The utilization of laparoscopy in ventral hernia repair: an update of outcomes analysis using ACS-NSQIP data

Long-Term Outcomes of Ventral Hernia Repair: An 11-Year Follow-Up

Background: Ventral hernia repair (VHR) is one of the most common general surgery procedures; however, few studies with long-term follow-up of VHR outcomes exist.

Methods: We performed a retrospective review of VHRs performed from 2000 to 2009 at a single institution. Our primary outcome was recurrence, and secondary outcomes were reoperations and complications including seroma, hematomas, abdominal wall abscess, wound infections, and mesh infections.

Results: Our sample population (n=420; mean age 46.3±11.7 years) included 230 females (54.8%), and cases included laparoscopic (n=31; 7.5%), laparoscopic converted to open (n=7; 1.7%), and open (n=373, 90%). As compared to suture repairs, mesh repair was associated with lower rates of complications (25.7% vs 29.5%, p=0.10) and recurrence (12.8% vs 15.2%, p=0.67). Laparoscopic repairs had lower rates of complications than open repairs (25% vs 26.8%; p=0.70) but similar rates of recurrence (13.8% and 13.6%; p=0.53). After logistic regression, obesity, chronic obstructive pulmonary disease, component separation technique, and prolonged operating time (>75th percentile) were associated with increased complications.

Conclusion: Obesity is a modifiable risk factor and must be addressed in patients undergoing VHRs. Mesh repair does not increase the risk of adverse long-term outcomes and may be performed safely in patients undergoing VHR.

Surgical site occurrences, not body mass index, increase the long-term risk of ventral hernia recurrence

BACKGROUND

Recurrence rates after ventral hernia repair vary widely and evidence about risk factors for recurrence are conflicting. There is little evidence for risk factors for long-term recurrence.

METHODS

Patients who underwent ventral hernia repair at our institution and were captured in the American College of Surgeons-National Surgical Quality Improvement Program database between 2002 and 2015 were included. We reviewed all demographic, procedural, and hernia-specific data.

RESULTS

Six hundred and thirty patients were included for analysis with a median follow-up of 4.9 years (inter-quartile range, 2-7.3 years). By univariate analysis, index hernia repairs were more likely to recur if defect size was ≥4 cm (P = .019), no mesh was used (P = .026), or if the repair was for a recurrent hernia (P = .001). Five-year cumulative incidence of recurrence and reoperation was 24.3% and 16.0%, respectively. Patients with a perioperative surgical site occurrence, which included superficial, deep-incisional, and organ space surgical site infections as well as wound disruption, had a 5-year cumulative incidence of recurrence of 54.9% compared with 22.6% for those without surgical site occurrence. By multivariable analysis, non-primary hernia repair (hazard ratio 1.7, 95% confidence interval 1.2-2.4, P = .005) and any postoperative surgical site occurrence (hazard ratio 1.9, 95% confidence interval 1.1-3.6, P = .02) were the only risk factors predictive of recurrence. Patient body mass index had no independent effect on recurrence.

CONCLUSION

1 in 4 patients undergoing an open ventral hernia repair will have a recurrence after 5 years, and this risk is doubled among patients who experience any perioperative surgical site occurrence. After controlling for patient comorbidities, including body mass index, hernia size, and mesh position, the most significant risk factor for recurrence after ventral hernia repair was a non-primary hernia and surgical site occurrence.

Robotic assistance in ventral hernia repair may decrease the incidence of hernia recurrence

Background:

Since the advent of laparoscopic surgery, many studies have shown the advantages of laparoscopic surgery over open surgery for ventral hernia repair (VHR). As robotic surgery is gaining popularity, we sought to compare the outcomes of this newer robotic-assisted technique to the outcomes of established open and laparoscopic techniques to assess for any additional benefit.

Methods:

A meta-analysis research design was employed. Multiple databases were queried for publications over the past 10 years and 23 articles were selected based on pre-determined selection criteria. Data were extracted and the arm-based network meta-analysis method was utilised to examine the effect difference for the three arms of our study: Open, laparoscopic and robotic-assisted VHR.

Results:

As expected, laparoscopy had an advantage over open VHR in terms of infection rates. This advantage was also observed in the robotic group over the open group; however, there was no statistical difference between the laparoscopic and robotic groups when infection rates were compared head-to-head. The robotic group had a significant advantage over both the open and more importantly, the laparoscopic groups in recurrence rates.

Conclusions:

The results of this study suggest that robotic surgery maintains some of the advantages of laparoscopic surgery and may also provide the additional advantage of recurrence rate reduction. This may be explained by the ability to perform a more complex hernia repair with robotic assistance secondary to the ease of closure of the fascial defect. More research is needed to validate this finding.

Impact of body mass index on minimally invasive ventral hernia repair: an ACS-NSQIP analysis

PURPOSE

Body mass index (BMI) ≥ 35 kg/m² is a known independent risk factor for complications following open ventral hernia repair (VHR). We sought to examine the relationship between BMI and minimally invasive VHR.

METHODS

The ACS-NSQIP database was queried for all patients age ≥ 18 years undergoing minimally invasive VHR (2005-2015). Patients were stratified into seven BMI classes: underweight (BMI < 18.5 kg/m²), normal weight (BMI 18.5-24.9), overweight (25-29.9), obese (30-34.5), severely obese (35-39.9), morbidly obese (40-49.9), and super obese (BMI ≥ 50), as well as by hernia type (reducible vs. strangulated) and time of repair (initial vs. recurrent). Multivariate logistic regression was employed to assess the risk of complication by BMI class.

RESULTS

A total of 55,180 patients met inclusion criteria, and 61.4% had a BMI > 30 kg/m². When stratified by BMI class, we found significant differences in age, gender, race, comorbidities, and pre-operative characteristics across groups. The overall complication rate was 4.0%, ranging from 3.0% for normal BMI patients, to 6.9% for patients with a BMI ≥ 50 kg/m². Recurrent repairs and strangulated hernias both demonstrated higher complication rates. All complications (surgical and medical) were significantly associated with BMI class after adjustment (p < 0.0001). Patients with a BMI ≥ 50 kg/m² had a 1.4 times greater risk for complications than patients with normal BMIs (18-24.9 kg/m², p = 0.01).

CONCLUSION

BMI ≥ 50 kg/m² was determined to be an independent risk factor for surgical and medical complications after minimally invasive VHR.

Hernia Management in Cirrhosis: Risk Assessment, Operative Approach, and Perioperative Care

BACKGROUND

The rising incidence of liver disease has complicated the management of common surgical pathologies. Hernias, in particular, are problematic given the shortage of high-quality data and differing expert opinions. We aim to provide a narrative review of hernia management in cirrhosis as a first step toward developing evidence-based recommendations for the care of these patients.

MATERIALS AND METHODS

A literature review using separate search strings was conducted for PubMed and Cochrane Central Register of Controlled Trials databases. Review articles, conference abstracts, randomized clinical trials, and observational studies were included. Articles without a focus on patients with end-stage liver disease were excluded. Manuscripts were selected based on relevance to perioperative risk assessment, medical optimization, surgical decision-making, and considerations of hernia repair in patients with cirrhosis.

RESULTS

The existing literature is varied with regard to focus and quality of data. Of the 4516 articles identified, 51 full-text articles were selected for review. In general, there is evidence to suggest that individuals with compensated cirrhosis may successfully undergo and benefit from hernia repair. Patients at high risk for decompensated cirrhosis may be best served by nonoperative management.

CONCLUSIONS

Carefully selected patients with cirrhosis may proceed with herniorrhaphy. A multidisciplinary approach is essential to provide high-quality care and improve outcomes.

Laparoscopic versus open ventral hernia repair in patients with chronic liver disease

BACKGROUND

Previous studies demonstrated laparoscopic ventral hernia repair (LVHR) to be associated with fewer short-term complications than open ventral hernia repair (OVHR). Little literature is available comparing LVHR and OVHR in chronic liver disease (CLD) patients.

METHODS

Patients with model for end-stage liver disease score ≥9 who underwent elective ventral hernia repair in the National Surgical Quality Improvement Program Database were included. 30-day outcomes were compared between LVHR and OVHR after adjusting for hernia disease severity, baseline comorbidities and demographic factors.

RESULTS

A total of 3594 ventral hernia repairs were included, 536 (14.9 %) of which were LVHR. After adjusting for other confounders, LVHR was associated with a lower incidence of wound-related complications (0.23, 95 % CI 0.07-0.74, p = 0.01), shorter length of stay (mean 3.7 vs. 5.0 days, p < 0.01) than OVHR, but similar systemic complications (p = 0.77), bleeding complications (p = 0.69), unplanned reoperation (p = 0.74) or readmission (p = 0.40). Propensity score-matched comparison showed similar conclusions. Five hundred and sixty-two patients had ascites, among whom 35 (6.2 %) underwent LVHR. In this subcohort, LVHR was associated with higher mortality (OR 5.36, 95 % CI 1.00-28.60, p = 0.05), systemic complications (OR 7.03, 95 % CI 2.06-24.00, p < 0.01), and unplanned reoperation (OR 6.03, 95 % CI 1.51-24.12, p = 0.01) than OVHR.

CONCLUSIONS

In comparison with OVHR, LVHR is associated with similar short-term outcomes except for lower wound-related complications and shorter length of stay in CLD patients. However, when patients have ascites, LVHR is associated with higher mortality, systemic complications, and unplanned reoperation.

Current Status and Challenges of Laparoscopy in Ventral Hernia Repair

Laparoscopic repair of ventral hernias gained strong popularity in the late nineties with some of the early enthusiasm lost later in time. We review the current status and challenges of laparoscopy in ventral hernia repair and best practices in this area. We specifically looked at patient and hernia defect factors, technical considerations that have contributed to the successes, and some of the failures of laparoscopic ventral hernia repair (LVHR). Patients best suited for a laparoscopic repair are those who are obese and diabetic with a total defect size not to exceed 10 cm in width or a "Swiss cheese" defect. Overlap of mesh to healthy fascia of at least 5 cm in every direction, with closure of the defect, is essential to prevent recurrence or bulging over time. Complications specifically related to surgical site occurrence favor the laparoscopic approach. Recurrence rates, satisfaction, and health-related quality of life results are similar to open repairs, but long-term data are lacking. There is still conflicting data regarding ways of fixating the mesh. The science of prosthetic material appropriate for intraperitoneal placement continues to evolve. The field continues to be plagued by single author, single institution, and small nonrandomized observational studies with short-term follow-up. The recent development of large prospective databases might allow for pragmatic and point-of-care studies with long-term follow-up. We conclude that LVHR has evolved since its inception, has overcome many challenges, but still needs better long-term studies to evaluate evolving practices.

Current Trends in Laparoscopic Ventral Hernia Repair

Background and Objectives:

The purpose of this study was to analyze the surgical technique, postoperative complications, and possible recurrence after laparoscopic ventral hernia repair (LVHR) in comparison with open ventral hernia repair (OVHR), based on the international literature.

Database:

A Medline search of the current English literature was performed using the terms laparoscopic ventral hernia repair and incisional hernia repair.

Conclusions:

LVHR is a safe alternative to the open method, with the main advantages being minimal postoperative pain, shorter recovery, and decreased wound and mesh infections. Incidental enterotomy can be avoided by using a meticulous technique and sharp dissection to avoid thermal injury.

Delayed repair of obstructing ventral hernias is associated with higher mortality and morbidity

BACKGROUND

Patients presenting with ventral hernia-related obstruction are commonly managed with emergent ventral hernia repair (VHR). Selected patients with resolution of obstruction may be managed in a delayed manner. This study sought to assess the effect of delay on VHR outcomes.

METHODS

The American College of Surgeons' National Surgical Quality Improvement Program database from 2005 to 2011 was queried using diagnosis codes for ventral hernia with obstruction. Those who underwent repair over 24 hours after admission were classified as delayed repair. Preoperative comorbid conditions, American Society of Anesthesiology (ASA) scores, and 30-day outcomes were evaluated.

RESULTS

We identified 16,881 patients with a mean age of 58 ± 15 years and body mass index of 36 ± 10. Delayed repair occurred in 27.7% of the patients. After controlling for comorbidities and ASA score, delayed VHR was independently associated with mortality (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.41 to 2.48, P < .001), morbidity (OR 1.4, 95% CI 1.24 to 1.50, P < .001), surgical site infection (OR 1.2, 95% CI 1.03 to 1.35, P = .016), and concurrent bowel resection (OR 1.2, 95% CI 1.03 to 1.34, P = .016).

CONCLUSIONS

VHR for obstructed patients is frequently performed over 24 hours after admission. After adjusting for comorbid conditions and ASA score, delayed VHR is independently associated with worse outcomes. Prompt repair after appropriate resuscitation should be the management of choice.