BACKGROUND: Ventral hernia repair is one of the most commonly performed surgical procedures worldwide. To reduce the risk of complications, pre- and intra-operative strategies have received increasing focus in recent years. To assess possible preventive surgical strategies, this European Hernia Society endorsed project was launched. The aim of this review was to evaluate the current literature focusing on pre- and intra-operative strategies for surgical site occurrences (SSO) and specifically surgical site infection (SSI) in ventral hernia repair. METHODS: A systematic review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Databases used were Pubmed and Web of Science. Original retrospective or prospective human adult studies describing at least one intra-operative intervention to reduce SSO after ventral hernia repair were considered eligible. RESULTS: From a total of 4775 results, a total of 18 papers were considered suitable after full text reading. Prehospital chlorhexidine gluconate (CHG) scrub appears to increase the risk of SSO in patients undergoing ventral hernia repair, while there is no association between any type of surgical hat worn and the incidence of postoperative wound events. Intraoperative measures as prophylactic negative pressure therapy, surgical drain placement and the use of quilt sutures seem beneficial for decreasing the incidence of SSO and/or SSI. No positive effect has been shown for antibiotic soaking of a synthetic mesh, nor for the use of fibrin sealants. CONCLUSION: This review identified a limited amount of literature describing specific preventive measures and techniques during ventral hernia repair. An advantage of prophylactic negative pressure therapy in prevention of SSI was observed, but different tools to decrease SSIs and SSOs continuously further need our full attention to improve patient outcomes and to lower overall costs.

3rd Department of Surgery and 1st Medical Faculty of Charles University Motol University Hospital Prague Czech Republic

Abdominal Wall Surgery Unit Department of General Surgery Hospital Universitari Vall d'Hebron Universitat Autònoma de Barcelona Barcelona Spain

Department for General and HPB Surgery and Liver Transplantation University Hospital Gent Gent Belgium

Department of Surgery University of Genoa Genoa Italy

Digestive Disease Center Bispebjerg Hospital University of Copenhagen Copenhagen Denmark

European Hernia Society Ospedale Policlinico San Martino IRCCS Genoa Italy

See more in PubMed

Helgstrand F, Rosenberg J, Kehlet H, Bisgaard T. Outcomes after emergency versus elective ventral hernia repair: a prospective nationwide study. World J Surg. (2013) 37(10):2273–9. 10.1007/s00268-013-2123-5. PubMed DOI

Jensen KK, Dressler J, Baastrup NN, Kehlet H, Jørgensen LN. Enhanced recovery after abdominal wall reconstruction reduces length of postoperative stay: an observational cohort study. Surgery. (2019) 165(2):393–7. 10.1016/j.surg.2018.07.035. PubMed DOI

Bueno-Lledó J, Torregrosa-Gallud A, Sala-Hernandez A, et al. Predictors of mesh infection and explantation after abdominal wall hernia repair. Am J Surg. (2017) 213(1):50–7. 10.1016/j.amjsurg.2016.03.007. PubMed DOI

Hawn MT, Gray SH, Snyder CW, Graham LA, Finan KR, Vick CC. Predictors of mesh explantation after incisional hernia repair. Am J Surg. (2011) 202(1):28–33. 10.1016/j.amjsurg.2010.10.011. PubMed DOI

Cox TC, Blair LJ, Huntington CR, Colavita PD, Prasad T, Lincourt AE, et al. The cost of preventable comorbidities on wound complications in open ventral hernia repair. J Surg Res. (2016) 206(1):214–22. 10.1016/j.jss.2016.08.009. PubMed DOI

Colavita PD, Tsirline VB, Belyansky I, Walters AL, Lincourt AE, Sing RF, et al. Prospective, long-term comparison of quality of life in laparoscopic versus open ventral hernia repair. Ann Surg. (2012) 256(5):714–23. 10.1097/sla.0b013e3182734130. PubMed DOI

Haskins IN, Horne CM, Krpata DM, Prabhu AS, Tastaldi L, Perez AJ, et al. A call for standardization of wound events reporting following ventral hernia repair. Hernia. (2018) 22(5):729–36. 10.1007/s10029-018-1748-6 PubMed DOI

Magill SS, Edwards JR, Bamberg W, Beldavs ZG, Dumyati G, Kainer MA, et al. Emerging infections program healthcare-associated infections and antimicrobial use prevalence survey team. Multistate point-prevalence survey of health care-associated infections. N Engl J Med. (2014) 370(13):1198–208. 10.1056/NEJMoa1306801 PubMed DOI PMC

Ban KA, Minei JP, Laronga C, Harbrecht BG, Jensen EH, Fry DE, et al. American College of surgeons and surgical infection society: surgical site infection guidelines, 2016 update. J Am Coll Surg. (2017) 224(1):59–74. 10.1016/j.jamcollsurg.2016.10.029 PubMed DOI

Weiser MR, Gonen M, Usiak S, Pottinger T, Samedy P, Patel D, et al. Memorial sloan kettering multidisciplinary surgical-site infection reduction team. Effectiveness of a multidisciplinary patient care bundle for reducing surgical-site infections. Br J Surg. (2018) 105(12):1680–7. 10.1002/bjs.10896 PubMed DOI PMC

Leaper DJ, Edmiston CE. World health organization: global guidelines for the prevention of surgical site infection. J Hosp Infect. (2017) 95(2):135–6. 10.1016/j.jhin.2016.12.016 PubMed DOI

Jolissaint JS, Dieffenbach BV, Tsai TC, Pernar LI, Shoji BT, Ashley SW, et al. Surgical site occurrences, not body mass index, increase the long-term risk of ventral hernia recurrence. Surgery. (2020) 167(4):765–71. 10.1016/j.surg.2020.01.001 PubMed DOI PMC

Sanchez VM, Abi-Haidar YE, Itani KM. Mesh infection in ventral incisional hernia repair: incidence, contributing factors, and treatment. Surg Infect. (2011) 12(3):205–10. 10.1089/sur.2011.033 PubMed DOI

Jensen KK, East B, Jisova B, Cano ML, Cavallaro G, Jørgensen LN, et al. The European hernia society prehabilitation project: a systematic review of patient prehabilitation prior to ventral hernia surgery. Hernia. (2022) 26(3):715–26. 10.1007/s10029-022-02573-2 PubMed DOI

World Health Organization. (2018). Global Guidelines for the Prevention of Surgical Site Infection, 2nd ed. Geneva, Switzerland: (WHO global office; ): World Health Organization. Available at: https://apps.who.int/iris/handle/10665/277399. License: CC BY-NC-SA 3.0 IGO

Stabilini C, Cavallaro G, Dolce P, Capoccia Giovannini S, Corcione F, Frascio M, et al. Pooled data analysis of primary ventral (PVH) and incisional hernia (IH) repair is no more acceptable: results of a systematic review and metanalysis of current literature. Hernia. (2019) 23(5):831–45. 10.1007/s10029-019-02033-4 PubMed DOI

Köckerling F, Schug-Paß C, Adolf D, Reinpold W, Stechemesser B. Is pooled data analysis of ventral and incisional hernia repair acceptable? Front. Surg. (2015) 2:15. 10.3389/fsurg.2015.00015. PubMed DOI PMC

Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. (2009) 6(7):e1000097. 10.1371/journal.pmed.1000097. PubMed DOI PMC

Prabhu AS, Krpata DM, Phillips S, Huang LC, Haskins IN, Rosenblatt S, et al. Preoperative chlorhexidine gluconate use can increase risk for surgical site infections after ventral hernia repair. J Am Coll Surg. (2017) 224(3):334–40. 10.1016/j.jamcollsurg.2016.12.013 PubMed DOI

Haskins IN, Prabhu AS, Krpata DM, Perez AJ, Tastaldi L, Tu C, et al. Is there an association between surgeon hat type and 30-day wound events following ventral hernia repair? Hernia. (2017) 21(4):495–503. 10.1007/s10029-017-1626-7 PubMed DOI

Schneeberger SJ, Kraft CT, Janis JE. No-touch technique of mesh placement in ventral hernia repair: minimizing postoperative mesh infections. Plast Reconstr Surg. (2020) 145(5):1288–91. 10.1097/PRS.0000000000006767 PubMed DOI

Yabanoğlu H, Arer İM, Çalıskan K. The effect of the use of synthetic mesh soaked in antibiotic solution on the rate of graft infection in ventral hernias: a prospective randomized study. Int Surg. (2015) 100(6):1040–7. 10.9738/INTSURG-D-14-00304.1 PubMed DOI PMC

Westphalen AP, Araújo AC, Zacharias P, Rodrigues ES, Fracaro GB, Lopes Filho Gde J. Repair of large incisional hernias. To drain or not to drain. Randomized clinical trial. Acta Cir Bras. (2015) 30(12):844–51. 10.1590/S0102-865020150120000009 PubMed DOI

Plymale MA, Harris JW, Davenport DL, Smith N, Levy S, Scott Roth J. Abdominal wall reconstruction: the uncertainty of the impact of drain duration upon outcomes. Am Surg. (2016) 82(3):207–11. 10.1177/000313481608200312 PubMed DOI

Wong A, Lee S, Nathan NS, Wang F, Hansen SL, Harris HW, et al. Postoperative prophylactic antibiotic use following ventral hernia repair with placement of surgical drains reduces the postoperative surgical-site infection rate. Plast Reconstr Surg. (2016) 137(1):285–94. 10.1097/PRS.0000000000001925 PubMed DOI

Krpata DM, Prabhu AS, Carbonell AM, Haskins IN, Phillips S, Poulose BK, et al. Drain placement does not increase infectious complications after retromuscular ventral hernia repair with synthetic mesh: an AHSQC analysis. J Gastrointest Surg. (2017) 21(12):2083–9. 10.1007/s11605-017-3601-0 PubMed DOI

Gassman A, Mehta A, Bucholdz E, Abthani A, Guerra O, Maclin MM, Jr, et al. Positive outcomes with negative pressure therapy over primarily closed large abdominal wall reconstruction reduces surgical site infection rates. Hernia. (2015) 19(2):273–8. 10.1007/s10029-014-1312-y PubMed DOI

Rodriguez-Unda N, Soares KC, Azoury SC, Baltodano PA, Hicks CW, Burce KK, et al. Negative-Pressure wound therapy in the management of high-grade ventral hernia repairs. J Gastrointest Surg. (2015) 19:2054–61. 10.1007/s11605-015-2894-0. PubMed DOI

Soares KC, Baltodano PA, Hicks CW, Cooney CM, Olorundare IO, Cornell P, et al. Novel wound management system reduction of surgical site morbidity after ventral hernia repairs: a critical analysis. Am J Surg. (2015) 209(2):324–32. 10.1016/j.amjsurg.2014.06.022 PubMed DOI

de Vries FEE, Atema JJ, Lapid O, Obdeijn MC, Boermeester MA. Closed incision prophylactic negative pressure wound therapy in patients undergoing major complex abdominal wall repair. Hernia. (2017) 21(4):583–9. 10.1007/s10029-017-1620-0 PubMed DOI PMC

Licari L, Campanella S, Carolla C, Viola S, Salamone G. Closed incision negative pressure therapy achieves better outcome than standard wound care: clinical outcome and cost-effectiveness analysis in open ventral hernia repair with synthetic mesh positioning. Cureus. (2020) 12(5):e8283. 10.7759/cureus.8283 PubMed DOI PMC

Hopkins B, Eustache J, Ganescu O, Cipolla J, Kaneva P, Fried GM, et al. S116: impact of incisional negative pressure wound therapy on surgical site infection after complex incisional hernia repair: a retrospective matched cohort study. Surg Endosc. (2021) 35(7):3949–60. 10.1007/s00464-020-07857-1 PubMed DOI

Bueno-Lledó J, Franco-Bernal A, Garcia-Voz-Mediano MT, Torregrosa-Gallud A, Bonafé S. Prophylactic single-use negative pressure dressing in closed surgical wounds after incisional hernia repair: a randomized, controlled trial. Ann Surg. (2021) 273(6):1081–6. 10.1097/SLA.0000000000004310 PubMed DOI

Prassas D, Schumacher FJ. Electric cauterization of the hernia sac in laparoscopic ventral hernia repair reduces the incidence of postoperative seroma: a propensity score-matched analysis. Hernia. (2018) 22(5):747–50. 10.1007/s10029-018-1790-4 PubMed DOI

Alhussini MA, Awad AT, Kholosy HM. Using quilting sutures in decreasing seroma formation after managing large ventral hernias: a comparative study. Hernia. (2019) 23(4):717–22. 10.1007/s10029-018-1850-9 PubMed DOI

Azoury SC, Rodriguez-Unda N, Soares KC, Hicks CW, Baltodano PA, Poruk KE, et al. The effect of TISSEEL fibrin sealant on seroma formation following complex abdominal wall hernia repair: a single institutional review and derived cost analysis. Hernia. (2015) 19(6):935–42. 10.1007/s10029-015-1403-4 PubMed DOI

White TJ, Santos MC, Thompson JS. Factors affecting wound complications in repair of ventral hernias. Am Surg. (1998) 64(3):276–80. ProQuest ID: 212793710. https://www.proquest.com/scholarly-journals/factors-affecting-wound-complications-repair/docview/212793710/se-2?accountid=11077 PubMed

Ramshaw B, Dean J, Forman B, Heidel E, Gamenthaler A, Fabian M. Can abdominal wall reconstruction be safely performed without drains? Am Surg. (2016) 82(8):707–12. 10.1177/000313481608200829 PubMed DOI

Simchen E, Rozin R, Wax Y. The Israeli study of surgical infection of drains and the risk of wound infection in operations for hernia. Surg Gynecol Obstet. (1990) 170(4):331–7. 10.1016/0196-6553(91)90047-G PubMed DOI

Grove TN, Kontovounisios C, Montgomery A, Heniford BT, Windsor ACJ, Warren OJ. Perioperative optimization in complex abdominal wall hernias: delphi consensus statement. BJS open. (2021) 5(5):zrab082. 10.1093/bjsopen/zrab082. PubMed DOI PMC

Allegranzi B, Zayed B, Bischoff P, Kubilay NZ, de Jonge S, de Vries F, et al. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis. (2016) 16(12):e288–303. 10.1016/S1473-3099(16)30402-9 PubMed DOI

Kapadia BH, Zhou PL, Jauregui JJ, Mont MA. Does preadmission cutaneous chlorhexidine preparation reduce surgical site infections after total knee arthroplasty? Clin Orthop Relat Res. (2016) 474(7):1592–8. 10.1007/s11999-016-4767-6 PubMed DOI PMC

Edmiston CE, Jr, Bruden B, Rucinski MC, Henen C, Graham MB, Lewis BL. Reducing the risk of surgical site infections: does chlorhexidine gluconate provide a risk reduction benefit? Am J Infect Control. (2013) 41(5 Suppl):S49–55. 10.1016/j.ajic.2012.10.030 PubMed DOI

Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database Syst Rev. (2015) 2(2):CD004985. 10.1002/14651858.CD004985.pub5 (Accessed October 12, 2021). PubMed DOI PMC

Summers MM, Lynch PF, Black T. Hair as a reservoir of staphylococci. J Clin Pathol. (1965) 18:13–5. 10.1136/jcp.18.1.13 PubMed DOI PMC

Mase K, Hasegawa T, Horii T, Hatakeyama K, Kawano Y, Yamashino T, et al. Firm adherence of Staphylococcus aureus and Staphylococcus epidermidis to human hair and effect of detergent treatment. Microbiol Immunol. (2000) 44(8):653–6. 10.1111/j.1348-0421.2000.tb02546.x PubMed DOI

Association of periOperative Registered Nurses (AORN). Guidelines for perioperative practice. Available at: https://www.aorn.org/about-aorn/aorn-newsroom/periop-today-newsletter/2019/2019-articles/guideline-revisions-for-2020 (Accessed June 25, 2021).

Harth KC, Rosen MJ, Thatiparti TR, Jacobs MR, Halaweish I, Bajaksouzian S, et al. Antibiotic-releasing mesh coating to reduce prosthetic sepsis: an in vivo study. J Surg Res. (2010) 163(2):337–43. 10.1016/j.jss.2010.03.065 PubMed DOI

Sadava EE, Krpata DM, Gao Y, Novitsky YW, Rosen MJ. Does presoaking synthetic mesh in antibiotic solution reduce mesh infections? An experimental study. J Gastrointest Surg. (2013) 17(3):562–8. 10.1007/s11605-012-2099-8 PubMed DOI

Dudai M, Gilboa Ittah K. Intraoperative hypertonic saline irrigation preventing seroma formation and reducing drain secretion in extended endoscopic hernia and linea alba reconstruction glue. Hernia. (2019) 23(6):1291–6. 10.1007/s10029-019-01956-2 PubMed DOI

Fatula LK, Nelson A, Abbad H, Ewing JA, Hancock BH, Cobb WS, et al. Antibiotic irrigation of the surgical site decreases incidence of surgical site infection after open ventral hernia repair. Am Surg. (2018) 84(7):1146–51. 10.1177/000313481808400728 PubMed DOI

He S, Xia J, Zhang W, Lai M, Cheng N, Liu Z, et al. Prophylactic abdominal drainage for pancreatic surgery. Cochrane Database Syst Rev. (2021) 12:CD010583. 10.1002/14651858.CD010583.pub5 PubMed DOI PMC

Anweier N, Apaer S, Zeng Q, Wu J, Gu S, Li T, et al. Is routine abdominal drainage necessary for patients undergoing elective hepatectomy? A protocol for systematic review and meta-analysis. Medicine. (2021) 100(6):e24689. 10.1097/MD.0000000000024689 PubMed DOI PMC

Cirocchi R, Kwan SH, Popivanov G, Ruscelli P, Lancia M, Gioia S, et al. Routine drain or no drain after laparoscopic cholecystectomy for acute cholecystitis. Surgeon. (2021) 19(3):167–74. 10.1016/j.surge.2020.04.011 PubMed DOI

Podda M, Di Saverio S, Davies RJ, Atzeni J, Balestra F, Virdis F, et al. Prophylactic intra-abdominal drainage following colorectal anastomoses. A systematic review and meta-analysis of randomized controlled trials. Am J Surg. (2020) 219(1):164–74. 10.1016/j.amjsurg.2019.05.006 PubMed DOI

Reiffel AJ, Barie PS, Spector JA. A multi-disciplinary review of the potential association between closed-suction drains and surgical site infection. Surg Infect. (2013) 14(3):244–69. 10.1089/sur.2011.126 PubMed DOI PMC

Gurusamy KS, Allen VB. Wound drains after incisional hernia repair. Cochrane Database Syst Rev. (2013) 12(12):CD005570. 10.1002/14651858.CD005570.pub4 (Accessed October 11, 2021). PubMed DOI

Ríos A, Rodríguez JM, Munitiz V, Alcaraz P, Pérez Flores D, Parrilla P. Antibiotic prophylaxis in incisional hernia repair using a prosthesis. Hernia. (2001) 5(3):148–52. 10.1007/s100290100026 PubMed DOI

Abramov D, Jeroukhimov I, Yinnon AM, Abramov Y, Avissar E, Jerasy Z, et al. Antibiotic prophylaxis in umbilical and incisional hernia repair: a prospective randomised study. Eur J Surg. (1996) 162(12):945–8; discussion 949. https://www.researchgate.net/publication/14206292 PubMed

Tran BNN, Johnson AR, Shen C, Lee BT, Lee ES. Closed-Incision negative-pressure therapy efficacy in abdominal wall reconstruction in high-risk patients: a meta-analysis. J Surg Res. (2019) 241:63–71. 10.1016/j.jss.2019.03.033 PubMed DOI

Berner-Hansen V, Oma E, Willaume M, Jensen KK. Prophylactic negative pressure wound therapy after open ventral hernia repair: a systematic review and meta-analysis. Hernia. (2021) 25(6):1481–90. 10.1007/s10029-021-02485-7 PubMed DOI

Klima DA, Brintzenhoff RA, Tsirline VB, Belyansky I, Lincourt AE, Getz S, et al. Application of subcutaneous talc in hernia repair and wide subcutaneous dissection dramatically reduces seroma formation and postoperative wound complications. Am Surg. (2011) 77(7):888–94. Erratum in: Am Surg. (2014):80(4):422 10.1177/000313481107700725 PubMed DOI

Massey LH, Pathak S, Bhargava A, Smart NJ, Daniels IR. The use of adjuncts to reduce seroma in open incisional hernia repair: a systematic review. Hernia. (2018) 22(2):273–83. 10.1007/s10029-017-1690-z PubMed DOI

Parameswaran R, Hornby ST, Kingsnorth AN. Medical talc increases the incidence of seroma formation following onlay repair of major abdominal wall hernias. Hernia. (2013) 17(4):459–63. 10.1007/s10029-013-1097-4 PubMed DOI

Morales-Conde S, Barranco A, Socas M, Alarcón I, Grau M, Casado MA. Systematic review of the use of fibrin sealant in abdominal-wall repair surgery. Hernia. (2011) 15:361–9. 10.1007/s10029-011-0809-x. PubMed DOI

Mobile Accelerometer Applications in Core Muscle Rehabilitation and Pre-Operative Assessment