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Development of incisional herniation after midline laparotomy.

ABSTRACT: Incisional herniation is a common complication after abdominal surgery associated with considerable morbidity. The aim of this study was to determine whether incisional hernia is an early complication, in order to understand better the aetiology of incisional hernia formation.This study involved the secondary analysis of a subset of patients included in a large RCT comparing small and large tissue bites (5?mm every 5?mm, or 1?cm every 1?cm) in patients scheduled to undergo elective abdominal surgery by midline laparotomy. The distance between the rectus abdominis muscles (RAM distance) was measured by standardized ultrasound imaging 1?month and 1?year after surgery. The relationship between the 1-year incidence of incisional hernia and the RAM distance at 1?month was investigated.Some 219 patients were investigated, 113 in the small-bites and 106 in the large-bites group. At 1?month after surgery the RAM distance was smaller for small bites than for large bites (mean(s.d.) 1·90(1·18) versus 2·39(1·34)?cm respectively; P?=?0·005). At 1?year, patients with incisional hernia had a longer RAM distance at 1?month than those with no incisional hernia (mean(s.d.) 2·43(1·48) versus 2·03(1·19)?cm respectively; relative risk 1·14, 95 per cent c.i. 1·03 to 1·26, P?=?0·015).A RAM distance greater than 2?cm at 1?month after midline laparotomy is associated with incisional hernia. Closure with small bites results in a smaller distance between the muscles.

SUBMITTER: Harlaar JJ

PROVIDER: S-EPMC5989969 | biostudies-literature | 2017 Feb

REPOSITORIES: biostudies-literature

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Development of incisional herniation after midline laparotomy.

Harlaar J J JJ Deerenberg E B EB Dwarkasing R S RS Kamperman A M AM Kleinrensink G J GJ Jeekel J J Lange J F JF

BJS open 20170201 1

<h4>Background</h4>Incisional herniation is a common complication after abdominal surgery associated with considerable morbidity. The aim of this study was to determine whether incisional hernia is an early complication, in order to understand better the aetiology of incisional hernia formation.<h4>Methods</h4>This study involved the secondary analysis of a subset of patients included in a large RCT comparing small and large tissue bites (5 mm every 5 mm, or 1 cm every 1 cm) in patients schedule ...[more]

PMID: 29951601

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Project description:ImportanceThe evidence provided supports routine and systematic capture of long-term outcomes after trauma, lengthening the follow-up for patients at risk for incisional hernia (IH) after trauma laparotomy (TL), counseling on the risk of IH during the postdischarge period, and consideration of preventive strategies before future abdominal operations to lessen IH prevalence as well as the patient and health care burden.ObjectiveTo determine burden of and factors associated with IH formation following TL at a population-based level across health care settings.Design, setting, and participantsThis population-based cohort study included adult patients who were admitted with traumatic injuries and underwent laparotomy with follow-up of 2 or more years. The study used 18 statewide databases containing data collected from January 2006 through December 2016 and corresponding to 6 states in diverse regions of the US. Longitudinal outcomes were identified within the Statewide Inpatient, Ambulatory, and Emergency Department Databases. Patients admitted with International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for traumatic injuries with 1 or more concurrent open abdominal operations were included. Data analysis was conducted from March 2020 through June 2020.Main outcomes and measuresThe primary outcome was IH after TL. Risk-adjusted Cox regression allowed identification of patient-level, operative, and postoperative factors associated with IH.ResultsOf 35 666 patients undergoing TL, 3127 (8.8%) developed IH (median [interquartile range] follow-up, 5.6 [3.4-8.6] years). Patients had a median age of 49 (interquartile range, 31-67) years, and most were male (21 014 [58.9%]), White (21 584 [60.5%]), and admitted for nonpenetrating trauma (28 909 [81.1%]). The 10-year IH rate and annual incidence were 11.1% (95% CI, 10.7%-11.5%) and 15.6 (95% CI, 15.1-16.2) cases per 1000 people, respectively. Within risk-adjusted analyses, reoperation (adjusted hazard ratio [aHR], 1.28 [95% CI, 1.2-1.37]) and subsequent abdominal surgeries (aHR, 1.71 [95% CI, 1.56-1.88]), as well as obesity (aHR, 1.88 [95% CI, 1.69-2.10]), intestinal procedures (aHR, 1.47 [95% CI, 1.36-1.59]), and public insurance (aHRs: Medicare, 1.38 [95% CI, 1.20-1.57]; Medicaid, 1.35 [95% CI, 1.21-1.51]) were among the variables most strongly associated with IH. Every additional reoperation at the index admission and subsequently resulted in a 28% (95% CI, 20%-37%) and 71% (95% CI, 56%-88%) increased risk for IH, respectively. Repair of IH represented an additional $36.1 million in aggregate costs (39.9%) relative to all index TL admissions.Conclusions and relevanceIncisional hernia after TL mirrors the epidemiology and patient profile characteristics seen in the elective setting. We identified patient-level, perioperative, and novel postoperative factors associated with IH, with obesity, intestinal procedures, and repeated disruption of the abdominal wall among the factors most strongly associated with this outcome. These data support preemptive strategies at the time of reoperation to lessen IH incidence. Longer follow-up may be considered after TL for patients at high risk for IH.

Project description:BackgroundThe incidence of incisional hernias (IHs) following midline abdominal incisions is difficult to estimate. Furthermore recent analyses have reported inconsistent findings on the superiority of absorbable versus non-absorbable sutures.ObjectiveTo estimate the mean IH rate following midline laparotomy from the published literature, to identify variables that predict IH rates and to analyse whether the type of suture (absorbable versus non-absorbable) affects IH rates.MethodsWe undertook a systematic review according to PRISMA guidelines. We sought randomised trials and observational studies including patients undergoing midline incisions with standard suture closure. Papers describing two or more arms suitable for inclusion had data abstracted independently for each arm.ResultsFifty-six papers, describing 83 separate groups comprising 14,618 patients, met the inclusion criteria. The prevalence of IHs after midline incision was 12.8% (range: 0 to 35.6%) at a weighted mean of 23.7 months. The estimated risk of undergoing IH repair after midline laparotomy was 5.2%. Two meta-regression analyses (A and B) each identified seven characteristics associated with increased IH rate: one patient variable (higher age), two surgical variables (surgery for AAA and either surgery for obesity surgery (model A) or using an upper midline incision (model B)), two inclusion criteria (including patients with previous laparotomies and those with previous IHs), and two circumstantial variables (later year of publication and specifying an exact significance level). There was no significant difference in IH rate between absorbable and non-absorbable sutures either alone or in conjunction with either regression analysis.ConclusionsThe IH rate estimated by pooling the published literature is 12.8% after about two years. Seven factors account for the large variation in IH rates across groups. However there is no evidence that suture type has an intrinsic effect on IH rates.

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Development of incisional herniation after midline laparotomy.

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Development of incisional herniation after midline laparotomy.

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