The effect of tobacco consumption and body mass index on complications and hospital stay after inguinal hernia surgery

The impact of smoking on ventral and inguinal hernia repair: a systematic review and meta-analysis

PURPOSE

Individual studies indicate poorer outcomes for smokers after hernia repair. Previous meta-analyses have examined the impact of smoking on specific outcomes such as recurrence and surgical site infection, but there has been a lack of comprehensive consensus or systematic review on this subject. Addressing this gap, our study undertakes a systematic review and meta-analysis to assess the impact of smoking on the outcomes of ventral hernia repair (VHR) and inguinal hernia repair.

SOURCE

A thorough search of Cochrane Central, Scopus, SciELO, and PubMed/MEDLINE, focusing on studies that examined the effect of smoking on inguinal and VHR outcomes was conducted. Key outcomes evaluated included recurrence, reoperation, surgical site occurrences (SSO), surgical site infection (SSI), and seroma.

PRINCIPAL FINDINGS

Out of 3296 screened studies, 42 met the inclusion criteria. These comprised 25 studies (69,295 patients) on VHR and 17 studies (204,337 patients) on inguinal hernia repair. The analysis revealed that smokers had significantly higher rates of recurrence (10.4% vs. 9.1%; RR 1.48; 95% CI [1.15; 1.90]; P < 0.01), SSO (13.6% vs. 12.7%; RR 1.44; 95% CI [1.12; 1.86]; P < 0.01) and SSI (6.6% vs. 4.2%; RR 1.64; 95% CI [1.38; 1.94]; P < 0.01) following VHR. Additionally, smokers undergoing inguinal hernia repair showed higher recurrence (9% vs. 8.7%; RR 1.91; 95% CI [1.21; 3.01]; P < 0.01), SSI (0.6% vs. 0.3%; RR 1.6; 95% CI [1.21; 2.0]; P < 0.001), and chronic pain (9.9% vs. 10%; RR 1.24; 95% CI [1.06; 1.45]; P < 0.01) rates. No significant differences were observed in seroma (RR 2.63; 95% CI [0.88; 7.91]; P = 0.084) and reoperation rates (RR 1.48; 95% CI [0.77; 2.85]; P = 0.236) for VHR, and in reoperation rates (RR 0.99; 95% CI [0.51; 1.91]; P = 0.978) for inguinal hernias between smokers and non-smokers. Analysis using funnel plots and Egger's test showed the absence of publication bias in the study outcomes.

CONCLUSION

This comprehensive meta-analysis found statistically significant increases in recurrence rates, and immediate postoperative complications, such as SSO and SSI following inguinal and VHR. Also, our subgroup analysis suggests that the MIS approach seems to be protective of adverse outcomes in the smokers group. However, our findings suggest that these findings are not of clinical relevance, so our data do not support the necessity of smoking cessation before hernia surgery. More studies are needed to elucidate the specific consequences of smoking in both inguinal and ventral hernia repair.

PROSPERO REGISTRATION

ID CRD42024517640.

The impact of smoking on inguinal hernia repair outcomes: a meta-analysis of multivariable-adjusted studies

PURPOSE

While the detrimental effects of smoking on postoperative outcomes are recognized, the extent of its risk for inguinal hernia repair remains unclear. Our study aims to assess the influence of smoking on patients who undergo inguinal hernia repair.

METHODS

We systematically reviewed PubMed, Embase, and Cochrane databases. Our goal was to identify studies that compared postoperative outcomes in smoking and non-smoking patients after inguinal hernia repair, and which employed a multivariate analysis to reduce possible confounding factors. Outcomes were recurrence, postoperative complications, and surgical site infection. Odds ratios (ORs) with 95% confidence intervals (CIs) were computed with the use of a random-effects model. Heterogeneity was examined with I2 statistics. This review was prospectively registered in PROSPERO (CRD42023445513).

RESULTS

Our analysis encompassed 11 studies, involving a total of 577,901 patients. Of these, 77,226 (or 13.4%) identified as smokers, with males constituting 90% of the cohort. In terms of surgical approaches, 58% underwent laparoscopic procedures were most common at 58%, followed by open surgeries at 41%, and 1% used robotic techniques. All included studies had a low risk of bias. Smoking was associated with a higher incidence of hernia recurrence (OR 2.95; 95% CI 2.08 to 4.18; p < 0.001; I2 = 0%). No differences were found in postoperative complication (OR 1.15; 95% CI 1.00 to 1.32; p = 0.05; I2 = 56%) or surgical site infection (OR 2.94; 95% CI 0.80 to 10.88; p = 0.11; I2 = 79%).

CONCLUSION

Smoking was associated with a three-fold increase in recurrence. Further studies are needed to evaluate the impact of preoperative smoking cessation on reducing recurrence.

Laparoscopic Inguinal Hernia Repair in the Obese Patient Population: A Single-Center Five-Year Experience

Purpose The objective of the present study is to evaluate the distribution of the transabdominal preperitoneal (TAPP) and the totally extraperitoneal repair (TEP) procedures among the obese and non-obese patient populations, to show how obesity impacts daily practice by reviewing the experience of a single center, and finally, to assess the outcomes of the operations. Methods All patients who underwent elective, minimally invasive inguinal hernia repair in our hospital from January 2017 to January 2022 were included in the present study. The data that were analyzed were patient demographics, each individual patient's American Society of Anesthesiology (ASA) score, the minimally invasive technique (TAPP or TEP) utilized, the body mass index (BMI), and other comorbidities such as underlying diabetes, hypertension, and smoking status. Results A total of 109 patients were included in the present analysis, of which 81 (74.3%) underwent elective TEP repairs while 28 (25.7%) underwent elective TAPP repairs. Overall, 39 (35.7%) patients were included in the obesity subgroup with an average BMI of 35.4 ± 4.9, with a range from 30.1 to 52.7, and 70 (64.3%) were included in the non-obese subgroup, with an average BMI of 23.2 ± 3.3 and a range from 16.2 to 29.7. Conclusions The laparoscopic approach to the inguinal hernia repair in obese patients has similar outcomes as an open approach regarding the 30-day events, in the hands of experienced surgeons with the advantages of the laparoscopic approach vs. the open one.

A Single-center Comparison of Unipedicled and Bipedicled Diep Flap Early Outcomes in 98 Patients

The deep inferior epigastric perforator (DIEP) flap is the gold standard for autologous breast reconstruction. One or two pedicles may be used. Our study is the first to compare unipedicled and bipedicled DIEP flaps on donor and recipient site outcomes in the same patient cohort.

Methods

This is a retrospective cohort study comparing DIEP flap outcomes between 2019 and 2022.

Results

There were 98 patients, categorized differently for recipient or donor site. The recipient groups were unilateral unipedicled (N = 52), bilateral unipedicled (N = 15), and unilateral bipedicled (N = 31), and donor site groups were unipedicled (N = 52) and bipedicled (N = 46, including bilateral unipedicled and unilateral bipedicled). Bipedicled DIEP flaps had 1.15 times greater odds of donor site complication (95% CI, 0.52-2.55). Adjusting for operative time that was longer in bipedicled DIEP flaps (P < 0.001), odds ratio decreased, and there was a lower probability of donor site complication for bipedicled flaps (OR, 0.84; 95% CI, 0.31-2.29). Odds of recipient area complication was not significantly different between groups. Unilateral unipedicled DIEP flaps had significantly higher rates of revisional elective surgery than unilateral bipedicled DIEP flaps (40.4% versus 12.9%; P = 0.029).

Conclusions

We demonstrate no significant difference in donor site morbidity between unipedicled and bipedicled DIEP flaps. Bipedicled DIEP flaps do have slightly higher rates of donor site morbidity, which can be partly explained by longer operative times. There is no significant difference in recipient site complications, and bipedicled DIEP flaps can reduce rates of further elective surgery.

The effect of smoking status on inguinal hernia repair outcomes: An ACHQC analysis

BACKGROUND

Smoking has been shown to negatively affect surgical outcomes, so smoking cessation prior to elective operations is often recommended. However, the effects of smoking status on inguinal hernia repair outcomes have not been extensively studied. Hence, we investigated the association between smoking status and short-term adverse outcomes following inguinal hernia repair.

METHODS

Abdominal Core Health Quality Collaborative database was queried for elective, clean inguinal hernia repairs, excluding those with concomitant procedures or where length of stay > 30 days. The resulting cohort was divided into three groups: current smokers, former smokers, and never smokers. Baseline patient, hernia, operative characteristics, and 30-day outcomes were compared. Multivariable logistic regression was used to evaluate the association between smoking status and overall and wound complications.

RESULTS

19,866 inguinal hernia repairs were included (current smokers = 2239, former smokers = 4064 and never smokers = 13,563). Current smokers and former smokers, compared to never smokers, had slightly higher unadjusted rates of overall complication rates (9% and 9% versus 7%, p = 0.003) and surgical site occurrences/infection (6% and 6% versus 4%, p < 0.001). However, on multivariable analysis, compared to current smokers, neither the rates of overall complications nor surgical site occurrences were significantly different in former smokers (OR = 0.93, 95% CI [0.76, 1.13] and OR = 0.92, 95% CI [0.73, 1.17]) and never smokers (OR = 0.99, 95% CI [0.83, 1.18] and OR = 0.86, 95% CI [0.70,1.06]) respectively.

CONCLUSIONS

Smoking status is not associated with short-term adverse outcomes following inguinal hernia repair. Mandating smoking cessation does not appear necessary to prevent short-term adverse outcomes.

Short-term outcomes of robotic inguinal hernia repair during robotic prostatectomy - An analysis of the Abdominal Core Health Quality Collaborative

BACKGROUND

Concomitant robotic-assisted laparoscopic prostatectomy (RALP) and robotic inguinal hernia repair (RIHR) has been reported. Nevertheless, data on its safety is lacking and some surgeons avoid performing both operations concurrently due to the potential risk of mesh related complications in the setting of a fresh vesicourethral anastomosis. We aimed to investigate differences in 30-day outcomes between patients undergoing RALP+RIHR and those undergoing RIHR alone.

METHODS

Patients who have undergone concomitant RALP and RIHR with 30-day follow-up available were identified within the Abdominal Core Health Quality Collaborative. Using a propensity score algorithm, they were matched with a cohort of patients undergoing RIHR alone based on confounders such as body mass index, age, ASA class, smoking, hernia size and recurrent status and prior pelvic operation. The groups were compared for 30-day rates of surgical site infection (SSI), surgical site occurrences (SSO), surgical site occurrences requiring operative intervention (SSOPI) and hernia recurrence.

RESULTS

24 patients underwent RALP + RIHR and were matched to 72 patients who underwent RIHR alone (3:1). Median age was 64 years, 33% were obese and 17% smokers. No significant differences were found on 30-day rates of overall complications (21% RALP + RIHR vs. 15% RIHR, p = 0.53) and surgical site occurrences (12% RALP + RIHR vs.11% RIHR, p = 0.85). No patient in the RALP + RIHR group had a 30-day SSI, SSOPI or early recurrence.

CONCLUSION

RALP+RIHR appears not to result in increased rates of wound complications, overall complications or early recurrence when compared to patient undergoing RIHR alone. Prospective, controlled studies with larger number of patients are needed to confirm our findings.

Comparison of BMI on operative time and complications of robotic inguinal hernia repair at a VA medical center

BACKGROUND

BMI is a risk factor for recurrence and post-operative complications in both open and laparoscopic totally extraperitoneal approach (TEP) repair. Robotic surgery using the transabdominal preperitoneal approach (TAPP) is a safe and viable option for inguinal hernia repair (IHR). The objective of this study is to determine how difference in BMI influences rate of operative time, complications, and rate of recurrence in a robotic TAPP IHR.

METHODS

We performed a retrospective review of patients who underwent robotic inguinal hernia repair between 2012 and 2019 at a Veterans Health Administration facility (N = 304). The operating time, outcomes, and overall morbidity and mortality for robotic IHR were compared between three different BMI Groups. These groups were divided into: "Underweight/Normal Weight" (BMI < 25) n = 102, "Pre-Obese" (BMI 25-29.9) n = 120, and "Obese" (BMI 30 +) n = 82.

RESULTS

The average operating time of a bilateral IHR by BMI group was 83.5, 98.4, and 97.8 min for BMIs < 25, 25-29.9, and 30 +, respectively. Operating time was lower in the Underweight/Normal BMI group compared to the Pre-Obese group (p = 0.006) as well as the Obese group (p = 0.001). For unilateral repair, the average operation length by group was 65.2, 70.9, and 85.6 min for BMIs < 25, 25-29.9, and 30 +, respectively, demonstrating an increased time for Obese compared to Underweight/Normal BMI (p = 0.001) and for Obese compared to Pre-Obese (p = 0.01). Demographic/comorbidity variables were not significantly different, except for a higher percentage of white patients in the Underweight/Normal BMI group compared to the Pre-Obese and Obese groups (p = 0.02 and p = 0.0003). There was no significant difference in complications or recurrence.

CONCLUSION

BMI has a significant impact on the operating time of both unilateral and bilateral robotic hernia repair. Despite this increased operative time, BMI group did not differ significantly in postoperative outcomes or in recurrence rates.

Transversus abdominis release (TAR) procedure: a retrospective analysis of an abdominal wall reconstruction group

Complex abdominal wall defects are important conditions with high morbidity, leading to impairment of patients' physical condition and quality of life. In the last decade, the abdominal wall reconstruction paradigm has changed due to the formation of experienced and excellence groups, improving clinical outcomes after surgery. Therefore, our study shows the perspective and outcomes of an abdominal wall reconstruction group (AWRG) in Colombia, focused on the transverse abdominis release (TAR) procedure. A retrospective review of a prospectively collected database was conducted. All the patients older than 18 years old that underwent TAR procedures between January 2014-December 2020 were included. Analysis and description of postoperative outcomes (recurrence, surgical site infection (SSI), seroma, hematoma, and re-intervention) were performed. 47 patients underwent TAR procedure. 62% of patients were male. Mean age was 55 ± 13.4 years. Mean BMI was 27.8 ± 4.5 kg/m². Abdominal wall defects were classified with EHS ventral Hernia classification having a W3 hernia in 72% of all defects (Mean gap size of 11.49 cm ± 4.03 cm). Mean CeDAR preoperative risk score was 20.5% ± 14.5%. Preoperative use of BOTOX Therapy (OR 1.0 P 0.00 95% CI 0.3-1.1) or pneumoperitoneum (OR 0.7 P 0.04 95% CI 0.3-0.89) are slightly associated with postoperative hematoma. In terms of hernia relapse, we have 12% of cases; all of them over a year after the surgery. TAR procedure for complex abdominal wall defects under specific clinical conditions including emergency scenarios is viable. Specialized and experienced groups show better postoperative outcomes; further studies are needed to confirm our results.

Kingsnorth's modified score as predictor of complications in open inguinal hernia repair

Purpose

This study aims to analyse the postoperative complications (30 days) on unilateral primary inguinal hernia repair and prove their correlation with the preoperative modified scoring system of Kingsnorth (KN).

Methods

Prospective study design collecting data from patients who underwent surgery for unilateral primary inguinal hernia in a University Hospital. The data were collected in the National Inguinal Hernia Registry (EVEREG). A statistical analysis to assess the association between the presence of postoperative complications and the preoperative and intraoperative variables was performed. The patients were classified depending on their KN score. Surgical complications and their relationship with the classification were specifically analysed. Study design was performed following STROBE statements.

Results

The sample included 403 patients who met the inclusion criteria from which 62 (15.3%) subjects presented postoperative complications. The variables that presented a statistically significant relationship with the appearance of complications were a KN score of 5–8 (OR 2.7; 95% CI 1.07–4.82; P = 0.03) and the involvement of a member of the abdominal wall surgery unit in the procedure (OR 0.28; 95% CI 0.08–0.92; P = 0.03). The KN score correlated with a longer duration of surgery (Pearson's correlation 0.291; P < 0.0001).

Conclusion

The KN classification can predict the onset of surgical wound complications on patients who undergo a primary unilateral inguinal hernia surgery. A KN score of 5–8 has a higher probability of wound complications. When surgery is performed by the abdominal wall surgery unit, the chances of postoperative complications decrease.

Excess Body Weight and Abdominal Hernia

Background

Obese patients have an increased incidence of ventral hernias; in over 50% of these cases, patients are symptomatic. At the same time, morbid obesity is a disease of epidemic proportions. The combination of symptomatic hernia and obesity is a challenge for the treating surgeon, because the risk of perioperative complications and recurrence increases with increasing BMI.

Summary

This review outlines this problem and discusses interdisciplinary approaches to the management of affected patients. In emergency cases, the hernia is treated according to the surgeon's expertise. In elective cases, an individual decision must be made whether bariatric surgery is indicated before hernia repair or whether both should be performed simultaneously. After bariatric surgery a weight reduction of 25-30% of total body weight in the first year can be achieved and it is often advantageous to perform a bariatric operation prior to hernia repair. Technically, the risk of complications is lower with minimally invasive procedures than with open ones, but laparoscopy is challenging in obese patients, and meshes can only be implanted in intraperitoneal position. This mesh position has to be questioned because of adhesions, recurrence rate, and risk of contamination during re-interventions in patients who are often still relatively young.

Key Messages

Obese patients with hernia need to be approached in an interdisciplinary manner, in some patients a weight loss procedure may be advantageous before hernia repair. Recent data show the benefits of robotic hernia surgery in obese patients, as not only haptic advantages result, but especially the mesh can be implanted in a variety of extraperitoneal positions in the abdominal wall with low morbidity.

Establishing the need for clinical follow-up after emergency appendicectomy in the modern era: Retrospective case series of 145 patients

Introduction

Emergency appendicectomy (EA) is a commonly performed operation, with an increasing number of EAs being performed as day-case. The aim of this study is to establish if there is a need for post-operative follow-up and if this could prevent adverse outcomes.

Methods

A retrospective analysis of patients who underwent EA at multiple centres over a six-month period was undertaken. They were contacted by telephone and a standardised questionnaire was used to ascertain post-operative outcomes, including duration of analgesia use, duration before return to normal daily activity (ADLs), surgical site infection rates (SSI) and rates of re-presentation to medical services. Patients were stratified into those who underwent laparoscopic versus open appendicectomy, smokers versus non-smokers, and body mass index (BMI).

Results

A total of 145 patients were included in the study. Patients undergoing open surgery (vs. laparoscopic surgery) required analgesia for significantly longer periods, with a significantly longer return to ADLs. Smokers, when compared to non-smokers experienced a significantly longer return to work/school; and significantly higher risk of SSI and re-presenting to accident & emergency; as did patients with a BMI >30 when compared to those with a BMI <30.

Conclusion

Most patients do not need formal outpatient assessment after EA. However, there is clearly a subset of higher risk patients who may benefit from this - patients who are smokers or obese. They have prolonged recovery times, and are at greater risk of SSI. Earlier surgical outpatient follow-up of these patients could prevent adverse outcomes.

Risk factors for perioperative complications in inguinal hernia repair - a systematic review

The current literature suggests that perioperative complications occur in 8%–10% of all inguinal hernia repairs. However, the clinical relevance of these complications is currently unknown. In our review, based on 571,445 hernia repairs reported in 39 publications, we identified the following potential risk factors: patient age, ASA score, diabetes, smoking, mode of admission (emergency vs. elective surgery), surgery in low resource settings, type of anesthesia, and (in men) bilateral and sliding hernias. The most commonly reported complications are bleeding (0.9%), wound infection (0.5%), and pulmonary and cardiovascular complications (0.2%). In 3.9% of the included publications, a reliable grading of the reported complications according to Clavien-Dindo classification was possible. Using this classification retrospectively, we could show that, in patients with complications, these are clinically relevant for about 22% of these patients (Clavien-Dindo grade ≥IIIa). About 78% of all patients suffered from complications needing only minor (meaning mostly medical) intervention (Clavien-Dindo grade <III). Especially with regard to the low incidence of complications in inguinal hernia repair, future studies should use the Clavien-Dindo classification to achieve better comparability between studies, thus enabling better correlation with potential risk factors.

The effect of tobacco use on outcomes of laparoscopic and open inguinal hernia repairs: a review of the NSQIP dataset

BACKGROUND

As the effort to reduce postoperative morbidity and mortality continues, the search for modifiable patient risk factors to reduce complications is ongoing. Tobacco use is associated with impaired wound healing, but its effect on inguinal hernia repair has not been studied in a large population. An ACS-NSQIP dataset was used to evaluate the effect of tobacco use on outcomes of inguinal hernia repairs.

METHODS

The ACS-NSQIP dataset was queried for patients who underwent open or laparoscopic inguinal hernia repairs, by primary procedure CPT codes, between years 2009-2012. Tobacco use was registered, as defined by the ACS-NSQIP, in two ways: current smoking (within the past 12 months), or history of smoking (having ever smoked). Univariate and multivariate analyses were used to investigate outcome variables for 30-day morbidity by type of smoking status, while adjusting for preoperative risk factors.

RESULTS

During the study period, 90,162 patients underwent inguinal hernia repair. 76 % of the cases were open compared to 24 % laparoscopic. The population was overwhelmingly male, 91 %, compared to 9 % female. The average age of patients was 42.5 years. Of the available data (69 % of patients), 38.5 % had a history of smoking. 18 % had smoked within the 12 months prior to surgery (current smokers). Their average number of pack years was 27.2 (SD 24.0) compared to 4.5 pack years (SD 14.7) for those who had not smoked 12 months prior to surgery (historical smokers). Using Fisher's exact test, having ever smoked was found to be significantly associated with pneumonia (p = 0.0008) and return to the operating room (p = 0.010). This relationship held when preoperative variables were controlled for using logistic regression (pneumonia, p = 0.002; return to the operating room, p = 0.002). When preoperative variables were controlled for and logistic regression was performed for current smokers, there was also a significant association with pneumonia (p = 0.005) and return to the operating room (p = 0.01).

CONCLUSION

Current smoking status is a modifiable risk of patients undergoing laparoscopic and open inguinal hernia repair. Failure to quit smoking prior to surgical repair is associated with complications like pneumonia and return to the operating room.

A Multidisciplinary Approach to Medical Weight Loss Prior to Complex Abdominal Wall Reconstruction: Is it Feasible?

Obesity is a major risk factor for perioperative morbidity, especially for patients undergoing complex incisional hernia repair. The feasibility and effectiveness of medical weight loss programs prior to complex abdominal wall reconstruction have not been well characterized. Here, we report our experience collaborating with a medical weight loss specialist utilizing a protein sparing modified fast in order to optimize weight loss prior to complex abdominal wall reconstruction. Morbidly obese patients (body mass index (BMI) > 35 kg/m(2)) evaluated by our medical weight loss specialist prior to complex ventral hernia repair were identified within our prospective database. Our primary outcome measure was the amount of weight lost prior to surgical intervention. Our secondary outcome measure was to determine the maintenance of weight loss during long-term follow-up after the surgical intervention. A total of 25 patients with a BMI > 35 kg/m(2) were evaluated by our medical weight loss specialist prior to undergoing a planned incisional hernia repair. The mean weight of the patients preoperatively was 128 kg ± 25 (range 96-205 kg) (mean ± standard deviation), and the mean BMI was 49 kg/m(2) ± 10 (range 36-85). After completion of the preoperative modified protein sparing fast, the mean preoperative weight loss of the group was 24 kg ± 21 (range 2-80 kg). The overall change in BMI for the group prior to surgery was 9 kg/m(2) ± 8 (0.6 to 33). The percentage of excess BMI loss and total BMI loss preoperatively was 37 % ± 23 (2 to 83) and 18 % ± 12 (1 to 43), respectively. Of the 24 patients that initially lost weight in the program preoperatively, 22 (88 %) successfully maintained their weight loss for the entire study period for an average of 18 months. Collaboration with a medical weight loss specialist and a surgeon with a structured approach using a modified protein sparing fast can successfully result in meaningful weight loss prior to complex abdominal wall reconstruction. The majority of patients in this study were able to maintain their weight loss during long-term follow-up. Utilization of a protein sparing modified fast in collaboration with a medical weight loss specialist is a valuable resource for guiding weight loss in patients with morbid obesity prior to elective complex surgical procedures.

Relationship between body mass index and the incidence of inguinal hernia repairs: a population-based study in Olmsted County, MN

PURPOSE

The relationship between body mass index (BMI) and the risk of inguinal hernia development is unclear. To explore the relationship, we determined whether the incidence of inguinal hernia repairs (IHR) varied across patients with different BMI categories.

STUDY DESIGN

A population-based incidence study was undertaken. We reviewed all IHR performed on adult residents of Olmsted County, MN from 2004 to 2008. Cases were ascertained through the Rochester Epidemiology Project, a records-linkage system with more than 97% population coverage.

RESULTS

During the study period, a total of 1,168 IHR were performed on 879 men and 107 women. The median BMI of the cohort was 26.7 kg/m2 (range 14.9-58.1, interquartile range 23.9-28.9). Incidence rates varied significantly as a function of BMI (p<0.001). Rates were highest among men who were either normal weight or overweight (419.8 and 421.1 per 100,000 person-years for BMI<25 and BMI 25-29.9, respectively), and lowest for obese and morbidly obese men (273.5 and 99.4 per 100,000 person-years for BMI 30-34.9 and BMI C 35, respectively). Findings were similar across all age categories and in patients who had an IHR that was initial or recurrent, direct or indirect, and unilateral or bilateral.

CONCLUSIONS

The incidence of IHR decreased as BMI increased. Obese and morbidly obese patients had a lower incidence of IHR than those who were normal weight or overweight. The causal mechanisms leading to such a relationship are unclear and warrant further study.

Organisational interventions to reduce length of stay in hospital: a rapid evidence assessment

Background

Available evidence on effective interventions to reduce length of stay in hospital is wide-ranging and complex, with underlying factors including those acting at the health system, organisational and patient levels, and the interface between these. There is a need to better understand the diverse literature on reducing the length of hospital stay.

Objectives

This study sought to (i) describe the nature of interventions that have been used to reduce length of stay in acute care hospitals; (ii) identify the factors that are known to influence length of stay; and (iii) assess the impact of interventions on patient outcomes, service outcomes and costs.

Data sources

We searched MEDLINE (Ovid), EMBASE, the Health Management Information Consortium and System for Information on Grey Literature in Europe for the period January 1995 to January 2013 with no limitation of publication type.

Methods

We conducted a rapid evidence synthesis of the peer-reviewed literature on organisational interventions set in or initiated from acute hospitals. We considered evidence published between 2003 and 2013. Data were analysed drawing on the principles of narrative synthesis. We also carried out interviews with eight NHS managers and clinical leads in four sites in England.

Results

A total of 53 studies met our inclusion criteria, including 19 systematic reviews and 34 primary studies. Although the overall evidence base was varied and frequently lacked a robust study design, we identified a range of interventions that showed potential to reduce length of stay. These were multidisciplinary team working, for example some forms of organised stroke care; improved discharge planning; early supported discharge programmes; and care pathways. Nursing-led inpatient units were associated with improved outcomes but, if anything, increased length of stay. Factors influencing the impact of interventions on length of stay included contextual factors and the population targeted. The evidence was mixed with regard to the extent to which interventions seeking to reduce length of stay were associated with cost savings.

Limitations

We only considered assessments of interventions which provided a quantitative estimate of the impact of the given organisational intervention on length of hospital stay. There was a general lack of robust evidence and poor reporting, weakening the conclusions that can be drawn from the review.

Conclusions

The design and implementation of an intervention seeking to reduce (directly or indirectly) the length of stay in hospital should be informed by local context and needs. This involves understanding how the intervention is seeking to change processes and behaviours that are anticipated, based on the available evidence, to achieve desired outcomes (‘theory of change’). It will also involve assessing the organisational structures and processes that will need to be put in place to ensure that staff who are expected to deliver the intervention are appropriately prepared and supported. With regard to future research, greater attention should be given to the theoretical underpinning of the design, implementation and evaluation of interventions or programmes. There is a need for further research using appropriate methodology to assess the effectiveness of different types of interventions in different settings. Different evaluation approaches may be useful, and closer relationships between researchers and NHS organisations would enable more formative evaluation. Full economic costing should be undertaken where possible, including considering the cost implications for the wider local health economy.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Effect of mesh type, surgeon and selected patients' characteristics on the treatment of inguinal hernia with the Lichtenstein technique. Randomized trial

Introduction

Though not entirely free of complications, the Lichtenstein technique is still considered the “gold standard” for inguinal hernia repair due to the low recurrence rate.

Aim

In our study we determined the effect of mesh type, surgeon and selected patients’ characteristics on treatment results. The latter were determined by the frequency of early complications, recovery time and return to normal activities, chronic pain and hernia recurrence.

Material and methods

Tension-free hernia repair with the Lichtenstein technique was performed in 149 male patients aged 20-89 years randomized to two trial groups. One group comprised 76 patients with heavyweight non-absorbable polypropylene mesh (HW group) and the other included 73 patients with lightweight partially absorbable mesh (LW group). The control schedule follow-up took place on the 7^th day as well as in the 3^rd and 6^th month after the operation. Statistical analysis was performed with multi-factor regression models.

Results

In the LW group patients returned to normal activity faster (p = 0.031), experienced less intensive chronic pain (p = 0.01) and expressed higher treatment satisfaction (p = 0.024) than the patients from the HW group. The type of mesh had an insignificant influence on the risk of early complications and hernia recurrence. Statistically significant differences were observed however with regard to surgeon, type and hernia duration, patient's general condition and body mass.

Conclusions

Both types of mesh are equally effective for prevention of hernia recurrence. Lightweight partially absorbable meshes are more beneficial to patients than the heavyweight non-absorbable type. The surgeon and patients’ characteristics have a significant impact on the treatment outcome.

Randomized clinical trial comparing inguinal hernia repair with Lichtenstein technique using non-absorbable or partially absorbable mesh. Preliminary report

INTRODUCTION

The Lichtenstein technique is currently considered the "gold standard" of open, anterior inguinal hernia repair. It is not free, however, of adverse effects, which may be caused by the implemented synthetic material.

AIM

Determination the influence of the mesh employed on treatment results including immediate complications, return to everyday activities, chronic pain occurrence and hernia recurrence.

MATERIAL AND METHODS

Tension-free hernia repair using the Lichtenstein technique was performed in all the 59 patients randomized to trial groups. Group P with heavyweight polypropylene mesh contained 34 patients; group V with lightweight, partially absorbable mesh (polypropylene/polyglactin 910) consisted of 25 people. Controlled, scheduled follow-up appointments took place after the 7(th) day and the 3(rd) and 6(th) month. Patients were clinically assessed and pain intensity was determined on an analogue-visual scale.

RESULTS

No statistically significant influence of the type of mesh on the risk of early complications, severe pain intensity, the length of hospital stay, time of recovery, or patients' satisfaction with treatment was observed. After 6 months also no statistically significant differences were observed between groups with regard to recurrence rate (P 3.4% vs. V 4.0%), chronic pain (P 5.9% vs. V 4.0%) and ailments such as "foreign body presence" (V vs. P, OR = 0.30, 95% CI 0.077-1.219, p = 0.093) incidence, although their probability was 70% lower for V mesh.

CONCLUSIONS

The preliminary results confirm the effectiveness of the Lichtenstein technique for hernia repair with both types of meshes. It appears that use of a partially absorbable mesh is connected with lower risk of postoperative complications, but the final results require multicentre trials in a larger series of patients.

Inguinal hernia repair in overweight and obese patients

Purpose

To describe the clinical characteristics and outcomes after inguinal hernia repair in overweight and obese patients.

Methods

We retrospectively reviewed the medical records of 636 adult patients who underwent mesh plug inguinal hernia repair performed by one surgeon from November 2001 to January 2009.The clinical characteristics and surgical outcomes of the patients were analyzed. According to the body mass index, patients higher than 23 were defined as overweight and obese patient group (O group) and patients between 18.5 and 23 were defined as normal weight patient group (N group). Seventeen underweight patients were excluded in this study.

Results

Of 619 cases, the number for O group was 344 (55.6%) and for N group was 275 (44.4%). The mean age was significantly higher in N group (62.2 ± 12.6 vs. 64.4 ± 14.8, P = 0.048). Underlying diseases were present in 226 (65.7%) of the O group and 191 (69.5%) of the N group (P = 0.322). Anesthesia method, operative time and postoperative hospital stay had no significant difference between the two groups. Postoperative complications developed in 41 (11.9%) of the O group and in 28 (10.2%) of the N group, respectively, and no major complications developed in either group.

Conclusion

Adult inguinal hernias developed at a relatively younger age in overweight and obese patients than in normal weight patients. There were no specific differences in other clinical characteristics and outcomes between the two groups. Therefore inguinal hernia repair in overweight and obese patients is a safe procedure as in normal weight patients.

[Risks related to tobacco use in general and intestinal surgery]

Peri-operative smoking history is an important risk factor, which is often under-appreciated by surgeons. In the first place, tobacco use predisposes patients to specific pathologies, which may require surgical intervention. Secondarily, smoking has been shown to increase surgical risks of mortality, morbidity and length of hospital stay. Of particular importance in general surgery is the increased risk of anastomotic leak with fistula formation, of deep infections, and of abdominal wall complications (infection and ventral hernia). If the patient can stop smoking prior to surgery, there is a concomitant decrease in post-operative complications. Surgeons should be familiar with the pharmacologic and behavioral interventions, which may help the patient with smoking cessation and should not hesitate to defer elective surgery for four to eight weeks so that the patient may have the full benefit of smoking cessation.

Local anesthetic hernia repair in overweight and obese patients

BACKGROUND

Inguinal hernia repair under local anesthesia (LA) has many advantages and is associated with high patient satisfaction. However, there are concerns of exceeding the maximum safe dose of LA agents in overweight and obese patients. The aim of the present study was to establish whether inguinal hernia repair could be safely performed under LA in overweight and obese patients.

METHODS

Patients who underwent elective LA hernia repair under a single consultant surgeon were studied retrospectively. Each patient received the same LA mixture developed at our hospital specifically for hernia repair. The mixture includes lignocaine and bupivocaine, both with adrenaline, made up to a volume of 100 ml with saline. Data were collected by case note review, and by postal and telephone surveys.

RESULTS

A total of 125 patients who underwent LA hernia repair, in whom body mass index (BMI) was measured, were studied. Based on the World Health Organization (WHO) classification, there were 35 (28%) normal weight patients and 63 (72%) overweight (BMI>or=25<30) or obese (BMI>or=30) patients. The median BMI was 27 (range 19-38). The mean volumes of LA mixture used for each group were 58 ml and 62 ml, respectively. High day case rates of 91% and 84% were obtained for the two groups, respectively. Complications included three wound hematomas and three simple wound infections, with no significant differences between groups. One patient developed a recurrent hernia (<1%).

CONCLUSIONS

Local anesthetic inguinal hernia repair in the obese is safe and well tolerated. Use of a large volume local anesthetic mixture is recommended in overweight and obese patients.

Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial

OBJECTIVE

To determine whether an intervention with smoking cessation starting 4 weeks before general and orthopedic surgery would reduce the frequency of postoperative complications.

SUMMARY BACKGROUND DATA

Complications are a major concern after elective surgery and smokers have an increased risk. There is insufficient evidence concerning how the duration of preoperative smoking intervention affects postoperative complications.

METHODS

A randomized controlled trial, conducted between February 2004 and December 2006 at 4 university-affiliated hospitals in the Stockholm region, Sweden. The outcome assessment was blinded. The follow-up period for the primary outcome was 30 days. Eligibility criteria were active daily smokers, aged 18 to 79 years. Of the 238 patients assessed, 76 refused participating, and 117 men and women undergoing surgery for primary hernia repair, laparoscopic cholecystectomy, or a hip or knee prosthesis were enrolled.

INTERVENTION

Smoking cessation therapy with individual counseling and nicotine substitution started 4 weeks before surgery and continued 4 weeks postoperatively. The control group received standard care. The main outcome measure was frequency of any postoperative complication.

RESULTS

An intention-to-treat analysis showed that the overall complication rate in the control group was 41%, and in the intervention group, it was 21% (P = 0.03). Relative risk reduction for the primary outcome of any postoperative complication was 49% and number needed to treat was 5 (95% CI, 3-40). An analysis per protocol showed that abstainers had fewer complications (15%) than those who continued to smoke or only reduced smoking (35%), although this difference was not statistically significant.

CONCLUSION

Perioperative smoking cessation seems to be an effective tool to reduce postoperative complications even if it is introduced as late as 4 weeks before surgery.

Impact of body mass index and tobacco smoking on outcome after open appendicectomy

Background

The effect of body mass index (BMI) and smoking on the risk of perforated appendix and postoperative complications in patients undergoing open appendicectomy for acute appendicitis was studied.

Methods

Record linkage was used to identify 6676 male construction workers who underwent open appendicectomy for acute appendicitis between 1971 and 2004. Multivariable binomial logistic regression analyses were performed.

Results

After adjustment for age, calendar period and BMI, smoking was significantly associated with an increased risk of perforated appendicitis (PA) (P = 0·004). The relative risk was 1·29 (95 per cent confidence interval 1·11 to 1·50) among current smokers with more than 10 pack-years of tobacco use. In patients with non-perforated appendicitis (NPA), the relative risk of overall postoperative complications was significantly associated with BMI (P &lt; 0·001), and was 2·60 (1·71 to 3·95) in obese patients and 1·51 (1·03 to 2·22) in current smokers with more than 10 pack-years of tobacco use. In patients with PA, overweight, obesity and smoking status were not associated with an increased risk of overall postoperative complications.

Conclusion

Perforation due to acute appendicitis was associated with current tobacco smoking. A BMI of 27·5 kg/m2 or more and current smoking were associated with overall postoperative complications in patients with NPA.