Postoperative Prophylactic Antibiotic Use following Ventral Hernia Repair with Placement of Surgical Drains Reduces the Postoperative Surgical-Site Infection Rate:

Drain versus no drain in elective open incisional hernia operations: a registry-based analysis with 39,523 patients

PURPOSE

Elective open incisional hernia operations are a frequently performed and complex procedure. Prophylactic drainage is widely practised to prevent local complications, but nevertheless the benefit of surgical drain placement remains a controversially discussed subject. Objective of this analysis was to evaluate the current status of patient care in clinical routine and outcome in this regard.

METHODS

The study based on prospectively collected data of the Herniamed Register. Included were all patients with elective open incisional hernia between 1/2005 and 12/2020 and completed 1-year follow-up. Multiple linear and logistic regression analysis was performed to assess the relation of individual factors to the outcome variables.

RESULTS

Analysed were data from 39,523 patients (28,182 with drain, 11,341 without). Patients with drain placement were significantly older, had a higher BMI, more preoperative risk factors, and a larger defect size. Drained patients furthermore showed a significant disadvantage in the outcome parameters intraoperative complications, general complications, postoperative complications, complication-related reoperations, and pain at the 1-year follow-up. No significant difference was observed with respect to the recurrent rate.

CONCLUSION

With 71.3%, the use of surgical drainages has a high level of acceptance in elective open incisional hernia operations. The worse outcome of patients is associated with the use of drains, independent of other influencing factors in the model such as patient or surgical characteristics. The use of drains may be a surrogate parameter for other unobserved confounders.

Microbiome Contributions to Health

The human microbiome is vast and is present in spaces previously thought to be sterile such as the lungs. A healthy microbiome is diverse and functions in an adaptive way to support local as well as organism health and function. Furthermore, a normal microbiome is essential for normal immune system development rendering the array of microbes that live in and on the human body key components of homeostasis. A wide array of clinical conditions and interventions including anesthesia, analgesia, and surgical intervention may derange the human microbiome in a maladaptive fashion with bacterial responses spanning decreased diversity to transformation to a pathogenic phenotype. Herein, we explore the normal microbiome of the skin, gastrointestinal tract, and the lungs as prototype sites to describe the influence of the microbiomes in each of those locations on health, and how care may derange those relations.

Do surgical drains reduce surgical site occurrence and infection after incisional hernia repair with sublay mesh? A non-randomised pilot study

INTRODUCTION

Surgical site occurrence (SSO) and surgical site infection (SSI) are common concerns with incisional hernia repair. Intraoperative drain placement is a common practice aiming to reduce SSO and SSI rates. However, literature on the matter is very poor. The aim of this study is to investigate the role of subcutaneous and periprosthetic drain placement on postoperative outcomes and SSO and SSI rates with incisional hernia repair.

METHODS

A non-randomised pilot study was performed between January 2018 and December 2020 and included patients with elective midline or lateral incisional hernia repair with sublay mesh placement. Patients were prospectively included, followed for 1 month and divided into three groups: group 1 without drainage, group 2 with subcutaneous drainage, and group 3 with subcutaneous and periprosthetic drains. Drains were placed at surgeon's discretion. All patients were included in the enhanced recovery program.

RESULTS

One hundred and four patients were included. Twenty-four patients (23.1%) did not have drains (group 1), 60 patients (57.7%) had a subcutaneous drain (group 2) and 20 patients (19.2%) had both a subcutaneous and a periprosthetic drains (group 3). SSO rates were significantly different between the 3 groups: 20.8% in group 1, 20.7% in group 2 and 50% in group 3 (p = 0.03). There was no significant difference in deep and superficial SSI rates between the 3 groups. Subgroup analysis revealed that adding a drain in direct contact with the mesh significantly increased SSO rate but did not influence SSI rate. Length of stay was also significantly increased by the presence of a drain, 3.1 ± 1.9 days for group 1; 5.9 ± 4.8 for group 2 and 5.9 ± 2.5 days for group 3 (p < 0.005).

CONCLUSION

Drain placement in direct contact with the mesh might increase SSO rate. More studies are necessary to evaluate the actual benefits of drainage after incisional hernia repair.

The European Hernia Society Prehabilitation Project: A Systematic Review of Intra-Operative Prevention Strategies for Surgical Site Occurrences in Ventral Hernia Surgery

Background

Ventral hernia repair is one of the most commonly performed surgical procedures worldwide. To reduce the risk of complications, pre- and intra-operative strategies have received increasing focus in recent years. To assess possible preventive surgical strategies, this European Hernia Society endorsed project was launched. The aim of this review was to evaluate the current literature focusing on pre- and intra-operative strategies for surgical site occurrences (SSO) and specifically surgical site infection (SSI) in ventral hernia repair.

Methods

A systematic review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Databases used were Pubmed and Web of Science. Original retrospective or prospective human adult studies describing at least one intra-operative intervention to reduce SSO after ventral hernia repair were considered eligible.

Results

From a total of 4775 results, a total of 18 papers were considered suitable after full text reading. Prehospital chlorhexidine gluconate (CHG) scrub appears to increase the risk of SSO in patients undergoing ventral hernia repair, while there is no association between any type of surgical hat worn and the incidence of postoperative wound events. Intraoperative measures as prophylactic negative pressure therapy, surgical drain placement and the use of quilt sutures seem beneficial for decreasing the incidence of SSO and/or SSI. No positive effect has been shown for antibiotic soaking of a synthetic mesh, nor for the use of fibrin sealants.

Conclusion

This review identified a limited amount of literature describing specific preventive measures and techniques during ventral hernia repair. An advantage of prophylactic negative pressure therapy in prevention of SSI was observed, but different tools to decrease SSIs and SSOs continuously further need our full attention to improve patient outcomes and to lower overall costs.

Large ventral hernias: to drain… And what to drain… That is the question!

BACKGROUND

Drain placement is common practice in repair of ventral hernias, specifically complex hernias. There is little-to-no evidence for benefit of drains and best practice in-terms of number, position, duration of use and type of drains. This study investigates drain profile in open repair of large ventral hernias.

METHODS

A retrospective two-centres audit with data collected via electronic and paper-based medical records from the 1 February 2015 to 29 June 2020. All elective and emergency cases were included. Main outcomes included surgical site infection (SSI), seroma and hematoma formation.

RESULTS

A total of 186 patients included, out of those 128(68.5%) had drain placed. Drain placement had a higher incidence of SSI (20.3% in drain group and 15.5% in no drain group), however, drains were more likely to be placed in complex ventral hernias. Drain practice varied significantly between surgeons, however, there was a clear trend to higher SSI rates with longer duration of drain use (specifically longer than 5 days, p-value: 0.05) and higher drain output on removal (specifically higher than 150 ml/24 h, p-value 0.004), furthermore, prolonged use did not decrease risk of seroma formation. Drain position, number of drains and suction pressure did not affect seroma or SSI rates.

CONCLUSION

Our data suggests no clear benefits of drain usage in most ventral hernia repairs. Prolonged drain use led to higher risk of SSI and did not decrease rate of seroma formation. If used, we recommend use of short drain duration<5 days. Further RCTs to evaluate drain placement in large ventral hernias are needed.

Surgical Site Infection: The Scourge of Abdominal Wall Reconstruction

Background: Surgical site infection (SSI) is a well-recognized and potentially catastrophic complication of abdominal wall reconstruction (AWR). The authors present a review of the literature surrounding SSI in AWR, exploring prevention and treatment strategies as well as risk factors. Methods: A comprehensive review of the current literature was undertaken. Evidence was reviewed and summarized with particular focus on prevention and treatment strategies available to hernia surgeons. Results: Patient risk factors for SSI are well described in the literature and include obesity, smoking, and other comorbidities. Contaminated hernias and cases involving enterocutaneous fistulae are also at higher risk of SSI. Surgical decisions such as type of mesh, plane of mesh placement, and fascial release may all contribute to SSI risk. To treat established mesh infection, conservative management with antibiotic agents and negative pressure therapy is a reasonable option in some cases. Removal of prosthesis appears to provide favorable results, however, repeat surgery can be problematic Conclusions: Surgical site infection remains an important pathology in the world of AWR. Surgeons have a wealth of tools in their arsenal to prevent and treat SSI and should be aware of the emerging evidence in the fast-moving specialty of hernia surgery. Complex cases should be handled by surgeons and centers with expertise in treating such patients.

Postoperative Prophylactic Antibiotics Reduce Surgical Site Infection Rates after Ventral Hernia Repair: A Systematic Review

SSIs after ventral hernia repair (VHR) represent a significant complication. The impact of postoperative prophylactic antibiotics on the SSI rates after VHRs is unclear. A systematic review of PubMed and Web of Science databases from inception through March 2016 investigating the effect of postoperative prophylactic antibiotics after VHRs was performed. Strict inclusion and exclusion criteria were implemented, and the methodological quality of the included studies was assessed. After systematic independent assessment of 216 citations, four studies, involving 344 patients, met the inclusion criteria. Among the included studies, 164 patients received >24 hours of postoperative prophylactic antibiotics, whereas 180 patients were controls. The overall incidence of SSI among patients receiving postoperative antibiotics was 14.6 per cent (95% confidence interval [CI], 9.9 to 20.9) which compares favorably with the control group: 35.5 per cent (95% CI, 28.9 to 42.7) (odds ratio: 0.3, 95% CI: 0.2 to 0.5, P < 0.01). Among patient's receiving postoperative antibiotics, the pooled average duration of postoperative antibiotic treatment was 6.2 ± 0.4 days. Based on the available evidence, the use of postoperative prophylactic antibiotics seems to be associated with lower SSI rates after VHRs. Future prospective randomized controlled trials should be conducted to further confirm the efficacy of this prophylactic intervention.

The Effect of Prolonged Postoperative Antibiotic Administration on the Rate of Infection in Patients Undergoing Posterior Spinal Surgery Requiring a Closed-Suction Drain: A Randomized Controlled Trial

BACKGROUND

Closed-suction drains are frequently used following posterior spinal surgery. The optimal timing of antibiotic discontinuation in this population may influence infection risk, but there is a paucity of evidence. The aim of this study was to determine whether postoperative antibiotic administration for 72 hours (24 hours after drain removal as drains were removed on the second postoperative day) decreases the incidence of surgical site infection compared with postoperative antibiotic administration for 24 hours.

METHODS

Patients undergoing posterior thoracolumbar spinal surgery managed with a closed-suction drain were prospectively randomized into 1 of 2 groups of postoperative antibiotic durations: (1) 24 hours, or (2) 24 hours after drain removal (72 hours). Drains were discontinued on the second postoperative day. The duration of antibiotic administration was not blinded. All subjects received a single dose of preoperative antibiotics, as well as intraoperative antibiotics if the surgical procedure lasted >4 hours. The primary outcome was the rate of complicated surgical site infection (deep or organ or space) within 1 year of the surgical procedure.

RESULTS

The trial was terminated at an interim analysis, when 552 patients were enrolled, for futility with respect to the primary outcome. In this study, 282 patients were randomized to postoperative antibiotics for 24 hours and 270 patients were randomized to postoperative antibiotics for 72 hours. A complicated infection developed in 17 patients (6.0%) in the 24-hour group and in 14 patients (5.2%) in the 72-hour group (p = 0.714). The superficial infection rate did not differ between the groups (p = 0.654): 9.6% in the 24-hour group compared with 8.1% in the 72-hour group. Patients in the 72-hour group had a median hospital stay that was 1 day longer (p < 0.001). At 1 year, patient-rated outcomes including leg and back pain and physical and mental functioning were not different between the groups.

CONCLUSIONS

The extension of postoperative antibiotics for 72 hours, when a closed-suction drain is required, was not associated with a reduction in the rate of complicated surgical site infection after posterior thoracolumbar spinal surgery.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of Levels of Evidence.

Use of Prolonged Prophylactic Antibiotics with Closed Suction Drains in Ventral Abdominal Hernia Repair

Closed suction drains (CSD) are commonly used in ventral hernia repair (VHR), with or without prolonged postoperative prophylactic antibiotics (PPA) for the duration of their use. We examine the evidence that PPA with CSD reduce surgical site infection (SSI) in patients undergoing VHR. We also examine the evidence assessing the association between SSI and CSD in VHR. A systematic review of PubMed, CIHNL, and Cochrane databases was performed to identify studies analyzing rates of SSI with CSD in patients undergoing abdominal VHR and related procedures with or without the concomitant use of PPA. The primary outcome was the rate of SSI. Five studies totaling 772 patients were identified, 525 patients were confirmed to have CSD, and 434 patients received prolonged antibiotics while drains were in place. PPA had no significant effect on SSI in two studies and were associated with decreased SSI in one study (Odds ratio 0.235, 95% confidence interval 0.090–0.617, P = 0.003). Two studies documented a higher rate of SSI in patients with CSD (79% vs 49% and 19% vs 10%) on univariate analysis. One study demonstrated a very low risk of SSI despite CSD (4.2%) and another demonstrated no increased risk with or without CSD. The use of drains is not clearly associated with an increased risk of SSI in VHR, and there is limited evidence to support antibiotic use while the drains are in place to decrease the potential risk. Prospective randomized studies are needed to more clearly assess these associations.

Tissue Expander Complications Do Not Preclude a Second Successful Implant-Based Breast Reconstruction

BACKGROUND

Implant-based breast reconstruction is the most common method of breast reconstruction in the United States, but the outcomes of subsequent implant-based reconstruction after a tissue expander complication are rarely studied. The purpose of this study was to determine the long-term incidence of implant loss in patents with a previous tissue expander complication.

METHODS

This is a retrospective review of the long-term outcomes of all patients with tissue expander complications at a large academic medical center from 2003 to 2013. Patients with subsequent tissue expander or implant complications were compared to those with no further complications to assess risk factors for additional complications or reconstructive failure.

RESULTS

One hundred sixty-two women were included in this study. The mean follow-up period was 8.3 ± 3.1 years. Forty-eight women (30 percent) went on to undergo a second tissue expander or implant placement. They did not differ from women who went on to autologous reconstruction or no further reconstruction. Of these, 34 women (71 percent) had no further complications and 38 women (79 percent) had a successful implant-based reconstruction at final follow-up. There were no patient or surgical factors significantly associated with a second complication or implant loss.

CONCLUSIONS

Following tissue expander complications, it is reasonable to offer women a second attempt at tissue expansion and implant placement. This study demonstrates that long-term success rates are high, and there are no definitive patient or surgical factors that preclude a second attempt at implant-based breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Reconstruction of the Abdominal Wall after Oncologic Resection: Defect Classification and Management Strategies

Compared with conventional ventral hernia repair, there are several additional considerations germane to the oncologic abdominal wall reconstruction, including the management of radiation soft-tissue injury, the management of bacterial contamination, and the location and extent of the defect. Herein, we review some of the unique challenges associated with oncologic abdominal wall reconstruction and introduce a new classification schema to assist the reconstructive surgeon in performing these complex cases.

Quality measures in ventral hernia repair: a systematic review

BACKGROUND

The US healthcare system is shifting towards reimbursement for quality over quantity of care. Quality measures are tied to financial incentives in these healthcare models. It is important that surgeons become familiar with quality measures addressing ventral hernia repair and understand candidate measures that may drive future quality measure development.

STUDY DESIGN

We performed a systematic review of society websites, quality measure databases, and the literature (Pubmed, Embase/Scopus, and Google Scholar) for quality measures addressing ventral hernia surgery. Clinical practice guidelines were included as candidate quality measures. All measures were categorized as structure, process or outcome according to Donabedian domains, as well as within the six National Quality Strategy (NQS) domains.

RESULTS

Thirty quality measures and candidate measures were identified. Eight candidate measures from the American Hernia Society addressed ventral hernia repair, and 22 quality measures in general surgery were also relevant to ventral hernia repair. Of the candidate measures, 6 (75%) were outcome and 2 (25%) were process measures. Of existing general surgery quality measures, 9 (41%) were outcome and 13 (59%) were process measures. No structural measures were identified. Overall, the majority of measures addressed NQS priorities of effective clinical care (33%) and patient safety (27%), while few addressed other domains.

CONCLUSION

Both the Donabedian domains of quality and NQS priorities were unequally represented in the current measures addressing ventral hernia repair. Recognizing and addressing the under-represented areas will provide a more balanced framework for developing quality measures and ensure that ventral hernia surgery is appropriately evaluated in value-based payment models.