Implementing a protocol to prevent incisional hernia in high-risk patients: a mesh is a powerful tool

Abstract

Purpose The small bites (SB) technique for closure of elective midline laparotomies (EMLs) and a prophylactic mesh (PM) in high-risk patients are suggested by the guidelines to prevent incisional hernias (IHs) and fascial dehiscence (FD). Our aim was to implement a protocol combining both the techniques and to analyze its outcomes. Methods Prospective data of all EMLs were collected for 2 years. Results were analyzed at 1 month and during follow-up. The incidence of HI and FD was compared by groups (M = Mesh vs. S = suture) and by subgroups depending on using SB. Results A lower number of FD appeared in the M group (OR 0.0692; 95% CI 0.008–0.56; P = 0.01) in 197 operations. After a mean follow-up of 29.23 months (N = 163; min. 6 months), with a lower frequency of IH in M group (OR 0.769; 95% CI 0.65–0.91; P < 0.0001). (33) The observed differences persisted after a propensity matching score: FD (OR 0.355; 95% CI 0.255–0.494; P < 0.0001) and IH (OR 0.394; 95% CI 0.24–0.61; P < 0.0001). On comparing suturing techniques by subgroups, both mesh subgroups had better outcomes. PM was the main factor related to the reduction of IH (HR 11.794; 95% CI 4.29–32.39; P < 0.0001). Conclusion Following the protocol using PM and SB showed a lower rate of FD and HI. A PM is safe and effective for the prevention of both HI and FD after MLE, regardless of the closure technique used.

Defining High-Risk Patients Suitable for Incisional Hernia Prevention

“…In another study, performed in low-risk IH patients ( 57 ) with 2-years follow-up, lower IH incidence in the SB group was revealed without statistical differences (3.6% vs. 12.1%; p = 0.20). The same authors performed another study in high-risk patients ( 58 ), demonstrating that when using PM after a median follow-up time of 29.3 months, IH incidence decreased (HR 11.79; p < 0.0001) independently of the closure technique (small or large bites). They also outline that the worst results were obtained when laparotomies were closed with neither SB nor PM.…”