New Insights in Incisional and Ventral Hernia Surgery

Incisional hernia is one of the most frequently seen complications after abdominal surgery. Incidences vary from 10% to 20% in ‘general population’ and can increase up to more than 30% in high-risk groups. Prevention of incisional hernia is of paramount importance. The key of prevention of incisional hernia is to avoid midline laparotomies. However, laparoscopic surgery is not always possible. In 2015, the European Hernia Society Guidelines stated that the evidence regarding prophylactic mesh augmentation for an elective midline laparotomy in high-risk patients, in order to reduce incisional hernia, is weak. More evidence was needed. The PRIMA trial was conducted: a multicenter randomized controlled trial, in which patients could be randomized in either primary suture of the abdomen, onlay mesh reinforcement or sublay mesh reinforcement. Patients in the onlay mesh reinforcement group developed significantly more frequent an incisional hernia, compared to patients who were allocated primary suture only (13% vs 30%, OR 0.37, 95%CI 0.20-0.69, p=0.0016). In the sublay mesh reinforcement group, more incisional hernias were identified compared to primary suture, however, this finding was not statistically significant (18% vs. 30%, OR 0.55, 0.30-1.00, p=0.05). Seromas were more frequent in patients with onlay mesh reinforcement (34/188) than in those assigned primary suture (5/107, p=0.002) or sublay mesh reinforcement (13/185, p=0.002). The incidence of wound and surgical site infections, re-admission or re-interventions did not significantly differ between treatment groups. There is no evidence that a biological or biosynthetic mesh should be preferred to synthetic meshes, in order to prevent incisional hernia in patients undergoing midline laparotomy. Currently, there are over 200 different meshes available on the market, all with a specific indication. Many studies have been performed regarding synthetic meshes (prolene or polypropylene), but also on biologic meshes. A new generation of meshes are the slowly resorbable synthetic meshes. These meshes might be interesting, since it can combine ‘best of both worlds’. Due to its slowly resorbable capacity, it can provide sufficient strength, which is needed to prevent the formation of incisional hernia. However, it might also lead to less chronic pain on long term or other mesh related complications. At this moment, clinical and experimental data are being published. The most important question is whether remodelling occurs and if this can lead to strong fascial tissue of good quality on long term. More experimental studies are needed, followed by randomized controlled trials and prospective registries.

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