BACKGROUND: Incisional hernias are one of the most common postoperative complications encountered by surgeons in daily practice. In our study, we compared the component separation technique (CST) with and without synthetic mesh in large incisional hernia surgery. MATERIALS AND METHODS: The files of 79 patients who underwent surgery for giant incisional hernia between January 2016 and November 2020 were reviewed retrospectively. The patients were divided into two groups: CST with mesh reinforcement (mesh+ group) and CST without mesh reinforcement (non-mesh group). The groups were compared in terms of recurrence, complications, and other clinical features. RESULTS: There were 36 patients in the mesh+ group and 38 patients in the non-mesh group. There was no significant difference between the two groups in terms of demographic parameters and clinical features. There was a statistically significant difference between the groups in terms of recurrence rate (P = 0.007, OR = 0.17). In addition, there was a significant difference between the two groups in terms of mean operation times (2.8 h and 1.9 h for mesh+ and non-mesh, respectively) (P = 0.000, 95% CI). Regardless of the use of mesh, recurrence was significantly higher in the presence of high body mass index (BMI) (P = 0.003, 95% CI) and comorbidity (P = 0.031, OR = 3.4). CONCLUSION: Repair of giant incisional hernias with mesh-reinforced CST is superior to the non-mesh technique in terms of hernia recurrence. Although CST without mesh reinforcement seems advantageous in terms of complications and operation time, we believe that the mesh-reinforced CST should be applied in suitable patients when the total cost, recurrence, and patient satisfaction are taken into account.
Keywords: Component separation technique, incisional hernia, recurrence
| Introduction|| |
Today, incisional hernias constitute 80% of all ventral hernias. Incisional hernias are seen at a rate of approximately 10%–50% after abdominal surgery., Many studies have investigated risk factors for the development of an incisional hernia. Some of these risk factors are: wound dehiscence, wound infection, smoking, obesity, steroid use, and malnutrition. In a meta-analysis by Hodgson in 2000, it was determined that the recurrence rate was the lowest when the first laparotomy was closed with continuous nonabsorbable sutures. Sorenson, on the other hand, found that smoking is an independent risk factor in the development of relapse. Raffetto et al. reported that the development of incisional hernia was nine times more common after abdominal aortic aneurysm surgery.,,
The high recurrence rate in incisional hernia surgery has led to the development of many different techniques. Giant incisional hernias can be defined as hernias larger than 10 cm. Tension-free repair is accepted as the standard approach by many authors, and suture repair alone is rarely used. The recurrence rate in patients with suture repair alone is higher than in those with graft repair., Reconstruction using prosthesis material placed preperitoneally is the most common method today.
In cases where primary closure of the abdominal fascia is not possible in giant incisional hernias, the decomposition technique, composite mesh, or biological mesh closure are the most preferred methods to close the defect. However, it may not be easy to reach composite meshes, especially biological meshes, due to the high cost. Nonabsorbable synthetic meshes are preferred in hernia repair, because they are cheap and easily accessible. However, if such materials come into direct contact with intestinal structures, complications such as fistulas can be seen. It is possible to prevent such complications by combining the mesh with the separation technique.
In this study, our aim is to investigate the effects of mesh-reinforced and non-mesh-reinforced CST and basic patient characteristics on hernia recurrence and complications in the repair of giant incisional hernias.
| Materials and Methods|| |
This study was approved by the Tekirdağ Namık Kemal University Non-Interventional Clinical Research Ethics Committee (Protocol no. 2021.184.06.14 dated 29 June 2021). All practices during our study complied with the ethical standards of the 1964 Declaration of Helsinki and national/institutional scientific research committees.
Collection of data
The files of 79 patients who underwent surgery for a giant incisional hernia in Tekirdağ Namık Kemal University Faculty of Medicine, Department of General Surgery between January 2016 and November 2020 were reviewed retrospectively. Patients with at least 1-year follow-up and abdominal defects larger than 10 cm were included in the study. The operation reports of 74 patients who met the inclusion criteria were analyzed by using the hospital information management system The width and the length of the hernia were measured by examining the preoperative computed tomography images of all patients included in the study. In all 74 patients, routine examination findings were recorded during the first, third, sixth, and twelfth months and the first year postoperatively. Follow-up was continued with annual controls. Computed tomography and ultrasonographic examinations were used for the diagnosis of recurrence and complications. Patients who did not undergo CST for hernia repair and those with a follow-up period of less than 1 year were excluded from the study.
The patients were divided into two groups: CST with mesh reinforcement (mesh+) and CST without mesh reinforcement (non-mesh). The evaluated parameters were: gender, age, comorbidity, hernia size, presence of previous incisional hernia surgery, smoking, BMI, duration of surgery, duration of follow-up with drain, length of hospital stay, return to normal life, complications, and recurrence. Demographic and biological differences between the mesh+ and non-mesh group are shown in [Table 1].
|Table 1: Demographic and biological differences between the mesh and nonmesh group|
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Standard antibiotics (Cefazolin 1 g iv) and thrombosis prophylaxis (4000IE low-molecular-weight Heparin sc) were administered preoperatively. General anesthesia was administered to all patients. The operating area was cleaned with Povidone-iodine.
Component separation technique
After the layers were passed to excise the old incision scar, the hernia sac was dissected from the surrounding tissues and visceral structures. Then, skin and subcutaneous adipose tissue dissection was performed at a distance of up to 5 cm from the lateral border of the rectus abdominal muscle. An incision was made in the rectus abdominis sheath, and the rectus muscle was separated from its posterior sheath. The external oblique muscle aponeurosis was transected through the rectus sheath. The external oblique muscle was dissected from the internal oblique muscle toward the mid axillary line. Later, both rectus fascia were closed with a running loop suture of polydioxanone (1 PDS loop Ethicon) in the midline. After homeostasis, two aspirating drains were placed under the skin and the skin was closed with nonabsorbable sutures.
Component separation technique using mesh
In this group, in addition to the procedure cited earlier, a 15 cm x 10 cm heavy weight prolene mesh (Prolene 109 g/m2 pore size 1.6 mm) was used to close the entire defect up to the released external oblique muscle aponeurosis. The lateral parts of the mesh were fixed to the external oblique aponeurosis with a 2-0 prolene suture.
SPSS software program, version 22.0 (SPSS, Chicago, Illinois) was used for statistical analysis. The median (min-max), frequency, and percentage were preferred whereas descriptive data were noted. Correlation between categorical variables was evaluated with the chi-square test. t Test was used for parametric data, and Mann Whitney U test was preferred for analysis of nonparametric data. A value of P < 0.05 was accepted for the statistical significance level. The sample of the study was calculated using the G-power program, and the effect size was D = 0.87, with 95% statistical power, and a total of 58, with at least 29 in both groups.
| Results|| |
The mean age of the 74 patients included in the study was found to be 56 (37–79): 28 were male and 46 were female. According to the BMI category of the World Health Organization (WHO), one patient was underweight, 30 patients were normal weight, 22 patients were overweight, 17 patients were category 1 obese, and one patient was category 2 obese. Also, 22 patients were smokers; 29 of them had at least one of the comorbidities such as diabetes, ischemic heart disease, kidney failure, chronic lung disease, and chronic liver disease. Abdominal wall defect lengths were calculated as 17.6 cm (10–24) on average in the craniocaudal axis and 11.9 cm (10–18) on average in width. Although the CST and mesh were used together in 36 patients (mesh+), the without mesh technique was used in 38 (non-mesh) patients. It was observed that the hernia length of the patients who preferred mesh was longer than the others (mean 18.7–16.3 cm) (P = 0.001, CI 95%).
When the mean operation times were compared (2.8 h–1.9 h), there was a significant difference between the two groups (P = 0.000, 95% CI). There was no significant difference between the two groups in terms of the duration of follow-up with regard to the drain, length of hospital stay, and time to return to normal life without pain (P = 0.90, 0.51, and 0.60, 95% CI). When these two groups were compared in terms of minor complications such as seroma or cellulitis development in the postoperative period and major complications such as hematoma requiring drainage and wound dehiscence, no statistically significant difference was observed (P = 0.32, OR = 1.77, P = 0.93, OR = 1.06) [Table 2]. An 8.3% recurrence rate was observed in patients who underwent mesh repair, whereas a 34.2% rate was found in those who underwent non-mesh repair. This shows that mesh repair has a statistically significantly less recurrence (P = 0.007, OR = 0.17) [Table 3].
|Table 2: Differences between mesh and non-mesh group during and after the operation|
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Gender (P = 0.075, OR = 3.2), age (P = 0.94, 95% CI), hernia length (P = 0.72, 95% CI), hernia width (P = 0.44, 95% CI), previous incisional hernia operation (P = 0.39, OR = 0.6), and smoking (P = 0.089, OR = 0.27) were not found to be significant in terms of recurrence. In the presence of comorbidity (P = 0.031, OR = 3.4) and those with a high BMI (P = 0.003, 95% CI), recurrence was significantly more common [Table 3].
BMI was found to be significant in terms of recurrence for mesh+ group (P = 0.000, 95% CI) or non-mesh group (P = 0.027, 95% CI). The presence of comorbidity was not statistically significant in terms of recurrence for mesh+ group (P = 0.25, OR = 4) and non-mesh group (P = 0.08, OR = 3.4).
| Discussion|| |
In this study, it was found that the mesh-reinforced decomposition technique is advantageous over the non-mesh-reinforced decomposition technique in terms of recurrence in the repair of large incisional hernias and that there was a high reherniation rate of 34% when only the CST was used. It was observed that increased BMI and comorbidity increased the recurrence rate regardless of the technique.
The decomposition method was first developed by Ramirez et al. and Albanese and for the tension-free reconstruction of large abdominal hernias. Later, many modified versions of this technique were identified. The high rate of recurrence in classical non-mesh repair is the most important reason for modifying this technique. Studies have shown that mesh repair is superior to only suture repair in terms of recurrence in incisional hernia repair regardless of hernia size., Mesh repair of incisional hernias has now become the standard approach as long-term outcomes are improved.,
Many systematic reviews have shown that CST without the use of mesh results in a high recurrence rate of up to 55%.,,,
In another prospective randomized study, the recurrence rate in CST performed without mesh at the end of 36 months was 52.6%.
In our study, in accordance with the literature, a high recurrence rate (34%) was seen in patients who only underwent CST. According to an expert consensus evaluating hernia management, it is recommended not to perform CST without mesh reinforcement due to the high recurrence rate. There are conflicting studies in the literature in terms of complications. Some articles report that infectious complications are a major problem for mesh repair. Although less recurrence is seen in mesh repairs, especially synthetic mesh repair is associated with various morbidities. Wound complications and contamination limit the use of prosthetic materials.
Tong et al. reported an overall complication rate of 21% and 50% for patients with and without mesh. In another study, 50% and 55% postoperative complication rates were reported for unmeshed and meshed anterior open CST. Although there was no statistical significance in terms of major and minor complications in our study, numerically more complications were seen in the mesh group. Studies have reported that increased BMI is a risk factor for many diseases, as well as a risk factor for recurrence after hernia surgery., Sauerland et al. reported that obesity is an independent risk factor for hernia recurrence and recommended that patients enter a weight loss program before surgery. In the present study, increased BMI was found to be statistically significant in terms of recurrence in both groups. There are studies showing that comorbidities such as diabetes, hypertension, ischemic heart disease, and chronic lung disease are risk factors for hernia recurrence.,, These types of diseases impair tissue perfusion and oxygenation and prevent the formation of adequate wound tension. However, it has been reported in studies supporting this idea that there is no relationship between the aforementioned diseases and recurrence., Although there was no statistical significance in the present study on a group basis, comorbidities were found to increase the recurrence rate when all patients were evaluated regardless of group.
Several reports have shown that hernia size is a risk factor for recurrence., However, hernia sizes are very variable in these studies. In our study, no significant relationship was found between hernia size and recurrence.
Many studies have reported that smoking is associated with hernia recurrence. Both Sorenson and Fischer showed that smoking is the strongest risk factor associated with an incisional hernia after the first laparotomy.,,
| Limitations|| |
Since the present study was designed retrospectively, there were no data on the reasons for preferring the operation technique (with or without mesh). It was seen that the hernia length of the cases in the mesh preferred group was higher than the ones in which the mesh was not preferred. According to the data obtained from the surgery reports, there was no contamination due to intestinal injury, etc. in any case.
| Conclusion|| |
As a result, it has been shown in this study and other studies that the CST with the mesh technique has a lower recurrence rate than the classical technique without a mesh. Classical CST may be an optimal method, especially for the repair of large midline hernias where the use of biomaterials is contraindicated. It is important not to use a mesh, especially in contaminated procedures where intestinal structures are opened. Complications such as mesh infection, skin necrosis, or infection seroma seen in CST with a mesh can be considered a handicap. Therefore, we believe that the existing methods should be improved to reduce both the recurrence rate and complications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Department of Surgery, Faculty of Medicine, TekirdagNamık Kemal University, Tekirdag.
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]