Patient profiles and outcomes following repair of irreducible and reducible Ventral Wall Hernias

Risk factors and outcomes for early returns to the operating room following abdominal wall hernia repairs

Background

Risks of re-operation in ventral hernias in non-American populations and recurrence have been studied extensively. However, data on early risk factors for reoperation in North America are still lacking. The most recent NSQIP study, analyzing risk factors for reoperation of ventral hernias was extracted from 2005-2008 data. Since then, there have been major advances in ventral hernia repair techniques. Here, we identify risk factors and indications for re-operation within 30 days.

Methods

NSQIP ACS data from 2020-2022 were used in our analysis. Additional procedures that posed significant morbidity and mortality were excluded. Risk factors were analyzed with univariate and multivariable models to determine association with re-operation within 30 days. ICD10 codes for re-operation were also analyzed.

Results

Of 56,260 patients, 2.38 % returned to the OR within 30 days. Higher ASA, male gender, surgical site infection (SSI), smoking, ascites, age group > 70, dialysis patients, open surgeries and dehiscence were significantly associated with re-operation whereas outpatient surgery was protective in univariate and multivariable models (p < 0.01). The most common indications for re-operation were surgical site occurrence (SSO) and recurrence of hernia. Mortality was significantly higher in the reoperation group, 3.29 %, compared to those patients that did not require early reoperation (0.36 %, p < 0.01).

Conclusions

Mortality and early reoperation rates have decreased in the past decade in the U.S, which could be attributed to advancement in ventral hernia repair techniques. Our analysis of risk factors for reoperation supports findings in the broader literature. This study also suggests that SSO and recurrence of hernia are leading diagnoses for early reoperation.

Operative time tracking for umbilical hernia patients

BACKGROUND

Army medical treatment facilities (MTFs) use a surgery scheduling system that reviews historical OR times to dictate expected procedural time when posting new cases. At a single military institution there was a noted inflation to umbilical hernia repair (UHR) times that was leading to issues with under-utilized operating rooms.

METHODS

This is a retrospective review determining what variables correlate with longer UHR operative time. Umbilical, ventral, epigastric, and incisional hernia repairs (both open and laparoscopic) were pulled from the local OR scheduling system at Dwight D. Eisenhower Army Medical Center from January 2013 to June 2018.

RESULTS

A total of 442 patients were included in the study with a mean age of 45.74 years and 54.98% male. Patient ASA level (p 0.045), primary vs. mesh repair (p < 0.001), number of hernias repaired (p 0.05), hernia size (p < 0.001), and absence of student nurse anesthetist (SRNA) (p 0.05) all correlated with longer UHR OR times. For the aggregated open hernia repair data, almost all independent variables of interest were statistically significant including age, PGY level, history of DM, case acuity, presence of SRNA, patient ASA level, patient's BMI, hernia defect size, number of hernias, history of prior repair, and history prior abdominal surgery. Multivariate regression analysis was done on the open hernia repair variables with only age and size of hernia being significant.

CONCLUSION

This data were used to create a new case request option (open UHR without mesh and open UHR with mesh) to more effectively utilize available OR time.

Body Mass Index impact on Extended Total Extraperitoneal Ventral Hernia Repair: a comparative study

PURPOSE

Obesity is a risk factor for developing abdominal wall hernias and is associated with major postoperative complications, such as surgical site infection, delayed wound healing and recurrent hernia. Therefore, treating incisional hernia in this patient subgroup is a challenge.

METHODS

We conducted a comparative, prospective study on patients who underwent primary ventral hernia surgery or incisional hernia surgery through the extended totally extraperitoneal pathway, with body mass indices (BMIs) ≤ 30 (no obesity) and BMI > 30 (with obesity). We collected demographic data, preoperative and intraoperative variables, complication and recurrence rate, hospital stay and follow-up as postoperative data.

RESULTS

From May 2018 to December 2020, 74 patients underwent this surgery, 38 patients without obesity and 36 with obesity. The median area of the hernia defect measured by CT was 57 cm² and 93 cm² in patients without and with obesity, respectively (p = 0.012). The median follow-up was 16 months. One patient without obesity experienced some postoperative complication compared with four patients with obesity (p > 0.05). No patient without obesity had recurrent hernia compared with two patients with obesity (p > 0.05).

CONCLUSIONS

There were statistically significant differences between patients with and without obesity in the size of the hernia defect. However, there were no significant differences in terms of complications, hospital stay, postoperative pain or relapses. Therefore, the minimally invasive completely extraperitoneal approach for patients with obesity appears to be a safe procedure despite our study limitations. Studies with longer follow-ups and a greater number of patients are needed.

Component separation and large incisional hernia: predictive factors of recurrence

PURPOSE

To clarify the factors related to recurrence after component separation technique (CST).

MATERIALS AND METHODS

A retrospective study was conducted of 381 patients who underwent CST between May 2006 and May 2017 at a tertiary center. All patients had a transverse hernia defect grade W3 in EHS classification. Recurrence rate was determined by clinical examination plus confirmation by abdominal CT scan.

RESULTS

At a median of 61.6 months of postoperative follow-up, we reported 34 cases of hernia recurrence (8.9%). On multivariate analysis, BMI > 30 (OR 2.20; CI 1.10-3.91, p = 0.031), immunosuppressive drug use (OR 1.06 CI 1.48-2.75, p = 0.003) and development of surgical site infection (OR 2.7; CI 1.53-4.01, p = 0.002) were factors of recurrence after CST. There was no difference in recurrence rate among repairs of primary and recurrent hernias, urgent repair, operative time, type of prosthesis, or concomitant procedures, even planned or unplanned enterotomies.

CONCLUSION

Obesity (BMI > 30), immunosuppressive drug use, and postoperative wound infections were predictors of recurrence after CST.

Development and Implementation of Preoperative Optimization for High-Risk Patients With Abdominal Wall Hernia

IMPORTANCE

Real-world surgical practice often lags behind the best scientific evidence. For example, although optimizing comorbidities such as smoking and morbid obesity before ventral and incisional hernia repair improves outcomes, as many as 25% of these patients have a high-risk characteristic at the time of surgery. Implementation strategies may effectively increase use of evidence-based practice.

OBJECTIVE

To describe current trends in preoperative optimization among patients undergoing ventral hernia repair, identify barriers to optimization, develop interventions to address these barriers, and then pilot these interventions.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study used a retrospective medical record review to identify hospital-level trends in preoperative optimization among patients undergoing ventral and incisional hernia repair. Semistructured interviews with 21 practicing surgeons were conducted to elicit barriers to optimizing high-risk patients before surgery. Next, a task force of experts was convened to develop pragmatic interventions to increase surgeon use of preoperative optimization. Finally, these interventions were piloted at 2 sites to assess acceptability and feasibility. This study was performed from January 1, 2014, to December 31, 2019.

MAIN OUTCOMES AND MEASURES

The main outcome was rate of referrals for preoperative patient optimization at the 2 pilot sites.

RESULTS

Among 23 000 patients undergoing ventral hernia repair, the mean (SD) age was 53.9 (14.3) years, and 12 315 (53.5%) were men. Of these, 8786 patients (38.2%) had at least 1 high-risk characteristic at the time of surgery, including 7683 with 1, 1079 with 2, and 24 with 3. At the hospital level, the mean proportion of patients with at least 1 of 3 high-risk characteristics at the time of surgery was 38.2% (95% CI, 38.1%-38.3%). This proportion varied widely from 21.5% (95% CI, 17.6%-25.5%) to 52.8% (95% CI, 43.9%-61.8%) across hospitals. Interviews with surgeons identified 3 major barriers to improving this practice: lost financial opportunity by not offering a patient an operation, lack of surgeon awareness of available resources for optimization, and organizational barriers. A task force therefore developed 3 interventions: a financial incentive to optimize high-risk patients, an educational intervention to make surgeons aware of available optimization resources, and on-site facilitation. These strategies were piloted at 2 sites where preoperative risk optimization referrals increased 860%.

CONCLUSIONS AND RELEVANCE

This study demonstrates a stepwise process of identifying a practice gap, eliciting barriers that contribute to this gap, using expert consensus and local resources to develop strategies to address these barriers, and piloting these strategies. This implementation strategy can be adopted to diverse settings given that it relies on developing and implementing strategies based on local practice patterns.

Development and Implementation of Preoperative Optimization for High-Risk Patients With Abdominal Wall Hernia

IMPORTANCE

Real-world surgical practice often lags behind the best scientific evidence. For example, although optimizing comorbidities such as smoking and morbid obesity before ventral and incisional hernia repair improves outcomes, as many as 25% of these patients have a high-risk characteristic at the time of surgery. Implementation strategies may effectively increase use of evidence-based practice.

OBJECTIVE

To describe current trends in preoperative optimization among patients undergoing ventral hernia repair, identify barriers to optimization, develop interventions to address these barriers, and then pilot these interventions.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study used a retrospective medical record review to identify hospital-level trends in preoperative optimization among patients undergoing ventral and incisional hernia repair. Semistructured interviews with 21 practicing surgeons were conducted to elicit barriers to optimizing high-risk patients before surgery. Next, a task force of experts was convened to develop pragmatic interventions to increase surgeon use of preoperative optimization. Finally, these interventions were piloted at 2 sites to assess acceptability and feasibility. This study was performed from January 1, 2014, to December 31, 2019.

MAIN OUTCOMES AND MEASURES

The main outcome was rate of referrals for preoperative patient optimization at the 2 pilot sites.

RESULTS

Among 23 000 patients undergoing ventral hernia repair, the mean (SD) age was 53.9 (14.3) years, and 12 315 (53.5%) were men. Of these, 8786 patients (38.2%) had at least 1 high-risk characteristic at the time of surgery, including 7683 with 1, 1079 with 2, and 24 with 3. At the hospital level, the mean proportion of patients with at least 1 of 3 high-risk characteristics at the time of surgery was 38.2% (95% CI, 38.1%-38.3%). This proportion varied widely from 21.5% (95% CI, 17.6%-25.5%) to 52.8% (95% CI, 43.9%-61.8%) across hospitals. Interviews with surgeons identified 3 major barriers to improving this practice: lost financial opportunity by not offering a patient an operation, lack of surgeon awareness of available resources for optimization, and organizational barriers. A task force therefore developed 3 interventions: a financial incentive to optimize high-risk patients, an educational intervention to make surgeons aware of available optimization resources, and on-site facilitation. These strategies were piloted at 2 sites where preoperative risk optimization referrals increased 860%.

CONCLUSIONS AND RELEVANCE

This study demonstrates a stepwise process of identifying a practice gap, eliciting barriers that contribute to this gap, using expert consensus and local resources to develop strategies to address these barriers, and piloting these strategies. This implementation strategy can be adopted to diverse settings given that it relies on developing and implementing strategies based on local practice patterns.

OPEN VS LAPAROSCOPIC HERNIA REPAIR IN THE BRAZILIAN PUBLIC HEALTH SYSTEM. AN 11-YEAR NATIONWIDE POPULATION-BASED STUDY

BACKGROUND

Abdominal wall hernia is one of the most common surgical pathologies. The advent of minimally invasive surgery raised questions about the best technique to be applied, considering the possibility of reducing postoperative pain, a lower rate of complications, and early return to usual activities.

OBJECTIVE

To evaluate the frequency of open and laparoscopic hernioplasties in Brazil from 2008 to 2018, analyzing the rates of urgent and elective surgeries, mortality, costs, and the impact of laparoscopic surgical training on the public health system.

METHODS

Nationwide data from 2008 to 2018 were obtained from the public health registry database (DATASUS) for a descriptive analysis of the selected data and parameters.

RESULTS

2,671,347 hernioplasties were performed in the period, an average of 242,850 surgeries per year (99.4% open, 0.6% laparoscopic). The economically active population (aged 20-59) constituted the dominant group (54.5%). There was a significant reduction (P<0.01) in open surgeries, without a compensatory increase in laparoscopic procedures. 22.3% of surgeries were urgent, with a significant increase in mortality when compared to elective surgeries (P<0.01). The distribution of laparoscopic surgery varied widely, directly associated with the number of digestive surgeons.

CONCLUSION

This study presents nationwide data on hernia repair surgeries in Brazil for the first time. Minimally invasive techniques represent a minor portion of hernioplasties. Urgent surgeries represent a high percentage when compared to other countries, with increased mortality. The data reinforce the need for improvement in the offer of services, specialized training, and equalization in the distribution of procedures in all regions.

Impact of Body Mass Index (BMI) on perioperative outcomes following minimally invasive retromuscular abdominal wall reconstruction: a comparative analysis

BACKGROUND

Morbidity and recurrence rates are higher in obese patients undergoing open abdominal wall reconstruction (AWR). Historically, body mass index (BMI) ≥ 40 has served as a relative contraindication to open AWR. The purpose of this study is to evaluate the impact of minimally invasive surgery (MIS) on outcomes after AWR for higher versus lower BMI patients.

METHODS

A retrospective review of a prospectively maintained database was conducted of all patients who underwent MIS AWR between September 2015 and April 2019 at our institution. Patients were subdivided into two groups based on their BMI: BMI ≤ 35 kg/m² and BMI > 35 kg/m². Patient demographics and perioperative data were evaluated using univariate and multivariate analysis.

RESULTS

461 patients were identified and divided into two groups: BMI ≤ 35 (n = 310) and BMI > 35 (n = 151). The two groups were similar in age (BMI ≤ 35: 56.3 ± 14.1 years vs. BMI > 35: 54.4 ± 11.9, p = .154). BMI > 35 group had more patients with ASA score of 3 (81% vs. 32%, p < .001) and comorbid conditions such as hypertension (70% vs. 45%, p < .001), diabetes mellitus (32% vs. 15%, p < .001), and history of recurrent abdominal wall hernia (34% vs. 23%, p = .008). BMI > 35 group underwent a robotic approach at higher rates (74% vs. 45%, p < .001). Patients who underwent a Rives-Stoppa repair from the higher BMI cohort also had a larger defect size (5.6 ± 2.4 cm vs. 6.7 ± 2.4 cm, p = .004). However, there were no differences in defect size in patients who underwent a transversus abdominus release (BMI ≤ 35: 9.7 ± 4.9 cm vs. BMI > 35: 11.1 ± 4.6 cm, p = .069). Both groups benefited similarly from a short length of stay, similar hospital charges, and lower postoperative complications.

CONCLUSION

Initial findings of our data support the benefits of elective MIS approach to AWR for patients with higher BMI. These patients derive similar benefits, such as faster recovery with low recurrence rates, when compared to lower BMI patients, while avoiding preoperative hernia incarceration, postoperative wound complications, and hernia recurrences. Future follow-up is required to establish long-term perioperative and quality of life outcomes in this patient cohort.

What's New in the Management of Incarcerated Hernia

Management of incarcerated hernias is a common issue facing general surgeons across the USA. When hernias are not able to be reduced, surgeons must make decisions in a short time frame with limited options for patient optimization. In this article, we review assessment and management options for incarcerated ventral and inguinal hernias.