The abdominal wall incisional hernia repair in cirrhotic patients

Preoperative Optimization for Abdominal Wall Reconstruction

Patients requiring abdominal wall reconstruction may have medical comorbidities and/or complex defects. Comorbidities such as smoking, diabetes, obesity, cirrhosis, and frailty have been associated with an increased risk of postoperative complications. Prehabilitation strategies are variably associated with improved outcomes. Large hernia defects and loss of domain may present challenges in achieving fascial closure, an important part of restoring abdominal wall function. Prehabilitation of the abdominal wall can be achieved with the use of botulinum toxin A, and preoperative progressive pneumoperitoneum.

Assessing surgical risk calculators on hernia repair candidates with cirrhosis

PURPOSE

Several risk calculators have been developed and deployed to help surgeons estimate the mortality risk that comes with performing hernia repair surgery on patient with severe liver disease. This study seeks to evaluate the accuracy of these risk calculators on patients with cirrhosis and identify the most suitable population of patient to use these calculators on.

METHODS

The American College of Surgeons National Surgery Quality Improvement Program (NSQIP) 2013-2021 datasets were queried for patients who underwent hernia repair surgery. Mayo Clinic's "Post-operative Mortality Risk in Patients with Cirrhosis" risk calculator, Model for End-Stage Liver Disease (MELD) calculator, NSQIP's Surgical Risk Calculator, and a surgical 5-item modified frailty index were assessed to determine whether they accurately predict mortality following abdominal hernia repair.

RESULTS

In total, 1368 patients met inclusion criteria. Receiver operating characteristic (ROC) curve analysis of the 4 mortality risk calculators resulted in the following: NSQIP Surgical Risk Calculator = 0.803 (p < 0.001); "Post-operative Mortality Risk in Patients with Cirrhosis" with an etiology of "Alcoholic or Cholestatic" yielded an AUC = 0.722 (p < 0.001); MELD score yielded an AUC = 0.709 (p < 0.001); and the modified 5-item frailty index yielded an AUC = 0.583 (p = 0.04).

CONCLUSION

The NSQIP Surgical Risk Calculator more accurately predicts 30-day mortality in patients with ascites undergoing hernia repair. However, if the patient is missing one of the 21 input variables required by this calculator, Mayo Clinic's 30-day mortality calculator should be consulted before the more widely used MELD score.

Risk factors of incisional hernia after laparoscopic colorectal surgery with periumbilical minilaparotomy incision: a propensity score matching analysis

Purpose

Incisional hernia is one of the most common complications after abdominal surgery conducted through a midline incision. Considerable debate remains regarding the design, comorbidity, suture material, and method. We investigated the risk factors for incisional hernia after laparoscopic colorectal surgery in the presence of limited surgery-related factors.

Methods

A retrospective study was designed with 541 patients who underwent laparoscopic colorectal surgery performed by a single operator from January 2015 to December 2017. Due to open conversions, other abdominal operations, or follow-up loss, only 445 patients were included in the study. After propensity score matching, 266 patients were included. The study was based on diagnosis of incisional hernia on computed tomography at 6 and 12 months postoperatively.

Results

Of the 266 total patients, 133 underwent abdominal closure using PDS (Ethicon), while the remaining 133 underwent closure with Vicryl (Ethicon). Of these patients, nine were diagnosed with incisional hernia at the 12-month follow-up six (4.5%) in the Vicryl group and three (2.3%) in the PDS group (p = 0.309). The incidence of incisional hernia was significantly increased in females (odds ratio [OR], 15.233; 95% confidence interval [CI], 1.905–121.799; p = 0.010), in patients with body mass index (BMI) of >25 kg/m² (OR, 4.740; 95% CI, 1.424–15.546; p = 0.011), and in patients with liver disease (OR, 19.899; 95% CI, 1.614–245.376; p = 0.020).

Conclusion

BMI of >25 kg/m², female, and liver disease were significant risk factors for incisional hernia after elective laparoscopic colorectal surgery performed through a transumbilical minilaparotomy incision.

CIRRHOTIC PATIENTS WITH ACUTE KIDNEY INJURY (AKI) HAVE HIGHER MORTALITY AFTER ABDOMINAL HERNIA SURGERY

BACKGROUND

The incidence of abdominal hernia in cirrhotic patients is as higher as 20%; in cases of major ascites the incidence may increase up to 40%. One of the main and most serious complications in cirrhotic postoperative period (PO) is acute kidney injury (AKI).

AIM

To analyze the renal function of cirrhotic patients undergoing to hernia surgery and evaluate the factors related to AKI.

METHODS

Follow-up of 174 cirrhotic patients who underwent hernia surgery. Laboratory tests including the renal function were collected in the PO.AKI was defined based on the consensus of the ascite´s club. They were divided into two groups: with (AKI PO) and without AKI .

RESULTS

All 174 patients were enrolled and AKI occurred in 58 (34.9%). In the AKI PO group, 74.1% had emergency surgery, whereas in the group without AKI PO it was only 34.6%.In the group with AKI PO, 90.4% presented complications, whereas in the group without AKI PO they occurred only in 29.9%. Variables age, baseline MELD, baseline creatinine, creatinine in immediate postoperative (POI), AKI and the presence of ascites were statistically significant for survival.

CONCLUSIONS

There is association between AKI PO and emergency surgery and, also, between AKI PO and complications after surgery. The factors related to higher occurrence were initial MELD, basal Cr, Cr POI. The patients with postoperative AKI had a higher rate of complications and higher mortality.

Frailty Is a Risk Factor for Postoperative Mortality in Patients With Cirrhosis Undergoing Diverse Major Surgeries

With a rising burden of cirrhosis surgeries, understanding risk factors for postoperative mortality is more salient than ever. The role of baseline frailty has not been assessed in this context. We evaluated the association between patient frailty and postoperative risk among diverse patients with cirrhosis and determined if frailty improves prognostication of cirrhosis surgical risk scores. This was a retrospective cohort study of U.S. veterans with cirrhosis identified between 2008 and 2016 who underwent nontransplant major surgery. Frailty was ascertained using the Hospital Frailty Risk Score (HFRS). Cox regression analysis was used to investigate the impact of patient frailty on postoperative mortality. Logistic regression was used to identify incremental changes in discrimination for postoperative mortality when frailty was added to the risk prediction models, including the Model for End-Stage Liver Disease (MELD), MELD-sodium (MELD-Na), Child-Turcotte-Pugh (CTP), Mayo Risk Score (MRS), and Veterans Outcomes and Costs Associated With Liver Disease (VOCAL)-Penn. A total of 804 cirrhosis surgeries were identified. The majority of patients (48.5%) had high-risk frailty at baseline (HFRS >15). In adjusted Cox regression models, categories of increasing frailty scores were associated with poorer postoperative survival. For example, intermediate-risk frailty (HFRS 5-15) conferred a 1.77-fold increased hazard relative to low-risk frailty (HFRS, <5; 95% confidence interval [CI], 1.06-2.95; P = 0.03). High-risk frailty demonstrated a similarly increased hazard (hazard ratio, 1.74; 95% CI, 1.05-2.88; P = 0.03), suggesting a threshold effect of frailty on postoperative mortality. The incorporation of frailty improved discrimination of MELD, MELD-Na, and CTP for postoperative mortality, but did not do so for the MRS or VOCAL-Penn score. Patient frailty was an additional important predictor of cirrhosis surgical risk. The incorporation of preoperative frailty assessments may help to risk stratify patients, especially in settings where the MELD-Na and CTP are commonly applied.

Inguinal Hernias in Cirrhotic Patients: From Diagnosis to Treatment

Cirrhosis has a strong association with abdominal wall hernias, especially in the presence of concomitant ascites. Major predisposing factors for hernia formation in this particular group of patients include increased intra-abdominal pressure and decreased muscle mass due to poor nutrition. Management of these patients is highly challenging and requires an experienced multidisciplinary surgical and medical approach. The aim of our review is to clarify crucial diagnostic and management approaches. Crucial medical and technical issues on this topic are widely discussed with special focus on indication, timing, and type of surgical repair, with an additional reference to the actual role of laparoscopy.

Safety and effectiveness of inguinal hernia repair in patients with liver cirrhosis: a retrospective study and literature review

PURPOSE

Inguinal hernia is a common feature of decompensated liver cirrhosis and a frequent cause of life-threatening complications. The traditional treatment of inguinal hernia in patients with liver cirrhosis includes non-operative management; however, emerging data suggest elective surgical repair as a preferable approach. Therefore, we aimed to assess the outcomes of inguinal hernia repair in patients with liver cirrhosis and describe their clinical characteristics.

METHODS

In this retrospective study, we included a total of 28 consecutive patients with liver cirrhosis who underwent inguinal hernia repair between March 2000 and May 2019 at the First People's Hospital of Xiaoshan, Hangzhou, China. We also reviewed the literature on inguinal hernia repair in patients with liver cirrhosis.

RESULTS

Emergency surgery for complicated hernia was performed in 17.9% of the study patients. Two patients developed major complications including wound hematoma in 1, who required reoperation, and gastrointestinal tract hemorrhage in the other patient, who required blood transfusion. Further, minor complications developed in 6 patients, including wound seroma in 1 and scrotal swelling in 5. Emergency hernia repair was found to be associated with a higher complication rate than elective surgery in patients with liver cirrhosis.

CONCLUSION

Elective surgery for inguinal hernia repair in patients with liver cirrhosis appears to be successful and might be associated with a lower complication rate than emergency surgery. Inguinal hernia repair is recommended for patients with liver cirrhosis to prevent the development of life-threatening complications.