Linking factors to incisional hernia following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

Abstract

Introduction: One of the most found complications of cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy is the development of incisional hernia, which is associated with higher need for re-intervention, decreased quality of life with a negative impact on patient's self-image and functional capability. Risk factors for its development remain unclear in this specific patient subset. This paper aims to analyze the incidence of incisional hernia in patients submitted to cytoreductive surgery ± hyperthermic intraperitoneal chemotherapy and identify risk factors related to its development. Methods: A retrospective observational study was conducted at São João University Hospital, considering adult patients who underwent cytoreductive surgery ± hyperthermic intraperitoneal chemotherapy, for peritoneal malignancy between July 2010 and December 2024. Data on demographic characteristics, laboratorial and imaging findings, surgical procedures, follow-up and outcomes were collected. Results: Our population comprised 210 adult patients, with a minimum follow up time of 3 months. Thirteen (6,2 %) patients developed incisional hernia, with a median time for development of 3,5 months. In univariate analysis, undergoing systemic therapy was a statistically significant protective factor for the development of incisional hernia in patients undergoing cytoreductive surgery for peritoneal carcinomatosis (OR: 0,294; p:0,038). Male gender and a body mass index > 25kg/m2 (OR: 7,741; 95% CI:0,979-61,224; p: 0.052) demonstrated a positive correlation with incisional hernia rate, despite not being statistically significant. Discussion: Our population's low incidence of incisional hernia (6,2%) after cytoreductive surgery might be explained by our center's surgical expertise and standardized practices, shared by a restricted group of specialized surgeons. Population heterogeneity found in literature, different criteria for incisional hernia consideration and different follow-up approaches may also contribute to the higher rates of prior reports. Undergoing systemic therapy proved to be a protective factor against incisional hernia development. This is possibly explained by the reduction of the associated tumor burden, ascites and intra-abdominal pressure, and the improvement in the tissue regeneration capacity. Inability to show statistical significance for our other variables, especially those near statistical significance, is believed to pertain to our study limitations, namely a lower minimum follow-up time, low number of events on each category due to population heterogeneity and missing data. Conclusion: The incidence of incisional hernia in our population (6,2%) was below the range reported in literature. Undergoing systemic therapy was presented as a protective factor for incisional hernia development in our population, and no differences between systemic therapy timing were found.