Risikoprofil und Rezidivprophylaxe der Narbenhernie – was ist evidenzbasiert?

 

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Zusammenfassung

Die Narbenhernie ist eine Spätkomplikation nach Laparotomie, bei der ein evidenzbasierter prophylaktischer Ansatz nach wie vor fehlt. Eine postoperative Narbenhernie entsteht aufgrund multipler Einflussfaktoren. Hierzu gehören präoperative Grund- oder Begleiterkrankungen. Eine diesbezügliche Risikoreduzierung gelingt meistens nicht. Es liegen eine Reihe Untersuchungen vor, die die Technik des chirurgischen Wundverschlusses verglichen haben. Konsens ist, dass die fortlaufende Fasziennaht mit langzeit- oder nicht resorbierbarem Nahtmaterial mit der geringsten Inzidenz an Narbenhernien einhergeht. Der Abstand zwischen den Nähten von einem Zentimeter und mindestens einem Zentimeter zum Faszienrand sowie ein Faden- und Wundlängenverhältnis von 4 : 1 sind nach wie vor gültige Prinzipien. Weitere evidenzbasierte Empfehlungen zur Verbesserung des Bauchwandverschlusses zur Reduzierung der Inzidenz von Narbenhernien gibt es nicht. Die Prophylaxe postoperativer Komplikationen durch eine adäquate Schmerztherapie, Atemtraining und eine möglichst frühzeitige Mobilisation sind Maßnahmen, um die Narbenhernieninzidenz zu senken. Allerdings liegen hierzu keine systematischen Untersuchungen vor. Um einer Narbenhernie vorzubeugen, bleiben somit nur pragmatische Ansätze, die allerdings den Anforderungen der evidenzbasierten Medizin nicht genügen.

Abstract

Incisional hernia is a late complication of laparotomy for which an evidence-based prohylactic approach is still lacking. Postoperatively, incisional hernias occur because of multiple factors. Preoperative comorbidities belong to these risk factors. A risk reduction related to concomitant diseases mostly does not succeed. There is a range of studies comparing the techniques of surgical wound closure. A consensus of these is that a running suture of the fascia with slowly absorbable or non-absorbable sutures results in the lowest incidence of incisional hernias. A one-cm distance between the stitches and a minimal distance of one cm to the fascial margin as well as a 4 : 1 suture length to wound length ratio are still valid principles. In any case, solely optimising the surgical technique of the abdominal wall closure is not able to reduce the incidence of incisional hernias. Prevention of postoperative complications by adequate pain management, respiratory training and early mobilisation are procedures to reduce the incidence of incisional hernias. However, systematic studies are lacking. To avoid an incisional hernia, only a practical approach remains which, however, does not meet the requirements of evidence-based medicine.

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Dr. med. D. Jargon

Abteilung für Allgemein- und Viszeralchirurgie · Chirurgische Universitätsklinik · Albert-Ludwigs-Universität Freiburg

Hugstetter Str. 55

79106 Freiburg

Phone: +49 / 7 61 / 2 70 28 06

Fax: +49 / 7 61 7 2 70 27 82

Email: dirk.jargon@uniklinik-freiburg.de