Antibiotics Versus Appendicectomy for the Treatment of Uncomplicated Acute Appendicitis: An Updated Meta-Analysis of Randomised Controlled Trials

Background

Uncomplicated acute appendicitis has been managed traditionally by early appendicectomy. However, recently, there has been increasing interest in the potential for primary treatment with antibiotics, with studies finding this to be associated with fewer complications than appendicectomy. The aim of this study was to compare outcomes of antibiotic therapy with appendicectomy for uncomplicated acute appendicitis.

Method

This meta-analysis of randomised controlled trials included adult patients presenting with uncomplicated acute appendicitis treated with antibiotics or appendicectomy. The primary outcome measure was complications. Secondary outcomes included treatment efficacy, hospital length of stay (LOS), readmission rate and incidence of complicated appendicitis.

Results

Five randomised controlled trials with a total of 1430 participants (727 undergoing antibiotic therapy and 703 undergoing appendicectomy) were included. There was a 39 % risk reduction in overall complication rates in those treated with antibiotics compared with those undergoing appendicectomy (RR 0.61, 95 % CI 0.44–0.83, p = 0.002). There was no significant difference in hospital LOS (mean difference 0.25 days, 95 % CI ?0.05 to 0.56, p = 0.10). In the antibiotic cohort, 123 of 587 patients initially treated successfully with antibiotics were readmitted with symptoms suspicious of recurrent appendicitis. The incidence of complicated appendicitis was not increased in patients who underwent appendicectomy after “failed” antibiotic treatment (10.8 %) versus those who underwent primary appendicectomy (17.9 %).

Conclusion

Increasing evidence supports the primary treatment of acute uncomplicated appendicitis with antibiotics, in terms of complications, hospital LOS and risk of complicated appendicitis. Antibiotics should be prescribed once a diagnosis of acute appendicitis is made or considered.

     

Use of Prophylactic Antibiotics to Prevent Abscess Formation Following Hepatic Ablation in Patients with Prior Enterobiliary Manipulation

Introduction

Prior enterobiliary manipulation confers a high risk for liver abscess formation after hepatic ablation. We aimed to determine if prophylactic antibiotics could prevent post-ablation abscess in patients with a history of hepaticojejunostomy.

Materials and Methods

This single-institution retrospective study identified 262 patients who underwent 307 percutaneous liver ablation sessions between January 2010 and August 2014. Twelve (4.6?%) patients with prior hepaticojejunostomy were included in this analysis. Ten (83>?%) had received an aggressive prophylactic antibiotic regimen consisting of levofloxacin, metronidazole, neomycin, and erythromycin base. Two (16.6?%) had received other antibiotic regimens. Clinical, laboratory, and imaging findings were used to identify abscess formation and antibiotic-related side effects.

Results

Twelve ablation sessions were performed during the period studied. During a mean follow-up period of 440 days (range, 77–1784 days), post-ablation abscesses had developed in 2 (16.6?%) patients, who both received the alternative antibiotic regimens. None of the 10 patients who received the aggressive prophylactic antibiotic regimen developed liver abscess. One of the 10 patients who received the aggressive prophylactic antibiotic regimen developed grade 2 antibiotic-related diarrhea and arthralgia.

Conclusion

An aggressive regimen of prophylactic antibiotics may be effective in preventing liver abscess formation after liver ablation in patients with prior hepaticojejunostomy.

     

Gasless transumbilical laparoscopic-assisted appendectomy as a safe and cost-effective alternative surgical procedure for mild acute appendicitis

Purpose

Several reports have demonstrated the effectiveness and feasibility of single incisional transumbilical laparoscopic-assisted appendectomy (TULAA). We developed a modified TULAA technique, gasless-TULAA, which involves lifting the abdominal wall with a retractor, without pneumoperitoneum or another incision.

Methods

We assessed the surgical outcomes of 257 patients treated for appendicitis in our hospital between 2005 and 2013. In a preoperative comprehensive evaluation, appendicitis without abscess was defined as mild appendicitis (mild appendicitis group: MAG), and appendicitis with abscess was defined as severe appendicitis (severe appendicitis group: SAG). The clinical outcomes were compared with those in other published reports. The cost-effectiveness of gasless-TULAA was compared with that of conventional multiport laparoscopic appendectomy (CMLA) in our hospital.

Results

In MAG (n = 228), the operation time and postoperative hospital stay were 46.9 ± 22.7 min and 2.6 ± 1.2 days, respectively. The gasless-TULAA was completed without trocars in 91.2 % of patients. The surgical outcomes of SAG were significantly worse than those of MAG (p < 0.001). The surgical cost of gasless-TULAA was significantly lower than that of CMLA (p < 0.001).

Conclusion

Gasless-TULAA is a cost-effective, safe, and readily available surgical technique for mild appendicitis, which can obviate the need for specialized equipment.

     

The current management of acute uncomplicated appendicitis: should there be a change in paradigm? A systematic review of the literatures and analysis of treatment performance

Introduction

Appendectomy has long been the mainstay of intervention for acute appendicitis, aiming at preventing perforation, peritonitis, abscess formation and recurrence. With better understanding of the disease process, non-operative management (NOM) with antibiotics alone has been proved a feasible treatment for uncomplicated appendicitis. This article aimed at systematically reviewing the available literatures and discussing the question whether NOM should replace appendectomy as the standard first-line treatment for uncomplicated appendicitis.

Method

A search of the Embase, Pubmed and Cochrane Library was performed using the keywords ‘acute appendicitis’ and ‘antibiotic therapy’. Meta-analysis with inverse variance model for continuous variable and Mantel Haenzel Model for dichotomous variable was performed to evaluate the one year treatment efficacy, morbidities rate, sick leave duration and length of hospital stay associated with emergency appendectomy and NOM.

Results

Six randomized control trials were identified out of 1943 publications. NOM had a significant lower treatment efficacy rate at one year, 0.10 (95% CI 0.03–0.36, p < 0.01), when compared to appendectomy. The morbidities rate was comparable between the two interventions. The length of hospital stay was longer, with a mean difference of 1.08 days (95% CI 0.09–2.07, p = 0.03), and the sick leave duration was shorter, a mean difference of 3.37 days (95% CI -5.90 to ?0.85 days, p < 0.01) for NOM.

Conclusion

The paradigm remains unchanged, that appendectomy is the gold standard of treatment for uncomplicated appendicitis, given its higher efficacy rate when compared to NOM.

     

Acute Appendicitis: A Weak Concordance Between Perioperative Diagnosis,Pathology and Peritoneal Fluid Cultivation

Background

The classification of acute appendicitis (AA) into various grades is not consistent, partly because it is not clear whether the perioperative or the histological findings should be the foundation of the classification. When comparing results from the literature on the frequency and treatment of AA it is important that the classifications are consistent. Furthermore, in the clinical settings, incorrect classification might lead to over diagnosing and a prolonged antibiotic treatment. The aim of our study was to investigate the concordance between perioperative diagnosis made by the surgeon and the histological findings of the removed appendix and furthermore compare this to the results from cultivation of peritoneal fluid aspirated perioperatively.

Methods

A prospective observational cohort study including patients (≥15 years of age) undergoing appendectomy.

Results

A total of 131 patients were included. In 116 (89 %) of these cases, appendicitis was confirmed histological. There was low concordance between the perioperative and histological diagnoses, varying from 16 to 76 % depending on grade of AA. Only 44 % of the patients receiving antibiotics postoperatively had a positive peritoneal fluid cultivation.

Conclusion

There was a low concordance in clinical and histopathological diagnoses of the different grades of appendicitis. Perioperative cultivation of the peritoneal fluid as a standard should be further examined. The potential could be a reduced postoperative antibiotic use.

Clinicaltrials.gov

Registration no.: NCT02304653.

     

Effect of Anti-TNF Agents on Postoperative Outcomes in Inflammatory Bowel Disease Patients: a Single Institution Experience

Background

Anti-tumor necrosis factor (TNF) agents have been an integral part in the treatment of inflammatory bowel disease. However, a subset of inflammatory bowel disease patients ultimately requires surgery and up to 30 % of them have undergone treatment with anti-TNF agents. Studies assessing the effect of anti-TNF agents on postoperative outcomes have been inconsistent. The aim of this study is to assess postoperative morbidity in inflammatory bowel disease patients who underwent surgery with anti-TNF therapy prior to surgery.

Methods

This is a retrospective review of 282 patients with inflammatory bowel disease undergoing intestinal surgery between 2013 and 2015 at the Mount Sinai Hospital. Patients were divided into two groups based on treatment with anti-TNF agents (infliximab, adalimumab, certolizumab) within 8 weeks of surgery. Thirty-day postoperative outcomes were recorded. Univariate and multivariate statistical analyses were carried out.

Results

Seventy-three patients were treated with anti-TNF therapy within 8 weeks of surgery while 209 patients did not have exposure. Thirty-day anastomotic leak, intra-abdominal abscess, wound infection, extra-abdominal infection, readmission, and mortality rates were not significantly different between the two groups.

Conclusions

The use of anti-TNF medications in inflammatory bowel disease patients within 2 months of intestinal surgery is not associated with an increased risk of 30-day postoperative complications.

     

72 h Is the Time Critical Point to Operate in Acute Appendicitis

Background and Aims

Delay of operative management of acute appendicitis may adversely affect post-operative outcomes and increase the likelihood of post-operative complications occurring. We aim to correlate the duration of symptoms with intra-operative findings to create a timeline of the pathological change in appendicitis.

Methods

Appendicectomies performed at a large teaching hospital between June 2015 and July 2016 were prospectively analysed. Time of onset of pain, operative findings, pre-operative C-reactive protein (CRP) and white cell count (WCC) were recorded. Intra-operative findings were categorised by the macroscopic appearance of the appendix, which was subdivided into erythematous, purulent, necrotic and perforated. These results were correlated with the symptom duration. Statistical analysis was completed using Mann-Whitney U and Chi-squared tests.

Results

One hundred and ninety patients had histologically confirmed appendicitis during the study period. Median time to operation from symptom onset was 49 h. Median time for the appearances of erythematous, purulent, necrotic and perforated appendicitis to develop was 36.5, 41, 55.5 and 86 h, respectively (p value < 0.0001). Median CRP of the non-perforated and perforated appendicitis groups was 22 and 161 mg/L, respectively (p value < 0.0001). Our data demonstrated that after 72 h of symptoms, the likelihood of a perforated appendicitis increased significantly (p value < 0.0001) when compared to 60–72 h.

Conclusions

A significant increase in the likelihood of a perforated appendicitis occurs after 72 h of symptoms, when compared to 60–72 h. We can therefore argue that it may be reasonable to prioritise patients approaching 72 h of symptoms for operative management.

     

Long-Term Results Following Antibiotic Treatment of Acute Appendicitis in Adults

Background

Antibiotic treatment of acute appendicitis has gained interest and inquiries. Reports have demonstrated both safety and high resolution of symptoms and inflammation following antibiotic treatment of appendicitis, but information on long-term results is required. Our present aim was therefore to evaluate long-term recurrence rate of initial antibiotics-alone treatment for suspected acute appendicitis.

Methods

Patients with favourable response to antibiotics in earlier randomized (RCT, n = 97) and population-based (PBT, n = 342) studies as well as subsequently treated non-randomized (Non-R, n = 271) patients are evaluated for long-term risk to relapse demanding surgical appendectomy; altogether 710 patients.

Results

Clinical characteristics among randomized and non-randomized patients were similar without any statistical difference according to abdominal symptoms and degree of systemic inflammation (CRP, WCC) when antibiotic treatment started. Females and males showed the same results. The median follow-up time was 2162 days (5.92 years), and the range across highest and lowest follow-up was 3495 days (range 2–3497) for the entire group, without significant differences among subgroups (RCT, PBT, Non-R). The cumulative probability for relapse of appendicitis demanding appendectomy was: 0.09, 0.12, 0.12 and 0.13 at 1-, 2-, 3- and 5-year follow-up, with a probability of 0.86 ± 0.013 without appendectomy after 8 years. This may imply an overall benefit of 60–70% by antibiotics during expected 10-year follow-up accounting for initial treatment failures at 10–23% in our published reports.

Conclusion

Antibiotic treatment is safe and effective as a first-line therapy in unselected adults with acute appendicitis with a risk around 15% for long-term relapse following favourable initial treatment response.

     

Antibiotics May be Safely Discontinued Within One Week of Percutaneous Cholecystostomy

Background

For patients with acute cholecystitis managed with percutaneous cholecystostomy (PC), the optimal duration of post-procedural antibiotic therapy is unknown. Our objective was to compare short versus long courses of antibiotics with the hypothesis that patients with persistent signs of systemic inflammation 72 h following PC would receive prolonged antibiotic therapy and that antibiotic duration would not affect outcomes.

Methods

We performed a retrospective cohort analysis of 81 patients who underwent PC for acute cholecystitis at two hospitals during a 41-month period ending November 2014. Patients who received short (≤7 day) courses of post-procedural antibiotics were compared to patients who received long (>7 day) courses. Treatment response to PC was evaluated by systemic inflammatory response syndrome (SIRS) criteria. Logistic and linear regressions were used to evaluate associations between antibiotic duration and outcomes.

Results

Patients who received short (n = 30) and long courses (n = 51) of antibiotics had similar age, comorbidities, severity of cholecystitis, pre-procedural vital signs, treatment response, and culture results. There were no differences in recurrent cholecystitis (13 vs. 12%), requirement for open/converted to open cholecystectomy (23 vs. 22%), or 1-year mortality (20 vs. 18%). On logistic and linear regressions, antibiotic duration as a continuous variable was not predictive of any salient outcomes.

Conclusions

Patients who received short and long courses of post-PC antibiotics had similar baseline characteristics and outcomes. Antibiotic duration did not predict recurrent cholecystitis, interval open cholecystectomy, or mortality. These findings suggest that antibiotics may be safely discontinued within one week of uncomplicated PC.

     

Atrial fibrillation after lung cancer surgery: incidence,severity, and risk factors

Purpose

Atrial fibrillation (Af) is a common post-operative cardiac complication after lung cancer surgery; however, the type of lung cancer surgery being performed has evolved, remarkably, into minimally invasive surgical procedures. The purpose of this study was to quantify the incidence and severity of post-operative Af and to identify the risk factors for Af, using a recent cohort of lung cancer surgery patients.

Methods

We reviewed, retrospectively, the medical records of 593 patients, who underwent lung cancer surgery between 2011 and 2013, for the development of post-operative Af.

Results

The overall incidence of post-operative Af in our study was 6.4 % (38/593). Three (8 %) of these 38 patients, subsequently, suffered brain infarction. Multivariate analysis revealed that mediastinal lymph node dissection (OR ND-2/ND-0–1 = 3.06; 95 % CI 1.06–10.9) was associated with the development of post-operative Af.

Conclusion

Omission of mediastinal lymph dissection for patients with early stage lung cancer and a high risk of Af should be considered to prevent post-operative Af.

     

Predictors of an unfavorable outcome 1.5 and 12 years after a first,uncomplicated lumbar disc surgery

Purpose

To identify predictors of both intermediate and long-term unfavorable outcomes after first time, uncomplicated lumbar disc surgery.

Methods

Patients (n = 120) who had undergone lumbar disc surgery were followed up 1.5 and 12 years thereafter. Baseline assessments were carried out 5–8 days after surgery. Clinical outcome was assessed in both follow-ups using the Low Back Pain Rating Scale. Statistical analysis included binary logistic and linear regression.

Results

Unfavorable outcomes were found in 50.5 % (1.5 years) and 52.6 % (12 years) of patients available for follow-up examination. Low pre-operative physical activity and severe pain in the first week after surgery were predictive of an unfavorable post-operative outcome at both follow-ups.

Conclusions

Identified predictors suggest that particular emphasis should put on comprehensive post-operative care at large and encouragement to adapt a physically active lifestyle in particular in rehabilitation concepts after first time uncomplicated lumbar disc surgery.

     

Predicting Acute Appendicitis? A comparison of the Alvarado Score,the Appendicitis Inflammatory Response Score and Clinical Assessment

Background

Patients presenting with suspected appendicitis pose a diagnostic challenge. The appendicitis inflammatory response (AIR) score has outperformed the Alvarado score in two retrospective studies. The aim of this study was to evaluate the AIR Score and compare its performance in predicting risk of appendicitis to both the Alvarado score and the clinical impression of a senior surgeon.

Methods

All parameters included in the AIR and Alvarado scores as well as the initial clinical impression of a senior surgeon were prospectively recorded on patients referred to the surgical on call team with acute right iliac fossa pain over a 6-month period. Predictions were correlated with the final diagnosis of appendicitis.

Results

Appendicitis was the final diagnosis in 67 of 182 patients (37 %). The three methods of assessment stratified similar proportions (~40 %) of patients to a low probability of appendicitis (p = 0.233) with a false negative rate of <8 % that did not differ between the AIR score, Alvarado score or clinical assessment. The AIR score assigned a smaller proportion of patients to the high probability zone than the Alvarado score (14 vs. 45 %) but it did so with a substantially higher specificity (97 %) and positive predictive value (88 %) than the Alvarado score (76 and 65 %, respectively).

Conclusions

The AIR score is accurate at excluding appendicitis in those deemed low risk and more accurate at predicting appendicitis than the Alvarado score in those deemed high risk. Its use as the basis for selective CT imaging in those deemed medium risk should be considered.

     

Comparing Lichtenstein with darning for inguinal hernia repair in an African population

Purpose

Being a relatively new entrant into our practice, mesh repair has not been compared with previously existing tissue-based techniques in our setting. This study is set out to compare darning with Lichtenstein technique of inguinal hernia repair in terms of frequency of post-operative complications, recovery and cost.

Method

Patients with uncomplicated, primary inguinal hernia were randomized to have their hernias repaired either by the Lichtenstein or darning technique. Details of their socio-demographic, hernia characteristics and intra-operative findings were recorded. Postoperatively patients were assessed for pain, wound site complications and recurrence. Both direct and indirect costs were calculated. Mean duration of follow-up was 7.5 months.

Result

Sixty-seven patients were studied. Thirty-three had Lichtenstein repair while 34 had darning repair. Lichtenstein repair was associated with less post-operative pain, less analgesic requirement, and shorter time of return to work activities, these were all statistically significant (p < 0.05). Frequency of post-operative complications was comparable in both groups with wound haematoma and scrotal oedema being the commonest. There was no recurrence in any of the groups. Total cost was comparable between the two groups.

Conclusion

Lichtenstein is superior to darning in terms of post-operative recovery while both techniques are comparable in terms of frequency of early post-operative complications and total cost.

     

Systematic Review and Meta-Analysis of Laparoscopic Versus Open Appendicectomy in Adults with Complicated Appendicitis: an Update of the Literature

Aims

To review and compare the outcomes of laparoscopic (LA) versus open appendicectomy (OA) in complicated appendicitis in adult patients, eight years after the last literature review.

Methods

The PRISMA guidelines were adhered to. Pre-defined inclusion and exclusion criteria were used to search the PubMed, Scopus and Cochrane databases and extract relevant data. Methodological and quality assessment was undertaken with outcome meta-analysis and subgroup analyses of methodological quality, type of study and year of study. Assessment of clinical and statistical heterogeneity and publication bias was conducted.

Results

Three randomised control trials (RCTs) (154LA vs 155OA) and 23 case–control trials were included (2034LA vs 2096OA). Methodological quality was low to average but with low statistical heterogeneity. Risk of publication bias was low, and meta-regression indicated shorter length of hospital stay (LOS) in more recent studies, Q = 7.1, P = 0.007. In the combined analysis LA had significantly less surgical site infections [OR = 0.30 (0.22,0.40); p < 0.00001] with reduced time to oral intake [WMD = -0.98 (-1.09,-0.86); P < 0.00001] and LOS [WMD = -3.49(-3.70,-3.29); p < 0.00001]. There was no significant difference in intra-abdominal abscess rates [OR = 1.11(0.85,1.45); p = 0.43]. Operative time was longer during LA [WMD = 10.51 (5.14,15.87); p = 0.0001] but did not reach statistical significance (p = 0.13) in the RCT subgroup analysis.

Conclusions

LA appears to have significant benefits with improved morbidity compared to OA in complicated appendicitis (level of evidence II).

     

Trans-fascial closure in laparoscopic ventral hernia repair

Background

Laparoscopic incisional hernia repair has become widely accepted in the management of incisional hernias. There has been recent interest in combining fascial closure along with mesh placement to improve outcomes. We report our experience with this technique.

Methods

Cases were evaluated retrospectively from 2012 to 2015. There were no exclusions. Cases were included which involved laparoscopic ventral hernia repair with fascial closure and mesh placement. Fascial closure was performed using non-absorbable sutures passed with a suture passage device percutaneously. A 5-cm overlap was performed using intra-peritoneal mesh. Fixation was performed using absorbable tacks in a double crown technique.

Results

One hundred and twelve cases were included. The mean age was 57 years old (range 33–81 years). Fifty-nine were females and 53 were males. The median post-operative stay for the non-fascial closure group was 0 days (range 0–12 days). The median post-operative stay for the fascial closure group was 0 days (range 0–12 days). All cases were followed up clinically at 6 weeks. In the non-fascial closure group, five patients developed a seroma (12 %). One patient developed a wound infection (3 %). Six patients presented with a recurrence over the study period (15 %). In the fascial closure group, four patients had a seroma, which was managed conservatively (5 %). One patient developed a wound infection (1 %). Five patients developed a recurrence over the study period (7 %).

Conclusion

We have shown comparable rates for seroma and recurrence to other series. Laparoscopic incisional hernia repair with defect closure is feasible and reduces seroma rate and recurrence.

     

The Effect of Unenhanced MRI on the Surgeons’ Decision-Making Process in Females with Suspected Appendicitis

Background

This prospective study evaluated the impact of the results of unenhanced magnetic resonance imaging (MRI) on the surgeon’s diagnosis of acute appendicitis in potentially fertile females.

Methods

112 female patients, aged 12–55, with suspected appendicitis underwent MRI of the abdomen. At three defined intervals; admission and clinical re-evaluation before and after revealing the MRI results, the surgeon recorded the attendance of each patient in operative treatment, observation or discharge. Appendicitis was confirmed or declined by pathology or by telephone follow-up in case of non-intervention.

Findings

Appendicitis was confirmed in 29 of 112 patients. At admission the surgeon’s disposition had a sensitivity of 97 % and specificity of 29 %. After knowing the MRI results, sensitivity was 97 % and specificity 64 %. The sensitivity and specificity of MRI alone were 89 and 100 %, with a negative and positive predictive value of 96 and 100 %, respectively.

Conclusion

We believe that MRI should perhaps be standard in all female patients during their reproductive years with suspected appendicitis. It avoids an operation in 32 % of cases and allows earlier planning for patients with an equivocal clinical picture. Trial number: OND1292733 (Narcis.nl).

     

Patient Adherence and Experience with Extended Use of Prophylactic Low-Molecular-Weight Heparin Following Pancreas and Liver Resection

Background

Guidelines recommend 28 days venous thromboembolism (VTE) prophylaxis with low-molecular-weight heparin (LMWH) following major abdominal surgery for cancer. Overall adherence with these recommendations is poor, but little is known about feasibility and tolerability from a patient perspective.

Methods

An institution-wide policy for routine administration of 28 days of post-operative LMWH following major hepatic or pancreatic resection for cancer was implemented in April 2013. Patients having surgery from July 2013 to June 2015 were approached to participate in an interview examining adherence and experience with extended duration LMWH.

Results

There were 100 patients included, with 81.4 % reporting perfect adherence with the regimen. The most frequent reasons for non-adherence were that a healthcare provider stopped the regimen or because of poor experience with injections. Most patients were able to correctly recall the reason for being prescribed LMWH (82.6 %), and 78.4 % of patients performed all injections themselves. Over half the patients (55.7 %) did not find the injections bothersome.

Conclusion

Patients reported high adherence and a manageable experience with post-operative extended-duration LMWH in an ambulatory setting following liver or pancreas resection. These findings suggest that patient adherence is not a major contributor to poor compliance with VTE prophylaxis guidelines.

     

Outcomes of utilizing absorbable mesh as an adjunct to posterior sheath closure during complex posterior component separation

Background

A minority of patients undergoing posterior component separation (PCS) have abdominal wall defects that preclude complete reconstruction of the visceral sac with native tissue. The use of absorbable mesh bridges (AMB) to span such defects has not been established. We hypothesized that AMB use during posterior sheath closure of PCS is safe and provides favorable outcomes.

Methods

We performed a retrospective review of consecutive patients undergoing PCS with AMB at two hernia centers. Main outcome measures included demographics, comorbidities, and post-operative complications.

Results

36 patients were identified. Post-operative wound complications included five surgical site infections. At a median of 27 months, there were five recurrent hernias (13.9%), 2 of which were parastomal, but no episodes of intestinal obstruction/fistula.

Conclusions

Utilization of AMB for large posterior layer deficits results in acceptable rates of perioperative wound morbidity, effective PCS repairs, and does not increase intestinal morbidity or fistula formation.

     

Ventral hernia repair with lateral component separation and onlay Biodesign graft

Background

Ventral hernia is common, complicating up to 20 % of laparotomies. Plication of the rectus sheath with lateral component separation (LCS) provides a durable repair with acceptable functional outcomes. Additional support to the anterior abdominal wall may be provided by synthetic or biological mesh. Biological grafts invoke local tissue remodeling and result in strong fibrocollagenous tissue able to support the dynamic stressor of the anterior abdominal wall. Biodesign graft is a new graft derived from porcine small-intestine submucosa. We aim to review the use of Biodesign mesh for repair of ventral hernia with LCS.

Methods

Patients underwent ventral hernia repair completed with plication of the rectus sheath, LCS, and use of an onlay Biodesign graft. Data was collected retrospectively. Key outcome measures included post-operative complications and recurrence.

Results

Twelve patients were included for analysis. Mean age was 51.2 years, with 50 % males and a median weight of 87 kg (65–111 kg). Median operative time was 210 min (147 to 278 min) and median length of stay was 4 days. At a mean follow-up of 14.0 months, 8/12 (66 %) developed seroma, 1/12 (8 %) developed abdominal wall abscess, and 1/12 (8 %) suffered flap failure requiring vacuum dressings for closure. No patients were complicated by ventral hernia recurrence.

Conclusions

Our results describe an early Australian experience of onlay Biodesign graft in the context of rectus sheath plication with LCS. We report acceptable rates of post-operative complications and recurrence.Level of evidence: IV, therapeutic study.