Prosthetic Mesh May Stand in the Way of Further Abdominal Operations

Surgical candidates with prior incisional hernia repair with mesh were prone to more complications and healthcare utilization when undergoing a subsequent operation through their

prosthetic-reinforced abdominal wall, a cohort study found.

When compared to surgical peers without a history of abdominal surgery, reoperation through the prosthetic-mesh footprint in the abdominal wall was associated with worse outcomes after a

subsequent abdominal operation:

"Surgeons may use these data to set appropriate expectations preoperatively when counseling patients with prior IHRWM [incisional hernia repair with mesh] who are planning to undergo

abdominal surgical procedures," according to John Fischer, MD, from the University of Pennsylvania Health System in Philadelphia, and colleagues, writing in JAMA Surgery.

"For example, these results become more relevant when weighing risks and benefits during the preoperative counseling of a 35-year-old with prior IHRWM who requires resection for a Crohn

stricture than when counseling a 75-year-old patient undergoing bowel resection for cancer, with the latter being less likely to undergo subsequent abdominal surgical procedures in their

lifetime," the study authors added.

Fischer's team noted that the observed trend "persisted" even when they compared matched patients who had a prior IHRWM to those with a history of abdominal surgical procedures.

Their population-based retrospective cohort study used data from 914,105 patients undergoing inpatient abdominal surgical procedures from January 2009 to December 2016 with at least 1 year

of follow-up. Data were collected from five geographically diverse statewide inpatient/ambulatory databases (Florida, Iowa, Nebraska, New York, and Utah).

The 3,517 patients with prior incisional hernia repair with mesh (44% in the 46-65 age range, 68.1% women, 67.2% white) were propensity score matched to controls without a history of

abdominal surgeries. After matching, common subsequent surgeries included small-bowel resection (24-26%), cholecystectomy (23-24%), colonic resection (21%), and salpingo oophorectomy (16%).

This analysis has its limitations, according to Benjamin Miller, MD, and Michael Rosen, MD, both of Cleveland Clinic in Ohio.

"Comparing patients without prior abdominal surgery with those with prior incisional hernia repair with mesh is not telling the real story of the mesh footprint. We all know a reoperative

abdomen is more hostile than a virgin abdomen, with the potential for more complications," the pair wrote in an editorial that accompanied the study.

"A more accurate story appears when we compare patients with prior abdominal surgery with those with prior incisional hernia repair with mesh. Compared with patients with prior abdominal

surgery, those with prior incisional hernia repair with mesh were only 3.2% more likely to have a surgical complication and were not more likely to undergo reoperation. The mesh footprint in

this study, then, is small," Miller and Rosen said.

Fischer's group also acknowledged the lack of granular clinical detail and critical operative details in the study. Mesh type, mesh location, and number and type of prior abdominal

operations are therefore unknown, the editorialists noted.

In addition, there was some loss of follow-up in the dataset.

Nevertheless, the study authors maintained that "these results facilitate surgeons' work in their role as abdominal-wall stewards and emphasize the need for increased long-term surveillance

of mesh implant devices and the inclusion of abdominal mesh history as a proxy of complexity when risk-stratifying patients for benchmarking, research, and reimbursement purposes."

Fischer received consulting fees from Becton Dickinson, Baxter, AbbVie, Gore, Integra, Allergan, and 3M.

Rosen received salary support as the ACHQC Medical Director.