Transcript الشريحة 1 - MEDtube.net

Tissue Versus Mesh Repairing
Incisional Hernia among Patients
Admitted to Aden Hospitals
2008 – 2010
Prepared by
Dr. Samah Ali Mansoor Mater
Supervisor
Professor Dr. Ali Karama Bin Taleb
Co. Supervisor
Assist. Professor Dr. Abdull-Hakeem Al-Tamimi
Advisor
Professor Dr. Aldo Sisto Diaz
Feb 26, 2012
INTRODUCTION
Incisional hernia
Is an abdominal wall defect that
occurs through an acquired scar,
and allows the protrusion of the
abdominal
cavity
structure(s) through
it on Valsalva
maneuver.
contained
10% of abdominal wall hernias.
Complication in (11%) of the laparotomies.
In Al- Gamhouria Modern hospital, in Aden:
5.7% of overall hernias admissions.
2.4% of surgical admissions.
This high incidence contribute to both patient
morbidity and health care costs.
The incidence worldwide remained relatively
stable during the last century despite medical
advances, gives testimony to the poor
understanding of the pathophysiology.
 Inadequate current repair
approaches in many respects.
This difficult task is likely because of:
– The multifactorial nature of incisional
hernias.
– Some of the factors that cause incisional
hernias to occur, will persist in certain
patients at the time of the repair.
Repair still a formidable challenge
for all surgeons.
No consensus about which type of
repair (Tissue or Mesh) is best.
Aim of the presented study
Compare Tissue and Mesh open repairs by
highlighting on:
The Complications occurred after each
one of them.
Some associated factors with those
complications.
PATIENTS
AND
METHODS
Descriptive,
prospective,
hospital based study
Consecutive
ventral
patients
incisional
with
hernia
operated in General Surgery
ward at Aden
Hospitals
June 1st 2008 – June 1st 2010
Exclusion criteria
– American Society of Anesthesiologists (ASA)
Class > III.
– Parastomal hernias and recurrent inguinal
hernias.
– Severe psychiatric or neurological diseases.
– Operated using laparoscopic repair approach.
American Society of Anesthesiologists' Physical
Status Classification
Class IV
Patient with incapacitating systemic
disease that is life threatening
Class V
Moribund patient not expected to
survive 24 hr without an operation
Definitions of the studied variables
Incisional hernia:
involved the anterior abdominal wall.
Obesity:
body mass index ≥ 30kg/m2.
The repair type:
- Tissue repair ► autogenous tissue
using only sutures (monofilament
non-absorbable), regardless the
technique.
- Mesh repair ► mesh (polypropylene
“prolene”) was used, regardless the
technique.
Surgeon specialists:
- Senior specialists ► experience was
>10 years.
- Junior specialists ► experience was
≤10 years.
Statistical analysis
Qualitative variables:
Frequencies with percentages
Chi-Square and Fisher Exact tests.
Quantitative variables:
Mean ± standard deviation
Student t test.
15
Predictor variables association:
Odds ratio (OR), with 95% confidence interval
(CI).
P-value of <0.05 was considered statistically significant.
RESULTS
Mesh
repair
67.8%
Tissue
repair
32.2%
Percentages of the types of hernia repair
in the studied patients
Distribution of the studied patients by
sex and type of hernia repair
Sex
Similar
Tissue
repair Mesh repair
Total
( n Hatti
= 29 )RN and( nMazidah
= 61 ) TM (from
n= 90 )
No.
Male
Female
14
15
%
AdenNo. Yemen
%
No.
Hameed et al from
48.3
15
24.6
29
Pakistan
51.7
46
75.4 et 61
Mehrotra
et al, Qadri
al,
%
32.2
67.8
Manohar et al,
Percentages calculatedMahabhaleshwar
by columns
et al from
Chi square test [χ2 : 5.05, p: 0.02]India
statistically significant
Distribution of the studied patients by
age group and type of hernia repair
Age group
(years)
< 30
30-39
40-49
50-59
≥ 60
Mean ± SD*
Range
Tissue repair
Mesh repair
Total
Consistent
( n = 29 )
( n = 61 )
( n= 90 )
Ammar et al from Eygpt 38
No.
%
No.
%
No.
%
Horowitz et al from United States of America 43.1
Memon et al from Pakistan 45
2
6.9
2
3.3
4
4.4
Basoglu et al from Turkey 52
8 Similar
27.6
8
13.1
16
17.7
Moussavian
et al from
5Hameed
17.2 et
39.3 53.4
al 24
andGermany
Memon
et29al from32.2
States of America
60
7 Xourafas
24.1et al from
14United 23.0
21
23.3
Pakistan
from Spain
7 Moreno-Egea
24.1 et al13
21.3 64
20
22.2
47.7 ± 14.7
24 – 75
49.0 ± 10.7
24 – 75
48.6 ± 12
24 – 75
Percentages
Similar calculated by columns
Chi square test [χ2 : 5.96, p: 0.20] statistically insignificant
Al-Salamah et al from Kingdom of Saudi Arabia ( 46.2 and 47.7
*Student t- test for 2 means [F: 0.22, p:0.63] statistically insignificant
respectively)
Percentages of risk factors by the
type of hernia repair
Risk factors in the studied patients by the type of hernia repair
Risk factors
(37 patients had ˃ 1)
Obesity
Tissue repair Mesh repair
Total
( n = 29 )
( n = 61 ) ( n= 90 )
No.
%
No.
%
No.
%
8
27.6
21
34.4
29
32.2
0.51
14.4
11.1
32.0%
13.3
6.7
5.6
0.24
,0.10
0.13
0.08
0.52
14
15.6
0.49
11
12.2
0.24
3
3.3
0.69
Co-morbidity
Malnutrition
6
20.7
7
11.5
13
Similar
Diabetes
mellitus et al from United
1
3.4States
9 of 14.8
10
Gleysteen
America
Chronic
pulmonary
disease
6
20.7
6
9.8
12
Nearly
Midway
Al-Hawaz study from4 Iraq
28.2%
, and
Chronic constipation
13.8
2
3.3
6
Johansson
et al 2from
Sweden
84.9
% and
Hameed
et al
from
Pakistan
40%
Chronic obstructive
uropathy
6.9
3
5
Abel-Baki
Cigarette smoking
et al 5from17.2
Eygpt9 42.9%
14.8
Lower than
Heavy lefting work
2
6.9
9
14.8
Hidalgo
et
al
study
from
Spain
57%
Lower than
Medications (steroids)
P
1
3.4
2
3.3
Klink et al study from Germany 32% ,
Multiple laparotomies
6
20.7
15 United
24.6 States
21 of 23.3
Veljkovic et al and Gleysteen
et
al from
Allergic diseases
4 , respectively.
13.8
5
8.2
9
10
America 48.3% and 50.4%
No risk factor detected
5
17.2
9
14.8
14
15.6
0.68
0.31
0.76
Percentage
General surgery
Gynecology and
Obstetrics surgery
Other Specialties
surgery
Percentages of the original operation
by the type of hernia repair
Original operations in the studied patients by the type of hernia repair
Tissue repair
( n = 29 )
No.
%
Original operation
General surgery:
Appendectomy
Similar
Mesh repair
( n = 61 )
No.
%
Total
( n= 90 )
No.
%
Similar
4
13.8
13
21.3
17
Similar
Al-Salamah et al from
Para-umbilical hernia
6
20.7
8
13.1
14
Kingdom
of
Saudi
Arabia
Basoglu et al, and
Al-Hawaz from
Open cholecystectomy
2 Iraq
6.9 58.9%
4
6.6
6
Yildirim
et al
from
Miscellaneous
4
13.8
10
Memon et 16.4
al from14
TurkeyPakistan
Subtotal
16
55.2
35
57.4
51
18.9
15.6
6.7
15.6
56.7
Gynecology and Obstetrics surgery:
Agbakwuru
et
24.1
13
21.3al from
20
Similar
Hysterectomy
2
6.9
7Nigeria
11.5
9
Miscellaneous Al-Hawaz from
1 Iraq
3.4 31.8%
3
4.9
4
Bhat
et al37.7
from 33
Subtotal
10
34.5
23
India
Cesarean section
Other Specialties surgery
Percentages calculated by columns
7
3
10.3
3
4.9
6
Chi square test [χ2 : 2.85, p: 0.89] statistically insignificant
22.2
10.0
4.4
36.7
6.7
Original Operation
Emergency
Similar
Chawla et al, Bhat et al from India
and Agbakwuru et al from Nigeria
Elective
Original operation by
the type of repair
37.7
Mesh Repair
62.3
Emergency
Elective
41.4
Tissue Repair
58.6
0
20
40
60
80
Incision of original operation by the type of repair
Incisions of original
Tissue repair
n = 29
operation
No.
Midline
Midline
15
Paramedian
5
Upper transverse
-
Mesh repair
n = 61
Similar
Total
n = 90
Zarin
et No.
al from%Pakistan
%
No.
Shukla et al from India
51.7 from
22 Canada
36.1
37
Birch
Hawn
al from
17.2 et 10
16.4United
15
States of America
-
5
8.2
5
Statistics
%
41.1
16.7
5.6
Lower transverse
5
17.2
14
23
19
21.1
Subcostal
1
3.4
2
3.3
3
3.3
Gridiron
2
6.9
8
13.1
10
11.1
Drain’s stab wound
1
3.4
-
-
1
1.1
χ2: 6.65
p: 0.35
Similar
Manohar et al from India 26%
Chawla et al from India 30%
Bhattarai et al from Nepal 32%
Khan et al from Pakistan 34%
Similar
Manohar et al from India 26%
Chawla et al from India 30%
Bhattarai et al from Nepal 32%
Khan et al from Pakistan 34%
History of incisional hernia by the type of hernia repair
Tissue repair Mesh repair
Total
(Consistent
n = 29 )
( n = 61 ) ( n= 90 )
History of previous repair operation
P
64.5%No. % No. %
Al-Hawaz from No.
Iraq 64.5%
%
Al-Ebous et al from Jordan 65.4%
No
previous
repair
No previous
repair
20
69.0
43
70.5
63 70.0
70.0
69.0
70.5
70.0
Finan et al 72%
72% , Xourafas et al 75.7%
75.7%
and Hawn et al 878.4%
78.4%
from
One previous repair
27.6
11
18.0
19
21.1
United States of America
More than one previous repair
Mean duration of hernia (months)
*Calculated
by the Chi square test
**Calculated by the Student t-test.
1
3.4
15.5 ± 22.8
(2 – 180)
7
11.5
32.7 ± 38.2
(2 - 180)
8
0.32*
8.9
27.1 ± 34.8
(2 - 180)
p< 0.05 is statistically significant
0.02**
History of incisional hernia by
the type of hernia repair
Tissue repair Mesh repair
Total
( n = 29 )
( n = 61 ) ( n= 90 )
History of previous repair operation
P
No.
%
No.
%
No.
%
No previous repair
20
69.0
43
70.5
63
70.0
One previous repair
8
27.6
11
18.0
19
21.1
More than one previous repair
1
3.4
7
11.5
8
8.9
Meanduration
durationofofhernia
hernia(months
(months)
Mean
)
*Calculated
by the Chi square test
**Calculated by the Student t-test.
15.5 ± 22.8
(2 – 180)
(2 – 180)
32.7 ± 38.2
(2 - 180)
(2 – 180)
27.1 ± 34.8
(2 - 180)
p< 0.05 is statistically significant
0.32*
0.02**
Defect diameter by the type of hernia repair
Defect diameter (cm)
Mesh repair
Total
( n = 61 ) ( n= 90 )
P
No.
%
No.
%
No.
%
<5
14
48.3
2
3.3
16
17.8
5 – 10
15
51.7
37
60.7
52
57.8
-
-
22
36.1
22
24.4
> 10
- Mean defect diameter (cm)
**Calculated
Tissue repair
( n = 29 )
5.2 ± 2.4
(2 – 10)
by the Chi square test
9.4 ± 4.2
(3 – 25)
8.1 ± 4.2
(2 – 25)
0.0000**
0.0000**
p< 0.05 is statistically significant
Repair operation circumstances by
the type of hernia repair
Repair operation circumstances
Tissue repair
( n = 29 )
No.
Elective
No.
%
No.
P
%
21
Similar
Hatti RN , and
27.6
2
3.3
10
Mazidah
TM
From59Yemen
72.4
96.7
80
88.9
29
100
96.7
- Current operation situation:
Emergency
%
Mesh repair Total
( n = 61 ) ( n= 90 )
8
11.1
0.001*
- Surgeon:
Senior specialist
58
95.1
87
0.31*
Junior specialist
*Calculated
-
by the Fisher Exact test
-
3
4.9
3
3.3
p< 0.05 is statistically significant
Repair operation circumstances by
the type of hernia repair
Repair operation circumstances
Consistent
with
Tissue
repair Mesh
repair Total
( n =the
29 ) range
( n = 61 ) ( n= 90 )
P
Luijendijk et al from The Netherlands
No.
%
No.
%
(45
min.%andNo.
58 min.)
Shukla et al from India
- Intra-operative accidental bowel injury:
(54 min. and 62 min.)
Yes
2
6.9al from
2 Sweden
3.3
4
4.4
Israelsson
et
(65 min. and 92 min.)
No
27
- Mean repair operation duration
(min)
93.1
55.7
55.7 ± 33.4
(30 – 150)
59
96.7
86
0.38*
95.6
76.1
76.1 ± 31.1 69.5 ± 33.2
(30 – 180) (30 – 180)
0.006#
*Calculated
by the Fisher Exact test
#Calculated by the Student t-test
p< 0.05 is statistically significant
Repair operation circumstances by
the type of hernia repair
Tissue repair Mesh repair Total
( n = 29 )
( n = 61 ) ( n= 90 )
Repair operation circumstances
P
No.
%
No.
%
No.
%
9
31
54
88.5
63
70
- Drain in situ:
Active
Passive
Not used
- Mean drain in situ stay length
(day)
*Calculated
by the Fisher Exact test
#Calculated by the Student t-test
Similar
8.2
12 13.3 0.0000**
Xourafas et al from
13
44.8 United
2
3.3
States15of 16.7
3.4 ± 2.0
4.3America
± 1.6
4.2 ± 1.7
7
24.1
(1 – 8)
5
(2 – 11)
**Calculated
(1 – 11)
by the Chi square test
p< 0.05 is statistically significant
0.024
Al-Hawaz from Iraq
(62.7%) in mesh group
Tissue repair
Mesh repair
95.1%
72.4%
-------------------------------------------------------
100% in both groups
Memon et al from
Pakistan,
Xourafas et al,
Rosen et al from
Iannitti et al
United States of America
Prophylactic antibiotic received by
the types hernias repair
Post-operative hospital stay by
the type of hernia repair
Tissue repair
Post-operative
Higher thann = 29
hospital stay group
Al-Hawaz
(5 days)
(day)
No. from
%
Iraq
Shukla
days) from
≤ 7 et al (6.2 18
62.1
India 7
8-15
24.1
≥ 16
4
13.8
Mesh repair
Total
n = 61 Higher nthan
= 90
P
No.
%
No.
% al (5.3
Shukla
et
days)
from
India
46
9
6
75.4
64
71.1
14.8
16
17.8
Lower10than11.1
9.8
0.42*
Lower than
Xourafas et al (11 days) from
7.9 ±from
6.7
7.9
± 9.3 States7.9of±America
8.5
Meanet
± SD
United
Bath
al (8.7 days)
0.99#
Range India
1– 30
2 – 62
1 – 62
Percentages
by columns
p> 0.05 is statistically insignificant
Xourafascalculated
et al (13
days) from
*Calculated by the Chi square test
#Calculated by the Student tUnited States of America
test
N.B.
Five of tissue repaired patients and eight
of mesh repaired ones (included one died)
were lost to followed, so had been
excluded.
Complications occurred in Ten of tissue
repaired patients and eighteen of mesh
repaired ones within 6 months of follow up.
Some patients had more than one post
repair complication.
Similar
Al-Hawaz from
Wound-related
complications
Iraq
Luijendijk et al from
systemic
The Netherlands
complications
Monteros et al,
Moore et al,
Le et al from
United States of
America
by the type of hernia repair
Post-repair complications by the type of repair
Post-repair
complications
Seroma
Tissue
repair
(n = 24)
Mesh
repair
(n = 53)
No.
%
No.
4
16.7
13
Wound infection
4
16.7
Recurrence
3
12.5
Pulmonary
complication
1
4.2
Pain
1
4.2
Prolonged ileus
complication
1
4.2
No complication
14
58.3
Percentages calculated by columns
OR: odds ratio
%
Total
(n = 77)
No.
%
Statistics
p
OR
Similar
95% CI
24.5 17 Kaafarani
22.1 0.44 0.62
0.13 – 2.36
et al from
United States of America
Similar
Similar
5
9.4 9 11.7 0.28 1.92 0.34 – 9.89
(23.3%)
Shukla
et al from
Similar
2 Shukla
3.8 5et al6.5from
0.17 3.64 0.38 – 45.68
India
India
Shukla
al3.9from
(14.7%)
2Luijendijk
3.8 3et
0.68 1.11 0.02 – 22.28
et al from
India
The
Netherlands
1 Burger
1.9 2et al2.6from
0.53 2.26 0.03 – 180.82
Xourafas et al from
The Netherlands
1
1.9States
2 of
2.6America
0.53 2.26 0.03 – 180.82
United
Hawn et al from
United
America
35 66States
49 of
63.6
0.51
1
p> 0.05 is statistically insignificant
CI: confidence interval
Characteristics of patients developed post-repair
complications by the type of repair
Patients characteristics
Female sex
Mean age (years)
Tissue repair Mesh repair
( n = 10 )
( n = 18 )
P
No.
%
No.
%
4
40.0
14
77.8
0.056
48.3 ± 14.6 49.5 ± 9.0
0.78
Patients had risk factors
8
80.0
17
94.4
0.28
Complicated after original operation
4
40.0
9
50.0
0.45
Mean duration of hernia (months)
12.4 ± 14.3 45.6 ± 40.2
Defect diameter > 5cm
6
Mean defect diameter (cm)
Had one or more previous repair
Percentages calculated by columns
60.0
100
0.01
6.3 ± 3.1
10.1 ± 3.5
0.008
2
7
0.28
20.0
18
0.019
38.9
p< 0.05 is statistically significant
Repair operation circumstances in patients developed
post-repair complications by the type of repair
Repair operation
circumstances
Tissue repair
( n = 10 )
No.
%
Intra-operative accidental
1
10.0
bowel injury
Mean repair operation
76.5 ± 45.3
duration (min)
Used active drain in situ
3
30.0
Mean drain in situ stay
5.2 ± 1.9
length (day)
Mean hospital stay (day)
11.1 ± 8.6
Percentages calculated by columns
Mesh repair
( n = 18 )
P
No.
%
1
5.6
0.59
84.2 ± 36.1
0.63
16
88.9
0.002
5.7 ± 2.0
0.53
14.5 ± 14.9
0.52
p< 0.05 is statistically significant
Events related to repair operation in patients developed
post-repair complications by the type of repair
Repair operation
related events
Tissue repair
( n = 10 )
No.
%
Mesh repair
( n = 18 )
No.
%
Intra-operative accidental
1
10.0
1
5.6
bowel injury
Mean repair operation
76.5 ± 45.3 84.2 ± 36.1
duration (min)
Used active drain in situ
3
30.0 16 88.9
Mean drain in situ stay
5.2 ± 1.9
5.7 ± 2.0
length (days)
Mean hospital stay (days)
11.1 ± 8.6 14.5 ± 14.9
Percentages calculated by columns
P
0.59
0.63
0.002
0.53
0.52
p< 0.05 is statistically significant
CONCLUSIONS
- Female
- ≥ 40 years
- Obesity
- multiple laparatomies
- Wound infection post-laparatmy
Associated
factors with
increasing
risk
Incisional hernia.
Post-repair complications
( esp. seroma, wound infection, and recurrence).
Chronicity
Post-repair
complications
(esp. after
mesh repair)
In each
repair group
Post-repair
complication(s)
In significant
number of patients
The most common complications
Wound-related
(esp. seroma, wound infection, and
recurrence)
after both repair types
Wound Seroma
Wound Infection
Recurrence
Mesh
Repair
Tissue
Repair
Despite that absolute
prevention of recurrence
was not achieved, the
mesh
repair
might
reduce that recurrence
Mesh repair
is superior to tissue
repair with regard to
the recurrence,
even in small defects
RECOMMENDATIONS
Periodic screening started from
the 1st month post-laparatomies
for patients having risk factors
(esp. females after the 4th decade
of life)
Early detection of
incisional hernia
Encourage Early
Incisional Hernia Repair
Minimize
Repair Complications
Encourage
weight in obese
stop smoking
Before and after laparatomies
and incisional hernia repair
Avoiding
Midline laparatomies
as possible
Minimize the risk for
Incisional Hernia
and Recurrence
Using Mesh
in different sized
incisional hernia
defects
Restricting Tissue
repair to small size
defects - if used
Long-term studies
to further verify
the safety and efficacy
of mesh use
Especially concerning the
recurrence
Further studies concerning
refinement in techniques and
the evolution of new resources
achieve more details
Improving incisional hernia
repair outcome
Table 3. Risk factors in the studied patients by the type of hernia repair
Similar
Consistent
Nearly Midway
Lower than
Lower
than
Hatti RN and Mazidah TM from Aden- Yemen
Mehrotra et al, Qadri et al, Manohar et al, and
Mahabhaleshwar et al from India
Ammar et al from Eygpt
Horowitz et al from United States of America
Memon et al from Pakistan
Basoglu et al from Turkey
Moussavian et al from Germany
Xourafas et al from United States of America
Moreno-Egea et al from Spain
Agbakwuru et al from Nigeria
Hameed et al from Pakistan
Bhat et al from India
Al-Hawaz from Iraq
Al-Ebous et al from Jordan
Finan et al from United States of America
Xourafas et al from United States of America
Hawn et al from United States of America
Johansson et al from Sweden
Abel-Baki et al from Eygpt
Klink et al study from Germany
Veljkovic et al and Gleysteen et al from United States of America
Basoglu et al, and Yildirim et al from Turkey
Al-Salamah et al from Kingdom of Saudi Arabia
Memon et al from Pakistan
Agbakwuru et al from Nigeria
Age group
(years)
< 30
30-39
40-49
50-59
≥ 60
Mean ± SD*
Range
Tissue repair
( n = 29 )
Mesh repair
( n = 61 )
Total
( n= 90 )
No.
%
No.
%
No.
%
2
8
5
7
7
6.9
27.6
17.2
24.1
24.1
2
8
24
14
13
3.3
13.1
39.3
23.0
21.3
4
16
29
21
20
4.4
17.7
32.2
23.3
22.2
47.7 ± 14.7
24 – 75
49.0 ± 10.7
24 – 75
48.6 ± 12
24 – 75
Percentages calculated by columns
Chi square test [χ2 : 5.96, p: 0.20] statistically insignificant
*Student t- test for 2 means [F: 0.22, p:0.63] statistically insignificant
Repair operation circumstances
Tissue repair Mesh repair Total
( n = 29 )
( n = 61 ) ( n= 90 )
No.
P
%
No.
%
No.
%
6.9
2
3.3
4
4.4
- Intra-operative accidental bowel injury:
Yes
2
0.38*
No
- Mean repair operation duration
(min)
27
93.1
55.7 ± 33.4
(30 – 150)
59
96.7
76.1 ± 31.1
(30 – 180)
86
95.6
69.5 ± 33.2
(30 – 180)
*Calculated
by the Fisher Exact test
#Calculated by the Student t-test
p< 0.05 is statistically significant
0.006#
by the type of hernia repair
Post-repair complications by the type of repair
Post-repair
complications
Tissue
repair
(n = 24)
Mesh
repair
(n = 53)
No.
%
Statistics
No.
%
No.
Seroma
4
16.7
13
24.5 17
22.1 0.44 0.62
0.13 – 2.36
Wound infection
4
16.7
5
9.4
9
11.7 0.28 1.92
0.34 – 9.89
Recurrence
3
12.5
2
3.8
5
6.5
0.17 3.64
0.38 – 45.68
Pulmonary
complication
1
4.2
2
3.8
3
3.9
0.68 1.11
0.02 – 22.28
Pain
1
4.2
1
1.9
2
2.6
0.53 2.26 0.03 – 180.82
Prolonged ileus
complication
1
4.2
1
1.9
2
2.6
0.53 2.26 0.03 – 180.82
No complication
14
58.3
35
66
49
63.6 0.51
Percentages calculated by columns
OR: odds ratio
%
Total
(n = 77)
p
OR
95% CI
1
p> 0.05 is statistically insignificant
CI: confidence interval