Incisional hernia after repair of wound dehiscence: incidence and risk factors

The true incidence of incisional hernia after wound dehiscence repair remains unclear because thorough long-term follow-up studies are not available. Medical records of all patients who had undergone wound dehiscence repair between January 1985 and January 1999 at the Erasmus University Medical Center Rotterdam were reviewed. Long-term follow-up was performed by physical examination of all patients in February 2001. One hundred sixty-eight patients underwent wound dehiscence repair. Of those, 42 patients (25%) died within 60 days after surgery. During a median follow-up of 37 months (range, 3-146 months), 55 of the remaining 126 patients developed an incisional hernia. The cumulative incidence of incisional hernia was 69 per cent at 10 years. Significant independent risk factors were aneurysm of the abdominal aorta (10-year cumulative incidence of 84%, P = 0.02) and severe dehiscence with evisceration (10-year cumulative incidence of 78%, P = 0.01). Wound dehiscence repair by interrupted sutures had no better outcome than repair by continuous sutures. Suture material did not influence incidence of incisional hernia. Incisional hernia develops in the majority of patients after wound dehiscence repair, regardless of suture material or technique. Aneurysm of the abdominal aorta and severe dehiscence with evisceration predispose to incisional hernia.     

Mass closure of abdominal wounds following major laparotomy in jaundiced patients.

Previous clinical studies have demonstrated an increased incidence of wound dehiscence and incisional hernia formation in jaundiced patients following major laparotomy. Nearly all of these patients had their wounds closed in layers. In order to determine the rate of wound failure in jaundiced patients when a mass closure technique is used, 343 non-jaundiced patients undergoing biliary surgery and 62 jaundiced patients undergoing surgery have been studied. All the wounds were closed using a mass closure technique and the patients were seen regularly as outpatients. There were no wound dehiscences in either group (incidence 0%). Twenty seven (7.9%) of the non-jaundiced patients and 4 (9.8%) of the surviving jaundiced patients developed incisional hernias within one year of operation. We conclude that the rate of wound dehiscence in jaundiced patients can be much reduced using the mass closure technique. The rate of incisional hernia formation in jaundiced patients following major laparotomy is similar to that found in non-jaundiced patients when this technique is used.     

Incidence of incisional hernia after dehiscence of the abdominal wound

The records of 103 patients whose abdominal wounds burst were studied in an attempt to assess the subsequent incidence of incisional hernia. Sufficient information about seventy patients was obtained. Forty-nine patients (47.6 per cent) had a hernia whereas twenty-one patients (20.4 per cent) definitely did not have a hernia. The incidence of hernia was associated with the age of the patient, the site of the wound, the day of resuture, an original diagnosis of malignancy, and the postoperative blood urea level but not with the technic employed in the resuture nor with infection.It is suggested that a blood-stained serous discharge and the “dip sign” should enable an early diagnosis of dehiscence to be made before the small bowel appears in the wound; after diagnosis, the wound should either be explored electively or the skin sutures left for at least three weeks until the skin heals.     

Chronic kidney disease is associated with high abdominal incisional hernia rates and wound healing disturbances

Background and objectives

Incisional hernias are among the most frequent complications following abdominal surgery with impact on morbidity and mortality rates. Elevated uremia toxins may inhibit granulation tissue formation and impair wound healing, thereby promoting incisional hernia development. Here, we quantified the hazard ratio for incisional hernia prevalence in patients at risk undergoing abdominal reoperations with interrelationship to kidney function. In the same cohort, incidence rates for de novo wound healing disturbances within a 4-month follow-up period were determined.

Design, setting, participants and measurements

Upon hospitalization for elective abdominal surgery in a university hospital (tertiary medical center), past medical histories were recorded in 251 patients and incisional hernia prevalence rates were calculated. Known modifiers for hernia formation as well as laboratory values for estimated glomerular filtration rate (eGFR) were recorded. The status of wound healing was assessed by a blinded investigator 4 months postoperatively. Chronic kidney disease (CKD) was defined as eGFR < 60 ml/min/1.73 m². To identify independent risk factors for incisional hernia or postoperative wound healing disorder, multivariate regression analyses were performed.

Results

The incisional hernia prevalence was 24.3 % in the overall cohort. Patients with CKD (32/251; 12.8 %) were more likely to suffer from incisional hernias with an odds ratio (OR) of 2.8 ([95 % CI 1.2–6.1]; p = 0.014) than patients with eGFR > 60 ml/min (219/251; 88.2 %). In multivariate analyses, CKD proved to be an independent risk factor for incisional hernia development with an OR similar to obesity (BMI > 25; OR 2.6 [95 % CI 1.3–5.1]; p = 0.007). In the prospective analysis, disturbed wound healing occurred in 32 of 251 (12.8 %) patients undergoing abdominal operations. Frequency of wound healing was increased when CKD was present (8/32; 25 %; OR 2.3 [95 % CI 1.1–6.7]; p = 0.026) compared to patients with eGFR > 60 ml/min (24/219; 11 %).

Conclusions

Chronic kidney disease is associated with impaired wound healing and constitutes an independent risk factor for incisional hernia development.     

Lateral paramedian incision

Prospective randomization of 360 patients undergoing abdominal surgery determined whether a standard lateral paramedian incision was made (group A) or one of two modifications in which the anterior sheath was incised medially and posterior sheath incised laterally (group B) or vice versa (group C), in order to determine the necessity for incising both layers laterally to provide the shutter mechanism which is held responsible for the integrity of this wound. Medial incision of the anterior rectus sheath significantly reduced the time required to perform the incision (P less than 0.02) and tended to reduce wound sepsis rate. However, this was achieved at the cost of a higher incisional hernia rate (0 per cent, 2.9 per cent and 4.6 per cent in groups A, B and C respectively, P less than 0.02). We conclude that lateral incision of both anterior and posterior rectus sheath is necessary to obviate the risk of wound hernia with the lateral paramedian incision.     

Incisional hernias in patients with aortic aneurysmal disease: the importance of suture technique.

OBJECTIVE: To study the rate of incisional hernia at 12 months in patients undergoing abdominal aortic aneurysm repair compared with others undergoing other surgery through midline incisions. METHODS: A prospective study of 1023 patients, 85 of these with aneurysmal disease. Wounds were continuously closed and the suture technique was monitored by the suture length to wound length ratio. RESULTS: Wound incisions were longer and operations lasted longer in aneurysm patients than in others. Incisional hernia was less common if closure was with a suture length to wound length ratio of at least four. Wounds were closed with a ratio of four or more in 39% (33 of 85) of aneurysm patients and in 59% (546 of 923) of others (p < 0.01). In aneurysm patients no wound dehiscence was recorded, the rate of wound infection was low and incisional hernia occurred in the same amount as in others. CONCLUSIONS: It is concluded that the rate of incisional hernia is similar in patients with abdominal aortic aneurysmal disease and others. Wounds are closed with a less meticulous suture technique in aneurysm patients.     

Production of VEGF and b-FGF in drainage fluid from patients undergoing incisional hernia repair

Wound healing is a complex process involving interaction between different cell types, such as growth factors. Among these, vascular endothelial growth factors (VEGF) and basic fibroblast growth factors (b-FGF) are the most important. The aim of this study was to assess the production of VEGF and b-FGF in wound drainage fluid from patients undergoing incisional abdominal hernia repair. Ten female patients with abdominal midline incisional hernia undergoing surgical repair were included in this study. In all cases a closed suction drain was placed in the wound below the fascia and removed on postoperative day 4. Wound fluid was collected on the I, II, III and IV day and its amount at each time was recorded. VEGF and b-FGF production were evaluated as the quantity produced in 24 hours. In all patients the amount of drainage fluid from the surgical wound was highest on the I day after surgery, after which there was a significant reduction. VEGF production increased progressively after the operation proving significantly higher only on the IV day. The amount of b-FGF, in contrast, was higher on the I day, decreasing thereafter on the following postoperative days. Analysis of the production of growth factors in the drainage fluid has enabled us to better assess the events that occur following surgical wounds and has confirmed the physiology of the healing process and the possible use of these factors in modulating positive healing.     

Addition of Rectus Sheath Relaxation Incisions to Emergency Midline Laparotomy for Peritonitis to prevent Fascial Dehiscence

The incidence of fascial dehiscence and incisional hernia after two methods for abdominal wound closure (rectus sheath relaxation incisions and conventional mass closure) was studied in a randomized prospective clinical trial in a consecutive series of 100 patients undergoing midline laparotomy for peritonitis. The two groups were well matched for etiologies of peritonitis, the surgical procedures performed, and the presence of known risk factors for fascial dehiscence. Fifty patients each were randomized either to the conventional continuous mass closure procedure or the rectus sheath relaxation incision technique (designed to increase wound elasticity and decrease tension in the suture line) using identical polypropylene sutures. The incidence of postoperative complications such as duration of ileus, chest infection, and wound infection were not statistically different between the two groups. The intensity of postoperative pain in the rectus sheath relaxation incision group was significantly less. The incidence of wound hematoma was significantly increased in the rectus sheath relaxation incision group. The incidences of fascial dehiscence (16% vs,28%; p < 0.05) and incisional hernia (18% vs, 30%; p < 0.05) were significantly lower after rectus sheath relaxation incisions compared to conventional mass closure. Closure of the midline laparotomy wound in cases of peritonitis using the rectus sheath relaxation technique is safe and less painful, provides increased wound elasticity and decreased tension on the suture line, and significantly decreases the incidence of wound dehiscence.     

Incisional hernia risk after hand-assisted laparoscopic surgery

Hand-assisted laparoscopic surgery (HALS) bridges traditional open surgery and pure laparoscopy. The HALS technique provides the necessary site for organ retrieval, reduces operative time, and realizes the postoperative benefits of laparoscopic techniques. Although the reported rates of incisional hernia should be theoretically low, we sought to determine our incidence of hernia after HALS procedures. A retrospective review of all HALS procedures was performed from July 2006 to June 2011. All patients who developed postoperative incisional hernias at the hand port site were confirmed by imaging or examination findings. Patient factors were reviewed to determine any predictors of hernia formation. Over the 5 years, 405 patients undergoing HALS procedures were evaluated: colectomy (264), nephrectomy (107), splenectomy/pancreatectomy (18), and ostomy reversal (10). The overall incidence of incisional hernia was 10.6 per cent. There were three perioperative wound dehiscences. The mean body mass index was significantly higher in the hernia group versus the no hernia cohort (32.1 vs 29.2 kg/m(2); P = 0.001). The hernia group also had a higher incidence of renal disease (18.6 vs 7.2%; P = 0.018). Mean time to hernia formation was 11.4 months (range, 1 to 57 months). Follow-up was greater than 12 months in 188 (46%) of patients, in which the rate of incisional hernia was 17 per cent. The rate of incisional hernia formation after hand-assisted laparoscopic procedures is higher than the reported literature. Because the mean time to hernia development is approximately 1 year, it is important to follow these patients to this end point to determine the true incidence of incisional hernia after hand-assisted laparoscopy.     

Incisional hernia in re-opened abdominal incisions: an overlooked risk factor

Many patients undergoing laparotomy will have had a previous incision in the abdominal wall which offers a convenient and logical route for reexploration. This study aims to examine the risk of subsequent incisional herniation in incisions made through previous scar tissue compared with incisions made through fresh tissues. Out of a total of 1022 laparotomies performed in a 5-year period on one surgical unit, the incisional hernia rates were available for assessment in 699 freshly made incisions, 142 reincisions and 36 incisional hernias. The incidence of incisional hernia was 6 per cent after freshly made incisions and this incidence was increased after both re-incision (12 per cent, P less than 0.05) and incisional hernia repair (44 per cent, P less than 0.01). With the exception of jaundice, none of the other commonly accepted risk factors for incisional herniation were significantly increased in those patients with re-incised wounds who subsequently developed a hernia, when compared with patients who did not develop a hernia. An increased risk of incisional herniation is present when laparotomy is performed through a previous abdominal incision.     

腹壁切口疝临床分析（附130例报告）

目的　探讨腹壁切口疝的病因和治疗。方法　回顾性分析 1 30例腹壁切口疝病人临床资料。结果　平均年龄 6 2 .8岁 ,女性占 5 8.5 %。术后一年内发病占 5 6 .2 % ,五年后发病占 2 6 .9%。纵型切口占 85 .4 % ,下腹部切口占 6 6 .9%。切口二期愈合者为 4 4 .6 %。 5 6例合成材料修补手术复发率为 7.1 %。结论　伤口二期愈合、腹内压升高、肥胖和糖尿病、老年人、女性、纵型切口、下腹部切口等是腹壁切口疝的致病因素 ;避免伤口感染 ,防治腹内压升高 ,促进伤口愈合 ,保证缝合质量是预防切口疝关键 ;大切口疝需使用合成材料修补 ,做好围手术期处理 ,可减少复发     

Fascia closure after midline laparotomy: results of a randomized trial

Four techniques to close the fascia after midline laparotomy were compared in a prospective randomized multicentre trial. The four techniques were: interrupted closure with polyglactin; continuous closure with polyglactin; continuous closure with polydioxanone-s, and continuous closure with nylon. The early postoperative results in 1491 patients revealed an incidence of wound infection of 8.6 per cent and of wound dehiscence of 2.3 per cent with no statistically significant differences between the four techniques. We reviewed 1156 patients after 1 year. Wound pain was present in 9.7 per cent of the patients, statistically significantly more in the group closed with nylon (16.7 per cent). Suture sinuses developed in 3.5 per cent of the patients, statistically significantly more frequently in the nylon group (7.7 per cent). The total number of incisional hernias detected 1 year postoperatively was high (15.2 per cent) (interrupted polyglactin 16.9 per cent, continuous polyglactin 20.6 per cent, continuous polydioxanone 13.2 per cent and continuous nylon 10.3 per cent). The difference between nylon and continuous polyglactin is statistically significant. The results of this trial indicate that although nylon has the lowest incidence of incisional hernia it also is associated with more wound pain and suture sinuses.     

Closure of abdominal wounds with polydioxanone. A prospective study

Polydioxanone, an absorbable synthetic monofilament suture, was used to close abdominal wounds in 200 consecutive operative procedures. All patients were followed up for one year. Despite a high incidence of risk factors for impaired wound healing, the incidence of dehiscence and evisceration was zero; incisional hernia occurred in 2.9% of vertical midline wounds and in 3.6% of transverse incisions. This new suture material is safe and effective for closure of abdominal wounds.     

Incidence of incisional hernias in patients operated on for aneurysm or occlusive disease

The purpose of this study was to evaluate the incidence of postoperative incisional hernias after elective open abdominal aortic aneurysm (AAA) repair versus aortofemoral reconstruction. In this open prospective study, 281 patients who underwent elective open AAA or aortofemoral repair were included. All patients were evaluated by clinical examination 1 month after the operation, every 6 months for the next 5 years, and every year thereafter for the presence of an incisional hernia. Mean duration of follow-up was 63.7 months (range, 12-144 months). Seventeen patients (6.2%) were lost to follow-up. The development of a postoperative incisional hernia was recorded and analyzed with regard to the demographic data and the traditional risk factors for atherosclerosis. Statistical analysis was performed using the Kaplan-Meier method and the Cox regression analysis. The development of a postoperative incisional hernia after AAA surgical repair had an incidence of 16.2 per cent versus 7.4 per cent after aortofemoral reconstruction. Patients electively operated on for AAA have a 3.8-fold increase of developing a postoperative incisional hernia over patients operated on for peripheral occlusive disease (POD).     

The search for an ideal method of abdominal fascial closure: a meta-analysis

BACKGROUND AND OBJECTIVE: The ideal suture for abdominal fascial closure has yet to be determined. Surgical practice continues to rely largely on tradition rather than high-quality level I evidence. The authors conducted a systematic review and meta-analysis of randomized controlled trials to determine which suture material and technique reduces the odds of incisional hernia. METHODS: MEDLINE and Cochrane Library databases were searched for articles in English published from 1966 to 1998 using the keywords "suture", "abdomen/surgery", and "randomized controlled trials". Randomized controlled trials, trials of adult patients, and trials with a Jadad Quality Score of more than 3, comparing suture materials, technique, or both, were included. Two independent reviewers critically appraised study quality and extracted data. The reviewers were masked to the study site, authors, journal, and date to minimize bias. The primary outcome was postoperative incisional hernia. Secondary outcomes included wound dehiscence, infection, wound pain, and suture sinus formation. RESULTS: The occurrence of incisional hernia was significantly lower when nonabsorbable sutures were used. Suture technique favored nonabsorbable continuous closure. Suture sinuses and wound pain were significantly lower when absorbable sutures were used. There were no differences in the incidence of wound dehiscence or wound infection with respect to suture material or method of closure. Subgroup analyses of individual sutures showed no significant difference in incisional hernia rates between polydioxanone and polypropylene. Polyglactin showed an increased wound failure rate. CONCLUSIONS: Abdominal fascial closure with a continuous nonabsorbable suture had a significantly lower rate of incisional hernia. The ideal suture is nonabsorbable, and the ideal technique is continuous.     

Surgical morbidity and mortality in one hundred and twenty-nine patients with obstructive jaundice

One hundred and twenty-nine jaundiced patients were operated upon for the relief of benign and malignant bile duct obstruction during a 10-year period, 1977-86. The overall mortality was 4.7 per cent but increased to 9.1 per cent in patients with a serum bilirubin greater than 300 mumol/l. In all, 46.5 per cent of patients had a rise in postoperative creatinine but renal dysfunction occurred in only 4.7 per cent. Wound infection developed in 3.1 per cent of patients and appeared unrelated to infected bile; 3.9 per cent of patients were treated for postoperative septicaemic episodes. The low morbidity and mortality observed suggests that preoperative biliary drainage need not be considered in routine surgical practice if simple measures to maintain urine flow and prevent postoperative sepsis are used.     

老年患者腹壁切口疝修补术后复发的危险因素探讨及风险列线图模型的建立

目的探讨老年患者腹壁切口疝修补术后复发的危险因素，并建立预测老年患者腹壁切口疝修补术后复发的风险列线图模型。 方法选取2014年1月至2019年12月于南京大学附属鼓楼医院进行诊治的260例行腹壁切口疝修补术老年患者作为研究对象，分析所选患者的临床资料，根据是否复发将所选患者分为复发组和正常组，采用Logistic回归分析筛选老年患者腹壁切口疝修补术后复发的危险因素，并建立老年患者腹壁切口疝修补术后复发的风险列线图模型。 结果260例腹壁切口疝修补术老年患者中术后复发患者36例（13.85%）。单因素分析结果显示，复发组和正常组患者性别、年龄、疝类型、疝部位、补片型号、固定补片、手术类型及饮酒史等资料差异均无统计学意义（P>0.05），而手术时间、医师水平、术后血肿、吸烟史及肥胖等资料差异均有统计学意义（P<0.05）。Logistic回归分析结果显示，手术时间≥120 min、医师水平、术后血肿、有吸烟史及肥胖等为老年患者腹壁切口疝修补术后复发的独立危险因素（P<0.05），均和老年患者腹壁切口疝修补术后复发高度相关。基于手术时间、医师水平、术后血肿、吸烟史及肥胖等老年患者腹壁切口疝修补术后复发的独立危险因素，建立预测老年患者腹壁切口疝修补术后复发的风险列线图模型，C-index指数为0.775（95% CI：0.728~0.823），预测值与实测值基本一致，说明本列线图的辨别力较好，列线图模型预测老年患者腹壁切口疝修补术后复发的受试者工作特征曲线显示，曲线下面积为0.807，表明本研究列线图的预测价值较高。 结论手术时间≥120 min、医师水平、术后血肿、有吸烟史及肥胖等为老年患者腹壁切口疝修补术后复发的独立危险因素，本研究所建立的列线图有助于预测老年患者腹壁切口疝修补术后复发的发生风险。     

Porcine dermal collagen (Permacol) for abdominal wall reconstruction

OBJECTIVE: A review of Eisenhower Army Medical Center's experience using Permacol (Tissue Science Laboratories, Covington, Georgia) for the repair of abdominal wall defects. METHODS: Retrospective review of medical records of patients undergoing abdominal wall reconstruction with Permacol. RESULTS: From July 30, 2003 to February 12, 2005, 9 patients underwent repair of complicated fascial defects with Permacol. Indications for surgery included reoperative incisional hernia repair after removal of a infected mesh (3 patients), reconstruction of a fascial defect after resection of an abdominal wall tumor (2 patients), incisional hernia repair in a patient with a previous abdominal wall infection after a primary incisional hernia repair (1 patient), incisional hernia repair in a patient with an ostomy and an open midline wound (1 patient), emergent repair of incisional hernia with strangulated bowel and multiple intra-abdominal abscesses (1 patient), and excision of infected mesh and drainage of intra-abdominal abscess with synchronous repair of the abdominal wall defect (1 patient). At a median follow-up of 18.2 months, 1 recurrent hernia existed after intentional removal of the Permacol. This patient developed an abdominal wall abscess 7 months after hernia repair secondary to erosion from a suture. Overall, 1 patient developed exposure of the Permacol after a skin dehiscence. The wound was treated with local wound care, and the Permacol was salvaged. Despite the presence of contamination (wound classification II, III, or IV) in 5 of 9 patients (56%), no infectious complications occurred. CONCLUSION: Complex reconstruction of the abdominal wall can be associated with a high complication rate. Placement of a permanent prosthetic mesh in a contaminated field is associated with a high rate of wound infections and subsequent mesh removal. Permacol becomes incorporated by tissue ingrowth and neovascularization. Permacol is a safe and acceptable alternative to prosthetic mesh in the repair of complicated abdominal wall defects.     

Effect of plasma fibronectin on the incisional wound healing in rats

BACKGROUND: Abdominal wall repair after celiotomy is important because insufficient incisional wound strength results in wound failures such as fascial dehiscence and herniation. Plasma fibronectin (pFn) has been shown to play an important role in wound healing. The purpose of this study was to investigate whether pFn improves incisional wound healing in a rat skin incision and celiotomy model. METHODS: Rats underwent a linear skin incision in the dorsal plane or a full-thickness incisional wound (celiotomy) in the abdominal wall. The same operative procedures were performed on rats whose pFn levels were reduced by antirat pFn serum. The wounds were sutured, and purified human pFn or albumin was given intravenously. RESULTS: After the celiotomy, pFn levels decreased immediately and reached a minimum at 3 h after incision. A single injection of pFn (10 mg/kg) significantly increased the breaking strength of the skin and the bursting pressure of the abdominal wall. The amount of hydroxyproline in the skin incisional wound with pFn was significantly greater than with an injection of albumin as control. In rats with pFn levels decreased by antirat pFn serum, a single administration of pFn significantly increased the breaking strength of the skin and the bursting pressure of the abdominal wall compared to a control injection of albumin. CONCLUSIONS: It is important for wound healing to maintain sufficiently high levels of pFn. A single intravenous injection of pFn after celiotomy may be useful in the prevention of fascial dehiscence and herniation.