Prophylactic onlay mesh at emergency laparotomy: promising early outcomes with long‐acting synthetic resorbable mesh

Abstract

Background: Careful surgical strategy is paramount in balancing the prevention of fascial dehiscence, incisional hernia (IH) and fear of additional mesh-related wound complications post-laparotomy. This study aims to review early outcomes of patients undergoing an emergency laparotomy with prophylactic TIGR ® mesh, used to reduce early fascial dehiscence and potential subsequent IH. Method: A retrospective, ethically approved review of 24 consecutive patients undergoing prophylactic TIGR ® mesh placement during emergency laparotomies by a single surgeon between January 2017 and June 2021 at a University Hospital. A standardized approach included onlay positioning of the mesh, small-bite fascial closure, and a wound bundle. We recorded patient demographics, operative indications, findings, degree of peritonitis, postoperative complications, and mortality. Result: The study included 24 patients; 16/24 (66.6%) were female and median age was 72.5 (range 31-86); 14/24 patients were ASA grade III or greater; 4/24 patients (16.6%) developed six complications and 3/6 occurred in a single patient. Complications included subphrenic abscess, seroma, intrabdominal hematoma, enterocutaneous fistula leading to deep wound infection and small bowel perforation. Five (20.8%) patients died in hospital; central venous catheter sepsis (n = 1), fungal septicaemia (n = 1) and multiorgan failure (n = 3). Surgical site infection and seroma rates were low, occurring in 2/24 patients (4% each). Conclusion: This study has identified that prophylactic onlay mesh in patients undergoing an emergency laparotomy is not associated with significant wound infection or seroma when used with an active wound bundle. The wider use of TIGR ® to prevent fascial dehiscence and potential long-term IH prevention should be considered. Recent randomized controlled trials have shown PMP to be beneficial during fascial closure, reducing IH rates by at least half. 1,2,9,10 There are numerous potential positions for mesh placement: onlay, inlay, sublay, underlay and intraperitoneal, each with their own

Hypertonic saline infusion does not improve the chance of primary fascial closure after damage control laparotomy: a randomized controlled trial

“…For example, in combination with a mesh-mediating traction system, which (by itself) has shown promising results, allowing a safe early abdominal closure [ 28 ]. For example, Alsaadi et al [ 29 ] reported a series of 24 patients requiring emergency laparotomy in whom prophylactic onlay mesh was used. They found that this intervention was associated with acceptable wound-healing outcomes and recommended it as a potential intervention to prevent fascial dehiscence in injured patients.…”

Continuous versus interrupted abdominal wall closure after emergency midline laparotomy: CONTINT: a randomized controlled trial [NCT00544583]

“…Furthermore, the large screened to randomized patient ratio implies a high risk of selection bias and limits the external validity of our results. Adding to that, the follow-up time of 1 year for incisional hernia might not be absolutely representative of the incisional hernia rates occurring after emergency midline laparotomy [ 41 , 42 ]. More than half of all screened patients fulfilled the exclusion criterion of previous laparotomy.…”

Prophylactic onlay mesh placement techniques for optimal abdominal wall closure: randomized controlled trial in an ex vivo biomechanical model

“…However, its use may be associated with a trend towards increased chronic pain (7.8 per cent) and seroma formation (12.9 versus 6.9 per cent) 11 . Synthetic meshes have been shown to be safe for use even in the setting of peritonitis 10 , and long-acting resorbable biosynthetic meshes, such as TIGR ® matrix mesh (Novus Scientific AB, Uppsala, Sweden), have been used safely for abdominal closure 13 without significant infection or seroma, including in a cohort of high-risk patients undergoing emergency laparotomy 14 . A recent multicentre RCT 15 published in the USA demonstrated significantly lower rates of incisional hernia at 2 years, and median mesh cost, with use of a synthetic mesh (5.6 per cent; US $105/€99) compared with a biological mesh (20.5 per cent; $21 539/€20,280), with no difference in the rates of surgical-site occurrence.…”