From the Journals

Follow-up data support using mesh for umbilical hernia repair



Patients with umbilical hernias and multiple comorbidities should be considered for mesh repair to reduce the risk of recurrence, say the authors of a study of the factors associated with umbilical hernia recurrence after repair.

The retrospective cohort study, published in JAMA Surgery, examined recurrence and mortality outcomes in 332 military veteran patients who underwent primary umbilical hernia repair between 1998 and 2008 and followed until June 2014.

The overall recurrence rate was 6% and a mean recurrence time after index repair of 3.1 years. The recurrence rate was significantly higher among patients who underwent primary suture repair, compared with those who underwent mesh repair (9.8% vs. 2.4%, P = .04). Mesh repair decreased the risk of recurrence more than threefold, compared with primary suture repair (odds ratio, 0.28; 95% confidence interval, 0.08-0.95).

Patients with ascites had a significantly greater risk of recurrence, compared with those without ascites (20% vs. 5.1%, P = .02), as did those with liver disease (35% vs. 13.8%, P = .02), and diabetes (55% vs. 32.7%).

“This information suggests that umbilical hernias should be repaired using mesh, especially if a patient has multiple comorbidities that are significantly associated with recurrence, such as obesity, diabetes, liver disease, and ascites,” wrote Divya A. Shankar, a medical student at Boston University School of Medicine, and her coauthors (JAMA Surg. 2017 Jan 25. doi: 10.1001/jamasurg.2016.5052).

Among these patients, only 1 died within 30 days, but the study captured mortality in this group over 6-16 years after their hernia surgery. Mortality rate in the group was 27% through the follow-up period. However, older individuals, smokers, patients with liver disease and ascites, and those who had to undergo emergency or semi-urgent repair or who required intraoperative bowel resection had significantly increased long-term mortality rates.

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“Although there is a trend toward higher mortality rates in patients who underwent emergency repair, it is difficult to interpret whether the deaths were related to the emergency or to underlying medical conditions given that the etiology of the majority of these deaths is unknown,” the authors wrote.

Among the deaths, 43 (48%) were from unknown causes, 18 (20%) were cancer related, 12 (13%) were related to renal disease, and 3 (3.3%) were related to sepsis.
Researchers found that patients with a history of hernias were significantly less likely to have an umbilical hernia recurrence, although a greater percentage of these patients – 61% – received mesh in contrast to the 44% of patients without a history of hernia.

Defect size did not appear to affect the rate of recurrence but the authors noted that defect size was only recorded in about half of the patients in the study.
“Because there was no significant difference between these groups, we are unable to conclude whether the size of defects should play a role in a surgeon’s decision to use mesh,” they wrote.
Sixty-one patients (18%) had at least one complication within 30 days of the repair, with the most common being seroma (9.6%), surgical site infection (6.9%) and hematoma (2.4%). Two patients experienced a mesh infection and three experienced ascites leaks. The rate of complications was slightly, but not significantly, higher in the patients who received mesh repair, compared with the primary suture repair.

“A surprise finding was that patient who underwent emergent or semi-emergent repair had a 2.2 times increased odds of death. Twenty deaths occurred more than 30 days after emergent or semi-urgent repair and 12 (60%) were secondary to unknown causes and 5 (25%) were secondary to liver disease,” the investigators noted.

“Interestingly, 193 (58%) patients who underwent umbilical hernia repair had other hernias that were either repaired before the index repair or developed postoperatively. Therefore, we propose that umbilical hernias may be a type of ‘field defect’ and we support the idea of that abnormal collegan metabolism could play a role in hernia development. ...We speculate that surgeons might be more inclined to use mesh in a patients with a history of other hernias.”
Despite the potential for complications, “elective hernia repair with mesh should be considered in patients with multiple comorbidities given that the use of mesh offers protection from recurrence without major morbidity.”

The study was supported by the VA Healthcare System. No conflicts of interest were declared.

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