The Abdominal Hernia-Q: Development, Psychometric Evaluation, and Prospective Testing

Quality of life and abdominal wall functionality after abdominal wall reconstruction: A prospective single center follow-up study

BACKGROUND

Fascial breakdown with the occurrence of an incisional hernia (IH) is an important and challenging complication of any laparotomy. For a long time, the success of the abdominal wall reconstruction (AWR) was measured only from the surgeon's perspective by defining outcome measures such as wound morbidity and recurrence. The understanding that complete recovery is difficult to assess without considering patients has shifted the paradigm of optimal outcomes to Patient Reported Outcome Measures (PROMS) and Quality of Life (QoL), which are pivotal to evaluate the success and efficacy of AWR.

METHODS

We conducted a prospective follow-up study of 91 patients undergoing mesh-augmented abdominal wall reconstruction for primary or recurrent incisional hernia between January 2021 and December 2023. Demographic data, comorbidities, and hernia characteristics were recorded. All patients were evaluated preoperatively by a native abdomino-pelvic CT scan to assess the characteristics of hernia (length, width, surface, and volume of the incisional hernia sac and of peritoneal cavity), the presence of mesh (if previously inserted), and abdominal wall muscles status. All intervention were performed by the same surgical team according to the techniques described by Rives - Stoppa (RS), Ramirez (ACS), and Novitsky (PCS). Abdominal wall function was assessed using trunk raising (TR) and double leg lowering (DLL) measurements performed preoperatively, 1 month, 6 months, and 1 year postoperatively. At the same time, pre- and post-operative quality of life was analysed using the EQ-5D score.

RESULTS

Mean age of 59.42 ± 12.28 years and a male/female ratio of 35/56 were recorded, most of them being obese. There were 36 (42%) patients with defects larger than 10 cm. The distribution of the type of surgical intervention was: RS 35 patients, ACS 13 patients, and PCS 43 patients. The mean value of combined score for the preoperative abdominal wall functionality was 4.41 ± 1.67 (2-8) while the mean value of preoperative EQ-5D index was 0.652 ± 0.026 (-0.32-1.00). QoL was poor and very poor for 48% (44) of the patients who recorded index values less than 0.56 (50% percentile). Preoperative EQ-5D index was highly correlated with Combined AWF score (r = 0.620; p < 0.0001) and the correlation was specific (AUC = 0.799; p < 0.0001; asymptotic 95%CI = 0.711-0.923). At 12 months, the AWF score increased to 8.13 ± 2.58 (1-10) and the QoL total score to 0.979 ± 0.007 (0.71-1). Good and very good total scores for QoL were recorded for 47 patients (84%) compared to 33 (36%) in the preoperative evaluation (χ2 with Yates continuity correction for two degrees of liberty = 46.04; p < 0.00001).

CONCLUSION

Our results suggest that patients can expect to see a significant overall improvement in all five components of QoL measured with the help of Eq. 5D questionnaire. This improvement is dependent by hernia size, and some individual patient's factors (diabetes, cardiovascular diseases, and age over 60 years).

Elective complex ventral hernia repair in contaminated fields: A propensity score-matched analysis of long-term quality of life and outcomes between different prostheses

BACKGROUND

Randomized studies have endorsed nonabsorbable prosthetics for contaminated ventral hernia surgery, yet the broader applicability and impact on patient-reported outcomes are still questioned. Here, we evaluated the long-term outcomes of elective contaminated ventral hernia repairs (based on Centers of Disease Control and Prevention [CDC] wound classification) using real-world data from a multicenter US cohort, focusing on quality of life and postoperative pain.

METHODS

The Abdominal Core Health Quality Collaborative database was queried for patients undergoing elective contaminated (CDC class II-IV) ventral hernia repair (2013-2023). After propensity matching, we compared long-term differences in patient-reported quality of life and pain scores (by HerQLes and PROMIS questionnaires) among those who underwent repair with nonabsorbable, absorbable synthetic, and biologic mesh.

RESULTS

A total of 1,073 patients were included, of whom 920 (86%), 56 (5%), and 97 (9%) underwent repair with nonabsorbable, absorbable synthetic, and biologic mesh, respectively. Among them, the median age was 62 years (interquartile range [IQR] 53-70), and 523 (49%) were male. The median length and width of the defect were 20 cm (IQR 12-25) and 13 cm (IQR 8-16), respectively. A transversus abdominis release was performed in 716 patients (67% of all cases). In most cases, the mesh was positioned in the retro-rectus (85%) and/or the preperitoneal space (45%). Before and after propensity matching (n = 185), the change from baseline in HerQLes and PROMIS scores at 6 months and at 1, 3, 5, and 6 years was comparable between different types of mesh. Lastly, there were no differences in readmission, surgical site infection, or surgical site occurrence at 30 days. Recurrence at 1 year was also comparable among groups.

CONCLUSION

In the long term, there were no differences in quality of life or pain scores with nonabsorbable, absorbable synthetic, or biologic mesh for elective ventral hernia repair in contaminated fields.

Comprehensive retrospective analysis of the European hernia Society quality of life in patients undergoing abdominal wall reconstruction

INTRODUCTION

This study aimed to analyze the European Hernia Society Quality of Life (EHS-QoL) in abdominal wall reconstruction by comparing preoperative scores with those at 1 and 2 postoperative years.

METHODS

Data from 105 patients with complex incisional hernias were collected preoperatively and at 1 and 2 years postoperatively. Statistical analyses included three ART ANOVA models to compare scores among the three time points and within each time point's items.

RESULTS

The EHS score significantly decreased from preoperative (Mdn ​= ​57) to 1 year (Mdn ​= ​10.5) and 2 years postoperative (Mdn ​= ​8). The most significant changes occurred between preoperative and 1-year measurements, particularly in pain levels during activities and limitations in heavy labor and activities outside the home.

CONCLUSION

Patients' quality of life notably improved at 1 year post-surgery, with some reaching near-maximum levels, and this improvement was generally sustained or increased at 2 years post-surgery.

State of the Art: Advances in Hernia Care

The field of hernia surgery has seen many recent advances and continues to evolve. Care of the hernia patient begins preoperatively by ensuring adequate preparation for surgery with surgeons now having the opportunity to accurately predict risk which can aid with informed consent. Imaging studies can now help surgeons diagnose and plan hernia surgery on an individual level based on hernia characteristics as well as abdominal wall musculature. In the operating room, new technology and surgical techniques have allowed surgeons to become increasingly sophisticated with goals of reducing tension on midline closures, utilizing minimally invasive and robotic techniques, and availability of new and varied mesh prosthetics. While modest improvements in outcomes have been witnessed by these advances, there is still opportunity for improvement which will be realized by continued research, use of registries, and education and training. Hernia prevention strategies focusing on minimally invasive surgery, laparotomy closure, and the use of prophylactic mesh will also help with the burden of incisional hernias. These advances in hernia surgery have led to the new field of Abdominal Core Health which helps represent this evolving and growing new subspecialty of general surgery.

Missing the Mark: Evaluating the Validity of the Ventral Hernia Screen in Detecting Recurrence

PURPOSE

Hernia recurrence is a primary metric in evaluating the success of ventral hernia repair (VHR). Current screening methods for hernia recurrence, including the validated Ventral Hernia Screening (VHS) questionnaire, have not yet been critically evaluated. The purpose of this study was to evaluate the predictive value of the VHS for hernia recurrence.

METHODS

This is a retrospective cohort study of adult patients who underwent primary VHR utilizing poly-4-hydroxybutyrate mesh at a single-institution from January 2016 to December 2021 who completed at least one VHS during their postoperative follow-up. All patients who screened positive underwent follow-up diagnostic computed tomography or physical examination for confirmation of hernia recurrence. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were assessed for each item and the VHS as a whole.

RESULTS

A total of 68 patients who completed 119 VHS questionnaires were included. The median time to VHS administration was 3.6 years (range .8-6.3 years). The VHS tool had a sensitivity of 40.0%, specificity of 71.1%, PPV of 5.7%, and NPV of 96.4%. Individual items of the VHS also produced poor screening effects, with sensitivities between 20 and 40%, specificities between 79 and 97%, PPVs between 4 and 25%, and NPVs from 95 to 97%.

CONCLUSION

The VHS was a poor positive predictive tool for hernia recurrence, with both a low PPV and sensitivity. Many patients may be unaware of when they truly have hernia recurrence in the long term. More rigorous tools need to be developed to monitor recurrence following VHR.

Transversus abdominis release with biosynthetic mesh for large ventral hernia repair: a 5-year analysis of clinical outcomes and quality of life

INTRODUCTION

Transversus abdominis release (TAR) may provide an optimal plane for mesh placement for large ventral hernias requiring medial myofascial flap advancement. Long-term outcomes of TAR for large ventral hernia repair (VHR) remains under-studied. This study aims to assess longitudinal clinical outcomes and quality of life (QoL) following large VHR with TAR and resorbable biosynthetic mesh.

METHODS

Retrospective review of clinical outcomes and prospective QoL was performed for patients undergoing VHR with poly-4-hydroxybutyrate mesh and TAR from 2016 to 2021. Patients with ≤ 24 months of follow-up, defects ≤ 150 cm2, and parastomal hernias were excluded. Cost-related data was collected for each patient's hospital course. QoL was compared using paired Wilcoxon signed-rank tests.

RESULTS

Twenty-nine patients met inclusion criteria. Median age and BMI were 61 years (53.2-68.1 years) and 31.4 kg/m2 (26.1-35.3 kg/m2). Average hernia defect was 390cm2 ± 152.9 cm2. All patients underwent previous abdominal surgery and were primarily Ventral Hernia Working Group 2 (58.6%). Two hernia recurrences (6.9%) occurred over the median follow-up period of 63.1 months (IQR 43.7-71.3 months), with no cases of mesh infection or explantation. Delayed healing and seroma occurred in 27 and 10.3% of patients, respectively. QoL analysis identified a significant improvement in postoperative QoL (p < 0.005), that continued throughout the 5-year follow-up period, with a 41% overall improvement. Cost analysis identified the hospital revenue generated was approximately equal to the direct costs of patient care. Higher costs were associated with ASA class and length of stay (p < 0.05).

CONCLUSION

Large VHR with resorbable biosynthetic mesh and TAR can be performed safely, with a low recurrence and complication rate, acceptable hospital costs, and significant improvement in disease-specific QoL at long-term follow-up.

Comparative Analysis of Ventral Hernia Repair and Transverse Abdominis Release With and Without Panniculectomy: A 4-Year Match-Pair Analysis

INTRODUCTION

Amid rising obesity, concurrent ventral hernia repair and panniculectomy procedures are increasing. Long-term outcomes of transverse abdominis release (TAR) combined with panniculectomy remain understudied. This study compares clinical outcomes and quality of life (QoL) after TAR, with or without panniculectomy.

METHODS

A single-center retrospective review from 2016 to 2022 evaluated patients undergoing TAR with and without panniculectomy. Propensity-scored matching was based on age, body mass index, ASA, and ventral hernia working group. Patients with parastomal hernias were excluded. Patient/operative characteristics, postoperative outcomes, and QoL were analyzed.

RESULTS

Fifty subjects were identified (25 per group) with a median follow-up of 48.8 months (interquartile range, 43-69.7 months). The median age and body mass index were 57 years (47-64 years) and 31.8 kg/m2 (28-36 kg/m2), respectively. The average hernia defect size was 354.5 cm2 ± 188.5 cm2. There were no significant differences in hernia recurrence, emergency visits, readmissions, or reoperations between groups. However, ventral hernia repair with TAR and panniculectomy demonstrated a significant increase in delayed healing (44% vs 4%, P < 0.05) and seromas (24% vs 4%, P < 0.05). Postoperative QoL improved significantly in both groups (P < 0.005) across multiple domains, which continued throughout the 4-year follow-up period. There were no significant differences in QoL among ventral hernia working group, wound class, surgical site occurrences, or surgical site occurrences requiring intervention (P > 0.05). Patients with concurrent panniculectomy demonstrated a significantly greater percentage change in overall scores and appearance scores.

CONCLUSIONS

Ventral hernia repair with TAR and panniculectomy can be performed safely with low recurrence and complication rates at long-term follow-up. Despite increased short-term postoperative complications, patients have a significantly greater improvement in disease specific QoL.

A Scoping Review of Quality-of-Life Assessments Employed in Abdominal Wall Reconstruction

INTRODUCTION

Surgeons use several quality-of-life instruments to track outcomes following abdominal wall reconstruction (AWR); however, there is no universally agreed upon instrument. We review the instruments used in AWR and report their utilization trends within the literature.

METHODS

This scoping review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews guidelines using the PubMed, Embase, Web of Science, ClinicalTrials.gov, and Cochrane databases. All published articles in the English language that employed a quality-of-life assessment for abdominal wall hernia repair were included. Studies which focused solely on aesthetic abdominoplasty, autologous breast reconstruction, rectus diastasis, pediatric patients, inguinal hernia, or femoral hernias were excluded.

RESULTS

Six hernia-specific tools and six generic health tools were identified. The Hernia-Related Quality-of-Life Survey and Carolinas Comfort Scale are the most common hernia-specific tools, while the Short-Form 36 (SF-36) is the most common generic health tool. Notably, the SF-36 is also the most widely used tool for AWR outcomes overall. Each tool captures a unique set of patient outcomes which ranges from abdominal wall functionality to mental health.

CONCLUSIONS

The outcomes of AWR have been widely studied with several different assessments proposed and used over the past few decades. These instruments allow for patient assessment of pain, quality of life, functional status, and mental health. Commonly used tools include the Hernia-Related Quality-of-Life Survey, Carolinas Comfort Scale, and SF-36. Due to the large heterogeneity of available instruments, future work may seek to determine or develop a standardized instrument for characterizing AWR outcomes.

Novel insights into patient's thoughts about their body image in abdominal wall hernia

BACKGROUND

Abdominal wall hernias (AWH) are frequently large and deforming. Despite this, little is known about how AWH impact upon body image. This study is the first study to qualitatively examine patients' subjective lived experiences of how AWH affects their body image.

METHODS

Fifteen patients were interviewed from a purposive sample of AWH patients awaiting surgery until no new narrative themes emerged. Interviews explored patient thoughts and experiences of AWH and body image. Data were examined using interpretative phenomenological analysis (IPA).

RESULTS

Two key themes pertaining to body image were identified: "Changes to perceptions of self" and "Fears concerning other's perceptions of them". Both themes were often interrelated and displayed detrimental effects AWH had on patients' body image.

CONCLUSIONS

Our findings illustrate that AWH detrimentally affected patients' body image. This aspect of patient care can be treated and managed through better pre-operative information, including on body image as part of a holistic needs assessment (HNA), and ensuring the results are addressed in a patient care package. These development suggestions may positively affect the AWH patient's experience and outcomes in terms of Quality of Life (QoL) by preparing patients better for realistic results regarding what can be achieved in terms of form, function thus making a more holistic recovery from surgery.

Optimal computed tomography-based biomarkers for prediction of incisional hernia formation

PURPOSE

Unstructured data are an untapped source for surgical prediction. Modern image analysis and machine learning (ML) can harness unstructured data in medical imaging. Incisional hernia (IH) is a pervasive surgical disease, well-suited for prediction using image analysis. Our objective was to identify optimal biomarkers (OBMs) from preoperative abdominopelvic computed tomography (CT) imaging which are most predictive of IH development.

METHODS

Two hundred and twelve rigorously matched colorectal surgery patients at our institution were included. Preoperative abdominopelvic CT scans were segmented to derive linear, volumetric, intensity-based, and textural features. These features were analyzed to find a small subset of OBMs, which are maximally predictive of IH. Three ML classifiers (Ensemble Boosting, Random Forest, SVM) trained on these OBMs were used for prediction of IH.

RESULTS

Altogether, 279 features were extracted from each CT scan. The most predictive OBMs found were: (1) abdominopelvic visceral adipose tissue (VAT) volume, normalized for height; (2) abdominopelvic skeletal muscle tissue volume, normalized for height; and (3) pelvic VAT volume to pelvic outer aspect of body wall skeletal musculature (OAM) volume ratio. Among ML prediction models, Ensemble Boosting produced the best performance with an AUC of 0.85, accuracy of 0.83, sensitivity of 0.86, and specificity of 0.81.

CONCLUSION

These OBMs suggest increased intra-abdominopelvic volume/pressure as the salient pathophysiologic driver and likely mechanism for IH formation. ML models using these OBMs are highly predictive for IH development. The next generation of surgical prediction will maximize the utility of unstructured data using advanced image analysis and ML.

Quality of Life With a Hernia-A Novel Patient Led Study

Introduction: Abdominal wall hernia surgery aims to relieve symptoms and to improve quality of life (QoL). The aim of this novel patient led research, was to help surgeons understand how hernias impact on patients' wellbeing. Methods: A questionnaire was developed by patient advocates. It was promoted through social media to gather anonymous feedback from patients. Results: 264 questionnaires were completed. The majority of the respondents were female (78.4%, n = 207), from English speaking countries (85.2%, n = 225), and had either parastomal hernias (36.0%, n = 95) or incisional hernias (28.0%, n = 74). Respondents described how their hernia affected sexual intimacy, either due to the dislike of their physical appearance, pain or the practicalities of their hernia getting in the way. They reported that their hernia restricted them from engaging in certain exercise activities, and a significant proportion also reported an impact on their diet. Conclusion: This study has identified that in addition to functional problems, living with a hernia can affect mental health as well as social and physical relationships. Existing hernia QoL tools are limited in the outcomes that they measure. Without a comprehensive hernia specific QoL tool, it remains difficult for a surgeon to accurately assess the impact that different treatment modalities may have on patients.

Abdominal wall hernia and mental health: patients lived experiences and implications for patient care

BACKGROUND

Abdominal wall hernia (AWH) affects mental health and mental health questions are frequently included within Patient-Reported Outcome Measures (PROMS) for this patient population. However, these questions have not been informed by the subjective lived experiences of mental health in AWH patients. This study is the first to qualitatively examine how AWH affects patients' mental health.

METHODS

Fifteen patients were interviewed from a purposive sample of AWH patients until no new themes emerged. Interviews explored patient thoughts and experiences of AWH and mental health. Data were examined using Interpretative Phenomenological Analysis (IPA).

RESULTS

Three key themes pertaining to mental health were identified: "psychological and emotional distress", "identity disruption" and "coping mechanisms and support systems".

CONCLUSION

Our findings illustrate that AWH is a pathology that can have a significant detrimental impact on people's mental health. This impact has implications for patient care and can be treated and managed through better psychological support. This support may positively affect AWH patient's experience and outcomes in terms of quality of life. This paper provides recommendations for improved AWH patient care in regard to mental health.

Integration and Implementation of Patient-Reported Outcomes: A Prospective, Observational Clinical Quality Improvement Study

BACKGROUND

Implementation of patient-reported outcomes (PROs) represents a critical barrier to their widespread use and poses challenges to workflow and patient satisfaction. The authors sought to implement PRO surveys into surgical practice and identify principles for successful and broader implementation.

METHODS

Outpatient surgical encounters from 2016 through 2019 related to hernia, breast surgery, or postbariatric body contouring were assessed with the Abdominal Hernia-Q, BREAST-Q, or BODY-Q surveys, respectively. Outcomes were implementation rates per quarter and time to optimal implementation (≥80%). Successful implementation principles were identified during the first implemented PRO instrument and applied to subsequent ones. Logistic regression models were used to estimate increase in rate of implementation per quarter by instrument controlling for clinic volume. Risk-adjusted generalized linear models determined predicted mean differences in total clinic time and patient satisfaction.

RESULTS

A total of 1206 encounters were identified. The overall survey implementation rate increased from 15% in the first quarter to 90% in the last quarter ( P < 0.01). Abdominal Hernia-Q optimal implementation was reached by 15 months. Principles for successful implementation of PROs were workflow optimization, appropriate patient selection, staff engagement, and electronic survey integration. Consistent application of these principles optimized time to optimal implementation for BREAST-Q [9 months; 18.1% increase in implementation per quarter (95% CI, 1.5 to 37.5); P < 0.01] and BODY-Q [3 months; 56.3% increase in implementation per quarter (95% CI, 26.8 to 92.6); P = 0.03]. Neither patient clinic time ( P = 0.16) nor patient satisfaction differed during the implementation of PROs process ( P = 0.98).

CONCLUSIONS

Prospective implementation of PROs can be achieved in surgical practice without an adverse effect on patient satisfaction or workflow. The proposed principles of implementation may be used to optimize efficiency for implementation of PROs.

The Abdominal Hernia-Q: a critical analysis of the components that impact quality-of-life

PURPOSE

Ventral hernias (VH) are a common surgical problem associated with significant morbidity. While assessment tools have examined quality-of-life (QoL), the relative change in specific domains of hernia-related QoL measures from pre- to post-operative period has yet to be comprehensively examined. Using the Abdominal Hernia-Q (AHQ), this study aims to assess the impact of ventral hernia repair (VHR) on key components of QoL.

METHODS

A retrospective chart review was conducted of patients undergoing VHR between September 2017 and September 2019 who had completed at least one pre- and post-operative AHQ. Post-operative intervals were created to capture AHQ responses around standard follow-up visits (< 1.5 months, 1.5-4.5 months, 4.5-11 months, and 11 + months) and scores were statistically analyzed.

RESULTS

A total of 136 patients were included, with an average age of 54.8 years at the time of VHR. Compared to the pre-operative period, the appearance score increased significantly (p < 0.05). The physical domain score increased from < 1.5 month to the 1.5-4.5 month period (p = 0.03) and remained significantly higher in later time period. The appearance score decreased from the 1.5-4.5 month to 4.5-11 month period (p = 0.05).

CONCLUSIONS

VHR leads to a sustained multi-dimensional increase in hernia-specific QoL measures during the post-operative course driven by early positive changes in appearance and sustained physical functioning. The initial increase in QoL is mainly driven by an improvement in appearance, while the sustained increase may be due to restored physical function.

Health-related quality of life in abdominal wall hernia: let's ask patients what matters to them?

INTRODUCTION

Quality of Life (QoL) is an important consideration in patients with abdominal wall hernia (AWH). What matters to patients and their everyday experience living with AWH may depend on a variety of personal, psychological, social and environmental factors. At present, no study has addressed what is important to this particular group of patients by asking the patients themselves. This study aims to determine QoL from the patient's perspective by examining the lived experience in this patient population.

METHODS

We interviewed 15 patients with AWH until thematic saturation. The patients were purposively sampled from AWH clinic between February 2020 and June 2020 using topic guides and interview schedules. Verbatim interview transcripts were coded and analysed using NVivo12 software and Interpretative Phenomenological Analysis (IPA). We adhered to consolidated criteria for reporting qualitative research (COREQ).

RESULTS

Fifteen participants (8 men and 7 women) of age range 36-85 years, median 65 years, covering all Ventral Hernia Working Group (VHWG) grades. Five superordinate themes were identified each with several subordinate themes, as follows: (1) body image (subthemes-'changes to perceptions of self' and 'fears concerning perceptions of others'). (2) Mental health (subthemes-'emotional responses', 'disruptions to previously solid aspects of identity', 'developing coping strategies'). (3) Symptoms (subthemes-'managing pain', 'freedom of movement', 'restriction and adaptation of function'). (4) Interpersonal relationships (subthemes-'difficulties socially connecting' and 'changes in sexual relations'). (5) Employment (subthemes-'financial pressure', 'return to work issues' and 'costs to family').

CONCLUSION

This is the first phenomenological qualitative study in the field of AWH and presents a rich account of what is important to these patients in terms of QoL. Developed from the patients' own words, the themes are interrelated and should shape our understanding of patients with AWH. This study provides qualitative examples of each theme. This study has identified new themes (body image, interpersonal relationships and employment) that are not incorporated in existing AWH-specific QoL instruments. This is important for surgeons because the study suggests that we are currently not capturing all data relevant to QoL in this specific patient group with current tools. The wider impact of this would be to help counsel patients and support them more holistically through the disease process and it's management. Further research is needed to generate a standardised AWH QoL instrument which incorporates bio-psycho-emotional-social themes important to patients, as identified by patients.

Three-Year Clinical Outcomes and Quality of Life after Retromuscular Resorbable Mesh Repair Using Fibrin Glue

BACKGROUND

With 400,000 hernias repaired annually, there is a need for development of efficient and effective repair techniques. Previously, the authors' group compared perioperative outcomes and hospital costs of patients undergoing ventral hernia repair with retromuscular mesh using suture fixation versus fibrin glue. This article reports on 3-year postoperative outcomes, including hernia recurrence, long-term clinical outcomes, and patient-reported quality of life.

METHODS

Patients who underwent ventral hernia repair performed by a single surgeon between 2015 to 2017 were identified. Patients with retromuscular resorbable mesh placed were included and matched by propensity score. Primary outcomes included hernia recurrence, surgical-site infection, surgical-site occurrence, and surgical-site occurrence/surgical-site infection requiring procedural interventions. Secondary outcomes included quality of life as assessed by the Hernia-Related Quality of Life Survey.

RESULTS

Sixty-three patients were eligible, and 46 patients were matched (23 suture fixation and 23 fibrin glue), with a median age of 62 years, a median body mass index of 29 kg/m2, and a median defect size of 300 cm2 (interquartile range, 180 to 378 cm2). Median follow-up was 36 months (interquartile range, 31 to 36 months). There was no difference in the incidence of hernia recurrence (13.0 percent for suture fixation and 8.7 percent for fibrin glue; p = 0.636) or other postoperative outcomes between techniques (all p > 0.05). Five patients required reoperation because of a complication (10.9 percent). Overall quality of life improved preoperatively to postoperatively at all time points (all p < 0.05), and no differences in quality-of-life improvement were seen between techniques (p > 0.05).

CONCLUSION

Ventral hernia repair with atraumatic resorbable retromuscular mesh fixation using fibrin glue demonstrates equivalent postoperative clinical and quality-of-life outcomes when compared to mechanical suture fixation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

A Systematic Review of Health State Utility Values in the Plastic Surgery Literature

Cost-utility analyses assess health gains acquired by interventions by incorporating weighted health state utility values (HSUVs). HSUVs are important in plastic and reconstructive surgery (PRS) because they include qualitative metrics when comparing operative techniques or interventions. We systematically reviewed the literature to identify the extent and quality of existing original utilities research within PRS.

Methods

A systematic review of articles with original PRS utility data was conducted in accordance with the Preferred Reporting Items for a Systematic Review and Meta-Analysis guidelines. Subspecialty, survey sample size, and respondent characteristics were extracted. For each HSUV, the utility measure [direct (standard gamble, time trade off, visual analog scale) and/or indirect], mean utility score, and measure of variance were recorded. Similar HSUVs were pooled into weighted averages based on sample size if they were derived from the same utility measure.

Results

In total, 348 HSUVs for 194 disease states were derived from 56 studies within seven PRS subspecialties. Utility studies were most common in breast (n = 17, 30.4%) and hand/upper extremity (n = 15, 26.8%), and direct measurements were most frequent [visual analog scale (55.4%), standard gamble (46.4%), time trade off (57.1%)]. Studies surveying the general public had more respondents (n = 165, IQR 103-299) than those that surveyed patients (n = 61, IQR 48-79) or healthcare professionals (n = 42, IQR 10-109). HSUVs for 18 health states were aggregated.

Conclusions

The HSUV literature within PRS is scant and heterogeneous. Researchers should become familiar with these outcomes, as integrating utility and cost data will help illustrate that the impact of certain interventions are cost-effective when we consider patient quality of life.

Resorbable Synthetic Ventral Hernia Repair in Contaminated Fields: Outcomes with Poly-4-Hydroxybutyrate Mesh

BACKGROUND

Hernia repair in the setting of contamination poses unique challenges, including complications such as recurrence and mesh infection. The ideal contaminated hernia repair including type of mesh use remains controversial. Poly-4-hydroxybutyrate is a biosynthetic scaffold for soft-tissue reinforcement and hernia repair and is potentially useful in contaminated hernia repair. The authors aim to describe postoperative outcomes, recurrence, and patient-reported outcomes after contaminated hernia repair with poly-4-hydroxybutyrate.

METHODS

Adult patients (≥18 years) undergoing a contaminated hernia repair with poly-4-hydroxybutyrate (Phasix) performed by a single plastic surgeon between January of 2015 and May of 2020 were identified. Patients with a ventral hernia defect and a Centers for Disease Control and Prevention wound class of II, III, or IV were included. Primary outcomes included recurrence, surgical-site infection, surgical-site occurrences, and surgical-site infection/occurrences requiring procedural interventions. As a secondary outcome, the authors assessed patient-reported outcomes as defined by the Abdominal Hernia-Q and Hernia-Related Quality of Life Survey.

RESULTS

Sixty patients were included with a median age of 52.5 and body mass index of 31 kg/m2. Median defect size was 300 cm2. Twenty-eight patients (46.7 percent) experienced a complication. The most common complications were surgical-site occurrence [n = 20 (33.3 percent)] and surgical-site infection [n = 10 (16.7 percent)]. Median follow-up was 24.2 months, with a recurrence rate of 8.3 percent (n = 4). Overall patient-reported outcomes improved postoperatively, and improvement was not affected by the presence of a complication.

CONCLUSIONS

Poly-4-hydroxybutyrateuse in contaminated hernia repair shows promising results with an acceptable safety profile. Although complications are frequent in this complex cohort, patient-reported outcomes improvement was significant even in patients with complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Longitudinal Clinical and Patient-Reported Outcomes After Transversus Abdominis Release for Complex Hernia Repair With a Review of the Literature

PURPOSE

Posterior component separation with transversus abdominis release (TAR) enables medial myofascial flap advancement in complex abdominal wall reconstruction. Here, we add to a growing body of literature on TAR by assessing longitudinal clinical and patient-reported outcomes (PROs) after complex ventral hernia repair (VHR) with TAR.

METHODS

Adult patients undergoing VHR with TAR between 10/15/2015 and 1/15/2020 were retrospectively identified. Patients with parastomal hernias and <12 months of follow-up were excluded. Clinical outcomes and PROs were assessed.

RESULTS

Fifty-six patients were included with a median age and body mass index of 60 and 30.8 kg/m², respectively. The average hernia defect was 384 cm² [IQR 205-471], and all patients had retromuscular mesh placed. The most common complications were delayed healing (19.6%) and seroma (14.3%). There were no cases of mesh infection or explantation. Previous hernia repair and concurrent panniculectomy were risk factors for developing complications (P < .05). One patient (1.8%) recurred at a median follow-up of 25.2 months [IQR 18.2-42.4]. Significant improvement in disease-specific PROs was maintained throughout the follow-up period (before to after P < .05).

CONCLUSION

Transversus abdominis release is a safe and efficacious technique to achieve fascial closure and retromuscular mesh in the repair of complex hernia defects.

Greatest Quality of Life Improvement in Patients With Large Ventral Hernias: An Individual Assessment of Items in the HerQLes Survey

BACKGROUND

Ventral hernia repair (VHR) has been shown to improve overall quality of life (QOL) by the validated 12-question Hernia-Related Quality-of-Life survey (HerQLes). However, which specific aspects of quality of life are most affected by VHR have not been formally investigated.

METHODS

Through retrospective analysis of the Abdominal Core Health Quality Collaborative national database, we measured the change in each individual component of the HerQLes questionnaire from a pre-operative baseline assessment to one-year postoperatively in VHR patients.

RESULTS

In total, 1,875 VHR patients had completed both pre- and post-operative questionnaires from 2014-2018. They were predominately Caucasian (92.3%), 57.9 ± 12.4 Y old, and evenly gender split (50.5% male, 49.5% female, P = 0.31). Most operations were performed open (80.5%) with fewer laparoscopic (7.5%) or robotic cases (12.1%). For each of the 12 individual categories, improvement in QOL from baseline to 1-Y was found to be statistically significant (P < 0.0001). This held true with subgroup analysis of small (<2 cm), medium (2-6 cm), and large (>6 cm) hernias (P < 0.0001), though a larger improvement was seen in 8 of 12 components in hernias >6 cm (P < 0.001). Operative approach did not carry a significant effect except in medium hernias (2-6 cm), where an open approach saw a greater improvement in the "accomplish less at work" item (P = 0.02).

CONCLUSIONS

VHR is associated with improvement in each of the 12 components of QOL measured in the HerQLes questionnaire, regardless of the size of their hernia. The amount of improvement, however, may be dependent on hernia size and approach.

Early Clinical and Patient-Reported Outcomes of a New Hybrid Mesh for Incisional Hernia Repair

INTRODUCTION

Consensus on the safety and efficacy of various types of mesh in reconstructing the abdomen has yet to be reached. Hybrid mesh products have been designed to address the need for a cost-effective mesh leveraging the tensile strength of a synthetic mesh while minimizing the prosthetic footprint within the abdominal wall through resorbable materials. In this study we evaluate early clinical outcomes and health related quality of life (HR-QOL) of a new Hybrid mesh, Synecor^TM, for Ventral Hernia Repair (VHR).

METHODS

Adult (>18 y old) patients undergoing VHR with Synecor^TM mesh by a single surgeon between 2017-2019 with ≥1-y follow-up were identified. We analyzed a composite of postoperative outcomes as well as the incidence of hernia recurrence, readmissions, mortality, and HR-QOL.

RESULTS

Thirty-five patients were included in our analysis with a median follow up of 2.1 y. The median age and BMI were 54.1 y and 33.2 kg/m², respectively. The rate of surgical site occurrences was 37.1%, with only one patient (2.9%) requiring surgical intervention. No patients developed a hernia recurrence. Overall HR-QOL improved significantly (preoperative mean 2.5 [SD 0.7] versus postoperative 3.4 [0.4]; P< 0.01), particularly in regards to pain, functional status, self-esteem and body image (all P < 0.05).

CONCLUSIONS

Abdominal reinforcement with Synecor^TM mesh at the time of VHR results in promising early recurrence rates, an acceptable safety risk profile, and an improvement in overall HR-QOL.

Onlay Poly-4-Hydroxybutyrate (P4HB) Mesh for Complex Hernia: Early Clinical and Patient Reported Outcomes

BACKGROUND

While mesh re-enforcement and advanced surgical techniques are cornerstones of complex ventral hernia repair (CVHR), the risk of complications and recurrence is common. We aim to evaluate the efficacy, safety, and patient reported outcomes (PROs) of patients undergoing CVHR with onlay Poly-4-hydroxybutyrate (P4HB).

METHODS

Adult (>18 y old) patients undergoing VHR with P4HB (Phasix) in the onlay plane by a single surgeon from 01/2015 to 05/2020 were reviewed. VHR was considered complex if patients had significant co-morbidities, large abdominal wall defects, a history of extensive abdominal surgery, and/or concurrent intra-abdominal pathology. A composite of postoperative outcomes including surgical site occurrences (SSO), surgical site infection (SSI), and surgical site occurrences requiring procedural intervention (SSOpi), as well as PROs as defined by the Abdominal Hernia-Q (AHQ), were analyzed.

RESULTS

A total of 51 patients were included with average age and body mass index of 56.4 and 29.9 kg/m². Median follow up was 20 mo with a hernia recurrence rate of 5.9% (n = 3). 21 patients had an SSO (41.2%), 8 had an SSI (15.7%), and 6 had an SSOpi (11.8%). There was an association with Ventral Hernia Working Group ≥ 2 and development of SSO. There was a significant improvement in overall PROs (P < 0.0001) with no difference in those patients with and without complications (P > 0.05).

CONCLUSION

For hernia patients with large defects and complex intra-abdominal pathology, a safe and effective repair is difficult. The use of onlay P4HB was associated with acceptable postoperative outcomes and recurrence rate.

Bilateral transversus abdominis release: Complex hernia repair without sacrificing quality of life

BACKGROUND

Transversus Abdominis Release (TAR) during ventral hernia repair (VHR) allows for further lateral dissection by dividing the transversus abdominis muscles (TAM). The implications of division of the TAM on clinical and patient-reported outcomes has not be extensively studied.

METHODS

Adult patients undergoing retrorectus (RR) VHR with biosynthetic mesh with or without bilateral TAR were retrospectively identified. Post-operative and patient-reported outcomes (PROs) were collected.

RESULTS

Of 50 patients, 24 underwent TAR and 26 had RR repair alone. Median defect sizes were 449 cm² and 208 cm², respectively (p < 0.001). Rates of SSO and SSI were similar (p > 0.05). One TAR patient (4.2%) and four RR patients (15.4%) recurred (p = 0.26), with median follow up of 24 and 38 months. PROs improved significantly in both groups (p < 0.05).

CONCLUSION

Despite more complex abdominal wall reconstruction on larger defects, TAR has minimal major adverse events, low recurrence rates, and does not negatively affect PROs.

Biologic Mesh in Surgery: A Comprehensive Review and Meta-Analysis of Selected Outcomes in 51 Studies and 6079 Patients

BACKGROUND

In recent decades, biologic mesh (BM) has become an important adjunct to surgical practice. Recent evidence-based clinical applications of BM include but are not limited to: reconstruction of abdominal wall defects; breast reconstruction; face, head and neck surgery; periodontal surgery; other hernia repairs (diaphragmatic, hiatal/paraesophageal, inguinal and perineal); hand surgery; and shoulder arthroplasty. Prior systematic reviews of BM in complex abdominal wall hernia repair had several shortcomings that our comprehensive review seeks to address, including exclusion of laparoscopic repair, assessment of risk of bias, use of an acceptable meta-analytic method and review of risk factors identified in multivariable regression analyses.

MATERIALS AND METHODS

We sought articles of BM for open ventral hernia repair reporting on early complications, late complications or recurrences and included minimum of 50. We used the quality in prognostic studies risk of bias assessment tool. Random effects meta-analysis was applied.

RESULTS

This comprehensive review selected 62 articles from 51 studies that included 6,079 patients. Meta-analytic pooling found that early complications are present in about 50%, surgical site occurrences (SSOs) in 37%, surgical site infections (SSIs) in 18%, reoperation in 7%, readmission in 20% and mortality in 3%. Meta-analytic estimates of late outcomes included overall complications (42%), SSOs (40%) and SSIs (22%). Specific SSOs included seroma (14%), hematoma (4%), abscess (10%), necrosis (5%), dehiscence (8%) and fistula formation (5%). Reoperation occurred in about 17%, mesh explantation in 9% and recurrence in 36%.

CONCLUSION

Estimates of nearly all outcomes from individual studies were highly heterogeneous and sensitivity analyses and meta-regressions generally failed to explain this heterogeneity. Recurrence is the only outcome for which there are consistent findings for risk factors. Bridge placement of BM is associated with higher risk of recurrence. Prior hernia repair, history of reintervention and history of mesh removal were also risk factors for increased recurrence.

Computed Tomography Image Analysis in Abdominal Wall Reconstruction: A Systematic Review

Ventral hernias are a complex and costly burden to the health care system. Although preoperative radiologic imaging is commonly performed, the plethora of anatomic features present and available in routine imaging are seldomly quantified and integrated into patient selection, preoperative risk stratification, and perioperative planning. We herein aimed to critically examine the current state of computed tomography feature application in predicting surgical outcomes.

Methods

A systematic review was conducted in accordance with the Preferred Reporting Items for a Systematic Review and Meta-Analysis (PRISMA) checklist. PubMed, MEDLINE, and Embase databases were reviewed under search syntax "computed tomography imaging" and "abdominal hernia" for papers published between 2000 and 2020.

Results

Of the initial 1922 studies, 12 papers met inclusion and exclusion criteria. The most frequently used radiologic features were hernia volume (n = 9), subcutaneous fat volume (n = 5), and defect size (n = 8). Outcomes included both complications and need for surgical intervention. Median area under the curve (AUC) and odds ratio were 0.68 (±0.16) and 1.12 (±0.39), respectively. The best predictive feature was hernia neck ratio > 2.5 (AUC 0.903).

Conclusions

Computed tomography feature selection offers hernia surgeons an opportunity to identify, quantify, and integrate routinely available morphologic tissue features into preoperative decision-making. Despite being in its early stages, future surgeons and researchers will soon be able to integrate 3D volumetric analysis and complex machine learning and neural network models to improvement patient care.

Hydrophilic and degradable polyesters based on l-aspartic acid with antibacterial properties for potential application in hernia repair

A polyester hernia patch has received extensive attention in mesh hernia repair.