in emergency laparotomy José A Pereira Abdominal Wall Unit Department of General Surgery Hospital del Mar University Pompeu Fabra Barcelona Spain A prophylactic ID: 929542
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Slide1
Incisional hernia prevention in emergency laparotomy
José A. PereiraAbdominal Wall UnitDepartment of General SurgeryHospital del MarUniversity Pompeu FabraBarcelona (Spain)
Slide2A prophylactic mesh in emergency?
Slide3Meshes, are they a real risk?
Slide4Meshes, are they a real risk?
Are commonly used in emergency hernia repairHave been used successfully in contaminated surgery (colon resection
)EHS guidelines suggest
using a prophylactic mesh in high risk patients Not
all
the
patients
in
emergencies
have a peritonitis nor contamination
95
%
Mesh
repair
Slide5Do we have enough evidence to
avoid using a mesh?
Slide6The most frequent situation
Slide7What do we have to do?
Hippocrates
(
Cos, c. 460 b. C.-Tesalia c. 370 b. C)
"
If in the first act you have hung a pistol on the wall, then in the following one it should be fired. Otherwise don't put it there
." From
Gurlyand's
Reminiscences of A. P. Chekhov
, in
Teatr
i iskusstvo 1904, No. 28, 11 July, p. 521
Slide8Our experience
Slide9Patients and methods
From January 2009 to July 2010
Slide10Patients and methods
Slide11Patients and methods
Slide12Patients and methods
Slide13Postoperative complications
Total
Group
M
Group
S
P
value
Wound
infection
(%)
54 (20.3)
20 (26.3)
34 (17.9)
0.13
Burst
abdomen (%)
4 (1.5)
0 (0)
4 (2.1)
0.58
A
mesh
was
safe
Slide14ResultsIncisional hernia
Median follow-up = 16.7 months
p<0,001
p<0,02
p<
0,002
p<0,09
(N=44)
(N=44)
(N=56)
p<0,001
p<0,01
p<0,001
A
mesh
was
effective
Slide15Anything else?
Slide16Using a protocol - July 2016 – March 2018
REOPERATIONMESH + SHORT STITCH
RISK FACTORS >2
Age >70
Malnutrition
Obesity (BMI)
COPD
Anaemia
Diabetes
Corticoids
CRF
Cancer
Immunosupresion
ObstructionPeritonitis
YES
NO
YES
MESH+SHORT STITCH
SHORT STITCH
NO
Slide17A protocol for Emergency midline laparotomy
Slide18Characteristics of patients
Age (SD)
62,9 (17,1)Age
>70 y. (%)67 (40.6)Gender (M/F) (%)101 (61,2)/64 (38,8)
BMI Kg/m
2
(SD)
26,0 (6,0)
ASA III/IV (%)
105 (65,4)
Comorbidities
(%)
106 (64,2)
Slide191 (0,9%)
Burst abdomen
N=1 (0,6%)
Slide20Incisional hernia
P=0.001
Six months follow-up
Following
the
protocol
has
better
results
Slide21More than anything else?
Slide22Emergency
surgery
2011-2017
N= 6500
Emergency
subcostal
laparotomy
2011-2017
n= 283 (4.35%)
Follow
-up 12
months
n = 202 ( 71.37%)
Suture
n=203 (71.7%)
Mesh
n=80 (28.3%)
Suture
n=150 (76.3%)
Mesh
n=52 (65%)
Incisional
hernia
31(10.9)
29 (19.1%)
2(3.8%)
0.008
Chronic pain
11 (3.9%)
6 (3.0%)
5 (6.2%)
0.302
Chronic infection
0 (0%)
-
0 (0%)
NA
Mesh
removal
0 (0%)
-
0 (0%)
NA
IH
Repair
7 (22.6%)
7 (24.1%)
0 (0%)
NA
Prevention
in
emergency
transverse
unilateral
laparotomy
All
Suture
Mesh
P
Burst
abdomen
6 (2.1%)
6 (3%)
0 (0%)
0.19
Slide23Conclusions
Using a prophylactic suprafascial polypropylene
mesh in the
closure of emergency
laparotomies
is
feasible
and
safe
for
the prevention
of incisional hernia and burst abdomen without
adding a
substantial
rate
of
morbidity
,
even
if
high
contamination
or
infections
are
present
Slide24Closing remarksWe
need urgently a study in emergencies
“As usual,
emergencies
don’t
leave
time
for
the
important
”
Slide25