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Al-Mansour MR, Ding DD, Yergin CG, Tamer R, Huang LC. The association of hernia-specific and procedural risk factors with early complications in ventral hernia repair: ACHQC analysis. Am J Surg 2024; 233:100-107. [PMID: 38494357 DOI: 10.1016/j.amjsurg.2024.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 01/29/2024] [Accepted: 02/15/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Many surgical risk assessment tools emphasize patient-specific risk factors. Our objective was to use a hernia-specific database to assess risk factors of complications in ventral hernia repair (VHR) focusing on hernia-specific and procedural factors. METHODS The ACHQC database was queried for elective VHR in adults from 2012 to 2023. Primary outcome was overall 30-day complications. Multivariable logistic regression was used for analysis. RESULTS 41,526 VHR were included. The rate of 30-day complications was 18%, surgical site infection 3%, surgical site occurrence requiring procedural intervention 4%, readmission 4%, reoperation 2%, and mortality 0.2%. Multivariable analysis demonstrated that BMI, ASA, frailty, COPD, anticoagulants, defect width, incisional and recurrent hernias, presence of stoma or prior mesh, prior abdominal wall infection, non-clean wound, operative time, open approach and myofascial release were associated with 30-day complications (OR = 1.01-1.66). Preoperative chlorhexidine, bowel preparation and fascial closure were associated with lower complication risk (OR = 0.70-0.89). CONCLUSION Hernia and procedural risk factors are associated with early complications following elective VHR. These factors need to be included in surgical risk assessment tools, to supplement patient-specific factors.
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Affiliation(s)
| | - Delaney D Ding
- University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Robert Tamer
- Center for Surgical Health Assessment, Research and Policy, The Ohio State University, Columbus, OH, USA
| | - Li-Ching Huang
- Vanderbilt University Medical Center, Nashville, TN, USA
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Maskal SM, de Figueiredo SMP, Weaver M, Schleicher M, Tu C, Ellis RC, Woo K, Fafaj A, Remulla D, Miller BT, Petro CC, Beffa LRA, Prabhu AS, Rosen MJ. Impact of the ventral hernia working group's publication: a bibliometric analysis. Hernia 2024:10.1007/s10029-024-03093-x. [PMID: 38888837 DOI: 10.1007/s10029-024-03093-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 06/09/2024] [Indexed: 06/20/2024]
Abstract
PURPOSE The Ventral Hernia Working Group (VHWG) proposed a ventral hernia grading guideline, primarily supported by expert opinion, recommending biologic mesh placement in high-risk patients. We investigated the relationship between this industry-sponsored guideline and discourse around ventral hernia repair (VHR). METHODS Medline platform from Web of Science's database identified publications "pre-VHWG"(1999-01-01 to 2009-12-31), and "post-VHWG"(2010-01-01 to 2020-12-31) describing VHR and complications or recurrence of VHR with the following comorbidities: COPD, smoking, diabetes, immunosuppression, or obesity. Poisson regression analyzed keyword frequency over time using logarithmically transformed data. RESULTS Of 1291 VHR publications identified pre-VHWG and 3041 publications identified post-VHWG, 172 (13.3%) and 642 (21.1%) publications respectively included prespecified keywords. The keyword groups "biologic"(IRR 3.39,95%CI1.34-11.4,p = 0.022) and "comorbid"(IRR 1.95, 95%CI1.09-3.74,p = 0.033) significantly increased with frequency after publication of the VHWG. CONCLUSION The VHWG publication likely contributed to a focus on comorbidities and biologic mesh in the ensuing literature within the field of VHR.
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Affiliation(s)
- Sara M Maskal
- Department of Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA.
| | | | - Matthew Weaver
- Floyd D. Loop Alumni Library, Cleveland Clinic, Cleveland, OH, USA
| | - Mary Schleicher
- Floyd D. Loop Alumni Library, Cleveland Clinic, Cleveland, OH, USA
| | - Chao Tu
- Department of Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - Ryan C Ellis
- Department of Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - Kimberly Woo
- Department of Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - Aldo Fafaj
- Department of Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - Daphne Remulla
- Department of Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - Benjamin T Miller
- Department of Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - Clayton C Petro
- Department of Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - Lucas R A Beffa
- Department of Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - Ajita S Prabhu
- Department of Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
| | - Michael J Rosen
- Department of Surgery, Cleveland Clinic, 2049 E 100th St, Desk A-100, Cleveland, OH, 44106, USA
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Fafaj A, de Figueiredo SMP, Rosen MJ, Petro CC. Preoperative optimization in hernia surgery: are we really helping or are we just stalling? Hernia 2024:10.1007/s10029-024-02962-9. [PMID: 38578363 DOI: 10.1007/s10029-024-02962-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 01/05/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Managing patients with abdominal wall hernias and multiple comorbidities can be challenging because these patients are at increased risk for postoperative complications. Preoperative optimization has been used to identify and intervene upon modifiable risk factors to improve hernia repair outcomes, however, waiting to achieve optimization may cause unnecessary delays. METHODS We describe our approach to preoperative optimization in hernia and we review the current evidence for preoperative optimization. CONCLUSION Modifying risk factors before undergoing elective hernia repair can improve the overall health of patients with multiple comorbidities. However, when considering the hernia-specific data, prolonging waiting times for patients to achieve full optimization is not justified. Surgeons should take a nuanced approach to balance achieving patient optimization without unnecessarily delaying surgical care.
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Affiliation(s)
- A Fafaj
- Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - S M P de Figueiredo
- Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - M J Rosen
- Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - C C Petro
- Center for Abdominal Core Health, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
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Messer N, Melland MS, Miller BT, Krpata DM, Beffa LRA, Zheng X, Petro CC, Maskal SM, Ellis RC, Prabhu AS, Rosen MJ. Evaluating the impact of lifting mandatory smoking cessation prior to elective abdominal wall reconstruction. A single-center experience. Am J Surg 2024; 229:52-56. [PMID: 37833195 DOI: 10.1016/j.amjsurg.2023.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/05/2023] [Accepted: 09/11/2023] [Indexed: 10/15/2023]
Abstract
INTRODUCTION Many studies identify active smoking as a significant risk factor for postoperative wound and mesh complications in patients undergoing abdominal wall reconstruction surgery. However, our group conducted an analysis using data from the ACHQC database, which revealed similar rates of surgical site infection (SSI) and surgical site occurrence requiring procedural intervention (SSOPI) between active smokers and non-smokers As a result, the Cl eveland Clinic Center for Abdominal Core Health instituted a policy change where active smokers were no longer subject to surgical delay. Our study aims to evaluate the impact of active smoking on the outcomes of these patients. METHODS We identified active smoking patients who had undergone open, elective, clean ventral hernia repair (VHR) with transversus abdominis release (TAR) and permanent synthetic mesh at Cleveland Clinic Foundation. Propensity matching was performed to create a 1:3 ratio of "current-smokers" and "never-smokers" and compared wound complications and all 30-day morbidity between the two groups. RESULTS 106 current-smokers and 304 never-smokers were matched. Demographics were similar between the two groups after matching, with the exception of chronic obstructive pulmonary disease (COPD) (22.1% vs. 13.4%, p < .001) and body mass index (BMI) (31.1 vs. 32.6, p = .02). Rates of SSI (12.2% vs. 6.9%, p = .13), SSO (21.7% vs. 13.2%, p = .052), SSOPI (11.3% vs. 6.3%, p = .13), and reoperation (1.9% vs. 3.9%, p = .53) were not significantly different between active smokers and never-smokers correspondingly. One case (0.3%) of partial mesh excision was observed in the never-smokers group (p = 1). The current-smokers group exhibited a significantly higher incidence of pneumonia compared to the never-smokers group (5.7% vs. 0.7%, p = .005). CONCLUSION Our study revealed that operating on active smokers did result in a slight increase in wound morbidity, although it did not reach statistical significance. Additionally, pulmonary complications were higher in the smoking group. Notably, we did not see any mesh infections in the smoking group during early follow up. We believe that this data is important for shared decision making on patients that are actively smoking contemplating elective hernia repair.
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Affiliation(s)
- Nir Messer
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA; Department of Surgery, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel -Aviv University, Tel Aviv, Israel.
| | - Megan S Melland
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Benjamin T Miller
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - David M Krpata
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Lucas R A Beffa
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Xinyan Zheng
- The Abdominal Core Health Quality Collaborative, USA
| | - Clayton C Petro
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Sara M Maskal
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ryan C Ellis
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ajita S Prabhu
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Michael J Rosen
- Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
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Tian YQ, Ren X, Yin YS, Wang J, Li X, Guo ZH, Zeng XY. Analysis of risk factors affecting the postoperative drainage after a laparoscopic partial nephrectomy: a retrospective study. Front Med (Lausanne) 2024; 11:1327882. [PMID: 38327705 PMCID: PMC10847592 DOI: 10.3389/fmed.2024.1327882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/04/2024] [Indexed: 02/09/2024] Open
Abstract
Purpose Laparoscopic partial nephrectomy (LPN) remains the most commonly used measure for treating localized renal cell cancer (RCC) with an increasing incidence of RCC ever since the 1990s. This study aimed to identify risk factors that affect the postoperative time of drainage and total drainage volume after LPN. Method The clinical data of 612 RCC patients who received LPN from January 2012 to December 2022 in our hospital, including the postoperative drainage time and total drainage volume, were retrospectively analyzed. Univariable and multivariable linear regression and correlation analyses were used to identify the correlations between 21 factors, which include gender, age, history of alcohol consumption, family history of RCC, body weight, body mass index (BMI), and operation time, postoperative drainage time, and total drainage volume. Results The mean time of drainage was 3.52 ± 0.71 days (range: 2 to 8 days), with an average total drainage volume of 259.83 ± 72.64 mL (range: 50 to 620 mL). Both univariable and multivariable linear regression analyses revealed several statistically significant associations. Gender (p = 0.04), age (p = 0.008), smoking history (p < 0.001), diabetes (p = 0.032), operation time (p = 0.014), and BMI (p = 0.023) were identified as significant factors associated with the time of drainage. On the other hand, age (p = 0.008), smoking history (p < 0.001), diabetes (p = 0.006), and BMI (p = 0.016) emerged as independent risk factors influencing the total drainage volume. Conclusion The duration of postoperative drainage was found to be associated with gender, age, smoking history, diabetes, operation time, and BMI. In contrast, the total drainage volume was primarily influenced by age, smoking history, diabetes, and high BMI following LPN. For patients with these conditions, meticulous attention to hemostasis and bleeding control is crucial during the perioperative period.
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Affiliation(s)
- Yi-Qun Tian
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- China Institute of Urology of Hubei Province, Wuhan, Hubei, China
| | - Xiang Ren
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- China Institute of Urology of Hubei Province, Wuhan, Hubei, China
| | - Yi-Sheng Yin
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- China Institute of Urology of Hubei Province, Wuhan, Hubei, China
| | - Jing Wang
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- China Institute of Urology of Hubei Province, Wuhan, Hubei, China
| | - Xing Li
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- China Institute of Urology of Hubei Province, Wuhan, Hubei, China
| | - Zi-Hao Guo
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- China Institute of Urology of Hubei Province, Wuhan, Hubei, China
| | - Xiao-Yong Zeng
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- China Institute of Urology of Hubei Province, Wuhan, Hubei, China
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McBee PJ, Larsen NK, Reilly MJ, Walters RW, Olson MA, Fitzgibbons RJ. Association of Nicotine Cessation Time on the Incidence of Recurrent Incisional Hernia Repair and Postoperative Surgical Site Occurrences. Am Surg 2023; 89:6127-6133. [PMID: 37501283 DOI: 10.1177/00031348231192042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
BACKGROUND Nicotine products are believed to be associated with a higher incidence of incisional hernia (IH) recurrence and postoperative complications after IH repair. METHODS A retrospective analysis of the Abdominal Core Health Quality Collaborative (ACHQC) database was performed. Outcomes included risk of IH recurrence, 30-day surgical site infection (SSI), and 30-day surgical site occurrence (SSO). RESULTS We included 14,663 patients. Nicotine users who quit within 1 year of surgery had a 26% higher risk of IH recurrence compared to patients who quit more than a year before surgery or never users. Patients who quit using nicotine within 1 year of surgery had a 54% higher odds of SSI compared to former nicotine users who quit more than a year before surgery. CONCLUSION Former nicotine users with less than 1 year of nicotine use cessation before surgery exhibited worse outcomes than those with more than a year of cessation or no prior use.
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Affiliation(s)
- Patrick J McBee
- Department of Surgery, Creighton University School of Medicine, Omaha, NE, USA
| | - Nicholas K Larsen
- Department of Surgery, Creighton University School of Medicine, Omaha, NE, USA
| | - Matthew J Reilly
- Department of Surgery, Creighton University School of Medicine, Omaha, NE, USA
| | - Ryan W Walters
- Department of Clinical Research, Creighton University School of Medicine, Omaha, NE, USA
| | - Molly A Olson
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
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Al-Mansour MR, Gabriel KH, Neal D. Gender, racial, and socioeconomic disparity of preoperative optimization goals in ventral hernia repair. Surg Endosc 2023; 37:9399-9405. [PMID: 37658198 DOI: 10.1007/s00464-023-10365-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 07/30/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Preoperative optimization cut-offs are frequently utilized to determine eligibility for elective ventral hernia repair. Our objective was to assess the relationship between gender, race, and socioeconomic status and preoperative optimization goals. METHODS We queried our institutional database for adults with ventral hernia diagnoses between 2016 and 2021. Demographics, comorbidities, laboratory, and operative data were collected and analyzed. The following cut-offs were used to determine eligibility for elective repair: body mass index (BMI) < 40 kg/m2, no active smoking, and glycated hemoglobin (HbA1c) < 8%. Socioeconomic status was assessed using the Distressed Communities Index. RESULTS A total of 5638 patients were included [Whites = 4321 (77%), Blacks = 794 (14%), Hispanics = 318 (6%), and other/unknown 205 (4%)]. Median age was 61 years and 50% were male. Most common hernia types were umbilical (36%) and incisional (20%). 10% had BMI > 40 kg/m2, 9% were active smokers and 4% had HbA1c > 8%. 21% of all patients did not meet the preoperative optimization cut-offs at time of diagnosis and those were less likely to undergo hernia repair during the study timeframe compared to those who did (OR 0.50; 95% CI [0.42-0.60]). There was a higher proportion of females (21%) and Blacks (22%) with BMI > 40 kg/m2 compared to males (11%) and other races (11-15%), p = 0.002. As the level of socioeconomic distress increased, there was a corresponding increase in the proportion of patients who did not meet preoperative optimization cut-offs from 16% in prosperous communities to 25% in distressed communities (p < 0.0001). CONCLUSION Nearly 1 of 5 patients with ventral hernias is affected by commonly used arbitrary preoperative optimization cut-offs. These cut-offs disproportionately impact females, Black patients and those with higher socioeconomic distress. These disparities need to be considered when planning preoperative optimization protocols and resource allocation to ensure equitable access to elective ventral hernia repair.
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Affiliation(s)
- Mazen R Al-Mansour
- Department of Surgery, University of Florida, Gainesville, FL, USA.
- Department of Surgery, University of Florida Health, PO Box 100108, Gainesville, FL, 32610-0108, USA.
| | | | - Dan Neal
- Department of Surgery, University of Florida, Gainesville, FL, USA
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8
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Maskal SM, Chang JH, Ellis RC, Phillips S, Melland-Smith M, Messer N, Beffa LRA, Petro CC, Prabhu AS, Rosen MJ, Miller BT. Distressed community index as a predictor of presentation and postoperative outcomes in ventral hernia repair. Am J Surg 2023; 226:580-585. [PMID: 37331908 DOI: 10.1016/j.amjsurg.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/26/2023] [Accepted: 06/10/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND We evaluated the impact of socioeconomic status on presentation, management, and outcomes of ventral hernias. METHODS The Abdominal Core Health Quality Collaborative was queried for adult patients undergoing ventral hernia repair. Socioeconomic quintiles were assigned using the Distressed Community Index (DCI): prosperous (0-20), comfortable (21-40), mid-tier (41-60), at-risk (61-80), and distressed (81-100). Outcomes included presenting symptoms, urgency, operative details, 30-day outcomes, and one-year hernia recurrence rates. Multivariable regression evaluated 30-day wound complications. RESULTS 39,494 subjects were identified; 32,471 had zip codes (82.2%).Urgent presentation (3.6% vs. 2.3%) and contaminated cases (0.83% vs. 2.06%) were more common in the distressed group compared to the prosperous group (p < 0.001). Higher DCI correlated with readmission (distressed: 4.7% vs prosperous: 2.9%,p < 0.001) and reoperation (distressed 1.8% vs prosperous: 0.92%,p < 0.001). Wound complications were independently associated with increasing DCI (p < 0.05). Clinical recurrence rates were similar at one-year (distressed: 10.4% vs prosperous: 8.6%, p = 0.54). CONCLUSIONS Inequity exists in presentation and perioperative outcomes for ventral hernia repair and efforts should be focused on increasing access to elective surgery and improving postoperative wound care.
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Affiliation(s)
| | | | - Ryan C Ellis
- Cleveland Clinic, General Surgery, Cleveland, USA
| | | | | | - Nir Messer
- Cleveland Clinic, General Surgery, Cleveland, USA
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Maskal S, Beffa L. The Role of Robotics in Abdominal Wall Reconstruction. Surg Clin North Am 2023; 103:977-991. [PMID: 37709400 DOI: 10.1016/j.suc.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Robotic abdominal wall reconstruction is becoming an accepted technique to approach complex hernias in a minimally invasive fashion. There remain a deficit of high-quality data to suggest significant clinical benefit but current randomized trials are ongoing. Robotic surgery can be applied to a range of abdominal wall defects safely and with positive outcomes which are at least equivocal to open abdominal wall techniques.
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Affiliation(s)
- Sara Maskal
- Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Lucas Beffa
- Lerner College of Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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10
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Haskins IN. Hernia Formation: Risk Factors and Biology. Surg Clin North Am 2023; 103:835-846. [PMID: 37709390 DOI: 10.1016/j.suc.2023.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
The incidence of ventral hernias in the United States is in increasing. Herein, the author details the etiology of congenital and acquired ventral hernias as well as the risk factors associated with the development of each of these types of ventral hernias.
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Affiliation(s)
- Ivy N Haskins
- Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, USA.
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11
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Kudsi OY, Kaoukabani G, Bou-Ayash N, Gokcal F. Does smoking influence the clinical outcomes of robotic ventral hernia repair? A propensity score matching analysis study. J Robot Surg 2023; 17:2229-2236. [PMID: 37285002 DOI: 10.1007/s11701-023-01645-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 06/01/2023] [Indexed: 06/08/2023]
Abstract
The purpose of this study is to compare the clinical outcomes of robotic ventral hernia repair (RVHR) between smokers and non-smokers. Data for patients undergoing RVHR between 2012 and 2022 were collected. Patients were assigned to either smoking (+) or smoking (-) groups, according to their smoking status in the last 3 months prior to their procedure. Pre-, intra- and postoperative variables including surgical site occurrences (SSO) and infections (SSI), and hernia recurrence were analyzed after a propensity score matching analysis based on the patients' demographics and hernia's characteristics. Each group consisted of 143 patients matched according to their preoperative characteristics. There were no differences in terms of demographics and hernia characteristics. Intraoperative complications occurred at a comparable rate between both groups (p = 0.498). Comprehensive Complication Index® and all complication grades of the Clavien-Dindo classification were similar between both groups. Surgical site occurrences and infections did not differ either [smoking (+) vs. smoking (-): 7.6% vs 5.4%, p = 0.472; 5 vs. 0, p = 0.060, respectively). Rates of SSOs and SSIs that required any intervention (SSOPI) were similar in both groups [smoking (+): 3.1% vs. smoking (-): 0.8%, p = 0.370]. With a mean follow-up of 50 months for the cohort, recurrences rates were also comparable with 7 recorded in the smoking (-) versus 5 in the smoking (+) group (p = 0.215). Our study showed comparable rates of SSOs, SSIs, SSOPIs, and recurrence between smokers and non-smokers following RVHR. Future studies should compare the open, laparoscopic, and robotic approaches in smokers.
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Affiliation(s)
- Omar Yusef Kudsi
- Good Samaritan Medical Center, One Pearl Street, Brockton, MA, 02301, USA.
- Tufts University School of Medicine, Boston, MA, USA.
| | - Georges Kaoukabani
- Good Samaritan Medical Center, One Pearl Street, Brockton, MA, 02301, USA
| | | | - Fahri Gokcal
- Good Samaritan Medical Center, One Pearl Street, Brockton, MA, 02301, USA
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12
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Yergin CG, Ding DD, Phillips S, Read TE, Al-Mansour MR. The effect of smoking status on inguinal hernia repair outcomes: An ACHQC analysis. Surg Endosc 2023:10.1007/s00464-023-10055-4. [PMID: 37043005 DOI: 10.1007/s00464-023-10055-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 03/26/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND Smoking has been shown to negatively affect surgical outcomes, so smoking cessation prior to elective operations is often recommended. However, the effects of smoking status on inguinal hernia repair outcomes have not been extensively studied. Hence, we investigated the association between smoking status and short-term adverse outcomes following inguinal hernia repair. METHODS Abdominal Core Health Quality Collaborative database was queried for elective, clean inguinal hernia repairs, excluding those with concomitant procedures or where length of stay > 30 days. The resulting cohort was divided into three groups: current smokers, former smokers, and never smokers. Baseline patient, hernia, operative characteristics, and 30-day outcomes were compared. Multivariable logistic regression was used to evaluate the association between smoking status and overall and wound complications. RESULTS 19,866 inguinal hernia repairs were included (current smokers = 2239, former smokers = 4064 and never smokers = 13,563). Current smokers and former smokers, compared to never smokers, had slightly higher unadjusted rates of overall complication rates (9% and 9% versus 7%, p = 0.003) and surgical site occurrences/infection (6% and 6% versus 4%, p < 0.001). However, on multivariable analysis, compared to current smokers, neither the rates of overall complications nor surgical site occurrences were significantly different in former smokers (OR = 0.93, 95% CI [0.76, 1.13] and OR = 0.92, 95% CI [0.73, 1.17]) and never smokers (OR = 0.99, 95% CI [0.83, 1.18] and OR = 0.86, 95% CI [0.70,1.06]) respectively. CONCLUSIONS Smoking status is not associated with short-term adverse outcomes following inguinal hernia repair. Mandating smoking cessation does not appear necessary to prevent short-term adverse outcomes.
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Affiliation(s)
| | - Delaney D Ding
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Sharon Phillips
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Thomas E Read
- Department of Surgery, University of Florida College of Medicine, PO Box 100109, Gainesville, FL, 32610, USA
| | - Mazen R Al-Mansour
- Department of Surgery, University of Florida College of Medicine, PO Box 100109, Gainesville, FL, 32610, USA.
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13
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Romero-Velez G, Lima DL, Pereira X, Farber BA, Friedmann P, Malcher F, Sreeramoju P. Risk Factors for Surgical Site Infection in the Undeserved Population After Ventral Hernia Repair: A 3936 Patient Single-Center Study Using National Surgical Quality Improvement Project. J Laparoendosc Adv Surg Tech A 2022; 32:948-954. [PMID: 35319294 DOI: 10.1089/lap.2021.0856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Ventral hernia repair (VHR) is one of the most common surgical procedures performed in the United States. Surgical site infections (SSI) carry significant morbidity for the patient and pose a very challenging problem for the surgeon, associated with up to 6.6% of cases. Thus, surgeons should be well versed in the risk factors implicated in SSI after VHR. Given the high burden of diabetes, obesity, and smoking in our patient population, we sought to study the rate of SSI and the risk factors that led to SSI in our population. Study Design: This is a retrospective study using the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) database for the years 2014-2019. We identified patients who underwent VHR at a single institution in the Bronx, New York. The rate of SSI was calculated, and then, risk factors for SSI were identified using logistic regression analysis. Results: A total of 3936 patients underwent VHR. Incisional hernias made up 41% of the cohort, and there were 37.4% laparoscopic repairs. During the 30-day follow-up, SSI was identified in 101 patients (2.6%). Factors associated with SSI include emergent surgery (adjusted odds ratio [aOR] = 2.57), body mass index >35 kg/m2 (aOR = 2.38), insulin-dependent diabetes mellitus (aOR = 2.36), and incisional hernia (aOR = 1.81). In addition, a laparoscopic approach was found to be a protective factor (aOR = 0.43, 95% confidence interval 0.25-0.75). Surprisingly, different from other studies, smoking cigarettes was not associated with SSI in our cohort. Conclusions: The rate of SSI after VHR in our institution is 2.6%, which is within that reported in the literature. Most of the variables associated with SSI are modifiable and are similar to those previously reported. Laparoscopic repairs appear to be protective for its occurrence.
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Affiliation(s)
| | - Diego L Lima
- Department of Surgery, Montefiore Medical Center, Bronx, New York, USA
| | - Xavier Pereira
- Department of Surgery, Montefiore Medical Center, Bronx, New York, USA
| | - Benjamin A Farber
- Department of Surgery, Montefiore Medical Center, Bronx, New York, USA
| | | | - Flavio Malcher
- Department of Surgery, NYU Langone Health, New York, New York, USA
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14
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Knewitz DK, Kirkpatrick SL, Jenkins PD, Al-Mansour M, Rosenthal MD, Efron PA, Loftus TJ. Preoperative computed tomography for acutely incarcerated ventral or inguinal hernia. Surgery 2022; 172:193-197. [PMID: 35304009 DOI: 10.1016/j.surg.2022.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 12/29/2021] [Accepted: 01/15/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The utility of preoperative computed tomography for urgent abdominal wall hernia repair is unclear. This study tests the hypothesis that there is no difference in patient outcomes for acutely incarcerated ventral or inguinal hernias diagnosed by preoperative computed tomography versus clinical assessment alone. METHODS This retrospective cohort analysis included 270 adult patients undergoing urgent repair of ventral or inguinal hernia. Demographics, risk factors for complications, operative management strategies, and 1-year outcomes were compared between patients with (n = 179) versus without (n = 91) preoperative computed tomography. RESULTS Among 179 preoperative computed tomography scans, 15 (8.4%) were ordered by surgeons, and all others were ordered by referring providers. The computed tomography and no computed tomography groups had similar age (58 vs 58 years, P = .77), body mass index (30.7 vs 30.6 kg/m2, P = .30), American Society of Anesthesiologists class (3.0 vs 3.0, P = .39), incidence of the systemic inflammatory response syndrome (19.0% vs 20.9%, P = .75), and incidence of recurrent hernia (16.8% vs 19.8%, P = .61). The interval between admission and incision was longer in the computed tomography group (11.2 hours vs 6.6 hours, P < .001). The computed tomography and no computed tomography groups had similar duration of surgery (125 minutes in both groups, P = .88), proportions of patients with biologic mesh (21.2% vs 17.6%, P = .52) and synthetic mesh (35.2% vs 46.2%, P = .09) placement, and 1-year outcomes including incidence of superficial (8.4% vs 6.6%, P = .81) and deep or organ/space surgical site infection (5.0% vs 6.6%, P = .59), mesh explant for infection (2.2% vs 3.3%, P = .69), reoperation for recurrent hernia (3.9% vs 1.1%, P = .27), and mortality (7.8% vs 4.4%, P = .44). CONCLUSION The performance of preoperative computed tomography was associated with a longer interval between admission and incision and no differences in mesh placement, mesh type, or 1-year patient outcomes. These results support the safety of performing urgent repair of acutely incarcerated ventral or inguinal hernias based on clinical assessment alone.
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Affiliation(s)
| | | | | | - Mazen Al-Mansour
- Department of Surgery, University of Florida Health, Gainesville, FL
| | | | - Philip A Efron
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - Tyler J Loftus
- Department of Surgery, University of Florida Health, Gainesville, FL.
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15
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Abstract
Smoking and obesity are commonly encountered problems in the elective, perioperative setting. This article reviews the risks posed by smoking and diabetes and explores way to mitigate such risks. Other means of perioperative optimization are also discussed in an effort to describe perioperative strategies that can improve patient outcomes.
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Affiliation(s)
- Sullivan A Ayuso
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC 28204, USA
| | - Jordan N Robinson
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC 28204, USA
| | - Paul D Colavita
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC 28204, USA
| | - B Todd Heniford
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC 28204, USA.
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16
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General Surgery: Management of Postoperative Complications Following Ventral Hernia Repair and Inguinal Hernia Repair. Surg Clin North Am 2021; 101:755-766. [PMID: 34537141 DOI: 10.1016/j.suc.2021.05.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Ventral and inguinal hernia repairs are some of the most commonly performed general surgery operations worldwide. This review focuses on the management of postoperative complications, which include surgical site infection, hernia recurrence, postoperative pain, and mesh-related issues. In each section, we aim to discuss classifications, risk factors, diagnostic modalities, and treatment options for common complications following hernia repair.
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Howard R, Ehlers A, Delaney L, Solano Q, Englesbe M, Dimick J, Telem D. Leveraging a statewide quality collaborative to understand population-level hernia care. Am J Surg 2021; 222:1010-1016. [PMID: 34090661 DOI: 10.1016/j.amjsurg.2021.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/09/2021] [Accepted: 05/25/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Although ventral hernia repair (VHR) is extremely common, there is profound variation in operative technique and outcomes. This study describes the results of a statewide registry capturing hernia-specific variables to understand population-level practice patterns. METHODS Retrospective analysis of adult patients in a new statewide hernia registry undergoing VHR in 2020. RESULTS 919 patients underwent VHR across 57 hospitals and 279 surgeons. Hernia width was <2 cm in 233 (25%) patients, 2-5 cm in 420 (46%) patients, 5-10 cm in 171 (19%) patients, and >10 cm in 95 (10%) patients. Mesh was used in 79% of cases and varied in use from 53% of hernias <2 cm to 95% of hernias >10 cm. The most common mesh type was synthetic non-absorbable (46%), followed by synthetic absorbable mesh (37%). The incidence of complications was significantly associated with hernia width. CONCLUSIONS A population-level, hernia-specific database captured operative details for 919 patients in 1 year. There was significant variation in mesh use and outcomes based on hernia size. These nuanced data may inform higher quality clinical practice.
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Affiliation(s)
- Ryan Howard
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.
| | - Anne Ehlers
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Lia Delaney
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Quintin Solano
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Michigan Surgical Quality Collaborative, Ann Arbor, MI, USA
| | - Justin Dimick
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Division of Minimally Invasive Surgery, Department of Surgery, Ann Arbor, MI, USA
| | - Dana Telem
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Division of Minimally Invasive Surgery, Department of Surgery, Ann Arbor, MI, USA.
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18
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Surgical "error traps" of open posterior component separation-transversus abdominis release. Hernia 2020; 25:1703-1714. [PMID: 33079331 DOI: 10.1007/s10029-020-02321-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/07/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Past techniques for the repair of complex incisional hernias have been met with unacceptably high recurrence rates and postoperative complications. The transversus abdominis release (TAR) is a versatile and durable solution gaining popularity amongst both abdominal wall specialists and general surgeons. However, several preoperative factors and specific intraoperative pitfalls can have a major impact on patient outcomes. METHODS The authors review the current literature and draw upon their own practice experience to highlight key preoperative and perioperative steps for avoiding common pitfalls or "error traps" often performed by a surgeon new to this surgical technique. RESULTS We discuss preoperative factors that influence the outcomes of patients undergoing incisional hernia repair. We show how a TAR that preserves the neurovascular bundles supplying the rectus complex and dissection in the correct plane prevents the formation of new, challenging unintended hernia defects and provides for wide prosthetic overlap offering the patient a sustainable repair. Lastly, we highlight key postoperative factors that affect a patient's recovery. CONCLUSIONS Avoidance of surgical error traps combined with technique mastery can lead to the successful repair of challenging abdominal wall defects using the TAR approach.
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19
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Reilly MJ, Larsen NK, Agrawal S, Thankam FG, Agrawal DK, Fitzgibbons RJ. Selected conditions associated with an increased incidence of incisional hernia: A review of molecular biology. Am J Surg 2020; 221:942-949. [PMID: 32977928 DOI: 10.1016/j.amjsurg.2020.09.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/16/2020] [Accepted: 09/01/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Incisional hernias (IH) following a laparotomy, on average, occur in 10-20% of patients, however, little is known about its molecular basis. Thus, a better understanding of the molecular mechanisms could lead to the identification of key target(s) to intervene pre-and post-operatively. METHODS We examined the current literature describing the molecular mechanisms of IH and overlap these factors with smoking, abdominal aortic aneurysm, obesity, diabetes mellitus, and diverticulitis. RESULTS The expression levels of collagen I and III, matrix metalloproteinases, and tissue inhibitors of metalloproteases are abnormal in the extracellular matrix (ECM) of IH patients and ECM disorganization has an overlap with these comorbid conditions. CONCLUSION Understanding the pathophysiology of IH development and associated risk factors will allow physicians to identify patients that may be at increased risk for IH and to possibly act preemptively to decrease the incidence of IH.
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Affiliation(s)
| | | | - Swati Agrawal
- Creighton University School of Medicine, Omaha, NE, 68178, USA; Department of Surgery, Creighton University Medical Center, Omaha, NE, 68131, USA
| | - Finosh G Thankam
- Department of Translational Research, Western University of Health Sciences, Pomona, CA, 91766, USA
| | - Devendra K Agrawal
- Department of Translational Research, Western University of Health Sciences, Pomona, CA, 91766, USA
| | - Robert J Fitzgibbons
- Department of Surgery, Creighton University Medical Center, Omaha, NE, 68131, USA.
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20
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Smoking and obesity are associated with increased readmission after elective repair of small primary ventral hernias: A nationwide database study. Surgery 2020; 168:527-531. [DOI: 10.1016/j.surg.2020.04.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 03/26/2020] [Accepted: 04/07/2020] [Indexed: 11/19/2022]
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Zolin SJ, Fafaj A, Krpata DM. Transversus abdominis release (TAR): what are the real indications and where is the limit? Hernia 2020; 24:333-340. [PMID: 32152808 DOI: 10.1007/s10029-020-02150-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 02/19/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE To review literature surrounding transversus abdominis release (TAR) for incisional hernia repair, with the aim of describing key preoperative and technical considerations for this procedure. METHODS Existing literature on TAR was reviewed and synthesized with the clinical experience and approach to TAR from a high-volume hernia center. RESULTS Recommendations regarding patient selection, optimization and technique for TAR are presented. CONCLUSIONS While published outcomes of TAR from expert centers are favorable, potentially devastating complications may result when TAR is performed incorrectly or in suboptimal clinical situations. Appropriate patient selection, optimization, and surgeon expertise are necessary if TAR is to be performed.
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Affiliation(s)
- S J Zolin
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100-133, Cleveland, OH, 44195, USA.
| | - A Fafaj
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100-133, Cleveland, OH, 44195, USA
| | - D M Krpata
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100-133, Cleveland, OH, 44195, USA
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22
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Nisiewicz MJ, Plymale MA, Davenport DL, Saleh S, Buckley TD, Hassan ZU, Roth JS. Validation and Extension of the Ventral Hernia Repair Cost Prediction Model. J Surg Res 2019; 244:153-159. [PMID: 31288184 DOI: 10.1016/j.jss.2019.06.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 04/30/2019] [Accepted: 06/06/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Repair of ventral and incisional hernias remains a costly challenge for health care systems. In a previous study of a single surgeon's elective open ventral hernia repair (VHR) practice, a cost model was developed, which predicted over 70% of hospital cost variation. The purpose of the present study was to evaluate the ventral hernia cost model with multiple surgeons' elective open VHR cases and extending to include nonelective and laparoscopic VHR. MATERIALS AND METHODS With the University of Kentucky Institutional Review Board approval, elective and emergent cases of open and laparoscopic VHR performed by multiple surgeons over 3 y were identified. Perioperative variables were obtained from the local American College of Surgeons National Surgery Quality Improvement Program database and electronic medical record review. Hospital cost data were obtained from the hospital cost accounting system. Forward multivariable regression of log-transformed costs identified independent cost drivers (P for entry < 0.05, and P for exit > 0.10). RESULTS Of the 387 VHRs, 74% were open repairs; mean age was 55 y, and 52% of patients were female. For open, elective cases (n = 211; mean cost of $19,145), the previously reported six-factor cost model predicted 45% of the total cost variation. With all VHRs included, additional variables were found to independently drive costs, predicting 59% of the total cost variation from the base cost. The biggest cost drivers were inpatient status (+$1013), use of biologic mesh (+$1131), preoperative systemic inflammatory response syndrome/sepsis (+$894), and preoperative open wound (+$786). CONCLUSIONS Ventral hernia repair cost variability is predictable. Understanding the independent drivers of cost may be helpful in controlling costs and in negotiating appropriate reimbursement with payers.
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Affiliation(s)
| | - Margaret A Plymale
- Division of General Surgery, Department of Surgery, University of Kentucky, Lexington, Kentucky
| | | | - Sherif Saleh
- University of Kentucky College of Medicine, Lexington, Kentucky
| | - Tori D Buckley
- University of Kentucky College of Medicine, Lexington, Kentucky
| | - Zain U Hassan
- University of Kentucky College of Medicine, Lexington, Kentucky
| | - John Scott Roth
- Division of General Surgery, Department of Surgery, University of Kentucky, Lexington, Kentucky.
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Alkhatib H, Tastaldi L, Krpata DM, Petro CC, Huang LC, Phillips S, Fafaj A, Rosenblatt S, Rosen MJ, Prabhu AS. Impact of modifiable comorbidities on 30-day wound morbidity after open incisional hernia repair. Surgery 2019; 166:94-101. [DOI: 10.1016/j.surg.2019.03.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 03/01/2019] [Accepted: 03/11/2019] [Indexed: 01/15/2023]
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