Enhanced recovery after giant ventral hernia repair

Development of an Enhanced Recovery After Surgery Program in Ventral Hernia

BACKGROUND

Enhanced Recovery After Surgery (ERAS) programs have spread after initial success in colorectal surgery decreasing length of stay (LOS) and decreasing opioid consumption. Adoption of ERAS specifically for ventral hernia patients remains in evolution. This study presents the development and implementation of an ERAS pathway for ventral hernia.

METHODS

A multidisciplinary team met weekly over 6 months to develop an ERAS pathway specific to ventral hernia patients. 75 process components and outcome measures were included, spanning multiple phases of care: Preoperative-Clinic, Preoperative Day of Surgery (DOS), Intraoperative, and Postoperative. Preoperative components included education and physiologic optimization. Pain control across phases of care focuses on nonopioid, multimodal analgesia. Postoperatively, the pathway emphasizes early diet advancement, early mobilization, and minimization of IV fluids. We compared compliance and outcome measures between a Pre Go-Live (PGL) period (9/1/2020-8/30/2021) and After Go-live (AGL) period (5/12/2022-5/19/2023).

RESULTS

There were 125 patients in the PGL group and 169 patients in the AGL group. Overall, ERAS compliance increased from 73.9% to 82.9% after implementation. Length of stay decreased from an average of 2.27 days PGL to 1.92 days AGL. Finally, the average daily postoperative opioid usage decreased from 25.4 to 13.5 MME after the implementation.

DISCUSSION

Enhanced Recovery After Surgery can be successfully applied to the care of hernia patients with improvements in LOS and decreased opioid consumption. Institutional support and multidisciplinary cooperation were key for the development of such a program.

Short-term Outcomes After Laparoscopic IPOM Versus Robot-assisted Retromuscular Repair of Small to Medium Ventral Hernias: A Nationwide Database Study

OBJECTIVE

To examine the short-term outcomes after laparoscopic intraperitoneal onlay mesh (IPOM) compared with robot-assisted retromuscular repair of small to medium-sized ventral hernia.

BACKGROUND

With the introduction of a robot-assisted approach, retromuscular mesh placement is technically more feasible compared with laparoscopic IPOM, with potential gains for the patient, including avoidance of painful mesh fixation and intraperitoneal mesh placement.

METHODS

This was a nationwide cohort study of patients undergoing either laparoscopic IPOM or robot-assisted retromuscular repair of a ventral hernia with a horizontal fascial defect <7 cm in the period 2017 to 2022, matched in a 1:2 ratio using propensity scores. Outcomes included postoperative hospital length of stay, 90-day readmission, and 90-day operative reintervention, and multivariable logistic regression analysis was performed to adjust for the relevant confounder.

RESULTS

A total of 1136 patients were included for analysis. The rate of IPOM-repaired patients hospitalized > 2 days was more than 3 times higher than after robotic retromuscular repair (17.3% vs. 4.5%, P < 0.001). The incidence of readmission within 90 days postoperatively was significantly higher after laparoscopic IPOM repair (11.6% vs. 6.7%, P =0.011). There was no difference in the incidence of patients undergoing operative intervention within the first 90 days postoperatively (laparoscopic IPOM 1.9% vs. robot-assisted retromuscular 1.3%, P =0.624).

CONCLUSIONS

For patients undergoing first-time repair of a ventral hernia, robot-assisted retromuscular repair was associated with a significantly reduced incidence of prolonged length of postoperative hospital stay and risk of 90-day readmission compared to laparoscopic IPOM.

Effects of Novel Multimodal Transversus Abdominis Plane Block on Postoperative Opioid Usage and Hospital Length of Stay Following Elective Ventral Hernia Repair

Background and objective Traditional transversus abdominis plane (TAP) blocks consisting of a local anesthetic, typically bupivacaine, have previously been shown to reduce postoperative pain following gastrointestinal surgery, including hernia repair. However, elective abdominal wall reconstructions for the repair of large ventral hernias continue to cause patients significant postoperative pain, resulting in prolonged hospital stays and need for opioid pain medication. This study aimed to analyze the postoperative opioid pain medication usage and hospital length of stay (LOS) in patients who received a nontraditional multimodal TAP block of ropivacaine (local anesthetic), ketorolac (non-steroidal anti-inflammatory), and epinephrine following elective ventral hernia repair. Methods A retrospective review of medical records for patients who underwent elective robotic ventral hernia repair by a single surgeon was conducted. Postoperative hospital LOS and opioid usage for patients with the multimodal TAP block were compared to those without. Results A total of 334 patients met the inclusion criteria for LOS analysis: 235 received the TAP block and 109 did not. Patients who received the TAP block had a statistically significant shorter LOS compared to patients who had no TAP block (1.09 ± 1.22 days vs. 2.53 ± 1.57 days; P<0.001). Medical records for 281 patients, 214 with the TAP block and 67 without the TAP block, contained information and were analyzed for postoperative opioid usage. A statistically significantly fewer number of patients who had the TAP block required hydromorphone patient-controlled analgesia pump (3.3% vs. 36%; P<0.001) and oral opioids (29% vs. 78%; P<0.001) postoperatively. Those with TAP block required intravenous opioids more frequently (50% vs 10%; P<0.001) although at much less dosages than those without TAP block (4.86 ± 2.62 mg vs. 10.29 ±3.90 mg; P<0.001). Conclusion In conclusion, this multimodal TAP block of ropivacaine, ketorolac, and epinephrine may represents an effective method to improve hospital LOS and postoperative opioid usage in patients undergoing robotic abdominal wall reconstruction for ventral hernia repair.

Endoscopic Anterior Component Separation and Transversus Abdominus Release are not Associated with Increased Wound Morbidity Following Retromuscular Incisional Hernia Repair

INTRODUCTION

Traditional anterior component separation during incisional hernia repair (IHR) is associated with a high rate of postoperative wound morbidity. Because extensive subcutaneous dissection is avoided by endoscopic anterior component separation (eACS) or open transversus abdominis release (TAR), we hypothesized that these techniques did not increase the incidence of surgical site occurrence (SSO) compared to IHR without component separation (CS).

MATERIAL AND METHOD

This was a retrospective single-center cohort study of patients undergoing open retromuscular IHR comparing patients with or without the use of CS. Retromuscular mesh repair was performed in all patients, and CS was obtained by eACS or TAR. The primary outcome was 90-day incidence of postoperative SSO. Secondary outcomes included length of stay (LOS), 90-day readmission, 90-day reoperation rate and 3-year recurrence rate.

RESULTS

A total of 321 patients underwent retromuscular repair, 168 (52.3%) of whom received either eACS or TAR. The addition of eACS or TAR was associated neither with development of SSO (odds ratio: 1.80, 95% confidence interval: 0.94-3.46, P = 0.077) nor with hernia recurrence (hazard ratio 0.77, 0.26-2.34, P = 0.648). There was no significant difference between the groups regarding the frequencies of 90-day readmission or 90-day reoperation.

CONCLUSION

eACS or TAR as adjuncts to open retromuscular IHR were not associated with increased wound morbidity or hernia recurrence.

Skin closure following abdominal wall reconstruction: three-layer skin suture versus staples

Skin closure following abdominal wall reconstruction (AWR) has received little attention, even though these patients have demonstrated insufficient wound healing. This study assessed the postoperative wound-related complications and patient-reported outcomes after skin closure using single- or triple layer closure following AWR. This was a retrospective study at a University Hospital from 2016 to 2018. Patients were grouped into a single-layer cohort (SLC) and a triple-layer cohort (TLC). Skin incisions closed with either technique were compared. Postoperative complications were registered from chart review (SLC: n = 48, TLC: n = 40). Patient reported-outcomes were assessed through the Patient Scar Assessment Questionnaire (PSAQ) and the Hernia Related Quality of Life survey. A total of 51 patients were included (SLC: n = 26, TLC: n = 25). There was no difference in wound complications after single- or triple-layer skin closure; seroma (SLC: 16.7% vs. TLC: 15%, p = 1.00), surgical site infection (SLC: 4.2% vs. TLC: 7.5%, p = .834), hematoma (SLC: 6.2% vs. TLC: 2.5%, p = .744) and wound rupture (SLC: 2.1% vs. TLC: 2.5%, p = 1.00). Patients who had incisions closed using single-layer closure were more satisfied; PSAQ satisfaction with scar symptoms (SLC: 6.7 points (IQR 0.0-18.3) vs. TLC: 26.7 points (IQR 0.0-33.3), p = .039) and scar aesthetics (SLC 25.9 points (IQR 18.5-33.3) vs. TLC: 37.0 (IQR 29.6-44.4), p = .013). There was no difference in 30-day wound complications after either skin closure technique. The results favoured the single-layer closure technique regarding the cosmetic outcome.Abbreviations: AWR: abdominal wall reconstruction; SLC: single-layer cohort; TLC: triple-layer cohort; PSAQ: patient scar assessment questionnaire; IH: incisional hernia; QOL: quality of life; BMI: body mass index; HerQLes: hernia-related quality of life; ASA: American Society of Anesthesiologists; SSO: surgical site occurence; SSI: surgical site infection; LOS: length of stay; RCT: randomized controlled trial.

Assessing Textbook Outcome After Implementation of Transversus Abdominis Release in a Regional Hospital

Background: The posterior component separation technique with transversus abdominis release (TAR) was introduced in 2012 as an alternative to the classic anterior component separation technique (Ramirez). This study describes outcome and learning curve of TAR, five years after implementation of this new technique in a regional hospital in the Netherlands. Methods: A standardized work up protocol, based on the Plan-Do-Check-Act cycle, was used to implement the TAR. The TAR technique as described by Novitsky was performed. After each 20 procedures, outcome parameters were evaluated and new quality measurements implemented. Primary outcome measure was Textbook Outcome, the rate of patients with an uneventful clinical postoperative course after TAR. Textbook Outcome is defined by a maximum of 7 days hospitalization without any complication (wound or systemic), reoperation or readmittance, within the first 90 postoperative days, and without a recurrence during follow up. The number of patients with a Textbook Outcome compared to the total number of consecutively performed TARs is depicted as the institutional learning curve. Secondary outcome measures were the details and incidences of the surgical site and systemic complications within 90 days, as well as long-term recurrences. Results: From 2016, sixty-nine consecutive patients underwent a TAR. Textbook Outcome was 35% and the institutional learning curve did not flatten after 69 procedures. Systemic complications occurred in 48%, wound complications in 41%, and recurrences in 4%. Separate analyses of three successive cohorts of each 20 TARs demonstrated that both Textbook Outcome (10%, 30% and 55%, respectively) and the rate of surgical site events (45%, 15%, and 10%) significantly (p < 0.05) improved with more experience. Conclusion: Implementation of the open transversus abdominis release demonstrated that outcome was positively correlated to an increasing number of TARs performed. TAR has a long learning curve, only partially determined by the technical aspects of the operation. Implementation of the TAR requires a solid plan. Building, and maintaining, an adequate setting for patients with complex ventral hernias is the real challenge and driving force to improve outcome.

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.

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.

Visceral obesity is a predictor of surgical site occurrence and hernia recurrence after open abdominal wall reconstruction

PURPOSE

High body mass index (BMI) increases the risk of postoperative complications and hernia recurrence after abdominal wall reconstruction (AWR). However, BMI does not provide specific information on the mass and distribution of adipose tissue. We hypothesized that visceral fat volume (VFV) was a better predictor than BMI for recurrence after AWR.

METHODS

We included all patients undergoing AWR at our institution from November 2010 to December 2016. Data were collected from a prospective database and all patients were summoned for follow-up. VFV was calculated from preoperative CT. The primary and secondary outcomes were hernia recurrence and 30-day postoperative surgical site occurrences (SSO), respectively.

RESULTS

We included a total of 154 patients. At follow-up, 42 (27.3%) patients had developed recurrence. The recurrence rate was significantly higher in patients with a VFV higher than the mean compared to a VFV lower than the mean, P = 0.004. After multivariable Cox-regression, VFV remained significantly predictive of recurrence (HR 1.09 per 0.5 L increase of VFV, P = 0.018). In contrary, BMI was not associated with hernia recurrence. There was no significant difference in the rate of SSO between patients with a VFV above and below the mean. A multivariable logistic regression model showed that VFV was significantly associated with development of SSO (OR 1.12 per 0.5 L increase, P = 0.009).

CONCLUSION

VFV was significantly associated with recurrence and SSOs after AWR. This study suggests VFV as a risk assessment tool for patients undergoing AWR.

Prophylactic negative pressure wound therapy after open ventral hernia repair: a systematic review and meta-analysis

PURPOSE

Negative pressure wound therapy on closed incisions (iNPWT) is a wound dressing system developed to promote wound healing and avoid complications after surgical procedures. The effect of iNPWT is well established in various surgical fields, however, the effect on postoperative wound complications after ventral hernia repair remains unknown. The aim of this systematic review and meta-analysis was to investigate the effect of iNPWT on patients undergoing open ventral hernia repair (VHR) compared with conventional wound dressing.

MATERIALS AND METHODS

This systematic review and meta-analysis followed the PRISMA guidelines. The databases PubMed, Embase, Cochrane Library, Web of science and Cinahl were searched for original studies comparing iNPWT to conventional wound dressing in patients undergoing VHR. The primary outcome was surgical site occurrence (SSO), secondary outcomes included surgical site infection (SSI) and hernia recurrence.

RESULTS

The literature search identified 373 studies of which 10 were included in the meta-analysis including a total of 1087 patients. Eight studies were retrospective cohort studies, one was a cross-sectional pilot study, and one was a randomized controlled trial. The meta-analysis demonstrated that iNPWT was associated with a decreased risk of SSO (OR 0.27 [0.19, 0.38]; P < 0.001) and SSI (OR 0.32 [0.17, 0.55]; P < 0.001). There was no statistically significant association with the risk of hernia recurrence (OR 0.62 [0.27, 1.43]; P = 0.26).

CONCLUSION

Based on the findings of this systematic review and meta-analysis iNPWT following VHR was found to significantly reduce the incidence of SSO and SSI, compared with standard wound dressing. INPWT should be considered for patients undergoing VHR.

Intraoperative Botulinum Toxin Chemodenervation and Analgesia in Abdominal Wall Reconstruction

Purpose. To analyze the impact of botulinum toxin chemodenervation on postoperative opiate consumption through a novel intraoperative injection protocol. Methods. A retrospective review of the implementation of a novel intraoperative botulinum toxin injection into both rectus and oblique musculature. Patients undergoing open retrorectus release, with and without intraoperative chemodenervation with Botox, were retrospectively collected between 2015 and 2019. Demographics, comorbidities, and opioid use in morphine milligram equivalents (MMEs) were retrospectively captured. Basic descriptive statistics and linear regression analysis were performed. Results. 19 patients in the Botox and 22 in the no Botox group were analyzed. Basic demographics were similar with female preponderance in the Botox group, 58% vs 27%, P = .05. Median hernia length was 15 cm for both groups (P = .57), median hernia width was 8 vs 9 cm (P = .39), epidural catheter used in 0 vs 4 (P = .11), transverse abdominal plane blocks in 3 vs 4 (P = 1), median MME usage was 191 vs 230 (P = .37) in the inpatient setting, 225 vs 300 (P = .17) in the outpatient setting, and 405 vs 568 (P = .07) in total for Botox vs no Botox groups. Stepwise linear regression analysis identified Botox as the only predictor for MME usage, P = .048. Conclusions. Chemodenervation was the only factor associated with reduced opioid usage compared to a standard group using multimodality analgesia. The role of muscular pain in laparotomy is likely underappreciated and understudied. Intraoperative selective muscular chemodenervation may play a significant role in recovery from abdominal surgery and requires further study.

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.

Enhanced recovery after abdominal wall reconstruction: a systematic review and meta-analysis

BACKGROUND

Enhanced recovery after surgery (ERAS) are evidence-based protocols associated with improved patient outcomes. The use of ERAS pathways is well documented in various surgical specialties. The aim of this systematic review and meta-analysis was to examine the efficacy of ERAS protocols in patients undergoing abdominal wall reconstruction (AWR).

METHODS

This systematic review and meta-analysis were reported according to PRISMA and MOOSE guidelines. The databases PubMed, EMBASE, CINAHL, Web of Science and Cochrane Library were searched for original studies comparing ERAS with standard care in patients undergoing AWR. The primary outcome was length of stay (LOS) and secondary outcomes were readmission and surgical site infection (SSI) and/or surgical site occurrences (SSO).

RESULTS

Five studies were included in the meta-analysis. All were retrospective cohort studies including 453 patients treated according to ERAS protocols, and 494 patients treated according to standard care. The meta-analysis demonstrated that patients undergoing AWR managed with ERAS had a mean 0.89 days reduction in LOS compared with patients treated with standard care (95% CI - 1.70 to - 0.07 days, p = 0.03). There was no statistically significant difference in readmission rate (OR 1.00, 95% CI 0.53 to 1.87, p = 1.00) or SSI/SSO (OR 1.19, 95% CI 0.67 to 2.11, p = 0.56) between groups.

CONCLUSIONS

The use of ERAS in patients undergoing AWR was found to significantly reduce LOS without increasing the readmission rate or SSI/SSO. Based on the existing literature, ERAS protocols should be implemented for patients undergoing AWR.

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.

Application of double circular suturing technique (DCST) in repair of giant incision hernias

Background

Our study aims to explore the feasibility and safety of a double circular suturing technique (DCST) in the repair of giant incision hernias.

Methods

The clinical data of 221 patients (95 men and 126 women; the average age was 61.6 years) receiving DCST in the repair of giant incision hernia between January 2010 and December 2018 was analyzed retrospectively. One hundred and five primary and 16 recurrent patients underwent herniorrhaphy with anti-adhesion underlay mesh repair using DCST.

Results

All the 221 operations were performed successfully. The average preparation time before the operation and hospital stays were 3.7 days (range, 1-6 days) and 7.5 days (range, 2-16 days), respectively. The average diameter of the hernia ring defect observed intraoperatively was 16.4 cm (range, 12-22 cm). The average time of operation was 83.6 min (range, 43-195 min). There were 2 cases of intestinal fistula, 4 cases of wound infection, 2 cases of mesh infection, 7 cases of serum tumescence, 3 cases of pulmonary infection, and 2 cases of wound dehiscence occurred. One hundred and ninety-five patients were followed up for 6.7 years (range, 0.8-9.5 years) postoperatively. Of them, 9 patients recurred; 14 patients had chronic pain whose visual analog scale (VAS) was 2-4 cm (average 2.7 cm).

Conclusions

With limited preparation time before operations, few postoperative complications, and recurrence rate, DCST in the repair of giant incision hernia is safe and possible clinically.

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.

Open retromuscular versus laparoscopic ventral hernia repair for medium-sized defects: where is the value?

PURPOSE

There is increasing emphasis on value in health care, defined as quality over cost required to deliver care. We analyzed outcomes and costs of repairing medium-sized ventral hernias to identify whether an open retromuscular or laparoscopic intraperitoneal onlay approach would provide superior value to the patient and healthcare system.

METHODS

A retrospective analysis of prospectively collected data from the Americas Hernia Society Quality Collaborative was performed for patients undergoing clean, elective repair of ventral hernias between 4 and 8 cm in width at our institution between 4/2013 and 12/2016 for whom at least 1-year follow-up was available. Recurrence rates, wound complications, length of stay, patient-reported outcomes, and perioperative costs were compared.

RESULTS

One hundred and eighty-six patients met criteria (105 open, 81 laparoscopic) with 93.5% having ≥ 2-year follow-up. Patients undergoing laparoscopic repair had higher BMI, lower ASA classification, slightly lower prevalence of recurrent hernias and less prior mesh utilization, and slightly smaller hernias. Length of stay was shorter in the laparoscopic group (median 1 vs. 3 days, p < 0.001), without increased readmissions. Recurrence rates, wound complications, and patient-reported outcomes were similar. Laparoscopic repair had higher up-front surgical costs, yet equivalent total perioperative costs.

CONCLUSION

Both laparoscopic and open approaches for elective repair of medium-sized ventral hernias offer similar clinical outcomes, patient-reported outcomes, and total perioperative costs. Laparoscopic repair appears to offer superior value based on a significantly reduced postoperative length of stay.

Is It Time to Reconsider Postoperative Epidural Analgesia in Patients Undergoing Elective Ventral Hernia Repair?: An AHSQC Analysis

OBJECTIVE

We aimed to evaluate the association of epidural analgesia (EA) with hospital length of stay (LOS), wound morbidity, postoperative complications, and patient-reported outcomes in patients undergoing ventral hernia repair (VHR).

BACKGROUND

EA has been shown to reduce LOS in certain surgical populations. The LOS benefit in VHR is unclear.

METHODS

Patients having VHR performed in the Americas Hernia Society Quality Collaborative (AHSQC) were separated into 2 comparable groups matched on several confounding factors using a propensity score algorithm: one group received postoperative EA, and the other did not. The groups were then evaluated for hospital LOS, 30-day wound morbidity, other complications, and 30-day patient-reported outcomes using pain and hernia-specific quality-of-life instruments.

RESULTS

A 1:1 match was achieved and the final analysis included 763 patients receiving EA and 763 not receiving EA. The EA group had an increased LOS (5.49 vs 4.90 days; P < 0.05). The rate of wound events was similar between the groups. There was an increased risk of having any postoperative complication associated with having EA (26% vs 21%; P < 0.05). Pain intensity-scaled scores were significantly higher (worse) in the EA group versus the non-EA group (47.6 vs 44.0; P = 0.04).

CONCLUSIONS

The LOS benefit of EA noted for other operations may not apply to patients undergoing VHR. Further study is necessary to determine the beneficial role of invasive pain management procedures in this group of patients with an extremely common disease state.

Retromuscular Mesh Repair Using Fibrin Glue: Early Outcomes and Cost-effectiveness of an Evolving Technique

Background

Retromuscular hernia repairs (RHRs) decrease hernia recurrence and surgical site infections but can cause significant pain. We aimed to determine if pain and postoperative outcomes differed when comparing suture fixation (SF) of mesh to fibrin glue fixation (FGF).

Methods

Patients undergoing RHR (n = 87) between December 1, 2015 and December 31, 2017 were retrospectively identified. Patients received SF of mesh (n = 59, 67.8%) before the senior author changing his technique to FGF (n = 28, 32.2%). These 2 cohorts were matched (age, body mass index, number of prior repairs, mesh type, defect size, and wound class). Outcomes were analyzed using a matched pairs design with multivariable linear regression.

Results

Two matched groups (21 FGF and 21 SF) were analyzed (45.2% female, average age 56 years, average body mass index 34.7 kg/m², and average defect size 330 cm²). Statistical significance was observed for FGF compared with SF: length of stay (3.7 versus 7.1 days, P = 0.032), time with a drain (17.2 versus 27.5 days, P = 0.012), 30-day postoperative visits (2 versus 3, P = 0.003), pain scores (5.2 versus 3.1, P = 0.019) and activity within the first 24 hours (walking versus sitting, P = 0.002). Operative time decreased by 23.1 minutes (P = 0.352) and postoperative narcotic represcription (3 versus. 8 patients, p=0.147) also decreased. Average cost for patients receiving SF was $36,152 compared to $21,782 for FGF (P = 0.035).

Conclusions

Sutureless RHR using FGF may result in decreased pain when compared with a matched cohort receiving SF, translating to enhanced recovery time, shortened hospital stay, and decreased costs.

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.

Delineating the burden of chronic post-operative pain in patients undergoing open repair of complex ventral hernias

BACKGROUND

After open complex ventral hernia repair (cVHR), chronic pain has a significant impact on quality of life and processes of care.

METHODS

Records of 177 patients undergoing cVHR were reviewed in order to characterize the burden of managing postoperative pain in the first post-operative year following open cVHR.

RESULTS

In this cohort, 91 patients initiated at least one unsolicited complaint of pain, though phone call (37), unscheduled clinic visit (45) or evaluation in the emergency room (9); among these an actionable diagnosis was found in 38 (41.8%). Among 41 patients who initiated additional unsolicited complaints of pain, an actionable diagnosis was found in only 3 patients. Risk factors for such complaints included pre-operative pain and the use of synthetic mesh.

CONCLUSIONS

Even in the absence of an actionable diagnosis, significant resources are utilized in evaluation and management of unsolicited complaints of pain in the first year after cVHR.

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

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols are evidence-based quality improvement pathways reported to be associated with improved patient outcomes. The purpose of this study was to compare short-term outcomes for open ventral hernia repair (VHR) before and after implementation of an ERAS protocol.

METHODS

After obtaining IRB approval, surgical databases were searched for VHR cases for two years prior and eleven months after protocol implementation for retrospective review. Groups were compared on perioperative characteristics and clinical outcomes using chi-square, Fisher's exact, or Mann-Whitney U test, as appropriate.

RESULTS

One hundred and seventy-one patients underwent VHR (46 patients with ERAS protocol in place and 125 historic controls). Age, gender, ASA Class, comorbidities, and smoking status were similar between the two groups. Body mass index was lower among ERAS patients (p = .038). ERAS patients had earlier return of bowel function (median 3 vs. 4 days) (p = .003) and decreased incidence of superficial surgical site infection (SSI) (7 vs. 25%) (p = .008) than controls.

CONCLUSION

An ERAS protocol for VHR demonstrated improved patient outcomes. A system-wide culture focused on enhanced recovery is needed to ensure improved patient outcomes.

Effect of Multimodal Analgesia on Opioid Use After Open Ventral Hernia Repair

BACKGROUND

There is limited data on enhanced recovery after surgery (ERAS) protocols after ventral hernia repair (VHR). This study reports the impact of multimodal analgesia on opioid use after open VHR.

METHODS

Retrospective review of open VHR treated during the initial 6 months after ERAS implementation. Protocol focused on opioid sparing using intraoperative ketamine and/or lidocaine infusion, selective epidural anesthesia, and postoperative ketamine infusion, ketorolac, and acetaminophen. Four groups were analyzed: 1-ERAS protocol with epidural analgesia, 2-historical controls with epidural analgesia prior to ERAS, 3-ERAS protocol without epidural, and 4-historical controls without epidural analgesia, prior to ERAS. Continuous variables were analyzed using ANOVA or Kruskal-Wallis tests, and subgroup analysis using Student's t test or Mann-Whitney U test. Discrete variables were analyzed using Pearson's chi-square test or Fisher's exact test.

RESULTS

Patients differed in hernia width, but were similar in comorbidity and operative technique. There was no difference in length of stay or readmission. Use of ERAS nearly eliminated patient-controlled analgesia use (group 1, 2.7%; group 2, 68.4%; group 3, 0%; group 4, 65.7%; p < 0.001). ERAS significantly reduced narcotic requirements on postoperative days 0, 1, and 2 (p < 0.001). To account for the bias of selective epidural analgesia, groups 1 and 2 (epidural) and groups 3 and 4 (no epidural) were compared separately. Opioid requirement and PCA use remained significantly lower in patients in the ERAS pathway.

CONCLUSION

Implementation of multimodal analgesia in the perioperative and postoperative setting significantly reduced opioid use after VHR.

The Development of Enhanced Recovery After Surgery Across Surgical Specialties

BACKGROUND

Enhanced recovery after surgery (ERAS^®) principles have gained traction in variety of surgical disciplines. The promise of a reduced length of stay without compromising patient safety or increasing readmission rates has produced a body of literature examining the implementation of ERAS in the care of general, thoracic, urologic, and gynecologic surgery patients.

METHODS

We performed a review of the literature pertaining to studies of ERAS implementation across colorectal surgery, general surgery, thoracic surgery, urology, and gynecology. The extent of ERAS implementation and reported outcomes across key studies as well as systematic reviews and meta-analyses in each field were summarized.

RESULTS

The implementation of ERAS protocols has not been uniform across surgical specialties. Despite this, ERAS has produced improvements in patient outcomes. The most commonly described benefit of ERAS application has been reduced length of stay; complication and readmission rates are most consistently decreased in the colorectal literature. Studies have started to measure more nuanced measures of postoperative patient well-being. Efforts are growing to standardize ERAS protocols across diverse fields and call attention to the need for quality control.

CONCLUSIONS

Challenges remain in the study and execution of ERAS. Controlling for adherence to ERAS components and implementing uniform ERAS protocols across studies are burgeoning topics that have significant implications for study design. The practice of ERAS and its benefits to patients are expected to evolve. Assessing improvements in postdischarge quality of life, timing of return to work and independent living, and adherence to scheduled delivery of adjuvant treatments will strengthen future ERAS investigations.

Assessing pre- and postoperative activity levels with an accelerometer: a proof of concept study

Background

Postoperative recovery after abdominal surgery is measured mostly based on subjective or self-reported data. In this article we aim to evaluate whether recovery of daily physical activity levels can be measured postoperatively with the use of an accelerometer.

Methods

In this multicenter, observational pilot study, 30 patients undergoing laparoscopic abdominal surgery (hysterectomy, adnexal surgery, cholecystectomy and hernia inguinal surgery) were included. Patients were instructed to wear an Actigraph wGT3X-BT accelerometer during one week before surgery (baseline) and during the first, third and fifth week after surgery. Wear time, steps taken and physical activity intensity levels (sedentary, light, moderate and vigorous) were measured. Patients were blinded for the accelerometer outcomes. Additionally, an activity diary comprising patients’ self-reported time of being recovered and a list of 18 activities, in which the dates of resumption of these 18 activities were recorded after surgery, was completed by the patient.

Results

Five patients were excluded from analyses because of technical problems with the accelerometer (n = 1) and protocol non-adherence (n = 4). Light, moderate, vigorous, combined moderate and vigorous intensity physical activity (MVPA), and step counts showed a clear recovery curve after surgery. Patients who underwent minor surgery reached their baseline step count and MVPA three weeks after surgery. Patients who underwent intermediate surgery had not yet reached their baseline step count during the last measuring week (five weeks after surgery). The results of the activity diaries showed a fair agreement with the accelerometer results (Cohens Kappa range: 0.273-0.391). Wearing the accelerometer was well tolerated and not regarded as being burdensome by the patients.

Conclusions

The accelerometer appeared to be a feasible way to measure recovery of postoperative physical activity levels in this study and was well tolerated by the patients. The agreement with self-reported physical recovery times was fair.

Electronic supplementary material

The online version of this article (doi:10.1186/s12893-017-0223-0) contains supplementary material, which is available to authorized users.

Ventral hernia repair in patients with abdominal loss of domain: an observational study of one institution's experience

PURPOSE

Abdominal wall hernias are a common problem. The success of abdominal wall reconstruction decreases with increasing hernia size. This study summarizes the outcomes of one surgeon's experience using a "sandwich" technique for hernia repair in patients with loss of abdominal domain.

METHODS

We reviewed our ventral hernia repair (VHR) experience from 2008 to 2015 among patients with loss of domain, as defined by a hernia defect greater than 300 cm². The percent of herniation through the defect, defined by a hernia sac-to-abdominal cavity volume ratio, was measured on preoperative CT scans by four independent reviewers and averaged. Outcomes were compared among those with giant ventral hernias (hernia sac-to-abdominal cavity volume >30%) and those with smaller defect ratios.

RESULTS

Over the study period, 21 patients underwent VHR. In 17 patients (81%), a "sandwich" technique was utilized. Ten patients had hernia sac-to-abdominal cavity defects less than 30%, and 11 had defects greater than 30%. Preoperative characteristics were similar in both groups with the exception of a higher ASA score in those with giant ventral hernias and more Ventral Hernia Working Group Grade 3 hernias in those without giant ventral hernias. Postoperative outcomes were similar in both groups. There were no mortalities. There were two recurrences (18%) in the giant VHR group and none in the smaller defect group (p = 0.16). Surgical site occurrences were noted in 48% of patients and did not differ between giant and non-giant VHR groups (50 vs 45%, p = 0.84). Average postoperative length of stay was significantly longer in the giant VHR group (31 vs. 17 days, p = 0.03).

CONCLUSIONS

Our results suggest that the "sandwich" technique for VHR is a safe and durable method to restore abdominal wall integrity in those with LOD, even in patients with giant ventral hernias.