Mesh bests suture repair for small umbilical hernias

Last Updated: 2018-03-01

By Marilynn Larkin

NEW YORK (Reuters Health) - Mesh, not suture repair, should be used for operations on all patients with umbilical hernias with a diameter up to 4 cm, researchers in the Netherlands suggest.

"Approximately 10% of abdominal wall hernias are defined as umbilical hernia," Dr. Ruth Kaufmann of Erasmus University Medical Center in Rotterdam told Reuters Health.

"Until now," she said by email, "publications about umbilical hernia were limited to retrospective cohort studies, prospective observational studies, hernia register analyses, and randomized controlled studies with smaller sample sizes than this study."

"Findings from a previous randomized controlled trial with 200 patients . . . conclude(d) that the hernia recurrence rate was significantly higher after suture repair (11%) compared with mesh repair (1%)," she added. "However, their study had no clear cutoff value for hernia diameter (i.e., all hernia diameters were included)."

To investigate, Dr. Kaufmann and colleagues randomly assigned 300 patients (median age, 52; 83% male) with 1-4 cm umbilical hernias to mesh or suture repair.

As reported online February 16 in the Lancet, after a maximum follow-up of 30 months (median, 25), there were significantly fewer recurrences in the mesh than in the suture group (4% vs. 12%).

The estimated risk of recurrence at two years was 3.6% for mesh vs. 11.4% for suture.

"Use of suture repair led in our study to recurrence rates that are three times as high as when mesh repair is used," Dr. Kaufmann stressed. "The use of mesh could save the patient a reoperation."

The most common postoperative complications were seroma - one in the suture group versus five in the mesh group, hematoma (two vs. three), and wound infection (one vs. three), according to the authors. These differences were not significant.

Dr. Kaufmann said, "This was the first randomized trial that provided high-level evidence advocating mesh repair in all smaller umbilical hernias with a defect size between 1 and 4 cm."

"The results of this trial, combined with previous studies, should lead to more uniformity in treatment strategies and enable the development of guidelines for treatment of umbilical hernia," she concluded.

Dr. Frederik Helgstrand of the University of Copenhagen, in Denmark, told Reuters Health the study "confirms results from a previous Danish register-driven study (http://bit.ly/2Fbvgc5). Thus, the use of mesh in small umbilical or epigastric hernias is already recommended in Denmark."

"In my practice, for small hernias <2 cm - with the exception of pregnant women (who had) previous hernia repair - mesh doesn't seem to reduce risk for recurrence," he said by email.

"Primary hernias are a very common and benign disease; therefore a repair should only be offered to patients (for whom) the symptoms from the hernia outweigh the risk for postoperative complications," he stressed.

"The choice of surgical technique - open or laparoscopic/robotic - depends on the patient's comorbidities," he added. "Obese patients can be relatively more complicated to repair with an open technique and are at higher risk for wound and subsequent mesh complications/infection," he continued. "They will probably benefit from a minimally invasive (laparoscopic) approach."

"If a mesh is used in very slim patients, especially if placed above the hernia defect (onlay), there may be a higher risk for foreign-body sensation," he noted. "Whether mesh will be beneficial to this subgroup of patients remains to be studied."

"Flat meshes used in open umbilical hernia repair cost approximately US$20," he said, "but an operation for recurrence can be more complex, with increased risk for postoperative complications. Thus, (we don't know) if a routine mesh is significantly more expensive on a long-term basis."

"On the other hand, we published (previously) that mesh may also lead to long-term complications," he said. (http://bit.ly/2GWYUiz)

"Although I don't think the long-term consequences of mesh (are more important than) the risk for recurrence, it is important to give patients thorough information on the pros and cons of using a mesh in the context of (their) other risk factors," he concluded.

SOURCES: http://bit.ly/2ERNRdM and http://bit.ly/2os05zJ

Lancet 2018.