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Taylor JS, López-Cañizares N, Valor C, Arias-Espinosa L, Phillips S, Pereira X, Damani T, Malcher F. Comparison of short-term outcomes following robotic ventral hernia repair in patients with obesity: a review of 9742 patients from the Abdominal Core Health Quality Collaborative database. J Robot Surg 2024; 18:265. [PMID: 38916797 DOI: 10.1007/s11701-024-02021-6] [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: 05/24/2024] [Accepted: 06/16/2024] [Indexed: 06/26/2024]
Abstract
Despite the paucity of evidence on robotic ventral hernia repair (RVHR) in patients with obesity, the robotic platform is being used more frequently in hernia surgery. The impact of obesity on RVHR outcomes has not been thoroughly studied. Obesity is considered a major risk factor for the development of recurrent ventral hernias and postoperative complications; however, we hypothesize that patients undergoing robotic repairs will have similar complication profiles despite their body mass index (BMI). We performed a retrospective analysis of patients aged 18-90 years who underwent RVHR between 2013 and 2023 using data from the Abdominal Core Health Quality Collaborative registry. Preoperative, intraoperative, and postoperative characteristics were compared in non-obese and obese groups, determined using a univariate and logistic regression analysis to compare short-term outcomes. The registry identified 9742 patients; 3666 were non-obese; 6076 were classified as obese (BMI > 30 kg/m2). There was an increased odds of surgical site occurrence in patients with obesity, mostly seroma formation; however, obesity was not a significant factor for a complication requiring a procedural intervention after RVHR. In contrast, the hernia-specific quality-of-life scores significantly improved following surgery for all patients, with those with obesity having more substantial improvement from baseline. Obesity does increase the risk of certain complications following RVHR in a BMI-dependent fashion; however, the odds of requiring a procedural intervention are not significantly increased by BMI. Patients with obesity have a significant improvement in their quality of life, and RVHR should be carefully considered in this population.
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Affiliation(s)
- Jordan S Taylor
- Department of Surgery, Division of General Surgery, New York University Langone Health, 530 First Avenue, 6th Floor, New York, NY, 10016, USA.
| | - Nicole López-Cañizares
- Department of Surgery, Division of General Surgery, New York University Langone Health, 530 First Avenue, 6th Floor, New York, NY, 10016, USA
| | - Cristhian Valor
- Department of Surgery, Division of General Surgery, New York University Langone Health, 530 First Avenue, 6th Floor, New York, NY, 10016, USA
| | - Luis Arias-Espinosa
- Department of Surgery, Division of General Surgery, New York University Langone Health, 530 First Avenue, 6th Floor, New York, NY, 10016, USA
| | - Sharon Phillips
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Xavier Pereira
- Department of Surgery, Division of General Surgery, New York University Langone Health, 530 First Avenue, 6th Floor, New York, NY, 10016, USA
| | - Tanuja Damani
- Department of Surgery, Division of General Surgery, New York University Langone Health, 530 First Avenue, 6th Floor, New York, NY, 10016, USA
| | - Flavio Malcher
- Department of Surgery, Division of General Surgery, New York University Langone Health, 530 First Avenue, 6th Floor, New York, NY, 10016, USA
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Mazzola Poli de Figueiredo S, Mao RMD, Dela Tejera G, Tastaldi L, Villasante-Tezanos A, Lu R. Body Mass Index Effect on Minimally Invasive Ventral Hernia Repair: A Systematic Review and Meta-analysis. Surg Laparosc Endosc Percutan Tech 2023; 33:663-672. [PMID: 37934831 DOI: 10.1097/sle.0000000000001235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 08/17/2023] [Indexed: 11/09/2023]
Abstract
PURPOSE Obesity is one of the most important risk factors for complications after ventral hernia repair (VHR), and minimally invasive (MIS) techniques are preferred in obese patients as they minimize wound complications. It is common practice to attempt weight loss to achieve a specific body mass index (BMI) goal; however, patients are often unable to reach it and fail to become surgical candidates. Therefore, we aim to perform a meta-analysis of studies comparing outcomes of obese and nonobese patients undergoing laparoscopic or robotic VHR. PATIENTS AND METHODS A literature search of PubMed, Scopus, and Cochrane Library databases was performed to identify studies comparing obese and nonobese patients undergoing MIS VHR. Postoperative outcomes were assessed by means of pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I2 statistics. RESULTS A total of 6483 studies were screened and 26 were thoroughly reviewed. Eleven studies and 3199 patients were included in the meta-analysis. BMI >40 kg/m 2 cutoff analysis included 5 studies and 1533 patients; no differences in hernia recurrence [odds ratios (OR): 1.64; 95% CI: 0.57-4.68; P = 0.36; I2 = 47%), seroma, hematoma, and surgical site infection (SSI) rates were noted. BMI >35 kg/m 2 cutoff analysis included 5 studies and 1403 patients; no differences in hernia recurrence (OR: 1.24; 95% CI: 0.71-2.16; P = 0.58; I2 = 0%), seroma, hematoma, and SSI rates were noted. BMI >30 kg/m 2 cutoff analysis included 4 studies and 385 patients; no differences in hernia recurrence (OR: 2.07; 95% CI: 0.5-8.54; P = 0.32; I2 = 0%), seroma, hematoma, and SSI rates were noted. CONCLUSION Patients with high BMI undergoing MIS VHR have similar hernia recurrence, seroma, hematoma, and SSI rates compared with patients with lower BMI. Further prospective studies with long-term follow-up and patient-reported outcomes are required to establish optimal management in obese patients undergoing VHR.
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Campanile FC, Podda M, Pecchini F, Inama M, Molfino S, Bonino MA, Ortenzi M, Silecchia G, Agresta F, Cinquini M. Laparoscopic treatment of ventral hernias: the Italian national guidelines. Updates Surg 2023:10.1007/s13304-023-01534-3. [PMID: 37217637 PMCID: PMC10202362 DOI: 10.1007/s13304-023-01534-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 05/10/2023] [Indexed: 05/24/2023]
Abstract
Primary and incisional ventral hernias are significant public health issues for their prevalence, variability of professional practices, and high costs associated with the treatment In 2019, the Board of Directors of the Italian Society for Endoscopic Surgery (SICE) promoted the development of new guidelines on the laparoscopic treatment of ventral hernias, according to the new national regulation. In 2022, the guideline was accepted by the government agency, and it was published, in Italian, on the SNLG website. Here, we report the adopted methodology and the guideline's recommendations, as established in its diffusion policy. This guideline is produced according to the methodology indicated by the SNGL and applying the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology. Fifteen recommendations were produced as a result of 4 PICO questions. The level of recommendation was conditional for 12 of them and conditional to moderate for one. This guideline's strengths include relying on an extensive systematic review of the literature and applying a rigorous GRADE method. It also has several limitations. The literature on the topic is continuously and rapidly evolving; our results are based on findings that need constant re-appraisal. It is focused only on minimally invasive techniques and cannot consider broader issues (e.g., diagnostics, indication for surgery, pre-habilitation).
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Affiliation(s)
- Fabio Cesare Campanile
- Division of General Surgery, ASL Viterbo, San Giovanni Decollato-Andosilla Hospital, Civita Castellana, Italy
| | - Mauro Podda
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Francesca Pecchini
- Department of General Surgery, Emergency and New Technologies, Baggiovara General Hospital, AOU Modena, Modena, Italy
| | - Marco Inama
- General and Mininvasive Surgery Department, Pederzoli Hospital, Peschiera del Garda, Verona, Italy
| | - Sarah Molfino
- General Surgery Unit Chirurgia III, ASST Spedali Civili di Brescia, Brescia, Italy
| | | | - Monica Ortenzi
- Department of General and Emergency Surgery, Marche Polytechnic University, Via Conca 71, 60126, Ancona, Italy.
| | - Gianfranco Silecchia
- Department of Medical-Surgical Sciences and Translation Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, S. Andrea Hospital, Rome, Italy
| | | | - Michela Cinquini
- Department of Oncology, Laboratory of Methodology of Sistematic Reviews and Guidelines Production, Istituto di Ricerche Farmacologiche Mario Negri IRCCS., Milan, Italy
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Marcolin P, Mazzola Poli de Figueiredo S, Walmir de Araújo S, Mota Constante M, Moura Fé de Melo V, Ginar da Silva S, Mao RMD, DeJesus J, Lu R. Preoperative Optimization Before Ventral Hernia Repair: A Systematic Review and Meta-analysis. Surg Laparosc Endosc Percutan Tech 2023; 33:211-218. [PMID: 36971526 DOI: 10.1097/sle.0000000000001160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 02/07/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Obesity is associated with an increased risk of ventral hernia development and recurrence rates after ventral hernia repair (VHR). The metabolic derangements caused by obesity can also lead to many postoperative complications. Therefore, it is a common practice to attempt weight loss before VHR. However, there is still no consensus on optimal preoperative management for obese patients with a ventral hernia. This study aims to perform a meta-analysis to evaluate the effect of preoperative weight optimization on VHR outcomes. METHODS We performed a literature search of PubMed, Scopus, and Cochrane Library databases to identify studies comparing obese patients who underwent surgical or non-surgical weight loss interventions before undergoing hernia repair surgery to obese patients who underwent hernia repair surgery without prehabilitation. Postoperative outcomes were assessed by means of pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I 2 statistics. RESULTS One thousand six hundred nine studies were screened and 13 were thoroughly reviewed. Five studies comprising 465 patients undergoing hernia repair surgery were included. No differences in hernia recurrence [odds ratio (OR) 0.66; 95% CI 0.23-1.89; P =0.44; I 2 =20%], seroma (OR 0.70; 95% CI 0.25-1.95; P =0.50; I 2 =5%), hematoma (OR 2.00; 95% CI 0.5-7.94; P =0.45; I 2 =0%), surgical site infection (OR 1.96; 95% CI 0.52-7.40; P =0.32; I 2 =0%), and overall complication (OR 0.80; 95% CI 0.37-1.74; P =0.58; I 2 =40%) rates were noted when comparing patients who underwent a preoperative weight loss intervention (prehabilitation or bariatric surgery) versus those who did not. In the subgroup analysis of patients who underwent bariatric surgery, we found no difference in hernia recurrence (OR 0.64; 95% CI 0.12-3.33; P = 0.59; I 2 =41%) or overall complications (OR 1.14; 95% CI 0.36-3.64; P =0.82; I 2 =64%). In the subgroup analysis of patients who lost weight versus patients who did not, there was no significant difference in overall complication rates (OR 0.86; 95% CI 0.34-2.21; P =0.76; I 2 =55%). CONCLUSIONS We found similar hernia recurrence, seroma, hematoma, and surgical site infection rates in patients who underwent preoperative optimization. These findings underline the need for prospective studies to define the optimal role of preoperative optimization and weight loss in obese patients undergoing ventral hernia repair.
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Affiliation(s)
| | | | | | | | | | - Shana Ginar da Silva
- Department of Epidemiology, Universidade Federal da Fronteira Sul, Passo Fundo, RS
| | - Rui-Min Diana Mao
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
| | - Jana DeJesus
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
| | - Richard Lu
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
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Madsen HJ, Gillette RA, Colborn KL, Henderson WG, Dyas AR, Bronsert MR, Lambert-Kerzner A, Meguid RA. The association between obesity and postoperative outcomes in a broad surgical population: A 7-year American College of Surgeons National Surgical Quality Improvement analysis. Surgery 2023; 173:1213-1219. [PMID: 36872175 DOI: 10.1016/j.surg.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/22/2023] [Accepted: 02/02/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND The number of obese surgical patients continues to grow, and yet obesity's association with surgical outcomes is not totally clear. This study examined the association between obesity and surgical outcomes across a broad surgical population using a very large sample size. METHODS This was an analysis of the 2012 to 2018 American College of Surgeons National Surgical Quality Improvement database, including all patients from 9 surgical specialties (general, gynecology, neurosurgery, orthopedics, otolaryngology, plastics, thoracic, urology, and vascular). Preoperative characteristics and postoperative outcomes were compared by body mass index class (normal weight 18.5-24.9 kg/m2, overweight 25.0-29.9, obese class I 30.0-34.9, obese II 35.0-39.9, obese III ≥40). Adjusted odds ratios were computed for adverse outcomes by body mass index class. RESULTS A total of 5,572,019 patients were included; 44.6% were obese. Median operative times were marginally higher for obese patients (89 vs 83 minutes, P < .001). Compared to normal weight patients, overweight and obese patients in classes I, II, and III all had higher adjusted odds of developing infection, venous thromboembolism, and renal complications, but they did not exhibit elevated odds of other postoperative complications (mortality, overall morbidity, pulmonary, urinary tract infection, cardiac, bleeding, stroke, unplanned readmission, or discharge not home (except for class III patients). CONCLUSION Obesity was associated with increased odds of postoperative infection, venous thromboembolism, and renal but not the other American College of Surgeons National Surgical Quality Improvement complications. Obese patients need to be carefully managed for these complications.
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Affiliation(s)
- Helen J Madsen
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO.
| | - Riley A Gillette
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Kathryn L Colborn
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO. https://twitter.com/ColbornKathryn
| | - William G Henderson
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO; Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | - Adam R Dyas
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Michael R Bronsert
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO
| | - Anne Lambert-Kerzner
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO
| | - Robert A Meguid
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO. https://twitter.com/MeguidRobert
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Obesity Stratification Predicts Short-Term Complications After Parastomal Hernia Repair. J Surg Res 2022; 280:27-34. [PMID: 35952554 DOI: 10.1016/j.jss.2022.07.002] [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: 04/30/2022] [Revised: 06/14/2022] [Accepted: 07/05/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION While previous studies have documented adverse outcomes among obese patients undergoing ventral and inguinal hernia repairs, there is a lack of literature regarding the impact of obesity on parastomal hernia (PSH) repair. This retrospective study aims to determine the value of obesity stratification in predicting postoperative complications in patients undergoing PSH repair. MATERIALS AND METHODS Outcomes of elective PSH repairs from 2010 to 2020 in the American College of Surgeons National Surgical Quality Improvement Program database were analyzed. Patient demographics, preoperative characteristics, and postoperative outcomes were compared using bivariate analysis and multivariable regression models. RESULTS A total of 2972 patients were retrospectively analyzed. Multivariable regression found, compared to nonobese patients, patients of obesity class ≥ II were 1.37 times more likely to develop complications overall (P = 0.006) and 1.55 times more likely to develop wound complications (P < 0.001). This group also yielded a 1.60 times higher risk of developing superficial wound infection (P = 0.007) and a 1.63 times greater risk of developing postoperative sepsis (P = 0.044). Total length of stay was longer for patients of obesity class ≥ II but not for obesity class I when compared to patients with body mass index <30.0 kg/m2. CONCLUSIONS Patients with a body mass index ≥35.0 kg/m2 are more susceptible to an increased rate of complications after PSH repairs. The findings of this study will allow surgeons to stratify obese patients who would benefit from preoperative weight loss interventions prior to PSH repair and discuss associated risks with patients to facilitate informed consent.
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Abstract
Ventral and incisional hernias in obese patients are particularly challenging. Suboptimal outcomes are reported for elective repair in this population. Preoperative weight loss is ideal but is not achievable in all patients for a variety of reasons, including access to bariatric surgery, poor quality of life, and risk of incarceration. Surgeons must carefully weigh the risk of complications from ventral hernia repair with patient symptoms, the ability to achieve adequate weight loss, and the risks of emergency hernia repair in obese patients.
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Velanovich V, Gonzalez C, Russo N, Hanna J, Tran T, Montera B, Chharath K, Saad A. Case–control comparison of separation of component retrorectus urinary bladder extracellular surgical device hernia repair with acellular dermal matrix underlay and prosthetic mesh overlay hernia repair. INTERNATIONAL JOURNAL OF ABDOMINAL WALL AND HERNIA SURGERY 2021. [DOI: 10.4103/ijawhs.ijawhs_46_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Gu Y, Wang P, Li H, Tian W, Tang J. Chinese expert consensus on adult ventral abdominal wall defect repair and reconstruction. Am J Surg 2020; 222:86-98. [PMID: 33239177 DOI: 10.1016/j.amjsurg.2020.11.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Surgical management of patients with ventral abdominal wall defects, especially complex abdominal wall defects, remains a challenging problem for abdominal wall reconstructive surgeons. Effective surgical treatment requires appropriate preoperative assessment, surgical planning, and correct operative procedure in order to improve postoperative clinical outcomes and minimize complications. Although substantial advances have been made in surgical techniques and prosthetic technologies, there is still insufficient high-level evidence favoring a specific technique. Broad variability in existing practice patterns, including clinical pre-operative evaluation, surgical techniques and surgical procedure selection, are still common. DATA SOURCES With the purpose of providing a best practice algorithm, a comprehensive search was conducted in Medline and PubMed. Sixty-four surgeons considered as experts on abdominal wall defect repair and reconstruction in China were solicited to develop a Chinese consensus and give recommendations to help surgeons standardize their techniques and improve clinical results. CONCLUSIONS This consensus serves as a starting point to provide recommendations for adult ventral abdominal wall repair and reconstruction in China and may help build opportunities for international cooperation to refine AWR practice.
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Affiliation(s)
- Yan Gu
- Hernia and Abdominal Wall Disease Center, Shanghai Jiao Tong University, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China.
| | - Ping Wang
- Department of Hernia Surgery, Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China
| | - Hangyu Li
- Department of General Surgery, Fourth Hospital of China Medical University, Shenyang, 110000, China
| | - Wen Tian
- Department of General Surgery, Chinese People's Liberation Army General Hospital, Beijing, 100853, China.
| | - Jianxiong Tang
- Department of General Surgery, Huadong Hospital, Fudan University, Shanghai, 200040, China.
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Shahait AD, Alghanem L, Cmorej P, Tracy W, Hasnain MR, Baldawi M, Girten K, Weaver D, Saleh KJ, Gruber SA, Mostafa G. Postoperative outcomes of ventral hernia repair in veterans. Surgery 2020; 169:603-609. [PMID: 33077198 DOI: 10.1016/j.surg.2020.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/30/2020] [Accepted: 09/01/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Ventral hernia repair is a common procedure with reported 15% to 37% morbidity and 0.3% to 1.4% mortality rates. This study examines the 30-day morbidity and mortality of open and laparoscopic ventral hernia repair in veterans, along with the impact of body mass index on these outcomes. METHODS The Veterans Affairs Surgical Quality Improvement Program was queried for all ventral hernia repairs during the period 2008 to 2015. In this retrospective analysis, we compared outcomes of open ventral hernia repair versus laparoscopic ventral hernia repair and among different body mass index classes. RESULTS A total of 19,883 patients were identified (92.6% male, mean age 59.7, 53.1% obese, and 71.6% with American Society of Anesthesiologists class ≥III). There were 95 (0.5%) mortalities, and complications occurred in 1,289 (6.5%) patients. Open ventral hernia repair was performed in 60.2%; 14.5% were recurrent, and 3.3% were performed as an emergency operation. When compared with open ventral hernia repair, the laparoscopic ventral hernia repair group had higher mean body mass index, less patients with American Society of Anesthesiologists class ≥III, fewer emergency operations, longer operative time, less complications, decreased mortality, and shorter duration of stay. Body mass index 35.00 to 49.99 was predictive of overall complications in the open ventral hernia repair group. CONCLUSION Ventral hernia repair can be performed in the veteran population with outcomes comparable to those in the private sector. Morbid obesity has a negative impact on ventral hernia repair outcomes that is most prominent following open surgery. Laparoscopic ventral hernia repair may offer superior outcomes when compared to open ventral hernia repair and may be considered.
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Affiliation(s)
- Awni D Shahait
- Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine/Detroit Medical Center, Detroit, MI; Department of Surgery, John D. Dingell VA Medical Center, Detroit, MI
| | - Lana Alghanem
- The Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI
| | - Peter Cmorej
- Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine/Detroit Medical Center, Detroit, MI; Department of Surgery, John D. Dingell VA Medical Center, Detroit, MI
| | - William Tracy
- Department of Surgery, John D. Dingell VA Medical Center, Detroit, MI
| | | | - Mohanad Baldawi
- Department of Surgery, John D. Dingell VA Medical Center, Detroit, MI
| | - Kara Girten
- Department of Surgery, John D. Dingell VA Medical Center, Detroit, MI
| | - Donald Weaver
- Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine/Detroit Medical Center, Detroit, MI
| | - Khaled J Saleh
- Department of Surgery, John D. Dingell VA Medical Center, Detroit, MI
| | - Scott A Gruber
- Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine/Detroit Medical Center, Detroit, MI; Department of Surgery, John D. Dingell VA Medical Center, Detroit, MI
| | - Gamal Mostafa
- Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine/Detroit Medical Center, Detroit, MI; Department of Surgery, John D. Dingell VA Medical Center, Detroit, MI.
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Addo A, Lu R, Broda A, George P, Huerta N, Park A, Zahiri HR, Belyansky I. Impact of Body Mass Index (BMI) on perioperative outcomes following minimally invasive retromuscular abdominal wall reconstruction: a comparative analysis. Surg Endosc 2020; 35:5796-5802. [PMID: 33051760 DOI: 10.1007/s00464-020-08069-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 09/29/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Morbidity and recurrence rates are higher in obese patients undergoing open abdominal wall reconstruction (AWR). Historically, body mass index (BMI) ≥ 40 has served as a relative contraindication to open AWR. The purpose of this study is to evaluate the impact of minimally invasive surgery (MIS) on outcomes after AWR for higher versus lower BMI patients. METHODS A retrospective review of a prospectively maintained database was conducted of all patients who underwent MIS AWR between September 2015 and April 2019 at our institution. Patients were subdivided into two groups based on their BMI: BMI ≤ 35 kg/m2 and BMI > 35 kg/m2. Patient demographics and perioperative data were evaluated using univariate and multivariate analysis. RESULTS 461 patients were identified and divided into two groups: BMI ≤ 35 (n = 310) and BMI > 35 (n = 151). The two groups were similar in age (BMI ≤ 35: 56.3 ± 14.1 years vs. BMI > 35: 54.4 ± 11.9, p = .154). BMI > 35 group had more patients with ASA score of 3 (81% vs. 32%, p < .001) and comorbid conditions such as hypertension (70% vs. 45%, p < .001), diabetes mellitus (32% vs. 15%, p < .001), and history of recurrent abdominal wall hernia (34% vs. 23%, p = .008). BMI > 35 group underwent a robotic approach at higher rates (74% vs. 45%, p < .001). Patients who underwent a Rives-Stoppa repair from the higher BMI cohort also had a larger defect size (5.6 ± 2.4 cm vs. 6.7 ± 2.4 cm, p = .004). However, there were no differences in defect size in patients who underwent a transversus abdominus release (BMI ≤ 35: 9.7 ± 4.9 cm vs. BMI > 35: 11.1 ± 4.6 cm, p = .069). Both groups benefited similarly from a short length of stay, similar hospital charges, and lower postoperative complications. CONCLUSION Initial findings of our data support the benefits of elective MIS approach to AWR for patients with higher BMI. These patients derive similar benefits, such as faster recovery with low recurrence rates, when compared to lower BMI patients, while avoiding preoperative hernia incarceration, postoperative wound complications, and hernia recurrences. Future follow-up is required to establish long-term perioperative and quality of life outcomes in this patient cohort.
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Affiliation(s)
- Alex Addo
- Department of Surgery, Anne Arundel Medical Center, 2000 Medical Parkway, Suite 100, Annapolis, MD, 21401, USA
| | - Richard Lu
- Department of Surgery, Anne Arundel Medical Center, 2000 Medical Parkway, Suite 100, Annapolis, MD, 21401, USA
| | - Andrew Broda
- Department of Surgery, Anne Arundel Medical Center, 2000 Medical Parkway, Suite 100, Annapolis, MD, 21401, USA
| | - Philip George
- Department of Surgery, Anne Arundel Medical Center, 2000 Medical Parkway, Suite 100, Annapolis, MD, 21401, USA
| | - Nick Huerta
- Department of Surgery, Anne Arundel Medical Center, 2000 Medical Parkway, Suite 100, Annapolis, MD, 21401, USA
| | - Adrian Park
- Department of Surgery, Anne Arundel Medical Center, 2000 Medical Parkway, Suite 100, Annapolis, MD, 21401, USA
| | - H Reza Zahiri
- Department of Surgery, Anne Arundel Medical Center, 2000 Medical Parkway, Suite 100, Annapolis, MD, 21401, USA
| | - Igor Belyansky
- Department of Surgery, Anne Arundel Medical Center, 2000 Medical Parkway, Suite 100, Annapolis, MD, 21401, USA.
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Are laparoscopic and open ventral hernia repairs truly comparable?: A propensity-matched study in large ventral hernias. Surg Endosc 2020; 35:4653-4660. [PMID: 32780243 DOI: 10.1007/s00464-020-07894-w] [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: 04/14/2020] [Accepted: 08/05/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The merits of laparoscopic (LVHR) and open preperitoneal ventral hernia repair (OPPVHR) have been debated for more than 2 decades. Our aim was to determine peri-operative and long-term outcomes in large hernias. METHODS A prospective, institutional database at a tertiary hernia center was queried for patients undergoing LVHR and OPPVHR. One-to-one propensity score matching was performed for hernia defect size and follow-up. RESULTS Three hundred and fifty-two LVHR and OPPVHR patients were identified with defect sizes closely matched between laparoscopic (182.0 ± 110.0 cm2) and open repairs (178.3 ± 99.8 cm2), p = 0.64. LVHR and OPPVHR patients were comparable: mean age 57.2 ± 12.1 vs 56.6 ± 12.0 years (p = 0.52), BMI: 32.9 ± 6.6 vs 32.0 ± 7.4 kg/m2 (p = 0.16), diabetes 19.0% vs 19.7% (p = 0.87), and smoking history 8.7% vs 23.0% (p < 0.001), respectively. OPPVHR had higher number of recurrent hernias (14.2% vs 44.9%, p < 0.001), longer operative time (168.1 ± 64.3 vs 186.7 ± 67.7 min, p = 0.006), and more components separation (0% vs 20.3%, p < 0.001). Mean mesh size was larger (p < 0.001) in the open group (634.4 ± 243.4 cm2 vs 841.8 ± 277.6 cm2). The hernia recurrence rates were similar (10.8% vs 9.2%, p = 0.62), with average follow-up of 39.3 ± 32.5 vs 40.0 ± 35.0 months (p = 0.89). Length of stay was higher in the OVHR cohort (5.4 ± 3.0 vs 6.3 ± 3.6 days, p < 0.001), but 30-day readmission rates (4.0% vs 6.4%, p = 0.31) were similar. Overall wound infection rate (2.9% vs 8.4%, p = 0.03) was higher in the OPPVHR group, but the mesh infection rate was similar between LVHR (1.7%) and OPPVHR (0.6%) (p = 0.33). Postoperative pain (41.1% vs 41.4%, p = 0.95) and overall QOL based on the Carolinas Comfort Scale at 6 months (p = 0.73) and 5-years (p = 0.36) were similar. CONCLUSION Laparoscopic and open preperitoneal repair for large ventral hernias have equivalent hernia recurrence rates, postoperative pain, and QOL on long-term follow-up. Patients undergoing OPPVHR were more likely to be recurrent, complex, require components separation, and more likely to develop postoperative wound complications.
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Abstract
BACKGROUND The safety and effectiveness of expectant management (e.g., watchful waiting or initially managing non-operatively) for patients with a ventral hernia is unknown. We report our 3-year results of a prospective cohort of patients with ventral hernias who underwent expectant management. METHODS A hernia clinic at an academic safety-net hospital was used to recruit patients. Any patient undergoing expectant management with symptoms and high-risk comorbidities, as determined by a surgeon based on institutional criteria, would be included in the study. Patients unlikely to complete follow-up assessments were excluded from the study. Patient-reported outcomes were collected by phone and mailed surveys. A modified activities assessment scale normalized to a 1-100 scale was used to measure results. The rate of operative repair was the primary outcome, while secondary outcomes include rate of emergency room (ER) visits and both emergent and elective hernia repairs. RESULTS Among 128 patients initially enrolled, 84 (65.6%) completed the follow-up at a median (interquartile range) of 34.1 (31, 36.2) months. Overall, 28 (33.3%) patients visited the ER at least once because of their hernia and 31 (36.9%) patients underwent operative management. Seven patients (8.3%) required emergent operative repair. There was no significant change in quality of life for those managed non-operatively; however, substantial improvements in quality of life were observed for patients who underwent operative management. CONCLUSIONS Expectant management is an effective strategy for patients with ventral hernias and significant comorbid medical conditions. Since the short-term risk of needing emergency hernia repair is moderate, there could be a safe period of time for preoperative optimization and risk-reduction for patients deemed high risk.
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Schlosser KA, Maloney SR, Gbozah K, Prasad T, Colavita PD, Augenstein VA, Heniford BT. The impact of weight change on intra-abdominal and hernia volumes. Surgery 2020; 167:876-882. [PMID: 32151368 DOI: 10.1016/j.surg.2020.01.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 01/05/2020] [Accepted: 01/14/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Weight loss is often encouraged or required before open ventral hernia repair. This study evaluates the impact of weight change on total, intra-abdominal, subcutaneous, and hernia volume. METHODS Patients who underwent open ventral hernia repair from 2007 to 2018 with two preoperative computed tomography scans were identified. Scans were reviewed using 3D volumetric software. Demographics, operative characteristics, and outcomes were evaluated. The impact of weight change on intra-abdominal, subcutaneous, and hernia volume was assessed using Spearman's correlation coefficients and linear regression models. RESULTS A total of 250 patients met the criteria with a mean defect area of 155.6 ± 155.4 cm2, subcutaneous volume of 6,800.0 ± 3,868.8 cm3, hernia volume of 915.7 ± 1,234.5 cm3, intra-abdominal volume equaling 4,250.2 ± 2,118.1 cm3, and time between computed tomography scans 13.9 ± 11.0 months. Weight change was associated with change in hernia, intra-abdominal, total, and subcutaneous volume (Spearman's correlation coefficients 0.17, 0.48, 0.51, 0.45, respectively, P ≤ 0.03 all values) and not associated in hernia length, width, or area (P ≥ 0.18 all values). A Δ5 kg was significantly associated with Δintra-abdominal volume (164.1 ± 30.0 cm3/Δ5 kg,P < .0001), Δtotal volume (209.9 ± 33.0 cm3/Δ5 kg, P < .0001), and Δsubcutaneous volume (234.4 ± 50.8 cm3/Δ5 kg, P < .0001). Per Δ5 kg, male patients had more than double the Δintra-abdominal, Δtotal, and Δsubcutaneous volume than did female patients. A weight change of 5 kg to10 kg was associated with approximately double the change in computed tomography parameters/Δ5 kg than any weight change after 10 kg. Regardless of weight change, all measured hernia parameters increased over time, with mean hernia volume of +40.6 ± 94.9 cm3/mo and area of +7.8 ± 13.3 cm2/mo (Spearman's correlation coefficient -0.03 to 0.07, P value 0.37-0.96). CONCLUSION Weight change is linearly correlated with intra-abdominal and subcutaneous fat gain or loss. Males show greater abdominal-related response to weight gain or loss. Hernia dimensions increase over time regardless of weight change.
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Affiliation(s)
- Kathryn A Schlosser
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Sean R Maloney
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Korene Gbozah
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Tanushree Prasad
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Paul D Colavita
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Vedra A Augenstein
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - B Todd Heniford
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC.
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Nieto E, Ponz C, Ananin S, Vazquez E. Obesity as a risk factor for complications and recurrences after ventral hernia repair. INTERNATIONAL JOURNAL OF ABDOMINAL WALL AND HERNIA SURGERY 2020. [DOI: 10.4103/ijawhs.ijawhs_35_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Chung I, Cheung BH, Law TT, Ng KK, Ng L, Wong KY. Laparoscopic versus open repair for small paraumbilical hernia: A retrospective review. Asian J Endosc Surg 2019; 12:306-310. [PMID: 30168291 DOI: 10.1111/ases.12644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/22/2018] [Accepted: 07/31/2018] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The advantages of laparoscopic surgery for ventral hernia repairs are well documented, but its application for small paraumbilical hernias has been less studied. There is no consensus regarding the best technique. METHODS All patients who had open (suture or mesh) and laparoscopic repair of primary paraumbilical hernia between September 2007 and September 2017 in a single center were identified. Hernial defects of 2 cm or less were included; recurrent hernias were excluded. Primary outcomes included operative time, length of hospital stay, and surgical complications. RESULTS Seventy-seven patients were recruited: 54 (70.1%) had open repair and 23 (29.9%) had laparoscopic repair. Forty-six patients (85%) in the open group had primary suture repair. The mean operative time was significantly shorter in the open group than in the laparoscopic group (27.2 vs 56.1 min, P < 0.05). The length of hospital stay in the open group was significantly shorter than in the laparoscopic group (0.8 vs 1.4 days, P = 0.00). Early complications rates were similar, with wound complications in 5.6% (3/54) of open repair patients and 4.3% (1/23) of laparoscopic repair patients (P = 1.0). Among open repair patients, 19 patients (35.2%) were successfully discharged within 12 h after operation. Two patients (3.7%) in the open simple suture group developed recurrence, but no recurrence was identified in the laparoscopic group; this was not statistically significant (P = 1.0). CONCLUSION The laparoscopic approach is comparable to the open approach in the repair of small paraumbilical hernias. For small paraumbilical hernias, we recommend that laparoscopic repair be reserved for obese patients or those with suspected multiple hernial defects.
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Affiliation(s)
- Iris Chung
- Department of Surgery, Queen Mary Hospital, Hong Kong
| | | | - Tsz Ting Law
- Department of Surgery, Tung Wah Hospital, Hong Kong
| | - Ka Kin Ng
- Department of Surgery, Tung Wah Hospital, Hong Kong
| | - Lily Ng
- Department of Surgery, Tung Wah Hospital, Hong Kong
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Impact of body mass index on minimally invasive ventral hernia repair: an ACS-NSQIP analysis. Hernia 2019; 23:899-907. [PMID: 31006062 DOI: 10.1007/s10029-019-01944-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 03/27/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE Body mass index (BMI) ≥ 35 kg/m2 is a known independent risk factor for complications following open ventral hernia repair (VHR). We sought to examine the relationship between BMI and minimally invasive VHR. METHODS The ACS-NSQIP database was queried for all patients age ≥ 18 years undergoing minimally invasive VHR (2005-2015). Patients were stratified into seven BMI classes: underweight (BMI < 18.5 kg/m2), normal weight (BMI 18.5-24.9), overweight (25-29.9), obese (30-34.5), severely obese (35-39.9), morbidly obese (40-49.9), and super obese (BMI ≥ 50), as well as by hernia type (reducible vs. strangulated) and time of repair (initial vs. recurrent). Multivariate logistic regression was employed to assess the risk of complication by BMI class. RESULTS A total of 55,180 patients met inclusion criteria, and 61.4% had a BMI > 30 kg/m2. When stratified by BMI class, we found significant differences in age, gender, race, comorbidities, and pre-operative characteristics across groups. The overall complication rate was 4.0%, ranging from 3.0% for normal BMI patients, to 6.9% for patients with a BMI ≥ 50 kg/m2. Recurrent repairs and strangulated hernias both demonstrated higher complication rates. All complications (surgical and medical) were significantly associated with BMI class after adjustment (p < 0.0001). Patients with a BMI ≥ 50 kg/m2 had a 1.4 times greater risk for complications than patients with normal BMIs (18-24.9 kg/m2, p = 0.01). CONCLUSION BMI ≥ 50 kg/m2 was determined to be an independent risk factor for surgical and medical complications after minimally invasive VHR.
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Schlosser KA, Arnold MR, Otero J, Prasad T, Lincourt A, Colavita PD, Kercher KW, Heniford BT, Augenstein VA. Deciding on Optimal Approach for Ventral Hernia Repair: Laparoscopic or Open. J Am Coll Surg 2018; 228:54-65. [PMID: 30359827 DOI: 10.1016/j.jamcollsurg.2018.09.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 08/06/2018] [Accepted: 09/14/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The decision to perform laparoscopic or open ventral hernia repair (VHR) is multifactorial. This study evaluates the impact of operative approach, BMI, and hernia size on outcomes after VHR. STUDY DESIGN The International Hernia Mesh Registry was queried for VHR (2007-2017). A predictive algorithm was constructed, factoring the impact of BMI, hernia size, age, sex, diabetes, and operative approach on outcomes. RESULTS Of the 1,906 VHRs, 58.8% were performed open, patient mean age was 54.9 ± 13.5 years, BMI was 31.2 ± 6.8 kg/m2, and defect area was 44.8 ± 88.1 cm2. Patients undergoing open VHRs were more likely to have an infection develop (3.1% vs 0.3%; p < 0.0001), but less likely to have a seroma develop (6.8% vs 15.3%; p < 0.0001) at mean follow-up 23.2 ± 12.0 months. With multivariate regression controlling for confounding variables, patients undergoing laparoscopic VHR had increased risk of seroma (odds ratio [OR] 1.78; 95% CI 1.05 to 3.03), a decreased risk of infection (OR 0.05; 95% CI 0.01 to 0.42), and had worse quality of life at 1, 6, 12, and 24 months postoperatively compared with patients undergoing open repair. Recurrent hernias were associated with subsequent recurrence (OR 2.69; 95% CI 1.24 to 5.81) and need for reoperation (OR 4.93; 95% CI 2.24 to 10.87). Multivariate predictive models demonstrated independent predictors of infection, including open approach, recurrent hernias, and low ratio of BMI to defect size. CONCLUSIONS Ideal outcomes are dependent on both patient and operative factors. Open repair in thin patients with large defects should be considered due to reduced complications and improved quality of life. Laparoscopic repair in obese patients and recurrent hernias can decrease the associated risk of infection.
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Affiliation(s)
- Kathryn A Schlosser
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Michael R Arnold
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Javier Otero
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Tanushree Prasad
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Amy Lincourt
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Paul D Colavita
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Kent W Kercher
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - B Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Vedra A Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC.
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Affiliation(s)
- Hamid Reza Zahiri
- Anne Arundel Medical Center, Department of Surgery, Division of Minimally Invasive Surgery, Annapolis, Maryland
| | - Igor Belyansky
- Anne Arundel Medical Center, Department of Surgery, Division of Minimally Invasive Surgery, Annapolis, Maryland
| | - Adrian Park
- Anne Arundel Medical Center, Department of Surgery, Division of Minimally Invasive Surgery, Annapolis, Maryland.
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The Impact of Body Mass Index on Abdominal Wall Reconstruction Outcomes: A Comparative Study. Plast Reconstr Surg 2017; 139:1234-1244. [PMID: 28445378 DOI: 10.1097/prs.0000000000003264] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Obesity and higher body mass index may be associated with higher rates of wound healing complications and hernia recurrence rates following complex abdominal wall reconstruction. The authors hypothesized that higher body mass indexes result in higher rates of postoperative wound healing complications but similar rates of hernia recurrence in abdominal wall reconstruction patients. METHODS The authors included 511 consecutive patients who underwent abdominal wall reconstruction with underlay mesh. Patients were divided into three groups on the basis of preoperative body mass index: less than 30 kg/m (nonobese), 30 to 34.9 kg/m (class I obesity), and 35 kg/m or greater (class II/III obesity). The authors compared postoperative outcomes among these groups. RESULTS Class I and class II/III obesity patients had higher surgical-site occurrence rates than nonobese patients (26.4 percent versus 14.9 percent, p = 0.006; and 36.8 percent versus 14.9 percent, p < 0.001, respectively) and higher overall complication rates (37.9 percent versus 24.7 percent, p = 0.007; and 43.4 percent versus 24.7 percent, p < 0.001, respectively). Similarly, obese patients had significantly higher skin dehiscence (19.3 percent versus 7.2 percent, p < 0.001; and 26.5 percent versus 7.2 percent, p < 0.001, respectively) and fat necrosis rates (10.0 percent versus 2.1 percent, p = 0.001; and 11.8 percent versus 2.1 percent, p < 0.001, respectively) than nonobese patients. Obesity class II/III patients had higher infection and seroma rates than nonobese patients (9.6 percent versus 4.3 percent, p = 0.041; and 8.1 percent versus 2.1 percent, p = 0.006, respectively). However, class I and class II/III obesity patients experienced hernia recurrence rates (11.4 percent versus 7.7 percent, p = 0.204; and 10.3 percent versus 7.7 percent, p = 0.381, respectively) and freedom from hernia recurrence (overall log-rank, p = 0.41) similar to those of nonobese patients. CONCLUSION Hernia recurrence rates do not appear to be affected by obesity on long-term follow-up in abdominal wall reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Abstract
OBJECTIVE To achieve consensus on the best practices in the management of ventral hernias (VH). BACKGROUND Management patterns for VH are heterogeneous, often with little supporting evidence or correlation with existing evidence. METHODS A systematic review identified the highest level of evidence available for each topic. A panel of expert hernia-surgeons was assembled. Email questionnaires, evidence review, panel discussion, and iterative voting was performed. Consensus was when all experts agreed on a management strategy. RESULTS Experts agreed that complications with VH repair (VHR) increase in obese patients (grade A), current smokers (grade A), and patients with glycosylated hemoglobin (HbA1C) ≥ 6.5% (grade B). Elective VHR was not recommended for patients with BMI ≥ 50 kg/m (grade C), current smokers (grade A), or patients with HbA1C ≥ 8.0% (grade B). Patients with BMI= 30-50 kg/m or HbA1C = 6.5-8.0% require individualized interventions to reduce surgical risk (grade C, grade B). Nonoperative management was considered to have a low-risk of short-term morbidity (grade C). Mesh reinforcement was recommended for repair of hernias ≥ 2 cm (grade A). There were several areas where high-quality data were limited, and no consensus could be reached, including mesh type, component separation technique, and management of complex patients. CONCLUSIONS Although there was consensus, supported by grade A-C evidence, on patient selection, the safety of short-term nonoperative management, and mesh reinforcement, among experts; there was limited evidence and broad variability in practice patterns in all other areas of practice. The lack of strong evidence and expert consensus on these topics has identified gaps in knowledge where there is need of further evidence.
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A Prospective Assessment of Clinical and Patient-Reported Outcomes of Initial Non-Operative Management of Ventral Hernias. World J Surg 2017; 41:1267-1273. [DOI: 10.1007/s00268-016-3859-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Pernar LIM, Pernar CH, Dieffenbach BV, Brooks DC, Smink DS, Tavakkoli A. What is the BMI threshold for open ventral hernia repair? Surg Endosc 2016; 31:1311-1317. [DOI: 10.1007/s00464-016-5113-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 07/11/2016] [Indexed: 12/20/2022]
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Holihan JL, Alawadi ZM, Harris JW, Harvin J, Shah SK, Goodenough CJ, Kao LS, Liang MK, Roth JS, Walker PA, Ko TC. Ventral hernia: Patient selection, treatment, and management. Curr Probl Surg 2016; 53:307-54. [DOI: 10.1067/j.cpsurg.2016.06.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 06/14/2016] [Indexed: 12/14/2022]
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Juo YY, Skancke M, Holzmacher J, Amdur RL, Lin PP, Vaziri K. Laparoscopic versus open ventral hernia repair in patients with chronic liver disease. Surg Endosc 2016; 31:769-777. [PMID: 27334967 DOI: 10.1007/s00464-016-5031-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 06/11/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Previous studies demonstrated laparoscopic ventral hernia repair (LVHR) to be associated with fewer short-term complications than open ventral hernia repair (OVHR). Little literature is available comparing LVHR and OVHR in chronic liver disease (CLD) patients. METHODS Patients with model for end-stage liver disease score ≥9 who underwent elective ventral hernia repair in the National Surgical Quality Improvement Program Database were included. 30-day outcomes were compared between LVHR and OVHR after adjusting for hernia disease severity, baseline comorbidities and demographic factors. RESULTS A total of 3594 ventral hernia repairs were included, 536 (14.9 %) of which were LVHR. After adjusting for other confounders, LVHR was associated with a lower incidence of wound-related complications (0.23, 95 % CI 0.07-0.74, p = 0.01), shorter length of stay (mean 3.7 vs. 5.0 days, p < 0.01) than OVHR, but similar systemic complications (p = 0.77), bleeding complications (p = 0.69), unplanned reoperation (p = 0.74) or readmission (p = 0.40). Propensity score-matched comparison showed similar conclusions. Five hundred and sixty-two patients had ascites, among whom 35 (6.2 %) underwent LVHR. In this subcohort, LVHR was associated with higher mortality (OR 5.36, 95 % CI 1.00-28.60, p = 0.05), systemic complications (OR 7.03, 95 % CI 2.06-24.00, p < 0.01), and unplanned reoperation (OR 6.03, 95 % CI 1.51-24.12, p = 0.01) than OVHR. CONCLUSIONS In comparison with OVHR, LVHR is associated with similar short-term outcomes except for lower wound-related complications and shorter length of stay in CLD patients. However, when patients have ascites, LVHR is associated with higher mortality, systemic complications, and unplanned reoperation.
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Affiliation(s)
- Yen-Yi Juo
- Department of Surgery, George Washington University Medical Center, 22nd and I Street, NW, 6th Floor, Washington, DC, 20037, USA.
| | - Matthew Skancke
- Department of Surgery, George Washington University Medical Center, 22nd and I Street, NW, 6th Floor, Washington, DC, 20037, USA
| | - Jeremy Holzmacher
- Department of Surgery, George Washington University Medical Center, 22nd and I Street, NW, 6th Floor, Washington, DC, 20037, USA
| | - Richard L Amdur
- Department of Surgery, George Washington University Medical Center, 22nd and I Street, NW, 6th Floor, Washington, DC, 20037, USA
| | - Paul P Lin
- Department of Surgery, George Washington University Medical Center, 22nd and I Street, NW, 6th Floor, Washington, DC, 20037, USA
| | - Khashayar Vaziri
- Department of Surgery, George Washington University Medical Center, 22nd and I Street, NW, 6th Floor, Washington, DC, 20037, USA
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Blair LJ, Ross SW, Huntington CR, Watkins JD, Prasad T, Lincourt AE, Augenstein VA, Heniford BT. Computed tomographic measurements predict component separation in ventral hernia repair. J Surg Res 2015; 199:420-7. [PMID: 26169031 DOI: 10.1016/j.jss.2015.06.033] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 06/11/2015] [Accepted: 06/12/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Preoperative imaging with computed tomography (CT) scans can be useful in preoperative planning. We hypothesized that CT measurements of ventral hernia defect size and abdominal wall thickness (AWT) would correlate with postoperative complications and need for complex abdominal wall reconstruction (AWR). MATERIALS AND METHODS Patients who underwent open ventral hernia repair and had preoperative abdominal CT imagining were identified from an institutional hernia-specific surgery outcomes database at our tertiary referral hernia center. Grade III and IV hernias and biologic mesh cases were excluded. CT measures of defect size and AWT were analyzed and correlated to complications and the need for AWR techniques using univariate, multivariate, and principal component (PC) analyses. PC1 and PC2 used five AWT measures, hernia defect width, and body mass index to create a new component variable. RESULTS There were 151 open ventral hernia repairs included in the study. Preoperative findings included 37.7% male; age 55.3 ± 12.5 years; body mass index (BMI) 33.3 ± 7.8 kg/m(2); 60.3% were recurrent hernias with average defect width 8.5 ± 5.0 cm and area 178.3 ± 214 cm(2); AWT at umbilicus 3.5 ± 1.8 cm; and AWT at pubis 7.0 ± 3.2. Component separation was performed in 24.0% of patients and panniculectomy in 34.4%. Wound complications occurred in 13.3% patients, and 2.7% had hernia recurrence. Increasing defect width, length, and area as well as select AWT measurements were associated with increased need for component separation, concomitant panniculectomy, and higher rates of wound and total complications (all P < 0.05). Using multivariate regression, PC1 was associated with wound complications (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.01-1.16); PC2 (hernia defect width) was associated with the need for component separation (OR, 1.16; 95% CI, 1.03-1.30). Hernia recurrence was not predicted by AWT or defect size (OR, 1.00; 95%CI, 0.87-1.15). CONCLUSIONS Preoperative CT measurements of hernia defects and AWT predict wound complications and the need for complex AWR techniques. Obtaining preoperative CT imaging should be a consideration in preoperative planning and may help with patient counseling.
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Affiliation(s)
- Laurel J Blair
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Samuel W Ross
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Ciara R Huntington
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - John D Watkins
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Tanushree Prasad
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Amy E Lincourt
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Vedra A Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - B Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina.
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