Open surgical procedures for incisional hernias.

den Hartog D, Dur AHM, Tuinebreijer WE, Kreis RW

Published Online:

January 19, 2011

An incisional hernia is a bulge of tissue or an organ through an operation scar in the abdominal wall. Incisional hernias occur in 10 to 23 percent after abdominal operations.
This review question the choice of open operative repair technique, somehow controversial due to a high failure rate, reported as high as 54%. Open mesh repair has a lower failure rate (recurrence) than open suture repair, but mesh repair are complicated by more wound infections. No conclusions could be drawn on which type of mesh should be used because of lack of trials. Also no inference was drawn about the position of the mesh (below or above the fascia). More randomized clinical trials are needed to answer all the remaining questions.

Abstract (click to read)

Background:

Incisional hernias occur frequently after abdominal surgery and can cause serious complications. The choice of a type of open operative repair is controversial. Determining the type of open operative repair is controversial, as the recurrence rate may be as high as 54%. This a update of an earlier version.

Objectives:

To identify the best available open operative techniques for incisional hernias.

Search strategy:

Electronic databases MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from 1990 to 14 September 2010 and trials were identified from the known trial reference lists.

Selection criteria:

Studies were eligible for inclusion if they were randomized trials comparing different techniques for open operative techniques for incisional hernias.

Data collection and analysis:

Statistical analyses were performed using the fixed effects model. Results were expressed as relative risk for dichotomous outcomes and weighted mean difference for continuous outcomes with 95% confidence intervals.

Main results:

Eight trials comparing different open repairs for incisional hernias were identified; one trial was excluded. The included studies enrolled 1,141 patients. The results of three trials comparing suture repair versus mesh repair were pooled. Hernia recurrence was more frequent, wound infection less frequent in the direct suture group compared to the onlay or sublay mesh groups. The recurrence rates of two trials comparing onlay and sublay positions were pooled. This comparison yielded no difference in recurrences (two studies pooled), although operation time was shorter in the onlay group (one study). No difference was found in recurrence, satisfaction with cosmetics, or infection between the onlay standard mesh and skin autograft groups, following analysis pooling the two treatment arms. However, the analysis demonstrated less pain in the skin autograft group. Other trials comparing different mesh materials or different positions of the mesh, or comparing mesh with the components separation technique are described individually. The comparison between lightweight and standard mesh showed a trend for more recurrences in the lightweight group. The comparison between onlay and intraperitoneal mesh positions resulted in non significant fewer hernia recurrences, less seroma formation and more postoperative pain in the intraperitoneal group. No differences in the recurrence rates between the components separation and the intraperitoneal mesh technique.

An update in October 2010 did not yield any further studies.

Authors' conclusions:

There is good evidence from three trials that open mesh repair is superior to suture repair in terms of recurrences, but inferior when considering wound infection. Six trials yielded insufficient evidence as to which type of mesh or which mesh position (on- or sublay) should be used. There was also insufficient evidence to advocate the use of the components separation technique.

This record should be cited as:

den Hartog D, Dur AHM, Tuinebreijer WE, Kreis RW. Open surgical procedures for incisional hernias. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD006438. DOI: 10.1002/14651858.CD006438.pub2

Assessed as up to date:

October 13, 2010

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Primary Review Group:

Colorectal Cancer Group

PEARLS - Practical Evidence About Real Life Situations (click to read)

Clinical question:

What is the best available open operative technique for incisional hernias?

Bottom line:

Open mesh repair has a lower failure rate (recurrence) than open suture repair (NNT* 5 to 17), but mesh repairs are complicated by more wound infections (NNH** 12). *NNT = number needed to treat to benefit one individual. **NNH = number needed to treat to cause harm in one individual.

Caveat:

Six trials yielded insufficient evidence as to which type of mesh or which mesh position (below or above the fascia) should be used. In all the studies, the suture repairs were inadequately described in terms of the different possibilities in direct closure technique. Furthermore, recurrence was not objectively defined and was generally diagnosed by clinical examination rather than through imaging techniques.

Context:

Incisional hernias occur in 10 to 23 per cent of patients after abdominal operations.¹ The recurrence rate following open suture repair may be as high as 54 per cent² and as high as 32 per cent for open mesh repair.³ Several conditions are associated with the development of incisional hernia: suture technique, wound infection, increased abdominal wall tension and metabolic connective tissue disorder, specifically abdominal aortic aneurysms.⁴ 1. Cassar K, Munro A. Brit J Surg 2002; 89:534–545. 2. Paul A et al. Europ J Surg 1998; 164:361–367. 3. Burger JWA et al. Annals Surg 2004; 240:578–585. 4. Klinge V et al. Europ Surg Res 2000; 32:43–48.

Cochrane Systematic Review:

Den Hartog D et al. Open surgical procedures for incisional hernias. Cochrane Reviews 2008, Issue 3. Article No. CD006438. DOI: 10.1002/14651858. CD006438.pub2. This review contains 7 trials involving 1141 participants.

Authored by:

Brian R McAvoy

Cochrane Primary Health Care Field

Health topics:

Gastroenterology > Non-neoplastic disease of the small & large bowel > Abdominal hernia

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Open surgical procedures for incisional hernias.

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