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Surgery Research 1 Credit CME

Long-term Recurrence and Complications Associated With Elective Incisional Hernia Repair

Original Investigation
Educational Objective
To learn about long-term recurrence and mesh-related complications following elective abdominal wall hernia repair.

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Key Points

Question  What are the long-term consequences in patients undergoing incisional hernia repair?

Findings  In this registry-based nationwide cohort study including 3242 patients, mesh repair was associated with a lower risk of reoperation for recurrence compared with nonmesh repair over a 5-year follow-up period. However, a risk of long-term mesh-related complications for open and laparoscopic mesh repairs partially offset these benefits.

Meaning  The overall benefits of mesh utilization for the repair of abdominal wall hernias are uncertain.


Importance  Prosthetic mesh is frequently used to reinforce the repair of abdominal wall incisional hernias. The benefits of mesh for reducing the risk of hernia recurrence or the long-term risks of mesh-related complications are not known.

Objective  To investigate the risks of long-term recurrence and mesh-related complications following elective abdominal wall hernia repair in a population with complete follow-up.

Design, Setting, and Participants  Registry-based nationwide cohort study including all elective incisional hernia repairs in Denmark from January 1, 2007, to December 31, 2010. A total of 3242 patients with incisional repair were included. Follow-up until November 1, 2014, was obtained by merging data with prospective registrations from the Danish National Patient Registry supplemented with a retrospective manual review of patient records. A 100% follow-up rate was obtained.

Exposures  Hernia repair using mesh performed by either open or laparoscopic techniques vs open repair without use of mesh.

Main Outcomes and Measures  Five-year risk of reoperation for recurrence and 5-year risk of all mesh-related complications requiring subsequent surgery.

Results  Among the 3242 patients (mean age, 58.5 [SD, 13.5] years; 1720 women [53.1%]), 1119 underwent open mesh repair (34.5%), 366 had open nonmesh repair (11.3%), and 1757 had laparoscopic mesh repair (54.2%). The median follow-up after open mesh repair was 59 (interquartile range [IQR], 44-80) months, after nonmesh open repair was 62 (IQR, 44-79) months, and after laparoscopic mesh repair was 61 (IQR, 48-78) months. The risk of the need for repair for recurrent hernia following these initial hernia operations was lower for patients with open mesh repair (12.3% [95% CI, 10.4%-14.3%]; risk difference, −4.8% [95% CI, –9.1% to –0.5%]) and for patients with laparoscopic mesh repair (10.6% [95% CI, 9.2%-12.1%]; risk difference, –6.5% [95% CI, –10.6% to –2.4%]) compared with nonmesh repair (17.1% [95% CI, 13.2%-20.9%]). For the entirety of the follow-up duration, there was a progressively increasing number of mesh-related complications for both open and laparoscopic procedures. At 5 years of follow-up, the cumulative incidence of mesh-related complications was 5.6% (95% CI, 4.2%-6.9%) for patients who underwent open mesh hernia repair and 3.7% (95% CI, 2.8%-4.6%) for patients who underwent laparoscopic mesh repair. The long-term repair-related complication rate for patients with an initial nonmesh repair was 0.8% (open nonmesh repair vs open mesh repair: risk difference, 5.3% [95% CI, 4.4%-6.2%]; open nonmesh repair vs laparoscopic mesh repair: risk difference, 3.4% [95% CI, 2.7%-4.1%]).

Conclusions and Relevance  Among patients undergoing incisional repair, sutured repair was associated with a higher risk of reoperation for recurrence over 5 years compared with open mesh and laparoscopic mesh repair. With long-term follow-up, the benefits attributable to mesh are offset in part by mesh-related complications.

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Article Information

Corresponding Authors: Thue Bisgaard, MD, DMSc, Kettegård Allé 30, 2650 Hvidovre, Copenhagen, Denmark (thue.bisgaard@gmail.com); Dunja Kokotovic, MB, Lykkebækvej 1, 4600 Køge, Denmark (dunja.kokotovic@hotmail.com).

Published Online: October 17, 2016. doi:10.1001/jama.2016.15217

Author Contributions: Dr Kokotovic had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Kokotovic, Helgstrand.

Drafting of the manuscript: Kokotovic, Bisgaard.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Kokotovic, Helgstrand.

Administrative, technical, or material support: Bisgaard.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Helgstrand reported receipt of personal fees from Bard and Etichon for educational presentations. No other disclosures were reported.

Funding/Support: The study was partly funded by the private Edgar Schnohr and Wife Gilberte Schnohr’s Foundation established to support independent surgical and anesthesiological research.

Role of the Funder/Sponsor: The foundation had no influence on design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Additional Contributions: We thank Steen Ladelund, MSc, Hvidovre Hospital, Hvidovre, and Thomas Helgstrand, MD, Rigshospitalet, Copenhagen, for contributions of statistical support in analyzing the cumulative incidence of recurrence and complications. No compensation for the contributions was provided.

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