Abstract

Background: Abdominal incision hernia is a common complication of abdominal surgery. Despite significant improvements in medical technology and healthcare, an increasing number of patients are also benefiting from complex surgical procedures. The objective of this study was to analyze the risk factors for incisional abdominal hernias and to identify measures that could reduce the incidence of this complication.

Material and methods: All patients included in the study are from the University Hospital of Trauma for a period of 3 years, from January 1, 2015, to December 31, 2017.

Eighty-seven adult patients who underwent surgical repair of incisional abdominal wall hernia were enrolled.

Variables that are compared in this study include the type of suture material, type of suture technique and concomitant diseases .etc.

Results: According to our study the risk factors for incisional hernia are related to patients and the abdominal surgery used, the size of the abdominal wall defects.

Conclusions: Risk factors such as the size of the defect, wound infection, obesity, use of steroids and chronic constipation have great importance and have to be strictly evaluated as they have more chances to lead to a possible recurrence…

Introduction

Incisional hernia refers to abdominal wall hernias at the site of a previous surgical incision.Medium incision hernias are more common than other sites, which are with all the components of the hernia such as the presence of defect, hernial sac, and herniated contents, or may be a weakness of the abdominal wall with a shallow herniated sac. , and occasional bounce of content.

Surgeons are often asked to evaluate patients with incisional hernias, as they can often be symptomatic for patients. Its classic clinical presentation is a bulge after a physical exertion or cough at the incision site. In cases of complicated incisional hernias, patients have an increased risk of incarceration, obstruction (if the contents are intestinal), or strangulation. Abdominal incision hernia can occur after any surgical procedure of the abdomen, where the abdominal wall is cut. Incisional hernia has also been reported after traumatic abdominal wall injuries [1]. Incisional hernias develop due to failure to properly close the abdominal wall [2]. Despite advances in abdominal wall closure techniques, the incidence rate of incisional hernia after laparotomy is as high as 15% to 20%. Although studies have been done on the ideal closure method to prevent incisional hernias, surgeons still often face incisional hernias. Causes of failure to close properly include: patient-related factors, disease-related factors, and technical factors [3].

The risk factors for recurrence include factors related to patient’s status, underlying disease, surgical technique and postoperative complications. The exact pathophysiologic mechanism for development for an incisional hernia is not clearly known [4]. It is believed to be multifactorial. Associated factors like technical factors, including those relating to suturing techniques of the fascia, disease factors, and patient factors contribute to the occurrence of an incisional hernia. Intimate edge to edge fascial healing is necessary to provide the strength of fascia against the development of hernia [5]. The presence of gaps between the two healing edges that will be filled with healing scar predisposes for incisional hernia. These gaps or poor healing sites can be caused by the above risk factors in variable combinations.

Chronically increased intraabdominal pressure predisposes more weak areas to develop hernias.

Surgical technique of wound closure also plays a role. Modified Smead Jones technique[7] (interrupted closure of the abdominal wall using nonabsorbable suture material, with sutures taken in a ‘far near-near far’ fashion) has been shown to decrease the incidence of early wound dehiscence. Perioperative factors appear to have the most significant correlation to incisional hernia formation, with wound infection being the most consistently reported risk factor. Other perioperative factors include deep abscesses, perioperative gastrointestinal complications and early reoperations.[6, 8]

Aim of Study; several mechanisms are reported to explain incisional abdominal hernia (IAH) risk factor. This article includes proven mechanisms of IAH, aiming to improve the preoperatory preparation of the patient, current used techniques and postoperative measures.

Material and methods

In this study there are included 87 adult patients from the University Hospital of Trauma, Tirana, Albania for a period of 3 years, from January 1, 2015 to December 31, 2017, which underwent a IAH repair.

Variables that are compared in this study involve: gender, age, duration of surgery, MBI status, postoperative wound complication, postoperative bleeding, type of surgery (acute/ elective); comorbid diseases, sort of material surgery.

Data analysis;

Statistical calculations were performed using SPSS 22.0 (Chicago, IL, USA). Data were retrieved in February 2015. Analyses were performed to assess the impact of each investigated risk factor and to estimate the cumulative incidence of incisional hernia.

The impact of each investigated risk factor on the incidence of incisional hernia was evaluated in a time-to-event analysis, applying the date of the primary procedure, Age, body mass index (BMI), comorbid disease and type of incision as risk factors for incisional hernia were analysed using Kendal’s Tau-b.

Gender, age, BMI, history of chronic obstructive pulmonary disease, diabetes with secondary complications, operation time, postoperative wound complication and adjuvant cytostatic treatment were included as covariates in the analysis.

Results

In 87 patients was recorded male in 48 (55.1%) and female 39(44.9%) with age range (age 20-75), the most affected age for incision was over 55 years in females and over 60 years in males, and correlation coefficient was 1.54(1.11-1.68) p<0.001.

In our study in according BMI data we found in most of cases 57 (65.5%) of cases were with BMI < 30, and 30 (34.5%) of cases were with BMI >30, and correlation coefficient was 1.54(1.31-1.08) p<0.001.

In according to the risk factors for IAH we have found these data as below; diabetes 11(12.6%), COPD (Chronic obstructive pulmonary disease) in 16 (18.3%), chronic constipation in 8(9.1%), postoperative wound infection are the main risk factors which are found to be the most frequent with 24 (27.6%), followed by obesity 13(14.9%) and use of corticosteroids in 8(9.1%).

In 80(92%) of the patients is used prolene mesh and in only 7 (8%), the defect is repaired using a combined prolen and vicryl mesh (Composite Polypropylene + Polyglycolic acid (Vicryl). In according of suturing material, from all the patients, in 74 (85%) the mesh was fixed using prolene 2.0 sutures and in 13(15%) of them PDS 2.0 sutures were used.

In according the technique of suturing, from all the patients, used to fix the mesh, in 205 patients or 64(74%) of them were used continuous sutures and in 23(26%) of patients interrupted sutures were applied.

Discussion

In 87 patients was recorded male in 48 (55.1%) and female 39(44.9%) with age range (age 20-75), the most affected age for incision was over 55 years [11] in females and over 60 years in males, and correlation coefficient was 1.54(1.11-1.68) p<0.001.

In our study, the cumulative incidence of incisional hernia was 10.5%, which is close to that in other recent studies as Regnard et al. [9] but lower than that in older studies from Ricles et al.[10] According Regnard et al. the actuarial rate of incisional hernia was shown to be 13% at 5 years, occurring during the first 24 months in 80% of cases [9]

In our Study found the postoperative wound infection are the main risk factors which are found to be the most frequent with 24 (27.6%) also the Regnard et al. shown that the two main factors on which surgeons are able to act preventively are the choice of incision site and the onset of wound abscesses [9].

Although the overall risk for incisional hernia is low, there are patients at risk that would benefit from prophylactic measures aiming to prevent incisional hernia.

Hesselink et al. [12] in their study with patients who had a IAH analyzed patient-related risk factors as; gender, age, obesity, chronic cough, prostatitis, constipation, diabetes mellitus, and corticosteroid use, as well as factors associated with surgery, including surgery technique (mainly, a discontinuous layer and a continuous closure layer), use of drainage, use of antibiotics, wound contamination (fecal or purulent discharge), duration of surgery, anesthesia technique, wound complications, mortality, and hospitalization period. In our study suggests that men, patients younger than 70 years, patients with BMI > 30 and patients undergoing procedures longer than 3 h could benefit from such prophylactic measures. Höeret al. [13] in their study shown the preoperative factors anaemia and BMI >25, the intraoperative factors recurrent incision and previous laparotomy, were of significant influence. Furthermore, we confirm that postoperative wound complication is a risk factor for incisional hernia and suggest that active measures to avoid wound complications will reduce the incidence of hernia.

As a rule, measures aiming at prevention of incisional hernia do not require large resources [9]

This high incidence may reflect failure to comply with updated guidelines or the tendency to neglect abdominal wall complication as an outcome measure following abdominal surgery in favour of others. Despite the fact that numerous studies have shown that incisional hernia and wound dehiscence are not inevitable complications following abdominal surgery, they still continue to occur after colorectal surgery.

Conclusions

This trial even though it has its limitations, comes to a conclusion that risk factors such as size of the defect, wound infection, obesity, use of steroids and chronic constipation have a great importance and has to be strictly evaluated as they have more chances to lead to a possible recurrence. Patients at high risk for developing an incisional hernia will certainly benefit from active prevention measures if these are implemented in routine surgical practice. Risk factors include the male gender, age < 70 years, obesity, long operation time and postoperative wound complications.

COI Statement: This paper has not been submitted in parallel.

It has not been published nor submitted for consideration beforehand.

This research received no specific grant from any funding agency in the public, commercial, or nonprofit sectors. There are no relevant or minor financial relationships from authors, their relatives or next of kin with external companies.

Conflict of Interest Statement

There is no conflict of interest

Authorship Contribution

DC, AD, AGJ, EC have done the conception or design of the work and data collection and analysis. KH, HK, MK have done the data analysis and interpretation as well as drafting the article and critical revision of the article.

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