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Best closure for contaminated ventral hernia depends on primary surgical objective

Key clinical point: Outcomes after surgery did not differ significantly, whether the incision was closed using sutures, low- or mid-density polypropylene mesh, or non–cross-linked biologic matrix material.

Major finding: Thirty-day rates of surgical site infection, hernia recurrence, and reoperation did not differ significantly among patients in whom the repair was closed using sutures (38%), synthetic mesh (40%), or biologic matrix (22%).

Data source: A retrospective analysis of consecutive open contaminated ventral hernia repairs performed at seven medical centers during a 2-year period.

Disclosures: This study was supported by the Center for Clinical and Translational Sciences. The authors’ financial disclosures were not reported.


 

FROM JOURNAL OF SURGICAL RESEARCH

References

Outcomes after contaminated open ventral hernia repair did not differ significantly, whether the incision was closed using sutures, low- or mid-density polypropylene mesh, or non–cross-linked biologic matrix material, in a multicenter study reported online in the Journal of Surgical Research.

In the absence of high-level evidence favoring any of these approaches, surgeons should carefully balance the risks and costs against the benefits when choosing how to close such incisions, said Ioana L. Bondre of the department of surgery, University of Texas Health Science Center, Houston, and her associates.

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At present, there is no widely accepted consensus and certainly no clinical guidelines regarding closure of contaminated ventral hernias. It is assumed that synthetic mesh and biologic mesh reduce the rate of hernia recurrence but at the cost of increased wound complications and surgical site infections. To examine this issue, the investigators performed a retrospective analysis of information in a database of all consecutive open ventral hernia repairs performed at seven medical centers during a 2-year period.

They focused on 761 patients in whom the repair was closed using sutures (38%), synthetic mesh (40%), or biologic matrix (22%). Thirty-day rates of surgical site infection (15.1%, 17.8%, and 21.0%, respectively), hernia recurrence (17.8%, 13.5%, and 21.5%, respectively), and reoperation (31.7%, 10.9%, and 15.6%, respectively) did not differ significantly among these three groups, Ms. Bondre and her associates said (J Surg Res. 2016 Feb;200[2]:488-94).

“Based on the available evidence, we currently recommend decisions to be based on the primary purpose of the procedure. If the primary purpose is not to perform a hernia repair (e.g., laparoscopic appendectomy for appendicitis), then a suture repair should be performed (e.g., umbilical hernia repair with sutures). However, if the primary purpose of the procedure includes hernia repair (e.g., colostomy reversal and parastomal hernia repair), mesh reinforcement should be used. Given the current evidence and practice patterns, we use mid-density synthetic mesh in wound class I procedures and biologic mesh in wound class II-IV repairs,” they noted.

This study was limited in that many patients were followed for only 1 month, which may not be sufficient time to capture long-term outcomes. Moreover, the database didn’t include information regarding outcomes that are most important to patients, such as chronic pain, chronic infections, and nonhealing surgical wounds, Ms. Bondre and her associates added.

This study was supported by the Center for Clinical and Translational Sciences. The authors’ financial disclosures were not reported.

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