It is time for colorectal surgeons to stop incisional hernia denial

Abstract

June s edition of Colorectal Disease sees the publication of a paper by Gignoux and colleagues that could be recommended to all colorectal surgeons to read and reflect upon [1]. It is a retrospective analysis of the French nationwide hospital database, the Programme de Medicalisation des Systemes d’Informations (PMSI). The authors have considered the incidence and risk factors for incisional hernia in over 400,000 laparotomies and the recurrence rate after subsequent repair. The question many will be asking at this point is ‘Why is this being published in a colorectal journal?’ Indeed, in many healthcare systems, hernia surgery is rapidly developing as a subspeciality of general surgery, so incisional hernia repair will fall less and less to the colorectal surgeon in the future. This specialization will undoubtably reduce failure rates after primary repair of incisional hernia. Interest in the prevention of incisional hernia has risen slowly in the last few years, perhaps as a result of the advent of the small stitch as a possible solution and the potential use of mesh [2]. However, what, if any, is the role of the colorectal surgeon in the prevention of incisional hernia? The data that Gignoux et al. present make sobering reading. The headline, according to these French data, is that the risk of requiring incisional hernia repair after any laparotomy is 5%. Clearly, the risk of incisional hernia is much higher; this paper only collects data on those that have been repaired. The actual incidence of incisional hernia after laparotomy is likely to be at least three times as high. Let us put that another way: after any laparotomy 1 in 20 patients will have an operation to fix an incisional hernia (with a variable level of success). How many of us mention that at the time of taking of informed consent? The shock comes when you notice that, of all the patients in a cohort of the highest incidence of repair by procedure, 72% were following lower gastrointestinal surgery – over to us, the colorectal surgeons. There are some common myths that need dispelling. The first is that incisional hernia is not a problem in colorectal surgery; these data and others clearly demonstrate that it is [3]. The second is that laparoscopic colorectal surgery prevents incisional hernia; it does not, but transverse incisions do [3,4]. I think this may be the most powerful argument in support of the use of intracorporeal anastomosis in right hemicolectomy to allow a Pfannenstiel extraction site, but I digress. The third is that 4:1 is the magic suture length to wound length ratio (SL:WL). Jenkins’ rule, which all surgeons learn for exams, was based on a series to prevent burst abdomen not incisional hernia [5]. In the STITCH study comparing small bites with large bites, there was a significant difference in incisional hernia at 1 year but the large bites (control) group still had a mean SL:WL of 4:1 [6]. The European Hernia Society is currently revising its guidelines on abdominal wall closure, and it will be interesting to see the new recommendation on this ratio; it must surely be higher [4]. Incisional hernia in the 21st century remains a real problem for both patients and healthcare systems. Prevention involves recognizing the importance of a sound evidencebased closure technique, reducing surgical site infection and perhaps, as we learn more, identifying highrisk patients and modifying strategy accordingly. It is time for colorectal surgeons to start owning the problem of incisional hernia in our practice and doing more to prevent it.