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Hernia (2021) 25:1095–1101

https://doi.org/10.1007/s10029-021-02446-0

ORIGINAL ARTICLE

Management of epigastric, umbilical, spigelian and small incisional


hernia as a day case procedure: results of long‑term follow‑up
after open preperitoneal flat mesh technique
M. Zuvela1,2 · D. Galun1,2 · A. Bogdanovic1,2   · N. Bidzic1,2 · M. Zivanovic1 · M. Zuvela1 · M. Zuvela1

Received: 15 April 2021 / Accepted: 9 June 2021 / Published online: 24 June 2021
© The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature 2021

Abstract
Purpose  To investigate short and long-term outcome after the open preperitoneal flat mesh technique (OPFMT) for umbili-
cal, epigastric, spigelian, small incisional and “port-site” hernia performed as a day case procedure.
Methods  We retrospectively analyzed records of patients who underwent OPFMT for umbilical, epigastric, Spigelian, small
incisional and “port-site” hernia in ambulatory settings between 2004 and 2020 at Clinical Center of Serbia. Demographic
and clinical characteristics, operative data and postoperative complications were compared between the groups. Univariate
and multivariate analyses were performed to identify predictive factors for mesh infection and recurrence.
Results  Overall, 476 patients were divided according to the type of hernia. Early postoperative complications were similar
in all study groups. Mesh infection, chronic pain and recurrence were different between groups (p = 0.013, p = 0.019 and
p = 0.011, respectively). Overall recurrence rate after OPFMT was 2.5%. Hernia defect, hematoma and length of postopera-
tive stay at the Day Surgery Unit were identified as potential predictors of mesh infection (Odds ratio 6.449, 22.143 and
1.546, respectively; p = 0.027, p = 0.011 and p = 0.038, respectively) while mesh infection was the only potential predictor
of recurrence in univariate analysis. Hematoma was an independent predictor of recurrence (Odds ratio 27.068; 95% Con-
fidence interval 2.355–311.073; p = 0.008).
Conclusion  The OPFMT performed under local anesthesia as a day case procedure is a safe technique associated with
favorable long-term outcome. Hematoma is an independent predictor of mesh infection occurrence.

Keywords  Umbilical hernia · Epigastric hernia · Ambulatory surgery · Day case surgery · Open preperitoneal technique

Introduction choice of anesthesia (local, regional or general). In general,


primary herniorraphy (the suture repair or tension repair)
Umbilical, epigastric, spigelian and small incisional hernia is associated with a higher rate of recurrence [3]. The two
repair is a common surgical procedure associated with low randomized controlled trials reported the recurrence rates
postoperative complication rate ranging between 3 and 8.9% after the Mayo technique of 7 and 11%, respectively [4, 5].
[1, 2]. In the literature there is no consensus about the man- Interestingly, almost 50% of elective umbilical hernia repair
agement of small primary and small incisional abdominal in the United States are performed by suture repair without
wall hernia and it is mainly related to: (a) the use of pros- mesh placement [6]. According to the guidelines from the
thetic mesh, (b) selection of the anatomical layer for mesh European and Americas Hernia Society, mesh is recom-
placement, (c) selection of the type of mesh (flat or plug), (d) mended for umbilical and epigastric hernia repair to reduce
the recurrence rate, while suture repair can be considered
for small hernia with the hernia defect of less than 1 cm [7].
* A. Bogdanovic A similar dilemma exists in the management of small
aleksandarbogdanovic81@yahoo.com incisional hernias. The selection of an operative technique
1
Clinic for Digestive Surgery, Clinical Center of Serbia, depends on the hernia defect size. An incisional hernia with
Koste Todorovica 6, 11 000 Belgrade, Serbia a defect exceeding 5 cm should always be repaired by one
2
School of Medicine, University of Belgrade, of the mesh techniques, while small-size defects ≤ 5 cm can
11 000 Belgrade, Serbia

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1096 Hernia (2021) 25:1095–1101

be repaired by suture technique although mesh techniques Operative technique


provide superior results [8].
The improvements of the tension-free mesh techniques All operations were performed under local infiltrative
led to hernia repair performance as a day case surgery pro- anesthesia. A combination of 20  ml 0.5% Levobupiv-
cedure. An early postoperative mobilization and reduced acaine, 30 ml 2% Procaine, and 50 ml saline solution was
pulmonary and thromboembolic events is achieved after used when the hernia defect was up to 4 cm; in defect
tension-free mesh techniques performed under the local exceeding 4 cm the combination used was 20 ml 0.5%
anesthesia bringing ambulatory hernia surgery available Levobupivacaine, 50 ml 2% Procaine and 50 ml saline
to majority of patients. Significant cost-benefits and lower solution. Antibiotic prophylaxis was administered preop-
readmission rates are achieved in ambulatory surgery saving eratively as a single dose. Low-weight heparin was admin-
the limited hospital resources available for the critically ill istered routinely two hours before surgery.
[9]. Moreover, local anesthesia is a more effective option For umbilical hernia repair a transversal semilunar skin
compared to general and spinal anesthesia [10, 11]. incision was made above the umbilicus. Epigastric and spi-
The majority of small primary ventral hernias could be gelian hernia repair was performed through a transversal
managed as a day case procedure. There is a lack of data skin incision while incisional hernia repair was performed
about pooled series of patients with umbilical, epigastric, through a skin incision along the operative scar. The her-
spigelian and small incisional hernias operated on an out- nia sac and fascia were dissected from the subcutaneous
patient basis under local anesthesia. fat tissue. The dissection extended up to 3 cm around the
The study aim was to evaluate an early postoperative and hernia defect. The hernia sac was not entered and it was
long-term surgical outcome after the open preperitoneal restored into the abdominal cavity together with its con-
flat mesh technique (OPFMT) used for small primary and tents. If hernia sac reduction was not possible, the hernia
incisional abdominal wall hernia performed as a day case sac was entered, its contents released and returned into
procedure. the abdominal cavity. During the small incisional her-
nia repair, entering the hernia sac is obligatory because
local intestinal adhesions surrounding hernia defect are
Methods expected. To avoid viscera injury, adhesions must be
divided up to 5 cm in radially direction. The hernia sac
Study population was reconstructed with absorbable running suture and
returned into the abdominal cavity.
A single-institution retrospective review of adult patients The size of the polypropylene flat mesh exceeded the
undergoing open umbilical, epigastric, spigelian, small size of the hernia defect for 2–3  cm in all directions,
incisional and “port-site” hernia repair between 2004 and except for hernia defects up to 0.5 cm where overlapping
2020 at the University Clinic for Digestive Surgery, Clinical of 1 cm is sufficient. The mesh was positioned preperito-
Center of Serbia was undertaken. The study was approved neally in the hernia sac that had previously been returned
by the institutional review board. Informed consent was into the abdominal cavity and anchored with at least 8
obtained from all study subjects. The inclusion criteria mattress non-absorbable sutures. For defect less than 1 cm,
were: OPFMT performed as elective surgical procedure 4 sutures are recommended. The mattress sutures were
for primary (umbilical, epigastric and Spigelian) and inci- passed through the abdominal wall at 2–3 cm distance
sional abdominal wall hernia, local anesthesia and the treat- from the edge of hernia defect and the edge of the mesh,
ment in the outpatient care settings. The exclusion criteria and tied at the anterior side of the fascia. The hernia defect
were strangulated hernia treated by the emergency surgery was sutured with a running, non-absorbable suture to sepa-
and American Society of Anesthesiologist (ASA) score 4. rate the mesh from the subcutaneous tissue.
All operations were performed by a single senior surgeon. The operative technique for spigelian hernia differs in
The indications for surgery were symptomatic hernia with minor details due to its specific anatomical characteristics,
defect ≥ 0.5 cm and the need for cosmetic surgery in patients as described previously [12].
with ASA score 1–3. Age, sex, ASA score, hernia recur-
rence, synchronous ventral or inguinal hernia at the other
site, the size of the hernia defect, operative time, length of Follow‑up
postoperative stay at the Day Surgery Unit, surgical site
occurrence (seroma, hematoma, superficial wound infection The first follow-up visit was performed four weeks after
or mesh infection) were recorded. During the follow-up vis- surgery. Thereafter, patients were followed up every third
its, presence of late postoperative complications: recurrence, month in the first postoperative year and then annually at
late mesh infection and chronic pain were reviewed.

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Hernia (2021) 25:1095–1101 1097

the Day Surgery Unit. Patients underwent physical exami- analysis of mesh infection and recurrence. Statistical analy-
nation and if the recurrence was suspected, transabdominal sis was performed using SPSS version 23.0 (SPSS Inc., Chi-
ultrasound or computed tomography was considered. The cago, IL, USA). P value ≤ 0.05 was considered statistically
recurrence was defined as an abdominal wall defect at the significant.
site of previous surgical repair. Patients who missed sched-
ule visits were contacted by phone. Forty five patients
were lost to follow-up.
Results
Statistical analysis
The study included 476 patients divided into five groups:
Continuous variables are expressed as median (range) and 245 (51.5%) with umbilical, 133 (27.9%) with epigastric,
were compared between the groups using ANOVA. Cat- 65 (13.7%) with small incisional, 17 (3.6%) with “port site”
egorical variables are expressed as absolute numbers (per- and 16 (3.4%) with Spigelian hernia. There was significant
centages) and were compared using the Chi-square test. To difference between the groups regarding sex, age, ASA, the
identify potential prognostic factors of mesh infection and presence of synchronous hernia at the other site on abdomi-
recurrence, univariate analysis and multivariate analysis nal wall, defect size, operative time and length of postop-
were carried out using logistic regression model. Multi- erative stay. Twenty one (4.4%) patients underwent surgery
variate analysis of independent prognostic factors was car- for recurrent hernia. Demographic and clinical characteris-
ried out for all factors with p ≤ 0.05 estimated in univariate tic are presented in details in Table 1. Early postoperative

Table 1  Demographic and clinical characteristics


Overall (%) U n (%) E n (%) SI n (%) PS n (%) S n (%) p
476 245 (51.5) 133 (27.9) 65 (13.7) 17 (3.6) 16 (3.4)

Sex, n (%)
 Male 284 (59.7) 167 (68.2) 65 (48.9) 34 (52.3) 7 (41.2) 11 (68.8) 0.001
 Female 192 (40.3) 78 (31.8) 68 (51.1) 31 (47.7) 10 (58.8) 5 (31.2)
Age, (years) 54 (23–94) 55 (23–94) 45 (24–83) 61 (27–84) 50.5 (34–77) 63 (42–83) < 0.001
ASA, n (%)
 1–2 425 (89.7) 221 (90.2) 125 (94) 53 (84.1) 15 (88.2) 11 (68.8) 0.014
 3 49 (10.3) 24 (9.8) 8 (6) 10 (15.9) 2 (11.8) 5 (31.3)
Recurrent hernia, n (%) 21 (4.4) 6 (2.5) 10 (7.5) 3 (4.6) 1 (5.9) 1 (6.3) 0.247
Synchronous hernia at the 70 (14.7) 31 (13.1) 25 (18.8) 5 (7.7) 2 (11.8) 6 (37.5) 0.021
other site, n (%)
Defect size (cm) 2 (0.5–7) 1.5 (0.5–7) 1.5 (0.5–5) 3 (0.5–7) 2 (1–4) 2.75 (1–6) < 0.001
Operative time (min) 45 (20–205) 45 (20–205) 45 (20–200) 50 (20–195) 50 (35–120) 60 (35–150) 0.004
LoS (h) 2 (1–7) 1 (1–7) 1 (1–5) 2 (1–6) 2 (1–4) 2.5 (1–6) < 0.001

Values are presented as median (range) unless indicated otherwise


U umbilical; E epigastric; SI small incisional; PS port site; S Spigelian; LoS length of postoperative stay

Table 2  Early and late Overall (%) U n (%) E n (%) SI n (%) PS n (%) S n (%) p
postoperative morbidity
476 245 (51.5) 133 (27.9) 65 (13.7) 17 (3.6) 16 (3.4)

Seroma, n (%) 1 (0.2) 1 (0.4) 0 0 0 0 0.918


Hematoma, n (%) 4 (0.8) 3 (1.2) 0 0 1 (5.9) 0 0.115
SWI, n (%) 1 (0.2) 1 (0.4) 0 0 0 0 0.918
Mesh infection, n (%) 8 (1.7) 2 (0.8) 2 (1.5) 2 (3.1) 2 (11.8) 0 0.013
Chronic pain, n (%) 4 (0.8) 0 1 (0.8) 2 (3.1) 0 1 (6.3) 0.019
Recurrence, n (%) 12 (2.5) 1 (0.4) 8 (6.1) 3 (4.7) 0 0 0.011

Values are presented as median (range) unless indicated otherwise


U umbilical; E epigastric; SI small incisional; PS port site; S Spigelian; SWI superficial wound infection

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complications (seroma, hematoma and superficial wound Table 4  Multivariate analysis of potential predictors for mesh infec-
infection) were similar in all study groups (Table 2). tion
The median follow-up was 50.5 (range, 1–180) months. Mesh infection
There was no significant difference in the follow-up period
OR 95% CI p
between the groups (p = 0.643). The most common late com-
plication was the recurrence. An overall recurrence rate after Hernia defect > 4 cm 3.811 0.504–28.807 0.195
OPFMT was 2.5%. The mesh infection and chronic pain Hematoma 27.068 2.355–311.073 0.008
occurred in 8 (1.7%) and 4 (0.8%) patients, respectively. Late LoS (h) 1.368 0.810–2.311 0.241
postoperative complications (mesh infection, chronic pain
LoS length of postoperative stay
and recurrence) were different between the groups (Table 2).
Three potential predictors of mesh infection were
identified using univariate analysis: hernia defect > 4 cm is advisable to diminish the incidence of pulmonary and
(Odds ratio 6.449; 95% Confidence interval 1.233–33.727; thromboembolic complications. It is an ideal solution to
p = 0.027), hematoma (Odds ratio 22.143; 95% Confidence the patients with concomitant diseases. Three fundamental
interval 2.043–239.985; p = 0.011) and length of postop- “postulates”—local anesthesia, open repair and ambulatory
erative stay (Odds ratio 1.546; 95% Confidence interval surgery—make the OPFMT universally suited to umbilical,
1.025–2.330; p = 0.038). The Mesh infection was the only epigastric, spigelian, small incisional and “port-site” hernia
potential predictor of recurrence (Odds ratio 15.133; 95% repair. The feasibility of OPFMT in the settings of general
Confidence interval 2.714–84.394; p = 0.002). Univariate surgery hospital without special medical equipment or spe-
analysis was presented in Table 3. Hematoma was inde- cial type of mesh, safety, cost effectiveness and good results
pendent predictor of mesh infection (Odds ratio 27.068; 95% make it highly recommended as the procedure of choice.
Confidence interval 2.355–311.073; p = 0.008) (Table 4). Furthermore, OPFMT under local anesthesia can be used
for simultaneous repair of ventral hernias at different sites.
In case of several hernias at different sites one separate flat
Discussion mesh is used for each hernia, while proximal umbilical or
epigastric hernia defects should be joint in one and repaired
The study results indicate that the original OPFMT under using one mesh.
local anesthesia performed for small primary and incisional Several technical considerations related to OPFMT are
abdominal wall hernias as a day case procedure is safe surgi- important to be emphasized. Sufficient tissue-flat mesh over-
cal method providing optimal long-term results. Therefore, lapping is 1–3 cm from the hernia defect border to all radi-
OPFMT has several advantages. ally directions for small ventral hernias. In strong selected
In a day case surgery, local anesthesia is preferable cases, incisional hernia with defect width more than 4 cm
compared to both regional and general anesthesia [13, 14]. could be repaired using OPFMT in local anesthesia. In the
Early mobilization of patients following local anesthesia presented analysis, median defect size of small incisional

Table 3  Univariate analysis of Mesh infection Recurrence


potential predictors for mesh
infection and recurrence OR 95% CI p OR 95% CI p

Sex (female) 0.886 0.209–3.750 0.869 0.487 0.130–1.821 0.285


Age 1.014 0.967–1.064 0.563 0.966 0.926–1.009 0.116
ASA (3) 2.972 0.583–15.143 0.190 1.749 0.372–8.223 0.479
Recurrent hernia 0.001 0.000–0.001 0.998 1.991 0.245–16.187 0.520
Synchronous hernia 0.001 0.000–0.001 0.997 0.533 0.068–4.198 0.550
Hernia defect > 3 cm 3.295 0.645–16.828 0.152 0.860 0.108–6.815 0.886
Hernia defect > 4 cm 6.449 1.233–33.727 0.027 1.652 0.205–13.325 0.638
Hernia defect > 5 cm 0.001 0.000–0.001 0.999 0 0–0.001 0.999
Seroma 0 0–0 1 0 0–0 1
Hematoma 22.143 2.043–239.985 0.011 0 0–0.001 0.999
Mesh infection – – – 15.133 2.714–84.394 0.002
Operative time (> 45 min) 7.403 0.904–60.643 0.062 1.040 0.331–3.273 0.946
LoS (h) 1.546 1.025–2.330 0.038 1.206 0.815–1.785 0.349

ASA American Society of Anesthesiologist; LoS length of postoperative stay

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hernia was 3 cm, ranging between 0.5 and 7 cm. In case of period, Lambertz et al. reported no cases of wound infec-
large incisional hernia, the mesh must be fixed with more tions or surgical complications during in-hospital stay in 54
than 8 mattress sutures to secure smaller tissue-mesh over- patients repaired for port-site incisional hernia [19]. Higher
lapping. The key factor in decision making whether to use incidence of mesh infection in incisional (small incisional
OPFMT for large incisional hernia is firmness and strength and port-site) hernia than in primary ventral hernias was
of surrounding fascial scar tissue on the remaining part of expected. In the late 1989 Houck demonstrated significantly
the incision. In patients with incisional hernias scheduled higher rate of infection after incisional hernia repair than
for OPPFMT, computed tomography (CT) is routinely in other clean general surgical procedures. Increased risk
performed. If preoperative assessment shows low quality for reinfection was also shown after herniorrhaphy of previ-
of adjacent tissue, OPFMT is insufficient and laparoscopic ously infected wound, despite complete healing of the skin
approach or sublay technique is recommended under general and absence of clinical signs of infection [20]. Tastaldi et al.
anesthesia. were also demonstrated closed association between history
OPFMT is performed using the already existing hernia of a surgical site infection and new infectious complications
sac for mesh positioning making the dissection of the pre- after open incisional hernia repair in a clean wound [21].
peritoneal space unnecessary. Minimal dissection reduces Thus, incisional hernia repair should be classified as clean-
the number of complications (seroma, hematoma and infec- contamined wounds and antibiotic prophylaxis should be
tion) as well as the operative time. Muschaweck described considered.
a similar technique for umbilical and epigastric hernias We analyzed two late complications after OPFMT for pri-
except for the insertion of a plug instead of a flat mesh into mary and incisional abdominal wall hernia. The incidence of
a repositioned intra-abdominal hernia sac [15]. A technique chronic pain was less than 1% (0.8) in entire cohort. Chronic
described by Manaouil et al. includes similar fixation and pain was the more common late complication following
size of flat mesh in the preperitoneal position [16]. The main “port-site” hernia repair and small incisional hernia repair.
difference is the dissection of the preperitoneal space and “Port site” hernia is a small recurrent hernia associated with
resection of the hernia sac while in OPFMT, the hernia sac more intensive scar in the operative field while larger mesh
is always preserved for mesh positioning. In addition, the and more single sutures may produce chronic pain or any
“stamp mesh technique” is performed under general anes- complaint around a scar after small incisional hernia repair.
thesia for umbilical hernias, unlike the presented technique Kaufmann et al. analyzed quality of life after umbilical her-
which is performed under local anesthesia for all types of nia repair using SF-360 quaistioner [22]. Authors concluded
ventral hernias in ambulatory surgery. The name of our tech- that after 2 years, 93% of patients in the suture repair group
nique may not be quite appropriate because there is no actual and 95% in the mesh group were free of pain. To prevent
dissection of the preperitoneal space. The name describes “port-site” hernia development, preperitoneal flat mesh aug-
the flat mesh positioning in front of the part of peritoneum mentation may be considered for trocar incisions larger than
which is formed by intraabdominally returned hernia sac 10 mm, but only for high-risk population: patients older than
wall. 60 years, patients with diabetes or pulmonary co-morbidi-
Our study demonstrated 1.9% of surgical site infection, ties, patients with the history of previous hernia and patients
0.2% of superficial wound infection and 1.7% of deep mesh who require incision enlargement for specimen retrieval.
infection. Mesh infection was the most common in “port- After the long follow-up period, the presented study indi-
site” hernia, and in small incisional hernia, while the inci- cated overall recurrence rate of 2.5%. This study result is
dence of superficial infection was similar between the study in consistence with other authors. In the comparative study
groups. Henriksen et al. reported nationwide data from the by Tunio, tension-free mesh repair was found to be a bet-
Danish Hernia Database [17]. A superficial surgical site ter technique than Mayo’s repair for umbilical hernia, while
infection rate after open repair of epigastric and umbilical recurrence rate after mesh repair was 2.3% [4]. Arroyo et al.
hernia was 2.5%, significantly more than after laparoscopic reported 1% recurrence rate after mesh repair of umbilical
approach, although the incidence of a reoperation for a hernia in the randomized control study [23]. A meta-analysis
severe condition and cumulative incidence of reoperation by Bisgaard et al. showed reduced relative risk of recur-
for recurrence were more common after laparoscopic repair. rence of 0.28 after mesh repair of umbilical hernia [24].
In the meta-analysis two mesh materials implanted during The authors of included randomized control trials reported
ventral hernia repair, polyester and polypropylene, were the follow-up period of 6, 12, 24, 24 and 64 months, respec-
compared regarding surgical site infection and recurrence tively. Median follow-up in the presented study was more
rate [18]. The authors suggested that mesh material does not than four years. In a recent updated trial sequential meta-
affect recurrence or infection in ventral hernia repair while a analysis of randomized controlled trials, Aiolfi et al. esti-
laparoscopic approach is associated with a decreased infec- mated similar relative risk of recurrence of 0.27 after hernia
tion rate compared to open repair. In a 10-years long study mesh repair. The recurrence was more frequently occurred in

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1100 Hernia (2021) 25:1095–1101

epigastric and small incisional hernia repair. Higher risk of Acknowledgments  This work has been supported by the Grant No.
recurrence after epigastric hernia repair may be explained by RS 41030 of the Ministry of Education, Science and Technological
Development of the Republic of Serbia.
the presence of multiple closed hernia defects along the mid-
line which could be overlooked during open repair through Funding None.
a small incision. Small incisional hernia is also associated
with higher risk of local recurrence. The quality of sur- Declarations 
rounding abdominal wall tissue is probably underestimated
by preoperative assessment or there are addition multiple Conflict of interest  The authors have no related conflicts of interest
incisional defects overlooked during surgery. The retromus- to declare.
cular sublay technique (Rives) was used for the management
Ethics approval  The study was approved by the institutional review
of recurrent hernias after OPFMT. The most common find- board.
ing was adherent greater omentum to recurrent hernia sac
around the hernia defect. The intestinal adhesions were not Human and animal rights statement  All procedures were approved by
found in any of the patients. the Ethical Committee of University Clinical Center of Serbia.
The presented study showed that only hematoma is an Consent to participate  Informed consent was obtained from all study
independent predictor of mesh infection, while mesh infec- subjects.
tion has been shown by univariate analysis as a predictor of
recurrence. Furthermore, patients with hematoma were asso-
ciated with 27 folds increased risk of mesh infection com-
pared to those without hematoma. In a large cohort of 1023 References
patients, diabetes, panniculectomy and operations requiring
biologic mesh were predictors of wound complications [25]. 1. Jairam AP, Kaufmann R, Muysoms F, Jeekel J, Lange JF (2017)
The feasibility of local anesthesia for the surgical treatment of
Jolissaint et al. indicated recurrent repair and any postop-
umbilical hernia: a systematic review of the literature. Hernia
erative surgical site occurrence were only two independent 21:223–231. https://​doi.​org/​10.​1007/​s10029-​017-​1577-z
factors predictive for hernia recurrence [26]. Cumulative 2. Helgstrand F (2016) National results after ventral hernia repair.
incidence of recurrence in patients with surgical site occur- Dan Med J 63:B5258
3. Shrestha D, Shrestha A, Shrestha B (2019) Open mesh versus
rence was double higher than those without. In the sensitive
suture repair of umbilical hernia: meta-analysis of randomized
subanalysis of predictors including only infectious complica- controlled trials. Int J Surg 62:62–66. https://​doi.​org/​10.​1016/j.​
tions without wound disruption, infection was confirmed as ijsu.​2018.​12.​015
predictor of recurrence. Interestingly, body mass index and 4. Tunio NA (2017) Hernioplasty: tension free mesh repair versus
Mayos repair for umbilical hernias. J Pak Med Assoc 67:24–26
smoking traditionally well-known risk factors, were not sig-
5. Polat C, Dervisoglu A, Senyurek G, Bilgin M, Erzurumlu K,
nificantly associated with recurrence. Nevertheless, obesity Ozkan K (2005) Umbilical hernia repair with the prolene hernia
is provocative factor for infectious complications which may system. Am J Surg 190:61–64. https://​doi.​org/​10.​1016/j.​amjsu​rg.​
increase risk of recurrence. In the study by Donovan et al., 2004.​09.​021
6. Funk LM, Perry KA, Narula VK, Mikami DJ, Melvin WS (2013)
greater risk of recurrence after umbilical hernia repair was
Current national practice patterns for inpatient management of
registered in patients with higher body mass index, current ventral abdominal wall hernia in the United States. Surg Endosc
smoking, simultaneous laparoscopic inguinal hernia repair, 27:4104–4112. https://​doi.​org/​10.​1007/​s00464-​013-​3075-4
diabetes and primary repair of umbilical hernia larger than 7. Henriksen NA, Montgomery A, Kaufmann R et al (2020) Guide-
lines for treatment of umbilical and epigastric hernias from the
1.5 cm, while infection showed borderline association with
European Hernia Society and Americas Hernia Society. Br J Surg
recurrence [27]. 107:171–190. https://​doi.​org/​10.​1002/​bjs.​11489
The main limitation of this study is retrospective design. 8. Tang J (2018) Chen S [China Guideline for Diagnosis and Treat-
Unknown effect of confounding factors and selection bias ment of Incisional Hernia (2018 edition)]. Zhonghua Wei Chang
Wai Ke Za Zhi 21:725–728
are possible. All consecutive patients meeting inclusion
9. Friedlander DF, Krimphove MJ, Cole AP et al (2019) Where is the
criteria were enrolled to overcome this study drawback. value in ambulatory versus inpatient surgery? Ann Surg. https://​
Another study limitation is relatively long study period lead- doi.​org/​10.​1097/​SLA.​00000​00000​003578
ing to variable follow-up period, improved patient selection 10. Rafiq MK, Sultan B, Malik MA, Khan K, Abbasi MA (2016)
Efficacy of local anaesthesia in repair of inguinal hernia. J Ayub
and surgical technique during the study.
Med Coll Abbottabad 28:755–757
In conclusion, the “open preperitoneal flat mesh tech- 11. Pere P, Harju J, Kairaluoma P, Remes V, Turunen P, Rosenberg
nique” for small primary and incisional abdominal wall her- PH (2016) Randomized comparison of the feasibility of three
nia performed under local anesthesia is associated with low anesthetic techniques for day-case open inguinal hernia repair. J
Clin Anesth 34:166–175. https://​doi.​org/​10.​1016/j.​jclin​ane.​2016.​
rate of early postoperative complications and acceptable rate
03.​062
of chronic postoperative pain and recurrence. Hematoma
is an independent predictor of mesh infection occurrence.

13
Hernia (2021) 25:1095–1101 1101

12. Zuvela M, Milicevic M, Galun D, Djuric-Stefanovic A, Bulajic P, incisional hernia repair. Surgery 166:88–93. https://​doi.​org/​10.​
Palibrk I (2013) Spigelian hernia repair as a day-case procedure. 1016/j.​surg.​2019.​01.​032
Hernia 17:483–486. https://​doi.​org/​10.​1007/​s10029-​012-​1002-6 22. Kaufmann R, Halm JA, Eker HH et al (2018) Mesh versus suture
13. Ozgun H, Kurt MN, Kurt I, Cevikel MH (2002) Comparison of repair of umbilical hernia in adults: a randomised, double-blind,
local, spinal, and general anaesthesia for inguinal herniorrhaphy. controlled, multicentre trial. Lancet 391:860–869. https://​doi.​org/​
Eur J Surg 168:455–459. https://​doi.​org/​10.​1080/​11024​15023​ 10.​1016/​S0140-​6736(18)​30298-8
21116​442 23. Arroyo A, Garcia P, Perez F, Andreu J, Candela F, Calpena R
14. Kulacoglu H, Yazicioglu D, Ozyaylali I (2012) Prosthetic repair (2001) Randomized clinical trial comparing suture and mesh
of umbilical hernias in adults with local anesthesia in a day-case repair of umbilical hernia in adults. Br J Surg 88:1321–1323.
setting: a comprehensive report from a specialized hernia center. https://​doi.​org/​10.​1046/j.​0007-​1323.​2001.​01893.x
Hernia 16:163–170. https://​doi.​org/​10.​1007/​s10029-​011-​0888-8 24. Bisgaard T, Kaufmann R, Christoffersen MW, Strandfelt P, Gluud
15. Muschaweck U (2003) Umbilical and epigastric hernia repair. LL (2019) Lower risk of recurrence after mesh repair versus non-
Surg Clin North Am 83:1207–1221. https://​doi.​org/​10.​1016/​ mesh sutured repair in open umbilical hernia repair: a systematic
S0039-​6109(03)​00119-1 review and meta-analysis of randomized controlled trials. Scand
16. Manaouil D, Henry X, Regimbeau JM, Loriau J, Verhaeghe P J Surg 108:187–193. https://d​ oi.​org/​10.​1177/​14574​96918​812208
(2003) Umbilical hernias treatment by the “stamp mesh tech- 25. Heniford BT, Ross SW, Wormer BA et al (2020) Preperitoneal
nique.” Ann Chir 128:563–566. https://​doi.​org/​10.​1016/​s0003-​ ventral hernia repair: a decade long prospective observational
3944(03)​00213-x study with analysis of 1023 patient outcomes. Ann Surg 271:364–
17. Henriksen NA, Jorgensen LN, Friis-Andersen H, Helgstrand F, 374. https://​doi.​org/​10.​1097/​SLA.​00000​00000​002966
Danish HD (2021) Open versus laparoscopic umbilical and epi- 26. Jolissaint JS, Dieffenbach BV, Tsai TC et al (2020) Surgical site
gastric hernia repair: nationwide data on short- and long-term out- occurrences, not body mass index, increase the long-term risk of
comes. Surg Endosc. https://d​ oi.o​ rg/1​ 0.1​ 007/s​ 00464-0​ 21-0​ 8312-5 ventral hernia recurrence. Surgery 167:765–771. https://​doi.​org/​
18. Totten C, Becker P, Lourd M, Roth JS (2019) Polyester vs poly- 10.​1016/j.​surg.​2020.​01.​001
propylene, do mesh materials matter? A meta-analysis and sys- 27. Donovan K, Denham M, Kuchta K et al (2019) Predictors for
tematic review. Med Devices (Auckl) 12:369–378. https://d​ oi.o​ rg/​ recurrence after open umbilical hernia repair in 979 patients. Sur-
10.​2147/​MDER.​S1989​88 gery 166:615–622. https://​doi.​org/​10.​1016/j.​surg.​2019.​04.​040
19. Lambertz A, Stuben BO, Bock B et al (2017) Port-site incisional
hernia - A case series of 54 patients. Ann Med Surg (Lond) 14:8– Publisher’s Note Springer Nature remains neutral with regard to
11. https://​doi.​org/​10.​1016/j.​amsu.​2017.​01.​001 jurisdictional claims in published maps and institutional affiliations.
20. Houck JP, Rypins EB, Sarfeh IJ, Juler GL, Shimoda KJ (1989)
Repair of incisional hernia. Surg Gynecol Obstet 169:397–399
21. Tastaldi L, Petro CC, Krpata DM et al (2019) History of surgical
site infection increases the odds for a new infection after open

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