Sažetak
Pozadina
Incizijska hernija nakon otvorene operacije dobro je poznata komplikacija. Napravljena je retrospektivna studija s ciljem utvrđivanja učestalosti i predodređujućih faktora incizijske hernije nakon operacije kolona zbog divertikularne bolesti.
Metode
Praćena je retrospektivna kohorta od 105 uzastopnih pacijenata podvrgnutih laparoskopskoj ili otvorenoj operaciji zbog komplikacija divertikuloze između siječnja 2000. i prosinca 2010. godine. Praćen je utjecaj demografskih čimbenika, kirurški pristup i vrijeme za razvitak incizijske hernije. Statistička evaluacija izvedena je pomoću Pearsonovog hi-kvadratnog testa i Mann-Whitneyevog testa.
Rezultati
U grupi od 31 muškarca i 74 žene, prosječne dobi 67 godina, incizijska hernija razvila se kod njih 27 (26%) u prosječnom vremenu praćenja od 5,5 godina. Incizijska hernija nađena je kod 23 pacijenta (9%) u grupi operiranoj laparoskopski u usporedbi s 25 od 82 pacijenta (30%) u grupi podvrgnutoj otvorenom zahvatu (P = 0,03). Nije dokazan veći rizik za incizijsku herniju nakon akutne operacije (P = 0,6). Važan demografski čimbenik koji utječe na učestalost pojavljivanja incizijske hernije bio je ženski spol (P = 0,003), ali ne i dob (P = 0,43). Srednje vrijeme pojave hernije bilo je 1,5 godina.
Zaključak
Laparoskopska kirurgija ima znatno nižu učestalost incizijske hernije u usporedbi s otvorenom kirurškom tehnikom. Ženski spol ima veći rizik za incizijsku herniju od akutne operacije ili dobi. Budući da je laparoskopija izvedivija kao elektivna operacija, kada govorimo o incizijskoj herniji, trebalo bi rano preporučiti sigmoidne resekcije, posebice ženama

Zuzana Adamova

English

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15Acta Chirurgica Croatica STRUČNI PRIKAZ / REVIEWAbstractBackgroundIncisional hernia after open surgery is a well-known complication. A retrospective study was conducted to determine the incidence and predisposing factors of incisional hernia after colonic surgery for diverticular disease. Methods   A retrospective cohort of 105 consecutive patients undergoing either laparoscopic or open surgery for complicated diverticulosis between January 2000 and December 2010 was identified. The influence of demographic data, surgical approach and timing for incisional hernia development were analysed. Statistical evaluation was performed using the chi-square test according to Pearson and Mann-Whitney test.ResultsIn a group of 31 men and 74 women, with an average age of 67 years, incisional hernia developed in 27 patients (26%) at a mean follow-up of 5.5 years. Incisional hernia was found in two of 23 patients (9%) in the laparoscopic surgery group compared with 25 of 82 patients (30%) in the open surgery group (P = 0.03). We did not prove a higher risk for incisional hernia after acute surgery (P = 0.6). Significant demographic factor influencing incisional hernia incidence was female gender (P = 0.003), but not age (P = 0.43). Mean time to hernia occurrence was 1.5 years.ConclusionLaparoscopic surgery leads to a significantly lower incidence of incisional hernia compared to open surgical technique. Female gender represents a higher Surgery Ward, Vsetin Hospital, Vsetin, Czech Republic Correspondence: Zuzana Adamova, MD, Vsetin Hospital, Surgery Ward, Nemocnicni 955, Vsetin 75532, Czech Republic, tel.: +420 723 134 666, fax: +420 571 419 295, e-mail: adamovaz@gmail.comrisk for incisional hernia than acute surgery or age. Because laparoscopy is more feasible as elective surgery, when speaking of incisional hernia, we should recommend sigmoid resections early, especially to women.Keywordsdiverticular disease, laparoscopy, open surgery, sigma resection, incisional herniaSažetakPozadinaIncizijska hernija nakon otvorene operacije dobro je poznata komplikacija. Napravljena je retrospektivna studija s ciljem utvrđivanja učestalosti i predodređujućih faktora incizijske hernije nakon operacije kolona zbog divertikularne bolesti.MetodePraćena je retrospektivna kohorta od 105 uzastopnih pacijenata podvrgnutih laparoskopskoj ili otvorenoj operaciji zbog komplikacija divertikuloze između siječnja 2000. i prosinca 2010. godine. Praćen je utjecaj demografskih čimbenika, kirurški pristup i vrijeme za razvitak incizijske hernije. Statistička evaluacija izvedena je pomoću Pearsonovog hi-kvadratnog testa i Mann-Whitneyevog testa.RezultatiU grupi od 31 muškarca i 74 žene, prosječne dobi 67 godina, incizijska hernija razvila se kod njih 27 (26%) u prosječnom vremenu praćenja od 5,5 godina. Incizijska hernija nađena je kod 23 pacijenta (9%) u grupi operiranoj laparoskopski u usporedbi s 25 od 82 pacijenta (30%) u grupi podvrgnutoj otvorenom zahvatu (P = 0,03). Nije dokazan veći rizik za incizijsku  INCISIONAL HERNIA AFTER SURGERY FOR DIVERTICULAR DISEASEIncizijska hernija nakon operacije zbog divertikularne bolestiZuzana Adamova INCISIONAL HERNIA AFTER SURGERy FOR DIVERTICULAR DISEASEActa Chir Croat 2013; 10: 15–1816 STRUČNI PRIKAZ / REVIEW Acta Chirurgica Croaticaherniju nakon akutne operacije (P = 0,6). Važan demografski čimbenik koji utječe na učestalost pojavljivanja incizijske hernije bio je ženski spol (P = 0,003), ali ne i dob (P = 0,43). Srednje vrijeme pojave hernije bilo je 1,5 godina.ZaključakLaparoskopska kirurgija ima znatno nižu učestalost incizijske hernije u usporedbi s otvorenom kirurškom tehnikom. Ženski spol ima veći rizik za incizijsku herniju od akutne operacije ili dobi. Budući da je laparoskopija izvedivija kao elektivna operacija, kada govorimo o incizijskoj herniji, trebalo bi rano preporučiti sigmoidne resekcije, posebice ženama.Ključne riječidivertikularna bolest, laparoskopija, otvorena operacija, resekcija sigme, incizijska hernijaIntroductionDiverticular disease of the colon is an acquired condition that results from herniation of the mucosa through sites of low resistance in areas of vascular passage defects of the colonic wall. Epidemiological studies have revealed that diverticular formation of the colon is primarily a disease that occurs in industrialized countries [1]. Approximately 60% of humans over the age of 60 living in westernized countries will develop colonic diverticula. It became prevalent after the 1920s and is possibly associated with decrease in fibre intake. Most patients with diverticulosis remain asymptomatic throughout their lifetime and only 25−30% develop symptoms at some stage [2].Diverticular disease produces a wide range of clinical presentations varying from minimal clinical discomfort to life-threatening complications. Uncomplicated diverticulitis is a domain of conservative therapy consisting of bowel rest and antibiotics [3, 4]. 60% of patients treated for the first episode of acute diverticulitis will recover and have no further clinical problems. Complicated diverticulitis Hinchey I could be handled exclusively in a conservative manner. Hinchey II may be drained under computed tomography (CT) control and so acute operation could be postponed to an elective one [5, 6]. Complicated diverticulosis, mainly Hinchey III and IV, is in the domain of surgical treatment [7]. Bleeding usually ceases spontaneously, while colonoscopy or angiography could be helpful.Laparoscopy is surely suitable for elective surgery [8]. In acute cases laparoscopy belongs to the hands of an experienced surgeon.The introduction of minimally invasive surgery for colorectal resection has resulted in reduced postoperative pain, decreased morbidity, earlier hospital discharge, faster return to normal activity and better cosmetic results [9, 10], but usually longer operative time, higher cost or specific morbidity such as trocar-site complications [9]. There are conflicting results regarding possible benefits of laparoscopic surgery compared with open surgery with respect to the development of incisional hernia [11, 12].The main objective of this study was to compare the rates of incisional hernia after laparoscopic and open colorectal surgery.Patients and methodsThis was a retrospective study including a cohort of 105 consecutive patients who underwent either laparoscopic or open surgery for complicated diverticular disease between January 2000 and December 2010 in our hospital. We looked up the occurrence of symptomatic incisional hernia in the patient records. Incisional hernia was defined as a bulge visible and palpable at the site of abdominal incision when the patient was standing with spontaneous or pressure-induced protrusion of abdominal contents. Diagnosis was made on the basis of clinical or ultrasound examination. We considered the hernia as symptomatic when it was limiting the patient in everyday activities because of its size or painfulness. Other data recorded for each patient included age, gender, indications for surgery (acute or elective), year and type of performed procedure. Surgical techniqueAll interventions were performed by the same surgical team. We used open technique on 82 patients. In the years 2000 and 2001 we performed six myotomies from median laparotomy, but later this method was abandoned. We included these patients into the open surgery group too, because the approach through the abdominal wall was the same as in the primary resection or Hartmann's procedure, which were used on other 76 patients. We used midline, transverse or oblique laparotomy. We started using laparoscopy more often only since 2005 and that is why the laparoscopically operated group is smaller (23 patients). We preferred laparoscopic sigmoid resection for elective surgery and we used it in acute ones in only four cases. We utilized four ports. Mobilization of the bowel and ligation of the vascular pedicle were performed intracorporeally. The specimen was removed through a midline incision approximately 5−8 cm long. Intraabdominal stapled anastomosis was performed in case of sigmoidectomy. For right hemicolectomy, bowel anastomosis was performed extracorporeally. Right hemicolectomy was indicated twice.The decision on suitability for laparoscopic resection was made on a case-by-case basis by the operating surgeon.  INCISIONAL HERNIA AFTER SURGERy FOR DIVERTICULAR DISEASE17Acta Chirurgica Croatica STRUČNI PRIKAZ / REVIEWStatistical evaluationThe patients' data were entered into a Microsoft Excel database. The data were analyzed using standard methods of descriptive statistics. To test for significance, the Pearson's chi-square test was used for nominal data and Mann-Whitney U test was used for continuous data. A P-value ≤ 0.05 was considered statistically significant.ResultsThis study included 105 patients, 31 men and 74 women, with an average age of 67 years (tab. 1). Mean follow-up was 5.5 years. The laparoscopic group consisted of 23 patients with a mean age of 63 years (range 38–86 years), and the open group consisted of 82 patients with a mean age of 68 years (range 36–94 years). Out of the 23 patients in the laparoscopic group, two (9%) patients developed a hernia compared with 25 (30%) of 82 patients in the open group (P = 0.03). Average time to incisional hernia was 1.5 years (1.5 years after open surgery and one year after laparoscopy).In total, 66 surgeries were elective, 39 operations were acute. Indication for acute surgery was complicated diverticulitis Hinchey I−IV and indication for elective surgery were recurrent attacks of inflammation, stenosis, chronic pain or bleeding. In nine (23%) cases hernia developed after the acute operation, 18 incisional hernias came up in the elective operated group (27%). We did not prove a statistically significant difference (P = 0.6). It is interesting that we did not find an increasing incidence of incisional hernia in older patients (P = 0.43).We compared the incisional hernia dependence according to gender. It appeared in 25 (30%) of 74 women and just in two (6%) of 31 men. The difference is statistically significant (P = 0.003).Table 1. Characteristics of groups operated on by using open and laparoscopic technique.Acute operationElective operation Women MenAverage ageIncisional herniaOpen 35 47 55 (67%) 27 (33%) 63 25Laparoscopy  4 19 19 (83%)   4 (17%) 68   2DiscussionIncisional hernia is a frequent late complication of major abdominal surgery with incidence rates of up to 20% after a 10-year follow-up period [13]. A study performed by Hoer et al. revealed that 31.5% of all incisional hernias developed in the first six months after the operation, 54.4% after 12 months, 74.8% after two years and 88.9% after five years [14]. Factors considered to increase the risk of incisional hernia are acute surgery [15, 16], using vertical incision, suture technique and materials [17], age over 60 years, obesity, post-operative wound infection [16], male gender [14] and comorbidity such as chronic obstructive pulmonary disease [17]. Smoking is also a risk factor for incisional hernia [18, 19].In our group, women have a higher risk of incisional hernia (P = 0.003). We did not show age dependency. Lumley et al. [20] performed a study focused on intermediate and long-term outcomes following laparoscopic colorectal surgery. In this study on 181 patients, during a median follow-up period of six years, incisional hernia developed only in one case (0.5%). Regadas et al. [21] looked up complications of laparoscopic colorectal resection and found four cases (4%) of incisional hernia out of 92 patients. According to Laurent et al., laparoscopic approach significantly decreases the risk of long-term incisional hernia 13% vs. 30%, 335 patients were included in this study [22]. Lumley's study concentrated mainly on patients with colorectal cancer, while Regadas and Laurent included only patients with colorectal cancer.    A study performed by Garret et al. was aimed to evaluate the outcomes for 200 patients with diverticular disease who underwent elective laparoscopic sigmoid colectomy. They found incisional hernia in just three (1.5%) patients [10]. Ihedioha et al. dealt with a group of 95 patients with the same diagnosis. They did not find a statistically significant reduction of incisional hernia rates after laparoscopic colorectal resections (9%) when compared with open colorectal resection (16%) [12]. A French study was more concerned with short-term benefit of elective laparoscopic treatment of sigmoid diverticulitis, but the 2.5-year follow-up found no incisional hernia [9].According to the conclusion of a Danish study performed on 201 patients, laparoscopic sigmoid resection leads to a significantly lower inciden-ce of incisional hernia compared to open surgical technique, 3.4% vs. 14.7% [13]. A large American study on 716 patients established 2.4% of incisional hernias after laparoscopic compa-red with 12.9% after open bowel resection (P = 0.00002) [11]. The study included both patients who had small bowel resections and colorectal surgery.So our results are consistent with most studies which prove the benefits of laparoscopy for colorectal resection in a long term perspective. Lower occurrence of incisional hernia in other studies compared to ours can be attributed to elective performances and that the specimen is not primarily infected in oncological  INCISIONAL HERNIA AFTER SURGERy FOR DIVERTICULAR DISEASE18 STRUČNI PRIKAZ / REVIEW Acta Chirurgica Croatica INCISIONAL HERNIA AFTER SURGERy FOR DIVERTICULAR DISEASEindication. Another reason is our preferred use of midline incision for specimen extraction. Midline incision is associated with a higher incisional hernia rate as compared to transverse [15, 23], paramedian [24] or oblique incision [25].  ConclusionLaparoscopic surgery leads to a significantly lower incidence of incisional hernia compared with open surgical technique. Female gender represents a higher risk for incisional hernia than acute surgery or age. Because laparoscopy is more feasible as elective surgery, when speaking of incisional hernia, we should recommend sigma resections early, especially to women.References1.  Hobson KG, Roberts PL. Etiology and pathophysiology of diverticular disease. Clin Colon Rectal Surg 2004 Aug;17(3): 147−153. 2.  Tursi A, Papagrigoriadis S. Review article: the current and evolving treatment of colonic diverticular disease. Aliment Pharmacol Ther 2009 Sep;15;30(6): 532−546. 3.  Beckham H, Whitlow CB. The medical and nonoperative treatment of diverticulitis. Clin Colon Rectal Surg 2009 Aug;22(3): 156−160.4.  Lopez DE, Brown CV. Diverticulitis: the most common colon emergency for the acute care surgeon. Scand J Surg 2010;99(2): 86−89.5.  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Incisional hernia after surgery for diverticular disease

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