British Journal of Surgery

Hernandez, Edgard Efren Lozada; Chavez, Elizabeth Escamilla; Villegas, Leticia Hernandez

doi: 10.1093/bjs/znab395.098pmid: N/A

Abstract Aim “Incisional hernia (IH) has an incidence of 10–23%, which can increase to 38% in specific risk groups. The objective of this study is to report the results at 3 years of follow-up of the use of the reinforced tension line (RTL) technique compared with primary suture only (PSO) closure in the prevention of IH in high-risk patients undergoing laparotomy.” Material and Methods “Open randomized controlled clinical trial. Included were patients older than 18 years who underwent midline laparotomy, emergency or scheduled, who were considered high risk, and who completed 3-year follow-up. The patients were randomized 1:1 to the RTL technique or to PSO. The objective was to report the incidence of IH and the complications associated with the closure method. Intention-to-treat analysis and Cox regression were performed.” Results “A total of 124 patients were randomized; 51 patients from the RTL group and 53 patients from the PSO group finished the 3-year follow-up. The incidence of IH was higher in the PSO group (15/53, 28.3%) than the RTL group (5/51, 9.8%) (p = 0.016, OR 0.35, 95% CI 0.14–0.88, number needed to treat 5.4, log-rank test p = 0.017). The groups were similar in the rates of surgical site infection, hematoma, seroma, and postoperative pain during follow-up.” Conclusions “The RTL technique is useful in the prevention of IH when compared with PSO in high-risk midline laparotomy patients, and it is not associated with a higher percentage of complications. Clinical trials NCT02136628, retrospectively registered” This content is only available as a PDF. © The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please email: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please email: [email protected]

Gómez, Jorge Zárate; Hernández, Pedro Álvarez de Sierra; Luengas, David Fernández; Someso, Silvia Conde; Eslait, Guillermo Supelano; Iribar, Begoña Peinado; López, Jose María Gil; Godino, Jesús Merello

doi: 10.1093/bjs/znab395.036pmid:

van Hout, Ludo; Bökkerink, Willem; Vriens, Patrick

doi: 10.1093/bjs/znab396.008pmid: N/A

Abstract Aim Patient Reported Outcomes (PROs) are essential for evaluating hernia surgery. Current measuring instruments for PROs have disadvantages: often lengthy and burdensome paper questionnaires, used at predetermined moments with low patient compliance and time-consuming data processing. The Q 1.6 Inguinal Hernia application was developed to overcome these challenges. This pilot study reports the first clinical feasibility results. Materials and Methods the ‘twitch crowdsourcing’ concept was applied: during the interval of unlocking a smartphone or tablet a short question is asked, multiple times a day. Questions from validated questionnaires were implemented. The adaptive question engine generates an individualized set of questions. Alerts are automatically generated when a complication is suspected. All inguinal hernia patients in a high-volume inguinal hernia center were eligible for inclusion. Patients signed informed consent. Results 229 patients answered over 50.000 pre- and postoperative questions of which 92% were answered. Pre- and postoperative patient characteristics and clinical outcomes confirmed a standard inguinal hernia population. Compliance was 91.7% after 14 days, 69.0% after 3 months and 28.8% after one year. Pain and functional limitations were measured with a numerical scale from zero to ten. After 3 and 7 days, 7.7% and 44.3% returned to work, respectively. Patients were highly satisfied (92.8% preferred the app to usual care). Conclusions this smartphone application shows promising results for clinical practice. Remote monitoring may become standard postoperative care after (inguinal) hernia surgery. The current application will be further improved and evaluated for cost-effectiveness, safety and validity. This content is only available as a PDF. © The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please email: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Christopher, Adrienne; Sanchez, Jonathon; Fischer, John

doi: 10.1093/bjs/znab396.003pmid: N/A

Abstract Aim Research indicates that prophylactic mesh may help prevent incisional hernia after laparotomy, but best practice patterns in these situations are still evolving. Here, we compare the failure loads (FLs) and biomechanical stiffness (BMS) of 35 porcine abdominal wall laparotomy incisions reinforced with meshes of various widths and fixation distances using biomechanical testing. Material and Methods In each specimen, a ten centimeter (cm) incision was made and closed using continuous 1-0 Maxon suture. Specimens were randomized to mesh width (none, 2.5cm, 3cm, 4cm, 6cm, 8cm) and tack separation (1.5cm, 2cm apart), and the meshes secured in an onlay fashion. Cyclic loads oscillating from 15 Newtons (N) to 140N were applied to stimulate abdominal wall stress, and the specimens subsequently loaded to failure. FLs (N) and BMS (N/mm) were comparatively analyzed. Results All specimens failed via suture pull-through. FLs and BMS were lowest in specimens with suture-only (421.43 N; 11.69 N/mm). FLs and BMS were significantly higher in 4cm mesh specimens (567.51N) than those with suture, 2.5cm, and 3.0cm mesh (all p < 0.05). FLs in specimens with a greater number of tacks were consistently higher in meshes of similar sizes, although these did not reach significance. Conclusions Four cm mesh re-enforcement is superior to suture-only and smaller meshes at preserving strength in laparotomy closure in the early stages of healing, but larger meshes (6cm, 8cm) do not provide additional benefit. Meshes with more fixation points may be advantageous, but additional data is needed to make definitive conclusions. This content is only available as a PDF. © The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please email: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Hoyuela, Carlos; Guillaumes, Salvador; Veres, Antoni; Hidalgo, Nils Jimmy; Juvany, Montserrat; Ardid, Jordi; Martrat, Antoni; Bachero, Irene; Cano, Manuel López

doi: 10.1093/bjs/znab396.018pmid: N/A

Abstract Aim To assess the 5-year outcomes of mesh fixation with cyanoacrylate or sutures for Lichtenstein hernioplasty (recurrence rate, chronic pain, and patient’s quality of life (QoL). Methods 370 patients who underwent Lichtenstein hernia repair were randomized to receive either cyanoacrylate or non-absorbable sutures for lightweight polypropylene mesh fixation. Postoperative outcomes were evaluated by an independent blinded observer. QoL was assessed using the EuraHS-QoL questionnaire (European Registry for Abdominal Wall Hernias). Results Initially 188 patients received Glue and 182 Suture. Mean follow-up: 72.6±7.8 months. 78.1% patients (Glue:147,Suture:142) completed 5-years follow-up. No significant differences were observed in terms of chronic pain. VAS score≥3: 8.1% vs 9.1%, Glue vs. Suture, respectively (P = 0.836). 8 patients (2.7%) (4 in each group) reported pain at rest, reaching 10.7% when analyzing pain during activity. QoL was unaffected (EHS-QoL score=0) in the majority of patients: 131 (89.2%) vs. 127 (89.5%) for Glue or Suture respectively (p = 0.930). QoL-score greater than 20/90 points: 2 patients (Glue) vs. 6 (Suture) (p = 0.099). The Suture group QoL-score was higher in all domains but without statistical significance. Foreign body sensation was slightly higher in Suture group (7.5% vs. 9.3%) but without reaching statistical significance (p = 0.534). There were no differences in the recurrence rate (2.6% vs. 3.8% for Glue and Suture respectively) (p = 0533). Conclusions Chronic discomfort rate after Lichtenstein hernioplasty is not negligible. Atraumatic mesh fixation with glue was quicker and resulted in less acute postoperative pain than sutures for Lichtenstein hernia repair, but with no statistical differences in terms of chronic pain nor the long-term patients’ QoL. This content is only available as a PDF. © The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please email: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Novik, Bengt; Sandblom, Gabriel; Ansorge, Christoph; Thorell, Anders

doi: 10.1093/bjs/znab396.038pmid: N/A

Abstract Aim The HerniaSurge guidelines concerning mesh and fixation options in laparoscopic totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) groin hernia repair are based on studies focusing on either mesh or fixation. We hypothesized that the value of such recommendations is limited by lacking knowledge on how mesh and fixation interact. The present registry-based nationwide cohort study compared different mesh/fixation combinations regarding relative risks for reoperation after TEP and TAPP. Material and Methods All TEP and TAPP with standard polypropylene (StdPPM) or lightweight (LWM) flat meshes, combined with either tacks, fibrin glue, or no fixation, registered in the Swedish Hernia Registry 2005-2017 were included. Endpoint was reoperation due to recurrence as of December 31, 2018. Multivariable Cox regression rendered relative risk differences between the exposures, expressed as hazard ratios (HR) with 95% confidence intervals (CI). Results Of 25 190 repairs, 924 (3.7%) were later reoperated for recurrence. The lowest, mutually equivalent, reoperation risks were associated with StdPPM without fixation (HR 1), StdPPM with metal tacks (HR 0.8, CI 0.4-1.4), StdPPM with fibrin glue (HR 1.1, CI 0.7-1.6), and LWM with fibrin glue (HR 1.2, CI 0.97-1.6). LWM correlated otherwise with increased risk, whether without fixation (HR 2.0, CI 1.6-2.6), or affixed with metal (HR 1.7, CI 1.1-2.7), or absorbable tacks (HR 2.4, CI 1.8-3.1). Conclusions With StdPPM, fixation seems not to improve outcomes, despite being costlier. Thus, for this mesh category, we recommend non-fixation. With LWM, we recommend fibrin glue fixation, which was the only LWM alternative on par with non-affixed StdPPM. This content is only available as a PDF. © The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please email: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Dhanani, Naila; Olavarria, Oscar; Lee, Kyung Hyun; Young, Charlotte; Primus, Frank; Mukhtar, Rita; Holihan, Julie; Liang, Mike; Harris, Hobart

doi: 10.1093/bjs/znab396.012pmid: N/A

Abstract Aim Biologic mesh has been increasingly utilized in complex ventral hernia repair despite limited evidence at low risk of bias supporting its growth. We hypothesized biologic mesh when compared to synthetic mesh would have fewer major complications at one year. Material and Methods We performed a participant-level meta-analysis of published randomized controlled trials (RCTs) comparing biologic to synthetic mesh at one year. Primary outcome was major complication (composite of mesh infection, recurrence, reoperation, or death) at one year post-operative. Secondary outcomes included length of index hospital stay, surgical site occurrence, and surgical site infection. Outcomes were assessed using frequentist generalized linear models. Results A total of 252 patients from two RCTs were included, 126 patients randomized to the intervention arm of biologic mesh and 126 patients randomized to the control of synthetic mesh. Median follow-up was 15 (12, 27) months. Major complication occurred in 41 (33%) patients randomized to biologic mesh, and 44 (35%) patients randomized to synthetic mesh, (relative risk [RR] 0.91, 95% confidence interval [CI] 0.54-1.55, p-value 0.740). There were 36 total recurrences, 23 (18%) in the biologic arm, and 13 (10%) in the synthetic arm (RR 1.83, 95% CI 0.84-3.99, p-value 0.130). The remainder of outcomes demonstrated no statistically significant differences. Conclusions The risk of major complication did not differ between biologic versus synthetic mesh. In patients undergoing ventral hernia repair, there was no clinical benefit with biologic mesh as opposed to synthetic mesh at one year post-operative. This content is only available as a PDF. © The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please email: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Bravo-Salva, Alejandro; Ochoa-Segarra, Francisco Rómulo; Gonzálz-Castillo, Ana María; Sancho-Insenser, Joan; Pera-Roman, Miguel; Rodrigues-Gonçalves, Victor; Pereira-Rodriguez, Jose Antonio; Cano, Manuel López

doi: 10.1093/bjs/znab395.033

Shmelev, Artem; Batarseh, Laith; Ahad, Ahmad

doi: 10.1093/bjs/znab395.092pmid: N/A

Abstract Aim Analysis of all healthcare encounters (readmissions and emergency department visits, EDV) following both inpatient and outpatient abdominal hernia repairs (AHR), with respect to the timeline of such encounters. Material and Methods Patients undergoing AHR were identified in Maryland State Inpatient and State Ambulatory Surgery and Services Databases, 2016-2017, and all their hospital and ED encounters were assembled into a comprehensive database, covering almost 95% of all AHR performed in Maryland. Results Of the total 26,215 patients who underwent AHR (3,333 inpatient and 22,950 outpatient; 48.7% inguinal and 53.0% ventral/umbilical), 5,802 (22.1%) had at least one postoperative encounter (4,186 EDV, 1,415 readmissions, and 248 encounters for mostly outpatient another AHR). 419 (80.4%) post-operative encounters within the first 48 hours were EDV and 98 (18.8%) were readmissions. Fraction of EDV within later encounters was in 69.6–71.1% range. Most frequent reasons for EDV were urinary complaints (24.1%, 10.6% and 4.0% on POD 0–2, 3–7, and 8–30, respectively), followed by pain control issues (18.1%, 24.9%, 14.4%) and delayed return of bowel function or constipation (10.5%, 9.9%, 3.4%). Readmissions mainly occurred for aforementioned GI complaints (15.3%, 19.9%, 6.9% on POD 0–2, 3–7, and 8–30, respectively), local surgical site infections (5.1%, 15.5%, 26.8%), and respiratory complications (8.2%, 6.6%, 4.1%). Conclusions 2.3% of all patients had at least one readmission while 6.4% patients had at least one EDV within 30 days following herniorrhaphy. Early postoperative EDV were mainly caused by urinary complaints, inadequately controlled pain, or delayed bowel function. Factors associated with these largely preventable complications require dedicated analysis. This content is only available as a PDF. © The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please email: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please email: [email protected]

Amador, Sara; Gómez, Montserrat Juvany; Martin, Aurora Aldeano; Palomino, Arantzazu Rada; Valentini, Mauro; Alonso, Xavier Mira

doi: 10.1093/bjs/znab395.059pmid: N/A

Abstract Aim Sublay mesh placement in incisional hernia repair (IH) does not seem to show lower surgical site infection (SSI) or recurrence than onlay placement, according to a recent review. Our aim was to analyze both techniques in an abdominal wall department. Material and Methods Prospective data collection of all IHs for four years. Results were analyzed at one month and during follow-up. The characteristics of IH, operative time, incidence of SSI and recurrence was compared by groups depending on location of the mesh in sublay (SM) or onlay (OM). Results “The surface area of the hernial defect was greater in the SM group (216±338 vs 68±84cm2; P = 0.002), as well as longer surgical time (131±91 vs 70±54 min; P < 0.001). A higher number of hematoma was diagnosed in the SM (OR 1.39; CI95% 1.21-1.60; P = 0.18) in 88 operations. No differences were observed in the incidence of SSI between the groups (27.7 vs 21.7%; P = 0.78). 74 patients completed a mean follow-up of 11.4 months, any difference in IH recurrence appeared (5.8 vs 9.1%; P = 0.63) in SM group vs OM group, respectively. Conclusions A SM repair is performed in IHs with large defects, which entails a longer surgical time and the appearance of hematoma, although no statistically significant differences in the rate of SSI or IH recurrence was observed between SM and OM repair. This content is only available as a PDF. © The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please email: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)