Wound complications after prosthetics of hernial defects of the anterior
abdominal wall: causes and methods of prevention (literature review).

Alexander Vasilyevich Chernykh; Черных Александр Васильевич; Asiyat Abdulnasirovna Magomedrasulova; Магомедрасулова Асият Абдулнасировна; Artem Nikolaevich Shevtsov; Шевцов Артем Николаевич; Maria Valeryevna  Aralova; Аралова Мария Валерьевна; Anastasia Sergeevna Lopatina; Лопатина Анастасия Сергеевна; Evgeny Andreevich Fedotov; Федотов Евгений Андреевич

doi:10.18499/2070-478X-2023-16-2-194-202

Wound complications after prosthetics of hernial defects of the anterior abdominal wall: causes and methods of prevention (literature review).

Authors: Chernykh A.V.¹, Magomedrasulova A.A.¹, Shevtsov A.N.¹, Aralova M.V.¹, Lopatina A.S.¹, Fedotov E.A.¹
Affiliations:
1. Voronezh State Medical University named after N.N. Burdenko
Issue: Vol 16, No 2 (2023)
Pages: 194-202
Section: Review of literature
URL: https://vestnik-surgery.com/journal/article/view/1639
DOI: https://doi.org/10.18499/2070-478X-2023-16-2-194-202
ID: 1639

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Abstract

Goal. To review the literature data on wound complications after prosthetic repair of hernial defects of the anterior abdominal wall, causes and methods of prevention.Results. An analysis of the literature has shown that the problem of wound complications during endoprosthetics for external abdominal hernias has not been completely solved. Among all postoperative complications after such hernias, seroma, infiltration and prolonged exudation are most common, less often ligature fistula, subcutaneous fat infarction, postoperative wound suppuration, cyst, granuloma, rejection of the prosthesis. The effectiveness of various methods of preventing wound complications during abdominal wall prosthetics is ambiguous. Conclusions. It is necessary to improve the known and develop new endoprostheses that would cause a minimal reaction of the body with good integration into tissues and high strength (to exclude relapses).

Keywords

Еxternal abdominal hernias, complications of herniation, hernia gate plastic surgery, mesh implant, prevention of wound complications

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Introduction
Treatment of external abdominal hernias is an urgent problem in modern surgery due to their high prevalence. Thus, according to various authors, the incidence of external abdominal hernias is 4-7% and, in general, tends to increase [16, 23, 24, 32, 61].
Every year, more than 20 million people perform in the world. surgical interventions for hernias of the anterior abdominal wall, which accounts for 10 to 21% of all surgical interventions [23, 32, 38, 61]. In Russia, the number of hernias is from 150 thousand to 200 thousand per year, of which the number of operations with primary ventral hernias is 17-20%, with postoperative ventral hernias – 70-80% [31, 22, 32, 47, 55].
Currently, more than 300 surgical methods and modifications of the treatment of abdominal hernias are known. Despite the improvement of methods of plasty of anterior abdominal wall defects, the results of treatment of this category of patients leave much to be desired. Thus, the number of recurrences in autoplasty of primary ventral hernias is 20-46%, and with prosthetic methods – 5-10%. The number of relapses in autoplastic methods of treatment of patients with postoperative ventral hernias is 10-30%, and in prosthetic methods – 3,8-14,2% [1, 4, 6, 7, 13, 15, 19, 21, 24, 25, 28-30, 32, 39, 47, 53, 66].
Since the second half of the XX century, mesh endoprostheses have been used in the treatment of patients with abdominal hernias. The use of mesh implants reduced the recurrence rate to 5-10%, but led to an increase in the frequency of wound complications [5, 9, 12, 16, 27, 29, 33, 36, 45, 44, 48, 58, 62, 65]. They are observed both with the use of various types of endoprostheses (polypropylene, polytetrafluoroethylene), and with various methods of their placement in tissues [50, 51, 54, 59]. Currently, there are 5 main positions of fixation of the endoprosthesis: inlay, onlay, sublay, underlay, IPOM.
Risk factors for postoperative complications
The results of the assessment of risk factors for postoperative complications in prosthetic plastic surgery of the anterior abdominal wall in various studies are contradictory. Many authors consider diabetes mellitus, hypertension, obesity, ligature and intestinal fistulas, more than one history of herniation, previously performed operations in the abdominal cavity, hospital stay of more than two weeks, the size of a hernial defect of more than 300 cm2 and the use of an autograft for plastic surgery to be significant risk factors for both general and local complications in the postoperative period [14, 71, 73, 77, 85]. According to other authors, the provoking factors of local complications, regardless of the method of placement of the mesh implant, are: body mass index (BMI) > 40 kg/m2 and prolonged presence of giant hernial sacs in subcutaneous fat with the formation of cavities [3, 44, 52, 74]. According to A.G. Sonis, wound complications are more common in patients with obesity and concomitant diseases of the cardiovascular system, with the plastic of median defects and with an area of plastic material more than 150 cm2 [50].
There is also an opinion that when hernial gates are plasticized with the help of a polymer mesh, postoperative complications are not associated with the use of synthetic material, but are the result of extensive preparation of skin-subcutaneous flaps, in which large perforant vessels extending from the trunks of the epigastric arteries intersect [42].
Complications
The reaction of the human body to the implantation of synthetic materials is currently insufficiently studied. The question remains open about the response of tissues to polypropylene, depending on the weaving option, structure, thickness and size of the endoprosthesis cell [17, 49, 66, 70, 81, 83].
Among all postoperative complications of herniation, seroma, infiltration, prolonged exudation, hematoma, ligature fistula, subcutaneous fat infarction, suppuration of the postoperative wound, cyst, granuloma, rejection of the prosthesis are usually mentioned [27, 67, 68, 76]. At the same time, researchers have an ambiguous attitude to various wound complications after prosthetic hernia gate surgery. The most relevant among them are wound suppuration, seroma, as well as infiltration and ligature fistula, which are considered in this work. Complications such as hematoma, prolonged exudation, subcutaneous fat infarction, cyst, granuloma and rejection of the prosthesis have significantly less clinical significance. [34, 41, 43, 74, 78].

Yu. S. Vinnik and co-authors indicate that the frequency of formation of postoperative infiltrate in patients with anterior abdominal wall plastic surgery is 8-14% [10, 11]. At the same time, there is an infiltrate itself (impregnation of tissues with serous and serous-fibrinous transudate) and an infiltrate with a hemorrhagic component (imbibition of the wound edges with blood).
The reasons for the formation of infiltrate in the area of the postoperative wound are: a local inflammatory reaction of the body (which is usually aseptic) to the endoprosthesis, as to a foreign body; rough traction during surgery and insufficient hemostasis [24]. According to the literature [61, 64], infiltrate is formed more often in patients with a high body mass index, with insufficient qualifications of the surgeon, the use of suture materials with high reactivity, the presence of adhesions, atherosclerosis, increased fragility of blood vessels, recurrent and irreparable hernia, the use of disaggregants and anticoagulants, hemophilia.
Infiltration can also be a consequence of the choice of an operational aid. The latter is becoming increasingly important with the development of new accesses. Thus, with standard accesses with dimensions at which sufficient exposure is created, the chance of making technical errors is less than with the desire to reduce the length of the surgical wound. Other researchers consider the presence of fluid accumulations in the residual cavities of subcutaneous fat and inadequate drainage of the postoperative wound to be the cause of inflammatory infiltration of the wound [27].
The clinical picture of inflammatory infiltration is manifested by edema, compaction, hyperemia, tension of the skin and subcutaneous tissue along the postoperative wound. The infiltrate can spread to the entire area where the incision is made, as well as move to adjacent departments. In the presence of hemorrhagic imbibition, the picture is externally supplemented by ecchymoses [10, 11, 27].
Ultrasound examination in the early postoperative period in patients with signs of infiltration is a simple and reliable screening method that allows you to start the necessary treatment in time. The ultrasound picture of the infiltrate of the postoperative wound is diffuse heterogeneous changes in subcutaneous fat with possible foci of sequestered fluid, represented by anechoic inclusions of irregular shape.
The infiltrate of the postoperative wound "resolves" within 2-3 weeks without any active interventions, however, with its significant size, it is possible to diverge, as a rule, the caudal edge of the wound with its subsequent drainage. The main method of treatment is the application of bandages with antiseptic solutions. Physiotherapy is possible.
Seroma.
Some authors consider seroma to be the most frequent complication of herniation with the use of endoprostheses [27, 28]. Various studies controversially assess the causes of the formation of seromas and their role. According to A.V. Samoilov, they are formed as a result of mechanical or chemical injury of tissues and a nonspecific inflammatory reaction to the prosthesis [47]. According to other authors, the main reason for the formation of seromas is the presence of a wound cavity and a mesh in it, as an alien body [38, 56]. At the same time, any physical activity contributes to the friction of tissues on the rough surface of the mesh, which is accompanied by an increase in the permeability of lymphatic vessels and the release of tissue fluid, from which proteins fall out onto the mesh and further gluing of the wound. Some authors consider the contact of the endoprosthesis with subcutaneous adipose tissue to be one of the reasons for the formation of gray, others associate their appearance only with extensive mobilization of subcutaneous adipose tissue [10, 22, 26, 36, 42].
Depending on the method by which the presence of seromas is determined, their frequency may vary: with ultrasound, it can reach 100%, and according to clinical data it will be low. On 5-7 days after surgery, almost all patients have a small amount of serous fluid in the area of the endoprosthesis. Liquid accumulations are also found not only in spaces directly in contact with the mesh, but also in the fiber (subcutaneous or preperitoneal), for example, when the endoprosthesis is located between the sheets of the vagina of the rectus abdominis muscle [37, 41]. S.Yu. Pushkin et al. [43] studied the nature of morphofunctional changes in tissues during the formation of fluid formations in a postoperative wound in patients after herniation. They found that the cause of the formation of residual cavities-“dead spaces” - in subcutaneous fat and the accumulation of exudate in them is a violation of the blood supply to the deep layers of tissues due to detachment of subcutaneous fat from aponeurosis and the lack of tight fit to it after surgery. At the same time, cavities in the subcutaneous tissue are observed not only after the use of synthetic prostheses, but also after plastic surgery with local tissues. Seromas of the postoperative wound after prosthetic repair of the hernial gate can become infected and cause suppuration. In the long term after surgery, seromas can reach huge sizes, simulating a tumor in the abdominal cavity [2, 35, 57].
It is important to note that the problem of seroma formation also exists in the laparoscopic treatment of ventral hernias, when the surgical trauma is minimal and there is no detachment of subcutaneous fat [24, 35, 62, 72, 84].
Ligature fistula.

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