Antibiotic prophylaxis in patients undergoing open mesh repair of inguinal hernia: a meta-analysis

The use of antibiotic prophylaxis in hernia repair is still under debate. The aim of this meta-analysis was to assess the effect of antibiotic prophylaxis in patients undergoing open mesh repair of inguinal hernia with respect to incidence of postoperative surgical site infection (SSI). A literature search was conducted in databases of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials. Study selection, data extraction, quality assessment, and meta-analysis were conducted according to the recommendations by Cochrane collaboration. Nine randomized controlled trials were included. Incidence of surgical site infection was 39/1642 (2.38%) in the antibiotic group and 70/1676 (4.18%) in the control group. Antibiotics showed a protective effect in preventing SSI after mesh inguinal hernia repair (odds ratio: 0.61, 95% confidence interval: 0.40-0.92, I(2): 0%). Antibiotic prophylaxis did reduce the incidence of SSI in hernia patients undergoing mesh hernioplasty. The cost effectiveness of antibiotic prophylaxis needs further evaluation.     

The role of antibiotic prophylaxis in prevention of wound infection after Lichtenstein open mesh repair of primary inguinal hernia: a multicenter double-blind randomized controlled trial

OBJECTIVE: To determine whether the use of prophylactic antibiotics is effective in the prevention of postoperative wound infection after Lichtenstein open mesh inguinal hernia repair. SUMMARY BACKGROUND DATA: A recent Cochrane meta-analysis (2003) concluded that "antibiotic prophylaxis for elective inguinal hernia repair cannot be firmly recommended or discarded." METHODS: Patients with a primary inguinal hernia scheduled for Lichtenstein repair were randomized to a preoperative single dose of 1.5 g intravenous cephalosporin or a placebo. Patients with recurrent hernias, immunosuppressive diseases, or allergies for the given antibiotic were excluded. Infection was defined using the Centers for Disease Control and Prevention criteria. RESULTS: We included 1040 patients in the study between November 1998 and May 2003. According to the intention-to-treat principle, 1008 patients were analyzed. There were 8 infections (1.6%) in the antibiotic prophylaxis group and 9 (1.8%) in the placebo group (P = 0.82). There was 1 deep infection in the antibiotic prophylaxis group and 2 in the placebo group (P = 0.57). Statistical analysis showed an absolute risk reduction of 0.19% (95% confidence interval, -1.78%-1.40%) and a number needed to treat of 520 for the total number of infections. For deep infection, the absolute risk reduction is 0.20% (95% confidence interval, -0.87%-0.48%) with a number needed to treat of 508. CONCLUSIONS: A low percentage (1.7%) of wound infection after Lichtenstein open mesh inguinal (primary) hernia repair was found, and there was no difference between the antibiotic prophylaxis or placebo group. The results show that, in Lichtenstein inguinal primary hernia repair, antibiotic prophylaxis is not indicated in low-risk patients.     

A randomized, double-blind, placebo-controlled trial to determine effectiveness of antibiotic prophylaxis for tension-free mesh herniorrhaphy

BACKGROUND: In recent years, use of prosthetic material for inguinal hernia repair has increased dramatically. Tension-free repairs have gained popularity not only for recurrent or complicated hernias, but for primary hernia repairs as well. Although routine use of prophylactic antibiotics is not recommended in the Philippines for open nonimplant herniorrhaphy, there is little direct clinical evidence on which to base recommendations when implantable mesh is used. STUDY DESIGN: We conducted a prospective, randomized, double-blind, placebo-controlled trial comparing wound infection rates in 360 patients (180 received prophylactic antibiotics, 180 received a placebo) undergoing primary inguinal hernia repair electively using polypropylene mesh. Age, gender, American Society of Anesthesiologists class, type of hernia, type of anesthesia, and duration of operation were recorded. Infections were evaluated 1 week, 2 weeks, and 1 month after operation by an independent surgeon. All complications were recorded. Results were assessed using chi-square, Fisher's exact test, and Student's t-tests as appropriate. RESULTS: Groups were well matched for all preoperative variables studied, including comorbid conditions. Six patients from the antibiotic group and four from the placebo group failed to followup after the second week. Superficial surgical site infection developed in 3 patients (1.7%) from the antibiotic group and 6 (3.3%) from the placebo group (p = 0.50). One from each group developed deep surgical site infection. Both patients were readmitted and underwent repeated debridement, which eventually resulted in graft loss. CONCLUSIONS: Preoperative administration of single-dose antibiotic for tension-free inguinal mesh herniorrhaphy did not markedly decrease risk of wound infection in this patient population. Our results do not support use of antibiotic prophylaxis for tension-free mesh herniorrhaphy.     

Use of systemic antibiotics for prophylaxis in surgery: a critical review.

We reviewed the English-language literature over a 16-year period (1960 through 1976) on the subject of prophylaxis with systemic antibiotics in surgery. Trials in genitourinary and cardiovascular surgery were not reviewed. Our definition of prophylaxis is antibiotic administration of the absence of infection or contamination. Of 131 articles reporting clinical trials using systemic antibiotics for prophylaxis, only 24 met the criterion on an appropriately designed study that generated evaluable data. In these, systemic antibiotics were shown to be of value in reducing wound infections after abdominal and vaginal hysterectomy, cesarean section, biliary surgery, total hip replacement, and microneurosurgical craniotomy. Antibiotic prophylaxis was of no value in laparotomy and groin hernia repair. Patients undergoing any of 21 different operations did not benefit from prophylactic antibiotic administration, though study groups were too small or infection rates too low to allow for firm conclusions. In certain patients at high risk of infection, systemic prophylaxis is warranted. Future clinical studies must be designed as randomized, blinded, prospective trials, with antibiotics administered by a parenteral route beginning preoperatively.     

The role of antibiotic prophylaxis on wound infection after mesh hernia repair under local anesthesia on an ambulatory basis

Mesh prosthesis, local anesthesia, and ambulatory care have been widely introduced in recent decades in the treatment of inguinal hernia. The use of antibiotic prophylaxis during open inguinal hernia repair has been controversial. No prospective trial has been conducted to assess the role of antibiotic prophylaxis in patients operated on for inguinal hernia under the above-mentioned conditions. A prospective, randomized, double-blinded trial was initiated to assess the efficacy of antibiotic prophylaxis in the prevention of wound infection during open mesh inguinal hernia repair under local anesthesia on an ambulatory basis. Ninety-nine consecutive hernia repairs were randomized to receive 1 g of parenteral Cefazolin preoperatively or a placebo. No wound infections existed in the therapeutic group (0/50). Four infections appeared in the control group (4/49), and the study was suspended for ethical reasons when differences reached values close to statistical significance (P=0.059). We conclude that a single dose of intravenous Cefazolin decreases the risk of wound infection during open mesh inguinal hernia repair under local anesthesia on an ambulatory basis.     

Groin hernia repair in Scotland

BACKGROUND: The use of mesh for groin hernia repair has dramatically changed the way this common operation is performed. The aim of this study was to survey the methods of groin hernia repair in Scotland and to assess patient satisfaction with the operation. METHODS: Between 1 April 1998 and 31 March 1999 all patients who underwent groin hernia repair in the National Health Service in Scotland were identified. As well as looking at the type of hernia repair performed and postoperative morbidity, patients were sent a Short Form-36 about 3 months after the operation to assess satisfaction and return to normal activity. RESULTS: Information was obtained on 5506 (97 per cent) of patients who underwent groin hernia repair during the study period. Eighty-five per cent of patients had an open mesh repair and 4 per cent had a laparoscopic repair. Most operations (85 per cent) were performed using general anaesthesia on an inpatient basis (78 per cent), and 8 per cent were for repair of a recurrent hernia. Potentially serious intraoperative complications were rare (seven patients), although they were significantly (P < 0. 001) more likely to be associated with a laparoscopic approach or repair of a femoral hernia: relative risk compared with open inguinal hernia repair 33 (95 per cent confidence interval (c.i.) 6-197) and 22 (95 per cent c.i. 3-152) respectively. Wound complications were common and 10 per cent of patients required a district nurse to attend the wound. Patients expressed a high degree of satisfaction; 94 per cent would recommend the same operation to someone else if required. CONCLUSION: An open mesh repair using general anaesthesia has become the repair of choice for a groin hernia in Scotland. Despite a high incidence of wound complications, patients are satisfied with this operation.     

Mesh compared with non-mesh methods of open groin hernia repair: systematic review of randomized controlled trials

BACKGROUND: Open tension-free methods of groin hernia repair have been widely adopted despite little rigorous evaluation. METHODS: Information was assimilated from all randomized or quasi-randomized trials comparing open mesh with open non-mesh methods to assess benefits and safety. Electronic databases were searched and members of the EU Hernia Trialists Collaboration consulted to identify trials. Prespecified data items were extracted from reports, and quantitative or, if not possible, qualitative meta-analysis was performed. RESULTS: Fifteen eligible trials, which included 4005 participants, were identified. There were similar numbers of complications in each group, with few data to address short-term pain and length of stay in hospital. Return to usual activities was quicker in the mesh group for seven of ten trials (P not significant). There were fewer reported recurrences in the mesh groups: overall 21 (1.4 per cent) of 1513 versus 72 (4.4 per cent) of 1634 (odds ratio 0.39 (95 per cent confidence interval 0.25-0. 59); P < 0.001). CONCLUSION: Although the rigorous search maximized trial identification, formal meta-analysis was limited by the variation in trial reporting. Within the data available, mesh repair was associated with fewer recurrences.     

Progressive fascial wound failure impairs subsequent abdominal wall repairs: a new animal model of incisional hernia formation

BACKGROUND: Fascial wound failure alters the phenotype of the abdominal wall. This study introduces a novel animal model of progressive failure of the ventral abdominal wall fascia, which generates large incisional hernias. MATERIAL AND METHODS: A mechanistic model of incisional hernia was compared with a model of acute myofascial defect hernia repair. Using biological tissue repair markers, tensiometric measurements and recurrent hernia rate, we measured the mechanism by which incisional hernias regenerate abdominal wall structure and function after mesh and suture herniorrhaphy. RESULTS: Recurrent incisional hernia formation was significantly increased after repairs of the hernia model, compared with the myofascial defect model (6/16 vs 0/16, P < .05). In the hernia model, there were significant decreases in the recovery of wound strength, energy, and extensibility before mechanical disruption, compared with the myofascial defect model. Unexpectedly, excision of fascial hernia wound edges did not significantly improve tissue repair outcomes in the hernia model group. CONCLUSIONS: Clinically accurate animal modeling can recreate the wound pathology expressed in mature incisional hernias. Progressive fascial wound failure decreases the fidelity of subsequent incisional hernia repair, compared with identically sized acute abdominal wall defect repairs. The mechanism appears to include decreased fascial wound strength and decreased tissue compliance after herniorrhaphy.     

Late-onset deep mesh infection after inguinal hernia repair

Background Groin sepsis requiring mesh removal is said to be a rare complication of tension-free inguinal hernioplasty. Furthermore, late-onset deep-seated prosthetic infection seems to be an unexpected complication. The aim of this study was to report our experience on late mesh infection occurring years after open hernia repair. Methods Between 1998 and 2005, 1,452 patients (954 men), median age 64 years (range 19–89) underwent groin hernioplasty using a tension-free polypropylene mesh technique. Five patients (0.35%) appeared with late mesh infection (between 2 and 4.5 years postoperatively). The patients’ records were retrospectively reviewed for the purpose of this study. Antibiotic prophylaxis had been given in the five patients, while none of them had a prior history of wound infection. Results The patients were re-operated and the meshes were removed. Pus was found in three patients and Staphylococcus aureus was isolated in one. There was no hernia recurrence and none of the patients had chronic groin pain for a period of 6–44 months postoperatively. Conclusion From the results of this study, it appears that late-onset deep-seated prosthetic mesh infection is an important complication which has been rarely reported upon. Its true incidence is yet to be established. Late graft infection does not seem to correlate to neither the administration or not of antibiotic prophylaxis, nor to the presence or not of previous superficial wound infection. Furthermore, graft infection does not seem to correlate to neither the type of mesh inserted, nor to the fixation material. With the increasing use of synthetic materials for primary and recurrent hernia repair, the number of patients presenting with late mesh infections is likely to increase.     

The internal retention repair of massive ventral hernia

We report the results of a new method of primary repair of massive ventral hernia in 409 patients using internal retention sutures. Notably, 40 per cent of these patients had failed Marlex mesh repairs. The mean transverse diameter of their hernial defects was 10.4 +/- 0.7 cm (range, 4-18 cm). The overall recurrence rate was 2.5 per cent, superior to other methods of primary repair, and equal or superior to Marlex mesh repair. Wound infection occurred in 5 per cent. The risk of wound infection was significantly increased (P less than 0.05) in patients with a history of prior wound infection. We conclude that the internal retention method of primary repair of ventral hernia for defects less than 18 cm in diameter is equal to Marlex in the repair of previously infected recurrent hernias of this size.     

腹壁切口疝的外科治疗(附53例临床分析)

目的总结治疗腹壁切口疝的临床经验.方法对1994年4月～2002年8月53例腹壁切口疝患者在年龄、手术方法、引流放置,抗生素应用及预后进行回顾性分析.结果53例患者采用人工合成材料或直接缝合修补.术后切口积液3例,无切口感染.随访时间3月～5年,治愈46例,复发7例.结论腹壁切口疝是腹部手术后常见的并发症之一,尤其是老年患者.合理使用人工合成材料及直接缝合修补法适可以获得良好的治疗效果.     

Early results from the use of the Lichtenstein repair in the management of strangulated groin hernia

Background Use of prosthetic repairs in the management of strangulated hernias has so far been very limited due to the fear of an associated higher incidence of complications, especially those related to the presence of the mesh. The aim of this study was to prospectively determine whether the use of the Lichtenstein repair in the management of strangulated groin hernias was associated with a higher rate of wound infection and/or mesh-related complications than in the elective setting. Patients and methods The results obtained from the use of the Lichtenstein repair in the management of 25 patients with strangulated groin hernias (group I) were compared to those of another 25 age- and sex-matched patients undergoing Lichtenstein repair for elective groin hernia repair (group II). Results In group I, one patient (4%) developed a scrotal hematoma. No other postoperative complications were encountered, whether related or unrelated to the presence of the mesh. No complications were encountered in group II patients. Throughout the 20-month duration of the present study, no mesh had to be removed and no recurrences were encountered in either group. Conclusion The good short-term results of the present study in terms of absence of wound infection, mesh-related complications and recurrence suggest that use of the Lichtenstein repair in the management of strangulated groin hernias is safe and is not associated with a higher rate of complications compared to its use in the elective setting.     

Massive incisional hernia: abdominal wall replacement with Marlex mesh

Marlex (polypropylene) mesh was used to replace the abdominal wall in massive incisional herniation in 50 patients. Seventeen unsuccessful attempts at primary repair had previously been made on nine patients. Patient follow-up ranged from 6 to 120 months (mean = 45 months). There was minor hernia recurrence in four (8 per cent) patients. In each instance it was due to partial detachment of the peripheral fixation of the patch. Complications were: wound infection, four (8 per cent); wound seroma, two (4 per cent); wound haematoma, one (2 per cent); and wound sinus, six (12 per cent). Complications did not necessitate removal of the patch in any case. Inadequate peripheral attachment of the patch has been the only cause of hernia recurrence and should be avoidable.     

Prophylactic antibiotics for mesh inguinal hernioplasty: a meta-analysis

OBJECTIVE: To assess the effectiveness of antibiotic prophylaxis in mesh hernioplasty. BACKGROUND: Antibiotic prophylaxis use in mesh inguinal hernioplasty is controversial. Available evidence is nonconclusive because of the low number of clinical trials assessing its effectiveness. Some trials have a small sample size that could overestimate or underestimate the real effectiveness of this intervention. Meta-analysis is a good method to improve these methodological flaws. METHODS: Meta-analysis intended to measure the benefits of antibiotic prophylaxis on surgical site infection rate in adult patients scheduled for mesh inguinal hernioplasty. Six randomized clinical trials were found. Quality was assessed using Cochrane Collaboration criteria. RESULTS: A total of 2507 patients were analyzed. Surgical site infection frequency was 1.38% in the antibiotic group versus 2.89% in the control group (odds ratio = 0.48; 95% confidence interval, 0.27-0.85). There was no statistical heterogeneity. Sensitivity analysis by quality did not show differences in overall results. CONCLUSION: Antibiotic prophylaxis use in patients submitted to mesh inguinal hernioplasty decreased the rate of surgical site infection by almost 50%.     

Hernia repair in elderly patients

Background This study evaluates a 5-year experience of the management of the most frequent abdominal wall hernias in an elderly population. Methods From April 1990 to December 1995, 231 inguinal, 12 femoral and seven umbilical hernias were repaired in 221 patients (mean age 74 (range 66–93) years). Concomitant diseases were present in 157 patients, A mesh repair was performed with ‘tension-free’ or ‘plug’ techniques in all but 23 inguinal and two femora! hernia repairs, in which the Bassini or Shouldice procedures were adopted. Ten emergency hernia repairs were performed for strangulation. A total of 232 operations, including four emergency hernia repairs, were carried out under local anaesthesia. Results There was no perioperative mortality. Acute intestinal bleeding occurred 2 days after surgery in a patient with colonic diverticular disease. Urinary retention occurred once following emergency hernia repair under general anaesthesia and twice after elective hernia repair under local anaesthesia. Local complications included four scrotl haematomas (2 per cent), three wound infections (1 per cent) and one case of orchitis with atrophy after repair of a recurrent hernia. There was one recurrence after a Bassini repair and one after Shouldice inguinal herniorrhaphy. No recurrence was observed after mesh repair. Conclusion Local anaesthetic mesh hernia repair is safe and effective in elderly patients. Age should be no bar to elective hernia repair. This policy should avoid the complications of emergency operation.     

抗生素对降低聚丙烯材料植入疝修补术后手术部位感染的价值探讨

目的评价预防性使用抗生素能否降低聚丙烯材料植入疝修补术后外科手术部位感染的发生率。方法 2011年1～12月我院择期聚丙烯材料植入疝修补术治疗成人腹股沟疝患者396例,选择年龄≤75岁,未合并糖尿病、肺部感染、肾脏功能不全、肝功能不全、免疫功能低下的患者339例,分成未用抗生素组(A组)165例,应用抗生素组(B组)174例,比较二组术后外科手术部位感染率。结果二组患者全部获得3个月以上的随访,A组术后发生局部血清肿4例,B组术后发生局部血清肿5例,均在严格无菌条件下局部抽吸及加压包扎后缓解。二组均无外科手术部位感染。结论预防性使用抗生素对降低聚丙烯材料植入疝修补术后外科手术部位感染的发生率并无价值。     

Incisional hernia repair in Sweden 2002

Incisional hernia is a common problem after abdominal surgery. The complication and recurrence rates following the different repair techniques are a matter of great concern. Our aim was to study the results of incisional hernia repair in Sweden. A questionnaire was sent to all surgical departments in Sweden requesting data concerning incisional hernia repair performed during the year 2002. Eight hundred and sixty-nine incisional hernia repairs were reported from 40 hospitals. Specialist surgeons performed the repair in 782 (83.8%) patients. The incisional hernia was a recurrence in 148 (17.0%) patients. Thirty-three per cent of the hernias were subsequent to transverse, subcostal or muscle-splitting incisions or laparoscopic procedures. Suture repair was performed in 349 (40.2%) hernias. Onlay mesh repair was more common than a sublay technique. The rate of wound infection was 9.6% after suture repair and 8.1% after mesh repair. The recurrence rate was 29.1% with suture repair, 19.3% with onlay mesh repair, and 7.3% with sublay mesh repair. This survey revealed that there is room for improvement regarding the incisional hernia surgery in Sweden. Suture repair, with its unacceptable results, is common and mesh techniques employed may not be optimal. This study has led to the instigation of a national incisional hernia register.     

Chronic pain after laparoscopic and open mesh repair of groin hernia

BACKGROUND: The aim of this study was to compare the incidence of chronic pain or discomfort after laparoscopic totally extraperitoneal (TEP) repair and open mesh repair of groin hernia, and to assess the impact of such pain on patients' physical activity. METHODS: A postal questionnaire was sent to patients who had TEP or open mesh repair of groin hernia between January 1998 and December 1999. The patients were asked about any persistent pain or discomfort in relation to the groin hernia repair and whether this pain or discomfort restricted their ability to undertake physical or sporting activity. RESULTS: Of the 560 available patients 454 (81.1 per cent) replied. Laparoscopic TEP repair was performed in 240 patients (52.9 per cent) and open mesh repair in 214 (47.1 per cent). Of the 454 patients, 136 (30.0 per cent) reported chronic groin pain or discomfort, which was significantly more common after open repair than after laparoscopic repair (38.3 versus 22.5 per cent; P < 0.01). Chronic groin pain or discomfort restricted daily physical or sporting activity in 18.1 per cent of the patients. The patients who had open repair complained of significantly more restriction of daily physical activity than patients who underwent laparoscopic repair (walking, P < 0.05; lifting a bag of groceries, P < 0.01). CONCLUSION: Chronic pain or discomfort was reported by 30.0 per cent of patients after groin hernia repair and was significantly more common after open mesh repair than after laparoscopic TEP repair. It restricted physical or sporting activities in 18.1 per cent of the patients and significantly more so after open mesh repair.     

Fate of the inguinal hernia following removal of infected prosthetic mesh

Open tension-free hernioplasty using a prosthetic mesh is a common operation for inguinal hernia repair because of the relative ease of the operation and low recurrence rate. Wound infection is a potential complication of all hernia repairs and deep-seated infection involving an inserted mesh may result in chronic groin sepsis which usually necessitates complete removal of mesh to produce resolution. Removal of mesh would potentially result in a weakness of the repair and subsequent hernia recurrence. We reviewed the outcome of all our patients who had mesh removal for sepsis over an 8-year period, particularly examining for hernia recurrence and chronic groin pain. This was a retrospective review of the database of patients who had mesh repair of inguinal hernias over an 8-year period. There were 2,139 inguinal hernias repaired using prosthetic mesh. All patients who had mesh removal for infection were identified and followed up. Fourteen patients had deep-seated wound infection which required mesh removal for resolution of sepsis. No peri-operative complications occurred during mesh removal. After a median follow-up of 44 months (range 5–91 months), there were two asymptomatic recurrences and none of the patients had chronic groin pain. Hernia recurrence is uncommon following mesh removal for chronic groin sepsis, suggesting that the strength of a mesh repair lies in the fibrous reaction evoked within the transversalis fascia by the prosthetic material rather than in the physical presence of the mesh itself. When there is established deep infection, there should be no unnecessary delay in removing an infected mesh in order to allow resolution of chronic groin sepsis.     

The use of the Kugel mesh in ventral hernia repairs

BACKGROUND: The management of ventral hernias is a common problem. Goals of hernia repair include reduction of the contents, reperitonealization of the abdomen, repair of the fascial defect, and restoration of the normal abdominal wall contour. Repairs frequently require the use of mesh to reduce the incidence of recurrence. A variety of repair techniques have been described, often associated with significant pain, prolonged recovery, and complications. METHODS: We describe a technique using a partial component separation, reperitonealization of the abdominal cavity with the hernia sack, and insertion of the Kugel mesh for bridging the gap. RESULTS: We have used this technique on 65 ventral hernias. Fifty-two patients went home from the recovery room and 11 stayed less than 23 hours. One patient had a wound infection and 2 had seromas. There have been no recurrences to date. CONCLUSIONS: Repair of ventral hernias with the Kugel mesh using a partial component separation is safe, effective and durable.