Early outcomes of an enhanced recovery protocol for open repair of ventral hernia

[Perioperative Management in Hernia Surgery]

Hernia surgery has evolved in recent years through the implementation of newer minimally invasive and robotic surgical techniques. Moreover, abdominal wall reconstruction for abdominal wall hernias has increased in complexity, due to a peri- and intraoperative strategy for expansion. Perioperative management in this area is also determined by Enhanced Recovery After Surgery (ERAS) pathways to improve peri- and postoperative outcomes after hernia surgery. This article aims to assess the influence of individual factors in the multimodal ERAS concept on outpatient and inpatient hernia repair and abdominal wall reconstruction, on the basis of current studies.

Consensus in ERAS protocols for ventral hernia repair: evidence-based recommendations from the ACHQC QI Committee

PURPOSE

Enhanced recovery after surgery (ERAS) protocols are widely used in the post-operative care of hernia patients. Despite their prevalence, an absence of published consensus guidelines creates significant heterogeneity in practices. The aim of this study was to evaluate elements in ERAS protocols utilized in ventral hernia repair from institutions across the United States and provide consensus recommendations for each identified element.

METHODS

Institutional members of the Abdominal Core Health Quality Collaborative (ACHQC) Quality Improvement (QI) committee submitted current ERAS protocols. Items within each protocol were classified as "elements", then assigned a topic. Any topic with ≥ 2 elements from separate institutions were labeled as a "theme," then grouped by stage in the patient care cycle. A brief review of current evidence was provided in addition to a ACHQC QI committee consensus statement.

RESULTS

A total of 295 elements from 6 tertiary referral centers specializing in hernia care were compiled into 24 themes and grouped by four separate stages: Pre-Admission Optimization, Pre-Operative Care, Intra-operative Care, and Post-Operative Management.

CONCLUSION

This article represents a multi-institutional review of ERAS protocols for ventral hernia repair and identifies common themes that may provide the framework for a unified ERAS protocol in hernia surgery. Future work may serve to develop societal guidelines defined specifically for enhanced recovery in ventral hernia repair.

Initial experience with enhanced recovery after surgery (ERAS) and early discharge protocols after robotic extended totally extraperitoneal (eTEP) hernia surgery

BACKGROUND

Though robotic adoption for eTEP surgery has decreased technical barriers to minimally invasive repairs of large ventral hernias, relatively few studies have examined outcomes of robotic-specific eTEP surgery. This study evaluates safety, feasibility, and early outcomes of ERAS/same-day discharge protocols for robotic eTEP ventral hernia repairs.

METHODS

A retrospective chart review was performed for all robotic eTEP hernia surgeries at a single institution between 2019 and 2022. Analysis included patient demographics, hernia characteristics, intraoperative data, and post-operative outcomes at 30 days. ERAS protocol included: judicious use of urinary catheters with removal at end of case if placed, bilateral transversus abdominus plane (TAP) blocks, post-operative abdominal wall binder, and opioid-sparing perioperative analgesia. Patients were discharged same day from post-anesthesia care unit (PACU) if they lacked comorbidities requiring observation post-anesthesia and demonstrated stable vital signs, adequate pain control, ability to void, and ability to ambulate. Hospital length of stay (LOS) was considered 0 for same-day PACU discharges or hospitalizations < 24 h.

RESULTS

102 patients were included in this case series. 69% (70/102) of patients were discharged same-day (mean LOS 0.47 ± 0.80 days). Within 30 post-operative days, 3% (3/102) of patients presented to the ER, 2% (2/102) were readmitted to the hospital, and 1% (1/102) required reoperation. There was 1 serious complication (Clavien-Dindo grade 3/4) with an aggregate complication rate of 7.8%.

CONCLUSIONS

Our initial experience with ERAS protocols and same-day discharges after robotic eTEP repair demonstrates this approach is safe and feasible with acceptable short-term patient outcomes. Compared to traditional open surgery for large ventral hernias, robotic eTEP may enable significant reductions in hospital LOS as adoption increases.

Prescription opioid use increases resource utilization following ventral hernia repair

BACKGROUND

Previous studies showed that preoperative opioid use is associated with increased postoperative opioid use and surgical site infection (SSI) in patients undergoing ventral hernia repair (VHR). Orthopedic surgery literature cites increased resource utilization with opioid use. This study aimed to determine the effect of preoperative opioid use on resource utilization after open VHR.

METHODS

A retrospective institutional review board-approved study of VHRs from a single tertiary care practice between 2013 and 2020 was performed. Medical records, the National Surgical Quality Improvement Program database, and Kentucky All Schedule Prescription Electronic Reporting data were reviewed for patient demographics, comorbidities, dispensed opiate prescriptions, hernia characteristics, and outcomes. Univariate logistic regression analyses assessed the effect of each patient's demographic and clinical characteristics. Multivariate logistic regression models analyzed significant factors from the univariate analyses. The primary outcome was resource utilization measured as readmission, emergency department visit, or >2 postoperative clinic visits within 45 days after VHR.

RESULTS

Overall, 381 patients who underwent VHR were identified; of which 101 patients had preoperative dispensed opioids. Multivariate analysis demonstrated that patient gender at birth, any new-onset SSI, and any preoperative opioid use were associated with increased postoperative resource utilization (odds ratio, 1.76; P = .026).

CONCLUSION

Preoperative opioid use was determined as a risk factor that increased resource utilization after open VHR. An understanding of the drivers of the increased use of resources is essential in developing strategies to improve healthcare value. Future research will focus on strategies to reduce the utilization of resources among patients who use opioids.

Auto-diuresis Predicts Return of Bowel Function

PURPOSE

Feeding a ventral hernia repair (VHR) patient before the return of bowel function (ROBF) can lead to distention and emesis. Many patients spontaneously diurese after surgery. We hypothesized that this auto-diuresis would signal ROBF.

MATERIALS AND METHODS

A total of 395 patients who underwent open, laparoscopic, or mixed VHR were evaluated for correlation between fluid status and ROBF or discharge. ROBF within 24 hours and discharge within 24 hours or 48 hours were used as outcome measures.

RESULTS

Patients remained an average 3.59 days after surgery in the hospital and the average ROBF was on day 2.99. The first shift of ≥700 mL of urine predicted ROBF (P=0.03) and discharge (P=0.04) within 24 hours. The first shift output of ≥500 mL predicted discharge within 48 hours (P=0.02).

CONCLUSION

Auto-diuresis after surgery is correlated to ROBF and discharge. Accurate fluid measurement can predict bowel function and allow early diet and discharge.

Physical activity recommendations pre and post abdominal wall reconstruction: a scoping review of the evidence

PURPOSE

There are no universally agreed guidelines regarding which types of physical activity are safe and/or recommended in the perioperative period for patients undergoing ventral hernia repair or abdominal wall reconstruction (AWR). This study is intended to identify and summarise the literature on this topic.

METHODS

Database searches of PubMed, CINAHL, Allied & Complementary medicine database, PEDro and Web of Science were performed followed by a snowballing search using two papers identified by the database search and four hand-selected papers of the authors' choosing. Inclusion-cohort studies, randomized controlled trials, prospective or retrospective. Studies concerning complex incisional hernia repairs and AWRs including a "prehabilitation" and/or "rehabilitation" program targeting the abdominal wall muscles in which the interventions were of a physical exercise nature. RoB2 and Robins-I were used to assess risk of bias. Prospero CRD42021236745. No external funding. Data from the included studies were extracted using a table based on the Cochrane Consumers and Communication Review Group's data extraction template.

RESULTS

The database search yielded 5423 records. After screening two titles were selected for inclusion in our study. The snowballing search identified 49 records. After screening one title was selected for inclusion in our study. Three total papers were included-two randomised studies and one cohort study (combined 423 patients). All three studies subjected their patients to varying types of physical activity preoperatively, one study also prescribed these activities postoperatively. The outcomes differed between the studies therefore meta-analysis was impossible-two studies measured hernia recurrence, one measured peak torque. All three studies showed improved outcomes in their study groups compared to controls however significant methodological flaws and confounding factors existed in all three studies. No adverse events were reported.

CONCLUSIONS

The literature supporting the advice given to patients regarding recommended physical activity levels in the perioperative period for AWR patients is sparse. Further research is urgently required on this subject.

Towards a complete cycle of care: a multidisciplinary pathway to improve outcomes in complex abdominal wall hernia repair

INTRODUCTION

The burden of complex abdominal wall hernia (CAWH) is increasing, with associated high morbidity and healthcare costs. This study evaluates current evidenoptce regarding multidisciplinary care for CAWH patients to improve patient outcomes.

METHODS

A systematic review of Scopus, MEDLINE, Embase, PubMed, Web of Knowledge and Cochrane Library was conducted to identify proposed or established multidisciplinary team (MDT) pathways, necessary MDT constituents, and to evaluate patient outcomes. The pre-optimization pathways were then compared with a recent Delphi consensus statement.

RESULTS

Seven articles matched the relevant search criteria. Three were concept articles, without prospective data analysis. Four were case series that applied multidisciplinary care and included limited data analyses with outcomes reported up to 50 months. The consensus was that CAWH MDT requires multiple clinical specialties, including hernia, upper gastrointestinal, colorectal and/or plastic and reconstructive surgeons, along with allied health specialists, radiologists, anaesthetists/pain specialists and infectious diseases consultants. A successful MDT should aim to achieve pre-optimization and plan the definitive repair. These pre-optimization pathways were similar to the recent Delphi consensus by international hernia experts. Using these data, we propose a CAWH multidisciplinary pathway model in an Australian tertiary hospital involving a stepwise approach with well-defined referral criteria, perioperative high-risk management with pre-optimization, surgical planning, postoperative care and follow-up protocols. This pathway incorporates prospective data collection in a Clinical Quality Registry (CQR) to validate its appropriateness.

CONCLUSIONS

CAWH MDT can provide comprehensive, patient-centred care with improved postoperative outcomes. CQR are important to better evaluate long-term outcomes and ensure rigorous quality control.

Bridged repair of large ventral hernia defects using an ovine reinforced biologic: A case series

Introduction

Of all hernia types, large ventral hernias have the most impact on patient quality of life, however they are also the most difficult type of hernia to repair and are associated with high rates of complications. This case series describes repair of large ventral hernias with an ovine reinforced biologic in a complex patient cohort with comorbidities and concomitant procedures.

Methods

The author performed bridged repair with an ovine reinforced biologic in 19 consecutive high-risk patients over a 5-year period. In all cases the reinforced biologic was used as an underlay.

Outcomes

Of the 19 patients, six (32%) experienced a surgical site occurrence including infection, seroma, abscess, fistula, bioloma, or bowel obstruction. Three patients (16%) had recurrences with two out of three of the recurrences occurring within 6 months of surgery.

Conclusions

Rates of SSO's and recurrences using ovine reinforced tissue matrix (RTM) were in line with or better than other published studies of bridged repair utilizing biologic or synthetic mesh reinforcement. Ovine RTM's should therefore be considered in complex large ventral hernia repairs.

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Large ventral hernias greatly impact patient quality of life.

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In some cases, large ventral hernias necessitate bridged repair with mesh.

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19 patients received bridged repair with an ovine reinforced matrix.

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Mean follow up of 23 months showed low complication and recurrence rates.

Factors Predicting Increased Length of Stay in Abdominal Wall Reconstruction

BACKGROUND

Enhanced recovery after surgery (ERAS) programs have become increasingly popular in general surgery, yet no guidelines exist for an abdominal wall reconstruction (AWR)-specific program. We aimed to evaluate predictors of increased length of stay (LOS) in the AWR population to aid in creating an AWR-specific ERAS protocol.

METHODS

A prospective, single institution hernia center database was queried for all patients undergoing open AWR (1999-2019). Standard statistical methods and linear and logistic regression were used to evaluate for predictors of increased LOS. Groups were compared based on LOS below or above the median LOS of 6 days (IQR = 4-8).

RESULTS

Inclusion criteria were met by 2,505 patients. On average, the high LOS group was older, with higher rates of CAD, COPD, diabetes, obesity, and pre-operative narcotic use (all P < .05). Longer LOS patients had more complex hernias with larger defects, higher rates of mesh infection/fistula, and more often required a component separation (all P < .05). Multivariate analysis identified age (β0.04,SE0.02), BMI (β0.06,SE0.03), hernia defect size (β0.003,SE0.001), active mesh infection or mesh fistula (β1.8,SE0.72), operative time (β0.02,SE0.002), and ASA score >4 (β3.6,SE1.7) as independently associated factors for increased LOS (all P < .05). Logistic regression showed that an increased length of stay trended toward an increased risk of hernia recurrence (P = .06).

CONCLUSIONS

Multiple patient and hernia characteristics are shown to significantly affect LOS, which, in turn, increases the odds of AWR failure. Weight loss, peri-operative geriatric optimization, prehabilitation of comorbidities, and operating room efficiency can enhance recovery and shorten LOS following AWR.

Impact of a Body Mass Index Threshold on Abdominal Wall Hernia Repair at a Safety-Net Hospital

BACKGROUND

Body mass index (BMI) thresholds are utilized as a preoperative optimization strategy for obese patients prior to elective abdominal wall hernia repair. The objectives of this study were to determine the proportion of patients at our institution who ultimately underwent hernia repair after initial deferral due to BMI and to evaluate outcomes of those who required emergent repair during the deferral period.

METHODS

A retrospective review was performed from 2016 to 2018 to identify all patients with abdominal wall hernias who were deferred surgery due to BMI. Patient characteristics, hernia type, change in BMI, progression to surgery, acuity of surgery (elective or emergent), and postoperative outcomes were examined.

RESULTS

200 patients were deferred hernia repair due to BMI. Of these, 150 (75%) did not undergo repair over a mean period of 27 months. The remaining 50 patients ultimately underwent repair, 36 of which (72%) were elective and 14 (28%) emergent. The mean initial BMI of the elective group was 35.3 ± 1.8, compared to 39.1 ± 5.3 in the no surgery group and 40.6 ± 8.2 in the emergent group (P < .01). While the elective group lost weight before surgery, the other groups did not. Patients who required emergent surgery had worse outcomes than those repaired electively.

CONCLUSIONS

Preoperative weight loss is unsuccessful in most obese patients presenting for abdominal wall hernia repair at our institution. Patients who required emergent hernia repair had worse outcomes than those who underwent elective repair. Our institution's BMI threshold is a failed optimization strategy that needs to be reconsidered.

Comparative effectiveness of surgeon-performed transversus abdominis plane blocks and epidural catheters following open hernia repair with transversus abdominis release

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.

The contribution of specific enhanced recovery after surgery (ERAS) protocol elements to reduced length of hospital stay after ventral hernia repair

BACKGROUND

Ventral hernia repair (VHR) is a commonly performed procedure that may be associated with prolonged hospitalization. Enhanced recovery after surgery (ERAS) protocols are intended to decrease hospital length of stay (LOS) and improve outcomes. This study evaluated the impact of compliance with individual VHR ERAS elements on LOS.

METHODS

With IRB approval, a medical record review (perioperative characteristics, clinical outcomes, compliance with ERAS elements) was conducted of open VHR consecutive cases performed in August 2013-July 2017. The ERAS protocol was implemented in August 2015; elements in place prior to implementation were accounted for in compliance review. Clinical predictors of LOS were determined through forward regression of log-transformed LOS. The effects of specific ERAS elements on LOS were assessed by adding them to the model in the presence of the clinical predictors.

RESULTS

Two-hundred and thirty-four patients underwent VHR (109 ERAS, 125 pre-ERAS). Across all patients, the mean LOS was 5.4 days (SD = 3.3). Independent perioperative predictors (P's < 0.05) of increased LOS were CDC Wound Class III/IV (38% increase above the mean), COPD (35%), prior infected mesh (21%), concomitant procedure (14%), mesh size (3% per 100 cm²), and age (8% increase per 10 years from mean age). Formal ERAS implementation was associated with a 15% or about 0.7 days (95% CI 6%-24%) reduction in mean LOS after adjustment. Compliance with acceleration of intestinal recovery was low (25.6%) as many patients were not eligible for alvimopan use due to preoperative opioids, yet when achieved, provided the greatest reduction in LOS (- 36%).

CONCLUSIONS

Implementation of an ERAS protocol for VHR results in decreased hospital LOS. Evaluation of the impact of specific ERAS element compliance to LOS is unique to this study. Compliance with acceleration of intestinal recovery, early postoperative mobilization, and multimodal pain management standards provided the greatest LOS reduction.

Use of Enhanced Recovery After Surgery (ERAS) in Laparoscopic Cholecystectomy (LC) Combined with Laparoscopic Common Bile Duct Exploration (LCBDE): A Cohort Study

Background

The have been few reports on use of ERAS in LC combined with LCBDE to promote postoperative recovery of patients. Therefore, the purpose of this cohort study was to explore the use of ERAS in patients who underwent LC combined with LCBDE.

Material/Methods

We collected clinical data of 445 patients who underwent elective laparoscopic cholecystectomy combined with laparoscopic common bile duct exploration from January 2015 to February 2019 in our hospital and divided the patients into an E-LC group and an LC group. The stress response index, postoperative complication rate, and postoperative rehabilitation effect of the 2 groups were compared and analyzed.

Results

The WBC count and CRP levels in the E-LC group were significantly lower than those of the LC group 1 day after surgery (p<0.05). In terms of the postoperative complications, the incidence of nausea, incisional pain, and vomiting in the E-LC group were lower than in the LC group, and the differences were statistically significant (p<0.05). In terms of the postoperative rehabilitation efficacy, flatus time and length of hospital stay after surgery in the E-LC group were significantly shorter than those in the LC group (p<0.05).

Conclusions

Use of ERAS in the perioperative period in patients who underwent LC combined with LCBDE reduces the stress response and postoperative complications and accelerates postoperative rehabilitation.

Clinical trial registration number

ChiCTR1900024292, http://www.chictr.org.cn/showprojen.aspx?proj=40785

Preoperative opioid use and incidence of surgical site infection after repair of ventral and incisional hernias

BACKGROUND

Preoperative opioid use is a risk factor for complications after some surgical procedures. The purpose of this study was to investigate the influence of preoperative opiates on outcomes after ventral hernia repair.

METHODS

With institutional review board approval, we conducted a retrospective review of consecutive ventral hernia repair cases during a 4-y period.

RESULTS

A striking 48% of the total 234 patients met criteria for preoperative opioid use. Preoperative characteristics and operative details were similar between patient groups (preoperative opioid use versus no preoperative opioid use). Median duration of hospital stay trended toward an increase for opioid users versus nonopioid users (P = .06). Return of bowel function was delayed in opioid users compared with nonopioid users (P = .018). Incidence of superficial surgical site infection was increased among patients who used opioids preoperatively (27% vs 8.3%; P <.001) and remained so after multivariable logistic regression, (adjusted odds ratio 2.9, 95% confidence interval 1.2-6.7; P = .013).

CONCLUSION

Among patients undergoing ventral hernia repair, those with preoperative opioid use experienced an increased incidence of superficial surgical site infection compared with patients without preoperative opioid use. Further study is needed to understand the relationship between opioid use and surgical site infection after ventral hernia repair.

Should enhanced recovery after surgery (ERAS) pathways be preferred over standard practice for patients undergoing abdominal wall reconstruction? A systematic review and meta-analysis

PURPOSE

Although many studies assessing enhanced recovery after surgery (ERAS) pathways in abdominal wall reconstruction (AWR) have recently demonstrated lower rates of postoperative morbidity and a decrease in postoperative length of stay compared to standard practice, the utility of ERAS in AWR remains largely unknown.

METHODS

A systematic literature search for randomized and non-randomized studies comparing ERAS (ERAS +) pathways and standard protocols (Control) as an adopted practice for patients undergoing AWR was performed using MEDLINE, the Cochrane Central Register of Controlled Trials, Scopus, Web of Science, and EMBASE databases. A predefined search strategy was implemented. The included studies were reviewed for primary outcomes: overall postoperative morbidity, abdominal wall morbidity, surgical site infection (SSI), and length of hospital stay; and for secondary outcome: operative time, estimated blood loss, time to discontinuation of narcotics, time to urinary catheter removal, time to return to bowel function, time to return to regular diet, and readmission rate. Standardized mean difference (SMD) was calculated for continuous variables and Odds Ratio for dichotomous variables.

RESULTS

Five non-randomized studies were included for qualitative and quantitative synthesis. 840 patients were allocated to either ERAS + (382) or Control (458). ERAS + and Control groups showed equivalent results with regard to the incidence of postoperative morbidity (OR 0.73, 95% CI 0.32-1.63; I²= 76%), SSI (OR 1.17, 95% CI 0.43-3.22; I²= 54%), time to return to bowel function (SMD - 2.57, 95% CI - 5.32 to 0.17; I²= 99%), time to discontinuation of narcotics (SMD - 0.61, 95% CI - 1.81 to 0.59; I²= 97%), time to urinary catheter removal (SMD - 2.77, 95% CI - 6.05 to 0.51; I²= 99%), time to return to regular diet (SMD - 0.77, 95% CI - 2.29 to 0.74; I²= 98%), and readmission rate (OR 0.82, 95% CI 0.52-1.27; I²= 49%). Length of hospital stay was significantly shorter in the ERAS + compared to the Control group (SMD - 0.93, 95% CI - 1.84 to - 0.02; I²= 97%).

CONCLUSIONS

The introduction of an ERAS pathway into the clinical practice for patients undergoing AWR may cause a decreased length of hospitalization. These results should be interpreted with caution, due to the low level of evidence and the high heterogeneity.

Recovery after laparoscopic parastomal hernia repair

BACKGROUND

The perioperative care and postoperative period after laparoscopic hernia repair have not been well described. The aim of this study was to describe the postoperative course after laparoscopic parastomal hernia repair.

METHODS

This was a prospective cohort study including consecutive patients undergoing laparoscopic parastomal hernia repair. The outcomes of interest were patient-reported pain, nausea and fatigue, time to stoma function, length of stay (LOS), use of transversus abdominis plane (TAP) block and epidural analgesia, the cumulative dose of morphine equivalent analgesics during the first 5 postoperative days, and postoperative complications.

RESULTS

Forty patients were included, 20% had ileostomy and 80% colostomy. The mesh was placed according to Sugarbaker (87.5%) and keyhole (12.5%) technique. Twenty-two patients (55%) required peripheral nervous blockades postoperatively. The median number of days to stoma function was 3 days (range 2-3.8). The mean cumulative dose of morphine equivalent analgesics was 21.9 mg on the day of surgery, 27.8 mg on the first postoperative day (POD1), 23.9 on POD2, 17.3 mg on POD3, 15.3 mg on POD4, 8.9 mg on POD5, and 115.2 mg in total. The median LOS was 4 days (range 3-6). The incidence of postoperative complications was 25%.

CONCLUSION

Laparoscopic parastomal hernia repair carried a high risk of complications. Further, analgesic treatment after surgery was insufficient, with high opioid requirements postoperatively, and more than half of the patients required peripheral nervous blockades, indicating that postoperative pain is a major issue in this patient group. Improved postoperative care for these patients is required.

Costs and Complications Associated with Infected Mesh for Ventral Hernia Repair

Background: Mesh hernia repair is widely accepted because of the associated reduction in hernia recurrence compared with suture-based repair. Despite initiatives to reduce risk, mesh infection and mesh removal are a significant challenge. In an era of healthcare value, it is essential to understand the global cost of care, including the incidence and cost of complications. The purpose of this study was to identify the outcomes and costs of care of patients who required the removal of infected hernia mesh. Methods: A review of databases from 2006 through June 2018 identified patients who underwent both ventral hernia repair (VHR) and re-operation for infected mesh removal. Patient demographic and operative details for both procedures, including age, Body Mass Index, mesh type, amount of time between procedures, and information regarding interval procedures were obtained. Clinical outcome measures were the length of the hospital stay, hospital re-admission, incision/non-incision complications, and re-operation. Hospital cost data were obtained from the cost accounting system and were combined with the clinical data for a cost and clinical representation of the cases. Results: Thirty-four patients underwent both VHR and removal of infected mesh material over the 12-year time frame and were included in the analyses; the average age at VHR was 48 years, and 16 patients (47%) were female. Following VHR, 21 patients (62%) experienced incision complications within 90 days post-operatively, the complications ranging from superficial surgical site infection (SSI) to evisceration. A mean of 22.65 months passed between procedures. After mesh removal, 16 patients (47%) experienced further incisional complications; and 22 (65%) patients had at least one re-admission. Eighteen patients (53%) required a minimum of one additional related operative procedure after mesh removal. Median hospital costs nearly doubled (p < 0.001) for the mesh removal ($23,841 [interquartile range {IQR} $13,596-$42,148]) compared with the VHR admission ($13,394 [IQR $8,424-$22,161]) not accounting for re-admission costs. A majority experienced hernia recurrence subsequent to mesh removal. Conclusions: Mesh infection after hernia repair is associated with significant morbidity and costs. Hospital re-admission, re-operations, and recurrences are common among these patients, resulting in greater healthcare resource utilization. Development of strategies to prevent mesh infection, identify patients most likely to experience infectious complications, and define best practices for the care of patients with mesh infection are needed.

Enhanced value with implementation of an ERAS protocol for ventral hernia repair

BACKGROUND

Open ventral hernia repair (VHR) is associated with postoperative complications and hospital readmissions. A comprehensive Enhanced Recovery after Surgery (ERAS) protocol for VHR contributes to improved clinical outcomes including the rapid return of bowel function and reduced infections. The purpose of this study was to compare hospital costs for patients cared for prior to ERAS implementation with patients cared for with an ERAS protocol.

METHODS

With IRB approval, clinical characteristics and postoperative outcomes data were obtained via retrospective review of consecutive VHR patients 2 years prior to and 14 months post ERAS implementation. Hospital cost data were obtained from the cost accounting system inclusive of index hospitalization. Clinical data and hospital costs were compared between groups.

RESULTS

Data for 178 patients (127 pre-ERAS, 51 post-ERAS) were analyzed. Preoperative and operative characteristics including gender, ASA class, comorbidities, and BMI were similar between groups. ERAS patients had faster return of bowel function (p = 0.001) and decreased incidence of superficial surgical site infection (p = 0.003). Hospital length of stay did not vary significantly pre and post ERAS implementation. Inpatient pharmacy costs were increased in ERAS group ($2673 vs. $1176 p < 0.001), but total hospital costs (14,692 vs. 15,151, p = 0.538) were similar between groups.

CONCLUSIONS

Standardization of hernia care via ERAS protocol improves clinical outcomes without impacting total costs.

Enhanced recovery after surgical repair of incisional hernias

AIM

Enhanced recovery programmes (ERPs) were developed to improve the patient's post-operative comfort and reduce post-operative morbidity after several types of major surgery including the incisional hernia repair. The aim of this review was to describe the features of ERPs in the setting for incisional hernia repair.

METHODS

The literature review was conducted until March 2019, but retrieved very few papers (n = 4) on this topic. All studies were retrospective.

RESULTS

Setting and comorbidities of incisional hernia patients are of such importance in many cases that prehabilitation (including tobacco use cessation, management of obesity, diabetes or malnutrition) should play a greater role compared with other specialties. The other peri-operative measures are similar to other specialties but their implementation was very heterogeneous in the published studies.

CONCLUSIONS

Like in other surgeries, ERPs were feasible and probably efficient to improve the post-operative course of incisional hernia patients. But the level of evidence remains low.

Enhanced recovery after abdominal wall reconstruction reduces length of postoperative stay: An observational cohort study

BACKGROUND

Enhanced recovery after surgery has been shown to lead to improved postoperative outcomes after several surgical procedures. However, only a few studies have examined the application of enhanced recovery after surgery after abdominal wall reconstruction. The aim of the current observational cohort study was to evaluate the outcomes of enhanced recovery after surgery after abdominal wall reconstruction in a large cohort.

METHOD

This was a retrospective cohort study comparing patients undergoing abdominal wall reconstruction in a standard care pathway (control group) with patients undergoing abdominal wall reconstruction in an enhanced recovery after surgery pathway. Registered outcomes included 30-day postoperative complications, length of stay, and readmission rate.

RESULTS

A total of 190 patients undergoing abdominal wall reconstruction for large incisional hernias were included in the study, of which 96 were treated according to standard protocol, and 94 underwent enhanced recovery after surgery pathway. Length of stay was significantly reduced after the introduction of enhanced recovery after surgery (median 4, interquartile range 3-6 days vs. control 5, 4-7 days, P < .001). There was no difference between the cohorts in the incidence of postoperative complications requiring operative intervention (enhanced recovery after surgery 10.6% vs control 10.4%, P = 1.0) or the rate of readmissions (enhanced recovery after surgery 16.0% vs control 12.5%, P = .635).

CONCLUSION

Enhanced recovery after surgery is feasible after abdominal wall reconstruction, leading to reduced length of stay without increasing the rate of complications or readmissions. Enhanced recovery should be implemented as standard in centers performing abdominal wall reconstruction.