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Talwar AA, McGraw JR, Thrippleton S, Broach RB, Heniford BT, Fischer JP. Missing the Mark: Evaluating the Validity of the Ventral Hernia Screen in Detecting Recurrence. Am Surg 2024; 90:1211-1216. [PMID: 38199603 DOI: 10.1177/00031348241227185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
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.
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Affiliation(s)
- Ankoor A Talwar
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - J Reed McGraw
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Sheri Thrippleton
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Robyn B Broach
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - B Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - John P Fischer
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, USA
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2
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Kudsi OY, Kaoukabani G, Bou-Ayash N, Gokcal F. Clinical outcomes and costs of retromuscular and intraperitoneal onlay mesh techniques in robotic incisional hernia repair. Surg Endosc 2024; 38:2850-2856. [PMID: 38568440 DOI: 10.1007/s00464-024-10776-0] [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: 03/20/2023] [Accepted: 03/04/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND This study aims to compare clinical outcomes and financial cost of intraperitoneal onlay mesh (IPOM) versus retromuscular (RM) repairs in robotic incisional hernia repairs (rIHR). METHODS Patients who underwent either IPOM or RM elective rIHR from 2012 to 2022 were included. Demographics, operative details, postoperative outcomes, and hospital costs were directly compared. RESULTS Sixty-nine IPOM and 55 RM were included. Age and body mass index (BMI) did not differ between both groups (IPOM vs RM: 59.3 ± 11.2 years vs. 57.5 ± 14 years, p = 0.423; BMI 34.1 ± 6.3 vs. BMI 33.2 ± 6.9, p = 0.435, respectively). Comorbidities and hernia characteristics were comparable. Extensive lysis of adhesions (> 30 min) was required more often in IPOM (18 vs. 6 in RM, p = 0.034). Defect closure was achieved in 100% of RM vs. 81.2% in IPOM (p < 0.001). Median (interquartile range) postoperative pain score was higher in RM than in IPOM [5(3-7) vs. 4(3-5), respectively, p = 0.006]. Median length of stay (0 day) and same-day discharge rate did not differ between groups (p = 0.598, p = 0.669, respectively). Six (8.7%) patients in the IPOM group versus one (1.8%) patient in the RM group were readmitted to hospital within 30 days postoperatively (p = 0.099). Perioperative complications were higher in IPOM (p = 0.011; 34.8% vs. 14.5% in RM) with higher Comprehensive Complication Index® morbidity scores [0(0-12.2) vs 0(0-0) in RM, p = 0.008)], Clavien-Dindo grade-II complications (8 vs 0 in RM, p = 0.009), and surgical site events (17 vs. 5 in RM, p = 0.024). Within a follow-up period of 57(± 28) months, recurrence rates were similar between both groups. Hospital costs did not differ between groups [IPOM: $9978 (7031-12,926) vs. RM: $8961(6701-11,222), p = 0.300]. Although postoperative complication costs were higher in IPOM ($2436 vs RM: $161, p = 0.020), total costs were comparable [IPOM: $12,415(8700-16,130) vs. RM: $9123(6789-11,457), p = 0.080]. CONCLUSION Despite retromuscular repairs having lower postoperative complications than intraperitoneal onlay mesh repairs, both techniques offered encouraging results in robotic incisional hernia repair at a comparable total cost.
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Affiliation(s)
- Omar Yusef Kudsi
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
| | | | | | - Fahri Gokcal
- Good Samaritan Medical Center, Brockton, MA, USA
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3
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van den Berg R, den Hartog FPJ, Bali C, Matsagkas M, Bevis PM, Earnshaw JJ, Debus ES, Honig S, Berrevoet F, Detry O, Stabilini C, Muysoms F, Tanis PJ. Protocol for an independent patient data meta-analysis of prophylactic mesh placement for incisional hernia prevention after abdominal aortic aneurysm surgery: a collaborative European Hernia Society project (I-PREVENT-AAA). BMJ Open 2024; 14:e081046. [PMID: 38626979 PMCID: PMC11029178 DOI: 10.1136/bmjopen-2023-081046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 03/05/2024] [Indexed: 04/19/2024] Open
Abstract
INTRODUCTION Incisional hernia (IH) is a prevalent and potentially dangerous complication of abdominal surgery, especially in high-risk groups. Mesh reinforcement of the abdominal wall has been studied as a potential intervention to prevent IHs. Randomised controlled trials (RCTs) have demonstrated that prophylactic mesh reinforcement after abdominal surgery, in general, is effective and safe. In patients with abdominal aortic aneurysm (AAA), prophylactic mesh reinforcement after open repair has not yet been recommended in official guidelines, because of relatively small sample sizes in individual trials. Furthermore, the identification of subgroups that benefit most from prophylactic mesh placement requires larger patient numbers. Our primary aim is to evaluate the efficacy and effectiveness of the use of a prophylactic mesh after open AAA surgery to prevent IH by performing an individual patient data meta-analysis (IPDMA). Secondary aims include the evaluation of postoperative complications, pain and quality of life, and the identification of potential subgroups that benefit most from prophylactic mesh reinforcement. METHODS AND ANALYSIS We will conduct a systematic review to identify RCTs that study prophylactic mesh placement after open AAA surgery. Cochrane Central Register of Controlled Trials, MEDLINE Ovid, Embase, Web of Science Core Collection and Google Scholar will be searched from the date of inception onwards. RCTs must directly compare primary sutured closure with mesh closure in adult patients who undergo open AAA surgery. Lead authors of eligible studies will be asked to share individual participant data (IPD). The risk of bias (ROB) for each included study will be assessed using the Cochrane ROB tool. An IPDMA will be performed to evaluate the efficacy, with the IH rate as the primary outcome. Any signs of heterogeneity will be evaluated by Forest plots. Time-to-event analyses are performed using Cox regression analysis to evaluate risk factors. ETHICS AND DISSEMINATION No new data will be collected in this study. We will adhere to institutional, national and international regulations regarding the secure and confidential sharing of IPD, addressing ethics as indicated. We will disseminate findings via international conferences, open-source publications in peer-reviewed journals and summaries posted online. PROSPERO REGISTRATION NUMBER CRD42022347881.
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Affiliation(s)
- Rudolf van den Berg
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Medicine, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Floris P J den Hartog
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Christina Bali
- Department of Surgery, University Hospital of Ioannina, Ioannina, Greece
| | | | - Paul M Bevis
- Department of Vascular Surgery, North Bristol NHS Trust, Westbury on Trym, UK
| | - Jonothan J Earnshaw
- Department of Vascular Surgery, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
| | - Eike S Debus
- Department of Vascular Medicine, University Medical Center Hamburg-Eppendorf University Heart & Vascular Center, Eppendorf, Hamburg, Germany
| | - Susanne Honig
- Department of Vascular Surgery, Hospital Robert Schuman Kirchberg Hospital, Luxembourg City, Luxembourg
| | - Frederik Berrevoet
- Department of General and Hepatobiliary Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Olivier Detry
- Department of Abdominal Surgery and Transplantation, Division of Abdominal Wall Surgery, CHU Liege, University of Liege, Liege, Belgium
| | - Cesare Stabilini
- Department of Surgical Sciences, University of Genoa, Genoa, Italy
| | - Filip Muysoms
- Department of Surgery, AZ Maria Middelares Hospital, Ghent, Belgium
| | - Pieter J Tanis
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
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O'Neill SM, Fry BT, Weng W, Rubyan M, Howard RA, Ehlers AP, Englesbe MJ, Dimick JB, Telem DA. Use of statewide financial incentives to improve documentation of hernia and mesh characteristics in ventral hernia repair. Surg Endosc 2024; 38:414-418. [PMID: 37821560 DOI: 10.1007/s00464-023-10498-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 09/24/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Documentation of intraoperative details is critical for understanding and advancing hernia care, but is inconsistent in practice. Therefore, to improve data capture on a statewide level, we implemented a financial incentive targeting documentation of hernia defect size and mesh use. METHODS The Abdominal Hernia Care Pathway (AHCP), a voluntary pay for performance (P4P) initiative, was introduced in 2021 within the statewide Michigan Surgical Quality Collaborative (MSQC). This consisted of an organizational-level financial incentive for achieving 80% performance on eight specific process measures for ventral hernia surgery, including complete documentation of hernia defect size and location, as well as mesh characteristics and fixation technique. Comparisons were made between AHCP and non-AHCP sites in 2021. RESULTS Of 69 eligible sites, 47 participated in the AHCP in 2021. There were N = 5362 operations (4169 at AHCP sites; 1193 at non-AHCP sites). At AHCP sites, 69.8% of operations had complete hernia documentation, compared to 50.5% at non-AHCP sites (p < 0.0001). At AHCP sites, 91.4% of operations had complete mesh documentation, compared to 86.5% at non-AHCP sites (p < 0.0001). The site-level hernia documentation goal of 80% was reached by 14 of 47 sites (range 14-100%). The mesh documentation goal was reached by 41 of 47 sites (range 4-100%). CONCLUSIONS Addition of an organizational-level financial incentive produced marked gains in documentation of intra-operative details across a statewide surgical collaborative. The relatively large effect size-19.3% for hernia-is remarkable among P4P initiatives. This result may have been facilitated by surgeons' direct role in documenting hernia size and mesh use. These improvements in data capture will foster understanding of current hernia practices on a large scale and may serve as a model for improvement in collaboratives nationally.
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Affiliation(s)
- Sean M O'Neill
- Department of Surgery, Michigan Medicine, University of Michigan, Taubman Center, TC 2924B, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.
| | - Brian T Fry
- Department of Surgery, Michigan Medicine, University of Michigan, Taubman Center, TC 2924B, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Wenjing Weng
- Michigan Surgical Quality Collaborative, Ann Arbor, MI, USA
| | - Michael Rubyan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
- University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Ryan A Howard
- Department of Surgery, Michigan Medicine, University of Michigan, Taubman Center, TC 2924B, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Anne P Ehlers
- Department of Surgery, Michigan Medicine, University of Michigan, Taubman Center, TC 2924B, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Michael J Englesbe
- Department of Surgery, Michigan Medicine, University of Michigan, Taubman Center, TC 2924B, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Justin B Dimick
- Department of Surgery, Michigan Medicine, University of Michigan, Taubman Center, TC 2924B, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Dana A Telem
- Department of Surgery, Michigan Medicine, University of Michigan, Taubman Center, TC 2924B, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
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Cuevas N, Beeson ST, Faulkner JD, Edgerton C, Hope WW. Teaching Small Bite Fascial Closure Technique: Improved Accuracy and Consistency Through Simulation. Am Surg 2023:31348231160852. [PMID: 36935586 DOI: 10.1177/00031348231160852] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
Despite evidence that small bite closure is beneficial, it is not well documented how accurately and consistently surgeons employ this technique. We created a felt model to simulate fascial closure and educate residents regarding small bites. This study aims to gauge accuracy and consistency of bite size in fascial closure and assess if utilizing a templated model could improve technique. Two 10 cm incisions were made in different pieces of felt. Residents were instructed to suture the incisions to simulate fascial closure by running the incisions closed with 1 cm and 5 mm bites respectively. The process was repeated with templated pieces of felt marking 1 and 0.5 cm to guide bite size. Residents were timed for each closure. The travel and distance from the midline for each bite was measured and analysis performed. 14 residents participated. Paired T-test compared means and standard deviations of bite size. Taking 5 mm bites took more time. Standard deviation of travel and right sided distance from midline were significantly smaller when a template was utilized. Standard deviation of travel as well as right sided distance was also improved when instructed to take 5 mm bites. This study demonstrates that a small bite technique results more closure and that when residents are instructed to take smaller bites. The adage, "aim small, miss small," holds true in fascial closure and may be one reason why small bites improve hernia rates. This study also suggests that the use of a template improves accuracy and consistency of closure regardless of bite size intention.
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Affiliation(s)
| | - Seth T Beeson
- Department of Surgery, 24520Novant Health New Hanover Regional Medical Center, Wilmington, NC, USA
| | | | - Colston Edgerton
- Department of Surgery, 24520Novant Health New Hanover Regional Medical Center, Wilmington, NC, USA
| | - William W Hope
- 24520New Hanover Regional Medical Center, Wilmington, NC, USA
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6
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Wegdam JA, de Jong DLC, Gielen MJCAM, Nienhuijs SW, Füsers AFM, Bouvy ND, de Vries Reilingh TS. Impact of a multidisciplinary team discussion on planned ICU admissions after complex abdominal wall reconstruction. Hernia 2023; 27:623-633. [PMID: 36890358 PMCID: PMC9994771 DOI: 10.1007/s10029-023-02762-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 02/18/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND Patients often need admission at an Intensive Care Unit (ICU), immediately after complex abdominal wall reconstruction (CAWR). Lack of ICU resources requires adequate patient selection for a planned postoperative ICU admission. Risk stratification tools like Fischer score and Hernia Patient Wound (HPW) classification may improve patient selection. This study evaluates the decision-making process in a multidisciplinary team (MDT) on justified ICU admissions for patients after CAWR. METHODS A pre-Covid-19 pandemic cohort of patients, discussed in a MDT and subsequently underwent CAWR between 2016 and 2019, was analyzed. A justified ICU admission was defined by any intervention within the first 24 h postoperatively, considered not suitable for a nursing ward. The Fischer score predicts postoperative respiratory failure by eight parameters and a high score (> 2) warrants ICU admission. The HPW classification ranks complexity of hernia (size), patient (comorbidities) and wound (infected surgical field) in four stages, with increasing risk for postoperative complications. Stages II-IV point to ICU admission. Accuracy of the MDT decision and (modifications of) risk-stratification tools on justified ICU admissions were analyzed by backward stepwise multivariate logistic regression analysis. RESULTS Pre-operatively, the MDT decided a planned ICU admission in 38% of all 232 CAWR patients. Intra-operative events changed the MDT decision in 15% of all CAWR patients. MDT overestimated ICU need in 45% of ICU planned patients and underestimated in 10% of nursing ward planned patients. Ultimately, 42% went to the ICU and 27% of all 232 CAWR patients were justified ICU patients. MDT accuracy was higher than the Fischer score, HPW classification or any modification of these risk stratification tools. CONCLUSION A MDT's decision for a planned ICU admission after complex abdominal wall reconstruction was more accurate than any of the other risk-stratifying tools. Fifteen percent of the patients experienced unexpected operative events that changed the MDT decision. This study demonstrated the added value of a MDT in the care pathway of patients with complex abdominal wall hernias.
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Affiliation(s)
- J A Wegdam
- Department of Surgery, Elkerliek Hospital, Helmond, The Netherlands.
| | - D L C de Jong
- Department of Surgery, Elkerliek Hospital, Helmond, The Netherlands
| | - M J C A M Gielen
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - S W Nienhuijs
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - A F M Füsers
- Department of Intensive Care, Elkerliek Hospital, Helmond, The Netherlands
| | - N D Bouvy
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
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Durbin B, Spencer A, Briese A, Edgerton C, Hope WW. If Evidence is in Favor of Incisional Hernia Prevention With Mesh, why is it not Implemented? JOURNAL OF ABDOMINAL WALL SURGERY : JAWS 2023; 2:11000. [PMID: 38312399 PMCID: PMC10831655 DOI: 10.3389/jaws.2023.11000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/16/2023] [Indexed: 02/06/2024]
Affiliation(s)
| | | | | | | | - William W. Hope
- Department of Surgery, Novant/New Hanover Medical Center, Wilmington, NC, United States
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8
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Samartsev VA, Parshakov AA, Gavrilov VA, Zhilina IP. SIMULTANEOUS SURGICAL INTERVENTION IN PATIENT WITH INCISIONAL HERNIA W3 AND HIGH OPERATIONAL RISK. A CLINICAL CASE. SURGICAL PRACTICE 2022. [DOI: 10.38181/2223-2427-2022-3-70-77] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The paper covers the clinical case of successful simultaneous intervention in a patient with acute calculous cholecystitis, incisional hernia M2-5W3, Obese (Class III) (BMI 42 kg/m2), IV-degree ptosis of the anterior abdominal, pulmonary embolism in the anamnesis with a cava filter installed and high operational risk. After preoperative preparation, a simultaneous surgical intervention (laparoscopic cholecystectomy, transverse abdominoplasty, separation hernioplasty) was performed. The patient was discharged from hospital on the 10th day of the postoperative period. Long-term results were evaluated after 2 months. A cardiovascular, thromboembolic and wound complications was not recorded.
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Affiliation(s)
- V. A. Samartsev
- Perm State Medical University named after academician E. A. Wagner; City Clinical Hospital No. 4
| | - A. A. Parshakov
- Perm State Medical University named after academician E. A. Wagner; City Clinical Hospital No. 4
| | - V. A. Gavrilov
- Perm State Medical University named after academician E. A. Wagner; City Clinical Hospital No. 4
| | - I. P. Zhilina
- Perm State Medical University named after academician E. A. Wagner
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Rios-Diaz AJ, Morris MP, Christopher AN, Patel V, Broach RB, Heniford BT, Hsu JY, Fischer JP. National epidemiologic trends (2008-2018) in the United States for the incidence and expenditures associated with incisional hernia in relation to abdominal surgery. Hernia 2022; 26:1355-1368. [PMID: 36006563 DOI: 10.1007/s10029-022-02644-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/04/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE It is unknown whether the trend of rising incisional hernia (IH) repair (IHR) incidence and costs until 2011 currently persists. We aimed to evaluate how the IHR procedure incidence, cost and patient risk-profile have changed over the last decade relative to all abdominal surgeries (AS). METHODS Repeated cross-sectional analysis of 38,512,737 patients undergoing inpatient 4AS including IHR within the 2008-2018 National Inpatient Sample. Yearly incidence (procedures/1,000,000 people [PMP]), hospital costs, surgical and patient characteristics were compared between IHR and AS using generalized linear and multinomial regression. RESULTS Between 2008-2018, 3.1% of AS were IHR (1,200,568/38,512,737). There was a steeper decrease in the incidence of AS (356.5 PMP/year) compared to IHR procedures (12.0 PMP/year) which resulted in the IHR burden relative to AS (2008-2018: 12,576.3 to 9,113.4 PMP; trend difference P < 0.01). National costs averaged $47.9 and 1.7 billion/year for AS and IHR, respectively. From 2008-2018, procedure costs increased significantly for AS (68.2%) and IHR (74.6%; trends P < 0.01). Open IHR downtrended (42.2%), whereas laparoscopic (511.1%) and robotic (19,301%) uptrended significantly (trends P < 0.01). For both AS and IHR, the proportion of older (65-85y), Black and Hispanic, publicly-insured, and low-income patients, with higher comorbidity burden, undergoing elective procedures at small- and medium-sized hospitals uptrended significantly (all P < 0.01). CONCLUSION IH persists as a healthcare burden as demonstrated by the increased proportion of IHR relative to all AS, disproportionate presence of high-risk patients that undergo these procedures, and increased costs. Targeted efforts for IH prevention have the potential of decreasing $17 M/year in costs for every 1% reduction.
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Affiliation(s)
- A J Rios-Diaz
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 51 North 39th Street, Wright Saunders Building, Philadelphia, PA, 19104, USA
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - M P Morris
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 51 North 39th Street, Wright Saunders Building, Philadelphia, PA, 19104, USA
| | - A N Christopher
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 51 North 39th Street, Wright Saunders Building, Philadelphia, PA, 19104, USA
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - V Patel
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 51 North 39th Street, Wright Saunders Building, Philadelphia, PA, 19104, USA
| | - R B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 51 North 39th Street, Wright Saunders Building, Philadelphia, PA, 19104, USA
| | - B T Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - J Y Hsu
- Center for Clinical Epidemiology and Biostatistics (CCEB), University of Pennsylvania, Philadelphia, PA, USA
| | - J P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 51 North 39th Street, Wright Saunders Building, Philadelphia, PA, 19104, USA.
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10
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Three-Year Clinical Outcomes and Quality of Life after Retromuscular Resorbable Mesh Repair Using Fibrin Glue. Plast Reconstr Surg 2022; 149:1440-1447. [PMID: 35426865 DOI: 10.1097/prs.0000000000009125] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
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11
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McAuliffe PB, Hsu JY, Broach RB, Borovskiy Y, Christopher AN, Morris MP, Fischer JP. Systematic variable reduction for simplification of incisional hernia risk prediction instruments. Am J Surg 2022; 224:576-583. [DOI: 10.1016/j.amjsurg.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/14/2022] [Accepted: 03/01/2022] [Indexed: 11/29/2022]
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12
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Beeson S, Faulkner J, Acquista E, Hope W. Decreasing Incisional Hernia by Teaching 4:1 Suture to Wound Length Ratio Early in Surgical Education. JOURNAL OF SURGICAL EDUCATION 2021; 78:e169-e173. [PMID: 34642098 DOI: 10.1016/j.jsurg.2021.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/20/2021] [Accepted: 09/16/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Incisional hernia formation has become a major burden for our healthcare system. One factor that has been shown to reduce incisional hernia rates that can be impacted on by the surgeon is the ability to achieve a 4:1 suture to wound length ratio. The purpose of this study is to evaluate whether a focused educational program for surgical residents can help improve laparotomy closures and be successful in achieving 4:1 suture to wound length ratios. DESIGN Following Institutional Review Board approval, consecutive abdominal wall closures were reviewed from December 2013 to July 2016. S:W length ratios were calculated in all cases and after 100 cases a formal audit of success and risk factors for not achieving a 4:1 ratio was performed followed by a formal resident education on laparotomy closure. The ability to achieve a 4:1 ratio for the first 100 cases following resident education was then compared to the 100 patients preceding the education with a p-value of <0.05 considered significant. RESULTS Two hundred patients underwent midline laparotomy with S:W length ratio calculated. In the first 100 patients, 76% of patients received a 4:1 S:W closure. Following resident education, this improved to 90% in the second 100 patients (p = 0.0083). Among patients where 2 residents performed the abdominal closure, 50% got an adequate 4:1 closure. This improved to 92% for the second 100 patients (p = 0.016). CONCLUSION A 4:1 S:W length ratio is a simple technique that has been proven to decrease incisional hernia. It requires no additional cost and can easily be implemented into practice. The act of formal resident education and measuring suture tails to calculate a S:W ratio on each case holds surgeons accountable and improves success rate of achieving a 4:1 ratio.
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Affiliation(s)
- Seth Beeson
- Department of Surgery, New Hanover Regional Medical Center, Wilmington, North Carolina
| | - Justin Faulkner
- Department of Surgery, New Hanover Regional Medical Center, Wilmington, North Carolina
| | - Elizabeth Acquista
- Department of Surgery, New Hanover Regional Medical Center, Wilmington, North Carolina
| | - William Hope
- Department of Surgery, New Hanover Regional Medical Center, Wilmington, North Carolina.
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Abstract
OBJECTIVE This systematic review aims to assess what is known about convalescence following abdominal surgery. Through a review of the basic science and clinical literature, we explored the effect of physical activity on the healing fascia and the optimal timing for postoperative activity. BACKGROUND Abdominal surgery confers a 30% risk of incisional hernia development. To mitigate this, surgeons often impose postoperative activity restrictions. However, it is unclear whether this is effective or potentially harmful in preventing hernias. METHODS We conducted 2 separate systematic reviews using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The first assessed available basic science literature on fascial healing. The second assessed available clinical literature on activity after abdominal surgery. RESULTS Seven articles met inclusion criteria for the basic science review and 22 for the clinical studies review. The basic science data demonstrated variability in maximal tensile strength and time for fascial healing, in part due to differences in layer of abdominal wall measured. Some animal studies indicated a positive effect of physical activity on the healing wound. Most clinical studies were qualitative, with only 3 randomized controlled trials on this topic. Variability was reported on clinician recommendations, time to return to activity, and factors that influence return to activity. Interventions designed to shorten convalescence demonstrated improvements only in patient-reported symptoms. None reported an association between activity and complications, such as incisional hernia. CONCLUSIONS This systematic review identified gaps in our understanding of what is best for patients recovering from abdominal surgery. Randomized controlled trials are crucial in safely optimizing the recovery period.
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Rios-Diaz AJ, Cunning J, Hsu JY, Elfanagely O, Marks JA, Grenda TR, Reilly PM, Broach RB, Fischer JP. Incidence, Burden on the Health Care System, and Factors Associated With Incisional Hernia After Trauma Laparotomy. JAMA Surg 2021; 156:e213104. [PMID: 34259810 DOI: 10.1001/jamasurg.2021.3104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Importance The evidence provided supports routine and systematic capture of long-term outcomes after trauma, lengthening the follow-up for patients at risk for incisional hernia (IH) after trauma laparotomy (TL), counseling on the risk of IH during the postdischarge period, and consideration of preventive strategies before future abdominal operations to lessen IH prevalence as well as the patient and health care burden. Objective To determine burden of and factors associated with IH formation following TL at a population-based level across health care settings. Design, Setting, and Participants This population-based cohort study included adult patients who were admitted with traumatic injuries and underwent laparotomy with follow-up of 2 or more years. The study used 18 statewide databases containing data collected from January 2006 through December 2016 and corresponding to 6 states in diverse regions of the US. Longitudinal outcomes were identified within the Statewide Inpatient, Ambulatory, and Emergency Department Databases. Patients admitted with International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for traumatic injuries with 1 or more concurrent open abdominal operations were included. Data analysis was conducted from March 2020 through June 2020. Main Outcomes and Measures The primary outcome was IH after TL. Risk-adjusted Cox regression allowed identification of patient-level, operative, and postoperative factors associated with IH. Results Of 35 666 patients undergoing TL, 3127 (8.8%) developed IH (median [interquartile range] follow-up, 5.6 [3.4-8.6] years). Patients had a median age of 49 (interquartile range, 31-67) years, and most were male (21 014 [58.9%]), White (21 584 [60.5%]), and admitted for nonpenetrating trauma (28 909 [81.1%]). The 10-year IH rate and annual incidence were 11.1% (95% CI, 10.7%-11.5%) and 15.6 (95% CI, 15.1-16.2) cases per 1000 people, respectively. Within risk-adjusted analyses, reoperation (adjusted hazard ratio [aHR], 1.28 [95% CI, 1.2-1.37]) and subsequent abdominal surgeries (aHR, 1.71 [95% CI, 1.56-1.88]), as well as obesity (aHR, 1.88 [95% CI, 1.69-2.10]), intestinal procedures (aHR, 1.47 [95% CI, 1.36-1.59]), and public insurance (aHRs: Medicare, 1.38 [95% CI, 1.20-1.57]; Medicaid, 1.35 [95% CI, 1.21-1.51]) were among the variables most strongly associated with IH. Every additional reoperation at the index admission and subsequently resulted in a 28% (95% CI, 20%-37%) and 71% (95% CI, 56%-88%) increased risk for IH, respectively. Repair of IH represented an additional $36.1 million in aggregate costs (39.9%) relative to all index TL admissions. Conclusions and Relevance Incisional hernia after TL mirrors the epidemiology and patient profile characteristics seen in the elective setting. We identified patient-level, perioperative, and novel postoperative factors associated with IH, with obesity, intestinal procedures, and repeated disruption of the abdominal wall among the factors most strongly associated with this outcome. These data support preemptive strategies at the time of reoperation to lessen IH incidence. Longer follow-up may be considered after TL for patients at high risk for IH.
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Affiliation(s)
- Arturo J Rios-Diaz
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia.,Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jessica Cunning
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Jesse Y Hsu
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Pennsylvania
| | - Omar Elfanagely
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Joshua A Marks
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Tyler R Grenda
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Patrick M Reilly
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
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15
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What Is the Proper Technique for Primary Laparotomy Closure? Adv Surg 2021; 55:197-214. [PMID: 34389092 DOI: 10.1016/j.yasu.2021.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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16
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National health disparities in incisional hernia repair outcomes: An analysis of the Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS) 2012-2014. Surgery 2021; 169:1393-1399. [PMID: 33422347 DOI: 10.1016/j.surg.2020.11.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/12/2020] [Accepted: 11/18/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Incisional hernias represent an acquired defect from failed healing of an abdominal facial incision and are therefore distinct from primary hernias. While literature regarding incisional hernia incidence, risk factors, and treatment are abundant, no study has examined national health disparities specific to incisional hernia repair. The objective of this study was to analyze national health disparities unique to surgical incisional hernia repair procedures. METHODS Patient data queried from the Healthcare Cost and Utilization Project National Inpatient Sample from 2012 to 2014 using International Classification of Diseases 9th revision procedure codes for incisional hernia repair were used to generate univariate and multivariate models including demographics, socioeconomic factors, admission status, and hospital characteristics. Primary outcomes were nonelective admission status, in-hospital mortality, surgical complications, and extended duration of stay. RESULTS We estimated that 89,258 incisional hernia repair procedures occurred annually from 2012 to 2014, incurring $6.3 billion in hospital charges. By multivariate analysis, multiple risk factors contribute to significantly increased odds of nonelective repair. These include age over 65, female sex, non-White race, nonprivate insurance, obesity, and increased Charlson comorbidity index. Nonelective incisional hernia repair was strongly correlated with worse outcomes including in-hospital mortality (odds ratio [95% confidence interval] 3.01 [2.51, 3.61]), postoperative complications (odds ratio 1.2 [1.14, 1.25]), and extended duration of stay (odds ratio 2.96 [2.81, 3.12]). After controlling for admission status, other disparities persisted including extended duration of stay for Black individuals (odds ratio 1.21 (1.12, 1.31]). CONCLUSION Providers should be aware of these significant health disparities in incisional hernia repair status and outcomes especially for elderly, non-White, nonprivate insurance, and obese/comorbid patients. Management strategies that increase access to elective repair and that prevent incisional hernia should be expanded to address these disparities.
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Loor MM, Dhanani NH, Trautner BW, Hughes TG, Schwartz J, Wei Q, Liang MK. Current surgeon practices for postoperative activity restrictions after abdominal surgery vary widely: A survey from the communities on the ACS website. Surgery 2020; 168:778-784. [DOI: 10.1016/j.surg.2020.05.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/06/2020] [Indexed: 10/23/2022]
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18
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Mesh position for hernia prophylaxis after midline laparotomy: A systematic review and network meta-analysis of randomized clinical trials. Int J Surg 2020; 83:144-151. [DOI: 10.1016/j.ijsu.2020.08.059] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/23/2020] [Accepted: 08/26/2020] [Indexed: 12/11/2022]
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19
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Köckerling F, Hoffmann H, Mayer F, Zarras K, Reinpold W, Fortelny R, Weyhe D, Lammers B, Adolf D, Schug-Pass C. What are the trends in incisional hernia repair? Real-world data over 10 years from the Herniamed registry. Hernia 2020; 25:255-265. [PMID: 33074396 DOI: 10.1007/s10029-020-02319-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 10/07/2020] [Indexed: 12/22/2022]
Abstract
INTRODUCTION There is an increasingly controversial debate about the best possible incisional hernia repair technique. Despite the good outcomes of laparoscopic IPOM, concerns about the intraperitoneal mesh placement and its potential intraabdominal complications have risen. Against that background, this paper now analyzes changes and trends in incisional hernia repair techniques in the recent decade. METHODS Between 2010 and 2019 a total of 61,627 patients with primary elective incisional hernia repair were enrolled in the Herniamed Registry. The outcome results were assigned to the year of repair and summarized as curves to visualize trends. The explorative Fisher's exact test was used for statistical calculation of significant differences. Since the number of cases entered into the Herniamed Registry for the years 2010-2012 was still relatively small, the years 2013 and 2019 were compared for statistical analysis. RESULTS In the analyzed time period, the proportion of incisional hernias repaired in open suture technique remained unchanged at about 10%. The proportion of laparoscopic IPOM repairs decreased significantly from 33.8% in 2013 to 21.0% (p < 0.001) in 2019. Conversely, the proportion of open sublay repairs increased significantly from 32.1% in 2013 to 41.4% (p < 0.001) in 2019. Starting in 2015, there has also been the introduction and increasing use (4.5% in 2013 vs. 10.0% in 2019; p < 0.001) of new minimally-invasive techniques with placement of a mesh into the sublay/retromuscular/preperitoneal abdominal wall layer (E/MILOS, eTEP, preperitoneal mesh technique). CONCLUSION Analysis of data from the Herniamed Registry shows a significant trend to the disadvantage of the laparoscopic IPOM and to the advantage of the open sublay operation and the new minimally-invasive techniques (E/MILOS, eTEP, preperitoneal mesh technique). Despite all the recommendations in the guidelines, 10% of incisional hernias continue to be treated by means of a suture technique.
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Affiliation(s)
- F Köckerling
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Neue Bergstrasse 6, 13585, Berlin, Germany.
| | - H Hoffmann
- Center for Hernia Surgery and Proctology, ZweiChirurgen GmbH, St. Johanns-Vorstadt 44, 4056, Basel, Switzerland.,University of Basel, Petersplatz 1, 4001, Basel, Switzerland
| | - F Mayer
- Department of Surgery, Paracelsus Medical University Salzburg, University Hospital of Salzburg, Müllner Hauptstrasse 48, 5020, Salzburg, Austria
| | - K Zarras
- Department of Visceral, Minimally Invasive and Oncologic Surgery, Academic Teaching Hospital of University of Düsseldorf, Marien Hospital, Rochusstraße 2, 40479, Düsseldorf, Germany
| | - W Reinpold
- Department of Surgery, Wilhelmsburger Hospital Groß Sand, Academic Teaching Hospital of University Hamburg, Groß Sand 3, 21107, Hamburg, Germany
| | - R Fortelny
- Department of General Surgery, Wilhelminen Hospital, Sigmund Freud University Vienna, Medical Faculty, Freudplatz 3, 1020, Vienna, Austria
| | - D Weyhe
- Department of General and Visceral Surgery, Pius Hospital, University Hospital of Visceral Surgery, Georgstraße 12, 26121, Oldenburg, Germany
| | - B Lammers
- Department of Surgery I, Section Coloproctology and Hernia Surgery, Lukas Hospital, Preussenstr. 84, 41464, Neuss, Germany
| | - D Adolf
- StatConsult GmbH, Halberstädter Strasse 40 a, 39112, Magdeburg, Germany
| | - C Schug-Pass
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Neue Bergstrasse 6, 13585, Berlin, Germany
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Matveev NL, Belousov AM, Bochkar VA, Makarov SA. [Minimally invasive ventral hernia repair: apply or save?]. Khirurgiia (Mosk) 2020:75-81. [PMID: 32869619 DOI: 10.17116/hirurgia202008175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Treatment of patients with ventral hernias remains one of the most pressing problems of abdominal surgery. Surgeons are trying to find a «gold standard» for the treatment of this pathology. Great hopes are placed on minimally invasive techniques, however, due to their high cost, they do not yet find mass distribution in everyday practice. In our opinion, this is short-sighted. We tried to analyze the feasibility of using minimally invasive techniques in the treatment of patients with ventral hernias of various locations, from the position of clinical and economic efficiency.
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Affiliation(s)
- N L Matveev
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A M Belousov
- Moscow Clinical Scientific Center, Moscow, Russia
| | - V A Bochkar
- Moscow Clinical Scientific Center, Moscow, Russia
| | - S A Makarov
- City Center for Innovative Medical Technologies of St. George City Hospital, St. Petersburg, Russia
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21
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Mulloy CD, Hoffman RD, Danos DM, Lau FH. Health Disparities in Incisional Hernia Presentation : An Analysis of HCUP-NIS Years 2012-2014. Am Surg 2020; 86:799-802. [PMID: 32683919 DOI: 10.1177/0003134820933574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Incisional hernias (IH) are iatrogenically created in 400 000 new patients annually. Without repair, IH-associated complications can result in major illness and death. The health disparities literature suggests that under-represented patients present more frequently with surgical emergencies. The health disparities associated with IH remain relatively unstudied. METHODS Inpatient admission data were obtained from the Healthcare Cost and Utilization Project National Inpatient Sample for 2012-2014. Patients with IH International Classification of Diseases ninth revision were included. Analyses were completed using survey specific procedures (SAS v.9.4). Type of admission within groups was compared via Rao-Scott chi-square tests. The probability of an elective admission was modeled via SurveyLogistic Procedure. RESULTS Of 39 296 cases, 38.5% IH admissions were urgent or emergent (nonelective). The proportion of nonelective admission was statistically higher (P < .0001) in patients >65 (40.9%) and females (40.3%). Among insurance types, self-paying patients had the highest proportion of nonelective admissions (64.3%). Racial disparities remained significant after adjusting for age, sex, and insurance. Compared with white patients, the odds of an admission being nonelective were significantly higher for black (odds ratio [OR] [95% CI]: 1.65 [1.53-1.77]], Hispanic (OR [95% CI]: 1.39 [1.28-1.51]), and other (OR [95% CI]: 1.2 [1.06-1.37]) patients. DISCUSSION These data show that multiple at-risk patient populations are significantly more likely to require urgent admission for IH-related complications. These include older, female, non-white, and uninsured patients. Systematic efforts to ameliorate these disparities should be developed.
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Affiliation(s)
- Clairissa D Mulloy
- 12258Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Ryan D Hoffman
- 12258Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Denise M Danos
- 12258Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Frank H Lau
- 12258Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA, USA
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One-Year Health Care Utilization and Recurrence After Incisional Hernia Repair in the United States: A Population-Based Study Using the Nationwide Readmission Database. J Surg Res 2020; 255:267-276. [PMID: 32570130 DOI: 10.1016/j.jss.2020.03.070] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/15/2020] [Accepted: 03/27/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Most data on health care utilization after incisional hernia (IH) repair are limited to 30-days and are not nationally representative. We sought to describe nationwide 1-year readmission burden after IH repair (IHR). METHODS Patients undergoing elective IHR discharged alive were identified using the 2010-2014 Nationwide Readmission Database. Transfers and incomplete follow-up were excluded. Descriptive statistics were used to describe rates of 1-year readmission, IH recurrence, and bowel obstruction. Cox regression allowed identification of factors associated with 1-year readmissions. Generalized linear models were used to estimate predicted mean difference in cumulative costs/year, which allowed estimation of IHR readmission costs/year nationwide. RESULTS Of 15,935 identified patients, 19.35% were readmitted within 1 y. Patients who were readmitted differed by insurance, Charlson index, illness severity, smoking status, disposition, and surgical approach compared with those who were not (P < 0.05). Of readmitted patients, 39.3% returned within 30 d; 50.9% and 25.6% were due to any and infectious complications, respectively; 25.6% presented to a different hospital; 35.4% required reoperation; 5.4% experienced bowel obstruction; and 5% had IHR revision. Factors associated with readmissions included Medicare (hazard ratio [HR] 1.46 [95% confidence interval 1.19-1.8]; P < 0.01) or Medicaid (HR 1.42 [1.12-1.8], P < 0.01); chronic pulmonary disease (1.38 [1.17-1.64], P < 0.01), and anemia (1.36, [1.05-1.75], P = 0.02). Readmitted patients had higher 1-year cumulative costs (predicted mean difference $12,190 [95% CI: 10,941-13,438]; P < 0.01). Nationwide cost related to readmissions totaled $90,196,248/y. CONCLUSIONS One-year readmissions after IHR are prevalent and most commonly due to postoperative complications, especially infections. One-third of readmitted patients require a subsequent operation, and 5% experience IH recurrence, intensifying the burden to patients and on the health care system.
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Goldwag JL, Wilson LR, Ivatury SJ, Pauli EM, Tsapakos MJ, Wilson MZ. Stoma closure and reinforcement (SCAR): A study protocol for a pilot trial. Contemp Clin Trials Commun 2020; 19:100582. [PMID: 32577580 PMCID: PMC7300121 DOI: 10.1016/j.conctc.2020.100582] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 05/21/2020] [Accepted: 06/07/2020] [Indexed: 12/21/2022] Open
Abstract
A quality metric for centers performing rectal cancer surgery is a high percentage of sphincter sparing procedures. These procedures often involve temporary bowel diversion to minimize the complications of an anastomotic leak. The most common strategy is a diverting loop ileostomy which is then closed after completion of adjuvant therapy or the patient recovers from surgery. Loop ileostomy is not without complications and the closure is complicated by a one in three chance of incisional hernia development. Strategies to prevent this problem have been designed using a variety of techniques with and without mesh placement. This proposed pilot study will test the safety and efficacy of a novel stoma closure technique involving permanent mesh in the retro rectus position during ileostomy closure. The study will prospectively follow 20 patients undergoing ileostomy closure using this technique and evaluate for safety of the procedure, quality of life, and feasibility for a larger randomized controlled trial. Patients will be followed post procedurally and evaluated for 30-day complications, as well as followed up with routine cancer surveillance computed tomography every 6 months in which the presence of stoma site incisional hernias will be evaluated. The results of this pilot study will inform the design of a multiple center, blinded randomized controlled trial to evaluate the utility of permanent mesh placement to decrease the incidence of prior stoma site incisional hernias.
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Affiliation(s)
- Jenaya L Goldwag
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Lauren R Wilson
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Srinivas J Ivatury
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Eric M Pauli
- Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Michael J Tsapakos
- Department of Radiology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Matthew Z Wilson
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
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Levy AS, Bernstein JL, Premaratne ID, Rohde CH, Otterburn DM, Morrison KA, Lieberman M, Pomp A, Spector JA. Poly-4-hydroxybutyrate (Phasix™) mesh onlay in complex abdominal wall repair. Surg Endosc 2020; 35:2049-2058. [PMID: 32385706 DOI: 10.1007/s00464-020-07601-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/24/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Poly-4-hydroxybutyric acid (P4HB, Phasix™) is a biosynthetic polymer that degrades by hydrolysis that can be woven into a mesh for use in soft tissue reinforcement. Herein, we describe our initial experience performing complex abdominal wall repair (CAWR) utilizing component separation and P4HB mesh as onlay reinforcement. METHODS All patients undergoing CAWR between June 2014 and May 2017 were followed prospectively for postoperative outcomes. Only those patients who underwent components separation with primary repair of the fascial edges followed by onlay of P4HB mesh were included in this study. RESULTS 105 patients (52 male, 53 female; mean age 59.2 years, range 22-84) met inclusion criteria. Mean BMI was 29.1 (range 16-48); 52% patients had prior attempted hernia repair, most with multiple medical comorbidities (71% of patients with ASA 3 or greater). 30% of cases were not clean at the time of repair (CDC class 2 or greater). Median follow-up was 36 months (range 9-63). Eighteen patients (17%) developed a hernia recurrence ranging from 2 to 36 months postoperatively. Five (5%) patients developed a localized superficial infection treated with antibiotics, three (2.8%) required re-operation for non-healing wounds, and six (6%) patients developed seroma. CONCLUSIONS These data demonstrate a relatively low rate of hernia recurrence, seroma, and other common complications of CAWR in a highly morbid patient population. Importantly, the rate of mesh infection was low and no patients required complete mesh removal, even when placed into a contaminated or infected surgical field.
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Affiliation(s)
- Adam S Levy
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Jaime L Bernstein
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Ishani D Premaratne
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Christine H Rohde
- Division of Plastic and Reconstructive Surgery, Columbia University Medical Center, New York, NY, USA
| | - David M Otterburn
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Kerry A Morrison
- Hansjorg Wyss Department of Plastic Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Michael Lieberman
- Division of General Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Alfons Pomp
- Division of General Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Jason A Spector
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, NY, USA.
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Wilson M, Goldwag J, Wilson L, Ivatury S, Tsapakos M. The prevalence of fascial defects at prior stoma sites in patients with colorectal cancer. INTERNATIONAL JOURNAL OF ABDOMINAL WALL AND HERNIA SURGERY 2020. [DOI: 10.4103/ijawhs.ijawhs_56_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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When the Mesh Goes Away: An Analysis of Poly-4-Hydroxybutyrate Mesh for Complex Hernia Repair. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2576. [PMID: 31942324 PMCID: PMC6908335 DOI: 10.1097/gox.0000000000002576] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 10/18/2019] [Indexed: 12/16/2022]
Abstract
Mesh reinforcement is a cornerstone of modern ventral hernia repair (VHR); yet, complications with synthetic mesh and cost of biologic have created a need for alternative options. Biosynthetic mesh is a resorbable scaffold that theoretically leverages the benefits and minimizes deficiencies of existing mesh types. This study evaluates 2-year outcomes following poly-4-hydroxybutyrate (P4HB) mesh reinforcement for complex VHR. Methods A retrospective review of all consecutive VHR with P4HB (n = 70) was conducted from 2015 to 2018 by a single surgeon. Clinical outcomes, quality of life (QoL; and cost were assessed. Results Seventy patients were included with an average age and body mass index of 58.6 years and 33 kg/m2, respectively. High-risk comorbidities included hypertension (59%), and smoking history (50%). Cases were primarily modified Ventral Hernia Working Group class 2 (50%), or 3 (36%), with average defect size of 323 cm2 (25-972 cm2). P4HB was placed in the retromuscular (80%) or onlay (20%) plane. Mean follow-up was 24 months (12.2-41 months). Hernia recurrence rate was 5.7% (n = 4) and occurred an average of 285 days (209-368 days) post-repair. Of the 21 surgical site occurrences (SSO), 5 (7%) required surgical intervention. A significant improvement in overall QoL (P = 0.001) was noted following repair. Defect size and SSOPI were independently associated with increased direct cost. Conclusions P4HB mesh for complex VHR is associated with favorable 2-year clinical outcomes, acceptable hernia recurrence rate, and a significant improvement in QoL. This study supports the use of biosynthetic mesh as an effective biomaterial for complex VHR.
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Costa A, Adamo S, Gossetti F, D'Amore L, Ceci F, Negro P, Bruzzone P. Biological Scaffolds for Abdominal Wall Repair: Future in Clinical Application? MATERIALS 2019; 12:ma12152375. [PMID: 31349716 PMCID: PMC6695954 DOI: 10.3390/ma12152375] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 07/22/2019] [Accepted: 07/24/2019] [Indexed: 12/11/2022]
Abstract
Millions of abdominal wall repair procedures are performed each year for primary and incisional hernias both in the European Union and in the United States with extremely high costs. Synthetic meshes approved for augmenting abdominal wall repair provide adequate mechanical support but have significant drawbacks (seroma formation, adhesion to viscera, stiffness of abdominal wall, and infection). Biologic scaffolds (i.e., derived from naturally occurring materials) represent an alternative to synthetic surgical meshes and are less sensitive to infection. Among biologic scaffolds, extracellular matrix scaffolds promote stem/progenitor cell recruitment in models of tissue remodeling and, in the specific application of abdominal wall repair, have enough mechanical strength to support the repair. However, many concerns remain about the use of these scaffolds in the clinic due to their higher cost of production compared with synthetic meshes, despite having the same recurrence rate. The present review aims to highlight the pros and cons of using biologic scaffolds as surgical devices for abdominal wall repair and present possible improvements to widen their use in clinical practice.
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Affiliation(s)
- Alessandra Costa
- Sezione di Istologia ed Embriologia Medica, Dipartimento SAIMLAL, Sapienza Università di Roma, Via A. Scarpa 16, 00161 Rome, Italy
| | - Sergio Adamo
- Sezione di Istologia ed Embriologia Medica, Dipartimento SAIMLAL, Sapienza Università di Roma, Via A. Scarpa 16, 00161 Rome, Italy
| | - Francesco Gossetti
- Dipartimento Assistenziale Integrato Cardio Toraco-Vascolare, Chirurgia e Trapianti d'Organo, Azienda Ospedaliera Universitaria Policlinico Umberto I. Dipartimento Universitario Chirurgia Generale e Specialistica "Paride Stefanini", Sapienza Università di Roma, Viale del Policlinico 155, 00161 Rome, Italy
| | - Linda D'Amore
- Dipartimento Assistenziale Integrato Cardio Toraco-Vascolare, Chirurgia e Trapianti d'Organo, Azienda Ospedaliera Universitaria Policlinico Umberto I. Dipartimento Universitario Chirurgia Generale e Specialistica "Paride Stefanini", Sapienza Università di Roma, Viale del Policlinico 155, 00161 Rome, Italy
| | - Francesca Ceci
- Dipartimento Assistenziale Integrato Cardio Toraco-Vascolare, Chirurgia e Trapianti d'Organo, Azienda Ospedaliera Universitaria Policlinico Umberto I. Dipartimento Universitario Chirurgia Generale e Specialistica "Paride Stefanini", Sapienza Università di Roma, Viale del Policlinico 155, 00161 Rome, Italy
| | - Paolo Negro
- Dipartimento Assistenziale Integrato Cardio Toraco-Vascolare, Chirurgia e Trapianti d'Organo, Azienda Ospedaliera Universitaria Policlinico Umberto I. Dipartimento Universitario Chirurgia Generale e Specialistica "Paride Stefanini", Sapienza Università di Roma, Viale del Policlinico 155, 00161 Rome, Italy
| | - Paolo Bruzzone
- Dipartimento Assistenziale Integrato Cardio Toraco-Vascolare, Chirurgia e Trapianti d'Organo, Azienda Ospedaliera Universitaria Policlinico Umberto I. Dipartimento Universitario Chirurgia Generale e Specialistica "Paride Stefanini", Sapienza Università di Roma, Viale del Policlinico 155, 00161 Rome, Italy.
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Discussion: Obesity and Abdominal Wall Reconstruction: Outcomes, Implications, and Optimization. Plast Reconstr Surg 2018; 142:36S-37S. [PMID: 30138263 DOI: 10.1097/prs.0000000000004846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Direct visualization transversus abdominis plane blocks offer superior pain control compared to ultrasound guided blocks following open posterior component separation hernia repairs. Hernia 2018; 22:627-635. [PMID: 29721629 DOI: 10.1007/s10029-018-1775-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 04/21/2018] [Indexed: 01/11/2023]
Abstract
PURPOSE Transversus abdominis plane (TAP) blockade with long-acting anesthetic can be used during open ventral hernia repair (VHR) with posterior component separation (PCS). TAP block can be performed under ultrasound guidance (US-TAP) or under direct visualization (DV-TAP). We hypothesized that US-TAP and DV-TAP provide equivalent postoperative analgesia following open VHR. METHODS A retrospective review of patients undergoing open VHR with PCS who received TAP blocks with 266 mg of liposomal bupivacaine was performed. Data included demographics, comorbidities, length of stay (LOS), average postoperative day (POD) pain scores, and narcotic requirements (normalized to mg oral morphine). Statistical analysis utilized Student's t test and Fisher's exact test. RESULTS Thirty-nine patients were identified (22 DV-TAP). There were no differences between the groups with respect to demographics, comorbidities, pre-operative pain medication usage (narcotic and non-narcotic) or herniorrhaphy-related data. The average POD0 pain score was lower for the DV-TAP group (2.35 vs 4.18; p = 0.019). Narcotic requirements on POD0 (48.0 vs 103.76 mg; p = 0.02), POD1 (128.45 vs 273.82 mg; p = 0.03), POD4 (54.29 vs 160.75 mg; p = 0.042), and during the complete hospitalization (408.52 vs 860.92 mg; p = 0.013) were lower in the DV-TAP group. There were no differences between initiation of diet or LOS. During the study, no changes were made to the VHR enhanced recovery pathway. CONCLUSIONS DV-TAP blocks appear to provide superior analgesia in the immediate postoperative period. To achieve similar post-operative pain scores, patients in the US-TAP group required significantly more narcotic administration during their hospitalization. The study highlights DV-TAP as a valuable addition to VHR recovery pathways.
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Rhemtulla IA, Mauch JT, Broach RB, Messa CA, Fischer JP. Prophylactic mesh augmentation: Patient selection, techniques, and early outcomes. Am J Surg 2018; 216:475-480. [PMID: 29709271 DOI: 10.1016/j.amjsurg.2018.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 04/10/2018] [Accepted: 04/16/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Incisional hernias (IH) following abdominal surgery are frequent and morbid. Prophylactic mesh augmentation (PMA) has emerged as a technique to reduce IH formation. We aim to report patient selection, techniques and early outcomes after PMA. METHODS Retrospective chart review identified descriptive characteristics, risk factors, operative technique, and early post-operative outcomes for PMA patients and matched non-PMA patients between January 1, 2016 and October 31, 2017. RESULTS 18 consecutive PMA cases were performed (55.6% female, mean age 54.3 years and mean BMI = 29.5 kg/m2). 88.9% of patients had at least two high-risk features for IH. Zero PMA patients developed IH compared to 5.3% non-PMA patients (p = 0.314) (6-months mean follow-up). No difference in surgical site occurrences (SSO) were identified between the two groups. CONCLUSIONS Early results are encouraging, demonstrating PMA is safe with equivocal SSO. Further studies are needed to assess if the reduction in IH formation is statistically significant with longer follow-up.
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Affiliation(s)
- Irfan A Rhemtulla
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, South Pavilion 14th Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Jaclyn T Mauch
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, South Pavilion 14th Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, South Pavilion 14th Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Charles A Messa
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, South Pavilion 14th Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, South Pavilion 14th Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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