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McLaughlin CM, Montelione KC, Tu C, Candela X, Pauli E, Prabhu AS, Krpata DM, Petro CC, Rosenblatt S, Rosen MJ, Horne CM. Outcomes of posterior component separation with transversus abdominis release for repair of abdominally based breast reconstruction donor site hernias. Hernia 2024; 28:507-516. [PMID: 38286880 DOI: 10.1007/s10029-023-02942-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 12/08/2023] [Indexed: 01/31/2024]
Abstract
PURPOSE Abdominally based autologous breast reconstruction (ABABR) is common after mastectomy, but carries a risk of complex abdominal wall hernias. We report experience with posterior component separation (PCS) and transversus abdominis release (TAR) with permanent synthetic mesh repair of ABABR-related hernias. METHODS Patients at Cleveland Clinic Foundation and Penn State Health were identified retrospectively. Outcomes included postoperative complications, hernia recurrence, and patient-reported outcomes (PROs): Hernia Recurrence Inventory, HerQLes Summary Score, Patient-Reported Outcome Measurement Information System (PROMIS) Pain Intensity 3a Survey, and the Decision Regret Scale (DRS). RESULTS Forty patients underwent PCS/TAR repair of hernias resulting from pedicled (35%), free (5%), muscle-sparing TRAMs (15%), and DIEPs (28%) from August 2014 to March 2021. Following PCS, 30-day complications included superficial surgical site infection (13%), seroma (8%), and superficial wound breakdown (5%). Five patients (20%) developed clinical hernia recurrence. At a minimum of 1 year, 17 (63%) reported a bulge, 12 (44%) reported pain, median HerQLes Quality Of Life Scores improved from 33 to 63/100 (p value < 0.01), PROMIS 3a Pain Intensity Scores improved from 52 to 38 (p value < 0.05), and DRS scores were consistent with low regret (20/100). CONCLUSION ABABR-related hernias are complex and technically challenging due to missing abdominal wall components and denervation injury. After repair with PCS/TAR, patients had high rates of recurrence and bulge, but reported improved quality of life and pain and low regret. Surgeons should set realistic expectations regarding postoperative bulge and risk of hernia recurrence.
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Affiliation(s)
- C M McLaughlin
- Department of General Surgery, Division of Plastic Surgery, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA.
| | - K C Montelione
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - C Tu
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - X Candela
- Department of Plastic Surgery, University of Pittsburgh Medical Center, Hershey, PA, USA
| | - E Pauli
- Department of General Surgery, Division of Minimally Invasive Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - A S Prabhu
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - D M Krpata
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - C C Petro
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - S Rosenblatt
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - M J Rosen
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - C M Horne
- Department of General Surgery, Division of Minimally Invasive Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
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DeLong CG, Crowell KT, Liu AT, Deutsch MJ, Scow JS, Pauli EM, Horne CM. Staged abdominal wall reconstruction in the setting of complex gastrointestinal reconstruction. Hernia 2024; 28:97-107. [PMID: 37648895 DOI: 10.1007/s10029-023-02856-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 07/27/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE Literature on one- versus two-staged abdominal wall reconstruction (AWR) with complex gastrointestinal reconstruction (GIR) is limited to single-arm case series with a focus on patients who complete all planned stages. Herein, we describe our experience with both one- and two-staged approaches to AWR/GIR, with attention to those who did not complete both intended stages. METHODS A retrospective review of prospectively collected data was conducted to identify patients who underwent a one- or two-stage approach to GIR/AWR from 2013 to 2020. The one-stage approach included GIR and definitive sublay mesh herniorrhaphy. The two-stage approach included Stage 1 (S1)-GIR and non-definitive herniorrhaphy and Stage 2 (S2)-definitive sublay mesh herniorrhaphy. RESULTS Fifty-four patients underwent GIR/AWR: 20 (37.0%) underwent a planned 1-stage operation while 34 (63.0%) underwent S1 of a planned 2-stage approach. Patients assigned to the 2-stage approach were more likely to be smokers, have a history of mesh infection, have an enterocutaneous fistula, and a contaminated wound class (p<0.05). Of the 34 patients who underwent S1, 12 (35.3%) completed S2 during the mean follow-up period of 44 months while 22 (64.7%) did not complete S2. Of these, 10 (45.5%) developed hernia recurrence but did not undergo S2 secondary to elective nonoperative management (40%), pending preoperative optimization (30%), additional complex GIR (10%), hernia-related incarceration requiring emergent surgery (10%), or unrelated death (10%). No differences in outcome including SSI, SSO, readmission, and recurrence were noted between the 12 patients who completed the two-stage approach and the 20 patients who completed a one-stage approach, despite increased risk factors for complications in the 2-stage group (p>0.05). CONCLUSION Planned two-stage operations for GIR/AWR may distribute operative complexity and post-operative morbidity into separate surgical interventions. However, many patients may never undergo the intended definitive S2 herniorrhaphy. Future evaluation of 1- versus 2-stage GIR/AWR is needed to clarify indications for each approach. This work must also consider the frequent deviations from intended clinical course demonstrated in this study.
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Affiliation(s)
- C G DeLong
- Department of Surgery, Penn State University College of Medicine, 500 University Drive, Hershey, PA, 17033-0850, USA
| | - K T Crowell
- Division of Colon and Rectal Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - A T Liu
- Department of Surgery, Penn State University College of Medicine, 500 University Drive, Hershey, PA, 17033-0850, USA
| | - M J Deutsch
- Division of Colon and Rectal Surgery, Penn State University College of Medicine, Hershey, PA, USA
| | - J S Scow
- Division of Colon and Rectal Surgery, Penn State University College of Medicine, Hershey, PA, USA
| | - E M Pauli
- Division of Minimally Invasive and Bariatric Surgery, Penn State University College of Medicine, Hershey, PA, USA
| | - C M Horne
- Division of Minimally Invasive and Bariatric Surgery, Penn State University College of Medicine, Hershey, PA, USA.
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Morrell DJ, Doble JA, Hendriksen BS, Horne CM, Hollenbeak CS, Pauli EM. Comparative effectiveness of surgeon-performed transversus abdominis plane blocks and epidural catheters following open hernia repair with transversus abdominis release. Hernia 2021; 25:1611-1620. [PMID: 34319465 DOI: 10.1007/s10029-021-02454-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 06/27/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Recovery protocols aim to limit narcotic administration following ventral hernia repair (VHR). However, little is known about the contribution of a protocol's individual components on patient outcomes. We previously reported that surgeon-performed transversus abdominis plane block (TAP-block) is more effective than ultrasound-guided TAP-block following VHR. This study evaluates the effectiveness of two postoperative analgesia modalities: epidural catheter and surgeon-performed TAP-block following VHR performed with transversus abdominis release (TAR). METHODS A retrospective analysis was performed on data prospectively collected between 2012 and 2019. All patients undergoing open VHR with TAR performed by a single surgeon were identified. Parastomal hernia repairs and any patients receiving ultrasound-guided TAP blocks or paraspinal blocks were excluded. Primary outcome was length of stay (LOS) with secondary outcomes including pain scores, opioid requirements, and 30-day morbidity. Linear regression was used to model LOS. RESULTS One hundred thirty-five patients met inclusion criteria (63 epidural, 72 TAP-block). The majority (67.4%) of patients were modified ventral hernia working group grade 2. The only statistically significant difference in postoperative pain scores between the groups was on postoperative day 2 (TAP block 3.19 versus epidural 4.11, p = 0.0126). LOS was significantly shorter in the TAP block group (4.7 versus 6.2 days, p = 0.0023) as was time to regular diet (3.2 versus 4.7 days, p < 0.0001). After controlling for confounders, epidural was associated with increased LOS by 1.3 days (p = 0.0004). CONCLUSION Epidural use following VHR with TAR is associated with increased LOS and increased time to regular diet without reducing pain or opioid use when compared to surgeon-performed TAP block.
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Affiliation(s)
- D J Morrell
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| | - J A Doble
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| | - B S Hendriksen
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| | - C M Horne
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| | - C S Hollenbeak
- Department of Health Policy and Administration, The Pennsylvania State University, University Park, PA, USA
| | - E M Pauli
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA.
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Horne CM, Augenstein V, Malcher F, Yunis J, Huang LC, Zolin SJ, Fafaj A, Thomas JD, Krpata DM, Petro CC, Rosen MJ, Prabhu AS. Understanding the benefits of botulinum toxin A: retrospective analysis of the Abdominal Core Health Quality Collaborative. Br J Surg 2021; 108:112-114. [PMID: 33711107 DOI: 10.1093/bjs/znaa050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/14/2020] [Accepted: 09/29/2020] [Indexed: 11/12/2022]
Abstract
This was a retrospective analysis of a prospectively maintained database that objectively evaluated the benefit of preoperative chemical component separation with botulinum toxin A in complex hernia repairs.
Continued evaluation.
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Affiliation(s)
- C M Horne
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - V Augenstein
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - F Malcher
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - J Yunis
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - L-C Huang
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - S J Zolin
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - A Fafaj
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - J D Thomas
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - D M Krpata
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - C C Petro
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - M J Rosen
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
| | - A S Prabhu
- Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Carolinas Medical Center, Montefiore Medical Center, Jonathan Yunis Center for Hernia Repair, Sarasota, FL, USA
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Haskins IN, Horne CM, Krpata DM, Prabhu AS, Tastaldi L, Perez AJ, Rosenblatt S, Poulose BK, Rosen MJ. A call for standardization of wound events reporting following ventral hernia repair. Hernia 2018; 22:729-736. [PMID: 29429064 DOI: 10.1007/s10029-018-1748-6] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 01/25/2018] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Postoperative wound events following ventral hernia repair are an important outcome measure. While efforts have been made by hernia surgeons to identify and address risk factors for postoperative wound events following VHR, the definition of these events lacks standardization. Therefore, the purpose of our study was to detail the variability of wound event definitions in recent ventral hernia literature and to propose standardized definitions for postoperative wound events following VHR. METHODS The top 50 cited ventral hernia, peer-reviewed publications from 1995 through 2015 were identified using the search engine Google Scholar. The definition of wound event used and the incidence of postoperative wound events was recorded for each article. The number of articles that used a standardized definition for surgical site infection (SSI), surgical site occurrence (SSO), or surgical site occurrence requiring procedural intervention (SSOPI) was also identified. RESULTS Of the 50 papers evaluated, only nine (18%) used a standardized definition for SSI, SSO, or SSOPI. The papers that used standardized definitions had a smaller variability in the incidence of wound events when compared to one another and their reported rates were more consistent with recently published ventral hernia repair literature. CONCLUSION Postoperative wound events following VHR are intimately associated with patient quality of life and long-term hernia repair durability. Standardization of the definition of postoperative wound events to include SSI, SSO, and SSOPI following VHR will improve the ability of hernia surgeons to make evidence-based decisions regarding the management of ventral hernias.
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Affiliation(s)
- I N Haskins
- Department of General Surgery, Comprehensive Hernia Center, The Cleveland Clinic Foundation, Cleveland, OH, USA. .,Department of General Surgery, Cleveland Clinic Comprehensive Hernia Center, The Cleveland Clinic, 9500 Euclid Avenue, A100, Cleveland, OH, 44195, USA.
| | - C M Horne
- Department of General Surgery, Comprehensive Hernia Center, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - D M Krpata
- Department of General Surgery, Comprehensive Hernia Center, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - A S Prabhu
- Department of General Surgery, Comprehensive Hernia Center, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - L Tastaldi
- Department of General Surgery, Comprehensive Hernia Center, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Arielle J Perez
- Department of General Surgery, Comprehensive Hernia Center, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - S Rosenblatt
- Department of General Surgery, Comprehensive Hernia Center, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - B K Poulose
- Department of Surgery, The Vanderbilt Hernia Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - M J Rosen
- Department of General Surgery, Comprehensive Hernia Center, The Cleveland Clinic Foundation, Cleveland, OH, USA
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