Prophylactic mesh placement in emergency midline laparotomy for intestinal perforation peritonitis: An appeal for caution

Abstract

Prophylactic mesh placement (PMP) is increasingly being used to reduce the incidence of incisional hernia after routine and emergency midline laparotomy (EML). However, such studies are not available for EMLs done solely for intestinal perforation. Patients who underwent non-absorbable PMP during EML for intestinal perforation (Group A, 15 patients) were compared with those who had a conventional abdominal wall closure (Group B, 20 patients). The incidence of wound dehiscence was significantly higher in Group A, while surgical site infection (SSI), and incisional hernia were similar in both groups. Mesh explantation was needed in half the cases. A prophylactically placed non-absorbable mesh in patients undergoing EML for intestinal perforation is associated with significantly higher rates of wound dehiscence and of mesh explantation and therefore, routine use of such a mesh appears not to be justified.

Keywords

prophylactic mesh emergency midline laparotomy intestinal perforation

Introduction

Prophylactic mesh placement (PMP) is recommended for selected high risk patients after routine midline laparotomy (RML).^1–4 A similar philosophy is driving the use of PMP in emergency cases including those with peritonitis.^5–9 However, objective evidence for its routine use, as synthesized by two recent meta-analyses, is limited.^10,11 Additionally, data are not available for the outcomes of PMP in patients undergoing EML for intestinal perforation peritonitis, prompting us to conduct this prospective observational study to assess its safety and efficacy in these cases.

Methods

Our prospective study was conducted between August 2019 and August 2021, in an Indian tertiary hospital. Ethical clearance was obtained from the institutional ethical committee.

Inclusion criteria were: age > 18 years, and EML being performed for intestinal perforation. Patients excluded were those who underwent EML for other indications, including peptic perforation, and those with a previous midline surgical scar or incisional hernia.

Patients were divided into two groups. The study group (Group A, 15 patients) had prophylactic placement of a non – absorbable mesh during EML performed in one unit of the surgery department. The control group (Group B, 20 patients) had EML without placement of the mesh, performed in other units of the department during the same time period. The outcome measures assessed were:

The frequency of surgical site infection (SSI), wound dehiscence, mesh related complications including explantation.

The surgical re-intervention rate.

The incidence of incisional hernia.

A preoperative assessment of the haemodynamic status (heart rate, and blood pressure), full blood count, and biochemical parameters (serum creatinine, liver function tests, serum sodium & potassium) were made at the time of admission. Patients were stratified by the Jabalpur Prognostic Scoring System (JPSS, score ranges from 0–21, 0–4 = Grade 1, 5–9 = Grade 2, 10–14 = Grade 3, 15–21 = Grade 4), a simplified prognostic scoring system using the parameters of age, presence of co-morbid illness, perforation-to-operation interval, pre-operative shock, heart rate, and serum creatinine.¹² This scoring system has been validated for predicting outcome in patients with typhoid ileal perforations, where the mortality increases with the score.¹³ Informed consent was obtained from all patients. After optimization, patients were taken for surgery under antibiotic cover with ceftriaxone with sulbactam and metronidazole.

Per-operatively, the bowel perforation was managed by suture repair, exteriorization; or by segmental resection & anastomosis, with or without a diverting stoma– according to the requirements of the case and the decision of the operating surgeon. Peritoneal lavage was performed in all; and two Ch 32 drains were placed, one in the pelvic cavity and one in the hepato-renal pouch.

In the control group A, patients underwent a single layer, continuous closure of the rectus sheath with No. 1 polypropylene suture. In the study group B, the peritoneum and posterior rectus sheath were approximated in a single layer, by a continuous No. 1 polypropylene suture. This was followed by placement of a macroporous (pore size >75 µm) polypropylene mesh in the retro-muscular space, extending 5 cm beyond the incision all around. The mesh was fixed with a polypropylene 2/0 suture. Two limbs (Ch 14) of a suction drain were placed superficial to the mesh and the two recti were approximated by interrupted sutures of polyglycolic 2-0. Finally, the anterior rectus sheath was closed in a continuous fashion with a No.1 polypropylene suture.

Postoperatively, patients were monitored for SSI, wound dehiscence, need for repeat surgery (including mesh removal). In-hospital mortality was recorded. The first follow-up visit was planned one week after discharge. Subsequent follow up was at six weeks, three months, and six months after surgery. At follow-up, patients were clinically examined to detect seroma, SSI, wound dehiscence, and incisional hernia. Ultrasonography with a high frequency probe was done to detect or confirm incisional hernias.

Statistical analysis was done using IBM SPSS Statistics for Windows, version 23 (IBM Corp., Armonk, N.Y., USA). The Student t test and the chi-square test were used to compare continuous & categorical variables respectively. A p value < 0.05 was considered statistically significant.

Results

A total of 35 patients were included in the study, 15 in Group A and 20 in Group B. Both groups were comparable in terms of the factors assessed pre-operatively (Table 1)

Table 1.

Preoperative factors.

Parameter	Group A (N=15)	Group B (N=20)	p Value
Age (years)	43.1	34.4	0.119
Male: Female	80:20	65:35	--
HR (per min)	98.9	98.3	0.997
MAP (mm Hg)	82.6	78.8	0.240
Haemoglobin (mmol/L)	7.39	7.51	0.720
TLC (cells*10^9L)	7.8	9.5	0.201
S. Creatinine (µmol/L)	123.79	114.95	0.774
JPSS score	5.2	5.0	0.852
Grade 1 (N)	6	11
Grade 2(N)	8	5
Grade 3 (N)	1	4
Grade 4 (N)	0	0

HR: Heart rate; MAP: Mean Arterial BP; TLC: Total Leucocyte Count; JPSS: Jabalpur Prognostic Scoring System.

In Group A, the perforation site was in the small bowel in 13 patients (3 jejunum, 10 ileum) and the appendix or large bowel in two patients. In Group B, the corresponding figures were 16 (4 jejunum, 12 ileum) and 4 respectively. Typhoid ileal perforation was the commonest cause and site of perforation; as seen in 67% patients of Group A, and 60% patients of Group B.

One patient of Group A died on the first post-operative day; hence outcome analysis was based on the 14 survivors of this group. On comparing outcomes, the two groups were similar in terms of the incidence of SSI, incisional hernia, and mortality. However, wound dehiscence was significantly higher in the prophylactic mesh group (40% vs. 10%, p = 0.026) (Table 2). There were four patients who suffered a leak from the bowel repair or anastomosis sites (three in Group A, one in Group B). All four underwent a second procedure to create a defunctioning stoma, and were subsequently discharged. Of these, the one patient without a mesh developed an incisional hernia two months later. Among patients with a mesh, 50% (7/14) needed a mesh explantation. (Table 2).

Table 2.

Outcome measures.

	Group A (N = 14*)	Group B (N=20)	p Value
SSI	8 (57%)	7 (35%)	0.201
Wound dehiscence	6 (42.8%)	2 (10%)	0.026
Incisional hernia	1 (7.1%)	2 (10%)	0.773
Mesh explantation	7 (50%)	NA (%)	NA
Mortality	1 (7.1%)	6 (30%)	0.088

*1patient died on POD 1; hence outcome analysis was conducted on 14 patients.

Discussion

The concept of PMP has gained acceptance and prominence in an attempt to reduce the unacceptable incidence, decreased quality of life and morbidity of a later incisional hernia after RML. This mandates further surgery involving a mesh repair or complex component separation techniques. Despite improvements in suture materials and closure techniques, the incidence of incisional hernia is an estimated 5–26% after a RML.¹⁴ This figure is higher in high-risk groups; such as the obese, and if the follow up is greater than three years; or when imaging techniques are used to search for incisional hernia.^15–18

Research has therefore rightly focused on selecting the high-risk cases needing PMP for RML and several studies including systematic reviews have established its safety and efficacy in these cases.^1–4 Simultaneously, though, the conventional dogma which dictated avoiding the use of synthetic mesh in the presence of infection has been challenged by studies which showed that such can be safely and effectively used in the settings of PMP for peptic perforation peritonitis and in groin hernias containing gangrenous bowel.^5,6,19–21

However, our observational study shows that PMP in EML for intestinal perforation peritonitis is associated with significantly higher (p = 0.026) wound dehiscence, as compared to the control group, and required explantation of the mesh in half of the cases. This observation goes against previous studies and questions the supposed safety of PMP in such cases. Possible reasons could be:

A greater intra-peritoneal load of bacterial flora exists in intestinal perforation than in peptic perforation, which is predominantly a chemical event. This can be accounted for by the higher aerobic culture positivity rates (44% in gastric perforation, 60–85% in small intestine and 100% in colonic perforations), and the higher bacterial load (c.100/g in the duodenum, rising to 1000/g in the colon).^22,23 This is reflected in the higher mortality rate of intra-abdominal infection caused by intestinal perforation (20–38% in small bowel, and 20–45% in colon), compared to gastroduodenal perforation (3–28%).²⁴

Some two thirds of patients in our study had typhoid ileal perforations. These are known to have many disease-related adverse factors such as non-migration of the omentum causing more generalized faecal peritonitis, and arise in a patient who is likely to be anaemic, hypo-proteinaemic, and may also have various medical complications such as myocarditis, pneumonia and endotoxic shock.¹³

The possibility of Zenker's degeneration, a prototype of coagulative necrosis of skeletal muscle such as the rectus abdominis, which can occur in severe toxaemia as in typhoid fever.²⁵

Previous observational studies & RCTs which have shown PMP effective in reducing incisional hernia after EML^5–9 have included a wide spectrum of aetiology (including cases without peritonitis), unlike our study which included only patients undergoing EML for intestinal perforation.

Obesity is probably the most important risk factor for incisional hernia, and up to 73% of Western population are overweight.²⁶ Thus, Western trials which may have a large proportion of such patients may show a greater ‘benefit’ from PMP, unlike our cohort of patients which more accurately reflect the population of LMICs. The limitations of our study are that it is non-randomised, with a small sample size, patients were not stratified by common risk factors for incisional hernia such as obesity, and it has a relatively short follow-up. Nonetheless, the high incidence of wound dehiscence and the need for mesh explantation in half the cases raises questions about the wisdom of PMP in the scenario of intestinal perforation peritonitis.

Conclusion

Our study shows that routine PMP in the presence of intestinal perforation peritonitis cases is not safe. Moreover, while the safety of PMP has been demonstrated in cases of peritonitis due to peptic perforation, its selection in high-risk cases remains to be elucidated. In such circumstances, the classical surgical teaching of not implanting foreign material in the presence of sepsis becomes important, especially in LMICs where the means of treating foreign-body sepsis effectively are limited.

The prophylactic placement of a non-absorbable mesh in patients undergoing emergency midline laparotomy for intestinal perforation is associated with significant rates of wound dehiscence and of mesh explantation, and is not justified.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Uday Somashekar

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