Gastrointestinal
Suture versus preperitoneal polypropylene mesh for elective umbilical hernia repairs

https://doi.org/10.1016/j.jss.2014.05.080Get rights and content

Abstract

Background

Repair of primary ventral hernias (PVH) such as umbilical hernias is a common surgical procedure. There is a paucity of risk-adjusted data comparing suture versus mesh repair of these hernias. We compared preperitoneal polypropylene (PP) repair versus suture repair for elective umbilical hernia repair.

Methods

A retrospective review of all elective open PVH repairs at a single institution from 2000–2010 was performed. Only patients with suture or PP repair of umbilical hernias were included. Univariate analysis was conducted and propensity for treatment-adjusted multivariate logistic regression.

Results

There were 442 elective open PVH repairs performed; 392 met our inclusion criteria. Of these patients, 126 (32.1%) had a PP repair and 266 (67.9%) underwent suture repair. Median (range) follow-up was 60 mo (1–143). Patients who underwent PP repair had more surgical site infections (SSIs; 19.8% versus 7.9%, P < 0.01) and seromas (14.3% versus 4.1%, P < 0.01). There was no difference in recurrence (5.6% versus 7.5%, P = 0.53). On propensity score–adjusted multivariate analysis, we found that body mass index (odds ratio [OR], 1.10) and smoking status (OR, 2.3) were associated with recurrence. Mesh (OR, 2.34) and American Society of Anesthesiologists (OR, 1.95) were associated with SSI. Only mesh (OR, 3.41) was associated with seroma formation.

Conclusions

Although there was a trend toward more recurrence with suture repair in our study, this was not statistically significant. Mesh repair was associated with more SSI and seromas. Further prospective randomized controlled trial is needed to clarify the role of suture and mesh repair in PVH.

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.

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