A retrospective study including all consecutive patients with a diagnosis of ovarian cancer or borderline ovarian tumor who underwent midline laparotomy was conducted in the Department of Obstetrics and Gynecology at Hospital del Mar, Barcelona, from January 2008 to December 2019. Patients included in the study should have been followed up at least one year after surgery.
Follow-up involved regular medical visits and imaging, according to the latest Oncology Guidelines12.
The exclusion criteria were as follows: laparoscopic approach, incision outside the midline, immediate postoperative period death and history of previous incisional hernia (IH).
To determine the efficacy of mesh placement in prevention of IH and to assess the optimal fascia suture technique, incidence of IH was reported depending on type of suture and/or mesh placement. A comparison was made between groups.
All risk factors related to abdominal wall complications were recorded: age, body mass index (BMI), alcohol intake, smoking habit, diabetes mellitus, cardiac risk factors, hypertension, steroid use, previous operations, preoperative serum haemoglobin level, preoperative serum albumin, creatinine level, American Society of Anaesthesiologists (ASA) score and suboptimal cytoreduction. Operative time and total hospital stay were also analysed.
Before 2015, the decision of mesh placement and suture technique was at the surgeon’s discretion, according to clinical estimation of IH risk. After this date, our hospital established a new protocol in accordance with the European Hernia Society guidelines on the closure of abdominal wall incisions, placing a prophylactic mesh in patients at risk of developing IH13,14.
For the primary suture procedure, the midline fascia was closed according to the principles of small bites technique or conventional large tissue bites described elsewhere previously and following the standard of care present at the time of surgery.4 The small bites technique consists in applying tissue bites of 5mm using a running, slowly absorbable suture (Polidyoxanone 2/0 USP, HR 26 Monoplus®, B. Braun. Melsungen. Germany) with a suture length-to-wound length ratio of 4:1. The conventional large tissue bites was applied with tissue bites of at least 1cm using a monofilament construction (Polydyoxanone 1 USP looped, needle HRT 48, PDSII ®Ethicon, Somerville, NJ, USA)4.
For suprafascial (onlay) mesh placement, an anterior plane was created between the anterior rectus fascia and the subcutaneous and a Polyvinylidene fluoride mesh (DynaMesh®-CICAT, Aachen, Germany) was used and sutured with a double crown of absorbable monofilament suture (PDS II, Ethicon, Somerville, NJ, USA). In all patients of this group, subcutaneous closed suction drains were placed.
IH was defined as any abdominal wall gap in the area of a postoperative scar palpable or perceptible by specialists or detected on radiologic follow-up, as determined by European Hernia Society (EHS)13.
Statistical analysis was performed using the Statistical Package for Social Sciences v. 18.0 (SPSS, Chicago, IL). Quantitative variables were expressed as mean and standard deviation (SD), and categorical variables as absolute numbers and percentages. The association between qualitative variables was assessed using contingency tables with Chi-square test and Fisher test, when necessary, and the analysis of the quantitative variables was performed with the Student t-test parametric test or the nonparametric Mann-Whitney U test when needed. Statistical significance was set at p<0.05. The odds ratio (OR) of hernia incidence was calculated with its confidence intervals (CI). Survival curves for IH incidence were estimated by a Kaplan-Meier method and risk was assessed using a log-rank test.
The study was approved by the Ethics Committee of the Hospital del Mar number 2020/9228 and was carried out in compliance with the guidelines of the Declaration of Helsinki, Fortaleza, Brazil, 2013. A waiver of informed consent was obtained from the Institutional Ethical Review Board from the home Institution.