OBJECTIVE: The objective of this study was to determine the best treatment
 of incisional hernia, taking into account recurrence, complications,
 discomfort, cosmetic result, and patient satisfaction. BACKGROUND:
 Long-term results of incisional hernia repair are lacking. Retrospective
 studies and the midterm results of this study indicate that mesh repair is
 superior to suture repair. However, many surgeons are still performing
 suture repair. METHODS: Between 1992 and 1998, a multicenter trial was
 performed, in which 181 eligible patients with a primary or first-time
 recurrent midline incisional hernia were randomly assigned to suture or
 mesh repair. In 2003, follow-up was updated. RESULTS: Median follow-up was
 75 months for suture repair and 81 months for mesh repair patients. The
 10-year cumulative rate of recurrence was 63% for suture repair and 32%
 for mesh repair (P < 0.001). Abdominal aneurysm (P = 0.01) and wound
 infection (P = 0.02) were identified as independent risk factors for
 recurrence. In patients with small incisional hernias, the recurrence
 rates were 67% after suture repair and 17% after mesh repair (P = 0.003).
 One hundred twenty-six patients completed long-term follow-up (median
 follow-up 98 months). In the mesh repair group, 17% suffered a
 complication, compared with 8% in the suture repair group (P = 0.17).
 Abdominal pain was more frequent in suture repair patients (P = 0.01), but
 there was no difference in scar pain, cosmetic result, and patient
 satisfaction. CONCLUSIONS: Mesh repair results in a lower recurrence rate
 and less abdominal pain and does not result in more complications than
 suture repair. Suture repair of incisional hernia should be abandoned.

/pdf/long-term-follow-up-of-a-randomized-controlled-trial-of-1m0wy0j602.pdf

Long-term Follow-up of a Randomized Controlled Trial of Suture Versus Mesh Repair of Incisional Hernia

Background Necrotizing pancreatitis with infected necrotic tissue is associated with a high rate of complications and death. Standard treatment is open necrosectomy. The outcome may be improved by a minimally invasive step-up approach. Methods In this multicenter study, we randomly assigned 88 patients with necrotizing pancreatitis and suspected or confirmed infected necrotic tissue to undergo primary open necrosectomy or a step-up approach to treatment. The step-up approach consisted of percutaneous drainage followed, if necessary, by minimally invasive retroperitoneal necrosectomy. The primary end point was a composite of major complications (new-onset multiple-organ failure or multiple systemic complications, perforation of a visceral organ or enterocutaneous fistula, or bleeding) or death. Results The primary end point occurred in 31 of 45 patients (69%) assigned to open necrosectomy and in 17 of 43 patients (40%) assigned to the step-up approach (risk ratio with the step-up approach, 0.57; 95% confidence interval, 0.38 to 0.87; P = 0.006). Of the patients assigned to the step-up approach, 35% were treated with percutaneous drainage only. New-onset multiple-organ failure occurred less often in patients assigned to the step-up approach than in those assigned to open necrosectomy (12% vs. 40%, P = 0.002). The rate of death did not differ significantly between groups (19% vs. 16%, P = 0.70). Patients assigned to the step-up approach had a lower rate of incisional hernias (7% vs. 24%, P = 0.03) and new-onset diabetes (16% vs. 38%, P = 0.02). Conclusions A minimally invasive step-up approach, as compared with open necrosectomy, reduced the rate of the composite end point of major complications or death among patients with necrotizing pancreatitis and infected necrotic tissue. (Current Controlled Trials number, ISRCTN13975868.)

/pdf/a-step-up-approach-or-open-necrosectomy-for-necrotizing-4fontie42x.pdf

A step-up approach or open necrosectomy for necrotizing pancreatitis

http://www.chcs.org.cn/upload/2014-09/14091721577197.pdf

Incisional ventral hernias: Review of the literature and recommendations regarding the grading and technique of repair

One result of the 2 million laparotomies performed in the United States each year is an incisional hernia rate of 3% to 20%,1 necessitating repair of approximately 90,000 ventral hernias annually. Factors associated with formation of an incisional hernia include wound infection, immunosuppression, morbid obesity, previous operations, prostatism, and surgery for aneurysmal disease. Abdominal wall defects are typically observed within the first 5 years after the surgical incision is made, but they may develop long afterward.2 These hernias contribute importantly to the long-term morbidity of conventional surgery. Until techniques for the prevention of hernias are established, repair of these defects will remain an important problem for all abdominal surgeons.

Many hernia repair methods have been described. Traditional primary repair entails a laparotomy with suture approximation of strong fascial tissue on each side of the defect. However, recurrence rates after this procedure range from 41% to 52% during long-term follow-up.2-4 Herniorrhaphies in which large prosthetic meshes are implanted appear to have lower failure rates (12-24%), but the required dissection of wide areas of soft tissue contributes to an increased incidence of wound infections and wound-related complications (12% or higher).3,5,6 These problems have stimulated a continuing search for new techniques for repairing ventral hernias.

The interest in less morbid herniorrhaphies and the appeal of minimally invasive surgery encouraged development of laparoscopic methods for repairing incisional hernias. These techniques are based on the same physical and surgical principles as the open underlay procedure described by Stoppa,3 Rives et al,7 and Wantz.8 Since the first report of laparoscopic ventral hernia repair (LVHR) in 1992,9 the operation has grown in popularity with the belief that it may offer shorter hospital stays, improved patient outcomes, and fewer complications than traditional open procedures. Several comparative studies are now available that support this assertion.10-14 Limiting factors in most of these and the noncomparative series that describe LVHR include limited sample size, varying techniques, and restricted follow-up.15-18

We here describe a study of outcomes achieved with LVHR performed by 4 attending surgeons using the same surgical technique and standardized perioperative regimens and follow-up protocols. The reported series includes every patient in whom the operation was performed or attempted. Data on most patients were collected prospectively, and the follow-up time extends to more than 8 years. The goal of the study was to assess the safety and efficacy of LVHR.

Laparoscopic repair of ventral hernias: nine years' experience with 850 consecutive hernias.

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(03)14746-0.pdf

Hernias: inguinal and incisional

Background 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. Methods 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. Results 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 recurren...

https://www.nejm.org/doi/pdf/10.1056/NEJM200008103430603

Boelhouwer Ru

Papers

A Comparison of Suture Repair with Mesh Repair for Incisional Hernia