The efficacy of goal-directed recommendations in overcoming barriers to elective ventral hernia repair in older adults

Natural history of groin hernias in women and factors leading to delay in repair: a single-institution study

BACKGROUND

The objective of this study was to describe the natural history of groin hernias in women at a high-volume tertiary medical center. Specifically, we abstracted the duration of symptoms prior to diagnosis, imaging modalities used, and operative findings. We hypothesized that females would experience a protracted preoperative clinical course.

METHODS

Our institutional hernia database was queried for elective groin hernia repairs from January 2018 to July 2023. Analyses were used to measure and describe demographics, clinical characteristics, and operative findings. In addition, patients' zip codes were linked to census track area deprivation index (ADI) values and a semi-qualitative inquiry was performed to explore reasons for the protracted preoperative clinical course.

RESULTS

Among 1331 patients, 8.4% were female. Majority were Caucasian (68.8%) and overweight (BMI 27.3 ± 5.8), averaging 61.2 years of age. Majority reported non-specific groin pain (73.8%) and an intermittent groin bulge (48.8%), with 40% experiencing symptoms for > 1 year. Patients averaged 1.2 clinic visits before seeing a surgeon. Indirect inguinal hernias were the most common (81.3%), followed by femoral (35%) and direct (26.3%). Sixty-three patients had preoperative imaging, including CT (56.8%), US (39.2%), and MRI (4.0%). The most common surgical approach was robotic (68.8%) followed by laparoscopic-TEP (22.5%). When stratified by duration of symptoms, ADI did not differ among our cohort (p = 0.497). Patient-related reasons for delaying surgery included interpersonal stressors (3.1%), symptoms not limiting ADLs (34.4%), and fear of mesh complications (3.1%). Providers advised against surgery due to malnutrition (3.1%), multiple prior repairs (9.4%), concomitant infection (3.1%), and severe ascites (6.3%).

CONCLUSION

Our study provides some insight into reasons for delay in inguinal hernia repair for women. While many reported symptoms for over a year, a minority sought treatment until they were ready to proceed with surgery. Future qualitative studies are needed to more thoroughly assess female's perspectives with groin hernias.

The effect of clinically significant weight loss prior to open ventral hernia repair

PURPOSE

The study aim was to assess the impact of clinically significant weight loss (CSWL; ≥5% weight reduction) on postoperative complications following abdominal wall reconstruction with the component separation technique (CST).

METHODS

A retrospective review of patients who underwent open ventral hernia repair (VHR) with CST from November 2008 to January 2022 was performed. Cohorts were stratified by presence of CSWL from baseline weight at preoperative consultation.

RESULTS

Of 180 total patients, 40 (22.2%) achieved CSWL prior to VHR. Mean age was 59.6 ± 11.2 years. Patients in the CSWL cohort represented a higher average body mass index (BMI) (33.6 vs. 31.7 kg/m2, p = 0.076), and were obese more frequently (80.0% vs. 56.4%, p = 0.007). The CSWL cohort had a higher proportion of patients in Ventral Hernia Working Group (VHWG) classification II (82.5% vs. 63.6%) while the non-CSWL cohort had more VHWG classification III/IV (20.0% vs. 10.0%, p = 0.078). Mean follow-up duration was 6.1 ± 13.4 months. Complications, including 30- and 90-day surgical site occurrence (SSO), return to operating room, readmission, and hernia recurrence (CSWL: 5.0% vs. non-CWL 1.4%, p = 0.179), were comparable between cohorts. BMI was an independent predictor of any complication (OR 1.07, p = 0.044) and 90-day SSO (OR 1.10, p = 0.043).

CONCLUSION

Achievement of CSWL prior to open VHR utilizing CST results in similar post-reconstruction outcomes to patients who maintained a comparable BMI at baseline. Higher day-of-surgery BMI was more consequential to postoperative complications than percent weight loss.

Is weight trajectory a better marker of wound complication risk than BMI in hernia patients with obesity?

BACKGROUND

Complex ventral hernias are frequently repaired via an open transversus abdominis release (TAR). Obesity, particularly a BMI > 40, is a strong predictor of wound morbidity following this procedure. We aimed to determine if preoperative weight loss may still be beneficial in patients with persistently elevated BMIs.

METHODS

A retrospective chart review of patients with obesity (BMI ≥ 30) who underwent open TAR at a tertiary academic medical center from January 2018 to December 2021 was completed. Demographics, medical history, operative details, and postoperative data were analyzed. Weight and BMI were recorded at three time points: > 6 months prior to initial surgical consultation, surgical consultation, and day of surgery.

RESULTS

In total, 182 patients with obesity underwent an open TAR. Twenty-seven patients (14.8%) underwent surgery with a BMI > 40; they did not have any significant differences in surgical site occurrences (SSO, 48.1% vs 32.9%, p = 0.13) or surgical site infections (SSI, 25.9% vs 23.2%, p = 0.76) compared to those with a BMI ≤ 40. The average timeframe analyzed for preoperative weight loss was 592 days. Patients who had at least a 3% weight loss (n = 49, 26.9%) had decreased rates of SSI compared to those who did not have this weight loss (12.2% vs 27.8%, p = 0.03), despite the groups having similar BMIs at the time of surgery (36.4 vs 36.0, p = 0.50). Patients who only had a 1% weight loss did not see a decrease in SSI rate compared to those who did not (20.6% vs 25.4%, p = 0.45).

CONCLUSION

Weight loss may be a better indicator of a patient's risk for wound morbidity following TAR than BMI alone, as weight loss of at least 3% resulted in fewer SSIs despite similar BMIs at time of surgery. Further research into optimal timing and amount of weight loss, as well as effects on long-term outcomes, is needed to confirm these findings.

Preoperative Optimization for Abdominal Wall Reconstruction

Patients requiring abdominal wall reconstruction may have medical comorbidities and/or complex defects. Comorbidities such as smoking, diabetes, obesity, cirrhosis, and frailty have been associated with an increased risk of postoperative complications. Prehabilitation strategies are variably associated with improved outcomes. Large hernia defects and loss of domain may present challenges in achieving fascial closure, an important part of restoring abdominal wall function. Prehabilitation of the abdominal wall can be achieved with the use of botulinum toxin A, and preoperative progressive pneumoperitoneum.