Major complications and mortality after ventral hernia repair: an eleven-year Swedish nationwide cohort study

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.

Ventral hernia is a chronic disease: a systematic review of long-term outcomes beyond 5 years

PURPOSE

To systematically evaluate the long-term outcomes of ventral hernia repair (VHR) and reassess its classification as a definitive surgical intervention. This review synthesizes evidence on postoperative complications including recurrence, chronic pain, and patient-reported outcomes to characterize the long-term burden of VHR and its impact on patient management. This study underscores the necessity of prolonged postoperative surveillance to accurately assess surgical efficacy and inform evidence-based follow-up trategies.

METHODS

A systematic review was conducted in accordance with PRISMA guidelines, searching PubMed, Embase, and Web of Science for studies with a mean or median follow-up of ≥5 years. Eligible studies reported outcomes including recurrence, reoperation, mesh infection, chronic pain, and quality of life. A random-effects meta-analysis was performed using STATA MP 18 to pool event rates for each outcome.

RESULTS

Among 2,721 patients followed for ≥5 years, 13% (95% CI: 9-17%) experienced recurrence. Long-term complications included seroma in 11% (95% CI: 6-17%, n = 1,778) and reoperation in 8% (95% CI: 5-11%, n = 1,833) of patients. Patient-reported outcomes, including chronic pain, were collected, with 15% (95% CI: 8-23%, n = 1,220) reporting its occurrence.

CONCLUSION

This systematic review evaluates the complexity of ventral hernia repair and proposes conceptual realignment in managing ventral hernias, viewing them through the lens of chronic disease to align treatment goals with long-term patient outcomes. The data suggests that ventral hernias exhibit characteristics of a chronic condition, requiring sustained medical oversight and potential reinterventions for chronic pain, recurrence, and other quality-of-life complications.

Electrospun meshes for abdominal wall hernia repair: Potential and challenges

Surgical meshes are widely used in abdominal wall hernia repairs. However, consensus on mesh treatment remains elusive due to varying repair outcomes, especially with the introduction of new meshes, posing a substantial challenge for surgeons. Addressing these issues requires communicating the features of emerging candidates with a focus on clinical considerations. Electrospinning is a versatile technique for producing meshes with biomechanical architectures that closely mimic the extracellular matrix and enable incorporation of bioactive and therapeutic agents into the interconnective porous network, providing a favorable milieu for tissue integration and remodeling. Although this promising technique has drawn considerable interest in mesh fabrication and functionalization, currently developed electrospun meshes have limitations in meeting clinical requirements for hernia repair. This review summarizes the advantages and limitations of meshes prepared through electrospinning based on biomechanical, biocompatible, and bioactive properties/functions, offering interdisciplinary insights into challenges and future directions toward clinical mesh-aided hernia repair. STATEMENT OF SIGNIFICANCE: Consensus for hernia treatments using surgical meshes remains elusive based on varying repair outcomes, presenting significant challenges for researchers and surgeons. Differences in understanding mesh between specialists, particularly regarding material characteristics and clinical requirements, contribute to this issue. Electrospinning has been increasingly applied in mesh preparation through various approaches and strategies, aiming to improve abdominal wall hernia by restoring mechanical, morphological and functional integrity. However, there is no comprehensive overview of these emerging meshes regarding their features, functions, and clinical potentials, emphasizing the necessity of interdisciplinary discussions on this topic that build upon recent developments in electrospun mesh and provide insights from clinically practical prospectives.

Early postoperative outcomes in a retrospective propensity score-matched comparison of robotic extended totally extraperitoneal (r-eTEP) and extended totally extraperitoneal (eTEP) repair for ventral hernia

BACKGROUND

The extended totally extraperitoneal technique (eTEP) is a novel approach for ventral hernia repair. This technique has been recently advanced using robotics (r-eTEP). The aim of this study is to perform a comprehensive analysis of the initial results of r-eTEP and to evaluate the safety and efficacy of this technique compared to the eTEP technique.

METHODS

This is a monocentric retrospective study of patients with ventral hernias who underwent surgery via eTEP or r-eTEP in our department between 2019 and 2023. Propensity score matching was applied to compare the groups. Preoperative patient and hernia characteristics, intraoperative findings, and postoperative outcomes were subsequently analysed.

RESULTS

Patient demographics were comparable between the groups. The r-eTEP group had a significantly greater proportion of M3 hernias (p = 0.006), M4 hernias (p = 0.020), incisional hernias (p = 0.002), and hernias with rectus diastasis (p < 0.001). The r-eTEP group had a significantly larger hernia defect (p = 0.003) and larger mesh size (p = 0.015). The r-eTEP group had a shorter hospital stay (p < 0.001) and shorter operative time, though not statistically significant (p = 0.211). Intraoperative and postoperative complications, as well as postoperative pain, were comparable between the groups.

CONCLUSION

The findings of the present study show that the r-eTEP technique may offer potential benefits as the overall hospital stay was shorter while intraoperative and postoperative complications were comparable for both techniques.

A literature-based cost-effectiveness analysis of device-assisted suturing versus needle-driven suturing during laparotomy closure

PURPOSE

Small-bites suturing technique for laparotomy closure is now recommended as the standard of care. However, uptake of the practice remains slow. A medical technology called the SutureTOOL has been developed which can facilitate implementation of small-bites. The aim of the study was to compare the economic and clinical outcomes of laparotomy closure for patients using manual needle-driver suturing versus device-assisted suturing (SutureTOOL) following open abdominal surgery.

METHODS

This cost-effectiveness analysis comparing device-assisted suturing to needle-driver suturing was performed from a healthcare perspective within Sweden, France, the UK, and the US. A decision tree model was developed to implement the analysis.

RESULTS

The SutureTOOL was found to be cost-effective, reducing costs between 22% and 40% across country contexts. Savings were associated with reduced post-operative complications and reductions in operating room time. Improvements in quality of life were minimal and not clinically significant, likely because of the short time horizon.

CONCLUSION

Cost-effectiveness was largely due to cost savings. Prior to procurement, hospitals should test the device to ensure that small-bite rates and reductions in operation time are replicable within their clinical context. If so, the device will improve quality of care for laparotomy wound closure.

Persistent ascending mesocolon: an unexpected content in a giant and complex paraumbilical hernia of a 48-year-old obese woman

Persistent ascending mesocolon (PAM) is a rare congenital anomaly in ⁓2%-4% of individuals. PAM is associated with various complications, including volvulus of the colon and caecum, bowel perforation, intestinal obstruction, and adhesions. This case is reported on a 48-year-old woman who reported to the Ho Teaching Hospital specialist clinic with a 13-year history of initial painless and reducible paraumbilical swelling. Management was based on a surgical approach. The content of the hernia sac was unusual with a viable appendix, caecum, ascending and transverse colons inclusive, and ascending mesocolon was persistent. The repair was done through an anterior component separation technique. An onlay mesh repair was fashioned with a 30 cm × 30 cm polypropylene mesh. This case report highlights the complexities of managing a giant paraumbilical hernia in a morbidly obese patient with a PAM, a rare congenital anomaly.

Analysis of hospitalization costs in adult inguinal hernia: based on quantile regression model

BACKGROUND

Inguinal hernia repair is a common surgical procedure with significant variability in hospitalization costs. Traditional cost analysis methods often overlook the distribution of costs across patient demographics and clinical factors. This study employs a quantile regression model to explore the determinants of hospitalization costs for adult inguinal hernia surgery, providing a detailed understanding of cost variations across different quantiles.

METHODS

We analyzed data from adult patients who underwent inguinal hernia surgery at Beijing Chaoyang Hospital from January 2015 to June 2023. The study included patient demographics, hernia-related information, surgery-related details, and cost-related data. A quantile regression model was used to assess the impact of various factors on hospitalization costs at different quantiles (10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%). Data were processed using StataSE 15.0 software.

RESULTS

Our study included 16,602 patients, predominantly male (91.86%) and Han Chinese (96.48%), with the 51-64 years age group being the largest (26.80%). The quantile regression analysis revealed significant cost variations across different quantiles. Younger patients incurred higher costs, with age coefficients ranging from -40.541 at the 90th quantile to -3.082 at the 10th quantile. Uninsured patients faced higher costs, with coefficients from 214.747 at the 80th quantile to 501.78 at the 10th quantile. Longer hospital stays correlated with increased costs, with coefficients from 342.15 at the 80th quantile to 405.613 at the 90th quantile. Patients hospitalized multiple times (≥3) had lower costs, with coefficients from -767.353 at the 40th quantile to -311.575 at the 80th quantile. Comorbidities significantly raised costs, with coefficients for three or more comorbidities ranging from 806.122 at the 80th quantile to 1,456.02 at the 40th quantile. Laparoscopic surgery was more expensive than open surgery, with coefficients from 1,834.206 at the 80th quantile to 2,805.281 at the 10th quantile. Bilateral surgeries and the use of biological mesh also resulted in higher costs, with coefficients for bilateral surgeries ranging from 1,067.708 at the 10th quantile to 2,871.126 at the 90th quantile and for biological mesh from 3,221.216 at the 40th quantile to 6,117.598 at the 90th quantile.

CONCLUSIONS

Hospitalization costs for inguinal hernia surgery are influenced by multiple factors, with significant variations across different patient groups. Strategies to control costs should be tailored to address the specific needs of patients, optimize surgical methods, and improve perioperative care. Future research should extend these findings across different healthcare settings and consider the latest advancements in medical technology and policy changes.

Variation in surgical approach and postoperative complication among older adults undergoing ventral hernia repair

BACKGROUND

Surgical decision-making for preference-sensitive operations among older adults is understudied. Ventral hernia repair (VHR) is one operation where granular data are limited to guide preoperative decision-making. We aimed to determine risk for VHR in older adults given clinically nuanced data including surgical and hernia characteristics.

METHODS

We performed a retrospective analysis of the Michigan Surgical Quality Collaborative Core Optimization Hernia Registry from January 2020 to March 2023. The primary outcome was postoperative complication across age groups: 18-64, 65-74, and ≥ 75 years, with secondary outcome of surgical approach. Mixed-effects logistic regression evaluated association between minimally invasive surgery (MIS) and 30-day complications, controlling for patient and hernia characteristics.

RESULTS

Among 8,659 patients, only 7% were 75 or older. MIS rates varied across hospitals [Median = 31.4%, IQR: (14.8-51.6%)]. The overall complication rate was 2.2%. Complication risk for undergoing open versus MIS approach did not vary between age groups; however, patients over age 75 undergoing laparoscopic repair had increased risk (aOR = 4.58, 95% CI 1.13-18.67). Other factors associated with risk included female sex (aOR = 2.10, 95% CI 1.51-2.93), higher BMI (aOR = 1.18, 95% CI 1.03-1.34), hernia width ≥ 6 cm (aOR = 3.15, 95% CI 1.96-5.04), previous repair (aOR = 1.44, 95% CI 1.02-2.05), and component separation (aOR = 1.98, 95% CI 1.28-3.05). Patients most likely to undergo MIS were female (aOR = 1.21, 95% CI 1.09-1.34), black (aOR = 1.30, 95% CI 1.12-1.52), with larger hernias: 2-5.9 cm (aOR = 1.76, 95% CI 1.57-1.97), or intraoperative mesh placement (aOR = 14.4, 95% CI 11.68-17.79). There was no difference in likelihood to receive MIS across ages when accounting for hospital (SD of baseline likelihood = 1.53, 95% CI 1.14-2.05) and surgeon (SD of baseline likelihood = 2.77, 95% CI 2.46-3.11) variation.

CONCLUSIONS

Our findings demonstrate that hernia, intraoperative, and patient characteristics other than age increase probability for complication following VHR. These findings can empower surgeons and older patients considering preoperative risk for VHR.

Application of Closed Incision Negative Pressure Wound Therapy in Ventral Hernia Repair Surgery Using a Polypropylene Mesh: A Randomized Clinical Trial

Background and Objectives: Surgical site infections (SSIs) are a significant complication following ventral hernia repair, potentially leading to prolonged hospital stays and increased morbidity. This study aimed to evaluate whether closed incision negative pressure wound therapy (ciNPWT) reduces the incidence of SSI after ventral hernia repair with polypropylene mesh compared to standard wound care. Materials and Methods: A randomized study was conducted with 100 patients undergoing ventral hernia repair using a polypropylene mesh. Participants were divided into two groups: a control group (n=50), which received standard sterile gauze dressing with an iodine-based disinfectant, and an intervention group (n=50), treated with the ciNPWT system (Vivano® by HARTMANN) for 5 days postoperatively. The primary outcome was the incidence of SSI within one year after surgery. Secondary outcomes included the influence of factors such as age, sex, smoking status, and hernia size on SSI occurrence. The study was approved by the Ethics Committee at the University Hospital Ostrava, adhering to the ethical standards of the Helsinki Declaration. Results: The incidence of SSI was lower in the ciNPWT group compared to the standard care group (4% vs. 12%), though this difference did not reach statistical significance. No significant effect of sex or smoking status on SSI was observed. The control group had a shorter mean length of hospital stay. Larger hernias in the non-ciNPWT group were more prone to SSIs, as expected. Conclusions: Although limited by a small sample size, the findings suggest that ciNPWT may be associated with a reduced rate of SSI following ventral hernia repair. Further studies with larger populations are needed to confirm these results.

The association of hernia-specific and procedural risk factors with early complications in ventral hernia repair: ACHQC analysis

BACKGROUND

Many surgical risk assessment tools emphasize patient-specific risk factors. Our objective was to use a hernia-specific database to assess risk factors of complications in ventral hernia repair (VHR) focusing on hernia-specific and procedural factors.

METHODS

The ACHQC database was queried for elective VHR in adults from 2012 to 2023. Primary outcome was overall 30-day complications. Multivariable logistic regression was used for analysis.

RESULTS

41,526 VHR were included. The rate of 30-day complications was 18%, surgical site infection 3%, surgical site occurrence requiring procedural intervention 4%, readmission 4%, reoperation 2%, and mortality 0.2%. Multivariable analysis demonstrated that BMI, ASA, frailty, COPD, anticoagulants, defect width, incisional and recurrent hernias, presence of stoma or prior mesh, prior abdominal wall infection, non-clean wound, operative time, open approach and myofascial release were associated with 30-day complications (OR ​= ​1.01-1.66). Preoperative chlorhexidine, bowel preparation and fascial closure were associated with lower complication risk (OR ​= ​0.70-0.89).

CONCLUSION

Hernia and procedural risk factors are associated with early complications following elective VHR. These factors need to be included in surgical risk assessment tools, to supplement patient-specific factors.

Bariatric surgery is as safe as other common operations: an analysis of the ACS-NSQIP

BACKGROUND

Metabolic and Bariatric Surgery (MBS) is the most effective management for patients with obesity and weight-related medical conditions. Nonetheless, some primary care physicians (PCPs) and surgeons from other specialties are reluctant to refer patients for MBS due to safety concerns.

OBJECTIVES

To compare the outcomes of patients who underwent MBS with those who underwent other common operations.

SETTING

American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP).

METHODS

Patients who underwent laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass (RYGB), classified as MBS, were compared to nine frequently performed procedures including hip arthroplasty and laparoscopic cholecystectomy, appendectomy, colectomy, hysterectomy, and hernia repairs, among others. A multivariable logistic regression was constructed to compare outcomes including readmission, reoperation, extended length of stay (ELOS) (>75th percentile or ≥3 days) and mortality.

RESULTS

A total of 1.6 million patients were included, with 11.1% undergoing MBS. The odds of readmission were marginally lower in the cholecystectomy (adjusted odds ratio [aOR] = .88, 95% confidence interval (CI) [.85, .90]) and appendectomy (aOR = .88, 95% CI [.85, .90]) cohorts. Similarly, odds of ELOS were among the lowest, surpassed only by same-day procedures such as cholecystectomies and appendectomies. The MBS group had significantly low odds of mortality, comparable to safe anatomical procedures such as hernia repairs. Infectious and thrombotic complications were exceedingly rare and amongst the lowest after MBS.

CONCLUSIONS

MBS demonstrates a remarkably promising safety profile and compares favorably to other common procedures in the short-term. PCPs and surgeons from other specialties can confidently refer patients for these low-risk, lifesaving operations.

Evaluation of 30-day outcomes for open ventral hernia repair using self-gripping versus nonself-gripping mesh

BACKGROUND

The use of mesh is standard of care for large ventral hernias repaired on an elective basis. The most used type of mesh includes synthetic polypropylene mesh; however, there has been an increase in the usage of a new polyester self-gripping mesh, and there are limited data regarding its efficacy for ventral hernia. The purpose of the study is to determine whether there is a difference in surgical site occurrence (SSO), surgical site infection (SSI), surgical site occurrence requiring procedural intervention (SSOPI), and recurrence at 30 days after ventral hernia repair (VHR) using self-gripping (SGM) versus non-self-gripping mesh (NSGM).

METHODS

We performed a retrospective study from January 2014 to April 2022 using the Abdominal Core Health Quality Collaborative (ACHQC). We collected data on patients over 18 years of age who underwent elective open VHR using SGM or NSGM and whom had 30-day follow-up. Propensity matching was utilized to control for variables including hernia width, body mass index, age, ASA, and mesh location. Data were analyzed to identify differences in SSO, SSI, SSOPI, and recurrence at 30 days.

RESULTS

9038 patients were identified. After propensity matching, 1766 patients were included in the study population. Patients with SGM had similar demographic and clinical characteristics compared to NSGM. The mean hernia width to mesh width ratio was 8 cm:18 cm with NSGM and 7 cm:15 cm with SGM (p = 0.63). There was no difference in 30-day rates of recurrence, SSI or SSO. The rate of SSOPI was also found to be 5.4% in the nonself-gripping group compared to 3.1% in the self-gripping mesh group (p < .005). There was no difference in patient-reported outcomes at 30 days.

CONCLUSIONS

In patients undergoing ventral hernia repair with mesh, self-gripping mesh is a safe type of mesh to use. Use of self-gripping mesh may be associated with lower rates of SSOPI when compared to nonself-gripping mesh.

Is simultaneous bariatric surgery and ventral hernia repair a safe and effective approach?

BACKGROUND

There is currently a lack of consensus regarding the timing of ventral hernia repair relative to bariatric surgery.

OBJECTIVES

To compare outcomes between patients undergoing simultaneous and selectively deferred ventral hernia repair and bariatric surgery.

SETTING

High volume UPPER gastrointestinal and Bariatric Unit. Sydney, Australia.

METHODS

A retrospective case series from a single institution's prospectively collected database (2003-21) was performed to determine the characteristics and outcomes in patients having simultaneous and deferred hernia repair relative to their bariatric surgery.

RESULTS

In our patient cohort (N = 134), 111 patients underwent simultaneous repair and 23 had a deferred procedure. Of the simultaneous patients, 95 (85.6%) underwent resection bariatric surgery. The median operative time in the simultaneous versus deferred groups was 155 versus 287 minutes and the length of stay was 3 versus 7 days. There has been one (.9%) mesh infection requiring explant, in an open, simultaneous repair undertaken in a gastric band patient, 3 (2.8%) infected seromas, 1 (.9%) surgical site infection, and 8 (7.5%) hernia recurrences in the simultaneous group. The deferred group has had no mesh infections, no hernia recurrence, and 2 (9.5%) infected seromas to date. There was 1 mortality in the simultaneous cohort (simultaneous gastric bypass group), from a massive Pulmonary Embolism (<30 days postoperatively) and one in the deferred group from an interval small bowel obstruction.

CONCLUSIONS

Simultaneous ventral hernia repair with bariatric surgery had a low rate of infection and a low mesh explant rate, even when coupled with resection bariatric surgery in this series. A combined approach may be safe, even in the clean-contaminated surgical context.

Impact of sex on ventral hernia repair outcomes: A systematic review and meta-analysis

BACKGROUND

Given the variability in abdominal physiology and hernia presentation between sexes, better comprehension of sex-related differences in outcomes would tailor surgical approach and counseling regarding postoperative outcomes. This meta-analysis aims to appraise the effect of sex on the outcomes of ventral hernia repair.

METHODS

A literature search in PubMed, EMBASE and Cochrane selected studies comparing outcomes of ventral hernia repair between sexes. Postoperative outcomes were assessed by pooled and meta-analysis. Statistical analysis was performed using RevMan 5.4.

RESULTS

We screened 3128 studies, reviewed 133, and included 18 observational studies, which encompassed 220,799 patients following ventral hernia repair. Postoperative chronic pain was significantly higher in female (OR 1,9; 95% CI 1,64-2,2; p ​< ​0,001). There were no significant differences in complications, readmission, or recurrence rates between females and males.

CONCLUSION

Female sex is associated with a higher risk of postoperative chronic pain following ventral hernia repair.

Body Mass Index Within Multifactor Predictors of Ventral Hernia Recurrence: A Retrospective Cohort Study

Background A ventral hernia is a protrusion of the peritoneum through the defective abdominal wall. Several risk factors increase the likelihood of hernial recurrence. One of the most common risk factors is obesity, defined by the World Health Organization (WHO) as increased body mass index (BMI). Few studies have explored the effects of BMI and other factors on hernia recurrence. Hence, we aimed to investigate the role of increased BMI in hernia recurrence in conjunction with various risk factors such as age, sex, type of hernia, the time elapsed between the occurrence and recurrence, complications of hernia, and procedure. Methods This retrospective cohort study was conducted at King Abdulaziz University Hospital (KAUH). All the patients were admitted between 2015-2022. A total of 1676 medical records were obtained from all patients who underwent hernia repair more than once or were diagnosed with a recurrent hernia during the study period. Results Our study revealed an insignificant correlation between a BMI of more than 25 kg/m² and the recurrence of inguinal hernias, predominantly indirect hernias. Furthermore, overweight and obese patients experience a longer interval between the first and second hernia repairs. Interestingly, all the patients with inguinal and umbilical hernias had the same diagnosis at the second presentation. However, the findings also included a significant increase in umbilical hernias in individuals with a high BMI and higher recurrence rates among male patients with inguinal hernias. Conclusion BMI higher than 25 kg/m² increases recurrence rates for umbilical hernias but decreases the recurrence of inguinal hernias.