Page 138 - Prevention and Treatment of Incisional Hernia- New Techniques and Materials

Chapter 6
same time and in most cases no documentation of either IH or PSH could be found, it is unclear whether PSH or IH occurred rst. Nevertheless an assumption was made on the basis of the patients’ anamneses that PSH occurred rst, but further prospective studies should be undertaken to con rm this assumed sequence. Also, no measurement of the suture length to wound length ratio was conducted, which could facilitate an increase in IH formation. In addition, in this study out of 574 patients only 150 patients were available for follow-up which could attribute to selection bias. The majority of these lost patients were due to death or due to them not being able to come to our outpatient clinic, possibly due a diminished physical state or to postoperative complications. A prospective trial could be able to control for this possible bias. Standard follow-up which includes radiological examination might also strengthen the results of future studies giving also give more insight into possible changes that occurred in the abdominal wall before and after operation and herniation.
Conclusion
This study con rms our hypothesis that PSH increases the chances of IH occurrence by seven times. Furthermore, patients operated in an emergency setting also have a 5 times higher chance of IH, as shown in the multivariate analyses of variance. Thus, PSH and - to a lesser extent - operation in an emergency setting can be added to the already known risk factors of IH development, namely AAA and obesity. Patients who are known to be prone to herniation can thus be treated prophylactically. Primary mesh augmentation in patients at risk for herniation has been shown to reduce the incidence of IH and PSH (9, 12), (36-39). Although colostomy operations are considered clean- contaminated or even contaminated operations, the contamination did not increase (mesh) infections in trials where mesh augmentation was used. In case of open colostomy creation it would be advisable to not only augment the midline or the colostomy with a mesh but augment both, in order to prevent IH and PSH formation. In case of PSH correction, an e ort should be made to correct both the IH and PSH. Creating an mesh overlap over the midline, as demonstrated by Berger et al, would reduce the chance of IH development and PSH recurrence (40). Further research is nevertheless needed to identify other possible preventive measures to reduce postoperative hernias and better understand the mechanical and biological factors in uencing the occurrence of IH.
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