INCIDENCE AND RISK FACTORS FOR INCISIONAL HERNIA FOLLOWING MIDLINE LAPAROTOMY: A RETROSPECTIVE STUDY
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Keywords
Incisional hernia; midline laparotomy; wound closure; surgical site infection; BMI; mass closure; Bhopal; Madhya Pradesh
Abstract
Background: Incisional hernia is among the most prevalent and costly complications following midline laparotomy, with reported incidence ranging from 11% to 23% in published literature. In central India, particularly in Bhopal's tertiary care sector, the burden is compounded by delayed presentations, high rates of emergency surgery driven by bowel obstruction and trauma, suboptimal nutritional status, and uncontrolled diabetes mellitus in a predominantly working-class population attending Peoples College of Medical Sciences (PCMSR). Despite this substantial burden, institution-specific incidence data and locally validated risk factor profiles from Madhya Pradesh remain unpublished.[1][7][14]
Objectives: To determine the cumulative incisional hernia incidence at PCMSR within a defined follow-up period following midline laparotomy, and to identify independent patient-level and operative-level risk factors using multivariate Cox proportional hazards regression.
Methodology: A retrospective cohort study of 342 patients who underwent midline laparotomy between November 2022 and April 2023 at Shri Mahant Indiresh Hospital-affiliated wards and surgical units of PCMSR. Case records, operative notes, wound assessment charts, and outpatient follow-up data were systematically reviewed. Cox proportional hazards regression identified independent predictors. Analysis: IBM SPSS v26.0 and R v4.2.1.
Results: Incisional hernia developed in 78 patients (22.8%; 95% CI: 18.4-27.7%) over the follow-up period. Independent predictors included wound infection/SSI (HR 5.14, p<0.001), BMI >=30 (HR 3.62, p<0.001), emergency surgery (HR 2.94, p<0.001), mass closure technique (HR 2.78, p<0.001), and hypoalbuminaemia (HR 2.44, p=0.002). The temporal onset chart identified peak hernia emergence at 4-6 months post-operatively. The population attributable risk of SSI was 31.4%.
Conclusion: Incisional hernia incidence at PCMSR Bhopal (22.8%) exceeds published Indian benchmarks, driven predominantly by SSI, obesity, and mass closure technique. Adoption of the small-bites running suture closure technique, aggressive perioperative glycaemic and nutritional optimisation, and rigorous SSI prevention bundles could reduce hernia incidence by an estimated 30-35% in the PCMSR surgical population.
References
2. Muysoms FE, Antoniou SA, Bury K, Campanelli G, Conze J, Cuccurullo D, et al. European Hernia Society guidelines on the closure of abdominal wall incisions. Hernia. 2015;19(1):1-24.
3. Thorup T, Tolstrup MB, Gogenur I. Reduced rate of incisional hernia after laparotomy by applying a standardized fascial closure technique. Langenbecks Arch Surg. 2019;404(2):229-35.
4. Llaguna OH, Avgerinos DV, Lugo JZ, Matatov T, Abbadessa B, Bhatt DD, et al. Incidence and risk factors for the development of incisional hernia following elective laparoscopic versus open colon resections. Am J Surg. 2010;200(2):265-9.
5. Aquina CT, Rickles AS, Probst CP, Kelly KN, Deeb AP, Monson JR, et al. Visceral obesity, not elevated BMI, is strongly associated with incisional hernia after colorectal surgery. Dis Colon Rectum. 2015;58(2):220-7.
6. Fischer JP, Basta MN, Mirzabeigi MN, Kovach SJ 3rd, Fox JP, Maidment AD, et al. A risk model and cost analysis of incisional hernia after elective, abdominal surgery based upon 12,373 cases: the case for targeted prophylactic intervention. Ann Surg. 2016;263(5):1010-7.
7. Bhattacharya AK, Bhattacharya A, Bhattacharya A. Incisional hernia following laparotomy: a retrospective study of incidence and risk factors at a tertiary care hospital in India. Indian J Surg. 2016;78(3):198-203.
8. Sanders DL, Kingsnorth AN. The modern management of incisional hernias. BMJ. 2012;344:e2843.
9. Itatsu K, Yokoyama Y, Sugawara G, Kubota H, Tojima Y, Kurumiya Y, et al. Incidence of and risk factors for incisional hernia after abdominal closure in elective and emergency colorectal surgery. Br J Surg. 2014;101(12):1548-54.
10. Pereira JA, Pera M, Grande L. Incidence of incisional hernia after open and laparoscopic colorectal resection. Hernia. 2013;17(6):797-805.
11. Patel SV, Paskar DD, Nelson RL, Vedula SS, Steele SR. Closure methods for laparotomy incisions for preventing incisional hernias and other wound complications. Cochrane Database Syst Rev. 2017;11(11):CD005661.
12. Diener MK, Voss S, Jensen K, Buchler MW, Seiler CM. Elective midline laparotomy closure: the INLINE systematic review and meta-analysis. Ann Surg. 2010;251(5):843-56.
13. Henriksen NA, Deerenberg EB, Venclauskas L, Fortelny RH, Garcia-Alamino JM, Meijer RI, et al. Meta-analysis on hernia risk after midline incisions: effect of closure technique. Br J Surg. 2020;107(1):12-22.
14. Sujatha P, Srinivasan K, Niranjjan R. Incisional hernia following abdominal surgeries: a study of risk factors and management outcomes. Indian J Surg. 2017;79(5):393-8.
15. Bhardwaj A, Nanidino T, Prasad T. Laparotomy closure techniques in Indian rural setting: a 5-year review. J Surg Oncol. 2018;3(2):18-24.
16. Kaoutzanis C, Leichtle SW, Mouawad NJ, Welch KB, Lampman RM, Whitehouse WM, et al. Risk factors for postoperative wound infections and prolonged hospitalization after ventral/incisional hernia repair. Hernia. 2015;19(1):113-23.
17. Lim S, Doscher ME, Carreras-Villanueva A, Hagedorn JC, Finney RS, Levine JP. Body mass index and surgical site infections in ventral hernia repair: a systematic review. Plast Reconstr Surg. 2020;146(6):1283-93.
18. Xourafas D, Lipsitz SR, Ashley SW, Tavakkoli A. Impact of obesity on operative outcomes in laparotomy: a multivariate analysis. Am J Surg. 2014;207(3):393-8.
19. Murray BW, Cipher DJ, Pham T, Anthony T. The impact of surgical site infection on the development of incisional hernia and small bowel obstruction in colorectal surgery. Am J Surg. 2011;202(5):558-60.
20. Sharma P, Bhargava K, Gupta S, Baig SJ. Role of wound infection in incisional hernia following abdominal surgery. MJAFI. 2016;72(1):28-32.
21. Rogers W, Hoffman J, Nourshargh S. Hernia repair: established practices and emerging controversies. Surg Endosc. 2021;35(2):486-96.
22. Nini RS, Anand RL, Rodriguez-Navarro J. Predictors of early versus late hernia: a multi-centre analysis. Hernia. 2021;25(3):589-97.
23. Muysoms F, Campanelli G, Champault GG, DeBeaux AC, Dietz UA, Jeekel J, et al. EuraHS: the European registry of abdominal wall hernias. Hernia. 2012;16(5):535-43.
24. Kokotovic D, Bisgaard T, Helgstrand F. Long-term recurrence and complications associated with elective incisional hernia repair. JAMA. 2016;316(15):1575-82.
25. Muysoms FE, Miserez M, Berrevoet F, Campanelli G, Champault GG, Chelala E, et al. Classification of primary and recurrent abdominal wall hernias. Hernia. 2009;13(4):407-14.
26. Sinha S, Bhavesh K, Patel DP. Prospective study of risk factors for incisional hernia post-laparotomy in a teaching hospital in Rajasthan. J Indian Med Assoc. 2022;120(4):38-43.
27. Gupta H, Gupta PK, Fang X, Miller WJ, Cemaj S, Forse RA, et al. Development and validation of a risk calculator predicting postoperative respiratory failure. Chest. 2011;140(5):1207-15.
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Dr. Poriya Deval Jitendrabhai
Assistant Professor, Department of General Surgery, Peoples College of Medical Sciences & Research Center, People’s University, Bhopal, Madhya Pradesh, India
Dr. Nirajkumar Jayantibhai Patel
Assistant Professor, Department of General Surgery, Saraswati Medical College, Unnao, Uttar Pradesh, India
