Reducing the incidence of surgical site infection after ventral hernia repair: Outcomes from the RINSE randomized control trial

BACKGROUND

The clinical and financial impact of surgical site infection after ventral hernia repair is significant. Here we investigate the impact of dual antibiotic irrigation on SSI after VHR.

METHODS

This was a multicenter, prospective randomized control trial of open retromuscular VHR with mesh. Patients were randomized to gentamicin ​+ ​clindamycin (G ​+ ​C) (n ​= ​125) vs saline (n ​= ​125) irrigation at time of mesh placement. Primary outcome was 30-day SSI.

RESULTS

No significant difference was seen in SSI between control and antibiotic irrigation (9.91 vs 9.09 ​%; p ​= ​0.836). No differences were seen in secondary outcomes: SSO (11.71 vs 13.64 ​%; p ​= ​0.667); 90-day SSO (11.1 vs 13.9 ​%; p ​= ​0.603); 90-day SSI (6.9 vs 3.8 ​%; p ​= ​0.389); SSIPI (7.21 vs 7.27 ​%, p ​= ​0.985); SSOPI (3.6 vs 3.64 ​%; p ​= ​0.990); 30-day readmission (9.91 vs 6.36 ​%; p ​= ​0.335); reoperation (5.41 vs 0.91 ​%; p ​= ​0.056).

CONCLUSION

Dual antibiotic irrigation with G ​+ ​C did not reduce the risk of surgical site infection during open retromuscular ventral hernia repair.

The compatibility of exoskeletons in perioperative environments and workflows: an analysis of surgical team members' perspectives and workflow simulation

Surgical team members in perioperative environments experience high physical demands. Interventions such as exoskeletons, external wearable devices that support users, have the potential to reduce these work-related physical demands. However, barriers such as workplace environment and task compatibility may limit exoskeleton implementation. This study gathered the perspectives of 33 surgical team members: 12 surgeons, four surgical residents, seven operating room (OR) nurses, seven surgical technicians (STs), two central processing technicians (CPTs), and one infection control nurse to understand their workplace compatibility. Team members were introduced to passive exoskeletons via demonstrations, after which surgical staff (OR nurses, STs, and CPTs) were led through a simulated workflow walkthrough where they completed tasks representative of their workday. Five themes emerged from the interviews (workflow, user needs, hindrances, motivation for intervention, and acceptance) with unique subthemes for each population. Overall, exoskeletons were largely compatible with the duties and workflow of surgical team members.

Use of Preoperative Endoscopic Capsule-Based pH Testing Before Bariatric Surgery

BACKGROUND

Vertical sleeve gastrectomy is the most performed bariatric operation in the US; however, a significant number of patients suffer from persistent or new-onset reflux. No consensus for objective preoperative evaluation in these patients exists. We compared capsule-based pH testing vs GERD symptom scoring to determine extent of preoperative GERD to aid in procedure selection for bariatric surgery.

STUDY DESIGN

An IRB-approved retrospective review of consecutive patients at a single institution was performed from April 2021 to December 2022. During initial consultation for bariatric surgery, a validated GERD symptom subjective survey was administered. All patients demonstrating interest in sleeve gastrectomy or had a history of reflux underwent upper endoscopy with capsule-based pH testing.

RESULTS

Sixty-two patients underwent preoperative endoscopy with capsule-based pH testing and completed GERD symptom assessment survey(s). Median BMI was 43.4 kg/m 2 and 66.1% of patients were not taking a proton-pump inhibitor before performance of pH testing. There was negligible linear association between the objective DeMeester score obtained by capsule-based pH probe and GERD symptom survey scores. Median GERD symptom survey scores did not differ between patients with and without a diagnosis of GERD based on pH testing (all p values >0.11).

CONCLUSIONS

An objective method for identifying severe GERD in the preoperative assessment may aid in the decision tree for procedure selection and informed consent process. Patients with significant preoperative GERD may be at higher risk for future GERD-related sleeve complications. Capsule-based pH testing may prove to be superior to subjective symptom scoring systems in this patient population.

Outcomes of subsequent abdominal operations after an initial ventral hernia repair

INTRODUCTION

Nearly 20% of ventral hernia repair (VHR) patients require a subsequent abdominal operation (SAO), and mesh position may impact the complexity and outcome of the SAO.

METHODS

Retrospective review of VHR with mesh from 2006 to 2020 from an internal database and the ACHQC. Primary outcomes measured incidence, complexity, and complications of SAO relative to mesh position.

RESULTS

SAO was required in 433 of 2539 (17.1%) patients, totaling 671 operations; 197/893 (22.1%) with intraperitoneal mesh (IPM) and 236/1646 (14.3%) with extraperitoneal mesh (EPM; p ​< ​0.001). SAO was directly related to VHR in 180 (232 total SAOs) and unrelated in 253 (439 total SAOs). There were no significant differences in complications after SAO between IPM and EPM, nor any difference in adhesion complexity.

CONCLUSION

Incidence of SAO is higher with IPM, but surgical outcomes are similar. Due to the risk of secondary mesh infection with IPM, significantly more of these were removed at the time of SAO.

Impact of methocarbamol on opioid use after ventral incisional hernia repair

BACKGROUND

Alternatives to opioid analgesia are needed to reduce the risk of abuse, misuse, and diversion. Musculoskeletal pain is a significant contributor to postoperative pain after ventral hernia repair (VHR). We report the impact of methocarbamol on opioid prescribing after VHR.

METHODS

Review of all robotic and open VHR, Jan 2020-July 2022. Data was collected in the Abdominal Core Health Quality Collaborative (ACHQC) with additional chart review to assess for opioid refills. A 2:1 propensity score match was performed comparing opioid prescribing in patients prescribed vs not prescribed methocarbamol.

RESULTS

101 patients received methocarbamol compared with 202 without. Similar number of patients received an opioid prescription (87.1 vs 86.6%; p = 0.904). Study patients received significantly lower MME prescription at discharge (60 v 75; p = 0.021) with no difference in refills (12.5 vs 16.6%; p = 0.386).

CONCLUSION

Addition of methocarbamol to a multimodal analgesic regimen after VHR facilitates reduction in prescribed opioid with no increase in refills.

Impact of methocarbamol on opioid use after primary ventral and inguinal hernia repair

BACKGROUND

Multimodal analgesia is now a mainstay of perioperative care. Our aim is to assess the impact of adding methocarbamol on opioid use for patients undergoing primary ventral (umbilical and epigastric) hernia repair (PVHR) and inguinal hernia repair (IHR).

METHODS

Retrospective review of patients undergoing PVHR and IHR who received methocarbamol, propensity score matched in a 2:1 fashion to patients not receiving methocarbamol.

RESULTS

Fifty-two PVHR patients receiving methocarbamol were matched to 104 control patients. Study patients were prescribed fewer opioids (55.8 vs 90.4%; p < 0.001) and received lower MME (20 vs 50; p < 0.001), with no difference in refills or rescue opioids. For IHR, study patients received fewer prescriptions (67.3 vs 87.5%; p < 0.001) and received lower MME (25 vs 40; p < 0.001), with no difference in rescue opioid (5.9 vs 0%; p = 0.374).

CONCLUSIONS

Methocarbamol significantly reduced opioid prescribing in patients undergoing PVHR and IHR without increasing the risk of refill or rescue opioid.

A Standardized Protocol for Opioid Prescribing After Surgery Decreases Total Morphine Equivalents Prescribed

INTRODUCTION

Perioperative opioid analgesia has been extensively reexamined during the opioid epidemic. Multiple studies have demonstrated over prescription of opioids, demonstrating the need for change in prescribing practices. A standard opioid prescribing protocol was implemented to evaluate opioid prescribing trends and practices.

OBJECTIVES

To evaluate opioid use after primary ventral, inguinal, and incisional hernia repair and to assess clinical factors that may impact opioid prescribing and consumption. Secondary outcomes include the number of refills, patients without opioid requirement, difference in opioid use based on patient characteristics and adherence to prescribing protocol.

METHODS

This is a prospective observational study examining patients undergoing inguinal, primary ventral and incisional hernias between February and November 2019. A standardized prescribing protocol was implemented and utilized for postoperative prescribing. All data was captured in the abdominal core health quality collaborative (ACHQC) and opioid use was standardized via morphine milligram equivalents (MME).

RESULTS

389 patients underwent primary ventral, incisional, and inguinal hernia repair, with a total of 285 included in the final analysis. 170 (59.6%) of patients reported zero opioid use postoperatively. Total opioid MME prescribed and high MME consumption were significantly higher after incisional hernia repair with a greater number of refills were required. Compliance with prescribing protocol resulted in lower MME prescription, but not actual lower MME consumption.

CONCLUSIONS

Implementation of a standardized protocol for opioid prescribing after surgery decreases the total MME prescribed. Compliance with our protocol significantly reduced this disparity, which has the potential for decreasing abuse, misuse, and diversion of opioids by better estimating actual postoperative analgesic requirements.

Robotic transversus abdominis release: A paradigm shift in complex abdominal wall surgery?

Abdominal wall reconstruction techniques have evolved significantly over the last fifty years and continue to do so at an increasing pace. Beginning with open incisional hernia repair with bilateral rectus myofascial release, multiple techniques to offset tension at the midline by exploring options of layered myofascial release have been described. This article reviews the history, technique, advancements, and future of myofascial release in abdominal wall reconstruction leading from the open Rives-Stoppa repair to the robotic-assisted iteration of the transversus abdominis release.

Effect of stapled versus layered skin closure on surgical site occurrences after abdominal wall reconstruction

BACKGROUND

The effect of skin closure technique on surgical site occurrences (SSO) after open abdominal wall reconstruction (AWR) with retromuscular polypropylene mesh placement is largely unknown. We hypothesize that layered subcuticular skin closure with cyanoacrylate skin adhesive is protective of surgical site infection compared to standard stapled closure.

METHODS

A retrospective review utilizing the Abdominal Core Health Quality Collaborative (ACHQC) database of all patients at Prisma Health-Upstate. All patients with open abdominal wall reconstruction (AWR) of midline incisional hernia defects with retromuscular polypropylene mesh placement from January 2013 to February 2020 were included. Patient demographics, comorbidities, type of hernia repair with mesh location, method of skin closure, and SSOs were collected. Skin closure method was divided into two groups, reflecting a temporal change in practice: staples (historical control group) versus subcuticular suture with cyanoacrylate skin adhesive with/without polymer mesh tape (study group). Primary endpoint was SSI and SSO. Secondary endpoints were SSO or SSI requiring procedural intervention (SSOPI/SSIPI). Standard statistical methods were utilized.

RESULTS

A total of 834 patients were analyzed, with 263 treated with stapled skin closure and 571 with subcuticular and adhesive closure. On univariate analysis, the incidence of SSI was significantly lower in the study group (11.8 vs 6.8%; p = 0.002), as was the need for SSIPI (11.8 vs 6.7%; p = 0.015). Rate of SSO was not significantly different between groups (28.1 vs 27.2%), but the rate of SSO requiring intervention was lower in the study group (14.1 vs 9.3%; p = 0.045).

CONCLUSION

Layered skin closure technique, including subcuticular closure and adhesive, may reduce the risk of surgical site infection after open AWR. A prospective randomized trial is planned to confirm these findings.

Effect of Hernia Mesh Weights on Postoperative Patient-Related and Clinical Outcomes After Open Ventral Hernia Repair: A Randomized Clinical Trial

Importance

Although multiple versions of polypropylene mesh devices are currently available on the market for hernia repair, few comparisons exist to guide surgeons as to which device may be preferable for certain indications. Mesh density is believed to impact patient outcomes, including rates of chronic pain and perception of mesh in the abdominal wall.

Objective

To examine whether medium-weight polypropylene is associated with less pain at 1 year compared with heavy-weight mesh.

Design, Setting, and Participants

This multicenter randomized clinical trial was performed from March 14, 2017, to April 17, 2019, with 1-year follow-up. Patients undergoing clean, open ventral hernia repairs with a width 20 cm or less were studied. Patients were blinded to the intervention.

Interventions

Patients were randomized to receive medium-weight or heavy-weight polypropylene mesh during open ventral hernia repair.

Main Outcomes and Measures

The primary outcome was pain measured with the National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Intensity Short Form 3a. Secondary outcomes included quality of life and pain measured at 30 days, quality of life measured at 1 year, 30-day postoperative morbidity, and 1-year hernia recurrence.

Results

A total of 350 patients participated in the study, with 173 randomized to receive heavy-weight polypropylene mesh (84 [48.6%] female; mean [SD] age, 59.2 [11.4] years) and 177 randomized to receive medium-weight polypropylene mesh (91 [51.4%] female; mean [SD] age, 59.3 [11.4] years). No significant differences were found in demographic characteristics (mean [SD] body mass index of 32.0 [5.4] in both groups [calculated as weight in kilograms divided by height in meters squared] and American Society of Anesthesiologists classes of 2-4 in both groups), comorbidities (122 [70.5%] vs 93 [52.5%] with hypertension, 44 [25.4%] vs 43 [24.3%] with diabetes, 17 [9.8%] vs 12 [6.8%] with chronic obstructive pulmonary disease), or operative characteristics (modified hernia grade of 2 in 130 [75.1] vs 140 [79.1] in the heavy-weight vs medium-weight mesh groups). Pain scores for patients in the heavy-weight vs medium-weight mesh groups at 30 days (46.3 vs 46.3, P = .89) and 1 year (30.7 vs 30.7, P = .59) were identical. No significant differences in quality of life (median [interquartile range] hernia-specific quality of life score at 1 year of 90.0 [67.9-96.7] vs 86.7 [65.0-93.3]; median [interquartile range] hernia-specific quality of life score at 30 days, 45.0 [24.6-73.8] vs 43.3 [28.3-65.0]) were found for the heavy-weight mesh vs medium-weight mesh groups. Composite 1-year recurrence rates for patients in the heavy-weight vs medium-weight polypropylene groups were similar (8% vs 7%, P = .79).

Conclusions and Relevance

Medium-weight polypropylene did not demonstrate any patient-perceived or clinical benefit over heavy-weight polypropylene after open retromuscular ventral hernia repair. Long-term follow-up of these comparable groups will elucidate any potential differences in durability that have yet to be identified.

Trial Registration

ClinicalTrials.gov Identifier: NCT03082391.

Critical view of robotic-assisted transverse abdominal release (r-TAR)

INTRODUCTION

Establishing straightforward and reproducible steps to describe the technique performed with the aid of the robotic system for complex hernia surgery is key for good outcomes. Even using the description of open surgery as a parameter for performing the robotic technique, it is important to stress the particularities of this access. To describe the steps to perform robotic-assisted TAR (r-TAR) in a standardized technique, with a critical and safe view of all the anatomical structures.

DESCRIPTION OF THE TECHNIQUE

We defined 8 landmarks for the critical view of safety in r-TAR which include: (1) patient position, trocar and docking; (2) posterior rectus sheath mobilization; (3) transversus abdominis release (TAR)-Top-down technique; (4) transversus abdominis release (TAR)-bottom-up technique and mesh insertion; (5) contralateral trocar insertion and redocking, 6) posterior sheath closure; (7) final mesh positioning; and (8) anterior defect closure and drains.

DISCUSSION

Complex hernia surgery using a robotic-assisted posterior component separation requires well-established steps so the procedure can be reproducible and achieve better results.

Implementation of an Evidence-Based Protocol Significantly Reduces Opioid Prescribing After Ventral Hernia Repair

BACKGROUND

Increased recognition of the dangers of opioid analgesia has led to significant focus on strategies for reducing use through multimodal analgesia, enhanced recovery protocols, and standardized guidelines for prescribing. Our institution implemented a standard protocol for prescribing analgesics at discharge after ventral hernia repair (VHR). We hypothesize that this strategy significantly reduces opioid use.

METHODS

A standardized protocol for discharge prescribing was implemented in March 2018. Patients were prescribed ibuprofen, acetaminophen, and opioids based on milligram morphine equivalent (MME) use the 24 hours prior to discharge. We retrospectively reviewed prescriptions of opioids for two 6-month periods-July-December 2017 (PRE) and July-December 2018 (POST)-for comparison using EPIC report and the South Carolina Prescription Monitoring Program. Analysis performed included Mann-Kendall linear trend test and Student's t-test for continuous variables.

RESULTS

VHR was performed in 105 patients in the PRE and 75 patients in the POST group. Total MME prescribed decreased significantly from mean 322.7 + 261.3/median 225 (IQR 150-400) MME to 141.6 + 150.4/median 100 (50-184) MME (P < .001). This represents a 57% reduction in mean opioid MME prescriptions. Acetaminophen prescribing increased from 10% to 65%, and ibuprofen from 7.6% to 61.3%. Refills were prescribed in 21 patients (20%) during the PRE period, which decreased to 10.7% during the POST group (P = .141). Implementation of an evidence-based protocol significantly reduces opioid prescribing after VHR.

DISCUSSION

A multimodal approach to postoperative pain management decreases the need for opioids. The additional implementation of an evidence-based prescribing protocol results in significant reduction of opioid use following VHR.

Robotic Versus Laparoscopic Approach to Hiatal Hernia Repair: Results After 7 Years of Robotic Experience

INTRODUCTION

Robotic hiatal hernia repair offers potential advantages over traditional laparoscopy, most notably enhanced visualization, improved ergonomics, and articulating instruments. The clinical outcomes, however, have not been adequately evaluated. We report outcomes of laparoscopic and robotic hiatal hernia repairs.

METHODS

A retrospective observational cohort study was performed of all hiatal hernia repairs performed from 2006 through 2019. Operative, demographic, and outcomes data were compared between laparoscopic and robotic groups. Discrete variables were analyzed with Chi-square of Fisher's exact test. Continuous variables were analyzed with Student's t test (mean) or Wilcoxon rank sum (medians). All analyses were performed using R statistical software.

RESULTS

Laparoscopic repair was performed in 278 patients and robotic repair in 114. More recurrent hernias were repaired robotically (24.5% vs 12.9%, P = .08). Operative times were no different between groups (175 vs 179 minutes; P = .681). Robotic repair resulted in significantly shorter length of stay (LOS; 2.3 vs 3.3 days; P = .003). Rate of readmission was no different, and there were no differences in acute complications. For patients with at least 1 year of follow-up, recurrence rates were lower after robotic repair (13.3% vs 32.8%; P = .008); however, mean follow-up is significantly longer after laparoscopic repair (23.7 ± 28.4 vs 15.1 ± 14.9 months; P < .001).

DISCUSSION

Robotic hiatal hernia repair offers technical advantages over laparoscopic repair with similar clinical outcomes.

Opioid Use After Inguinal and Ventral Hernia Repair

BACKGROUND

Recent data on opioid consumption indicate that patients typically require far less than is prescribed. Prisma Health Upstate Hernia Center adopted standardized postoperative prescribing after hernia repair and began tracking patient-reported opioid utilization. The aim of this study is to evaluate patient opioid use after hernia repair in order to guide future prescribing.

METHODS

All patients who underwent primary ventral (umbilical and epigastric), incisional, and inguinal hernia repair between February and May 2019 were reviewed. Patients reported the number of opioid pills taken at their first postoperative visit and documented either in the progress note or in the Americas Hernia Society Quality Collaborative (AHSQC) patient-reported outcomes (PRO) questionnaire. All demographic, operative, and outcomes data were captured prospectively in the AHSQC. Opioid use reported as milligram morphine equivalents (MME).

RESULTS

A total of 162 surgeries were performed during the study period, and 107 had patient-reported opioid use for analysis. Inguinal hernia repair was performed in 36 patients, 10 primary ventral hernia repairs, and 61 incisional hernia repairs. No opioid use was reported in 63.9% of inguinal hernias, 60% of primary ventral hernias, and 20% of incisional hernias. Inguinal hernia patients consumed a mean of 10.5 MME, primary ventral patients 11 MME, and incisional hernia patients 78.5 MME.

CONCLUSION

Patients require little to no opioid after primary ventral or inguinal hernia repair and opioid-free surgery is feasible. Incisional hernia is more heterogenous, but the majority of patients still required less opioid than previously thought.

Computed tomography imaging in ventral hernia repair: can we predict the need for myofascial release?

INTRODUCTION

Currently, the need for additional myofascial release (AMR) in addition to retromuscular dissection during open Rives-Stoppa hernia repair is determined intraoperatively based on the discretion of the surgeon. We developed a novel method to objectively predict the need for AMR preoperatively using computed tomography (CT)-measured rectus width to hernia width ratio (RDR).

METHODS

A retrospective chart review of all patients who underwent open retro-muscular mesh repair of midline ventral hernia between August 1, 2007 and February 1, 2018, who had a preoperative CT scan within 1 year prior to their operation. The primary endpoint was the ability of the defect ratio to predict the need for AMR in pursuit of fascial closure. The secondary endpoint was the ability of Component Separation Index (CSI) to predict the need for AMR to obtain fascial closure.

RESULTS

Of 342 patients, 208 repaired with rectus abdominis release alone (RM group), while 134 required AMR (RM + group). An RDR of > 1.34 on area under the curve analysis predicted the need for AMR with 77.6% accuracy. There was a linear decrease in the need for AMR with increasing RDR: RDR < 1 required AMR in 78.8% of cases, RDR 1.1-1.49 in 52%, RDR 1.5-1.99 in 32.1%, and RDR > 2 in just 10.8%. Similarly, CSI > 0.146 predicted the need for AMR with 76.3% accuracy on area under the curve analysis.

CONCLUSION

The RDR is a practical and reliable tool to predict the ability to close the defect during open Rives-Stoppa ventral hernia repair without AMR. An RDR of > 2 portends fascial closure with rectus abdominis myofascial release alone in 90% of cases.

Antibiotic Irrigation of the Surgical Site Decreases Incidence of Surgical Site Infection after Open Ventral Hernia Repair

Surgical site infections (SSI) are common complications after open ventral hernia repair (OVHR), potentially requiring further intervention. Antibiotic lavage before abdominal closure has been shown to lower the incidence in intra-abdominal and soft tissue SSI. A retrospective review of OVHR was performed with mesh at Greenville Health System Hernia Center between 2008 and 2017. Patients were divided into three groups, receiving no antibiotic irrigation (Grp 1, n = 260), gentamicin alone (Grp 2, n = 263), or gentamicin + clindamycin (G + C) irrigation (Grp 3, n = 299). Differences in categorical variables among the three groups were tested using chi-squared or Fischer's exact test (for n < 5). Analysis of continuous variables was performed using analysis of variance or Kruskal-Wallis test for differences in length of stay. Logistic regression was performed using all clinically relevant variables to determine the effects of irrigation on SSI. Incidence of surgical site occurrence was significantly lower after G + C irrigation (Grp 1, 28.1%; Grp 2, 35.4%; Grp 3, 19.7%; P < 0.001). Incidence of SSI was significantly lower after G + C irrigation, but not G alone (Grp 1, 16.5%; Grp 2, 15.2%; and Grp 3, 5.4%; P < 0.001). Multivariate logistic regression demonstrated significantly increased SSI with contaminated wounds (OR 2.96; 95% confidence interval (CI) 1.39-6.21), dirty wounds (OR 3.84; 95% CI 1.49-9.69), and chronic obstructive pulmonary disease (OR 3.70; 95% CI 2.16-6.38), as expected. Use of G + C was an independent predictor of decreased SSI (OR 0.33; 95% CI 0.16-0.67). Irrigation with a combined G + C antibiotic irrigation significantly reduces the incidence of surgical site infection after OVHR with mesh.

Antibiotic Irrigation of the Surgical Site Decreases Incidence of Surgical Site Infection after Open Ventral Hernia Repair

Surgical site infections (SSI) are common complications after open ventral hernia repair (OVHR), potentially requiring further intervention. Antibiotic lavage before abdominal closure has been shown to lower the incidence in intra-abdominal and soft tissue SSI. A retrospective review of OVHR was performed with mesh at Greenville Health System Hernia Center between 2008 and 2017. Patients were divided into three groups, receiving no antibiotic irrigation (Grp 1, n = 260), gentamicin alone (Grp 2, n = 263), or gentamicin 1 clindamycin (G 1 C) irrigation (Grp 3, n = 299). Differences in categorical variables among the three groups were tested using chi-squared or Fischer's exact test (for n < 5). Analysis of continuous variables was performed using analysis of variance or Kruskal-Wallis test for differences in length of stay. Logistic regression was performed using all clinically relevant variables to determine the effects of irrigation on SSI. Incidence of surgical site occurrence was significantly lower after G 1 C irrigation (Grp 1, 28.1%; Grp 2, 35.4%; Grp 3, 19.7%; P < 0.001). Incidence of SSI was significantly lower after G 1 C irrigation, but not G alone (Grp 1, 16.5%; Grp 2, 15.2%; and Grp 3, 5.4%; P < 0.001). Multivariate logistic regression demonstrated significantly increased SSI with contaminated wounds (OR 2.96; 95% confidence interval (CI) 1.39–6.21), dirty wounds (OR 3.84; 95% CI 1.49–9.69), and chronic obstructive pulmonary disease (OR 3.70; 95% CI 2.16–6.38), as expected. Use of G 1 C was an independent predictor of decreased SSI (OR 0.33; 95% CI 0.16–0.67). Irrigation with a combined G 1 C antibiotic irrigation significantly reduces the incidence of surgical site infection after OVHR with mesh.

Flank and Lumbar Hernia Repair

Flank and lumbar hernias are challenging because of their rarity and anatomic location. Several challenges exist when approaching these specific abdominal wall defects, including location, innervation of the lateral abdominal wall musculature, and their proximity to bony landmarks. These hernias are confined by the costal margin, spine, and pelvic brim, which makes closure of the defect, including mesh placement, difficult. This article discusses the anatomy of lumbar and flank hernias, the various etiologies for these hernias, and the procedural steps for open and robotic preperitoneal approaches. The available clinical evidence regarding outcomes for various repair techniques is also reviewed.

Prophylactic placement of permanent synthetic mesh at the time of ostomy closure prevents formation of incisional hernias

BACKGROUND

Reversal of an enterostomy results in a high rate of incisional hernia at the ostomy site. Prophylactic mesh reinforcement of the fascial defect is typically not considered due to the contaminated nature of the case. We present the outcomes of a series of prophylactic mesh reinforcements with retromuscular, large-pore polypropylene at the time of enterostomy reversal.

METHODS

Retrospective review of all ostomy reversals was performed. All cases with placement of synthetic mesh reinforcement were identified from a prospectively maintained, hernia database. Primary end points were surgical site occurrence, surgical site infection, and hernia occurrence.

RESULTS

Ostomy reversal was performed in 359 patients; 91 were reinforced with mesh and 268 without mesh. Colostomy reversal was performed in 56.5% and ileostomy in 43.5%. The mesh group had a greater body mass index and a greater incidence of chronic obstructive pulmonary disease, but groups were otherwise similar. A midline incisional hernia was present in 45% of the mesh group vs 4.5% in the controls. Incidence of surgical site occurrence and surgical site infection were similar for mesh and control groups (21 vs 22.8%; P = .82 and 20 vs 19.8%; P = 1.000, respectively). Superficial surgical site infection was less with mesh (8 vs 16.4%; P = .039). Incidence of a hernia developing at the stoma site was decreased markedly with mesh (1% vs 17.2%; P < .001), as was the occurrence of a midline hernia (6% vs 19%; P = .004). Mesh was placed across the midline prophylactically in 29.7% of cases, which decreased midline hernia formation from 24.1% to 4% (P = .019).

CONCLUSION

Retromuscular placement of permanent synthetic mesh at the time of enterostomy reversal is effective in preventing development of incisional hernia without increased risk of surgical site occurrence or surgical site infection.

Patterns of Recurrence and Mechanisms of Failure after Open Ventral Hernia Repair with Mesh

Recurrence after ventral hernia repair (VHR) remains a significant complication. We sought to identify the technical aspects of VHR associated with recurrence. Patients who underwent open midline VHR between 2006 and 2013 (n = 261) were retrospectively evaluated. Patients with recurrence (Group 1, n = 48) were compared with those without recurrence (Group 2, n = 213). Smoking, diabetes, and body mass index were not different between groups. More patients in Group 1 underwent clean-contaminated, contaminated, or dirty procedures (43.8 vs 27.7%; P = 0.021). Group 1 had a higher incidence of surgical site occurrence (52.1 vs 32.9%; P = 0.020) and surgical site infection (43.8 vs 15.5%; P < 0.001). Recurrences were due to central mesh failure (CMF) (39.6%), midline recurrence after biologic or bioabsorbable mesh repair (18.8%), superior midline (16.7%), lateral (16.7%), and after mesh explantation (12.5%). Most CMF (78.9%) occurred with light-weight polypropylene (LWPP). Recurrence was higher if the midline fascia was unable to be closed. Recurrence with midweight polypropylene (MWPP) was lower than biologic (P < 0.001), bioabsorbable (P = 0.006), and light-weight polypropylene (P = 0.046) mesh. Fixation, component separation technique, and mesh position were not different between groups. Wound complications are associated with subsequent recurrence, whereas midweight polypropylene is associated with a lower overall risk of recurrence and, specifically, CMF.

Patterns of Recurrence and Mechanisms of Failure after Open Ventral Hernia Repair with Mesh

Recurrence after ventral hernia repair (VHR) remains a significant complication. We sought to identify the technical aspects of VHR associated with recurrence. Patients who underwent open midline VHR between 2006 and 2013 (n = 261) were retrospectively evaluated. Patients with recurrence (Group 1, n = 48) were compared with those without recurrence (Group 2, n = 213). Smoking, diabetes, and body mass index were not different between groups. More patients in Group 1 underwent clean-contaminated, contaminated, or dirty procedures (43.8 vs 27.7%; P = 0.021). Group 1 had a higher incidence of surgical site occurrence (52.1 vs 32.9%; P = 0.020) and surgical site infection (43.8 vs 15.5%; P < 0.001). Recurrences were due to central mesh failure (CMF) (39.6%), midline recurrence after biologic or bioabsorbable mesh repair (18.8%), superior midline (16.7%), lateral (16.7%), and after mesh explantation (12.5%). Most CMF (78.9%) occurred with light-weight polypropylene (LWPP). Recurrence was higher if the midline fascia was unable to be closed. Recurrence with midweight polypropylene (MWPP) was lower than biologic (P < 0.001), bioabsorbable (P = 0.006), and light-weight polypropylene (P = 0.046) mesh. Fixation, component separation technique, and mesh position were not different between groups. Wound complications are associated with subsequent recurrence, whereas midweight polypropylene is associated with a lower overall risk of recurrence and, specifically, CMF.

Effect of Multimodal Analgesia on Opioid Use After Open Ventral Hernia Repair

BACKGROUND

There is limited data on enhanced recovery after surgery (ERAS) protocols after ventral hernia repair (VHR). This study reports the impact of multimodal analgesia on opioid use after open VHR.

METHODS

Retrospective review of open VHR treated during the initial 6 months after ERAS implementation. Protocol focused on opioid sparing using intraoperative ketamine and/or lidocaine infusion, selective epidural anesthesia, and postoperative ketamine infusion, ketorolac, and acetaminophen. Four groups were analyzed: 1-ERAS protocol with epidural analgesia, 2-historical controls with epidural analgesia prior to ERAS, 3-ERAS protocol without epidural, and 4-historical controls without epidural analgesia, prior to ERAS. Continuous variables were analyzed using ANOVA or Kruskal-Wallis tests, and subgroup analysis using Student's t test or Mann-Whitney U test. Discrete variables were analyzed using Pearson's chi-square test or Fisher's exact test.

RESULTS

Patients differed in hernia width, but were similar in comorbidity and operative technique. There was no difference in length of stay or readmission. Use of ERAS nearly eliminated patient-controlled analgesia use (group 1, 2.7%; group 2, 68.4%; group 3, 0%; group 4, 65.7%; p < 0.001). ERAS significantly reduced narcotic requirements on postoperative days 0, 1, and 2 (p < 0.001). To account for the bias of selective epidural analgesia, groups 1 and 2 (epidural) and groups 3 and 4 (no epidural) were compared separately. Opioid requirement and PCA use remained significantly lower in patients in the ERAS pathway.

CONCLUSION

Implementation of multimodal analgesia in the perioperative and postoperative setting significantly reduced opioid use after VHR.

An Evaluation of Parastomal Hernia Repair Using the Americas Hernia Society Quality Collaborative

The purpose of this review was to evaluate outcomes relating to parastomal hernia repair. Data from the Americas Hernia Society Quality Collaborative were used to identify patients undergoing parastomal hernia repair from 2013 to 2016. Parastomal hernia repairs were compared with other repairs using Pearson's test and Wilcoxon test with a P value <0.05 considered significant. Parastomal hernia repairs were performed in 311 patients. Techniques of repair include open in 85 per cent and laparoscopic in 15 per cent. Mesh was used in 92 per cent with keyhole in 34 per cent, flat mesh in 33 per cent, and Sugarbaker in 25 per cent. Mesh types were permanent synthetic in 79 per cent, biologic in 13 per cent, absorbable synthetic in 6 per cent, and hybrid synthetic/biologic in 2 per cent. Most common location for mesh was sublay in 84 per cent followed by onlay in 14 per cent and inlay in 2 per cent with 59 per cent of patients undergoing a myofascial release. Ostomy disposition included ostomy left in situ (47%), moved to a new site (18%), taken down (22%), and rematured in same location in (13%). Outcomes related to parastomal hernia repair included 10 per cent surgical site infection, 24 per cent surgical site occurrence, and 12 per cent surgical site occurrences requiring procedural interventions with a 13 per cent readmission rate and 6 per cent reoperation rate. When comparing parastomal hernias with other ventral hernia repairs, parastomal hernias had a significantly higher surgical site infection, surgical site occurrence, surgical site occurrences requiring procedural intervention, readmission, reoperation rate, and length of stay, and were less commonly performed laparoscopically (P < 0.05). Most parastomal hernias are being repaired open with synthetic mesh in the sublay position. Less favorable outcomes of parastomal hernia repair when compared with other ventral hernia repairs are likely related to the complexity of parastomal hernia repair.

Open Retromuscular Repair of Parastomal Hernias with Synthetic Mesh

Parastomal hernias (PHs) cause significant morbidity in patients with permanent ostomies, and several laparoscopic and open repair techniques have been described. We report our experience with open retromuscular repair of PHs using permanent synthetic mesh. A prospectively maintained database was retrospectively reviewed to identify patients undergoing PH repair. Primary outcomes are surgical site occurrence, surgical site infection (SSI), and hernia recurrence. Variables were analyzed using Pearson's χ2 test or Fisher's exact test. Values of P < 0.05 were considered significant. Forty-six patients underwent retromuscular PH repair with permanent synthetic mesh. There were 26 patients with colostomies and 20 with ileostomies. All the patients were repaired using a keyhole retromuscular technique and direct passage of stoma through mesh. Transversus abdominis release was performed in 65.2 per cent of cases. Permanent synthetic polypropylene mesh was used in all cases. Surgical site occurrence occurred in 47.8 per cent of patients, SSI in 17.4 per cent, and hernia recurrence in 21.7 per cent. Resiting the stoma yielded the highest rate of SSI (40%) compared with leaving the stoma in situ (11.8%) or rematuring the stoma (0%; P = 0.011). Open keyhole retromuscular PH repair of PH with permanent synthetic mesh is safe, effective, and durable.

An Evaluation of Parastomal Hernia Repair Using the Americas Hernia Society Quality Collaborative

The purpose of this review was to evaluate outcomes relating to parastomal hernia repair. Data from the Americas Hernia Society Quality Collaborative were used to identify patients undergoing parastomal hernia repair from 2013 to 2016. Parastomal hernia repairs were compared with other repairs using Pearson's test and Wilcoxon test with a P value <0.05 considered significant. Parastomal hernia repairs were performed in 311 patients. Techniques of repair include open in 85 per cent and laparoscopic in 15 per cent. Mesh was used in 92 per cent with keyhole in 34 per cent, flat mesh in 33 per cent, and Sugarbaker in 25 per cent. Mesh types were permanent synthetic in 79 per cent, biologic in 13 per cent, absorbable synthetic in 6 per cent, and hybrid synthetic/biologic in 2 per cent. Most common location for mesh was sublay in 84 per cent followed by onlay in 14 per cent and inlay in 2 per cent with 59 per cent of patients undergoing a myofascial release. Ostomy disposition included ostomy left in situ (47%), moved to a new site (18%), taken down (22%), and rematured in same location in (13%). Outcomes related to parastomal hernia repair included 10 per cent surgical site infection, 24 per cent surgical site occurrence, and 12 per cent surgical site occurrences requiring procedural interventions with a 13 per cent readmission rate and 6 per cent reoperation rate. When comparing parastomal hernias with other ventral hernia repairs, parastomal hernias had a significantly higher surgical site infection, surgical site occurrence, surgical site occurrences requiring procedural intervention, readmission, reoperation rate, and length of stay, and were less commonly performed laparoscopically (P < 0.05). Most parastomal hernias are being repaired open with synthetic mesh in the sublay position. Less favorable outcomes of parastomal hernia repair when compared with other ventral hernia repairs are likely related to the complexity of parastomal hernia repair.

Open Retromuscular Repair of Parastomal Hernias with Synthetic Mesh

Parastomal hernias (PHs) cause significant morbidity in patients with permanent ostomies, and several laparoscopic and open repair techniques have been described. We report our experience with open retromuscular repair of PHs using permanent synthetic mesh. A prospectively maintained database was retrospectively reviewed to identify patients undergoing PH repair. Primary outcomes are surgical site occurrence, surgical site infection (SSI), and hernia recurrence. Variables were analyzed using Pearson's χ2 test or Fisher's exact test. Values of P < 0.05 were considered significant. Forty-six patients underwent retromuscular PH repair with permanent synthetic mesh. There were 26 patients with colostomies and 20 with ileostomies. All the patients were repaired using a keyhole retromuscular technique and direct passage of stoma through mesh. Transversus abdominis release was performed in 65.2 per cent of cases. Permanent synthetic polypropylene mesh was used in all cases. Surgical site occurrence occurred in 47.8 per cent of patients, SSI in 17.4 per cent, and hernia recurrence in 21.7 per cent. Resiting the stoma yielded the highest rate of SSI (40%) compared with leaving the stoma in situ (11.8%) or rematuring the stoma (0%; P = 0.011). Open keyhole retromuscular PH repair of PH with permanent synthetic mesh is safe, effective, and durable.

A Large Single-Center ‘Experience of Open Lateral Abdominal Wall Hernia Repairs

Lateral abdominal wall hernias may occur after a variety of procedures, including anterior spine exposure, urologic procedures, ostomy closures, or after trauma. Anatomically, these hernias are challenging and require a complete understanding of abdominal wall, interparietal and retroperitoneal, anatomy for successful repair. Mesh placement requires extensive dissection of often unfamiliar planes, and its fixation is difficult. We report our experience with open mesh repair of lateral abdominal wall hernias. A retrospective review of a prospectively maintained database was performed to identify patients with a classification of lateral abdominal wall hernia who underwent an open repair. A total of 61 patients underwent open lateral hernia repairs. Mean patient age was 58 years (range 25–78), with a mean body mass index of 32 kg/m2 (range 19.0–59.1). According to the European Hernia Society classification, defects were located subcostal (L1, 14 patients), flank (L2, 33 patients), iliac (L3, 11 patients), and lumber (L4, 3 patients). Mean defect size was 78.6 cm2, with a mean greatest single dimension of 9.2 cm (range 2–25 cm). Retromuscular or interparietal repair was performed in 50.8 per cent, preperitoneal in 41.0 per cent, intraperitoneal in 6.6 per cent, and onlay in 1.6 per cent. The rate of surgical site occurrence was 49.2 per cent, primarily seroma and surgical site infection rate was 13.1 per cent. With a mean follow-up of 15.4 months, seven patients (11.5%) have documented recurrence. Synthetic mesh reconstruction of lateral wall hernias is challenging. Our experience demonstrates the safety and success of repair using synthetic mesh primarily in the retromuscular, interparietal, or preperitoneal planes.

A Large Single-Center Experience of Open Lateral Abdominal Wall Hernia Repairs

Lateral abdominal wall hernias may occur after a variety of procedures, including anterior spine exposure, urologic procedures, ostomy closures, or after trauma. Anatomically, these hernias are challenging and require a complete understanding of abdominal wall, interparietal and retroperitoneal, anatomy for successful repair. Mesh placement requires extensive dissection of often unfamiliar planes, and its fixation is difficult. We report our experience with open mesh repair of lateral abdominal wall hernias. A retrospective review of a prospectively maintained database was performed to identify patients with a classification of lateral abdominal wall hernia who underwent an open repair. A total of 61 patients underwent open lateral hernia repairs. Mean patient age was 58 years (range 25-78), with a mean body mass index of 32 kg/m(2) (range 19.0-59.1). According to the European Hernia Society classification, defects were located subcostal (L1, 14 patients), flank (L2, 33 patients), iliac (L3, 11 patients), and lumber (L4, 3 patients). Mean defect size was 78.6 cm(2), with a mean greatest single dimension of 9.2 cm (range 2-25 cm). Retromuscular or interparietal repair was performed in 50.8 per cent, preperitoneal in 41.0 per cent, intraperitoneal in 6.6 per cent, and onlay in 1.6 per cent. The rate of surgical site occurrence was 49.2 per cent, primarily seroma and surgical site infection rate was 13.1 per cent. With a mean follow-up of 15.4 months, seven patients (11.5%) have documented recurrence. Synthetic mesh reconstruction of lateral wall hernias is challenging. Our experience demonstrates the safety and success of repair using synthetic mesh primarily in the retromuscular, interparietal, or preperitoneal planes.

Evolution and advances in laparoscopic ventral and incisional hernia repair

Primary ventral hernias and ventral incisional hernias have been a challenge for surgeons throughout the ages. In the current era, incisional hernias have increased in prevalence due to the very high number of laparotomies performed in the 20^th century. Even though minimally invasive surgery and hernia repair have evolved rapidly, general surgeons have yet to develop the ideal, standardized method that adequately decreases common postoperative complications, such as wound failure, hernia recurrence and pain. The evolution of laparoscopy and ventral hernia repair will be reviewed, from the rectoscopy of the 4^th century to the advent of laparoscopy, from suture repair to the evolution of mesh reinforcement. The nuances of minimally invasive ventral and incisional hernia repair will be summarized, from preoperative considerations to variations in intraoperative practice. New techniques have become increasingly popular, such as primary defect closure, retrorectus mesh placement, and concomitant component separation. The advent of robotics has made some of these repairs more feasible, but only time and well-designed clinical studies will tell if this will be a durable modality for ventral and incisional hernia repair.

Surgical Site Occurrences of Simultaneous Panniculectomy and Incisional Hernia Repair

Horizontal panniculectomy (PAN) offers the advantage of wide exposure for hernia repair with elimination of excess skin and adiposity, at the expense of massive subcutaneous flap creation and its attendant risks. We report our experience with ventral hernia repair (VHR) with PAN compared with patients with hernia repair alone. A prospective database was reviewed retrospectively for all patients undergoing open VHR + PAN. A matched cohort of patients without PAN was used for comparison, resulting in 43 study and 43 control patients. Incidence of surgical site occurrences (SSO), surgical site infection (SSI), and recurrence were analyzed. A total of 43 patients underwent PAN + VHR with mesh. Mean body mass index was 34.3 kg/m2, with 35 per cent having undergone prior bariatric surgery. Repair techniques included retromuscular (74.4%), preperitoneal (11.6%), intraperitoneal (6.9%), onlay (4.6%), and suture (2.3%). Mesh used was polypropylene (76.7%), polyester (18.6%), bioabsorbable (2.3%), and polytetrafluoroethylene (ePTFE) (2.3%). Component separation was performed in 44.2 per cent of patients. There was a significant difference in total SSO between PAN + VHR and VHR alone (46.5% vs 27.9%; P < 0.001), though the difference for individual SSOs was not significant. There was no difference in SSI between groups (16.3% vs 20.9%; P = 0.776). Mean follow-up was 11.4 months, with recurrence rate of 11.6 per cent in the PAN group and 9.3 per cent in the control group ( P = 0.725). Panniculectomy at the time of VHR does not increase the incidence of SSI, though higher rates of skin necrosis and cellulitis were seen. There is no difference in recurrence. This approach is a valid option for patients with excessive abdominal panniculus requiring VHR.

Open retromuscular mesh repair of complex incisional hernia: predictors of wound events and recurrence

BACKGROUND

Mesh repair of incisional hernias has been consistently shown to diminish recurrence rates after repair, with an increased risk of infectious complications. We present a consecutive series of elective, retrorectus mesh repairs of the abdominal wall and attempt to determine predictors of wound events and recurrence.

STUDY DESIGN

A retrospective review was performed to include elective, retromuscular mesh repairs of complex incisional hernias from August 2006 to August 2013. Demographics, operative details, and postoperative events including wound events, surgical site infections (SSI), and recurrences were recorded.

RESULTS

Over the 7-year period, 255 retromuscular mesh repairs of midline incisional defects were performed. Median age of the patients was 58 years, with an average BMI of 32.2 kg/m(2). Average size of the fascial defect was 181.4 cm(2), with recurrent defects making up 48% of repairs. Wound events occurred in 37.7% of cases; SSIs occurred in 19.6% of cases. Recurrence rate was 16.9%, with mean time to recurrence of 19.2 months. With respect to mesh type, recurrences were 16.2% with synthetic, 17.1% for bioabsorbable, and 25% for biologic mesh. When evaluating polypropylene meshes, recurrence was more likely with lightweight mesh (22.9%) vs midweight mesh (10.6%) (p = 0.045). Predictors of SSI included history of mesh infection (odds ratio [OR] 4.8, 95% CI 1.9 to 12.1; p < 0.001) and recurrent repairs (OR 2.5, 95% CI 1.1 to 5.8; p < 0.05). The only predictor of recurrence was the presence of an SSI (OR 3.1, 95% CI 1.5 to 6.3; p < 0.01).

CONCLUSIONS

Wound events are common after open mesh repairs of complex incisional hernias. Previous mesh infections and recurrent repairs increase the likelihood of an SSI, which significantly increases the risk of recurrence. Recurrences after retrorectus mesh repairs are significantly higher with lightweight compared with mid-weight meshes.

Concomitant sublay mesh repair of umbilical hernia and abdominoplasty

Concomitant mesh repair of large umbilical hernias and abdominoplasty pose a serious risk of devascularizing the umbilical stalk. A technique of placing mesh in a sublay manner, deep to the fascial defect, for an umbilical herniorrhaphy to avoid damage to the deep umbilical perforators during an abdominoplasty is described.

Criteria for definition of a complex abdominal wall hernia

PURPOSE

A clear definition of "complex (abdominal wall) hernia" is missing, though the term is often used. Practically all "complex hernia" literature is retrospective and lacks proper description of the population. There is need for clarification and classification to improve patient care and allow comparison of different surgical approaches. The aim of this study was to reach consensus on criteria used to define a patient with "complex" hernia.

METHODS

Three consensus meetings were convened by surgeons with expertise in complex abdominal wall hernias, aimed at laying down criteria that can be used to define "complex hernia" patients, and to divide patients in severity classes. To aid discussion, literature review was performed to identify hernia classification systems, and to find evidence for patient and hernia variables that influence treatment and/or prognosis.

RESULTS

Consensus was reached on 22 patient and hernia variables for "complex" hernia criteria inclusion which were grouped under four categories: "Size and location", "Contamination/soft tissue condition", "Patient history/risk factors", and "Clinical scenario". These variables were further divided in three patient severity classes ('Minor', 'Moderate', and 'Major') to provide guidance for peri-operative planning and measures, the risk of a complicated post-operative course, and the extent of financial costs associated with treatment of these hernia patients.

CONCLUSION

Common criteria that can be used in defining and describing "complex" (abdominal wall) hernia patients have been identified and divided under four categories and three severity classes. Next step would be to create and validate treatment algorithms to guide the choice of surgical technique including mesh type for the various complex hernias.

The Need for Fundoplication at the Time of Laparoscopic Paraesophageal Hernia Repair

Most authors recommend an antireflux operation at the time of laparoscopic paraesophageal hernia (PEH) repair. A fundoplication combats the potential postoperative reflux resulting from disruption of the hiatal anatomy and may minimize recurrence. The purpose of this study is to evaluate the differences in postoperative dysphagia, reflux symptoms, and hiatal hernia recurrence in patients with and without a fundoplication at the time of laparoscopic paraesophageal hernia repair. Patients undergoing laparoscopic PEH repair from July 2006 to June 2012 were identified. Open repairs and reoperative cases were excluded. Patient characteristics, operative details, complications, and postoperative outcomes were recorded. Over the six-year period, 152 laparoscopic PEH repairs were performed. Mean age was 65.8 years (range, 31 to 92) and average body mass index was 29.9 kg/m2 (range, 18 to 52 kg/m2). Concomitant fundoplication was performed in 130 patients (86%), which was determined based on preoperative symptoms and esophageal motility. Mean operative times were similar with fundoplication (188 minutes) and without (184.5 minutes). At a mean follow-up of 13.9 months, there were 19 recurrences: 12.3 per cent (16 of 130) in the fundoplication group and 13.6 per cent (three of 22) in those without. Dysphagia lasting greater than six weeks was present in eight patients in the fundoplication group (6.2%) and in none in those without ( P = 0.603). Eighteen percent of patients without a fundoplication reported postoperative reflux compared with 5.4 per cent of patients with a fundoplication ( P = 0.055). In the laparoscopic repair of PEH, the addition of a fundoplication minimizes postoperative reflux symptoms without additional operative time. Neither dysphagia nor hiatal hernia recurrence is affected by the presence of a fundoplication.