Encuesta nacional a unidades de cirugía colorrectal sobre el cierre de pared abdominal / National survey of colorectal surgery units on abdominal wall closure

Introducción: El objetivo de este estudio es valorar el estado actual y conocimiento de los cirujanos colorrectales españoles en el cierre de pared abdominal. Métodos: Se realizó un cuestionario de 25 preguntas cerradas de respuesta única utilizando un software específico para encuestas online que se distribuyó a cirujanos que se dedican, principalmente, a la cirugía colorrectal en su servicio o pertenecen a una Unidad de Cirugía Colorrectal. Resultados: Respondieron la encuesta 53 cirujanos. La mayoría prefiere el cierre de la laparotomía media con una sutura continua (96,23%) de monofilamento de absorción muy lenta (67,92%) en un solo plano (81,13%). Los puntos en masa, los sistemas de retención y las suturas loop siguen utilizándose. El calibre de sutura habitualmente más utilizado fue del 1 USP (United States Pharmacopeia) (58,49%). La aguja más utilizada es de cuerpo cilíndrico y punta trocar. Solo el 50% realiza habitualmente cierre de la pared tras colocación de un trocar igual o mayor de 10mm. Prácticamente todos conocen la regla del 4:1 y creen que se debe aplicar, pero la técnica de puntos cortos no se realiza. El 50% no colocaría nunca una prótesis profiláctica. El cierre lo suele realizar el mismo cirujano que ha llevado a cabo todo el procedimiento. Uno de cada 5 confiesa desconocer la tasa de hernias incisionales de su unidad. Conclusiones: Se evidencia una falta de consenso y conocimientos básicos en cuanto a los aspectos técnicos de cierre y a la prevención de la aparición de hernias incisionales. Parece aceptado el uso de sutura continua, en un solo plano, con sutura monofilamento de reabsorción lenta. (AU)

Introduction: The purpose of this study is to assess the current status and knowledge of the Spanish colorectal surgeons on the wall closure. Methods: A single answer questionnaire of 25 closed questions was conducted using specific software for online surveys that was distributed to a cohort of colorectal surgeons. Results: 53 surgeons replied to the survey. The vast majority prefer a closure of the midlaparotomy with a very slow absorbing monofilament (67,92%) continuous suture (96,23%) in a single plane (81,13%). Mass stitches, retention systems, and loop sutures continue to be used. The most commonly used suture gauge was USP 1 (United States Pharmacopeia) (58,49%). The most commonly used needle is with a cylindrical body and a trocar tip. Only 50%, routinely perform wall closure after placement of a trocar equal to or greater than 10mm. Almost everyone knows the 4: 1 rule and thinks it should be applied, but the small bites technique is not performed. 50% would never place a prophylactic prosthesis. The closure is usually performed by the same surgeon who has performed the entire procedure. One out of five confesses not knowing the rate of incisional hernias in his unit. Conclusion: There is a lack of consensus and basic knowledge regarding the technical aspects of closure and the prevention of the appearance of incisional hernias. The use of slow absorbing monofilament continuous suture in a single plane seems well accepted. (AU)

National survey of colorectal surgery units on abdominal wall closure.

INTRODUCTION: The purpose of this study is to assess the current status and knowledge of the Spanish colorectal surgeons on the wall closure. METHODS: A single answer questionnaire of 25 closed questions was conducted using specific software for online surveys that was distributed to a cohort of colorectal surgeons. RESULTS: 53 surgeons replied to the survey. The vast majority prefer a closure of the midlaparotomy with a very slow absorbing monofilament (67.92%) continuous suture (96.23%) in a single plane (81.13%). Mass stitches, retention systems, and loop sutures continue to be used. The most commonly used suture gauge was USP 1 (United States Pharmacopeia) (58.49%). The most commonly used needle is with a cylindrical body and a trocar tip. Only 50%, routinely perform wall closure after placement of a trocar equal to or greater than 10 mm. Almost everyone knows the 4:1 rule and thinks it should be applied, but the small bites technique is not performed. 50% would never place a prophylactic prosthesis. The closure is usually performed by the same surgeon who has performed the entire procedure. One out of five confesses not knowing the rate of incisional hernias in his unit. CONCLUSION: There is a lack of consensus and basic knowledge regarding the technical aspects of closure and the prevention of the appearance of incisional hernias. The use of slow absorbing monofilament continuous suture in a single plane seems well accepted.

Hernias at the extraction incision after laparoscopic colon and rectal resection: Influence of incision location and use of prophylactic mesh. / Hernias de la incisión de asistencia tras resección colorrectal laparoscópica. Influencia de la localización de la incisión y del uso de una malla profiláctica.

OBJECTIVES: To determine the incidence of incisional hernia (IH) in the extraction incision (EI) in colorectal resection for cancer. To analyze whether the location of the incision has any relationship with the incidence of hernias and whether mesh could be useful for prevention in high-risk patients. METHODS: Retrospective review of the colon and rectal surgery database from January 2015 to December 2016. Data were classified into 2groups, transverse (TI) and midline incision (MI), and the latter was divided into 2subgroups (mesh [MIM] and suture [MIS]). Patients were classified using the HERNIAscore. Hernias were diagnosed by clinical and/or CT examination. RESULTS: A total of 182 out of 210 surgical patients were included. After a median follow-up of 13.0 months, 39 IH (21.9%) were detected, 23 of which (13.4%) were in the EI; their frequency was lower in the TI group (3.4%) and in the MIM group (5.9%) than in the MIS group (29.5%; p=0.007). The probability of developing IH in the MIS group showed an OR=11.7 (95%CI: 3.3-42.0) compared to the TI group and 4.3 (IC 95%: 1.1-16.3) versus the MIM group. CONCLUSIONS: The location of the incision is relevant to avoid incisional hernias. Transverse incisions should be used as the first option. When a midline incision is needed, a prophylactic mesh could be considered in high risk patients because it is safe and associated with low morbidity.

Incisional hernia prevention and use of mesh. A narrative review. / Profilaxis de la hernia incisional y utilización de mallas. Revisión narrativa.

Incisional hernias are a very common problem, with an estimated incidence around 15-20% of all laparotomies. Evisceration is another important problem, with a lower rate (2.5-3%) but severe consequences for patients. Prevention of both complications is an essential objective of correct patient treatment due to the improved quality of life and cost savings. This narrative review intends to provide an update on incisional hernia and evisceration prevention. We analyze the current criteria for proper abdominal wall closure and the possibility to add prosthetic reinforcement in certain cases requiring it. Parastomal, trocar-site hernias and hernias developed after stoma closure are included in this review.

Incisional hernia prevention using a cyanoacrilate-fixed retrofascial mesh. / Prevención de la hernia incisional mediante malla retrofascial fijada con cianoacrilato.

INTRODUCTION: The rate of incisional hernia in high-risk patients (obesity, cancer, etc.) is high, even in laparoscopic surgery. The aim of this study is to evaluate the safety of the use of cyanoacrylate fixed prophylactic meshes in the assistance incision in overweight or obese patients undergoing laparoscopic colorectal surgery. METHODS: A prospective, non-randomized cohort study of patients undergoing elective laparoscopic resection for colorectal cancer between January 2013 and March 2016 was performed. Those with a body mass index greater than 25kg / m2 were evaluated to implant a prophylactic meshes fixed with cyanoacrylate (Histoacryl®) as reinforcement of the assistance incision. RESULTS: 52 patients were analyzed (mean body mass index: 28.4±2kg / m 2). Prophylactic meshes was implanted in 15 patients. The time to put the mesh in place was always less than 5minutes. There was no significant difference in wound infection rate (12% vs. 10%). No mesh had to be explanted. Although the mean follow-up was shorter (14.1±4 vs. 22.3±9 months), there were no incisional hernia in the mesh group. On the other hand, in the non-mesh group, 1 acute evisceration (2.7%) and 4 incisional hernia of the assistance incision were observed (10.8%). There were no significant differences between groups regarding trocar incisional hernia (6.6 vs. 5.4%). CONCLUSIONS: The implantation of a reinforcement prophylactic mesh in overweight or obese patients undergoing laparoscopic colorectal surgery is safe and seems to reduce the short-term rate of incisional hernia. Fixation with cyanoacrylate is a rapid method that facilitates the procedure without additional complications.

The use of an algorithm for prophylactic mesh use in high risk patients reduces the incidence of incisional hernia following laparotomy for colorectal cancer resection. / Un algoritmo para la colocación de malla profiláctica en pacientes de riesgo reduce la incidencia de hernia incisional tras laparotomía por cáncer colorrectal.

OBJECTIVE: Incisional hernia (IH) after colorectal surgery is highly prevalent. The objective of this study is to assess the utility of an algorithm to decide on mesh augmentation after a midline laparotomy for colorectal resection to prevent IH in high-risk patients. METHODS: A prospective study was conducted including all patients undergoing a midline laparotomy for colorectal resection between January 2011 and June 2014, after the implementation of a decision algorithm for prophylactic mesh augmentation in selected high-risk patients. Intention-to-treat analyses were conducted between patients in which the algorithm was correctly applied and those in which it was not. RESULTS: From the 235 patients analysed, the algorithm was followed in 166 patients, the resting 69 cases were used as a control group. From an initial adherence to the algorithm of 40% in the first semester, a 90.3% adherence was achieved in the seventh semester. The incidence of IH decreased as the adherence to the algorithm increased (from 28 to 0%) with a time-related correlation (R2=0.781). A statistically significant reduction in IH incidence was demonstrated in high-risk groups in which the algorithm was correctly applied (10,2 vs. 46,3%; p=0,0001; OR: 7,58;95%; CI: 3,8-15). Survival analysis showed that the differences remained constant during follow-up. CONCLUSION: The implementation of the algorithm reduces the incidence of IH in high-risk patients. The adherence to the algorithm also correlates with a decrease in the incidence of IH.