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| ORIGINAL ARTICLE |
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| Year : 2018 | Volume
: 1
| Issue : 1 | Page : 9-12 |
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Antibiotic prophylaxis in laparoendoscopic hernia surgery
Ferdinand Kockerling
Department of Surgery, Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Berlin, Germany
| Date of Submission | 02-May-2018 |
| Date of Acceptance | 02-May-2018 |
| Date of Web Publication | 16-May-2018 |
Correspondence Address:
Ferdinand Kockerling
Department of Surgery, Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charite Medical School, Vivantes Hospital, Neue Bergstrasse 6, D-13585, Berlin
Germany
 Source of Support: None, Conflict of Interest: None  | 7 |
DOI: 10.4103/ijawhs.ijawhs_4_18
INTRODUCTION: Whether antibiotic prophylaxis can really reduce the rate of surgical site infections (SSIs) or rather tends to increase the risk of antimicrobial resistance development is being increasingly questioned even for elective surgery in a clean surgical field. Since compared with the open technique, the laparoendoscopic technique per se reduces the SSI rate, that possibility must also be considered for laparoendoscopic repair of inguinal and abdominal wall hernias despite these techniques always using a mesh as a foreign body.
MATERIALS AND METHODS: A systematic search of the literature was conducted in Medline/PubMed and the Cochrane database. Thirty-two relevant publications were identified.
RESULTS: Overall, there is a paucity of studies on antibiotic prophylaxis in laparoendoscopic hernia surgery. Those studies available are not able to demonstrate that the use of antibiotic prophylaxis in laparoendoscopic repair of inguinal and abdominal wall hernias has a definite effect on the SSI rate. Hence, antibiotic prophylaxis can be omitted with for patients with no risk factors. But that does not apply for patients with risk factors, such as obesity, diabetes mellitus, emergency surgery, contaminated surgical field, recurrent hernia, chronic obstructive pulmonary disease, abdominal aortic aneurysm, prior SSI, long operative time, and other factors influencing the SSI rate.
CONCLUSION: Further studies are urgently needed on antibiotic prophylaxis in laparoendoscopic hernia surgery in particular in association with risk factors.
Keywords: Antibiotic prophylaxis, incisional hernia, inguinal hernia, laparoendoscopic repair, ventral hernia
How to cite this article:
Kockerling F. Antibiotic prophylaxis in laparoendoscopic hernia surgery. Int J Abdom Wall Hernia Surg 2018;1:9-12 |
| Introduction | |  |
In 2013, the American Society of Health-System Pharmacists (ASHP), the Infectious Diseases Society of America (IDSA), the Surgical Infection Society (SIS), and the Society for Healthcare Epidemiology of America (SHEA) jointly published clinical practice guidelines for antimicrobial prophylaxis in surgery.[1] In these guidelines, antibiotic prophylaxis is strongly recommended on evidence Level A for mesh and suture repair of hernias.[1] However, whether antibiotic prophylaxis can really reduce the rate of surgical site infections (SSIs) or rather tends to increase the risk of antimicrobial resistance development is being increasingly questioned.[2] For surgical procedures with lower SSI risk antibiotic prophylaxis before or during surgery is often not indicated.[2] The indiscriminate use of antibiotic prophylaxis must be avoided since the problem of antibiotic resistance is rapidly emerging worldwide.[3]
The introduction of laparoscopic surgery has reduced the SSI rate for many procedures.[4] Meta-analysis comparing transabdominal preperitoneal patch plasty (TAPP) and totally endoscopic patch plasty (TEP) with open inguinal hernia repair have also demonstrated a reduction in the SSI rate from 2.3%–1% to 2.0%–1.0%, respectively.[5],[6]
In randomized controlled trials (RCTs), wound infection rates following open inguinal hernia repair without antibiotic prophylaxis are reported to be between 4.2% and 8.9% and with antibiotic prophylaxis between 0% and 8.8%.[7]
Systematic reviews and meta-analyses of laparoscopic versus open abdominal incisional hernia repair also demonstrated significantly lower wound infection and wound complication rates for the endoscopic approach.[8],[9],[10],[11]
In laparoscopic ventral and incisional hernia repair, the SSI rate in primary hernias is reduced to 2.3% compared to 9.2% in open repair and in incisional hernias to 1.6% for laparoscopic compared to 10.1% in open repair.[12]
Considering the highly significant reduction in the SSI rate after hernia repair on using the laparoscopic technique, the question arises as to whether antibiotic prophylaxis can further reduce wound complications. It was now aimed to answer that key question through a review of the literature
| Materials and Methods | | |
A systematic search of the literature was conducted in Medline/Pubmed and the Cochrane database up until the end of April 2018. The following search terms were used: “surgical site infection” and “hernia,” “antibiotic prophylaxis” and “hernia,” “antibiotic prophylaxis” and “hernia surgery,” “antibiotics” and “hernia,” “antibiotic prophylaxis” and “TEP,” “antibiotic prophylaxis” and “TAPP,” “antibiotic prophylaxis” and “laparoscopic IPOM,” “antibiotic prophylaxis” and “endoscopic hernia repair” and “antibiotic prophylaxis” and “endoscopic surgery.” In addition, a manual search of the references was performed to identify relevant publications. The literature search identified a total of 32 relevant publications, which form the basis for the following review.
| Results | | |
Laparoscopic inguinal hernia repair
Meta-analyses
Up until 2017, eight systematic reviews and meta-analyses comparing inguinal hernia repair with and without antibiotic prophylaxis with a maximum of 16 prospective randomized trials (RCTs) with 5519 patients were published.[13],[14],[15],[16],[17],[18],[19],[20] However, all meta-analyses report on open inguinal hernia repair since no RCT that met the requirements and reported on the efficacy of antibiotic prophylaxis in laparoendoscopic inguinal hernia repair was available.
The meta-analysis with the greatest number of analyzed RCTs (n = 16) and patients (n = 5519) showed for antibiotic prophylaxis in open inguinal hernia repair a significant reduction in the overall incidence of SSI from 4.8% to 3.2% (odds ratio [OR] = 0.68; 95% confidence interval [CI] (0.51–091).[19] However, after removal of the two outlier studies, which were identified by evaluating the standardized residual, the result of the meta-analysis became nonsignificant (OR = 0.76; 95% CI 0.56–1.02).[19] The authors concluded that the results of their meta-analysis do not support the routine use of antibiotic prophylaxis for open mesh repair of inguinal hernias.[19]
Randomized controlled trials
There is only one RCT comparing endoscopic inguinal hernia repair with and without antibiotic prophylaxis;[21] however, this has been excluded from the Cochrane review due to incorrect randomization, lack of definition of wound infection, and underpower with only 40 patients in each arm.[22]
Observational studies
In a registry-based comparison of laparoendoscopic inguinal hernia repairs (n = 48, 201) with and without antibiotic prophylaxis, no significant influence on postoperative impaired wound healing or on deep infection could be identified.[23] The positive impact of the laparoendoscopic approach on avoidance of impaired wound healing and deep infection with mesh involvement is already so great that antibiotic prophylaxis has no additional benefit.[23]
Guidelines
The Guidelines of the European Hernia Society for the treatment of inguinal hernia concluded that antibiotic prophylaxis does not significantly reduce the number of wound infections.[24] That conclusion remained unchanged in the update of 2014.[25]
A statement on endoscopic inguinal hernia repair by a Consensus Development Conference of the European Association of Endoscopic Surgery points out that there is not enough evidence to support the routine use of prophylactic antibiotics in elective laparoendoscopic inguinal hernia repair.[26]
The guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia of the International Endohernia Society stated that there is insufficient evidence for routine antibiotic prophylaxis in laparoendoscopic repair.[22] Antibiotic prophylaxis for elective laparoendoscopic inguinal hernia repair cannot be universally recommended.[22] The Update did not change the statement and recommendation.[27] The new International Guidelines for groin hernia management also strongly recommend that no antibiotic prophylaxis be administered to any patient in any risk environment undergoing laparoendoscopic inguinal hernia repair.[28]
Laparoscopic ventral and incisional hernia repair
There are no meta-analyses or RCTs available for comparison of laparoscopic ventral and incisional hernia repair with and without antibiotic prophylaxis.
Observational studies
In a registry-based comparative study of patients undergoing elective laparoscopic incisional hernia repair the overall SSI rate showed no significant difference. In the multivariable analysis, the inclusion of patient-related risk factors and defect size >10 cm significantly increased the SSI rates and complication-related reoperations.[29]
Guidelines
In the guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias of the International Endohernia Society, no clear recommendation can be given due to the lack of studies for or against the use of antibiotic prophylaxis.[30] It appears advisable, however, to consider administration of antibiotic prophylaxis for patients with risk factors such as advanced age, corticosteroid medication, immunosuppressive therapy, obesity, diabetes, malignant tumor, or in larger defects.[30]
The SAGES guidelines for laparoscopic ventral hernia repair refers to the 2013 practice guidelines of the ASHP, IDSA, SIS, and SHEA and recommend a single-dose first-generation cephalosporin as antibiotic prophylaxis.[31]
A consensus development conference also stated that the rate of infection is significantly lower after laparoscopic ventral and incisional hernia repair than after open surgery.[32] Predisposing risk factors for wound and mesh infection are obesity, diabetes mellitus, emergency surgery, contaminated surgical field, recurrent hernia, chronic obstructive pulmonary diseases, abdominal aortic aneurysm, prior SSI, use of larger microporous or expanded polytetrafluoroethylene mesh, performance of concomitant procedures through the same incision, longer operative time, lack of tissue coverage of the mesh, enterotomy, and enterocutaneous fistula.[32]
| Discussion | | |
Due to the ongoing debate about the link between the uncritical use of antibiotics and the rapid worldwide spread of antimicrobial resistance development, their use must be questioned in each setting.[2],[3] Antibiotics should only be used when there is an evidence-based requirement for this.[2],[3] That is also particularly true for antibiotic prophylaxis.[2],[3] Laparoendoscopic repair of inguinal and abdominal wall hernias always requires the use of meshes. The general recommendations for surgery involving implantation of foreign material into the body stipulate that antibiotic prophylaxis be always administered.[1] However, meta-analyses demonstrate that laparoendoscopic repair of inguinal and abdominal wall hernias has significantly lower SSI rates compared with the open surgical techniques.[5],[6],[7],[8],[9],[10],[11] Unfortunately, there are hardly any studies that report on the effect of antibiotic prophylaxis in laparoendoscopic hernia surgery. Even for open inguinal hernia surgery, eight meta-analyses did not identify any definite effect of antibiotic prophylaxis.[13],[14],[15],[16],[17],[18],[19],[20] A large registry-based study did not find any evidence that antibiotic prophylaxis affected the SSI rate following laparoendoscopic inguinal hernia repair.[23] Accordingly, in the guidelines, antibiotic prophylaxis is not universally recommended for laparoendoscopic inguinal hernia repair.[22],[24],[25],[26],[27],[28] Only in the presence of risk factors, such as obesity, diabetes mellitus, immunosuppression, recurrent operation, emergency surgery, contaminated surgical field, chronic obstructive pulmonary diseases, etc., should antibiotic prophylaxis be administered until such time as reliable data on antibiotic prophylaxis are available for this group of patients.
Even fewer study findings are available for laparoendoscopic repair of ventral and incisional hernias. No RCTs or meta-analyses have been identified on this topic. Only from meta-analyses comparing laparoscopic with open inguinal hernia surgery can a significant reduction in the SSI rate associated with the minimally invasive approach be demonstrated.[8],[9],[10],[11] One registry-based study investigated the influence of antibiotic prophylaxis in laparoscopic repair of incisional hernias.[29] That study revealed that for patients with no risk factors undergoing laparoscopic incisional hernia surgery antibiotic prophylaxis could be omitted since this did not further reduce the SSI rate. However, for now, that only applies to patients without the aforementioned risk factors.
| Conclusion | | |
In summary, it can be stated that antibiotic prophylaxis can be omitted for patients with no additional risk factors undergoing laparoendoscopic repair of inguinal and abdominal wall hernias. However, the repository of data underpinning that recommendation should be expanded through further RCTs and registry-based analyses. Of particular importance here are studies that investigate the role of antibiotic prophylaxis for patients with SSI risk factors. Until such time as these studies are available, patients with inguinal and abdominal wall hernias and additional risk factors should continue to receive antibiotic prophylaxis in laparoendoscopic hernia surgery.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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