With mesh for incisional hernia: fewer recurrences, more complications

Last Updated: 2016-10-18

By Will Boggs MD

NEW YORK (Reuters Health) - The use of prosthetic mesh for incisional hernia repair is associated with fewer recurrences but more complications, researchers from Denmark report.

"Repair for incisional hernia should be reinforced by a mesh as a standard, but the long-term risk of mesh-related complications should be included in the standard information to patients prior to the operation," Dr. Thue Bisgaard from Hvidovre Hospital in Denmark told Reuters Health by email.

Mesh is placed as an adjunct to hernia repair in at least half of the abdominal wall hernia repairs performed in the United States.

Dr. Bisgaard and colleagues used data from the Danish Hernia Database to analyze the long-term consequences of mesh reinforcement in elective incisional hernia repair. Their study included 3,242 patients, 34.5% of whom had open mesh repair, 54.2% of whom had laparoscopic mesh repair, and 11.3% of whom had non-mesh repair.

The cumulative risk of reoperation for recurrence at five years was significantly lower for patients with open mesh repair (12.3%) and laparoscopic mesh repair (10.6%) than for patients with non-mesh repair (17.1%), according to the October 18th JAMA online report.

Larger hernia size was associated with increased risk of reoperation for recurrence, and older age was associated with reduced risk of reoperation for recurrence.

During the study period, the risk of mesh-related complications increased continuously with time, with the cumulative incidence of a mesh-related complication requiring surgical treatment reaching 4.5% at five years (5.6% for open mesh repair and 3.7% for laparoscopic mesh repair).

In contrast, the long-term repair-related complication rate for patients with an initial non-mesh repair was only 0.8%.

For both open and laparoscopic mesh repair, the risk of mesh-related complications increased with increasing mesh size. In open repairs, coated polypropylene had fewer complications than did uncoated polypropylene.

"Although rare (5%), the incidence of mesh-related complications was progressively increasing throughout the study period suggesting that mesh-related complications rate may continue to accrue with even longer follow-up," Dr. Bisgaard said.

"The present study highlights the need to assess long-term safety of incisional hernia repair operations before making definitive conclusions about their eventual benefits," Dr. Bisgaard concluded. "More long-term studies of mesh repair using well-functioning registries such as the one in Denmark are warranted."

He added, "Well-functioning clinical nationwide databases containing perioperative prospective registered information and long-term follow-up (such as the Danish Hernia Database) hold statistical power to monitor even low incidences of outcome such as postoperative complications and reoperation rate of recurrences. Nationwide clinical databases may serve as a platform for surgeons and commercial mesh manufacturers before routine recommendation of specific types and mesh placement (i.e., outside or inside the abdominal cavity of the abdomen)."

Dr. Kamal M. F. Itani from VA Boston Health Care System and Boston University, West Roxbury, Massachusetts, who wrote an editorial related to this report, told Reuters Health by email, "We should continue to optimize the patient risk factors prior to undertaking these elective operations in order to improve long term outcome and mortality. We still have a lot to learn about best technique and best mesh."

Even better, he said, "Prevent an incisional hernia in the first place. We should do more work and conduct more research on how to prevent incisional hernias than time and energy on repairing them when they occur."

"These results were an eye opener on how imperfect the operations and materials are for the repair of ventral hernias," Dr. Itani added. "We still have much work to do."

In his editorial, he concludes, "To provide more rigorous data to better understand optimal approaches to this common clinical problem, surgeons will need to design large multicenter pragmatic trials with long-term follow-up. When commercial entities want to test a product, they should fund an independent research group to conduct the trial to avoid the perception of bias. Because hernia is so common and the evidence base supporting its treatment is so limited, there is a pressing need to design, fund, and conduct these trials."

Dr. Vedra Augenstein from Carolinas Medical Center, Charlotte, North Carolina, who recently reviewed the use of biologic mesh in ventral hernia repair, told Reuters Health by email, "Prevention of hernias is key. Once faced with a hernia, patients need to be medically optimized for surgery. Preventing recurrence is important and there are numerous studies including a randomized trial showing that mesh for ventral, inguinal and umbilical hernias decreases the long term risk of recurrence."

"To prevent mesh complications, however, carefully selecting the mesh, technique, and position for the mesh is very important and needs to be based on long-term human data which takes into consideration the most important factors predictive of complications such as mentioned," she said. "Treatment of incisions postoperatively is also very important. Research in the field is ongoing and needs careful consideration before changing practice."

SOURCE: http://bit.ly/2eq9OyO and http://bit.ly/2eeXxAT

JAMA 2016.