The incidence and impact of enterotomy during laparoscopic and robotic ventral hernia repair: a nationwide readmissions analysis

INTRODUCTION

Our aim was to define the national incidence of enterotomy (ENT) during minimally invasive ventral hernia repair (MIS-VHR) and evaluate impact on short-term outcomes.

METHODS

The 2016-2018 Nationwide Readmissions Database was queried using ICD-10 codes for MIS-VHR and enterotomy. All patients had 3-months follow-up. Patients were stratified by elective status; patients without ENT (No-ENT) were compared against ENT patients.

RESULTS

In total, 30,025 patients underwent LVHR and ENT occurred in 388 (1.3%) patients; 19,188 (63.9%) cases were elective including 244 elective-ENT patients. Incidence was similar between elective versus non-elective cohorts (1.27% vs 1.33%; p = 0.674). Compared to laparoscopy, ENT was more common during robotic procedures (1.2% vs 1.7%; p = 0.004). Comparison of elective-No-ENT vs elective-ENT showed that elective-ENT patients had a longer median LOS (2 vs 5 days; p < 0.001), higher mean hospital cost ($51,656 vs $76,466; p < 0.001), increased rates of mortality (0.3% vs 2.9%; p < 0.001), and higher 3-month readmission (10.1% vs 13.9%; p = 0.048). Non-elective cohort comparison demonstrated non-elective-ENT patients had a longer median LOS (4 vs 7 days; p < 0.001), higher mean hospital cost ($58,379 vs $87,850; p < 0.001), increased rates of mortality (0.7% vs 2.1%;p < 0.001), and higher 3-month readmission (13.6% vs 22.2%; p < 0.001). In multivariable analysis (odds ratio, 95% CI), higher odds of enterotomy were associated with robotic-assisted procedures (1.386, 1.095-1.754; p = 0.007) and older age (1.014, 1.004-1.024; p = 0.006). Lower odds of ENT were associated with BMI > 25 kg/m² (0.784, 0.624-0.984; p = 0.036) and metropolitan teaching vs metropolitan non-teaching (0.784, 0.622-0.987; p = 0.044). ENT patients (n = 388) were more likely to be readmitted with post-operative infection (1.9% vs 4.1%; p = 0.002) or bowel obstruction (1.0% vs 5.2%;p < 0.001) and more likely to undergo reoperation for intestinal adhesions (0.3% vs 1.0%; p = 0.036).

CONCLUSION

Inadvertent ENT occurred in 1.3% of MIS-VHRs, had similar rates between elective and urgent cases, but was more common for robotic procedures. ENT patients had a longer LOS, and increased cost and infection, readmission, re-operation and mortality rates.

Trends in Incisional and Ventral Hernia Repair: A Population Analysis From 2001 to 2021

Background Incisional and ventral hernias are highly prevalent, with primary ventral hernias occurring in approximately 20% of adults and incisional hernias developing in up to 30% of midline abdominal incisions. Recent data from the United States have shown an increasing incidence of elective incisional and ventral hernia repair (IVHR) and emergency repair of complicated hernias. This study examines Australian population trends in IVHR over a two-decade study period. Methods This retrospective study was performed using procedure data from the Australian Institute of Health and Welfare and population data from the Australian Bureau of Statistics captured between 2000 and 2021 to calculate incidence rates per 100,000 population by age and sex for selected subcategories of IVHR operations. Trends over time were evaluated using simple linear regression. Results There were 809,308 IVHR operations performed in Australia during the study period. The cumulative incidence adjusted for population was 182 per 100,000; this increased by 9.578 per year during the study period (95%CI = 8.431-10.726, p<.001). IVHR for primary umbilical hernias experienced the most significant increase in population-adjusted incidence, 1.177 per year (95%CI = 0.654-1.701, p<.001). Emergency IVHR for incarcerated, obstructed, and strangulated hernias increased by 0.576 per year (95%CI = 0.510-0.642, p<.001). Only 20.2% of IVHR procedures were performed as day surgery. Conclusions Australia has seen a significant increase in IVHR operations performed in the last 20 years, particularly those for primary ventral hernias. IVHR for hernias complicated by incarceration, obstruction, and strangulation also increased significantly. The proportion of IVHR operations performed as day surgery is well below the target set by the Royal Australasian College of Surgeons. With the increasing incidence of IVHR operations and an increasing proportion of these being emergent, elective IVHR should be performed as day surgery when it is safe.

Racial/Ethnic Disparities in Longer-term Outcomes Among Emergency General Surgery Patients: The Unique Experience of Universally Insured Older Adults

OBJECTIVES

To determine whether racial/ethnic disparities in 30/90/180-day mortality, major morbidity, and unplanned readmissions exist among universally insured older adult (≥65 years) emergency general surgery patients; vary by diagnostic category; and can be explained by variations in geography, teaching status, age-cohort, and a hospital's percentage of minority patients.

SUMMARY OF BACKGROUND DATA

As the US population ages and discussions surrounding the optimal method of insurance provision increasingly enter into national debate, longer-term outcomes are of paramount concern. It remains unclear the extent to which insurance changes disparities throughout patients' postacute recovery period among older adults.

METHODS

Survival analysis of 2008 to 2014 Medicare data using risk-adjusted Cox proportional-hazards models.

RESULTS

A total of 6,779,649 older adults were included, of whom 82.8% identified as non-Hispanic white (NHW), 9.2% non-Hispanic black (NHB), 5.6% Hispanic, and 1.5% non-Hispanic Asian (NHA). Relative to NHW patients, each group of minority patients was significantly less likely to die [30-day NHB vs NHW hazard ratio (95% confidence interval): 0.88 (0.86-0.89)]. Differences became less apparent as outcomes approached 180 days [180-day NHB vs NHW: 1.00 (0.98-1.02)]. For major morbidity and unplanned readmission, differences among NHW, Hispanic, and NHA patients were comparable. NHB patients did consistently worse. Efforts to explain the occurrence found similar trends across diagnostic categories, but significant differences in disparities attributable to geography and the other included factors that combined accounted for up to 50% of readmission differences between racial/ethnic groups.

CONCLUSION

The study found an inversion of racial/ethnic mortality differences and mitigation of non-NHB morbidity/readmission differences among universally insured older adults that decreased with time. Persistent disparities among nonagenarian patients and hospitals managing a regionally large share of minority patients warrant particular concern.

Development of a Disease-based Hernia Program and the Impact on Cost for a Hospital System

OBJECTIVE

The aim of this study was to assess the impact of developing a hernia program on mesh utilization.

BACKGROUND

With the ongoing changes in healthcare, the value of all interventions will see increased scrutiny. Hernia mesh can be one of the most costly components of hernia repairs. A disease-based institutional hernia program that defines roles for mesh utilization and measures outcomes has the potential to add significant value to hospital systems.

METHODS

In August 2014, a disease-based hernia program was initiated across a hospital system. In collaboration with hospital administration, surgical operations, and all surgeons involved in the care of hernia patients, general guidelines for mesh utilization based on CDC wound class were created. All hernia repairs performed between January 2013 and November 2015 were reviewed.

RESULTS

Approximately, 13,937 hernias were repaired during the study period. Biologic mesh was used in 0.4% of clean, 7.1% of clean-contaminated, 38.5% of contaminated, and 58.8% of dirty cases. After initiation of the hernia program there was a reduction in biologic mesh utilization across the system (clean: 66% reduction; clean-contaminated: 63% reduction; contaminated: 55% reduction; dirty: 47% reduction). Surgeons who participated in the hernia program used significantly less biologic mesh in clean (P < 0.01), clean-contaminated (P = 0.01) and contaminated (P < 0.01) hernia repairs.

CONCLUSIONS

The development of a system-wide hernia program based on collaboration with the hospital administration, operating room purchasing and clinicians resulted in a significant reduction in costly mesh utilization. This collaborative effort from all stakeholders involved in the care of a specific disease process could provide a reproducible model to improve the value equation through cost reduction strategies in today's healthcare environment.

Decreasing Surgical Site Infections after Ventral Hernia Repair: A Quality-Improvement Initiative

BACKGROUND

Surgical site infections (SSIs) remain prevalent after ventral hernia repair (VHR). In 2013-2014, a safety-net academic hospital initiated a two-pronged quality-improvement (QI) project: (1) Development and implementation of evidence-based guidelines; and (2) creation of a specialized hernia clinic to manage challenging patients and complex ventral hernias. Our objective was to decrease SSI rates after elective VHR.

METHODS

The primary outcome was SSI 30 days post-operatively, which was assessed in aggregate and with a stratified analysis based on case complexity using the χ² test.

RESULTS

A total of 399 patients in the pre-QI period and 390 patients in post-QI period (178 patients in general surgery clinics; 212 patients in the specialty hernia clinic) underwent VHR. Patients treated in the post-QI period were less likely to experience an SSI (13.5% vs. 1.5%; p < 0.001). On subgroup analysis of the post-QI clinics, specialty hernia clinic patients had an even lower risk of SSI than those in general surgery clinics (1.4% versus 1.7%).

CONCLUSIONS

The QI initiatives of evidence-based guidelines and the specialty hernia clinic were associated with lower SSI rates. Differences in peri-operative management included differences in patient selection and pre-operative preparation and increased use of synthetic mesh and laparoscopy. Future studies must investigate the long-term outcomes of these initiatives.

The increased cost of ventral hernia recurrence: a cost analysis

PURPOSE

Over 300,000 ventral hernia repairs (VHRs) are performed each year in the US. We sought to assess the economic burden related to ventral hernia recurrences with a focused comparison of those with the initial open versus laparoscopic surgery.

METHODS

The Premier Alliance database from 2009 to 2014 was utilized to obtain patient demographics and comorbid indices, including the Charlson comorbidity index (CCI). Total hospital cost and resource expenses during index laparoscopic and open VHRs and subsequent recurrent repairs were also obtained. The sample was separated into laparoscopic and open repair groups from the initial operation. Adjusted and propensity score matched cost outcome data were then compared amongst groups.

RESULTS

One thousand and seventy-seven patients were used for the analysis with a recurrence rate of 3.78 %. For the combined sample, costs were significantly higher during recurrent hernia repair hospitalization ($21,726 versus $19,484, p < 0.0001). However, for index laparoscopic repairs, both the adjusted total hospital cost and department level costs were similar during the index and the recurrent visit. The costs and resource utilization did not go up due to recurrence, even though these patients had greater severity during the recurrent visit (CCI score 0.92 versus 1.06; p = 0.0092). Using a matched sample, the total hospital recurrence cost was higher for the initial open group compared to laparoscopic group ($14,520 versus $12,649; p = 0.0454).

CONCLUSIONS

Based on our analysis, need for recurrent VHR adds substantially to total hospital costs and resource utilization. Following initial laparoscopic repair, however, the total cost of recurrent repair is not significantly increased, as it is following initial open repair. When comparing the initial laparoscopic repair versus open, the cost of recurrence was higher for the prior open repair group.

Is There an Increasing Regionalization of Surgical Repair of Craniosynostosis Procedures Into Teaching Hospitals? Implications of Regionalization

Objective The objective of the present study is to examine whether surgical repairs for craniosynostosis have been regionalized to teaching hospitals over the 8-year period from 2003 to 2010. Design Retrospective analysis of hospital discharge database. Setting Nationwide Inpatient Sample for years 2003 to 2010. All patients aged up to 3 years who had a surgical repair for craniosynostosis were selected. Interventions Surgical repair for craniosynostosis. Main Outcome Measures Performance of surgery in a teaching hospital. Results During the study period (years 2003 to 2010), a total of 19,417 patients aged up to 3 years underwent a surgical repair for craniosynostosis. The number of surgical procedures increased during the study period. It ranged from 1628 procedures in year 2003 to 3001 procedures during 2010. Data show that 83.3% of all procedures in 2003 were performed in teaching hospitals; whereas, 97.5% of procedures in 2010 were performed in teaching hospitals. Following adjustment for patient-level factors, year 2010 was associated with increased odds of having the surgical procedures performed in a teaching hospital as opposed to a nonteaching hospital when compared with year 2003 (odds ratio = 10.43, 95% confidence interval, 1.10 to 98.98; P = .04). Conclusions An increasing proportion of surgical repairs of craniosynostosis are performed in teaching hospitals, suggesting there is an increasing concentration of these complex surgical procedures in select centers. As more longitudinal data become available, the relative benefits and drawbacks associated with regionalization of surgical repairs of craniosynostosis should be examined.

Inpatient outcomes after elective versus nonelective ventral hernia repair

BACKGROUND

Patients who present emergently with hernia-related concerns may experience increased morbidity with repair when compared with those repaired electively. We sought to characterize the outcomes of patients who undergo elective and nonelective ventral hernia (VH) repair using a large population-based data set.

MATERIALS AND METHODS

The Nationwide Inpatient Sample was queried for primary International Classification of Diseases, Ninth Revision codes associated with VH repair (years 2008-2011). Outcomes were inhospital mortality and the occurrence of a preidentified complication. Multivariable analysis was performed to determine the risk factors for complications and mortality after both elective and nonelective VH repair.

RESULTS

We identified 74,151 VH repairs performed during the study interval. Of these procedures, 67.3% were elective and 21.6% were performed laparoscopically. Nonelective repair was associated with a significantly higher rate of morbidity (22.5% versus 18.8%, P < 0.01) and mortality (1.8% versus 0.52, P < 0.01) than elective repair. Elective repairs were more likely to occur in younger patients, Caucasians, and were more likely to be performed laparoscopically. Logistic modeling revealed that female gender, Caucasian race, elective case status, and laparoscopic approach were independently associated with a lower probability of complications and mortality. Minority status and Medicaid payer status were associated with increased probability of nonelective admission.

CONCLUSIONS

Patients undergoing elective VH repair in the United States tend to be younger, Caucasian, and more likely to have a laparoscopic repair. Nonelective VH is associated with a substantial increase in morbidity and mortality. We recommend that patients consider elective repair of VHs because of the increased morbidity and mortality associated with nonelective repair.

Surgeon volume plays a significant role in outcomes and cost following open incisional hernia repair

TITLE

Surgeon Volume Plays a Significant Role in Outcomes and Cost Following Open Incisional Hernia Repair

PURPOSE

Incisional hernia is a common complication following gastrointestinal surgery. Many surgeons elect to perform incisional hernia repairs despite performing only limited numbers of hernia repairs annually. This study examines the relationship between surgeon/facility volume and operative time, reoperation rates, and cost following initial open hernia repair.

METHODS

The New York Statewide Planning and Research Cooperative System was queried for elective open initial incisional hernias repairs from 2001 to 2006. Surgeon/facility volumes were calculated as mean number of open incisional hernia repairs per year from 2001 to 2006. Reoperations for recurrent hernia over a 5-year period were identified using ICD-9/CPT codes. Multivariable regression was used to compare patient, surgeon, and facility characteristics with operative time, hernia reoperation, and hospital charges.

RESULTS

Eighteen thousand forty-seven patients met the inclusion criteria. The hernia reoperation rate was 9%, and median time to reoperation was 1.4 years (mean = 1.8). After adjusting for clinical factors, surgeons performing an average of ≥36 repairs/year had significantly lower reoperation rates (HR = 0.59, 95% confidence interval (CI) = 0.48,0.72), operative time (incidence rate ratio (IRR) = 0.67, 95% CI = 0.64,0.71), and downstream charges (IRR = 0.63, 95% CI = 0.57,0.69). Facility characteristics (volume, academic affiliation, location) were not associated with reoperation.

CONCLUSIONS

This study found a strong association between individual surgeon incisional hernia repair volume and hernia reoperation rates, operative efficiency, and charges. Preferential referral to high-volume surgeons may lead to improved outcomes and lower costs.

A little slower, but just as good: postgraduate year resident versus attending outcomes in laparoscopic ventral hernia repair

INTRODUCTION

The purpose of this study was to analyze the effect of residents on patient outcomes in laparoscopic ventral hernia repair (LVHR).We hypothesized that increasing postgraduate year (PGY) level would correlate with better outcomes.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2005 to 2011 for elective LVHR. Attending only cases were used as the control, and resident cases were stratified into junior (PGY 1-3), chief (4-5), and fellow (6+) cases. Standard statistical tests and multivariate regression controlling for age, body mass index, Charlson comorbidity index, smoking, functional status, and inpatient cases were performed for trainee involvement and PGY level.

RESULTS

There were 6,841 ventral hernia repairs that met inclusion criteria: 2,773 attending and 4,068 resident cases. There were 1,644 junior, 1,983 chief, and 441 fellow cases. Patients were similar between the attending and resident groups. The resident group had a higher rate of inpatient cases, general complications, longer operative time, and hospital length of stay. After controlling for confounders in multivariate analysis, only operative time was significantly different; resident cases were 17.7 min longer (CI 15.0-20.6; p < 0.001). There was no significant difference in the rate of wound or major complications, readmission, reoperation, or mortality between attending and resident cases. Demographics were not significantly different between the PGY level strata. On multivariate regression by PGY level with attending alone as the reference, only operative time was significantly different. Juniors (15.7 min, CI 12.2-19.2), chiefs (18.0 min, CI 14.7-21.3), and fellows (24.9 min, CI 19.1-30.7) had significantly longer cases than attending alone; all p < 0.001.

CONCLUSION

Trainee involvement during LVHR does not change the clinical outcomes for patients as compared to those performed by an attending only. Operative time is significantly longer with increasing PGY level, perhaps indicating the complexity of the operation or increasing trainee involvement as primary surgeon. However, patient care does not suffer, affirming the current surgical training curriculum is appropriate.

Nationwide outcomes of nontrauma splenectomy

INTRODUCTION

Due to the impact of LeapFrog and many scientific publications, regionalization for solid-organ operations gained momentum in the early 2000s. This study examines the effects of regionalization for medically indicated, nontrauma splenectomies (NTSs) in the USA.

METHODS

The Nationwide Inpatient Sample (NIS) data were analyzed for NTS based on International Classification of Disease Ninth Revision Clinical Modification codes for 1998–1999 (the 1990s) and 2008–2009 (the 2000s). The hospitals in the NIS were stratified by volume and divided into high volume (HV), medium volume, and low-volume (LV) terciles based on the annual volume of splenectomies performed (<5, 5–10, and 11+, respectively). Demographics, comorbidities, complications, admission status, and in-patient mortality were recorded. Univariate and multivariate statistical analyses were utilized.

RESULTS

NIS recorded 4,293 NTS performed in the 1990s and 3,384 in the 2000s. Despite the decrease in operative volume, regionalization did not occur: in the first decade 30, 37, and 33 % of cases occurred in LV center (LVC), medium volume center, and HV center (HVC), respectively, compared with 34, 30, and 36 % in the second decade (p < 0.001). Patients were older in low-volume hospitals (LVC) than in high-volume hospitals (HVC) in both decades (in the 1990s: 45.3 vs. 52.7 years, p < 0.001; in the 2000s: 49.1 vs. 54.5 years, p < 0.001). The Charlson Comorbidity Index scores were not different in LVC compared with HVC in both decades (the 1990s: 1.31 vs. 1.23, p = 0.73; the 2000s: 1.54 vs. 1.41, p = 0.72). In both decades, LVC had more emergent admissions than HVC (20.3 vs. 16.8 %, p = 0.03; 28.8 vs. 19.5 %, p < 0.001). Complication rates were higher in LVC in both decades (the 1990s: 16.9 vs. 13.6 %, p = 0.02; the 2000s: 19.8 vs. 15.5 %, p = 0.006). Mortality was not different for HVC and LVC in both decades (the 1990s: 3.75 vs. 4.27, p = 0.49; the 2000s: 2.94 vs. 4.03, p = 0.15).

CONCLUSIONS

NTS has not been affected by regionalization, which is dissimilar to other solid-organ abdominal procedures. Indeed, the benefit of regionalization for splenectomy has not been established.