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      A Comparison of Suture Repair with Mesh Repair for Incisional Hernia

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          Abstract

          Incisional hernia is an important complication of abdominal surgery. Procedures for the repair of these hernias with sutures and with mesh have been reported, but there is no consensus about which type of procedure is best. Between March 1992 and February 1998, we performed a multicenter trial in which we randomly assigned to suture repair or mesh repair 200 patients who were scheduled to undergo repair of a primary hernia or a first recurrence of hernia at the site of a vertical midline incision of the abdomen of less than 6 cm in length or width. The patients were followed up by physical examination at 1, 6, 12, 18, 24, and 36 months. Recurrence rates and potential risk factors for recurrent incisional hernia were analyzed with the use of life-table methods. Among the 154 patients with primary hernias and the 27 patients with first-time recurrent hernias who were eligible for the study, 56 had recurrences during the follow-up period. The three-year cumulative rates of recurrence among patients who had suture repair and those who had mesh repair were 43 percent and 24 percent, respectively, with repair of a primary hernia (P=0.02; difference, 19 percentage points; 95 percent confidence interval, 3 to 35 percentage points). The recurrence rates were 58 percent and 20 percent with repair of a first recurrence of hernia (P=0.10; difference, 38 percentage points; 95 percent confidence interval, -1 to 78 percentage points). The risk factors for recurrence were suture repair, infection, prostatism (in men), and previous surgery for abdominal aortic aneurysm. The size of the hernia did not affect the rate of recurrence. Among patients with midline abdominal incisional hernias, mesh repair is superior to suture repair with regard to the recurrence of hernia, regardless of the size of the hernia.

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          Long-term complications associated with prosthetic repair of incisional hernias.

          To determine whether the type of prosthetic material and technique of placement influenced long-term complications after repair of incisional hernias. Retrospective cohort analytic study. University-affiliated hospital. Two hundred patients undergoing open repair of abdominal incisional hernias with prosthetic material between 1985 and 1994. Four types of prosthetic material were used and placed either as an onlay, underlay, sandwich, or finger interdigitation technique. The materials were monofilamented polypropylene mesh (Marlex, Davol Inc, Cranston, RI), double-filamented mesh (Prolene, Ethicon Inc, Somerville, NJ), expanded polytetrafluroethylene patch (Gore-Tex, WL Gore & Associates, Phoenix, Ariz) or multifilamented polyester mesh (Mersilene, Ethicon Inc). The incidence of recurrence and complications such as enterocutaneous fistula, bowel obstruction, and infection with each type of material and technique of repair were compared with univariate and multivariate analysis. On univariate analysis, multifilamented polyester mesh had a significantly higher mean number of complications per patient (4.7 vs 1.4-2.3; P<.002), a higher incidence of fistula formation (16% vs 0%-2%; P<.001), a greater number of infections (16% vs 0%-6%; P<.05), and more recurrent hernias (34% vs 10%-14%; P<.05) than the other materials used. The additional mean length of stay to treat complications was also significantly longer (30 vs 3-7 days; P<.001) when polyester mesh was used. The deleterious effect of polyester mesh on long-term complications was confirmed on multiple logistic regression (P=.002). The technique of placement had no influence on outcome. Polyester mesh should no longer be used for incisional hernia repair.
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            Incisional hernia: A 10 year prospective study of incidence and attitudes

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              Greater risk of incisional hernia with morbidly obese than steroid-dependent patients and low recurrence with prefascial polypropylene mesh.

              Incisional hernia is a serious complication of abdominal surgery. We compared incisional hernia frequency following gastric bypass (GBP) for morbid obesity versus total abdominal colectomy and ileal pouch-anal anastomosis (IPAA) for ulcerative colitis. A prefascial polypropylene mesh repair was also evaluated. All patients had midline incisions, xiphoid to umbilicus in GBP patients and midepigastrium to pubis in IPAA patients. Fascia were closed with running No. 2 polyglycolic acid suture. Ninety-eight patients underwent prefascial polypropylene mesh repair; 80 were GBP patients, 46 had 1 previous repair, and 17 had 2 to 9 previous repairs (6 with properitoneal mesh). Incisional hernia occurred in 20% (198/968) of GBP patients (19% without versus 41% with a previous hernia, P or = 30 kg/m2). Additional risk factors for hernia in GBP patients included wound infection, diabetes, sleep apnea, and obesity hypoventilation. For the 98 patients who underwent prefascial polypropylene mesh repair, the mean follow-up was 20 +/- 2 months (range 6 to 104), and complications occurred in 35% of patients, including minor wound infection (12%), major wound infection (5%), seroma (5%), hematoma (3%), chronic pain (6%), and recurrent hernia (4%). Severe obesity is a greater risk factor for incisional hernia and hernia recurrence than chronic steroid use in nonobese colitis patients. A prefascial polypropylene mesh repair minimizes recurrence.
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                Author and article information

                Journal
                New England Journal of Medicine
                N Engl J Med
                Massachusetts Medical Society
                0028-4793
                1533-4406
                August 10 2000
                August 10 2000
                : 343
                : 6
                : 392-398
                Article
                10.1056/NEJM200008103430603
                10933738
                ca09cbd4-0628-4ed4-81a7-d494111639a6
                © 2000
                History

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