Diverticular Disease Increases Risk of Incisional Hernia After Elective Colectomy

Diverticular disease as an indication for surgery seldom receives serious attention as a risk factor for incisional hernia. However, two recent genome-wide association studies, one published in Nature Genetics and the other in Gut, linked diverticular disease to gene mutations related to aberrant connective formation. The former study also suggested a common etiology of diverticular disease and hernia.

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In the largest U.S. study of the issue to date, researchers at Massachusetts General Hospital found a significant relationship between diverticular disease as an indication for elective colectomy and subsequent incidence of incisional hernia. Department of Surgery's Numa P. Perez, MD, a surgery resident, Paul M. Cavallaro, MD, a research resident, and David C. Chang PhD, MPH, MBA, director of Healthcare Research and Policy Development at the Codman Center,  Robert Goldstone, MD, and Liliana Bordeianou, MD, MPH, FACS, FASCRS, chief of the Colorectal Surgery Center, and a colleague published the findings in the Journal of Gastrointestinal Surgery.

Methods

Using the New York Statewide Planning and Research Cooperative System database, the researchers identified 8,279 adults who underwent elective sigmoid or left hemicolectomy for diverticulitis (82%) or colon cancer (18%) between 2010 and 2016. Procedures could be open or laparoscopic.

306 patients in the diverticulitis group and 46 in the colon cancer group had a skin or connective tissue disorder, such as scleroderma, Marfan syndrome, Ehlers–Danlos syndrome or polycystic kidney disease.

Incisional Hernia Diagnosis

In multivariable analyses the risk of incisional hernia for the diverticulitis group compared with the colon cancer group was:

• Entire cohort—adjusted HR (aHR), 1.8 (P=0.001)
• Patients who had open surgery—aHR, 2.2 (P=0.01)
• Patients who had laparoscopic surgery—aHR, 1.7 (P=0.02)

Other significant risk factors for incisional hernia were obesity (aHR, 2.4), skin or connective tissue disorder (aHR, 1.6), smoking (aHR, 1.5), open surgery (aHR, 1.3) and female sex (aHR, 1.3).

The elevated risk for patients with skin and connective tissue disorders did not persist for those undergoing laparoscopic colectomies.

Incisional Hernia Repair

The results for the secondary endpoint were similar. The risk of an incisional hernia repair for the diverticulitis group compared with the colon cancer group was:

• Entire cohort—aHR, 2.1 (P<0.001)
• Patients who had open surgery—aHR, 2.9 (P=0.004)
• Patients who had laparoscopic surgery—aHR, 1.8 (P=0.03)

Other significant risk factors for incisional hernia repair were obesity (aHR, 2.3), greater hospital volume (aHR, 1.3) and female sex (aHR, 1.3).

Recommendations for Surgeons

Patients with diverticular disease who undergo colectomy or any other abdominal surgery should be categorized as being at higher risk of incisional hernia. Virtually all surgeons already maximize their efforts to prevent this dreaded complication, but for patients with diverticular disease, they should follow stringent evidence-based best practices for fascial closure.

At Mass General, the preferred approach for sigmoid resections is a Pfannenstiel incision when possible. These transverse suprapubic incisions significantly reduce the risk of incisional hernia compared with conventional midline incisions and also improve cosmesis for many patients. Recent data suggest, however, they may be associated with higher infection rates.

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