Comparison of Surgical Treatment Results of Large Incisional Hernias - Cureus

Incisional hernias hap successful astir 11-23% of patients undergoing abdominal surgery. However, this complaint increases to 35% successful high-risk patients [1-3]. Post-laparotomy incisional hernias are associated with inadequate healing of the abdominal fascia. Inadequate fascia healing tin beryllium owed to galore factors, specified arsenic the surgical method and the patient's biologic factors. In the studies of literature, the hazard factors that are effectual successful the improvement of incisional hernia are stated as advanced age, obesity, BMI ≥ 35 kg/m2, diabetes, hernia size > 15 cm, American Society of Anesthesiologists (ASA) ≥ 3, chronic lung disease, respiratory failure, respiratory complications, progressive smokers, need for ICU cares, coiled infection, patients who underwent exigency country for intestinal strangulation, concomitant bowel surgery, patients who person received chemotherapy, the usage of glucocorticosteroids, anemia, and hypoalbuminemia. However, it has been stated that the astir important hazard origin is coiled infection [4,5].

According to the European Hernia Society (EHS) classification, incisional hernias are divided into the pursuing groups: (a) tiny (<5 cm wide oregon long), (b) mean (5-10 cm wide oregon long), and (c) ample (>10 cm wide oregon long) [6]. However, researchers person referred to hernias with a transverse diameter of ≥15 cm arsenic elephantine hernias [2,7,8]. Of each patients with an incisional hernia, 15-47% person a ample incisional hernia (LIH), of which astir 11% are elephantine incisional hernias [1,2,9].

Surgical absorption of incisional hernias is simply a large situation for surgeons owed to the precocious complication rate. In studies of LIH, the morbidity complaint ranges from 4% to 100% (median: 32%), the recurrence complaint ranges from 0% to 35% (median: 5-8.3%) after a follow-up play of 1 to 5 years, and the mortality complaint ranges from 0% to 5% (median: 0-2%) [1,2,10]. Surgical attraction of LIH is much hard than for tiny and medium-sized hernias and requires experience. It is recommended that experienced surgeons execute the attraction of LIH [1,11]. The prime of optimal surgical method successful treating LIH is controversial, and the fig of high-level evidence-based papers is constricted [2,12].

Surgical tract infection, recurrence, mesh infection, coiled dehiscence, seroma, and bowel wounded are complications reported successful the lit pursuing incisional hernia repair. Among them, coiled corruption is the astir common. The information that the diligent has comorbid factors and a ample ventral hernia complicates the absorption of LIH [10-13].

It is recommended that mesh beryllium utilized successful the surgical attraction of incisional hernias larger than 2 cm due to the fact that of the little recurrence complaint [8,14,15]. In the superior closure of ventral hernias, the recurrence complaint is up to 60%, portion this complaint is 10-30% for repairs with mesh [1,3,16].

Surgical methods are referred to arsenic onlay, inlay, oregon sublay, depending connected the anatomic presumption successful which the mesh is placed. In the onlay position, the mesh is fixed by placing it connected the anterior aboveground of the rectus musculus and fascia. In the inlay position, besides known arsenic interposition bridging mesh, the mesh is fixed to the edges of the fascial defect. In the sublay position, the mesh is fixed down the rectus musculus and abdominal fascia. In the sublay position, the mesh is attached either supraperitoneally oregon retroperitoneally (within the abdominal cavity) to the anterior aboveground of the peritoneum [1].

This survey aims to comparison the results of the 3 astir commonly utilized surgical techniques for LIHs and to sermon them successful airy of the existent literature.

The support for the survey was obtained from the Ethics Committee of Erzurum Atatürk University Faculty of Medicine (No.: 02.06.2022/B.30.2.ATA.0.01.00/464).

A full of 601 big patients who underwent country for incisional hernia betwixt January 2014 and December 2020 were retrospectively analyzed successful a tertiary aesculapian module infirmary located successful eastbound Turkey. According to the EHS definition, hernias with a facial defect of 10 cm oregon much successful immoderate absorption were defined arsenic LIH. Patients implicit 18 years of property with a fascial defect greater than 10 cm successful immoderate absorption were included successful the study. Patients undergoing exigency surgery, patients with bowel perforation, intra-abdominal infection, an ASA people greater than 3, and patients who underwent uncommon hernia repair methods were not included successful the analysis. A full of 366 patients were included successful the study. The surgeries were performed by wide surgeons experienced successful LIH.

Depending connected the surgical method used, patients were divided into 3 groups: the unfastened onlay prolene method (OPM; n = 300), the laparoscopic intraperitoneal sublay dual mesh (IPSDM) method (n = 40), and the unfastened IPSDM method (n = 26).

Patients with postoperative complications were divided into 5 groups. Group 1 was defined arsenic coiled complications, radical 2 arsenic surgical-related complications, radical 3 arsenic aesculapian complications, radical 4 arsenic patients with recurrence, and radical 5 arsenic patients with mortality.

Propylene mesh was utilized successful the unfastened OPM technique and dual-composite mesh was utilized successful the laparoscopic IPSDM and unfastened IPSDM techniques. Preoperative antibiotic prophylaxis (cefazolin sodium) was administered to each patients. Deep vein thrombosis prophylaxis and antibiotic prophylaxis were fixed to each patients. The bladder and tummy were catheterized. Discharged patients were monitored connected time 10 and time 30. Patients without symptoms were called for follow-up aft 1 year.

Data connected age, sex, BMI, duration of operation, magnitude of infirmary stay, postoperative complications, recurrence, and mortality were statistically compared.

Statistical analysis

SPSS mentation 26 bundle (IBM Corp., Armonk, NY) was utilized for statistical analysis. Quantitative parameters were expressed arsenic arithmetic mean ± modular deviation, and categorical variables were expressed arsenic numbers and percentages. The organisation of numerical information was assessed with the Shapiro-Wilk test, the Kolmogorov-Smirnov test, and histogram graphs. Nonparametric tests were performed for information that did not amusement mean distribution. The chi-square trial was utilized to comparison categorical data. Data were analyzed with a 95% assurance interval, and p < 0.05 was accepted arsenic statistically significant.

Of the patients, 141 were male and 225 were female, and the mean property was 58.0 ± 28 (range: 24-82) years. The mean BMI was 31.6 ± 15 (range: 20-52). The mean diameter of the fascial defect was 13.6 ± 9.8 (range: 10.5-30) cm. The mean operative clip of the patients was 115 + 52 minutes, and the infirmary enactment was 5.8 ± 5 days. The mean follow-up clip of patients was 36 ± 25 months (20-70) (Table 1).

A full of 300 (81.9%) patients were operated connected with the unfastened OPM method, 40 (10.9%) patients with the laparoscopic IPSDM method, and 26 (7.1%) patients with the unfastened IPSDM method.

In presumption of hernia diameter by groups, the hernia defect diameter was 13.3 ± 5.5 cm for the unfastened OPM method, 11.3 ± 2.5 cm for the laparoscopic IPSDM method, and 22 ± 7.5 cm for the unfastened IPSDM method. The larger defect diameter with the unfastened IPSDM method was statistically important compared to some attraction methods (p < 0.001). There was nary statistically important quality betwixt attraction groups successful age, sex, and BMI (kg/m2) (p > 0.005).

Wound complications occurred successful 98 (26.7%) patients successful radical 1. The organisation by the radical was 90 patients (30%) successful unfastened OPM, 4 patients (10%) successful the laparoscopic IPSDM method, and 4 patients successful the unfastened IPSDM (15.3%). Higher coiled complications successful the unfastened OPM method compared to the different 2 groups were statistically important (p = 0.009).

Complications related to the surgical process occurred successful 12 (3.2%) patients. Surgical complications occurred successful six patients (2%) successful the unfastened OPM method and six patients (15%) successful the laparoscopic IPSDM, and nary complications related to the surgical process were observed successful the unfastened IPSDM. The complaint of surgical complications successful the laparoscopic IPSDM method was statistically important compared to the different 2 groups (p = 0.002). In addition, aboriginal detachment of the mesh aft country was statistically important successful 2 patients successful the laparoscopic IPSDM method compared with the different methods (p = 0.017).

Medical complications occurred successful a full of 24 (6.5%) patients. Complications occurred successful 19 (6.3%) patients with unfastened OPM, successful 2 (5%) patients with laparoscopic IPSDM, and successful 3 patients (11.5%) with unfastened IPSDM. There was nary statistically important quality betwixt the groups successful aesculapian complications (p = 0.540).

Recurrence was observed successful 34 patients (9.2%). Recurrence was observed successful 28 patients (9.3%) successful the unfastened OPM method, and six patients (15%) successful the laparoscopic IPSDM, portion nary recurrence was observed successful unfastened IPSDM. Although nary recurrence was observed successful immoderate diligent successful the unfastened IPSDM, determination was nary statistically important quality betwixt the groups (p = 0.099).

Mortality owed to aesculapian complications was observed successful a full of 3 (0.8%) patients. Mortality was observed successful 2 patients (0.6.7%) successful the unfastened OPM and successful 1 diligent (0.25%) successful the laparoscopic IPSDM, portion nary recurrence was observed successful the unfastened IPSDM. There was nary statistically important quality betwixt the groups successful mortality rates (p = 0.450) (Table 2).

Wound complications are the astir communal morbidity aft LIH repair. Infections, seromas, hematomas, and tegument erosions are communal aft LIH repairs. There is simply a ample quality betwixt the surgical methods utilized and coiled complications. Wound complications alteration from 13% to 48%, depending connected the surgical method utilized [1,8]. In our study, coiled complications occurred successful 98 (26.7%) patients. Depending connected the group, coiled complications occurred successful 90 patients (30%) successful the unfastened OPM method, 4 patients (10%) successful the laparoscopic IPSDM method, and 4 patients (15.3%) successful the unfastened IPSDM method. When the attraction methods were compared successful presumption of the incidence of seroma, hemorrhage, superficial coiled infection, heavy coiled infection, tegument erosion, tegument necrosis, mesh reaction, and enterocutaneous fistula reported arsenic coiled complication types, nary statistical quality was recovered (p > 0.05) (Table 2). However, considering the full fig of patients who experienced coiled complications, it was recovered that the complication complaint was higher for the unfastened OPM method compared to the different methods (p = 0.009). It was suggested that the wide detachment of tegument and fascia for mesh placement mightiness beryllium wherefore coiled complications were much communal with the unfastened OPM method.

Complications related to the surgical process occurred successful a full of 12 patients. There were six patients (2%) successful the unfastened OPM method, six patients (15%) successful the laparoscopic IPSDM method, and nary surgical complications were observed successful the unfastened IPSDM method. In the laparoscopic IPSDM method, aboriginal mesh detachment aft country was statistically important successful 2 patients (p = 0.017). When the complication complaint owed to the full surgical process was compared, it was recovered that the surgical complication complaint was statistically higher for the laparoscopic IPSDM method than for the different 2 methods (p = 0.002). Two reasons were effectual for the precocious complaint of surgical complications with the laparoscopic IPSDM method. First, detachment of the mesh successful the archetypal signifier owed to the much hard positioning of the mesh successful the laparoscopic method; second, unrecognized bowel wounded was recovered to beryllium the origin (Table 2).

In radical 3, aesculapian complications occurred successful 24 (6.5%) patients. There was nary important quality betwixt the groups successful the complaint of aesculapian complications (p = 0.054). To debar aesculapian complications successful treating LIH, preventive prophylactic treatments against pulmonary atelectasis and thromboembolic events should beryllium initiated, particularly successful patients with precocious comorbidities and precocious BMI, and patients should beryllium monitored closely.

The main criterion for the occurrence of an LIH repair is the recurrence complaint [15]. According to the groups, recurrence was observed successful 28 patients (9.3%) successful the unfastened OPM method, and successful six (15%) patients successful the laparoscopic IPSDM method, whereas nary recurrence was observed successful the unfastened IPSDM method. When the surgical attraction methods were compared, nary statistically important quality was recovered betwixt the groups (p = 0.099). However, it was noticeable successful the unfastened IPSDM method that the hernia defect was larger, but nary recurrence was observed (Table 2). A meta-analysis survey conducted successful the lit reported that sublay presumption mesh placement was little recurrent successful the agelong word [1,17]. There are 2 aspects to the attraction of LIH. Proper placement of the mesh astatine the defect margins to wholly screen the defect and beardown fixation of the mesh to the abdominal wall. Sublay mesh is utilized successful some the unfastened IPSDM and the laparoscopic IPSDM methods. However, the deficiency of recurrence successful the onlay IPSDM method was thought to beryllium a fixation with much prolene sutures and amended positioning of the mesh astatine the defect margins. Information connected however the surgical method is applied successful the unfastened IPSDM method was explained successful our erstwhile nonfiction [18]. Mortality successful tiny incisional hernias is usually owed to aesculapian problems specified arsenic cardiovascular and pulmonary problems successful patients with precocious comorbidity. Mortality successful patients with analyzable LIHs is associated with coiled complications, coiled infections, mesh infections, sepsis, and multiorgan failure. In a survey by Basta et al., 80% of patients who experienced mortality had aesculapian complications, whereas mortality occurred successful 20% due to the fact that of surgical complications [19]. In our diligent group, mortality occurred successful 3 patients. In 2 patients operated connected with the unfastened OPM method, mortality was owed to cardiovascular and pulmonary problems. One diligent with the laparoscopic IPSDM method died from bowel perforation and sepsis. The mortality complaint was reported to beryllium 0.8%, which is accordant with the literature.

Some studies reported a shorter infirmary enactment for the laparoscopic method [20]. In our study, nary important quality successful infirmary enactment was recovered successful each 3 methods (p = 0.43). In our study, it was thought that the mean infirmary enactment was accrued owed to the complications of aboriginal mesh detachment (n = 2) and bowel wounded (n = 3) successful the laparoscopic IPSDM method. In a survey by Cox et al., complications aft incisional hernia country were reported to summation the magnitude of infirmary enactment [13].

In a survey conducted by Al Chalabi et al., it was recovered that the operative clip was longer successful the radical of patients who underwent laparoscopic incisional hernia, though this was not statistically important [21]. In our study, it was recovered statistically important that the duration of cognition was shorter successful the unfastened IPSDM method compared to some the unfastened OPM method and the laparoscopic IPSDM method successful presumption of mean duration of cognition (p < 0.001). It was suggested that the operative clip was shorter with the unfastened IPSDM method than with the unfastened OPM method due to the fact that the fascia was not detached extensively. Because of method difficulties, specified arsenic positioning the mesh successful the abdomen successful the laparoscopic IPSDM method, it was assumed that the mean duration of cognition was longer than the unfastened IPSDM method.

The main regulation of our survey is that it is simply a retrospective study. Selection bias whitethorn pb to bias successful the prime of attraction method. Despite these limitations, we judge that our survey has definite strengths. Considering the fig of patients analyzed, our survey is simply a ample series. It is simply a unsocial survey successful presumption of investigating aboriginal complications and recurrence hazard according to the benignant of surgical method to beryllium applied. It volition lend to the studies connected the morbidity rates and recurrence rates successful the enactment of the surgical attraction benignant for LIHs. Prospective randomized objective and method studies with akin groups of patients are needed to get much close results.

Although the hernia defect was greater with the unfastened IPSDM method compared with different methods, it was much beneficial than different methods successful presumption of the complication complaint associated with the surgical procedure, the wide complication rate, the operative time, and the recurrence rate. The wide coiled complication complaint of laparoscopic IPSDM is simply a much beneficial method successful presumption of aesculapian complications. Although unfastened OPM is the astir commonly utilized method, it has the highest infirmary magnitude of enactment and wide complication rate.

However, determination seems to beryllium a request for high-quality, evidence-based studies from large-scale randomized trials to get much meaningful results.