be reduced by improvements in suture technique as well as suture material. Several factors, such as stitch length, suture tension, elasticity, and tensile strength of the suture material are discussed and currently under investigation. A Swedish randomized controlled trial showed a significant reduction in the incisional hernia rate by shortening the stitch length. However, a non-elastic thread was used and follow-up ended after 12 months. Therefore, we designed a multicenter, international, double-blinded, randomized trial to analyze the influence of stitch length, using an elastic, extra-long term absorbable monofilament suture, on the long term clinical outcome of abdominal wall closure.MethodsIn total, 468 patients undergoing an elective, median laparotomy will be randomly allocated to either the short stitch or the long stitch suture technique for abdominal wall closure in a 1:1 ratio. Centers located in Germany and Austria will participate. The primary endpoint measure is the incisional hernia rate 1 year postoperatively, as verified by ultrasound. The frequency of short term and long term complications as well as costs, length of hospital stay and patients’ quality of life (EQ-5D-5 L) will be considered as secondary parameters. Following hospital discharge, patients will be examined after 30 days and 1, 3, and 5 years after surgery.DiscussionThis study will provide further evidence on whether a short stitch suture technique in combination with an elastic, extra-long term absorbable monofilament suture can prevent incisional hernias in the long term, compared with the long stitch suture technique.Trial registrationNCT01965249.