Page 113 - Prevention and Treatment of Incisional Hernia- New Techniques and Materials

Figure 2: Forrest plots of a meta-analysis performed by the Guidelines Development Group on prophylactic mesh augmentation with polypropylene mesh after laparotomy on the outcomes incisional hernia (2A), seroma (2B) and wound infection (2C).
Fig 2.A
Incisional hernia
EHS guidelines
Mesh augmentation Suture Risk Ratio Risk Ratio Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CIYear M-H, Random, 95% CI
Gutierrez 2003 0 Strelczyk 2006 0 El-Kadrawy 2009 1 Bevis 2010 5 Abo-Ryia 2013 1 Caro-Tarrago 2014 2
Total (95% CI)
44 36 20 37 32 80
249
5 8 3
16 9 30
44 6.8% 38 7.0% 20 11.1% 43 39.8% 32 12.7% 80 22.7%
257 100.0%
0.09 [0.01, 1.60] 2003 0.06 [0.00, 1.04] 2006 0.33 [0.04, 2.94] 2009 0.36 [0.15, 0.90] 2010 0.11 [0.01, 0.83] 2013 0.07 [0.02, 0.27] 2014
Total events 9
Heterogeneity: Tau2 = 0.18; Chi2 = 6.17, df = 5 (P = 0.29); I2 = 19% Test for overall effect: Z = 4.48 (P < 0.00001)
71
0.17 [0.08, 0.37]
0.01 0.1 Favours mesh
1 10 100
Favours suture
Fig 2.B
Wound infection
5
Mesh augmentation Suture Risk Ratio Risk Ratio Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CIYear M-H, Random, 95% CI
Gutierrez 2003 1 Strelczyk 2006 0 El-Kadrawy 2009 2 Bevis 2010 2 Abo-Ryia 2013 5 Caro-Tarrago 2014 8
Total (95% CI)
44 36 20 37 32 80
249
1 44 4.9% 0 38
4 20 14.6% 2 43 10.0% 5 32 28.2% 8 80 42.3%
257 100.0%
1.00 [0.06, 15.49] 2003 Not estimable 2006 0.50 [0.10, 2.43] 2009 1.16 [0.17, 7.85] 2010 1.00 [0.32, 3.12] 2013 1.00 [0.39, 2.53] 2014
Total events 18
Heterogeneity: Tau2 = 0.00; Chi2 = 0.68, df = 4 (P = 0.95); I2 = 0% Test for overall effect: Z = 0.28 (P = 0.78)
20
0.92 [0.50, 1.68]
0.01 0.1 Favours mesh
1 10 100 Favours suture
Fig 2.C
Seroma
Mesh augmentation Suture Risk Ratio Risk Ratio Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CIYear M-H, Random, 95% CI
Gutierrez 2003 1 Strelczyk 2006 5 El-Kadrawy 2009 4 Bevis 2010 2 Abo-Ryia 2013 6 Caro-Tarrago 2014 23
Total (95% CI)
44 36 20 37 32 80
249
3 4 3 0 5 9
44 4.6% 38 15.0% 20 12.3% 43 2.5% 32 19.6% 80 45.9%
257 100.0%
0.33 [0.04, 3.08] 2003 1.32 [0.38, 4.53] 2006 1.33 [0.34, 5.21] 2009
5.79 [0.29, 116.89] 2010 1.20 [0.41, 3.54] 2013 2.56 [1.26, 5.17] 2014
Total events 41
Heterogeneity: Tau2 = 0.00; Chi2 = 4.66, df = 5 (P = 0.46); I2 = 0% Test for overall effect: Z = 2.20 (P = 0.03)
24
1.71 [1.06, 2.76]
0.01 0.1 Favours mesh
1 10 100 Favours suture
Which mesh type, which mesh position and which type of mesh xation?
No comparative studies are published between di erent mesh type, mesh position or method of mesh xation. Pans et al.(111) found no signi cant protective e ect on incisional hernia rate by intra-peritoneal augmentation with a polyglactin mesh (Vicryl; Ethicon) on incisional hernia rate in a RCT on obesity surgery (n = 288). Llaguna et al.(112) placed a biological mesh (Alloderm; LifeCell) in a retro-muscular position in bariatric patients. In this non- randomised comparative study (n = 106 of which 44 with mesh) a signi cantly
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