S. Shakir1, Z. Borab2, M. A. Lanni1, M. G. Tecce1, J. MacDonald3, W. W. Hope4, J. M. Weissler1, M. J. Carney1, J. P. Fischer1 1University Of Pennsylvania,Plastic Surgery,Philadelphia, PA, USA 2Drexel University College Of Medicine,Philadelphia, Pa, USA 3University Of Western Ontario,London, ONTARIO, Canada 4New Hanover Regional Medical Center,Surgery,Wilmington, NC, USA
Introduction: Incisional hernia (IH) is a morbid and challenging complication with an extraordinary financial burden to the healthcare system. With nearly 350,000 repairs and expenditures in excess of $3 billion annually, there is a clear need for reparative strategies to diminish hernia recurrence. As greater emphasis is being placed on disease prevention, and as surgical technique and mesh technology evolves, the surgical paradigm must transition from a reparative approach to preventative action. Restoration of tensile strength is paramount in reducing risk of IH, yet the optimal intervention is not known. This systematic review and meta-analysis reviews incidence of IH and complications after elective laparotomy using either PMA or conventional fascial repair.
Methods: A systematic review of the literature was conducted in accordance with PRISMA guidelines to identify studies comparing PMA to primary suture closure (PSC) repair in elective, midline laparotomies during index operation. The primary outcome of interest was development of IH. Inclusion criteria included patients between the ages of 18-75 years and at least 1 IH risk factor (BMI ≥ 25 kg/m2, prior abdominal surgery, history of AAA, ≥45 years of age, and smoking or history of COPD). Exclusion criteria included prior hernia or existing abdominal mesh, non-elective cases, history of metastatic cancer, immunosuppression, active infection, life expectancy less than 24 months, and pre-existing pregnancy.
Results: Overall, 14 studies were included. Of the total 2114 patients, 1152 participants underwent PMA. PMA significantly decreased the risk of IH compared to PSC (RR=0.15, 95% CI 0.07-0.30). PMA reduced the risk of IH regardless of mesh location (i.e. onlay, retrorectus or preperitoneal), however, PMA use was associated with an increased rate of seroma (RR 1.95, 95% CI 1.31 to 2.91; 10 studies). PMA patients are at increased risk for chronic wound pain compared to PSC [RR=1.70, 95% CI 1.04 to 2.78).
Conclusion: The existing literature provides high level evidence demonstrating that prophylactic mesh lowers the rate of IH after elective, open intra-abdominal surgery. Risk stratification models in conjunction with an increased emphasis on preventative medicine, strategies such as PMA offer safe and efficacious risk reduction in high-risk laparotomy patients. Given the evidence gap, however, further study is undoubtedly warranted.
