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 contained structure(s) through it on Valsalva maneuver.

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.

A im 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 patients with ventral incisional hernia operated in General Surgery ward at Aden Hospitals June 1 st 2008 – June 1 st 2010

– American Society of Anesthesiologists (ASA) Class > III. – Parastomal hernias and recurrent inguinal hernias. – Severe psychiatric or neurological diseases. – Operated using laparoscopic repair approach. Exclusion criteria

American Society of Anesthesiologists' Physical Status Classification Patient with incapacitating systemic disease that is life threatening Class IV Moribund patient not expected to survive 24 hr without an operation Class V

Incisional hernia: involved the anterior abdominal wall. Obesity: body mass index ≥ 30kg/m 2. Definitions of the studied variables

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.

analysis Statistical Qualitative variables: Frequencies with percentages Chi-Square and Fisher Exact tests. Quantitative variables: Mean ± standard deviation Student t test. Predictor variables association: Odds ratio (OR), with 95% confidence interval (CI). P-value of <0.05 was considered statistically significant. 15

RESULTS

Percentages of the types of hernia repair in the studied patients

Sex Tissue repair ( n = 29 ) Mesh repair ( n = 61 ) Total ( n= 90 ) No.% % % Male Female Percentages calculated by columns Chi square test [χ 2 : 5.05, p: 0.02] statistically significant Distribution of the studied patients by sex and type of hernia repair Hatti RN and Mazidah TM from Aden- Yemen Hameed et al from Pakistan Mehrotra et al, Qadri et al, Manohar et al, Mahabhaleshwar et al from India Similar

Age group (years) Tissue repair ( n = 29 ) Mesh repair ( n = 61 ) Total ( n= 90 ) No.% % % < ≥ Mean ± SD * Range 47.7 ± – ± – ± – 75 Percentages calculated by columns Chi square test [χ 2 : 5.96, p: 0.20] statistically insignificant * Student t- test for 2 means [F: 0.22, p:0.63] statistically insignificant Distribution of the studied patients by age group and type of hernia repair Hameed et al and Memon et al from Pakistan Similar Ammar et al from Eygpt 38 Ammar et al from Eygpt 38 Horowitz et al from United States of America 43.1 Horowitz et al from United States of America 43.1 Memon et al from Pakistan 45 Memon et al from Pakistan 45 Basoglu et al from Turkey 52 Basoglu et al from Turkey 52 Moussavian et al from Germany 53.4 Moussavian et al from Germany 53.4 Xourafas et al from United States of America 60 Xourafas et al from United States of America 60 Moreno-Egea et al from Spain 64 Moreno-Egea et al from Spain 64 Al-Salamah et al from Kingdom of Saudi Arabia ( 46.2 and 47.7 respectively) Similar Consistent

Percentages of risk factors by the type of hernia repair

Risk factors (37 patients had ˃ 1) Tissue repair ( n = 29 ) Mesh repair ( n = 61 ) Total ( n= 90 ) P No.% % % Obesity Co-morbidity Malnutrition Diabetes mellitus Chronic pulmonary disease Chronic constipation Chronic obstructive uropathy Cigarette smoking Heavy lefting work Medications (steroids) Multiple laparotomies Allergic diseases No risk factor detected Risk factors in the studied patients by the type of hernia repair Gleysteen et al from United States of America 32.0%, Al-Hawaz study from Iraq 28.2%, and Hameed et al from Pakistan 40% Hidalgo et al study from Spain 57% Similar Lower than Johansson et al from Sweden 8 % and Abel-Baki et al from Eygpt 42.9% Klink et al study from Germany 32%, Veljkovic et al and Gleysteen et al from United States of America 48.3% and 50.4%, respectively. Lower than Nearly Midway

Percentage General surgery Gynecology and Other Specialties Obstetrics surgery surgery Percentages of the original operation by the type of hernia repair

Original operation Tissue repair ( n = 29 ) Mesh repair ( n = 61 ) Total ( n= 90 ) No.% % % General surgery: Appendectomy Para-umbilical hernia Open cholecystectomy Miscellaneous Subtotal Gynecology and Obstetrics surgery: Cesarean section Hysterectomy Miscellaneous Subtotal Other Specialties surgery Percentages calculated by columns Chi square test [χ2 : 2.85, p: 0.89] statistically insignificant Original operations in the studied patients by the type of hernia repair Basoglu et al, and Yildirim et al from Turkey Similar Al-Hawaz from Iraq 58.9% Similar Al-Hawaz from Iraq 31.8% Similar Al-Salamah et al from Kingdom of Saudi Arabia Memon et al from Pakistan Agbakwuru et al from Nigeria Bhat et al from India Similar

Chawla et al, Bhat et al from India and Agbakwuru et al from Nigeria Original operation by the type of repair Similar

Statistics Total n = 90 Mesh repair n = 61 Tissue repair n = 29 Incisions of original operation %No.% % χ 2 : 6.65 p: Midline Paramedian Upper transverse Lower transverse Subcostal Gridiron Drain’s stab wound Incision of original operation by the type of repair Midline Zarin et al from Pakistan Shukla et al from India Birch from Canada Hawn et al from United States of America Similar Midline

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% Similar

History of incisional hernia by the type of hernia repair History of previous repair operation Tissue repair ( n = 29 ) Mesh repair ( n = 61 ) Total ( n= 90 ) P No.% % % No previous repair * One previous repair More than one previous repair Mean duration of hernia (months ) 15.5 ± 22.8 (2 – 180) 32.7 ± 38.2 ( ) 27.1 ± 34.8 ( ) 0.02 ** * Calculated by the Chi square test p< 0.05 is statistically significant ** Calculated by the Student t-test. No previous repair Al-Hawaz from Iraq 64.5% Al-Ebous et al from Jordan 65.4% Finan et al 72%, Xourafas et al 75.7% and Hawn et al 78.4% from United States of America Consistent % 64.5% 75.7% 78.4% 72%

History of incisional hernia by the type of hernia repair History of previous repair operation Tissue repair ( n = 29 ) Mesh repair ( n = 61 ) Total ( n= 90 ) P No.% % % No previous repair * One previous repair More than one previous repair Mean duration of hernia (months ) 15.5 ± 22.8 (2 – 180) 32.7 ± 38.2 ( ) 27.1 ± 34.8 ( ) 0.02 ** * Calculated by the Chi square test p< 0.05 is statistically significant ** Calculated by the Student t-test. (2 – 180) Mean duration of hernia (months) (2 – 180)

Defect diameter (cm) Tissue repair ( n = 29 ) Mesh repair ( n = 61 ) Total ( n= 90 ) P No.% % % < ** 5 – > Mean defect diameter (cm) 5.2 ± 2.4 (2 – 10) 9.4 ± 4.2 (3 – 25) 8.1 ± 4.2 (2 – 25) ** ** Calculated by the Chi square test p< 0.05 is statistically significant Defect diameter by the type of hernia repair

Similar Hatti RN, and Mazidah TM From Yemen Repair operation circumstances by the type of hernia repair

Repair operation circumstances Tissue repair ( n = 29 ) Mesh repair ( n = 61 ) Total ( n= 90 ) P No.% % % - Intra-operative accidental bowel injury: Yes * No Mean repair operation duration (min) 55.7 ± 33.4 (30 – 150) 76.1 ± 31.1 (30 – 180) 69.5 ± 33.2 (30 – 180) # * 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 Luijendijk et al from The Netherlands (45 min. and 58 min.) Shukla et al from India (54 min. and 62 min.) Israelsson et al from Sweden (65 min. and 92 min.) Consistent with the range

Repair operation circumstances Tissue repair ( n = 29 ) Mesh repair ( n = 61 ) Total ( n= 90 ) P No.% % % - Drain in situ: Active ** Passive Not used Mean drain in situ stay length (day) 3.4 ± 2.0 (1 – 8) 4.3 ± 1.6 (2 – 11) 4.2 ± 1.7 (1 – 11) * Calculated by the Fisher Exact test ** Calculated by the Chi square test # Calculated by the Student t-test p< 0.05 is statistically significant Repair operation circumstances by the type of hernia repair Similar Xourafas et al from United States of America

Prophylactic antibiotic received by the types hernias repair Mesh repair Tissue repair Al-Hawaz from Iraq (62.7%) in mesh group % in both groups Memon et al from Pakistan, Xourafas et al, Rosen et al from Iannitti et al United States of America 72.4% 95.1%

Post-operative hospital stay group (day) Tissue repair n = 29 Mesh repair n = 61 Total n = 90 P No.% % % ≤ ≥ * Mean ± SD Range 7.9 ± 6.7 1– ± – ± – # Percentages calculated by columns p> 0.05 is statistically insignificant * Calculated by the Chi square test # Calculated by the Student t-test Post-operative hospital stay by the type of hernia repair Higher than Lower than Higher than Al-Hawaz ( 5 days) from Iraq Shukla et al ( 6.2 days) from India Bath et al ( 8.7 days) from India Xourafas et al ( 13 days) from United States of America Shukla et al ( 5.3 days) from India Xourafas et al ( 11 days) from United States of America

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.

by the type of hernia repair Wound-related complications systemic complications Similar Al-Hawaz from Iraq Luijendijk et al from The Netherlands Monteros et al, Moore et al, Le et al from United States of America

Post-repair complications Tissue repair (n = 24) Mesh repair (n = 53) Total (n = 77) Statistics No.% % %pOR95% CI Seroma – 2.36 Wound infection – 9.89 Recurrence – Pulmonary complication – Pain – Prolonged ileus complication – No complication Percentages calculated by columns p> 0.05 is statistically insignificant OR: odds ratio CI: confidence interval Post-repair complications by the type of repair Similar Shukla et al from India (14.7%) Kaafarani et al from United States of America (23.3%) Shukla et al from India Luijendijk et al from The Netherlands Xourafas et al from United States of America Similar Shukla et al from India Burger et al from The Netherlands Hawn et al from United States of America Similar

Patients characteristics Tissue repair ( n = 10 ) Mesh repair ( n = 18 ) P No.% % Female sex Mean age (years) 48.3 ± ± Patients had risk factors Complicated after original operation Mean duration of hernia (months) 12.4 ± ± Defect diameter > 5cm Mean defect diameter (cm) 6.3 ± ± Had one or more previous repair Percentages calculated by columns p< 0.05 is statistically significant Characteristics of patients developed post-repair complications by the type of repair

Repair operation circumstances Tissue repair ( n = 10 ) Mesh repair ( n = 18 ) P No.% % Intra-operative accidental bowel injury Mean repair operation duration (min) 76.5 ± ± Used active drain in situ Mean drain in situ stay length (day) 5.2 ± ± Mean hospital stay (day)11.1 ± ± Percentages calculated by columns p< 0.05 is statistically significant Repair operation circumstances in patients developed post-repair complications by the type of repair

Events related to repair operation in patients developed post-repair complications by the type of repair Repair operation related events Tissue repair ( n = 10 ) Mesh repair ( n = 18 ) P No.% % Intra-operative accidental bowel injury Mean repair operation duration (min) 76.5 ± ± Used active drain in situ Mean drain in situ stay length (days) 5.2 ± ± Mean hospital stay (days)11.1 ± ± Percentages calculated by columns p< 0.05 is statistically significant

CONCLUSIONS

- Female - ≥ 40 years - Obesity - multiple laparatomies - Wound infection post-laparatmy Incisional hernia. Post-repair complications ( esp. seroma, wound infection, and recurrence). Associated factors with increasing risk

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 Mesh Repair Wound Infection Recurrence 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 1 st month post-laparatomies for patients having risk factors (esp. females after the 4 th decade of life) Early detection of incisional hernia

Minimize Repair Complications Encourage Early Incisional Hernia Repair

weight in obese stop smoking Encourage 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 Improving incisional hernia repair outcome achieve more details

THANKS

Table 3. Risk factors in the studied patients by the type of hernia repair Similar Lower than Nearly Midway Lower than Consistent

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 Ammar et al from Eygpt Horowitz et al from United States of America Horowitz et al from United States of America Memon et al from Pakistan Memon et al from Pakistan Basoglu et al from Turkey Basoglu et al from Turkey Moussavian et al from Germany Moussavian et al from Germany Xourafas et al from United States of America Xourafas et al from United States of America Moreno-Egea et al from Spain 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 Turkey 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) Tissue repair ( n = 29 ) Mesh repair ( n = 61 ) Total ( n= 90 ) No.% % % < ≥ Mean ± SD * Range 47.7 ± – ± – ± – 75 Percentages calculated by columns Chi square test [χ 2 : 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 ( n = 29 ) Mesh repair ( n = 61 ) Total ( n= 90 ) P No.% % % - Intra-operative accidental bowel injury: Yes * No Mean repair operation duration (min) 55.7 ± 33.4 (30 – 150) 76.1 ± 31.1 (30 – 180) 69.5 ± 33.2 (30 – 180) # * Calculated by the Fisher Exact test # Calculated by the Student t-test p< 0.05 is statistically significant

by the type of hernia repair

Post-repair complications Tissue repair (n = 24) Mesh repair (n = 53) Total (n = 77) Statistics No.% % %pOR95% CI Seroma – 2.36 Wound infection – 9.89 Recurrence – Pulmonary complication – Pain – Prolonged ileus complication – No complication Percentages calculated by columns p> 0.05 is statistically insignificant OR: odds ratio CI: confidence interval Post-repair complications by the type of repair