GastrointestinalSuture versus preperitoneal polypropylene mesh for elective umbilical hernia repairs
Introduction
Although primary ventral hernia (PVH) repairs are among the most common general surgery procedures, with over 270,000 performed in the United States each year [1], there is currently no accepted gold standard. PVH, as defined by the European Hernia Society (EHS) [2], is the most commonly umbilical hernias (and less commonly epigastric, spigelian, or lumbar hernias). In open repairs, multiple suture techniques and various mesh repairs are used, with mixed results. Reported recurrence rates for elective PVH repairs vary, ranging from 0%–20%, and wound infection rates range from 0%–29% ([8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], Table 1). However, these studies are limited by small sample size and quality, making it difficult to determine the best surgical approach (Table 1). The estimated annual cost for ventral hernia repairs in the United Sates is 3.2 billion dollars [1]. Determining the best surgical practice for repairing primary ventral hernias could reduce the reoperations and complications necessitated by recurrences and complications. A small amount of improvement in this area will result in a huge payoff for patients, the health care system, and society [3].
The purpose of this study was to evaluate outcomes of simple suture repair compared with a specific mesh repair, preperitoneal polypropylene (PP), in open, elective umbilical hernia repair. In addition, our secondary purpose was to identify factors contributing to poor outcomes with these procedures.
Section snippets
Study population
A retrospective chart review was conducted on all patients who underwent elective open umbilical hernia repairs at a single institution from January 2000 to December 2010. Institutional review board approval was obtained. A computerized patient record system was used to collect patient information. Patients were included if they underwent an elective open umbilical hernia repair with suture or PP. Patients were excluded if they had any other type of hernia repaired, non-PP repair, or recurrent
Results
Of 442 elective open PVH repairs performed during the study period, 31 patients had a mesh repair other than PP, 19 had nonumbilical PVH (epigastric, spigelian, or lumbar), and 392 met our inclusion criteria. Of these 392 patients, 126 (32.1%) had a repair with PP (mesh), and 266 (77.9%) underwent suture repair.
Patients with mesh repair were more likely to have larger hernia defects (4.7 ± 0.3 versus 2.0 ± 0.2, P < 0.01) and have an elevated BMI (32.5 ± 0.4 versus 30.5 ± 0.3, P < 0.01). Table 2
Discussion
Our study demonstrates that PP mesh repair of elective open umbilical hernias is associated with more infections and seromas than suture repair and did not yield lower recurrence rates. Although there was a trend toward fewer recurrences, the outcomes were not statistically significant. Given the reported risk-adjusted recurrence rates in this study (suture 10% and mesh 5.6%), 1254 patients would be needed to power a prospective randomized controlled trial (PRCT) with an alpha = 0.05 and
Conclusions
We found no difference in hernia recurrence rates between patients undergoing suture repair and mesh repair of umbilical hernias; however, this may be a type 2 error. The use of mesh with umbilical hernias may be associated with increased SSI and seroma formation. These results demonstrate the need for further research with larger samples, appropriately controlled and matched patients, and improved statistical analysis to determine the best method for repairing open primary ventral hernias.
Acknowledgment
Authors' contributions: R.L.B., L.T.L., S.C.H., and M.K.L. interpreted the data and participated in designing the article. R.L.B. collected the data. R.L.B., wrote the manuscript. L.T.L., S.C.H., and M.K.L. S.C.H. analyzed the data. L.T.L., M.K.L., and S.C.H revised the article. M.K.L. was responsible for conceiving. All authors approved the final version of the article.
References (26)
- et al.
Long-term follow-up of technical outcomes for incisional hernia repair
J Am Coll Surg
(2010) - et al.
Umbilical hernia repair with the prolene hernia system
Am J Surg
(2005) - et al.
Predictors of recurrence in veteran patients with umbilical hernia: single center experience
Am J Surg
(2006) - et al.
More than 150 consecutive open umbilical hernia repairs in a major Veterans Administration Medical Center
Am J Surg
(2008) - et al.
Epidemiology and cost of ventral hernia repair: making the case for hernia research
Hernia
(2012) - et al.
Classification of primary and incisional abdominal wall hernias
Hernia
(2009) Categorical data analysis
(2002)- et al.
Applied linear statistical models
(2005) R: a language and environment for statistical computing
(2012)- et al.
Outcomes of complex abdominal herniorrhaphy: experience with 106 cases
Ann Plast Surg
(2012)
Management of complicated umbilical hernias in cirrhotic patients using permanent mesh: randomized clinical trial
Hernia
Randomized clinical trial comparing suture and mesh repair of umbilical hernia in adults
Br J Surg
Umbilical hernia, mayo or mesh?
Hernia
Cited by (26)
Predictors for recurrence after open umbilical hernia repair in 979 patients
2019, Surgery (United States)Citation Excerpt :Many smaller umbilical hernia studies have found variable but comparable results. In a retrospective review of 392 open umbilical hernia repairs, Berger et al11 reported similar results demonstrating BMI and smoking status to be associated with recurrence. Yao et al12 reviewed 199 OUHR and reported no difference between the recurrence rates amongst obese and nonobese patients.
Abdominoplasty with simultaneous laparoscopic umbilical hernia repair: A practical approach to preserve the umbilical vascularization
2019, Annales de Chirurgie Plastique EsthetiqueCitation Excerpt :Various open hernia techniques were described to prevent damaging the umbilical supply, the combined method of abdominoplasty with concomitant laparoscopic hernia repair is a suitable option in cases where the risk of devasularizing the umbilicus is to be avoided, and additionally there are other well-known advantages of laparoscopy and use of mesh for treating larger sized hernias in patients with high risk of recurrence. Data from multiple studies show a lower recurrence rates with mesh use [2–4] one study observed a recurrence rate of 6.5% in the suture repair vs. 3.2% in the mesh group [3]. Preserving the umbilical blood supply can be problematic, especially in patients who present with risk factors such as: large abdominal apron, smoking, diabetes, steroids, post-bariatric population and patients with long umbilical stalks.
Open mesh versus suture repair of umbilical hernia: Meta-analysis of randomized controlled trials
2019, International Journal of SurgeryCitation Excerpt :However, the studies included in the meta-analysis had significant selection bias, thereby provided a low level of evidence. Eleven retrospective cohort studies including 2533 patients (mesh repair = 855; suture repair = 1678) showed significantly low incidence of recurrence after open mesh repair [6,7,21–29]. Although the number of RCTs included in the study is limited to four, the analysis of data on 620 patients has shown low risk of heterogeneity and bias, thereby provide a high level of evidence.
Mesh repair of paraumblical hernia, outcome of 58 cases
2018, Annals of Medicine and SurgeryCitation Excerpt :Several factors have been implicated for recurrence after PUH repair; large seroma and surgical site infection are classical complications that may result in recurrence. Obesity and excessive weight gain following repair are other factors [6,14,15]. Size of the hernia defect interferes with the type of the operation and many surgeons still make their decisions on the basis of the size of the PUH defect, and it still a matter of controversy; a postal questionnaire study from Scotland revealed that surgeons preferred mesh repair for defects >5 cm, whereas similar preference rates for suture and mesh repairs were obtained for defects <2 cm [16].
Umbilical Hernia Repair: Overview of Approaches and Review of Literature
2018, Surgical Clinics of North AmericaPredictors of recurrence of umbilical hernias following primary tissue repair in obese veterans
2016, American Journal of SurgeryCitation Excerpt :Similarly, in other studies with long-term follow-up (70 months) of patients with small UHs (<3 cm) demonstrated no statistical difference of recurrence between tissue and mesh repair (n = 162, 77% tissue repair, P = .14).17 A retrospective review, inclusive of 392 patients with UHs, showed that there was no difference in recurrence if preperitoneal polypropylene mesh was used compared with tissue repair of UHs.15 These studies have also cited an increase in SSI if mesh is utilized (19% with mesh vs 11.5% with primary repair).18,19