Optimizing patient selection in ventral hernia repair with concurrent panniculectomy: An analysis of 1974 patients from the ACS-NSQIP datasets

Outcomes after Ventral Hernia Repair with Concurrent Panniculectomy: A Large Database Review

BACKGROUND

Patients with large pannus and ventral hernias may benefit from undergoing panniculectomy performed concurrently with open ventral hernia repair (VHR-PAN). However, there have been concerns related to increased surgical site occurrences (SSOs) when adding a panniculectomy. This study aimed to evaluate outcomes of open VHR with and without panniculectomy using a large hernia-specific database.

STUDY DESIGN

The Abdominal Core Health Quality Collective database was queried from 2012 to 2023 for patients who underwent VHR-only vs VHR-PAN. Patient and surgical characteristics were described and compared. Short-term outcomes including surgical site infection, SSO, and SSO requiring procedural intervention were compared. Patient-reported outcomes and hernia recurrence were compared at 1 year. Logistic regression was used to identify risks associated with the above outcomes.

RESULTS

A total of 28,140 patients underwent open VHR, with panniculectomy data (yes or no) available for 2,108 patients, including 870 who underwent VHR-PAN. Patients who underwent VHR-PAN were more likely to be female (78.3% vs 64.8%, p < 0.0001), have a BMI greater than 40 (21.0% vs 7.8%, p < 0.0001), and have a larger median hernia width (10.0 [7.0 to 15.0] vs 8.0 [3.0 to 13.0], p < 0.0001). In a matched analysis, there was no significant difference in surgical site infection, SSO, SSO requiring procedural intervention, or 1-year hernia recurrences rates in the VHR-PAN group (p < 0.05).

CONCLUSIONS

This study demonstrated that VHR with concurrent panniculectomy is not significantly associated with an increased risk of complications. Concurrent panniculectomy can be considered for selected patients needing VHR.

Primary ventral and incisional hernias: comprehensive review

BACKGROUND

Primary ventral and incisional hernias are frequent conditions that impact the quality of life of patients. Surgical techniques for ventral hernia repair are constantly evolving and abdominal wall surgery has turned into a highly specialized field.

METHODS

This is a narrative review of the most recent and relevant literature on the treatment of primary ventral and incisional hernias performed by eight experts in ventral hernia surgery from across the world and includes review of classification systems, preoperative measures, descriptions of surgical techniques, and postoperative complications.

RESULTS

Repairs of primary ventral and incisional hernias range from simple open procedures in healthy patients with small defects to complex procedures when patients are co-morbid and have large defects. Optimizing patient-related risk factors before surgery is important to decrease complication rates. Surgical repair techniques from open repairs to minimally invasive procedures are described in detail in the review. Minimally invasive techniques are technically more demanding and take longer, but decrease the risk of surgical-site infections and shorten the duration of hospital stay.

CONCLUSION

Treatment of ventral hernias aims to improve the quality of life of patients. The risks and benefits of procedures should be weighed against patients' complaints and co-morbidities. Optimizing patient-related risk factors before surgery is important.

A Ventral Hernia Management Pathway; A "Getting It Right First Time" approach to Complex Abdominal Wall Reconstruction

INTRODUCTION

Abdominal wall reconstruction (AWR) is an emerging specialty, involving complex multi-stage operations in patients with high medical and surgical risk. At our hospital, we have developed a growing interest in AWR, with a commitment to improving outcomes through a regular complex hernia MDT. An MDT approach to these patients is increasingly recognized as the path forward in management to optimize patients and improve outcomes.

METHODS

We conducted a literature review and combined this with our experiential knowledge of managing these cases to create a pathway for the management of our abdominal wall patients. This was done under the auspices of GIRFT (Getting It Right First Time) as a quality improvement project at our hospital.

RESULTS

We describe, in detail, our current AWR pathway, including the checklists and information documents we use with a stepwise evidence and experience-based approach to identifying the multiple factors associated with good outcomes. We explore the current literature and discuss our best practice pathway.

CONCLUSION

In this emerging specialty, there is limited guidance on the management of these patients. Our pathway, the "Complex Hernia Bundle," currently provides guidance for our abdominal wall team and may well be one that could be adopted/adapted by other centers where challenging hernia cases are undertaken.

Comparative Analysis of Ventral Hernia Repair and Transverse Abdominis Release With and Without Panniculectomy: A 4-Year Match-Pair Analysis

INTRODUCTION

Amid rising obesity, concurrent ventral hernia repair and panniculectomy procedures are increasing. Long-term outcomes of transverse abdominis release (TAR) combined with panniculectomy remain understudied. This study compares clinical outcomes and quality of life (QoL) after TAR, with or without panniculectomy.

METHODS

A single-center retrospective review from 2016 to 2022 evaluated patients undergoing TAR with and without panniculectomy. Propensity-scored matching was based on age, body mass index, ASA, and ventral hernia working group. Patients with parastomal hernias were excluded. Patient/operative characteristics, postoperative outcomes, and QoL were analyzed.

RESULTS

Fifty subjects were identified (25 per group) with a median follow-up of 48.8 months (interquartile range, 43-69.7 months). The median age and body mass index were 57 years (47-64 years) and 31.8 kg/m2 (28-36 kg/m2), respectively. The average hernia defect size was 354.5 cm2 ± 188.5 cm2. There were no significant differences in hernia recurrence, emergency visits, readmissions, or reoperations between groups. However, ventral hernia repair with TAR and panniculectomy demonstrated a significant increase in delayed healing (44% vs 4%, P < 0.05) and seromas (24% vs 4%, P < 0.05). Postoperative QoL improved significantly in both groups (P < 0.005) across multiple domains, which continued throughout the 4-year follow-up period. There were no significant differences in QoL among ventral hernia working group, wound class, surgical site occurrences, or surgical site occurrences requiring intervention (P > 0.05). Patients with concurrent panniculectomy demonstrated a significantly greater percentage change in overall scores and appearance scores.

CONCLUSIONS

Ventral hernia repair with TAR and panniculectomy can be performed safely with low recurrence and complication rates at long-term follow-up. Despite increased short-term postoperative complications, patients have a significantly greater improvement in disease specific QoL.

A Procedure and Complication-Specific Assessment of Smoking in Aesthetic Surgery: A Systematic Review and Meta-Analysis

Background: The popularity of aesthetic surgery is on the rise, as is patients' expectations towards excellent surgical results. In order to meet these expectations, risk factors that hinder desired outcomes, such as smoking, need to be identified and addressed. To that end, the present study summarizes an updated systematic review focused on the effects of smoking on cosmetic surgical procedures and outcomes. Methods: A systematic review of studies comparing aesthetic surgical outcomes by procedure, between tobacco smokers and non-smokers was carried out, querying PubMed, Embase and the Cochrane databases. Data regarding surgical outcomes were extracted and meta-analyzed by a random effects model in conjunction with the Mantel-Haenszel statistical method. Results: Eighty-two studies were included in the final synthesis. Abdominoplasty/panniculectomy (n = 19 cohorts) and breast reduction (n = 27 cohorts) were the most common types of procedures included in this review. Other than mastopexy and rhinoplasty, smoking conferred a statistically significant increased risk of overall complications for all studied aesthetic procedures. Conclusions: The data demonstrates that smoking is a clear risk factor for the vast majority of aesthetic plastic surgeries studied. Although our meta-analysis suggests that smoking is not a risk factor for complications in mastopexies and rhinoplasties, these two specific analyses may have been biased, and should therefore be re-evaluated with future additional evidence. The results of this systematic review confirm the importance of smoking cessation and education relative to the outcomes of common cosmetic surgical procedures.

Evaluating Outcomes and Weight Loss After Panniculectomy

OBJECTIVE

The objective of this study was to evaluate long-term outcomes and weight loss after panniculectomy.

METHODS

A retrospective chart review study was performed on 225 consecutive patients who had undergone panniculectomy from 2002 and 2020. Demographic variables including smoking status, medical comorbidities, and prior history of weight loss/bariatric surgery were collected for 173 patients. Preoperative and postoperative body mass index (BMI) were calculated in addition to postoperative outcomes.

RESULTS

The study population was 85% female with a mean age of 57 years and an average follow-up of 3.9 years. Relevant comorbidities included obesity (88%), hypertension (65%), diabetes (37%), and smoking (8%), and the majority (53%) of patients had undergone prior bariatric surgery. The overall complication rate was 40%. Twenty percent of patients required reoperation or readmission, and 20% had minor complications addressed in an outpatient setting. Patients who had higher preoperative BMI experienced a significant long-term reduction in BMI. In addition, patients who did not undergo prior bariatric surgery tended to lose weight more often and by larger amounts than patients who had prior bariatric surgery (71.6% vs 57.6, P = 0.023). Complications were not uncommon and included infection (17%), delayed wound healing (16%), seroma (8%), and hematoma (3%). Patients who had prior bariatric surgery were at reduced risk of any complication (P = 0.012). Smoking increased the incidence of infection (38.5% of smokers vs 15.6% of nonsmokers, P = 0.039). Concomitant hernia repair increased the risk of overall complications (64.3% vs 35.9%, P = 0.003) and delayed wound healing (39.2% vs 11.7%, P < 0.001). In the subgroup of patients who did not lose weight, a panniculus weight greater than 5 kg was associated with an increased complication rate (61.5% vs 27%, P = 0.03).

CONCLUSIONS

Patients who underwent a panniculectomy tended to lose weight postoperatively, particularly those who had not undergone previous bariatric surgery. Complications were not uncommon, especially in patients with a smoking history. Prior bariatric surgery patients had a significant decrease in postoperative complications but tended to lose less weight after panniculectomy than those without prior bariatric surgery. Concomitant hernia repair put patients at an increased risk of complications.

Panniculectomy: Practical Pearls and Pitfalls

Panniculectomy is an increasingly common operation, given the current obesity epidemic and the increasing prevalence of bariatric surgery. At first glance, it could be considered a technically simple operation; however, this procedure can be fraught with complications, given the patient population and high demands placed on compromised abdominal tissue. Sufficient attention must be given to the nuances of patient optimization and surgical planning to maximize safe and ideal outcomes. We highlight our practical tips when performing standard or massive panniculectomy for preoperative optimization, intraoperative techniques, and postoperative management to reduce complication and maximize outcomes of this procedure from a surgeon's and a patient's perspective.

Concurrent Ventral Hernia Repair Is Effective in Patients Undergoing Abdominally Based Microsurgical Breast Reconstruction

Background The abdomen remains the most preferable donor site for autologous breast reconstruction. Many patients in this population will have had prior abdominal surgery, which is the chief risk factor for having a ventral hernia. While prior studies have examined the impact of prior abdominal surgery on breast reconstruction, limited data exist on the management of patients with a preexisting ventral hernia. The objective of this study was to investigate outcomes of performing ventral hernia repair concurrent with abdominally based microsurgical breast reconstruction.

Methods A 5-year retrospective review of patients undergoing abdominally based microsurgical breast reconstruction was performed. The experimental group consisted of patients with a preexisting ventral hernia that was repaired at the time of breast reconstruction, and was compared with a historical cohort of patients without preexisting hernias.

Results There were a total of 18 and 225 patients in the experimental and control groups, respectively. There was a higher incidence of prior abdominal surgery in the experimental group (p = 0.0008), but no other differences. Mean follow-up was 20.5 ± 5.2 months. There were no instances of recurrent hernia or flap loss in the experimental group. No significant differences were observed between the experimental and control groups in the incidence of donor-site complications (27.8 vs. 20.9%, respectively; p = 0.55), recipient site complications (27.8 vs. 24.0%, respectively; p = 0.78), operative time (623 ± 114 vs. 598 ± 100 minutes, respectively; p = 0.80), or length of stay (3.4 ± 0.5 vs. 3.1 ± 0.4 days, respectively; p = 0.98).

Conclusion Concurrent ventral hernia repair at the time of abdominally based microsurgical breast reconstruction appears to be safe and effective. Larger studies are needed to further define this relationship.

Expectant Management of Patients with Ventral Hernias: 3 Years of Follow-up

BACKGROUND

The safety and effectiveness of expectant management (e.g., watchful waiting or initially managing non-operatively) for patients with a ventral hernia is unknown. We report our 3-year results of a prospective cohort of patients with ventral hernias who underwent expectant management.

METHODS

A hernia clinic at an academic safety-net hospital was used to recruit patients. Any patient undergoing expectant management with symptoms and high-risk comorbidities, as determined by a surgeon based on institutional criteria, would be included in the study. Patients unlikely to complete follow-up assessments were excluded from the study. Patient-reported outcomes were collected by phone and mailed surveys. A modified activities assessment scale normalized to a 1-100 scale was used to measure results. The rate of operative repair was the primary outcome, while secondary outcomes include rate of emergency room (ER) visits and both emergent and elective hernia repairs.

RESULTS

Among 128 patients initially enrolled, 84 (65.6%) completed the follow-up at a median (interquartile range) of 34.1 (31, 36.2) months. Overall, 28 (33.3%) patients visited the ER at least once because of their hernia and 31 (36.9%) patients underwent operative management. Seven patients (8.3%) required emergent operative repair. There was no significant change in quality of life for those managed non-operatively; however, substantial improvements in quality of life were observed for patients who underwent operative management.

CONCLUSIONS

Expectant management is an effective strategy for patients with ventral hernias and significant comorbid medical conditions. Since the short-term risk of needing emergency hernia repair is moderate, there could be a safe period of time for preoperative optimization and risk-reduction for patients deemed high risk.

Management of Incidental Hernia Discovered During Abdominal Contouring in Post-Bariatric Surgery Patients

PURPOSE

An increase in bariatric surgery has led to a rise in postbariatric contouring procedures. Despite a comprehensive preoperative assessment, body habitus in these patients may significantly limit the abdominal exam. Abdominal contouring procedures typically elevate large portions of the skin and fat off the abdominal wall, and unexpected hernia may be discovered intraoperatively. No study to date has characterized such hernia discovery at the time of body contouring surgery. We reviewed our experience of management of incidental hernia found during abdominoplasty or panniculectomy after laparoscopic bariatric surgery.

METHODS

Records of all post-bariatric surgery patients undergoing abdominal contouring procedures between 2007 and 2017 were reviewed to identify patients with incidental hernias discovered intraoperatively. These patients were further examined by reviewing operative details, patient-specific factors, and outcomes.

RESULTS

Six hundred eighty-one post-bariatric surgery patients underwent abdominal body contouring procedures with incidental ventral hernia discovered in 36 patients (5.3% [45 hernias]). At the time of plastic surgery, average age was 49 years (range, 25-64 years), and body mass index was 30.7 kg/m (range 25-43 kg/m). Of 36 patients with incidental hernia, 26 patients (72.2%) had a single hernia, and the remainder had multiple (27.8%). Mean hernia size was 4.1 cm (range, 0.25-24 cm). Most hernias were located paraumbilical/umbilical (46.7%) or epigastric (37.8%). Ninety-eight percent of hernias were repaired primarily (n = 44) by the plastic surgeon, and in 1 case (2%), mesh repair was performed by a consulting general surgeon. Average follow-up was 1.9 ± 0.3 years. Only 1 patient (2.8%) developed hernia recurrence after 48 months. Other postoperative complications included superficial wound healing problems (19.4%), seroma (16.7%), suture abscess (5.6%), and cellulitis that resolved with antibiotics (5.6%).

CONCLUSIONS

This is the first study to characterize incidental hernia discovered at the time of body contouring in the post-bariatric surgery patient. The body contouring surgeon should be aware of this common finding. Hernias typically discovered during panniculectomy or abdominoplasty arise in umbilical or epigastric regions, likely from prior laparoscopic port sites, and can be safely repaired by the plastic surgeon with low overall complication rates.

Panniculectomy at the time of living donor renal transplantation: An 8-year experience

Panniculectomy can be performed as a prophylactic procedure preceding transplantation to enable obese patients to meet criteria for renal transplantation. No literature exists on combined renal transplant and panniculectomy surgery (LRT-PAN). We describe our 8-year experience performing LRT-PAN. A retrospective chart review of all patients who had undergone LRT-PAN from 2010 to 2018 was conducted. Data were collected on patient demographics, allograft survival and function, and postoperative course. Fifty-eight patients underwent LRT-PAN. All grafts survived, with acceptable function at 1 year. Median length of stay was 4 days with a mean operative duration of 363 minutes. The wound complication rate was 24%. Ninety-day readmission rate was 52%, with medical causes as the most common reason for readmission (45%), followed by wound (32%) and graft-related complications (23%). Body mass index, diabetes status, and previous immunosuppression did not influence wound complication rate or readmission (P = .7720, P = .0818, and P = .4830, respectively). Combining living donor renal transplant and panniculectomy using a multidisciplinary team may improve access to transplantation, particularly for the obese and postobese population. This combined approach yielded shorter-than-expected hospital stays and similar wound complication rates, and thus should be considered for patients in whom transplantation might otherwise be withheld on the basis of obesity.

Outcomes of Ventral Hernia Repair With Concomitant Panniculectomy

PURPOSE

Combined ventral hernia repair and panniculectomy (VHR/PAN) is controversial, and the safety profile including anticipated complications has been questioned. We present a retrospective case series review of patients from the University of Maryland Medical Center to help surgeons counsel patients on the risks and benefits of this procedure.

METHODS

A retrospective database was collected using current procedural terminology codes for VHR/PAN. The patient-specific variables that were studied include the following: sex, body mass index (BMI), smoking, diabetes, chronic obstructive pulmonary disease, cirrhosis, immunosuppression, length of operation, acute incarcerated hernias, hernia size and location, mesh size and location, pannus weight, concomitant component separation, use of negative-pressure wound therapy, intestinal violation, follow-up duration, ventral hernia working group, history of bariatric surgery, previous hernia repair, skin dehiscence, skin necrosis, chronic wound, surgical site infection, seroma, hematoma, fascial dehiscence, hernia recurrence, unplanned return to operating room, and medical complication. Both univariate and multivariate analyses were performed to determine which factors affected the complication outcomes.

RESULTS

There were 106 patients with an average age and BMI of 53 years and 39, respectively. Fifty-eight patients (54.72%) had at least 1 surgical site occurrence. Twenty-three patients (21.70%) had at least 1 repair failure. Twenty-eight patients (26.42%) had an unplanned trip back to the operating room. Seventeen patients (16.04%) had at least 1 medical complication.

CONCLUSIONS

The risk factors associated with developing complications are higher BMI, longer operating time, larger mesh size, larger hernia size, component separation, use of biologic mesh, chronic obstructive pulmonary disease, and intestinal violation. The use of negative-pressure wound therapy decreased complication rates, and patients with a previous hernia repair seemed to benefit the most from having a combined VHR/PAN. However, when compared with previous reports of VHR alone, VHR/PAN does seem to increase wound complications and reoperation rates.

Single-Institution Experience With Component Separation for Ventral Hernia Repair: A Retrospective Review

PURPOSE

In this study, we reviewed our institution's experience using component separation for repair of ventral hernias.

METHODS

This was a retrospective review of all component separations for ventral hernia between July 2009 and December 2015. Recorded data included body mass index (BMI), preoperative albumin, smoking history, comorbidities, additional procedures, length of surgery, hospitalization, recurrence, and postoperative complications.

RESULTS

One hundred ninety-six component separations were performed in the study period. The average patient age was 56 years, and 65.3% of patients were female. The average BMI was 32.6 kg/m; preoperative albumin was 3.59; 18.4% were current smokers; 28.1% were diabetic; and 14.3% had heart disease. Postoperative complications developed in 16.8% of patients. Recurrence developed in 8.7% of patients. Patients who developed a postoperative complication had a higher BMI (P = 0.025) and lower albumin (P = 0.047) compared with patients who did not develop complications. Current smokers were more likely to develop complications (P = 0.008). More than one third of patients had additional procedures at the time of the ventral hernia repair. The addition of a plastic surgery procedure was not associated with an increased risk of developing a complication (P = 0.25). Patients who developed complications had a significantly longer hospital course (P < 0.001) but no difference in total operative time (P = 0.975). Increased number of comorbidities did not statistically correlate with an increased complication rate (P = 0.65) or length of hospital stay (P = 0.43).

CONCLUSIONS

We identified risk factors that increase the likelihood of postoperative complications and length of hospital stay. In addition, this study suggests that more comorbidities and additional procedures at the time of the hernia repair may not have as large of impact on complication risk as previously thought.

Panniculectomy after bariatric surgical weight loss: Analysis of complications and modifiable risk factors

INTRODUCTION

Bariatric surgery results in massive weight loss, leaving many patients with redundant skin that can cause significant physical and psychosocial limitations. We sought to identify variables associated with postoperative complications and adjuncts associated with the mitigation of postoperative complications.

METHODS

A retrospective review was performed of all post-bariatric surgery patients who underwent panniculectomy over a 10-year period.

RESULTS

Total 706 patients included. Overall complication rate was 56%: dehiscence (24%), surgical site infection (22%), seroma (18%), and post-operative bleeding (5%). Return to operating room rate was 12%. Significant factors were: BMI >26 (p < 0.01), fleur-de-lis panniculectomy (p < 0.01), concomitant hernia repair (p < 0.01). Multivariate regression analysis demonstrated ASA class >2 (OR 1.97, p < 0.05) and incision type (OR 1.64, p < 0.05) to be independent predictors of morbidity.

CONCLUSION

High morbidity for post-bariatric panniculectomy is primarily local wound complications. Potentially modifiable factors that increase the complication risk profile include higher BMI, higher ASA class, and the use of fleur-de-lis incision.

Comparison of Surgeon Specialty in Open Ventral Hernia Repair

BACKGROUND

Ventral hernia repair is a common procedure and is undertaken by surgeons with varying training backgrounds. Outcomes after hernia repair depend on numerous factors, some being patient or surgeon specific. It remains unclear what the ideal roles are for general and plastic surgeons in open ventral hernia repair. We hypothesized that open ventral hernia repair by plastic surgeons is safe and comparable with general surgeons.

METHODS

We performed a retrospective observational study using data from the National Surgical Quality Improvement Program database from 2007 to 2013. Patients with a primary diagnosis of ventral hernia undergoing open repair were identified. Multivariate regression modeling was performed, adjusting for surgeon specialty, patient characteristics, common concurrent procedures, and the total number of concurrent procedures. Outcomes studied were major and minor 30-day complications, operation time, readmission, unplanned reoperation, and length of hospital stay.

RESULTS

We identified 53,746 patients who underwent open repair, 53,282 (99.1%) by general surgeons (GS) and 464 (0.9%) by plastic surgeons (PS). There were significantly different rates of concurrent panniculectomy (12.1% PS vs 2.4% GS) and component separation (24.8% PS vs 5.3% GS), representing increased PS case complexity. 52.3% of GS and 92.9% of PS performed panniculectomy without an alternate specialty surgeon. 81.3% of GS and 97.4% of PS performed component separation without an alternate specialty surgeon. The PS patients had a significantly longer uncorrected length of stay and operation time than GS patients (all P < 0.001). Similarly, PS was positively associated with uncorrected major and minor complications (P < 0.001). However, these relationships did not persist on multivariate analysis after adjusting for demographic characteristics, medical comorbidities, concurrent procedures, and total procedure load. Furthermore, PS was associated with lower odds of major complications (operating room, 0.49; P = 0.05) compared with GS.

CONCLUSIONS

Outcomes of hernia repair by plastic surgeons are comparable with general surgeons, despite plastic surgeons being involved in many complex cases. Interestingly, we identified that general surgeons are performing adjunctive procedures to ventral hernia previously handled by plastic surgeons. Although further study is warranted, we conclude that for open ventral hernia repair, plastic surgeons provide a comparable alternative to general surgeons.

Using Crowdsourcing as a Platform to Evaluate Lay Perception of Prophylactic Mesh Placement

BACKGROUND

Prophylactic mesh placement (PMP) at the time of open abdominal surgery has gained momentum over the last decade. However, there remains an identifiable gap in the literature regarding patient-reported outcomes and qualitative metrics. In effort to gauge the population's understanding or familiarity with PMP, this study provides an educational framework and uses crowdsourcing as a novel means to assess perception among the general population.

METHODS

A cross-sectional survey study was conducted among the general public to elicit perspectives on PMP. An online crowdsourcing platform was used to capture responses to a questionnaire. Pearson's correlation coefficients, paired t-test, chi-square test, and Fisher's exact tests were performed.

RESULTS

Of 433 respondents, 338 (78.1%) were included. Individuals who had previously undergone surgery and those who had prior hernia repair were more likely to choose PMP than surgically naïve patients (P = 0.06).

CONCLUSIONS

The majority of respondents support the use of PMP. This study contributes to the existing body of literature on PMP and serves as the first qualitative description to gauge the population's perception and understanding of this surgical technique. Within the evolving health care landscape, understanding quality-of-life measures have become increasingly important in defining successful surgical outcomes. Although the data-driven level-I evidence supports the clinical use of PMP, this study intends to establish a framework for future patient-reported outcome studies.

Concomitant Panniculectomy Affects Wound Morbidity but Not Hernia Recurrence Rates in Abdominal Wall Reconstruction: A Propensity Score Analysis

BACKGROUND

Studies of abdominal wall reconstruction with concurrent panniculectomy have reported contradictory results. The authors hypothesized that patients undergoing abdominal wall reconstruction with concurrent panniculectomy experience more wound healing complications but similar rates of hernia recurrence compared with abdominal wall reconstruction alone.

METHODS

Of 548 consecutive patients, 305 patients (55.7 percent) underwent abdominal wall reconstruction alone and 243 (44.3 percent) underwent abdominal wall reconstruction with concurrent panniculectomy. Mean follow-up was 30 months. The authors compared these two groups' postoperative complications and outcomes before and after propensity score analysis.

RESULTS

Abdominal wall reconstruction with concurrent panniculectomy patients had a significantly higher overall complication rate (38.3 percent versus 29.2 percent; p = 0.025) and a trend toward a higher surgical-site occurrence rate (27.6 percent versus 20.7 percent; p = 0.06) compared with abdominal wall reconstruction alone. There were significantly higher incidences of skin dehiscence (19.3 percent versus 12.5 percent; p = 0.032), fat necrosis (10.7 percent versus 3.6 percent; p = 0.002), and infection abscess (9.5 percent versus 4.3 percent; p = 0.023) but no significant difference in hernia recurrence (6.9 percent versus 11.5 percent; p = 0.27) at long-term follow-up. Propensity score analysis yielded 188 pairs of matched patients with no significant differences in overall complication and hernia recurrence rates. Significantly higher rates of fat necrosis (9.6 percent versus 4.3 percent; p = 0.041) and abscess (10.1 percent versus 3.2 percent; p = 0.007) were observed in the abdominal wall reconstruction with concurrent panniculectomy group.

CONCLUSIONS

Abdominal wall reconstruction with concurrent panniculectomy is associated with higher wound morbidity but similar surgical-site occurrence and hernia recurrence rates at long-term follow-up. The authors believe that panniculectomy can be safely performed when indicated.

Ventral Hernia Management: Expert Consensus Guided by Systematic Review

OBJECTIVE

To achieve consensus on the best practices in the management of ventral hernias (VH).

BACKGROUND

Management patterns for VH are heterogeneous, often with little supporting evidence or correlation with existing evidence.

METHODS

A systematic review identified the highest level of evidence available for each topic. A panel of expert hernia-surgeons was assembled. Email questionnaires, evidence review, panel discussion, and iterative voting was performed. Consensus was when all experts agreed on a management strategy.

RESULTS

Experts agreed that complications with VH repair (VHR) increase in obese patients (grade A), current smokers (grade A), and patients with glycosylated hemoglobin (HbA1C) ≥ 6.5% (grade B). Elective VHR was not recommended for patients with BMI ≥ 50 kg/m (grade C), current smokers (grade A), or patients with HbA1C ≥ 8.0% (grade B). Patients with BMI= 30-50 kg/m or HbA1C = 6.5-8.0% require individualized interventions to reduce surgical risk (grade C, grade B). Nonoperative management was considered to have a low-risk of short-term morbidity (grade C). Mesh reinforcement was recommended for repair of hernias ≥ 2 cm (grade A). There were several areas where high-quality data were limited, and no consensus could be reached, including mesh type, component separation technique, and management of complex patients.

CONCLUSIONS

Although there was consensus, supported by grade A-C evidence, on patient selection, the safety of short-term nonoperative management, and mesh reinforcement, among experts; there was limited evidence and broad variability in practice patterns in all other areas of practice. The lack of strong evidence and expert consensus on these topics has identified gaps in knowledge where there is need of further evidence.

Development of a Clinically Actionable Incisional Hernia Risk Model after Colectomy Using the Healthcare Cost and Utilization Project

BACKGROUND

Incisional hernia remains a persistent and burdensome complication after colectomy. Through individualized risk-assessment and prediction models, we aimed to improve preoperative risk counseling for patients undergoing colectomy; identify modifiable preoperative risk factors; and encourage the use of evidence-based risk-prediction instruments in the clinical setting.

STUDY DESIGN

A retrospective review of the Healthcare Cost and Utilization Project data was conducted for all patients undergoing either open or laparoscopic colectomy as identified through the state inpatient databases of California, Florida, and New York in 2009. Incidence of incisional hernia repair was collected from both the state inpatient databases and the state ambulatory surgery and services databases in the 3 states between index surgery and 2011. Hernia risk was calculated with multivariable hierarchical logistic regression modeling and validated using bootstrapping techniques. Exclusion criteria included concurrent hernia, metastasis, mortality, and age younger than 18 years. Inflation-adjusted expenditure estimates were calculated.

RESULTS

Overall, 30,741 patients underwent colectomy, one-third of these procedures performed laparoscopically. Incisional hernia repair was performed in 2,563 patients (8.3%) (27-month follow-up). Fourteen significant risk factors were identified, including open surgery (odds ratio = 1.49; p < 0.0001), obesity (odds ratio = 1.49; p < 0.0001), and alcohol abuse (odds ratio = 1.39; p = 0.010). Extreme-risk patients experienced the highest incidence of incisional hernia (19.8%) vs low-risk patients (3.9%) (C-statistic = 0.67).

CONCLUSIONS

We present a clinically actionable model of incisional hernia using all-payer claims after colectomy. The data presented can structure preoperative risk counseling, identify modifiable patient-specific risk factors, and advance the field of risk prediction using claims data.

Flank Hernia Repair with Suture Anchor Mesh Fixation to the Iliac Crest

Traumatic or postsurgical flank hernias are complex and prone to recurrence, particularly at the border of the iliac crest. We reviewed our experience using suture anchors drilled into the iliac crest to fixate the mesh to bone. Our study of 10 repairs in eight patients was Institutional Review Board exempt. We obtained demographics, body mass index, diabetes, methicillin-resistant Staphylococcus aureus (MRSA) history, smoking status, steroid use, number of prior repairs, defect size, mesh size, number of anchors, and recurrence and infection at follow-up. We performed Kaplan-Meier analysis using a composite of recurrence or infection. Three of eight (interquartile range, 37.5%) patients were male. Median age and body mass index were 47.5 years (31.0, 54.7) and 32.2 (29.0, 36.0), respectively. Three patients had prior repairs, one each with two, three, and five prior attempts at fixation. One of eight patients (12.5%) had a history of MRSA infection. One of eight patients (12.5%) had a history of intermittent steroid use for sarcoidosis. Defect size was 90 cm2 (62.2, 165) and mesh size was 155 cm2 (150, 232) with four anchors (4, 5.5). Procedural complications included 2/10 (20%) with recurrence and 1/10 (10%) with postoperative MRSA infection. Follow-up was 12 months (3.0, 25.0). Mean freedom from recurrence and mesh infection (Kaplan-Meier) was 43.5 months (95% confidence interval = 24.2, 62.8). In conclusion, our series is one of the largest in the literature involving the suture anchor technique. Despite a high-risk patient population due to trauma, obesity, and prior smoking and MRSA history, we achieved an acceptable recurrence rate. Further study may benefit from a randomized trial design.

Perioperative Glycemic Control in Plastic Surgery: Review and Discussion of an Institutional Protocol

Perioperative hyperglycemia is a well-known risk factor for surgical morbidity such as wound healing, infection, and prolonged hospitalization. This association has been reported for a number of surgical subspecialties, including plastic surgery. Specialty-specific guidelines have become increasingly available in the literature. Currently, glucose management guidelines for plastic surgery are lacking. Recognizing that multiple approaches exist for perioperative glucose, protocol-based models provide the necessary structure and guidance for approaching glycemic control. In this article, we review the influence of diabetes on outcomes in plastic surgery patients and propose a practical approach to perioperative blood glucose management based on current Endocrine Society and Mayo Clinic institutional guidelines.

Total Abdominal Wall Reconstruction with Component Separation, Reinforcement, and Vertical Abdominoplasty in Patients with Complex Ventral Hernias

Large complex ventral hernias act as tissue expanders for skin and subcutaneous fat. The purpose of this study is to evaluate outcomes of total abdominal wall reconstruction with component separation, posterior reinforcement, and vertical abdominoplasty in patients with large complex ventral hernias. Between 2010 and 2014, 58 patients underwent total abdominal wall reconstruction with component separation, intra-abdominal reinforcement, and vertical abdominoplasty. Between 2010 and 2012, patients underwent the conventional technique of component separation, while a perforator-preserving technique was performed during 2013 and 2014. Reinforcement material used was either synthetic mesh in clean cases or biologic mesh if contamination was present. All of the excessive skin and subcutaneous fat was removed in a vertical fashion. Data were analyzed with Mann-Whitney's U test or Fisher's exact test, as indicated. There were 27 moderately complex and 31 majorly complex hernias. Mean hernia size was 16 × 12 cm. The mean size of the removed skin island was 21 × 12 cm. Patients with contamination during the repair had longer in-hospital stays. Overall the local wound complication rate was 24 %, and was lower with the perforator-preserving technique compared to the conventional technique of component separation (11 vs. 48 %; OR 0.13, CI 0.03-0.5; p = 0.003). The overall postoperative morbidity rate was higher in the presence of contamination, and in patients with lower preoperative serum albumin levels. Mean total follow-up was 14 months with a 1-year recurrence-free survival of 96 %.

LEVEL OF EVIDENCE IV

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National Outcomes for Open Ventral Hernia Repair Techniques in Complex Abdominal Wall Reconstruction

Modern adjuncts to complex, open ventral hernia repair often include component separation (CS) and/or panniculectomy (PAN). This study examines nationwide data to determine how these techniques impact postoperative complications. The National Surgical Quality Improvement Program database was queried from 2005 to 2013 for inpatient, elective open ventral hernia repairs (OVHR). Cases were grouped by the need for and type of concomitant advancement flaps: OVHR alone (OVHRA), OVHR with CS, OVHR with panniculectomy (PAN), or both CS and PAN (BOTH). Multivariate regression to control for confounding factors was conducted. There were 58,845 OVHR: 51,494 OVHRA, 5,357 CS, 1,617 PAN, and 377 BOTH. Wound complications (OVHRA 8.2%, CS 12.8%, PAN 14.4%, BOTH 17.5%), general complications (15.2%, 24.9%, 25.2%, 31.6%), and major complications (6.9%, 11.4%, 7.2%, 13.5%) were different between groups ( P < 0.0001). There was no difference in mortality. Multivariate regression showed CS had higher odds of wound [odds ratio (OR) 1.7, 95% confidence interval (CI) 1.5–2.0], general (OR 1.5, 95% CI: 1.3–1.8), and major complications (OR 2.1, 95%, CI: 1.8–2.4), and longer length of stay by 2.3 days. PAN had higher odds of wound (OR 1.5, 95%, CI: 1.3–1.8) and general complications (OR 1.7, 95% CI: 1.5–2.0). Both CS and PAN had higher odds of wound (OR 2.2,95%, CI: 1.5–3.2), general (OR 2.5, 95%, CI: 1.8–3.4), and major complications (OR 2.2, 95%CI: 1.4–3.4), and two days longer length of stay. In conclusion, patients undergoing OVHR that require CS or PAN have a higher independent risk of complications, which increases when the procedures are combined.

Surgical Site Occurrences of Simultaneous Panniculectomy and Incisional Hernia Repair

Horizontal panniculectomy (PAN) offers the advantage of wide exposure for hernia repair with elimination of excess skin and adiposity, at the expense of massive subcutaneous flap creation and its attendant risks. We report our experience with ventral hernia repair (VHR) with PAN compared with patients with hernia repair alone. A prospective database was reviewed retrospectively for all patients undergoing open VHR + PAN. A matched cohort of patients without PAN was used for comparison, resulting in 43 study and 43 control patients. Incidence of surgical site occurrences (SSO), surgical site infection (SSI), and recurrence were analyzed. A total of 43 patients underwent PAN + VHR with mesh. Mean body mass index was 34.3 kg/m2, with 35 per cent having undergone prior bariatric surgery. Repair techniques included retromuscular (74.4%), preperitoneal (11.6%), intraperitoneal (6.9%), onlay (4.6%), and suture (2.3%). Mesh used was polypropylene (76.7%), polyester (18.6%), bioabsorbable (2.3%), and polytetrafluoroethylene (ePTFE) (2.3%). Component separation was performed in 44.2 per cent of patients. There was a significant difference in total SSO between PAN + VHR and VHR alone (46.5% vs 27.9%; P < 0.001), though the difference for individual SSOs was not significant. There was no difference in SSI between groups (16.3% vs 20.9%; P = 0.776). Mean follow-up was 11.4 months, with recurrence rate of 11.6 per cent in the PAN group and 9.3 per cent in the control group ( P = 0.725). Panniculectomy at the time of VHR does not increase the incidence of SSI, though higher rates of skin necrosis and cellulitis were seen. There is no difference in recurrence. This approach is a valid option for patients with excessive abdominal panniculus requiring VHR.