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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