Emergency repair of complicated abdominal wall hernias may be associated with worsen outcome and a significant rate of postoperative complications. There is no consensus on management of complicated abdominal hernias. The main matter of debate is about the use of mesh in case of intestinal resection and the type of mesh to be used. Wound infection is the most common complication encountered and represents an immense burden especially in the presence of a mesh. The recurrence rate is an important topic that influences the final outcome. A World Society of Emergency Surgery (WSES) Consensus Conference was held in Bergamo in July 2013 with the aim to define recommendations for emergency repair of abdominal wall hernias in adults. This document represents the executive summary of the consensus conference approved by a WSES expert panel. In 2016, the guidelines have been revised and updated according to the most recent available literature.
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Bacteria inherently colonize all surgical wounds, but not all of these contaminations ultimately lead to infection. In most patients, infection does not occur because innate host defences are able to eliminate microbes at the surgical site. However, there is some evidence that the implantation of foreign materials, such as prosthetic mesh, may lead to a decreased threshold for infection [3].
Several studies show clear advantages of mesh use in elective cases, where infection is uncommon [7]. Mesh is easy to use, has low complication rates, and significantly reduces the rate of hernia recurrence. However, few studies have investigated the outcome of mesh use in an emergency setting, where there is often surgical field contamination due to bowel involvement [8, 9].
A computerized search was done by the bibliographer in different databanks (MEDLINE, Scopus, Embase), and citations were included for the period between January 2000 and December 2016 using the primary search strategy: hernia, groin, inguinal, femoral, crural, umbilical, epigastric, spigelian, ventral, incisional, incarcerated, strangulated, acute, emergency, repair, suture, mesh, direct, synthetic, polypropylene, prosthetic, biologic, SSI, wound infection, bowel resection, intestinal resection, complication, morbidity, recurrence, timing, laparoscopy combined with AND/OR. No search restrictions were imposed. The dates were selected to allow comprehensive published abstracts of clinical trials, consensus conference, comparative studies, congresses, guidelines, government publication, multicenter studies, systematic reviews, meta-analysis, large case series, original articles, and randomized controlled trials. Narrative review articles were also analysed to determine other possible studies. Recommendation guidelines are evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE), a hierarchical, evidence-based rubric [11, 12] summarized in Table 2.
Another retrospective study published in 2008 investigated the role of laparoscopy in the management of incarcerated (non-reducible) ventral hernias. The authors concluded that laparoscopic repair of ventral abdominal wall hernias could be safely performed with low subsequent complication rates, even in the event of an incarcerated hernia. Careful bowel reduction with adhesiolysis and mesh repair in an uncontaminated abdomen (without inadvertent enterotomy) using a 5-cm-mesh overlap was an important factor predictive of successful clinical outcome [31].
The use of mesh in clean surgical fields (CDC wound class I) is associated with lower recurrence rate, if compared to tissue repair, without an increase in the wound infection rate. Prosthetic repair with a synthetic mesh is recommended for patients with intestinal incarceration and no signs of intestinal strangulation or concurrent bowel resection (clean surgical field) (grade 1A recommendation).
For patients with intestinal incarceration and no signs of intestinal strangulation or concurrent bowel resection, the surgical field is presumed clean and the infectious risk for synthetic mesh is low. The absence of intestinal wall ischaemia makes patients less prone to bacterial translocation.
A wide variety of small-sized retrospective studies comparing mesh use to suture repair in the treatment of acute irreducible hernias have been published [39, 43, 44]. The prospective randomized trial by Abdel-Baki et al. compared the use of mesh repair (group 1, 21 patients) and tissue repair (group 2, 21 patients) in 42 cases with acute para-umbilical hernia. The wound infection rate between the two groups was not statistically significant. At follow-up (mean 16 5.5 months), there were four recurrences in group 2 (4/21, 19%) and no recurrences in group 1 (P
The prospective 6-year study by Abd Ellatif et al. included 115 patients who underwent acutely incarcerated abdominal wall hernia repair. The results showed low rates of wound infection (4.3%) and recurrence (4.3%), with a mean follow-up of 42 months. The authors therefore concluded that mesh hernioplasty is crucial to prevent recurrence and that it is safe for repairing acutely incarcerated hernias [45].
The retrospective study by Venara et al. compared the 30-day outcome after acute hernia (inguinal, femoral, and umbilical) repair with or without mesh. The study included 166 patients, of which 64 were treated with and 102 without mesh repair. Among the 64 patients who underwent mesh repair, four patients had concomitant bowel resection. Among the 102 patients who underwent primary repair, 21 patients had concomitant bowel resection. The mesh repair was neither related to a significant increase of complications (P = 0.89) nor related to surgical site infection (SSI) (P = 0.95), overall morbidity (OR = 1.5, confidence interval (CI) = 95%, P = 0.458), and major complications (OR = 1.2, CI = 95%, P = 0.77) [37].
A recent prospective study included 202 patients with acutely incarcerated groin hernias. The results showed extremely low rates of wound infection, mesh infections, and recurrence. The authors concluded that the use of mesh in incarcerated hernias is safe [46].
For patients having a complicated hernia with intestinal strangulation and/or concomitant need of bowel resection without gross enteric spillage (clean-contaminated surgical field, CDC wound class II), emergent prosthetic repair with a synthetic mesh can be performed (without any increase in 30-day wound-related morbidity) and is associated with a significant lower risk of recurrence, regardless the size of hernia defect (grade 1A recommendation).
In 2000, Mandalà et al. published a series of patients with incisional hernias treated with non-absorbable prostheses and associated visceral surgery. The low incidence of suppurative complications, with neither removal of the patch nor recurrences in the short term, showed that non-absorbable mesh repair in potentially contaminated fields was safe [47].
Retrospective studies by Vix et al., Birolini et al., and Geisler et al. report wound-related morbidity rates of 10.6, 20, and 7%, respectively, following mesh use in both clean-contaminated and contaminated procedures [48,49,50].
On the other hand, in 2010, Xourafas et al. retrospectively examined the impact of mesh use on ventral hernia repairs with simultaneous bowel resections attributable to either cancer or bowel occlusion. Researchers found a significantly higher incidence of postoperative infection in patients with a prosthetic mesh compared to those without mesh. According to the multivariate regression analysis, prosthetic mesh use was the only significant risk factor, irrespective of other variables such as drain use, defect size, or type of bowel resection [52].
The large-sized US National Surgical Quality Improvement Program (NSQIP) study by Choi et al., analysed and compared postoperative outcome following ventral hernia repair, in the 5-year period from 1 January 2005 to 4 April 2010, including 6721 clean-contaminated cases, of which 3879 underwent mesh repair and 2842 underwent non-mesh repair. The results did not show a significant statistical difference in the rate of deep incisional SSI and return to OR within 30 days, between the mesh and non-mesh groups [53].
One of the few available studies investigating acute hernia repair is the small-sized retrospective analysis by Nieuwenhuizen et al. including 23 patients who underwent acute hernia repair with intestinal resection, and surprisingly, it revealed a higher incidence of wound infection in the primary suture group (5/14, 35%) than in the mesh group (2/9, 22%) [54].
The prospective 6-year study by Abd Ellatif et al. included 163 patients who underwent acutely incarcerated abdominal wall hernia mesh repair, of which 48 required intestinal resection and anastomosis and 155 did not. No significant difference was found in terms of postoperative morbidities, wound infection, and recurrence rate between the two groups. The authors therefore concluded that mesh hernia repair is crucial to prevent recurrence and that it is safe for repairing acutely incarcerated hernias, even in case of intestinal resection [45].
Haskins et al. evaluated the outcomes after emergency ventral hernia repair in 1357 patients with CDC wound class II from the American College of Surgeons (ACS) NSQIP database and did not find any statistical significance in wound-related or additional 30-day patient morbidity or mortality, between mesh and non-mesh emergency ventral hernia repair. The authors concluded that emergency ventral hernia repair with a mesh can be safely performed without an increase in wound-related or additional early patient morbidity or mortality in CDC wound class II [56].
The randomized trial by Kassem and El-Haddad compared the use of onlay polypropylene mesh positioned and supported by omentum and/or peritoneum versus inlay implantation of polypropylene-based composite mesh in 60 patients with complicated wide-defect ventral hernias, including 12 bowel resections. Postoperatively, seven patients developed a wound infection (11.6%) and two patients developed a recurrence (3%), after 3 and 8 months, respectively [57]. 2ff7e9595c
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