Emergent Laparoscopic Ventral Hernia Repairs

BACKGROUND

Emergent repairs of incarcerated and strangulated ventral hernia repairs (VHR) are associated with higher perioperative morbidity and mortality than those repaired electively. Despite increasing utilization of minimally invasive techniques in elective repairs, the role for laparoscopy in emergent VHR is not well defined, and its feasibility has been demonstrated only in single center studies.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database (2009-2016) was queried for emergent VHR. Laparoscopic and open techniques were compared using univariate and multivariate analyses.

RESULTS

A total of 11,075 patients who underwent emergent ventral and incisional hernia repairs were identified: 85.5% open ventral hernia repair (OVHR), 14.5% laparoscopic ventral hernia repair (LVHR). Patients who underwent emergent OVHRs were older, more comorbid, and more likely to be septic at the time of surgery than those undergoing emergent LVHRs. Emergent OVHR patients were more likely to have minor complications (22.1% versus 11.0%; OR 1.7; 95% CI 1.069-2.834). After controlling for confounding variables, LVHR and OVHR had similar outcomes, with the exception of higher rates of superficial surgical site infection in OVHR (5.0% versus 1.8%; odd's ratio (OR) 2.7; 95% confidence interval (CI) 1.176-6.138). Following multivariate analysis, laparoscopic approach demonstrated similar outcomes in major complications, reoperation, and 30-d mortality compared to open repairs. However, when controlling for other confounding factors, LVHR had reduced length of stay compared to OVHR (6.7 versus 4.0 d; 1.6 d longer, standard error 0.77, P < 0.03).

CONCLUSIONS

Emergent LVHR is associated with fewer superficial surgical site infection and shorter length of stay than OVHR but no difference in major complications, reoperation or 30-d mortality is associated with LVHR in the emergency setting.

Laparoscopic versus open surgery for the repair of congenital duodenal obstructions in infants and children

BACKGROUND

Laparoscopic repair of congenital duodenal obstruction (LCDO) was described more than 15 years ago. However, studies comparing outcomes of LCDO with open repair (OCDO) are rare. Standardized assessments of complications using the Clavien-Dindo classification (CDC) and the comprehensive complication index (CCI) are not available.

METHODS

All patients undergoing OCDO or LCDO between 2004 and 2017 were identified from the institutional database by retrospective analysis. Postoperative outcomes were assessed, including all complications using the CDC and the CCI.

RESULTS

Forty-seven consecutive patients were identified; 27 patients underwent LCDO and 20 patients had OCDO. Both groups did not differ regarding demographics, associated congenital anomalies, intraoperative pathologic findings, and operative procedures. LCDO was associated with a longer operative time [mean (SD), 202 (89) vs. 112 (41) min, P < 0.0001], shorter time to initiation of feeds [median (range), 1 (0-4) vs. 3 (1-12) days, P = 0.0027], and shorter time to full feeds [mean (SD), 8.2 (4.1) vs. 12.2 (6.4) days, P = 0.0243] compared to OCDO. Shorter length of postoperative hospital stay in LCDO group was achieved for patients without cardiac anomalies [mean (SD), 9.4 (3.1) days in LCDO group vs. 17.2 (9.4) days in OCDO, P = 0.0396] and patients without other anomalies [median (range), 12 (3-38) days in LCDO group vs. 21 (7-31) days in OCDO, P = 0.0460]. LCDO was associated with a lower CCI [median (range) 0 (0-39.7) vs. 4.3 (0-100), P = 0.0270].

CONCLUSIONS

Despite a longer operative time for LCDO, a number of advantages of LCDO over OCDO were recognized comparing both approaches in the repair of congenital duodenal obstruction. Such advantages include a lower morbidity, reduced time to initiation and completion of full enteral feeds, and shorter length of postoperative hospitalization for patients without concomitant cardiac anomalies and for patients without other anomalies when operated laparoscopic. In view of the present results, LCDO, performed in selected patients, appears to represent a viable alternative to OCDO.

Laparoscopic versus open ventral hernia repair: longitudinal outcomes and cost analysis using statewide claims data

BACKGROUND

There is still considerable debate regarding the best operative approach to ventral hernia repair. Using two large statewide databases, this study sought to evaluate the longitudinal outcomes and associated costs of laparoscopic and open ventral hernia repair.

METHODS

All patients undergoing elective ventral hernia repair from 2007-2011 were identified from inpatient discharge data from California and New York. In-hospital morbidity, in-hospital mortality, incidence of readmission, and incidence of revisional ventral hernia repair were evaluated as a function of surgical technique. The associated costs of medical care for laparoscopic versus open ventral hernia repair were evaluate for both the index procedure and all subsequent admissions and procedures within the study period.

RESULTS

A total of 13,567 patients underwent elective ventral hernia repair with mesh; 9228 (69%) underwent OVHR and 4339 (31%) underwent LVHR. At time of the index procedure, LVHR was associated with a lower incidence of reoperation (OR 0.29, CI 0.12-0.58, p = 0.001), wound disruption (OR 0.35, CI 0.16-0.78, p = 0.01), wound infection (OR 0.50, CI 0.25-0.70, p < 0.001), blood transfusion (OR 0.47, CI 0.36-0.61, p < 0.001), ARDS (OR 0.74, CI 0.54-0.99, p < 0.05), and total index visit complications (OR 0.72, CI 0.64-0.80, p < 0.001). LVHR was associated with significantly fewer readmissions (OR 0.81, CI 0.75-0.88, p < 0.001) and a lower risk for revisional VHR (OR 0.75, CI 0.64-0.88, p < 0.001). LVHR was associated with lower total costs at 1 year ($3451, CI 1892-5011, p < 0.001).

CONCLUSIONS

Open ventral hernia repair was associated with a higher incidence of perioperative complications, postoperative readmissions and need for revisional hernia repair when compared to laparoscopic ventral hernia repair, even when controlling for patient sociodemographics. In congruence, open ventral hernia repair was associated with higher costs for both the index hernia repair and tallied over the length of follow-up for readmissions and revisional hernia repair.