Prophylactic mesh may prevent incisional hernia in high-risk patients

Last Updated: 2018-11-30

By Marilynn Larkin

NEW YORK (Reuters Health) - In high-risk patients undergoing open abdominal surgery, implanting intraperitoneal mesh before closure may prevent incisional hernia, researchers say.

"The population at risk was defined as patients with previous abdominal surgery, obesity, presence of tumors and male gender," Dr. Guido Beldi of the University of Bern, Switzerland, said in an email to Reuters Health.

"The important aspect about our study is that we explored only patients at risk and that in such patients the number needed to prophylactically implant a mesh is much lower," he noted. "However, further research is needed to develop a next generation of prosthetic meshes that allows support of the abdominal wall without the risk of aggravating surgical site infections."

Dr. Beldi and colleagues conducted an open-label randomized trial in 150 patients (mean age, 64.2; 68% male) undergoing elective open abdominal surgery from 2011 to 2014. Patients were randomly assigned to prophylactic intraperitoneal implantation or standard abdominal closure

As reported online November 21 in JAMA Surgery: "In the intervention group, a mesh was implanted before closure of the abdominal wall in a standardized fashion. A double layered polypropylene-polyvinylidene fluoride mesh (Dynamesh-IPOM, FEG Textiltechnik) was tailored to overlap lateral and cranial-caudal borders by at least 5 cm. The mesh was placed intraperitoneally and fixed to the abdominal wall using single stitches with polypropylene sutures in all 4 corners. After the initial fixation, the borders of the mesh were fixed to the abdominal wall circumferentially using running polypropylene suture to prevent any intestinal structures to herniate onto the mesh."

Follow-up examinations were performed one and three years post-surgery.

The cumulative incidence of incisional hernia was 7.2% in the mesh group compared with 18.5% in controls.

Significantly more patients in the mesh group had abdominal pain at six weeks (65% vs. 44%), but not at 12 or 36 months.

No difference in surgical site infections was observed, but time to complete healing of such infections was significantly longer in patients with mesh implantation - a median of eight weeks, versus five.

Further, trunk extension was significantly decreased after mesh implantation compared with controls (mean, 1.73 cm vs. 2.40 cm).

"We identified that incisional hernia may be prevented by prophylactic mesh implantation. However, in case of surgical site infection, the wound needs longer time to heal when compared with patients without mesh implantation," Dr. Beldi concluded.

Dr. Liane Feldman of McGill University in Montreal, coauthor of a related editorial, told Reuters Health by email, "There are different studies evaluating where the mesh is actually placed - onlay, retrorectus or intraperitoneal. The onlay technique requires minimal training and in trials was performed by a wide variety of surgeons. However, it is associated with more seromas, a troubling but non-life-threatening short-term complication."

"The reason I don't think (prophylactic mesh implantation) is ready to be recommended more widely," she said, "is that we know mesh is a double-edged sword - it's good at preventing or repairing hernias, but has long-term complications ranging from relatively minor skin infections, sinuses or chronic seromas to more serious, like fistulas, obstructions, chronic pain, and abscess."

"We need a better understanding of the trade-offs, especially when used in the real world outside of randomized trials," Dr. Feldman concluded.

SOURCE: http://bit.ly/2QubNcf and http://bit.ly/2QwnQWk

JAMA Surg 2018.