Establishment and initial experiences from the Danish Ventral Hernia Database

Long-term outcomes after elective inguinal hernia mesh-repair in patients with inflammatory bowel disease

BACKGROUND

Knowledge of long-term outcomes following elective inguinal hernia mesh-repair in patients with inflammatory bowel disease (IBD) remains limited. Pathophysiological differences between Crohn's disease (CD) and ulcerative colitis (UC) may influence mesh-related complications and recurrence risk. The primary objective was to assess the reoperation risk for mesh-related complications, and secondarily, recurrence after inguinal hernia mesh-repair in patients with CD and UC. The impact of fistulising disease (intra-abdominal/perianal) and surgical technique (open/laparoscopic) on both outcomes was also analysed based on the available data.

METHODS

This nationwide cohort study (2007-2016) followed IBD patients undergoing elective inguinal hernia mesh-repair to assess risks of reoperation for mesh-related complications or recurrence. Risks were estimated using cumulative incidence and Cox regression analyses.

RESULTS

Among 1,072 patients with IBD (CD = 264, UC = 698, IBD-unclassified = 110), the five-year reoperation risk was 0.5% for mesh-related complications and 5.7% for recurrence. Fistulising disease was present in 6.9% (n = 74) of all patients with IBD: perianal in 95% (n = 70) and intra-abdominal in 5% (n = 4). There were too few mesh-related complications (n = 5) to support statistical analysis of this outcome. Recurrence risk was not significantly affected by IBD subtype: CD (reference), UC (HR = 1.67, 95% CI: 0.77-3.64), IBD-U (HR = 0.91, 95% CI: 0.24-3.44), or surgical technique: transabdominal preperitoneal (TAPP) (reference), and Lichtenstein (HR = 0.80, 95% CI: 0.43-1.47).

CONCLUSION

This study suggests that inguinal hernia mesh-repair is also safe among IBD patients regardless of subtype, surgical technique, or perianal fistulation. Similarly, recurrence risk was unaffected by these factors. Limited data prevented conclusions on intra-abdominal fistulising disease as a potential risk-factor for poor surgical outcomes.

Emergency umbilical and epigastric hernia repair: nationwide registry-based study of long-term recurrence, mesh-related, and other complications

BACKGROUND

Emergency umbilical and epigastric hernia repairs (EUEHR) are common but understudied procedures. The role of different mesh positions in emergency settings is a topic of significant interest.

METHODS

A retrospective nationwide Danish cohort study of patients who underwent EUEHR from 2015 to 2020. A complete follow-up was obtained on December 31, 2023, through linkage of nationwide registries and full scrutiny of medical files for those patients who underwent a reoperation. The primary outcome was operation for recurrence. Secondary outcomes were non-recurrence reoperations, early (< 90 days) reoperations, and operations for severe complications. Multivariable analyses were performed using Fine-and-Gray competing risk models.

RESULTS

639 patients were registered in the database, and 70.6% underwent mesh repair (open onlay: 44.1%, open sublay: 15.3%, or laparoscopic intraperitoneal (lap-IPOM): 11.1%. The median follow-up time was 4.3 years. The 5-year risk of operations for recurrence was lower after mesh use compared to suture (n = 6 (1.7%) vs. n = 8 (4.7%); p = 0.023), with a hazard ratio (HR) 0.32 (95% CI (0.11-0,92); p = 0.034). The 5-year risk of operation for other complications was similar between the suture and mesh group (n = 28 (6.2%) vs. n = 9 (4.8%); p = 0.40, HR 1.12 (0.51-2.48; p = 0.77)). Surgical site infection occurred in 1.1%, 4.3%, 2.0%, and 2.8% of suture, onlay, sublay, and Lap-IPOM repairs, respectively. Few complications were directly mesh related: onlay n = 3 (1.1%), sublay n = 2 (2.0%), and Lap-IPOM n = 1 (1.4%). Early (< 90 days) operation for other complications was more frequent after onlay than suture repair (Odds-ratio 2.95 (0.094-12.2): p = 0.066). In sub-group analysis, lap-IPOM showed a trend towards more severe complications than suture repair (HR 7.85 (0.82-75.5); p = 0.074).

CONCLUSION

Mesh repair significantly reduced operation for recurrence after EUEHR compared to suture repair with a similar risk of operation for other complications. Onlay may cause more early reoperations compared to suture repair and lap-IPOM may be associated with more severe complications.

Mesh-related complications and recurrence after incisional hernia repair in patients with fistulizing versus non-fistulizing Crohn's disease

PURPOSE

Patients with Crohn's disease (CD) frequently undergo multiple abdominal operations, which increase the risk of incisional hernia repair (IHR) and associated mesh-related complications. Patients with intra-abdominal fistulizing CD (FCD) may be more susceptible to mesh-related complications than patients with non-fistulizing CD (non-FCD). The primary objective was to evaluate the risk of reoperation due to mesh-related complications after IHR in patients with FCD and non-FCD. Secondarily, the study evaluated the impact of isolated perianal fistulizing CD on mesh-related complications and the difference in hernia recurrence reoperation rates between FCD and non-FCD patients.

METHODS

This nationwide study followed patients from 30 days after their first recorded IHR until reoperation due to mesh-related complications or hernia recurrence. Cumulative incidence proportion and Cox regression analysis were used to estimate the risk of these outcomes.

RESULTS

A total of 334 patients with CD (FCD, n = 55; non-FCD, n = 279) underwent IHR between 2007 and 2016 with a follow-up rate of 100%. FCD patients had a significantly higher 5 year risk of reoperation for mesh-related complications (HR 15.95, 95% CI 4.29-59.35) compared with non-FCD patients. None of the patients with isolated perianal fistulizing disease required a reoperation for mesh-related complications. The overall risk of reoperation for recurrence was 8.7%, and did not vary significantly between FCD and non-FCD patients (HR 1.06, 95% CI 0.44-2.58).

CONCLUSIONS

FCD may be associated with higher rates of mesh-related complications compared with non-FCD, although larger studies are needed to confirm this finding. Conversely, isolated perianal fistulas do not appear to be associated with an increased risk of mesh-related complications. The benefits associated with mesh should be balanced with the risk of long-term mesh-related complications in patients with FCD.

STRONGHOLD first-year results of biomechanically calculated abdominal wall repair: a propensity score matching

PURPOSE

Every year around 70,000 people in Germany suffer from an abdominal incisional hernia that requires surgical treatment. Five years after reconstruction about 25% reoccur. Incisional hernias are usually closed with mesh using various reconstruction techniques, summarized here as standard reconstruction (SR). To improve hernia repair, we established a concept for biomechanically calculated reconstructions (BCR). In the BCR, two formulas enable customized patient care through standardized biomechanical measures. This study aims to compare the clinical outcomes of SR and BCR of incisional hernias after 1 year of follow-up based on the Herniamed registry.

METHODS

SR includes open retromuscular mesh augmented incisional hernia repair according to clinical guidelines. BCR determines the required strength (Critical Resistance to Impacts related to Pressure = CRIP) preoperatively depending on the hernia size. It supports the surgeon in reliably determining the Gained Resistance, based on the mesh-defect-area-ratio, further mesh and suture factors, and the tissue stability. To compare SR and BCR repair outcomes in incisional hernias at 1 year, propensity score matching was performed on 15 variables. Included were 301 patients with BCR surgery and 23,220 with standard repair.

RESULTS

BCR surgeries show a significant reduction in recurrences (1.7% vs. 5.2%, p = 0.0041), pain requiring treatment (4.1% vs. 12.0%, p = 0.001), and pain at rest (6.9% vs. 12.7%, p = 0.033) when comparing matched pairs. Complication rates, complication-related reoperations, and stress-related pain showed no systematic difference.

CONCLUSION

Biomechanically calculated repairs improve patient care. BCR shows a significant reduction in recurrence rates, pain at rest, and pain requiring treatment at 1-year follow-up compared to SR.

Drain Versus No Drain in Open Mesh Repair for Incisional Hernia, Results of a Prospective Randomized Controlled Trial

BACKGROUND

Open mesh repair of incisional hernia is associated with different local complications, particularly bleeding and seroma formation. Traditionally, drains have been placed perioperatively to prevent these complications, despite the lack of scientific evidence or expert consensus. We formulated the hypothesis that the absence of drainage would reduce number of patients presenting collections or complications. The present study aimed to compare postoperative complication rates after open mesh repair for incisional hernia with or without prophylactic wound drainage.

METHODS

Prospective randomized study using standardized surgical technique and drain placement. The primary endpoint was the evaluation of residual fluid collection with ultrasound on postoperative day 30. Other complications, subdivided into medical and surgical, were analyzed as secondary endpoints.

RESULTS

There were 144 patients randomized (70 with drain, 74 without drain). No difference was identified between both groups for fluid collection at 30 days (60.3% vs. 62%, p = 0.844). However, less surgical complications were identified in the drain group (21.7% vs. 42.7%, p = 0.007), with a lower wound dehiscence rate (1.5% vs. 9.3%, p = 0.041).

CONCLUSIONS

Prophylactic drainage in open incisional hernia repair does not objectively reduce the rate of postoperative fluid collections. Therefore, our results do not support the use of routine drainage in incisional hernia repair.

TRIAL REGISTRATION

Trial registration on clinicaltrials.gov (NCT00478348).

Outcomes of parastomal hernia repair after national centralization

BACKGROUND

In 2010, it was decided to centralize parastomal hernia repairs to five specialized hernia centres in Denmark to improve outcomes. The aim of this nationwide cohort study was to evaluate whether centralization of parastomal hernia repairs has had an impact on outcomes. Specifically, readmission, reoperation for complication, and operation for recurrence were analysed before and after centralization.

METHODS

By merging clinical and administrative outcome data from the Danish Hernia Database with those from the Danish National Patient Registry, all patients undergoing parastomal hernia repair in Denmark from 1 January 2007 to 31 December 2018 were included. Centralization was defined as having at least 70 per cent of procedures were performed at one of the five national centres. Readmission, reoperation, and recurrence rates for emergency and elective repairs were evaluated before and after centralization.

RESULTS

In total, 1062 patients were included. Median follow-up was 992 days. Overall, the centralization process took 7 years. For elective repairs, the readmission, reoperation, mortality, and recurrence rates were comparable before and after centralization, but more patients overall and more patients with co-morbidity were offered surgery after centralization. For emergency repairs, there was a significant reduction in rates of reoperation (from 44.9 per cent (48 of 107) to 23 per cent (14 of 62); P = 0.004) and mortality (from 10.3 per cent (11 of 107) to 2 per cent (1 of 62); P = 0.034) after centralization.

CONCLUSION

Centralization led to more elective operations and better outcomes when emergency repair was needed. Centralization of parastomal hernia repair led to more patients receiving elective repair and significantly improved outcomes after emergency repair.

Assessing the Validity and Cover Rate of the National Swedish Hernia Register

Aim

To assess the validity and cover rate of the Swedish hernia register.

Material and Methods

Since the start of the Swedish Hernia register an annual review of randomly selected hospitals has been carried out, and since 2013 in a more standardized form to allow a systematic data collection and evaluation. 10% of all clinics were randomly selected each year in a specific region of Sweden, ensuring a systematic validation of all regions from north to south. Data from 2013 to 2018 were analyzed regarding data quality and from 2014 to 2018 regarding cover rate. All operations registered at the validated clinics were compared with the Swedish Hernia Register to assess cover rate. Fifty operations were randomly selected at each clinic and data in the Swedish Hernia register were compared with the medical records to evaluate data quality.

Results

Fifty-five clinics was evaluated and a total of 73,764 variables were compared with the medical records. Cover rate between 2014 and 2018 was 97%. The proportion of correct variables was 98% between 2013 and 2018. Most frequent errors were ASA score, date at which the patient was put on the waiting list and postoperative complications.

Conclusion

This unique validation of a national hernia register shows a high cover rate and good quality of data. Efforts to maintain and improve national registers are of great importance. Research with data from the Swedish hernia register should be evaluated on the basis of the results presented in this study.

Early outcomes of component separation techniques: an analysis of the Spanish registry of incisional Hernia (EVEREG)

AIM

To analyze the outcomes of component separation techniques (CST) to treat incisional hernias (IH) in a large multicenter cohort of patients.

METHODS

All IH repair using CST, registered in EVEREG from July 2012 to December 2019, were included. Data on the pre-operative patient characteristics and comorbidities, IH characteristics, surgical technique, complications, and recurrence were collected. Outcomes between anterior (ACS) and posterior component separation (PCS) techniques were compared. Risk factors for complications and recurrences were analyzed.

RESULTS

During the study period, 1536 patients underwent CST (45.5% females) with a median age of 64.0 years and median body mass index (BMI) of 29.7 kg/m². ACS was the most common technique (77.7%). Overall complications were frequent in both ACS and PCS techniques (36.5%), with a higher frequency of wound infection (10.6% vs. 7.0%; P = 0.05) and skin necrosis (4.4% vs. 0.1%; P < 0.0001) with the ACS technique. Main factors leading to major complications were mesh explant (OR 1.72; P = 0.001), previous repair (OR 0.75; P = 0.038), morbid obesity (OR 0.67; P = 0.015), ASA grade (OR 0.62; P < 0.0001), COPD (OR 0.52; P < 0.0001), and longitudinal diameter larger than 10 cm (OR 0.58; P = 0.001). After a minimum follow-up of 6 months (median 15 months; N = 590), 59 (10.0%) recurrences were diagnosed. Operations performed in a non-specialized unit were significantly associated with recurrences (HR 4.903, CI 1.64-14.65; P = 0.004).

CONCLUSION

CST is a complex procedure with a high rate of complications. Both ACS and PCS techniques have similar complication and recurrence rates. Operations performed in a specialized unit have better outcomes.

Leveraging a statewide quality collaborative to understand population-level hernia care

BACKGROUND

Although ventral hernia repair (VHR) is extremely common, there is profound variation in operative technique and outcomes. This study describes the results of a statewide registry capturing hernia-specific variables to understand population-level practice patterns.

METHODS

Retrospective analysis of adult patients in a new statewide hernia registry undergoing VHR in 2020.

RESULTS

919 patients underwent VHR across 57 hospitals and 279 surgeons. Hernia width was <2 cm in 233 (25%) patients, 2-5 cm in 420 (46%) patients, 5-10 cm in 171 (19%) patients, and >10 cm in 95 (10%) patients. Mesh was used in 79% of cases and varied in use from 53% of hernias <2 cm to 95% of hernias >10 cm. The most common mesh type was synthetic non-absorbable (46%), followed by synthetic absorbable mesh (37%). The incidence of complications was significantly associated with hernia width.

CONCLUSIONS

A population-level, hernia-specific database captured operative details for 919 patients in 1 year. There was significant variation in mesh use and outcomes based on hernia size. These nuanced data may inform higher quality clinical practice.

Building a national hernia registry in South Africa: initial ventral hernia repair results from a diverse healthcare sector

PURPOSE

The purpose of this paper was to introduce a new registry in a developing country by describing the demographics, management and 30-day outcomes of patients undergoing ventral hernia repair in the public and private healthcare sectors of South Africa.

METHODS

This study was a retrospective review of a prospectively maintained hernia registry from the 1st of February 2019 to 29th of February 2020.

RESULTS

353 ventral hernia repair cases were recorded of which 47% were incisional hernias and the remainder were primary hernias. The median age was 54 years with even distribution of males and females. Half of the patients were obese with a median BMI of 31 kg/m². The private sector performed 190 cases (54%) and the public sector 163 cases (46%). The public sector had more current smokers undergoing elective repairs, 28% vs 15%, p = 0.01 and performed more emergency repair cases, 21% vs 8%, p < 0.01. The majority (89%) of hernias were repaired with mesh and one-third were repaired laparoscopically. 30 day follow up was obtained in 30% of cases, the private sector had better follow up rates (42% vs 14%).

CONCLUSION

Participation in the HIG (SA) registry was low with poor follow up over the first year. Ongoing prospective data capture on the HIG (SA) hernia registry will continue to provide further insights into hernia repair practices in South Africa.

Intraperitoneal Tension-free Repair of a Small Midline Ventral Abdominal Wall Hernia: Randomized Study with a Mean Follow-up of 3 Years

Funding received from Cousin Biotech, Wervicq Sud, France, and CR Bard Inc., Cranston, RI. The aim of this prospective randomized study was to determine the long-term recurrence and complication rates after small abdominal wall hernia repair with two different bilayer prostheses. Hernia repair using prosthetic mesh material has become the preferred method of repair, because the recurrence rates are much lower than with conventional repair techniques. The use of a hernia bilayer patch, composite expanded polytetrafluoroethylene (ePTFE)-polypropylene, with intraperitoneal placement behind the hernia defect, through a small incision, may be efficient, safe, and cost-effective. This study is a randomized, single-institution trial, including 83 selected consecutive patients with primary (umbilical, epigastric) or incisional anterior abdominal wall defects from 2 to 5 cm. Hernia repair was performed by direct local access in ambulatory surgery; the prosthesis used was a circular bilayer with an inner face in ePTFE to avoid bowel adhesion. One group was treated with a Ventralex® Hernia Patch (Bard USA). The second group was treated with a Cabs'Air® Composite (Cousin Biotech France), which was delivered with two to four fixation sutures and a balloon to properly deploy the mesh intraperitoneally. Patients’ characteristics and operative and postoperative data were prospectively collected. The primary outcome was late recurrence. Secondary outcomes included, pain, discomfort and quality of life before and after (3 months) surgery using the SF-12 questionnaire, patient-surgeon satisfaction, and early and late complications. Among 98 patients, 83 were included in the study protocol between January 2007 and August 2011. The two groups were comparable according to pre- and intraoperative data. According to surgeon experience, placement of the Cabs'Air® device was significantly faster ( P = 0.01) and easier. At 3 months, there was significantly less pain and less discomfort for the Cabs'Air® group and patient satisfaction rate was higher. This was confirmed by all components of the SF-12 questionnaire. Long-term follow-up was available for 77 patients. The mean follow-up was similar for the two groups (42 months; range, 14 to 70 months). At this point, for the Ventralex® group, there were four recurrences (11.7%); one mesh infection; one small bowel obstruction; and six cases (15.7%) of severe pain resulting from a mass syndrome (shrinkage) with a sense of the presence of a foreign body. Six reoperations (15.6%) were required with explant of the prosthesis. There were no recurrences or late complications in the comparative group. The Ventralex® Hernia Patch is associated with inconsistent deployment, spreading, or shrinkage, which account for late complications and decreases the overlap, which contributes to the recurrence rate. The Cabs'Air®-associated balloon facilitates superior deployment of the prosthesis allowing for good fixation with four sutures.

Factors influencing harmonized health data collection, sharing and linkage in Denmark and Switzerland: A systematic review

INTRODUCTION

The digitalization of medicine has led to a considerable growth of heterogeneous health datasets, which could improve healthcare research if integrated into the clinical life cycle. This process requires, amongst other things, the harmonization of these datasets, which is a prerequisite to improve their quality, re-usability and interoperability. However, there is a wide range of factors that either hinder or favor the harmonized collection, sharing and linkage of health data.

OBJECTIVE

This systematic review aims to identify barriers and facilitators to health data harmonization-including data sharing and linkage-by a comparative analysis of studies from Denmark and Switzerland.

METHODS

Publications from PubMed, Web of Science, EMBASE and CINAHL involving cross-institutional or cross-border collection, sharing or linkage of health data from Denmark or Switzerland were searched to identify the reported barriers and facilitators to data harmonization.

RESULTS

Of the 345 projects included, 240 were single-country and 105 were multinational studies. Regarding national projects, a Swiss study reported on average more barriers and facilitators than a Danish study. Barriers and facilitators of a technical nature were most frequently reported.

CONCLUSION

This systematic review gathered evidence from Denmark and Switzerland on barriers and facilitators concerning data harmonization, sharing and linkage. Barriers and facilitators were strictly interrelated with the national context where projects were carried out. Structural changes, such as legislation implemented at the national level, were mirrored in the projects. This underlines the impact of national strategies in the field of health data. Our findings also suggest that more openness and clarity in the reporting of both barriers and facilitators to data harmonization constitute a key element to promote the successful management of new projects using health data and the implementation of proper policies in this field. Our study findings are thus meaningful beyond these two countries.

Comparison of hernia registries: the CORE project

INTRODUCTION

The aim of the international CORE project was to explore the databases of the existing hernia registries and compare them in content and outcome variables.

METHODS

The CORE project was initiated with representatives from all established hernia registries (Danish Hernia Database, Swedish Hernia Registry, Herniamed, EuraHS, Club Hernie, EVEREG, AHSQC) in March 2015 in Berlin. The following categories were used to compare the registries: initiation and funding, data collection and use for certification of hernia centers, patient data and data protection, operative data, registration of complications and follow-up data.

RESULTS

The Danish Hernia Database is the only one to qualify as a genuine national registry where participation is compulsory for entry of all procedures by all surgeons performing a hernia operation. All other registries have to be considered as voluntary and completeness of data depends upon the participating hospitals and surgeons. Only the Danish Hernia Database and the Swedish Hernia Registry are publicly funded. All other registries are reliant on financial support from the medical technology industry. As an incentive for voluntary participation in a hernia registry, hospitals or surgeons are issued a certificate confirming that they are taking part in a quality assurance study for hernia surgery. Due to data protection and privacy regulations, most registries are obliged or have chosen to enter their patient data anonymously or coded. The Danish Hernia Database and Swedish Hernia Registry utilize a national personal patient code. In the Herniamed Registry, patient data are saved in a coded and anonymous format after obtaining the patient's informed consent.

CONCLUSION

Despite the differences in the way data are collected for each of the listed hernia registries, the data are indispensable in clinical research.

Risk factors for bad outcomes in incisional hernia repair: Lessons learned from the National Registry of Incisional Hernia (EVEREG)

INTRODUCTION

Registries are powerful tools for identifying factors predicting bad results. Our objective was to analyse data from the Spanish Registry of Incisional Hernia (EVEREG) to detect risk situations for the development of complications and recurrences.

METHODS

We have analysed data of the cohort of hernias registered during the period from July 2012 to June 2014. We have compared the data between complicated and non-complicated patients in the short and long term follow-up. Data compared were: patient demographics, comorbid condition, hernia defect characteristics and surgical technique to determine which of them may be predictors of poor outcomes.

RESULTS

During the period of study, we collected data from 1,336 hernias (43.7% males; 56.3% females) with a mean age of 63.6 years (SD 12.4) and BMI of 30.4 (SD 5.4). In the multivariate analysis, factors associated with complications were: age >70 years, previous neoplasm, diameter greater than 10cm, previous repair and bowel resection. Factors related with recurrences were: parastomal hernia, previous repair, emergency repair, postoperative complications and reoperation. A separation of components was the only protective factor for this type of analysis (OR 0.438; CI 0.27-0.71; p=0.0001).

CONCLUSIONS

Risk factors for the development of complications and recurrences must be considered for promoting preoperative patient prehabilitation, planning the surgical technique and referring patients to specialized abdominal wall units.

Systematic review and network meta-analysis of methods of mesh fixation during laparoscopic ventral hernia repair

BACKGROUND

Ventral hernia repairs are common and have high recurrence rates. They are usually repaired laparoscopically with an intraperitoneal mesh, which can be fixed in various ways. The aim was to evaluate the recurrence rates for the different fixation techniques.

METHODS

This systematic review included studies with human adults with a ventral hernia repaired with an intraperitoneal onlay mesh. The outcome was recurrence at least 6 months after operation. Cohort studies with 50 or more participants and all RCTs were included. PubMed, Embase and the Cochrane Library were searched on 22 September 2016. RCTs were assessed with the Cochrane risk-of-bias assessment tool and cohort studies with the Newcastle-Ottawa scale. Studies comparing fixation techniques were included in a network meta-analysis, which allowed comparison of more than two fixation techniques.

RESULTS

Fifty-one studies with a total of 6553 participants were included. The overall crude recurrence rates with the various fixation techniques were: absorbable tacks, 17·5 per cent (2 treatment groups); absorbable tacks with sutures, 0·7 per cent (3); permanent tacks, 7·7 per cent (20); permanent tacks with sutures, 6·0 per cent (25); and sutures, 1·5 per cent (6). Six studies were included in a network meta-analysis, which favoured fixation with sutures. Although statistical significance was not achieved, there was a 93 per cent chance of sutures being better than one of the other methods.

CONCLUSION

Both crude recurrence rates and the network meta-analysis favoured fixation with sutures during laparoscopic ventral hernia repair.

The Open Abdomen Route by EuraHS: introduction of the data set and initial results of procedures and procedure-related complications

INTRODUCTION

Open abdomen management has become a well-established strategy in the treatment of serious intra-abdominal pathologies. Key objectives are fistula prevention and high fascial closure rates. The current level of evidence on laparostoma is insufficient. This is due to the rareness of laparostomas, the heterogeneity of study cohorts, and broad diversity of techniques. Collecting data in a standardised, multicentre registry is necessary to draw up evidence-based guidelines.

MATERIALS AND METHODS

In order to improve the level of evidence on laparostomy, CAMIN (surgical working group for military and emergency surgery) of DGAV (German Society for General and Visceral Surgery), initiated the implementation of a laparostomy registry. This registry was established as the Open Abdomen Route by EuraHS (European Registry of Abdominal Wall Hernias). Key objectives include collection of data, quality assurance, standardisation of therapeutic concepts and the development of guidelines. Since 1 May 2015, the registry is available as an online database called Open Abdomen Route of EuraHS (European Registry of Abdominal Wall Hernias). It includes 11 categories for data collection, including three scheduled follow-up examinations.

RESULTS

As part of this pilot study, all entries of the first 120 days were analysed, resulting in a review of 82 patients. At 44%, secondary peritonitis was the predominant indication. The mortality rate was 22%. A comparison of methods with and without fascial traction reveals fascial closure rates of 67% and 25%, respectively (intention-to-treat analysis, p < 0.03). Inert visceral protection was used in 67% of patients and achieved a small bowel fistula incidence of only 5.5%.

DISCUSSION

Optimising laparostomy management techniques in order to achieve low incidence of fistulation and high fascial closure rates is possible. The method that ensures the best possible outcome-based on current evidence-would involve fascial traction, visceral protection and negative pressure. The laparostomy registry is a useful tool for quickly generating sufficient evidence for open abdomen treatment.

The Danish Ventral Hernia Database - a valuable tool for quality assessment and research

AIM

The Danish Ventral Hernia Database (DVHD) provides national surveillance of current surgical practice and clinical postoperative outcomes. The intention is to reduce postoperative morbidity and hernia recurrence, evaluate new treatment strategies, and facilitate nationwide implementation of evidence-based treatment strategies. This paper describes the design and purpose of DVHD.

STUDY POPULATION

Adult (≥18 years) patients with a Danish Civil Registration Number and undergoing surgery under elective or emergency conditions for ventral hernia in a Danish surgical department from 2007 and beyond. A total of 80% of all ventral hernia repairs performed in Denmark were reported to the DVHD.

MAIN VARIABLES

Demographic data (age, sex, and center), detailed hernia description (eg, type, size, surgical priority), and technical aspects (open/laparoscopic and mesh related factors) related to the surgical repair are recorded. Data registration is mandatory. Data may be merged with other Danish health registries and information from patient questionnaires or clinical examinations.

DESCRIPTIVE DATA

More than 37,000 operations have been registered. Data have demonstrated high agreement with patient files. The data allow technical proposals for surgical improvement with special emphasis on reduced incidences of postoperative complications, hernia recurrence, and chronic pain.

CONCLUSION

DVHD is a prospective and mandatory registration system for Danish surgeons. It has collected a high number of operations and is an excellent tool for observing changes over time, including adjustment of several confounders. This national database registry has impacted on clinical practice in Denmark and led to a high number of scientific publications in recent years.

Abdominal wall hernias-A local manifestation of systemically impaired quality of the extracellular matrix

BACKGROUND

Throughout life, inguinal hernia develops in approximately every fourth man, some of whom develop multiple hernias. If patients at risk of developing multiple hernias could be identified by a serologic biomarker, treatment might be able to be tailored and improved. Evidence suggests that abdominal wall hernia formation is associated with altered collagen metabolism. The aim of this study was to evaluate biomarkers for type IV and V collagen turnover in patients with multiple hernias and control subjects without hernia.

METHODS

Venous blood was collected from 88 men (mean age, 62 years) with a history of more than 3 hernia repairs and 86, age-matched men without hernias. Biomarkers for synthesis of collagen type IV (P4NP) and type V (P5CP) as well as breakdown (C4M and C5M) were measured in serum by validated, solid-phase, competitive assays. Collagen turnover was indicated by the ratio between the biomarker for synthesis and breakdown.

RESULTS

Type IV collagen turnover was 1.4-fold increased in patients with multiple hernias compared to control subjects (P < .001), whereas type V collagen turnover was 1.7-fold decreased (P < .001). Diagnostic power of P5CP was 0.83 (95%C.I.:0.77-0.89), P < .001.

CONCLUSION

Patients with multiple hernias exhibit increased turnover of type IV collagen and a decreased turnover of type V collagen, demonstrating systemically altered collagen turnover. Biomarkers for type V collagen turnover may be used to identify patients at risk for or with multiple hernias.

Current Status and Challenges of Laparoscopy in Ventral Hernia Repair

Laparoscopic repair of ventral hernias gained strong popularity in the late nineties with some of the early enthusiasm lost later in time. We review the current status and challenges of laparoscopy in ventral hernia repair and best practices in this area. We specifically looked at patient and hernia defect factors, technical considerations that have contributed to the successes, and some of the failures of laparoscopic ventral hernia repair (LVHR). Patients best suited for a laparoscopic repair are those who are obese and diabetic with a total defect size not to exceed 10 cm in width or a "Swiss cheese" defect. Overlap of mesh to healthy fascia of at least 5 cm in every direction, with closure of the defect, is essential to prevent recurrence or bulging over time. Complications specifically related to surgical site occurrence favor the laparoscopic approach. Recurrence rates, satisfaction, and health-related quality of life results are similar to open repairs, but long-term data are lacking. There is still conflicting data regarding ways of fixating the mesh. The science of prosthetic material appropriate for intraperitoneal placement continues to evolve. The field continues to be plagued by single author, single institution, and small nonrandomized observational studies with short-term follow-up. The recent development of large prospective databases might allow for pragmatic and point-of-care studies with long-term follow-up. We conclude that LVHR has evolved since its inception, has overcome many challenges, but still needs better long-term studies to evaluate evolving practices.

Recurrent umbilical or epigastric hernia during and after pregnancy: A nationwide cohort study

BACKGROUND

Umbilical and epigastric (umb/epi) hernia repairs are performed commonly in fertile female patients. Recent studies suggest mesh repair to be superior to suture repair; however, evidence is lacking concerning the optimal treatment of umb/epi hernias in female patients who might wish future pregnancies. The aim of this study was to compare the cumulative recurrence rate after mesh versus suture repair of umb/epi hernia in female patients subsequently becoming pregnant.

METHODS

This retrospective nationwide cohort study included female patients who underwent primary umb/epi hernia repair and subsequently became pregnant between 2007 and 2013. The follow-up began at first day of pregnancy and ended May 2015. Data were obtained from the Danish Ventral Hernia Database, Medical Birth Registry, and National Patient Registry. Patients with recurrence before pregnancy were excluded.

RESULTS

In total, 224 patients were analyzed. The median follow-up was 3.8 years (range 0.1-8.1). The cumulative recurrence rate was 16.3% after mesh repair and 10.9% after suture repair, P = .299. Univariate Cox regression analysis (mesh repair hazard ratio 1.63, 95% confidence interval 0.71-3.72, P = .249) and multivariate analysis adjusted for body mass index and hernia defect size (mesh repair hazard ratio 2.77, confidence interval 0.98-7.85, P = .055) likewise showed no significant difference in the risk of recurrence when we compared mesh and suture repair.

CONCLUSION

Contrary to findings in the general operative patient, mesh repair was not associated with a lesser risk of recurrence compared with suture repair for treatment of umb/epi hernia in female patients with subsequent pregnancy.

Recurrence rate after absorbable tack fixation of mesh in laparoscopic incisional hernia repair

Background

The mesh fixation technique in laparoscopic incisional hernia repair may influence the rates of hernia recurrence and chronic pain. This study investigated the long-term risk of recurrence and chronic pain in patients undergoing laparoscopic incisional hernia repair with either absorbable or non-absorbable tacks for mesh fixation.

Methods

This was a nationwide consecutive cohort study based on data collected prospectively concerning perioperative information and clinical follow-up. Patients undergoing primary, elective, laparoscopic incisional hernia repair with absorbable or non-absorbable tack fixation during a 4-year interval were included. Follow-up was by a structured questionnaire regarding recurrence and chronic pain, supplemented by clinical examination, and CT when indicated. Recurrence was defined as either reoperation for recurrence or clinical/radiological recurrence.

Results

Of 1037 eligible patients, 84·9 per cent responded to the questionnaire, and 816 were included for analysis. The median observation time for the cohort was 40 (range 0–72) months. The cumulative recurrence-free survival rate was 71·5 and 82·0 per cent after absorbable and non-absorbable tack fixation respectively (P = 0·007). In multivariable analysis, the use of absorbable tacks was an independent risk factor for recurrence (hazard ratio 1·53, 95 per cent c.i. 1·11 to 2·09; P = 0·008). The rate of moderate or severe chronic pain was 15·3 and 16·1 per cent after absorbable and non-absorbable tack fixation respectively (P = 0·765).

Conclusion

Absorbable tack fixation of the mesh was associated with a higher risk of recurrence than non-absorbable tacks for laparoscopic mesh repair of incisional hernia, but did not influence chronic pain.

Risk of morbidity, mortality, and recurrence after parastomal hernia repair: a nationwide study

BACKGROUND

Surgical outcome results after repair for parastomal hernia are sparsely reported and based on small-scale studies.

OBJECTIVE

This study aims to analyze surgical risk factors for 30-day reoperation and mortality, and, secondarily, to report the risk of reoperation for recurrence.

DESIGN

This is a retrospective analysis of nationwide perioperative surgical variables. The primary outcome was reoperation for surgical complications and/or mortality within 30 days after parastomal hernia repair. Follow-up was obtained from the Danish National Patient Register. Detailed patient-related data were based on hospital files. Multivariate analysis was based on a compound parameter: 30-day reoperation or death.

SETTING AND PATIENTS

All patients with a parastomal hernia repair registered in the Danish Hernia Database from January 1, 2007 to December 31, 2010 were included.

MAIN OUTCOME MEASURES

Univariate and logistic regression was used to identify risk factors for 30-day reoperation or death.

RESULTS

The study included 174 patients with a parastomal hernia repair (142 elective and 32 emergency repairs; 56 open and 118 laparoscopic repairs). Median follow-up was 20 months (range, 0-47). A total of 13.2% were reoperated because of postoperative complications, and 6.3% of patients died within the first 30 postoperative days. Emergency repair was the strongest risk factor for reoperation or death in multivariate analyses (OR, 7.6; 95% CI, 2.7-21.5). No difference was found in preoperative risk of poor outcome between elective and emergency repairs (Charlson score 4 (range, 0-12) vs 5 (0-11), p = 0.07). After 3 years, the cumulated reoperation rate for recurrence was 10.8% (open 17.2% and laparoscopic 3.8%).

LIMITATIONS

Patients' comorbidity was based on retrospective data, and the study had a relatively short follow-up.

CONCLUSION

In the present nationwide study, repair for a parastomal hernia was associated with high rates of morbidity, mortality, and repair for recurrence. Emergency repair was the only important risk factor to predict poor 30-day postoperative outcome.

Current national practice patterns for inpatient management of ventral abdominal wall hernia in the United States

BACKGROUND

The health-care burden related to ventral hernia management is substantial, with more than 3 billion dollars in expenditures annually in the US. Previous studies have suggested that the utilization of laparoscopic repair remains relatively low although national volume estimates have not been reported. We sought to estimate the inpatient national volume of elective ventral hernia surgery and characterize the proportion of laparoscopic versus open operations.

METHODS

We analyzed data from the Nationwide Inpatient Sample to identify adults with a diagnosis of an umbilical, incisional, or ventral hernia who underwent an elective inpatient repair between 2009 and 2010. Cases that involved other major abdominal or pelvic operations were excluded. Covariates included patient demographics, surgical approach, and use of mesh. National surgical volume estimates were generated and length of stay and total hospital charges were compared for laparoscopic versus open repairs.

RESULTS

A total of 112,070 ventral hernia repairs were included in the analysis: 72.1 % (n = 80,793) were incisional hernia repairs, while umbilical hernia repairs comprised only 6.9 % (n = 7,788). Laparoscopy was utilized in 26.6 % (n = 29,870) of cases. Mesh was placed in 85.8 % (n = 96,265) of cases, including 49.3 % (n = 3,841) of umbilical hernia repairs and 90.1 % (n = 72,973) of incisional hernia repairs. Length of stay and total hospital charges were significantly lower for laparoscopic umbilical, incisional, and "other" ventral hernia repairs (p values all <0.001). Total hospital charges during this 2-year period approached 4 billion dollars ($746 million for laparoscopic repair; $3 billion for open repair).

CONCLUSIONS

Utilization of laparoscopy for elective abdominal wall hernia repair remains relatively low in the US despite its excellent outcomes. Given the substantial financial burden associated with these hernias, future research focused on preventing the development and optimizing the surgical treatment of ventral abdominal wall hernias is warranted.

Direct and recurrent inguinal hernias are associated with ventral hernia repair: a database study

BACKGROUND

A systemically altered connective tissue metabolism has been demonstrated in patients with abdominal wall hernias. The most pronounced connective tissue changes are found in patients with direct or recurrent inguinal hernias as opposed to patients with indirect inguinal hernias. The aim of the present study was to assess whether direct or recurrent inguinal hernias are associated with an elevated rate of ventral hernia surgery.

METHODS

In the nationwide Danish Hernia Database, a cohort of 92,457 patients operated on for inguinal hernias was recorded from January 1998 until June 2010. Eight-hundred forty-three (0.91 %) of these patients underwent a ventral hernia operation between January 2007 and June 2010. A multivariate logistic regression analysis was applied to assess an association between inguinal and ventral hernia repair.

RESULTS

Direct (Odds Ratio [OR] = 1.28 [95 % CI, 1.08-1.51]) and recurrent (OR = 1.76, [95 % CI, 1.39-2.23]) inguinal hernias were significantly associated with ventral hernia repair after adjustment for age, gender, and surgical approach (open or laparoscopic).

CONCLUSIONS

Patients with direct and recurrent inguinal herniation are more prone to ventral hernia repair than patients with indirect inguinal herniation. This is the first study to show that herniogenesis is associated with type of inguinal hernia.

DynaMesh® in the repair of laparoscopic ventral hernia: a prospective trial

PURPOSE

To investigate mesh-related complications in patients undergoing laparoscopic ventral hernia repair using DynaMesh®.

METHODS

In the period 1 January 2005 through 31 December 2010, 181 consecutive patients undergoing laparoscopic ventral hernia repair in our day surgery unit using DynaMesh® were entered prospectively in the National Danish Hernia Database. Data concerning abdominal reoperations after hernia repair were later collected on all 181 patients from the National Danish Health Registry. Postoperative telephone interviews were conducted estimating postoperative pain and patient satisfaction.

RESULTS

Six % (11 patients) were reoperated because of mesh-related complications. Three had small bowel obstruction and one had a colonic fistula with mesh infection, all causing bowel resection and mesh removal. Mesh-related cutaneous fistula was seen in one patient. Six patients had a symptomatic recurrence requiring reoperation. Abdominal wall hematomas were seen in two cases, while two other patients had symptomatic large seromas, of which one was drained surgically. After a median follow-up of 34 months (range 12-63) in 140 patients, 66 % were pain free (0 on the Numeric Rating Scale (NRS)). Of 26 patients with moderate to severe pain (NRS > 3) at follow-up, only 4 regretted the operation. Sixteen patients thought they had a recurrence, of these only 3 regretted the operation.

CONCLUSION

The use of DynaMesh® in laparoscopic ventral hernia repair was associated with a 6 % risk of mesh-related reoperation in a high volume setting. Despite chronic pain in 19 %, after 34 months follow-up patient satisfaction was high.

Nationwide prospective study of outcomes after elective incisional hernia repair

BACKGROUND

Incisional hernia repair is a frequent surgical procedure, but perioperative risk factors and outcomes have not been prospectively assessed in large-scale studies. The aim of this nationwide study was to analyze surgical risk factors for early and late outcomes after incisional hernia repair.

STUDY DESIGN

We conducted a prospective nationwide study on all elective incisional hernia repairs registered in the Danish Ventral Hernia Database between January 1, 2007 and December 31, 2010. Main outcomes measures were surgical risk factors for 30-day readmission, reoperation (excluding recurrence), and mortality after incisional hernia repair. Late outcomes included reoperation for recurrence during the follow-up period. Follow-up was obtained by merging the Danish Ventral Hernia Database with the Danish National Patient Register. Results were evaluated by multivariate analyses.

RESULT

The study included 3,258 incisional hernia repairs. Median follow-up was 21 months (interquartile range 10 to 35 months). The 30-day readmission, reoperation, and mortality rates were 13.3%, 2.2%, and 0.5%, respectively. Advanced age, open repair, large hernia defect, and vertical incision at the primary laparotomy were significant independent risk factors for poor early outcomes (p < 0.05). The cumulated risk of recurrence repair after open and laparoscopic repair was 21.1% and 15.5%, respectively (p = 0.03). Younger age, open repair, hernia defects >7 cm, and onlay or intraperitoneal mesh positioning in open repair were significant risk factors for poor late outcomes (p < 0.05).

CONCLUSIONS

Elective incisional hernia repair were beset with high rates of readmission and reoperation for recurrence. Readmission and reoperation for recurrence were most pronounced after open repair and repair for hernia defects up to 20 cm. Additionally, sublay mesh position reduced the risk of reoperation for recurrence after open repairs.

EuraHS: the development of an international online platform for registration and outcome measurement of ventral abdominal wall hernia repair

BACKGROUND

Although the repair of ventral abdominal wall hernias is one of the most commonly performed operations, many aspects of their treatment are still under debate or poorly studied. In addition, there is a lack of good definitions and classifications that make the evaluation of studies and meta-analyses in this field of surgery difficult.

MATERIALS AND METHODS

Under the auspices of the board of the European Hernia Society and following the previously published classifications on inguinal and on ventral hernias, a working group was formed to create an online platform for registration and outcome measurement of operations for ventral abdominal wall hernias. Development of such a registry involved reaching agreement about clear definitions and classifications on patient variables, surgical procedures and mesh materials used, as well as outcome parameters. The EuraHS working group (European registry for abdominal wall hernias) comprised of a multinational European expert panel with specific interest in abdominal wall hernias. Over five working group meetings, consensus was reached on definitions for the data to be recorded in the registry.

RESULTS

A set of well-described definitions was made. The previously reported EHS classifications of hernias will be used. Risk factors for recurrences and co-morbidities of patients were listed. A new severity of comorbidity score was defined. Post-operative complications were classified according to existing classifications as described for other fields of surgery. A new 3-dimensional numerical quality-of-life score, EuraHS-QoL score, was defined. An online platform is created based on the definitions and classifications, which can be used by individual surgeons, surgical teams or for multicentre studies. A EuraHS website is constructed with easy access to all the definitions, classifications and results from the database.

CONCLUSION

An online platform for registration and outcome measurement of abdominal wall hernia repairs with clear definitions and classifications is offered to the surgical community. It is hoped that this registry could lead to better evidence-based guidelines for treatment of abdominal wall hernias based on hernia variables, patient variables, available hernia repair materials and techniques.

Predictors of mesh explantation after incisional hernia repair

BACKGROUND

Prosthetic mesh used for incisional hernia repair (IHR) reduces hernia recurrence. Mesh infection results in significant morbidity and challenges for subsequent abdominal wall reconstruction. The risk factors that lead to mesh explantation are not well known.

METHODS

This is a multisite cohort study of patients undergoing IHR at 16 Veterans Affairs hospitals from 1998 to 2002.

RESULTS

Of the 1,071 mesh repairs, 55 (5.1%) had subsequent mesh explantation at a median of 7.3 months (interquartile range 1.4-22.2) after IHR with permanent mesh prosthesis. Infection was the most common reason for explantation (69%). No differences were observed by the type of repair. Adjusting for covariates, same-site concomitant surgery (hazard ratio [HR] = 6.3) and postoperative surgical site infection (HR = 6.5) were associated with mesh explantation.

CONCLUSIONS

Patients undergoing IHR with concomitant intra-abdominal procedures have a greater than 6-fold increased hazard of subsequent mesh explantation. Permanent prosthetic mesh should be used with caution in this setting.

Low risk of trocar site hernia repair 12 years after primary laparoscopic surgery

BACKGROUND

The risk of trocar site hernia (TSH) may be 0-22%, but no large scaled data with long-term follow-up are available. The purpose of this study was to estimate the long-term risk of TSH repair.

METHODS

All patients in Denmark who underwent a laparoscopic procedure in 1997 were identified using the Danish National Patient Register and followed during a 12-year period. Hospital records for patients with an incisional or umbilical hernia repair were tracked and manually analyzed for possible relationship between reoperation and the initial laparoscopy.

RESULTS

We included 7,626 patients. During follow-up, we identified 95 patients with TSH repair with a cumulative risk of 1.3% being lowest after minor gynecological procedures and appendectomy and highest after fundoplication, cholecystectomy, and oophorectomy. The TSH was mainly at the umbilicus site (n = 63, 66%), and 15 (16%) of the TSH repairs were performed as an emergency procedure.

CONCLUSIONS

The long-term risk of TSH repair is low, but the risk of an emergency operation for TSH is relatively high, which suggests that all patients with a TSH should be offered elective repair.

A nationwide study on readmission, morbidity, and mortality after umbilical and epigastric hernia repair

BACKGROUND

Repair for umbilical and epigastric hernia is a minor and common surgical procedure. Early outcomes are not well documented.

METHODS

All patients ≥18 years operated on for umbilical or epigastric hernia in Denmark during a 2-year period (2005-2006) were analysed according to hospital stay, risk of readmission, complications, and mortality <30 days after operation. Patients with acute operations and patients having an umbilical and epigastric hernia repair secondary to other surgical procedures were excluded. Results were based on data from the National Patient Registry.

RESULTS

A total 3,431 operations (open repairs 3,165; laparoscopic repairs 266) in 3,383 patients were performed. The median hospital stay was 0 day (range 0-61 days) (open 0 day; laparoscopic 1 day); 75% stayed in hospital for 0 days, 20% for 1 day and 5% > 1 day. Readmissions occurred in 5.3% of cases (open 4.9%; laparoscopic 10.5%). In the majority of patients readmissions were due to wound-related problems (haematoma, bleeding and/or infection) (46%), seroma (19%), or pain (7%). At 30 days, complications and mortality occurred in 4.1% (open 3.7%; laparoscopic 8.2%) and 0.1% (open 0.1%; laparoscopic 0.4%), respectively.

CONCLUSION

This first prospective nationwide study on elective umbilical and epigastric hernia repair found low morbidity and mortality but a high readmission rate mostly because of wound problems, seroma formation, or pain. Future research should focus on early outcomes in terms of wound problems, seroma formation, and pain after umbilical and epigastric hernia repair.