Three of the articles this month relate to the use of mesh in hernia repair. The first of these, from Moreno-Egea et al, relates to the fixation of the mesh in total extraperitoneal inguinal hernioplasty and concludes that except for individual cases of direct bilateral hernias, no advantage is accrued by fixation of the mesh and it does increase cost.
The second of these presentations deals with the use of mesh in preventing parastomal herniation by using a large-pore lightweight mesh with a reduced polypropylene content and a high proportion of absorbable material, placed dorsal to the rectus abdominis muscle and anterior to the posterior rectus sheath. It was sewn in such a manner as to prevent contact with the bowel. When compared with no mesh, it reduced hernia formation and complications were not associated with it.
The third application of mesh deals with the intraperitoneal esophago-gastric hiatus. In a meta-analysis, Targarona et al have concluded that the use of mesh for hiatal repair is safe and prevents recurrences. However, data on long-term results are lacking, and infrequent and severe complications may arise. The mesh should be used selectively, based on clinical experience. Dr Hoover’s critique of the article points out the hazards of meta-analysis and the lack of clinical experience in this review.
This article by Hansen et al reviewed 105 patients undergoing nonincidental appendectomy within 3 days of their examination. Each patient’s findings were reviewed by a different radiologist and pathologist. No single finding or computed tomographic scan could reliably and accurately predict the severity of appendicitis, although the combination of fat stranding, appendix diameter, dependent fluid, appendolithiasis, and extraluminal air contributed most heavily to the severe diagnosis and the need for immediate operation.
This study from Morales et al purports to identify those factors responsible for intra-abdominal infection in trauma patients. By analysis, they conclude that a high abdominal trauma index score (higher than 24), the contamination of the abdominal cavity, and admission to the intensive care unit are independent risk factors for the development of organ/space surgical site infection. As pointed out in the Invited Critique, more severely injured patients are more likely to require admission to the intensive care unit and are more likely to sustain postoperative complications (increased incidence of intra-abdominal infection).
While Bucher et al hit on many points in favor of the avoidance of mechanical bowel preparation in patients undergoing elective colorectal surgery, the Invited Critique brings us back to a rational approach by pinpointing studies disclosing superior clinical outcomes in prepared patients. Dr Pickleman cautions against the wholesale adoption of elective surgery without preoperative bowel preparation.
This Month in Archives of Surgery. Arch Surg. 2004;139(12):1275. doi:10.1001/archsurg.139.12.1275