Surg Today DOI 10.1007/s00595-014-0907-3
ORIGINAL ARTICLE
Prospective randomized evaluation of open preperitoneal versus preaponeurotic primary elective mesh repair for paraumbilical hernias Mohammad Hamdy Abo-Ryia • Osama Helmy El-Khadrawy Gamal Ibrahim Moussa • Ahmad Mohammad Saleh
•
Received: 1 October 2013 / Accepted: 1 April 2014 Ó Springer Japan 2014
Abstract Purpose The aim of this study was to compare the preperitoneal versus the preaponeurotic mesh positioning in open paraumbilical hernia repair. Methods During the period from January 2011 until July 2012, 60 adult patients were randomly assigned to two equal groups. The patients in group A were treated by preperitoneal mesh repair and those in group B underwent preaponeurotic mesh repair. Both groups were assessed and compared. Results There were no significant differences between the two groups in the demographics, hernia characteristics, risk factors, type of anesthesia, American Society of Anesthesiologists score or the mean follow-up period. The length of the operation was significantly shorter in group B than in group A (P value = 0.01). There were no significant differences in the early postoperative complications except for the development of a seroma, which developed only in group B (P value = 0. 044). The postoperative pain was significantly lower in group A than in group B (P value = 0.01). The time of return to normal daily activities was significantly shorter in group A than in group B (P value = 0.001). Conclusion The preperitoneal mesh placement during the repair of paraumbilical hernias is superior to the preaponeurotic placement, because it is associated with fewer
M. H. Abo-Ryia O. H. El-Khadrawy G. I. Moussa A. M. Saleh Gastrointestinal Surgery Unit, General Surgery Department, Tanta University Hospital, Tanta, Egypt M. H. Abo-Ryia (&) Department of Surgery, Tanta University Hospital, Tanta, Egypt e-mail: [email protected]; [email protected]
complications, less pain and a shorter time of return to normal daily activities. Keywords Paraumbilical hernia Mesh repair Preperitoneal Preaponeurotic
Introduction Herniation through the umbilical ring (umbilical hernias) and hernias adjacent to the umbilical ring (paraumbilical hernias) are common in the adult population, accounting for 10–14 % of all hernias [1]. These hernias are generally more common in females than males and are associated with high morbidity and mortality. There is a high tendency for incarceration and strangulation, and emergency repair is often necessary for these types of hernias [2]. However, there seems to be a discrepancy between the importance of paraumbilical hernias and the attention the condition has received in the literature to date [3]. A Medline literature search confirmed that no firm consensus currently exists on the best technique for primary repair of these hernias [4]. The recurrence rates after tissue repair are variable, with reports ranging from 15 to 40 % [5], while the use of prosthetic material for open umbilical hernia repair has been reported to reduce the recurrence rates [4]. Mesh repair, preaponeurotic (onlay), retromuscular or preperitoneal (sublay) and intra-abdominal (underlay) placement or even combinations have been described with acceptable results [6]. To determine the optimal treatment for these hernias, this study was performed to assess and compare the preperitoneal and the preaponeurotic mesh positioning in the repair of primary uncomplicated umbilical and paraumbilical hernias.
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Patients and methods This study was carried out in the General Surgery Department of Tanta University Hospital during the period from January 2011 until July 2012, and included 60 adult patients with primary uncomplicated umbilical or paraumbilical hernias. The study was approved by the local ethics committee of the Faculty of Medicine at Tanta University. We excluded all patients with recurrent, incarcerated or strangulated hernias, those with previous midline laparotomy, decompensated liver disease, an ASA score over III and those who did not provide consent. The patients were distributed into two equal groups (A and B) using the block randomization method. The patients in group A underwent preperitoneal mesh repair, and those in group B underwent preaponeurotic mesh repair. The two procedures were explained in detail to each patient, and informed consent was signed prior to surgery. All patients were instructed to clean their umbilicus carefully using BetadineÒ solution the night before surgery. General and spinal anesthesia were administered at the anesthesiologist’s discretion, and based on the patient preference. A broad-spectrum antibiotic in the form of amoxicillin– clavulinic acid (1.2 g) was given at the start of the operation. Obese patients were given perioperative prophylactic low-molecular-weight heparin.
proleneÒ mesh was fixed by 2/0 proleneÒ sutures both circumferentially and centrally. A closed suction drain was then inserted, and the umbilicus was repositioned using 2/0 vicrylÒ stitches. The subcutaneous tissue was irrigated with saline, and the wound was closed as above. Postoperative management The intraoperative findings, intraoperative and postoperative complications, the time to drain removal (in the preaponeurotic group) and the time to return to normal daily activities were recorded for each patient. All patients were prescribed analgesia in the form of diclofenac sodium (100 mg) suppositories, which were administered twice daily, and were asked to grade their pain using a visual analog scale (VAS) of 0–10 cm the next day. All cases were managed as 1 day cases (discharged within 24 h after surgery), and the patients in group B were discharged with the drain after instructing them how to deal with it. The drain was removed when its effluent was \50 cc per 24 h for two consecutive days. The follow-up was performed by physical examination in the outpatient clinic at 1, 3, 6 and 12 months by a surgeon who was blinded to the study group.
Results The surgical technique in group A A paraumbilical skin incision was made relative to the size and site of the hernia swelling, and then subcutaneous dissection of the hernia was performed to expose the edges of the defect. If the contents of the sac were reduced freely, the sac was inverted. Otherwise, the sac was opened, freed from adhesions, the contents were reduced and the hernia was closed. The peritoneum was subsequently dissected from the posterior rectus sheath on both sides, above and below for at least 4–5 cm beyond the edge of the defect. Then, prolene Òmesh was inserted and spread in the space that was created, and the defect was closed by proleneÒ 0 sutures, taking bites through the mesh center to avoid its dislocation. The umbilicus was repositioned by 2/0 vicryl Ò stitches. The subcutaneous tissue was closed by interrupted 2/0 vicrylÒ sutures, and the skin was closed with subcutaneous 3/0 proleneÒ sutures. The surgical procedure in group B In group B, after the dissection and reduction of the hernia, the defect was closed by proleneÒ 0 sutures, and the subcutaneous tissue was dissected to expose the aponeurosis for 5–6 cm all around the edge of the defect, then the
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Forty-nine females (81.7 %) and 11 (18.3 %) males were randomly assigned to one of two equal groups in this prospective study. The demographic findings (age, gender, BMI) revealed no significant differences between the groups. The follow-up period in this study ranged from 6 to 24 months with similar means in both groups. The hernia characteristics, in terms of the type, reducibility and duration were also similar in both groups. Four risk factors were identified in the population of this study (smoking, chronic chest disease, obesity (BMI [30 kg/m2) and multiparity), and thirty patients (50 %) had at least one risk factor, while more than one risk factor was present in 21 patients (35 %),with no significant differences in the distribution between the two groups (Table 1). Both groups were similar in terms of the anesthesia type, ASA grade and defect size, with no significant differences between the groups. However, the mean length of the operation was significantly shorter in group (B) than in group (A) (36.67 ± 4.08 vs. 47.33 ± 4.58 min) (P value = 0.01). The early postoperative complications that occurred in this study were superficial wound infections in five patients (8.3 %), hematomas in four patients (6.67 %) and seromas in five patients (8.3 %). Seroma formation was detected during the follow-up by physical examinations, and was
Surg Today Table 1 The patient demographics, hernia characteristics and risk factors in the two groups
Variable
Group A N (30)
Group B N (30)
t test
v2
P
Mean age
46.80 ± 12.12
48.33 ± 12.34
0.343
ns
BMI in kg/m2
29.74 ± 3.23
29.90 ± 3.18
0.165
ns
Mean follow-up (months)
15.2 ± 4.5
16.1 ± 4.3
0.254
ns
Female
25
24
Male
5
6
Umbilical
8
5
Paraumbilical
22
25
7 23
\1 year [1 year
Gender 0.240
ns
0.87
ns
8 22
0.19
ns
5
6
0.79
ns
25
24
Type
Reducibility Reducible Totally or partially irreducible Duration
Risk factors
#FE Fisher’s exact test, ns not significant
Table 2 The intraoperative data, complications and postoperative data in the two groups
Smoking
4
4
#FE ns
Chest disease
3
4
FE 1.000 ns
Obesity (BMI [30)
8
10
FE ns
Multiparity
10
8
FE ns
Variable
Group A N (30)
Group B N (30)
General Spinal
12 18
10 20
ASA (I, II, III)
(15, 13, 2)
(14, 15, 1)
47.33 ± 4.58
36.67 ± 4.08
t test
v2
P
0.15
ns
Anesthesia
Mean length of operation (min)
ns 6.736
0.01*
Defect size (cm) B3
19
20
[3
11
10
2
3
0.536
ns
Early postoperative complications Infection
FE ns
Hematoma
2
2
FE ns
Seroma
0
5
FE 0.044*
ns not significant * Significant (P \ 0.05)
Mean VAS score
4.87 ± 1.24
7.07 ± 1.10
5.12
0.01*
Mean time to return to normal activities (days)
8.2 ± 2.78
17.2 ± 5.25
7.166
0.001*
confirmed by ultrasound examination in suspected cases. There were no significant differences between the two groups with regard to wound infections and hematomas, and all cases were successfully managed conservatively. However, all five cases that developed a seroma were in group B (P value = 0. 044). Repeated aspiration under
aseptic measures was sufficient to cure the condition in all cases. The postoperative pain was significantly lower in group A than in group B (P value = 0.01). The time to return to normal daily activities was also significantly shorter in group A than in group B (P value = 0.001). The time to
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drain removal in group B ranged from 5 to 15 days, with a mean of 7.47 ± 3.11 days. No recurrence developed in either group during the follow-up period (Table 2).
Discussion The case for mesh versus non-mesh repair of defects in the abdominal wall has previously been argued, with the conclusion that the evidence-base is sufficiently strong to recommend that: all defects in the abdominal wall, whether inguinal, incisional or umbilical hernias, and of whatever size, should be repaired with the use of prosthetic mesh [7]. In cases with umbilical and paraumbilical hernias, several randomized controlled and observational studies compared the suture versus the mesh repair method, and concluded that mesh plugs or flat mesh led to significantly lower recurrence rates after repair [1, 5, 8–11]. A few previous studies have compared the onlay (preaponeurotic) versus the sublay or preperitoneal positioning of the mesh in umbilical/paraumbilical hernia repair [12, 13]. The present study was designed to compare the preperitoneal versus the preaponeurotic mesh repair of umbilical and paraumbilical hernias. In this study, the mean length of the operation was significantly shorter in the preaponeurotic mesh group (group B) than in the preperitoneal mesh group (group A); 36.67 ± 4.08 vs. 47.33 ± 4.58 min (P value = 0.01). This was in agreement with the previous study by Zaghloul [12], who reported a mean length of the operations of 35 vs. 45 min. This is because the careful dissection of the preperitoneal space while keeping the peritoneum intact takes longer than the dissection of skin flaps to expose a sufficient area of the aponeurosis for the mesh fixation. Despite using prophylactic antibiotics in the present study, postoperative superficial wound infections, characterized by local tenderness and redness of the skin, were found in five cases (8.3 %). However, all of them responded to conservative management (antibiotics and dressing), with no need to remove the mesh. This incidence was lower than that reported by other studies [12–14]. The possible reasons for the infections may be the poorly vascularized thin skin flaps and the intrinsic bacterial colonization of the area, which is difficult to clean even with modern iodophor solutions. Hence, surgical site infections may be more common after an umbilical hernia repair than after an inguinal hernia repair [3], and an incidence of superficial wound infection of around 10 %is not surprising, even after routine prophylactic antibiotic use [14, 15]. In this study, no seromas developed in the preperitoneal group (0 %), but were found in five cases (16.7 %) in the preaponeurotic group (P value = 0. 044). Comparable findings were reported by other studies [12, 13, 16]. The
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major factor involved in the occurrence of a seroma is the large dead space that is inevitably created by the dissection of the skin flaps during the preaponeurotic mesh repair. Therefore, adequate and prolonged closed suction drainage is needed postoperatively to help avoid seroma formation [17]. In this study, the mean score for postoperative pain by the VAS was significantly lower in the preperitoneal group than in the preaponeurotic group; 4.87 ± 1.24 vs. 7.07 ± 1.10 (P value = 0.01). Milad et al. [13] reported that the mean postoperative pain score was significantly lower for the patients in the sublay group than in the onlay group; at 4.7 vs. 7.2. The increased pain score in the preaponeurotic group may be explained by the wider subcutaneous dissection and the presence of a drain. Another important advantage of the preperitoneal mesh technique in this study was the significantly shorter time to return to normal daily activities (8.2 ± 2.78 vs. 17.2 ± 5.25 days) [P value = 0.001]. This longer time in the preaponeurotic mesh repair group is largely explained by the need for drain insertion in all cases, which was removed after a time ranging from five to 15 days, with a mean of 7.47 ± 3.11 days. In addition, even seroma collection occurred in five cases after drain removal; all of whom required repeated aspirations under aseptic measures until complete resolution. Milad et al. [13] reported a mean time of drain removal of 10 days, ranging from seven to 15 days in their preaponeurotic mesh repair group. The mesh in the preperitoneal space buttresses the fascial defect from the inside, following the idea of Pascal’s theory, where the pressure will be equally distributed all over the mesh, which is sandwiched between the intraabdominal pressure and the muscular tone of the abdominal wall. The application of the preaponeurotic mesh does not follow this theory, and the abdominal wall forces may break down the primary closure and push the mesh off the outer fascial surface, predisposing to herniation [18]. There were some limitations associated with this study, including the small number of patients and the short follow-up period (a mean of 15 months),because the assessment of hernia repair needs years of follow-up before firm conclusions can be drawn with regard to efficacy. Nevertheless, after a mean follow-up of 15 months, the preperitoneal mesh repair of umbilical/paraumbilical hernias appears to be superior to the preaponeurotic repair; because it was significantly less painful, had a significantly lower rate of complications and a significantly shorter time to the return to normal daily activities. These advantages outweigh the longer operation. However, a longer followup will be needed to confirm the long-term patency of the repairs. Conflict of interest
MA: declares no conflict of interest.
Surg Today OE: declares no conflict of interest. GM: declares no conflict of interest. AS: declares no conflict of interest.
References 1. Sanjay P, Reid TD, Davies EL, et al. Retrospective comparison of mesh and sutured repair for adult umbilical hernias. Hernia. 2005;9:248–51. 2. Muschaweck U. Umbilical and epigastric hernia repair. Surg Clin North Am. 2003;83:1207–21. 3. Kulacoglu H, Yazicioglu D, Ozyaylali I. Prosthetic repair of umbilical hernias in adults with local anesthesia in a day-case setting: a comprehensive report from a specialized hernia center. Hernia. 2012;16:163–70. 4. Solomon TA, Wignesvaran P, Chaudry MA, et al. A retrospective audit comparing outcomes of open versus laparoscopic repair of umbilical/paraumbilical hernias. Surg Endosc. 2010;24:3109–12. 5. Aslani N, Brown CJ. Does mesh offers an advantage over tissue in the open repair of umbilical hernias? A systematic review and meta-analysis. Hernia. 2010;14:455–62. 6. Berrevoet F, D’Hont F, Rogiers X, et al. Open intra-peritoneal versus retromuscular mesh repair for umbilical hernias less than 3 cm diameter. Am J Surg. 2011;201:85–90. 7. Gilbert AI, Graham MF, Voigt WJ. Incisional, epigastric and umbilical hernias. In: Cameron JL, editor. Current surgical therapy. 7th ed. St. Louis: Mosby; 2001. p. 611–6. 8. Arroyo A, Garcıa P, Perez F, et al. Randomized clinical trial comparing suture and mesh repair of umbilical hernia in adults. Br J Surg. 2001;88:1321–3.
9. Polat C, Dervisoglu A, Senyurek G, et al. Umbilical hernia repair with the Prolene hernia system. Am J Surg. 2005;190:61–4. 10. Abdel-Baki NA, Bessa SS, Abdel-Razek AH. Comparison of prosthetic mesh repair and tissue repair in the emergency management of incarcerated para-umbilical hernia: a prospective randomized study. Hernia. 2007;11:163–7. 11. Kamer E, Unalp HR, Derici H, et al. Laparoscopic cholecystectomy accompanied by simultaneous umbilical hernia repair: a retrospective study. J Postgrad Med. 2007;53:176–80. 12. Zaghloul NM. Pre-peritoneal versus subcutaneous mesh repair for adult para-umbilical hernia. El-minia Med Bull. 2004;15:293–300. 13. Milad NM, Said SM, Samir M. Comparison between onlay and retromuscular drainless mesh repair for para-umbilical hernia with divarication of recti. Kasr El Aini J Surg. 2009;10:11–6. 14. Kurzer M, Belsham PA, Kark AE. Tension-free mesh repair of umbilical hernia as a day case using local anesthesia. Hernia. 2004;8:104–7. 15. Jezupovs A, Mihelsons M. The analysis of infection after polypropylene mesh repair of abdominal wall hernia. World J Surg. 2006;30:2270–8. 16. Elsesy A, Balbaa MA, Badr MLA, et al. Retromuscular preperitoneal versus traditional onlay mesh repair in treatment of incisional hernias. MMJ. 2008;21(1):209–20. 17. Waldrep DJ, Shabot MM, Hiatt JR. Mature fibrous cyst after mesh hernioplasty. A newly described pathological entity. Am Surg. 1993;59:716–8. 18. El-Khadrawy OH, Moussa G, Mansour O, et al. Prophylactic prosthetic reinforcement of midline abdominal incisions in highrisk patients. Hernia. 2009;13:267–74.
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ORIGINAL ARTICLE
Prospective randomized evaluation of open preperitoneal versus preaponeurotic primary elective mesh repair for paraumbilical hernias Mohammad Hamdy Abo-Ryia • Osama Helmy El-Khadrawy Gamal Ibrahim Moussa • Ahmad Mohammad Saleh
•
Received: 1 October 2013 / Accepted: 1 April 2014 Ó Springer Japan 2014
Abstract Purpose The aim of this study was to compare the preperitoneal versus the preaponeurotic mesh positioning in open paraumbilical hernia repair. Methods During the period from January 2011 until July 2012, 60 adult patients were randomly assigned to two equal groups. The patients in group A were treated by preperitoneal mesh repair and those in group B underwent preaponeurotic mesh repair. Both groups were assessed and compared. Results There were no significant differences between the two groups in the demographics, hernia characteristics, risk factors, type of anesthesia, American Society of Anesthesiologists score or the mean follow-up period. The length of the operation was significantly shorter in group B than in group A (P value = 0.01). There were no significant differences in the early postoperative complications except for the development of a seroma, which developed only in group B (P value = 0. 044). The postoperative pain was significantly lower in group A than in group B (P value = 0.01). The time of return to normal daily activities was significantly shorter in group A than in group B (P value = 0.001). Conclusion The preperitoneal mesh placement during the repair of paraumbilical hernias is superior to the preaponeurotic placement, because it is associated with fewer
M. H. Abo-Ryia O. H. El-Khadrawy G. I. Moussa A. M. Saleh Gastrointestinal Surgery Unit, General Surgery Department, Tanta University Hospital, Tanta, Egypt M. H. Abo-Ryia (&) Department of Surgery, Tanta University Hospital, Tanta, Egypt e-mail: [email protected]; [email protected]
complications, less pain and a shorter time of return to normal daily activities. Keywords Paraumbilical hernia Mesh repair Preperitoneal Preaponeurotic
Introduction Herniation through the umbilical ring (umbilical hernias) and hernias adjacent to the umbilical ring (paraumbilical hernias) are common in the adult population, accounting for 10–14 % of all hernias [1]. These hernias are generally more common in females than males and are associated with high morbidity and mortality. There is a high tendency for incarceration and strangulation, and emergency repair is often necessary for these types of hernias [2]. However, there seems to be a discrepancy between the importance of paraumbilical hernias and the attention the condition has received in the literature to date [3]. A Medline literature search confirmed that no firm consensus currently exists on the best technique for primary repair of these hernias [4]. The recurrence rates after tissue repair are variable, with reports ranging from 15 to 40 % [5], while the use of prosthetic material for open umbilical hernia repair has been reported to reduce the recurrence rates [4]. Mesh repair, preaponeurotic (onlay), retromuscular or preperitoneal (sublay) and intra-abdominal (underlay) placement or even combinations have been described with acceptable results [6]. To determine the optimal treatment for these hernias, this study was performed to assess and compare the preperitoneal and the preaponeurotic mesh positioning in the repair of primary uncomplicated umbilical and paraumbilical hernias.
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Patients and methods This study was carried out in the General Surgery Department of Tanta University Hospital during the period from January 2011 until July 2012, and included 60 adult patients with primary uncomplicated umbilical or paraumbilical hernias. The study was approved by the local ethics committee of the Faculty of Medicine at Tanta University. We excluded all patients with recurrent, incarcerated or strangulated hernias, those with previous midline laparotomy, decompensated liver disease, an ASA score over III and those who did not provide consent. The patients were distributed into two equal groups (A and B) using the block randomization method. The patients in group A underwent preperitoneal mesh repair, and those in group B underwent preaponeurotic mesh repair. The two procedures were explained in detail to each patient, and informed consent was signed prior to surgery. All patients were instructed to clean their umbilicus carefully using BetadineÒ solution the night before surgery. General and spinal anesthesia were administered at the anesthesiologist’s discretion, and based on the patient preference. A broad-spectrum antibiotic in the form of amoxicillin– clavulinic acid (1.2 g) was given at the start of the operation. Obese patients were given perioperative prophylactic low-molecular-weight heparin.
proleneÒ mesh was fixed by 2/0 proleneÒ sutures both circumferentially and centrally. A closed suction drain was then inserted, and the umbilicus was repositioned using 2/0 vicrylÒ stitches. The subcutaneous tissue was irrigated with saline, and the wound was closed as above. Postoperative management The intraoperative findings, intraoperative and postoperative complications, the time to drain removal (in the preaponeurotic group) and the time to return to normal daily activities were recorded for each patient. All patients were prescribed analgesia in the form of diclofenac sodium (100 mg) suppositories, which were administered twice daily, and were asked to grade their pain using a visual analog scale (VAS) of 0–10 cm the next day. All cases were managed as 1 day cases (discharged within 24 h after surgery), and the patients in group B were discharged with the drain after instructing them how to deal with it. The drain was removed when its effluent was \50 cc per 24 h for two consecutive days. The follow-up was performed by physical examination in the outpatient clinic at 1, 3, 6 and 12 months by a surgeon who was blinded to the study group.
Results The surgical technique in group A A paraumbilical skin incision was made relative to the size and site of the hernia swelling, and then subcutaneous dissection of the hernia was performed to expose the edges of the defect. If the contents of the sac were reduced freely, the sac was inverted. Otherwise, the sac was opened, freed from adhesions, the contents were reduced and the hernia was closed. The peritoneum was subsequently dissected from the posterior rectus sheath on both sides, above and below for at least 4–5 cm beyond the edge of the defect. Then, prolene Òmesh was inserted and spread in the space that was created, and the defect was closed by proleneÒ 0 sutures, taking bites through the mesh center to avoid its dislocation. The umbilicus was repositioned by 2/0 vicryl Ò stitches. The subcutaneous tissue was closed by interrupted 2/0 vicrylÒ sutures, and the skin was closed with subcutaneous 3/0 proleneÒ sutures. The surgical procedure in group B In group B, after the dissection and reduction of the hernia, the defect was closed by proleneÒ 0 sutures, and the subcutaneous tissue was dissected to expose the aponeurosis for 5–6 cm all around the edge of the defect, then the
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Forty-nine females (81.7 %) and 11 (18.3 %) males were randomly assigned to one of two equal groups in this prospective study. The demographic findings (age, gender, BMI) revealed no significant differences between the groups. The follow-up period in this study ranged from 6 to 24 months with similar means in both groups. The hernia characteristics, in terms of the type, reducibility and duration were also similar in both groups. Four risk factors were identified in the population of this study (smoking, chronic chest disease, obesity (BMI [30 kg/m2) and multiparity), and thirty patients (50 %) had at least one risk factor, while more than one risk factor was present in 21 patients (35 %),with no significant differences in the distribution between the two groups (Table 1). Both groups were similar in terms of the anesthesia type, ASA grade and defect size, with no significant differences between the groups. However, the mean length of the operation was significantly shorter in group (B) than in group (A) (36.67 ± 4.08 vs. 47.33 ± 4.58 min) (P value = 0.01). The early postoperative complications that occurred in this study were superficial wound infections in five patients (8.3 %), hematomas in four patients (6.67 %) and seromas in five patients (8.3 %). Seroma formation was detected during the follow-up by physical examinations, and was
Surg Today Table 1 The patient demographics, hernia characteristics and risk factors in the two groups
Variable
Group A N (30)
Group B N (30)
t test
v2
P
Mean age
46.80 ± 12.12
48.33 ± 12.34
0.343
ns
BMI in kg/m2
29.74 ± 3.23
29.90 ± 3.18
0.165
ns
Mean follow-up (months)
15.2 ± 4.5
16.1 ± 4.3
0.254
ns
Female
25
24
Male
5
6
Umbilical
8
5
Paraumbilical
22
25
7 23
\1 year [1 year
Gender 0.240
ns
0.87
ns
8 22
0.19
ns
5
6
0.79
ns
25
24
Type
Reducibility Reducible Totally or partially irreducible Duration
Risk factors
#FE Fisher’s exact test, ns not significant
Table 2 The intraoperative data, complications and postoperative data in the two groups
Smoking
4
4
#FE ns
Chest disease
3
4
FE 1.000 ns
Obesity (BMI [30)
8
10
FE ns
Multiparity
10
8
FE ns
Variable
Group A N (30)
Group B N (30)
General Spinal
12 18
10 20
ASA (I, II, III)
(15, 13, 2)
(14, 15, 1)
47.33 ± 4.58
36.67 ± 4.08
t test
v2
P
0.15
ns
Anesthesia
Mean length of operation (min)
ns 6.736
0.01*
Defect size (cm) B3
19
20
[3
11
10
2
3
0.536
ns
Early postoperative complications Infection
FE ns
Hematoma
2
2
FE ns
Seroma
0
5
FE 0.044*
ns not significant * Significant (P \ 0.05)
Mean VAS score
4.87 ± 1.24
7.07 ± 1.10
5.12
0.01*
Mean time to return to normal activities (days)
8.2 ± 2.78
17.2 ± 5.25
7.166
0.001*
confirmed by ultrasound examination in suspected cases. There were no significant differences between the two groups with regard to wound infections and hematomas, and all cases were successfully managed conservatively. However, all five cases that developed a seroma were in group B (P value = 0. 044). Repeated aspiration under
aseptic measures was sufficient to cure the condition in all cases. The postoperative pain was significantly lower in group A than in group B (P value = 0.01). The time to return to normal daily activities was also significantly shorter in group A than in group B (P value = 0.001). The time to
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Surg Today
drain removal in group B ranged from 5 to 15 days, with a mean of 7.47 ± 3.11 days. No recurrence developed in either group during the follow-up period (Table 2).
Discussion The case for mesh versus non-mesh repair of defects in the abdominal wall has previously been argued, with the conclusion that the evidence-base is sufficiently strong to recommend that: all defects in the abdominal wall, whether inguinal, incisional or umbilical hernias, and of whatever size, should be repaired with the use of prosthetic mesh [7]. In cases with umbilical and paraumbilical hernias, several randomized controlled and observational studies compared the suture versus the mesh repair method, and concluded that mesh plugs or flat mesh led to significantly lower recurrence rates after repair [1, 5, 8–11]. A few previous studies have compared the onlay (preaponeurotic) versus the sublay or preperitoneal positioning of the mesh in umbilical/paraumbilical hernia repair [12, 13]. The present study was designed to compare the preperitoneal versus the preaponeurotic mesh repair of umbilical and paraumbilical hernias. In this study, the mean length of the operation was significantly shorter in the preaponeurotic mesh group (group B) than in the preperitoneal mesh group (group A); 36.67 ± 4.08 vs. 47.33 ± 4.58 min (P value = 0.01). This was in agreement with the previous study by Zaghloul [12], who reported a mean length of the operations of 35 vs. 45 min. This is because the careful dissection of the preperitoneal space while keeping the peritoneum intact takes longer than the dissection of skin flaps to expose a sufficient area of the aponeurosis for the mesh fixation. Despite using prophylactic antibiotics in the present study, postoperative superficial wound infections, characterized by local tenderness and redness of the skin, were found in five cases (8.3 %). However, all of them responded to conservative management (antibiotics and dressing), with no need to remove the mesh. This incidence was lower than that reported by other studies [12–14]. The possible reasons for the infections may be the poorly vascularized thin skin flaps and the intrinsic bacterial colonization of the area, which is difficult to clean even with modern iodophor solutions. Hence, surgical site infections may be more common after an umbilical hernia repair than after an inguinal hernia repair [3], and an incidence of superficial wound infection of around 10 %is not surprising, even after routine prophylactic antibiotic use [14, 15]. In this study, no seromas developed in the preperitoneal group (0 %), but were found in five cases (16.7 %) in the preaponeurotic group (P value = 0. 044). Comparable findings were reported by other studies [12, 13, 16]. The
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major factor involved in the occurrence of a seroma is the large dead space that is inevitably created by the dissection of the skin flaps during the preaponeurotic mesh repair. Therefore, adequate and prolonged closed suction drainage is needed postoperatively to help avoid seroma formation [17]. In this study, the mean score for postoperative pain by the VAS was significantly lower in the preperitoneal group than in the preaponeurotic group; 4.87 ± 1.24 vs. 7.07 ± 1.10 (P value = 0.01). Milad et al. [13] reported that the mean postoperative pain score was significantly lower for the patients in the sublay group than in the onlay group; at 4.7 vs. 7.2. The increased pain score in the preaponeurotic group may be explained by the wider subcutaneous dissection and the presence of a drain. Another important advantage of the preperitoneal mesh technique in this study was the significantly shorter time to return to normal daily activities (8.2 ± 2.78 vs. 17.2 ± 5.25 days) [P value = 0.001]. This longer time in the preaponeurotic mesh repair group is largely explained by the need for drain insertion in all cases, which was removed after a time ranging from five to 15 days, with a mean of 7.47 ± 3.11 days. In addition, even seroma collection occurred in five cases after drain removal; all of whom required repeated aspirations under aseptic measures until complete resolution. Milad et al. [13] reported a mean time of drain removal of 10 days, ranging from seven to 15 days in their preaponeurotic mesh repair group. The mesh in the preperitoneal space buttresses the fascial defect from the inside, following the idea of Pascal’s theory, where the pressure will be equally distributed all over the mesh, which is sandwiched between the intraabdominal pressure and the muscular tone of the abdominal wall. The application of the preaponeurotic mesh does not follow this theory, and the abdominal wall forces may break down the primary closure and push the mesh off the outer fascial surface, predisposing to herniation [18]. There were some limitations associated with this study, including the small number of patients and the short follow-up period (a mean of 15 months),because the assessment of hernia repair needs years of follow-up before firm conclusions can be drawn with regard to efficacy. Nevertheless, after a mean follow-up of 15 months, the preperitoneal mesh repair of umbilical/paraumbilical hernias appears to be superior to the preaponeurotic repair; because it was significantly less painful, had a significantly lower rate of complications and a significantly shorter time to the return to normal daily activities. These advantages outweigh the longer operation. However, a longer followup will be needed to confirm the long-term patency of the repairs. Conflict of interest
MA: declares no conflict of interest.
Surg Today OE: declares no conflict of interest. GM: declares no conflict of interest. AS: declares no conflict of interest.
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