Emergency laparotomy is frequently associated with worst outcomes in severely ill patients and with a higher risk of burst abdomen and IH. As such, prophylactic measures for these patients are more relevant to prevent these complications.
Few data are available on long-term outcomes after the use of prophylactic mesh in an emergency setting. To our knowledge, the present study is the first study to analyze the long-term results of IH prevention with mesh in emergency midline laparotomies. One of the strengths of our study is that the median follow-up time was longer than 5 years in 70% of the cohort.
The characteristics of the patients in both groups showed small differences. There were more patients in the M group with a revision laparotomy or with previous midline incision, both of which are well-known risk factors for burst abdomen12 and IH, and probably, this circumstance is the explanation for the higher frequency of using a mesh for prevention. This measure was clearly effective in revision laparotomy as there was a reduction in the incidence of IHs (14.3% M group vs 53.7% S group; CI: 1.24-11.29; O.R 3.75; P=0.005).
In our results, almost one third of the diagnosed IHs appeared after 2 years of follow-up. Therefore, studies with a shorter term would probably underestimate the real incidence of IHs. Our data support similar results obtained in other studies over a long-term follow-up period for elective patients20.
Despite the use of mesh reinforcement to prevent IH, it seems that IH is delayed but does not disappear completely as observed in hernia-free survival analysis by the parallelism of accumulated incidence lines. Hence, the use of a mesh as a prophylaxis seems to act as a “palliative” more than a curative measure; therefore, we believe that new closure, prevention techniques, and mesh materials should be investigated to evaluate their long-term outcomes.
When an IH appears despite previous use of a prophylactic mesh and needs to be repaired, the risk of recurrence seems to be high, as revealed by our study (100%). The presence of a previous mesh could be related to a more difficult operation, but the small size of the sample precludes to make conclusions.
In the present study, the number of patients analyzed was higher than that in our previous analysis11. This is because in the previous study, some patients had not reached the minimum follow-up for the study inclusion (one year), whereas in the present study, those patients were included as they exceeded the follow-up time.
The use of synthetic mesh in contaminated environments, as in emergency laparotomies, is controversial17, but other studies have demonstrated its safety in contaminated complex ventral hernia repairs30. Our results support the view that concerns regarding mesh infections are exaggerated, and the risk of mesh-related complications is minimal. This also confirms our previous results on the safety and efficacy of the use of synthetic mesh in emergency midline laparotomy reinforcement, even in the presence of peritonitis 11, thus ensuring that mesh reinforcement maintains its capability to prevent IHs with a minimum rate of complications after a long-term follow-up.
Prophylactic mesh significantly reduces IHs, even when used in high-risk subgroups31 . All the analyzed subgroups (Table 3) seemed to benefit, and only in obese patients, the incidence of IHs was higher (53.3%) in the S group but without reaching statistical significance (OR 2.31, 0.894-5.94, P=0.053) probably due to the sample size.
The use of retention sutures had no influence on reducing IHs, and moreover, had a higher incidence of IHs when used (39.5%). These results are similar to those of other studies that evaluated retention sutures32 and supports their discontinuation as a preventive method.
In our study, the closure of aponeurosis was not performed using the “small bites” technique as the benefits of this technique to reduce IH33 have not yet been published, and moreover, this study was conducted in patients with elective operations. However, some evidence has been recently published, and the “small bites” technique also seems to be useful in emergency laparotomy 15,16; however, more investigation on this topic is needed.
One of the main warnings against the use of prophylactic mesh in emergencies is the risk of SSI and chronic mesh infection as emergency surgical fields are commonly associated with contamination. Fear of mesh colonization with its complications have pushed some groups to search for alternatives such as biological or absorbable meshes in contaminated ventral hernia repairs 34–37. In our study, there was low incidence of such complications, and the capability of mesh prevention was specifically useful in contaminated surgeries and in the presence of postoperative SSI. Both were independent risk factors for IH after emergency midline laparotomies closed with a suture, with a high power of influence (HR 2.98 and 3.82, respectively). Hence, we believe that the use of prophylactic synthetic suprafascial mesh reinforcement in high-risk patients, including those with contaminated surgeries, after the closure of an emergency midline laparotomy is a good prevention measure, although it is mandatory to conduct further high-quality studies as prospective or randomized control trials to confirm this.
The use of a mesh in high-risk patients in elective midline laparotomies has a strong recommendation from the EHS guidelines21 and is a cost-effective measure38. The use of onlay position is effective in preventing IHs and is easy and rapid to perform for a General Surgeon when compared with other mesh insertion planes, such as the retrorectus plane, which is known to have a lower complication rate in prophylactic abdominal wall reinforcements39.
In conclusion, the rate of IHs after emergency midline laparotomies is high and increases with time, even when using a prophylactic mesh. High-risk patients, contaminated surgeries, and SSIs clearly benefit from mesh reinforcement with a low IH rate and long-term complications. Prophylactic mesh in the emergency setting to prevent IHs seems to be a safe and feasible procedure, supported by long-term evaluation.