Borab Zachary M, Shakir Sameer, Lanni Michael A, Tecce Michael G, MacDonald John, Hope William W, Fischer John P
Drexel University College of Medicine, Philadelphia, PA.
Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA.
Surgery. 2017 Apr;161(4):1149-1163. doi: 10.1016/j.surg.2016.09.036. Epub 2016 Dec 28.
Operative intervention to correct incisional hernia affects 150,000 patients annually, with 1 in 3 repairs recurring within 9 years. The aim of this study was to compare the incidence of incisional hernia and postoperative complications in elective midline laparotomy patients after the use of prophylactic mesh placement and primary suture closure.
A systematic review was performed to identify studies comparing prophylactic mesh placement to primary suture closure in elective, midline laparotomy at index abdominal aponeurosis closure. The primary outcome was incisional hernia. Secondary outcomes included postoperative complications.
Fourteen studies were included (2,114 patients), with 1,152 receiving prophylactic mesh placement. Prophylactic mesh placement decreased the risk of incisional hernia overall when compared to primary suture closure (relative risk = 0.15; P < .00001) and in trials using only polypropylene mesh versus 4:1 primary suture closure (relative risk = 0.15; P = .003). Prophylactic mesh placement reduced the risk of incisional hernia regardless of mesh location or composition: onlay (relative risk = 0.07; P < .0001), retrorectus (relative risk = 0.04; P = .002), and preperitoneal (relative risk = 0.18; P = .02). Prophylactic mesh placement increased risk of seroma overall (relative risk = 1.95; P < .0001), onlay (relative risk = 2.43; P = .01) and preperitoneal (relative risk = 1.47; P = .01) but not retrorectus plane (relative risk = 1.55; P = .26). Polypropylene mesh increased seroma risk only in the onlay position (relative risk = 2.77; P = .04). Prophylactic mesh placement patients are at increased risk for chronic wound pain compared to primary suture closure (relative risk = 1.70; P = .03).
Prophylactic mesh placement is associated with an 85% postoperative incisional hernia risk reduction when compared to primary suture closure in at-risk patients undergoing elective, midline laparotomy closure. This technique appears to be safe with comparable complication profiles, barring an increased risk of seroma, especially with the onlay technique, and the possibility for an increased risk of chronic pain. Despite this verification, evidence from large domestic trials that sufficiently addresses major knowledge gaps is simply lacking.
手术干预修复切口疝每年影响150,000名患者，三分之一的修复在9年内复发。本研究的目的是比较在择期中线剖腹手术患者中使用预防性补片植入和一期缝合关闭后切口疝的发生率及术后并发症。
进行一项系统评价，以确定在择期中线剖腹手术中，在腹直肌前鞘关闭时比较预防性补片植入与一期缝合关闭的研究。主要结局是切口疝。次要结局包括术后并发症。
纳入14项研究（2114例患者），其中1152例接受预防性补片植入。与一期缝合关闭相比，预防性补片植入总体上降低了切口疝的风险（相对危险度=0.15；P<0.00001），在仅使用聚丙烯补片与4:1一期缝合关闭的试验中也是如此（相对危险度=0.15；P=0.003）。无论补片位置或成分如何，预防性补片植入均降低了切口疝的风险：覆盖法（相对危险度=0.07；P<0.0001）、腹直肌后（相对危险度=0.04；P=0.002）和腹膜前（相对危险度=0.18；P=0.02）。预防性补片植入总体上增加了血清肿的风险（相对危险度=1.95；P<0.0001），覆盖法（相对危险度=2.43；P=0.01）和腹膜前（相对危险度=1.47；P=0.01），但腹直肌后平面未增加（相对危险度=1.55；P=0.26）。聚丙烯补片仅在覆盖位置增加血清肿风险（相对危险度=2.77；P=0.04）。与一期缝合关闭相比，预防性补片植入患者发生慢性伤口疼痛的风险增加（相对危险度=1.70；P=0.03）。
在接受择期中线剖腹手术关闭的高危患者中，与一期缝合关闭相比，预防性补片植入可使术后切口疝风险降低85%。除血清肿风险增加（尤其是覆盖法）和慢性疼痛风险可能增加外，该技术似乎具有相似的并发症谱，是安全的。尽管有此验证，但国内大型试验中仍缺乏充分解决主要知识空白的证据。
