RESUMO
INTRODUCTION: Individuals diagnosed with connective tissue disorders (CTD) are known to be predisposed to incisional hernia formation. However, there is a scarcity of data on outcomes for these patients undergoing hernia repair. We sought to describe our outcomes in performing abdominal wall reconstructions in these complex patients. METHODS: Adult patients with CTD undergoing open, elective, posterior component separation with permanent synthetic mesh at our institution from January 2018 to October 2022 were queried from a prospectively collected database in the Abdominal Core Health Quality Collaborative. We evaluated 30-day wound morbidity, perioperative complications, long-term hernia recurrence, and patient-reported quality of life. RESULTS: Twelve patients were identified. Connective tissue disorders included Marfan's n = 7 (58.3%), Loeys-Dietz syndrome n = 2 (16.7%), Systemic Lupus Erythematosus n = 2 (16.7%), and Scleroderma n = 1 (8.3%). Prior incisions included three midline laparotomies and nine thoracoabdominal, mean hernia width measured 14 cm, and 9 were recurrent hernias. Surgical site occurrences (SSOs) were observed in 25% of cases, and 16.7% necessitated procedural intervention. All twelve patients were available for long-term follow-up, with a mean of 34 (12-62) months. There were no instances of reoperation or mesh excision related to the TAR procedure. One patient developed a recurrence after having his mesh violated for repair of a new visceral aneurysm. Mean HerQLes scores at 1 year were 70 and 89 at ≥ 2 years; Mean scaled PROMIS scores were 30.7 at 1 year and 36.3 at ≥ 2 years. CONCLUSION: Ventral hernia repair with TAR is feasible in patients with connective tissue disorder and can be a suitable alternative in patients with large complex hernias.
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Doenças do Tecido Conjuntivo , Herniorrafia , Telas Cirúrgicas , Humanos , Feminino , Masculino , Doenças do Tecido Conjuntivo/complicações , Doenças do Tecido Conjuntivo/cirurgia , Adulto , Pessoa de Meia-Idade , Herniorrafia/métodos , Parede Abdominal/cirurgia , Hérnia Ventral/cirurgia , Hérnia Incisional/cirurgia , Recidiva , Qualidade de Vida , Estudos Retrospectivos , Complicações Pós-Operatórias , Idoso , Resultado do TratamentoRESUMO
BACKGROUND: Recurrent ventral hernia repair can be challenging due to scarred tissue planes and the increasing complexity of disease related to multiple recurrences. Given the challenges of acquiring complete and accurate prior operative reports, surgeons often rely on computed tomography (CT) scans to obtain information and plan for re-operation. Still, the contribution of CT scans and the ability of surgeons to interpret them is controversial. Previously, we examined the ability of surgeons to determine prior operative techniques based on CT scans. Here, we assessed the accuracy of expert abdominal wall reconstruction (AWR) surgeons in identifying the type of prior mesh using CT imaging. METHODS: A total of 22 highly experienced AWR surgeons were asked to evaluate 21 CT scans of patients who had undergone open ventral hernia repair with bilateral transversus abdominis release utilizing mesh. The surgeons were required to identify the mesh type from a multiple-choice selection. Additionally, negative controls (patients without a history of prior laparotomy) and positive controls (patients with laparotomy but no ventral hernia repair) were incorporated. The accuracy of the surgeons and interrater reliability was calculated. RESULTS: The accuracy rate of the surgeons in correctly identifying the mesh type was 46%, with heavy-weight synthetic mesh (HWSM) being identified only 35.4% of the time, Strattice mesh and medium-weight synthetic mesh (MWSM) were identified at 46.3%, and 51.8%, respectively. The interrater reliability analysis found a moderate level of agreement 0.428 (95% CI 0.356-0.503), and the repeatability measure was poor-0.053 (95% CI 0-0.119); this indicates that surgeons cannot reliably replicate the identification process. CONCLUSIONS: Surgeons' ability to accurately identify the type of previous mesh using CT scans is poor. This study underscores the importance of documenting the type of mesh used in the operative report and the need for standardized operative notes to improve the accuracy and consistency of documentation.
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Hérnia Ventral , Herniorrafia , Telas Cirúrgicas , Tomografia Computadorizada por Raios X , Humanos , Hérnia Ventral/cirurgia , Hérnia Ventral/diagnóstico por imagem , Cirurgiões , Reprodutibilidade dos Testes , Competência Clínica , Feminino , MasculinoRESUMO
PURPOSE: Heavyweight polypropylene (HWPP) mesh is thought to increase inflammatory response and delay tissue integration compared to mediumweight (MWPP). Reactive fluid volume (i.e., drain output) may be a reasonable surrogate for integration. We hypothesized that daily drain output is higher with HWPP compared to MWPP in open retromuscular ventral hernia repair (VHR). METHODS: This is a post-hoc analysis of a multicenter, randomized clinical trial conducted March 2017-April 2019 comparing MWPP and HWPP for VHR. Retromuscular drain output in milliliters was measured at 24-h intervals up to postoperative day seven. Univariate analyses compared differences in daily drain output and time to drain removal. Multivariable analyses compared total drain output and wound morbidity within 30 days and hernia recurrence at 1 year. RESULTS: 288 patients were included; 140 (48.6%) HWPP and 148 (51.4%) MWPP. Daily drain output for days 1-3 was higher for HWPP vs. MWPP (total volume: 837.8 mL vs. 656.5 mL) (p < 0.001), but similar on days 4-7 (p > 0.05). Median drain removal time was 5 days for both groups. Total drain output was not predictive of 30-day wound morbidity (p > 0.05) or hernia recurrence at 1 year (OR 1, p = 0.29). CONCLUSION: While HWPP mesh initially had higher drain outputs, it rapidly returned to levels similar to MWPP by postoperative day three and there was no difference in clinical outcomes. We believe that drains placed around HWPP mesh can be managed similarly to MWPP mesh.
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Hérnia Ventral , Polipropilenos , Humanos , Telas Cirúrgicas/efeitos adversos , Herniorrafia/efeitos adversos , Hérnia Ventral/cirurgia , DrenagemRESUMO
PURPOSE: Abdominally based autologous breast reconstruction (ABABR) is common after mastectomy, but carries a risk of complex abdominal wall hernias. We report experience with posterior component separation (PCS) and transversus abdominis release (TAR) with permanent synthetic mesh repair of ABABR-related hernias. METHODS: Patients at Cleveland Clinic Foundation and Penn State Health were identified retrospectively. Outcomes included postoperative complications, hernia recurrence, and patient-reported outcomes (PROs): Hernia Recurrence Inventory, HerQLes Summary Score, Patient-Reported Outcome Measurement Information System (PROMIS) Pain Intensity 3a Survey, and the Decision Regret Scale (DRS). RESULTS: Forty patients underwent PCS/TAR repair of hernias resulting from pedicled (35%), free (5%), muscle-sparing TRAMs (15%), and DIEPs (28%) from August 2014 to March 2021. Following PCS, 30-day complications included superficial surgical site infection (13%), seroma (8%), and superficial wound breakdown (5%). Five patients (20%) developed clinical hernia recurrence. At a minimum of 1 year, 17 (63%) reported a bulge, 12 (44%) reported pain, median HerQLes Quality Of Life Scores improved from 33 to 63/100 (p value < 0.01), PROMIS 3a Pain Intensity Scores improved from 52 to 38 (p value < 0.05), and DRS scores were consistent with low regret (20/100). CONCLUSION: ABABR-related hernias are complex and technically challenging due to missing abdominal wall components and denervation injury. After repair with PCS/TAR, patients had high rates of recurrence and bulge, but reported improved quality of life and pain and low regret. Surgeons should set realistic expectations regarding postoperative bulge and risk of hernia recurrence.
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Parede Abdominal , Neoplasias da Mama , Hérnia Ventral , Hérnia Incisional , Mamoplastia , Humanos , Feminino , Músculos Abdominais/cirurgia , Hérnia Ventral/cirurgia , Estudos Retrospectivos , Qualidade de Vida , Neoplasias da Mama/complicações , Neoplasias da Mama/cirurgia , Herniorrafia/efeitos adversos , Herniorrafia/métodos , Resultado do Tratamento , Mastectomia/efeitos adversos , Recidiva Local de Neoplasia/cirurgia , Parede Abdominal/cirurgia , Mamoplastia/efeitos adversos , Dor/cirurgia , Telas Cirúrgicas/efeitos adversos , Recidiva , Hérnia Incisional/etiologia , Hérnia Incisional/cirurgiaRESUMO
INTRODUCTION: Ventral hernia repair (VHR) outcomes can be adversely affected by modifiable patient co-morbidities, such as diabetes, obesity, and smoking. Although this concept is well accepted among surgeons, the extent to which patients understand the significance of their co-morbidities is unknown, and a few studies have sought to determine patient perspectives regarding the impact of their modifiable co-morbidities on their post-operative outcomes. We attempted to determine how accurately patients predict their surgical outcomes after VHR compared to a surgical risk calculator while considering their modifiable co-morbidities. METHODS: This is a prospective, single-center, survey-based study evaluating patients' perceptions of how their modifiable risk factors affect outcomes after elective ventral hernia repair. Pre-operatively, after surgeon counseling, patients predicted the percentage of impact that they believed their modifiable co-morbidities (diabetes, obesity, and smoking) had on 30-day surgical site infections (SSI) and hospital readmissions. Their predictions were compared to the Outcomes Reporting App for CLinicians and Patient Engagement (ORACLE) surgical risk calculator. Results were analyzed using demographic information. RESULTS: 222 surveys were administered and 157 were included in the analysis after excluding for incomplete data. 21% had diabetes, 85% were either overweight with body mass index (BMI) 25-29.9 or obese (BMI ≥ 30), and 22% were smokers. The overall mean SSI rate was 10.8%, SSOPI rate was 12.7%, and 30-day readmission rate was 10.2%. ORACLE predictions correlated with observed SSI rates (OR 1.31, 95% CI 1.12-1.54, p < 0.001), but patient predictions did not (OR 1.00, 95% CI 0.98-1.03, p = 0.868). The correlation between patient predictions and ORACLE calculations was weak ([Formula: see text] = 0.17). Patient predictions were on average 10.1 ± 18.0% different than ORACLE, and 65% overestimated their SSI probability. Similarly, ORACLE predictions correlated with observed 30-day readmission rates (OR 1.10, 95% CI 1.00-1.21, p = 0.0459), but patient predictions did not (OR 1.00, 95% CI 0.975-1.03, p = 0.784). The correlation between patient predictions and ORACLE calculations for readmissions was weak ([Formula: see text] = 0.27). Patient predictions were on average 2.4 ± 14.6% different than ORACLE, and 56% underestimated their readmission probability. Additionally, a substantial proportion of the cohort believed that they had a 0% risk of SSI (28%) and a 0% risk of readmission (43%). Education, income and healthcare employment did not affect the accuracy of patient predictions. CONCLUSIONS: Despite surgeon counseling, patients do not accurately estimate their risks after VHR when compared to ORACLE. Most patients overestimate their SSI risk and underestimate their 30-day readmission risk. Furthermore, several patients believed that they had a 0% risk of SSI and readmission. These findings persisted regardless of level of education, income level, or healthcare employment. Additional attention should be directed toward setting expectations prior to surgery and using applications such as ORACLE to assist in this process.
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Hérnia Ventral , Herniorrafia , Humanos , Estudos Prospectivos , Herniorrafia/efeitos adversos , Herniorrafia/métodos , Hérnia Ventral/epidemiologia , Hérnia Ventral/cirurgia , Hérnia Ventral/complicações , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/cirurgia , Fatores de Risco , Obesidade/complicações , Obesidade/epidemiologia , Estudos RetrospectivosRESUMO
BACKGROUND: Recurrent ventral hernia repair can be complex and requires a thorough understanding of prior interventions, myofascial releases, and location of prosthetic material. Without detailed operative reports, this information can be challenging to obtain, and some surgeons have suggested prior operative details can be discerned from radiographic imaging. We evaluated the accuracy and interrater reliability of surgeons to identify the type of prior VHR using CT imaging. METHODS: Fifteen expert abdominal wall reconstruction surgeons individually reviewed 21 CT scans of patients after various VHR approaches and determined the approach from a multiple-choice selection. Negative controls (no prior laparotomy) and positive controls (laparotomy without VHR) were also included. Surgeon accuracy and interrater reliability were measured. RESULTS: Surgeons were unable to identify the correct VHR over 50% of the time: open TAR and Rives-Stoppa were identified 42% of the time, open anterior component separation 24%, and robotic IPOM and eTEP 22% of the time, respectively. Surgeon interrater reliability, or agreement on answers-whether correct or incorrect-was fair (coefficient 0.23, p = 0.01). CONCLUSIONS: Surgeons' ability to accurately identify the type of previous VHR using post-operative CT scans is poor. Without the knowledge of prior repairs, surgeons may find it difficult to choose the best reoperative approach, anticipate operative complexities, and schedule appropriate OR time. All of which guides patient counseling and expectations. This highlights the importance to accurately reflect VHR details in operative reports and use necessary resources to obtain operative reports, since surgeons cannot reliably use CT scans to identify prior repairs.
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Hérnia Ventral , Cirurgiões , Humanos , Hérnia Ventral/cirurgia , Reprodutibilidade dos Testes , Músculos Abdominais/cirurgia , Herniorrafia/métodos , Tomografia Computadorizada por Raios X , Telas Cirúrgicas , Estudos RetrospectivosRESUMO
PURPOSE: Excessive post-operative opioid prescribing has led to efforts to match prescriptions with patient need after surgery. We investigated opioid prescribing practices, rate of patient-requested opioid refills, and associated factors after laparoscopic inguinal hernia repair (LIHR). METHODS: LIHRs at a single institution from 3/2019 to 3/2021 were queried from the Abdominal Core Health Quality Collaborative for demographics, perioperative details, and patient-reported opioid usage. Opioid prescriptions at discharge and opioid refills were extracted from the medical record. Univariate and multivariable regression were used to identify factors associated with opioid refills within 30-days of surgery. RESULTS: Four hundred and ninety LIHR patients were analyzed. The median number of opioid tablets prescribed was 12 [interquartile range (IQR) 10-15], and 4% requested a refill. On univariate analysis, patients who requested refills were younger [55 years (IQR 37-61) vs. 62 years (IQR 36.8-61), p = 0.012], more likely to have undergone transabdominal preperitoneal repair (75% vs. 26.4%, p < 0.001), have a scrotal component (30% vs. 11%, p = 0.022), and have permanent tacks used (80% vs. 49.4%, p = 0.014). There was a 12% increase in the odds of opioid refill for every 1 tablet of oxycodone prescribed at discharge (95% CI for OR 1.04-1.21, p = 0.003) after controlling for age and surgery type. Patient-reported opioid use was available for 289 (59%) patients. Post-operatively, 67% of patients used ≤ 4 opioid tablets, and 87% used no more than 10 opioid tablets. CONCLUSION: Most patients use fewer opioid tablets than prescribed. Requests for opioid refills are rare following LIHR (4%) and associated with higher opioid prescribing.
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Hérnia Inguinal , Laparoscopia , Masculino , Humanos , Analgésicos Opioides/uso terapêutico , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/etiologia , Hérnia Inguinal/cirurgia , Hérnia Inguinal/etiologia , Herniorrafia/efeitos adversos , Padrões de Prática Médica , Estudos RetrospectivosRESUMO
BACKGROUND: Prehospital chlorhexidine gluconate (CHG) skin washes are used to prevent wound complications, but little evidence supports this practice in hernia surgery. A propensity-matched retrospective review published by our group in 2016 found that prehospital CHG was associated with an increased risk of surgical site occurrences (SSO) and surgical site infections (SSI) after ventral hernia repair. Prehospital CHG was, therefore, abandoned by three of five surgeons at the Cleveland Clinic Foundation (CCF) by April 2017. We aimed to determine if discontinuation of prehospital CHG affected wound morbidity rates after incisional hernia repair. METHODS: The Abdominal Core Health Quality Collaborative was queried for all patients who underwent open, clean incisional hernia repairs with 30-day follow-up from 2014 to 2019. Using an interrupted time series (ITS) analysis model adjusted for group and mean propensity score, wound morbidity before and after April 1, 2017 (start of Q2) was compared between three groups: CCF surgeons who abandoned prehospital CHG (Group 1), CCF surgeons who continued using prehospital CHG (Group 2), and non-CCF surgeons using prehospital CHG (Group 3). Outcomes included rates of SSOs, SSIs, and surgical site occurrences requiring procedural intervention (SSOPI) at 30 days. RESULTS: In total, 4276 patients were included in the analysis (Group 1: 339 before Q2 vs 673 after Q2; Group 2: 211 before Q2 vs 175 after Q2; Group 3: 1312 before Q2 vs 1566 after Q2). Rates of SSO, SSIs, and SSOPIs at 30 days were similar across all three groups before and after prehospital CHG discontinuation. CONCLUSION: Stopping prehospital CHG wash did not result in increased wound morbidity after open, clean, incisional hernia repair. We have abandoned CHG use in this context.
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Serviços Médicos de Emergência , Hérnia Ventral , Hérnia Incisional , Humanos , Clorexidina , Hérnia Incisional/cirurgia , Melhoria de Qualidade , Herniorrafia/efeitos adversos , Herniorrafia/métodos , Hérnia Ventral/etiologia , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/prevenção & controle , Infecção da Ferida Cirúrgica/cirurgia , Estudos Retrospectivos , Morbidade , Telas Cirúrgicas/efeitos adversosRESUMO
PURPOSE: Chronic postoperative inguinal pain (CPIP), a complication of inguinal hernia repair, may negatively affect mental health. The rates of psychological disorders in patients with CPIP are unknown. We aimed to describe the prevalence of psychological disorders coinciding with CPIP. METHODS: A retrospective chart review was performed of all patients seen at the Cleveland Clinic Center for Abdominal Core Health's inter-disciplinary Chronic Groin Pain Clinic. This clinic is unique in that all patients are evaluated by a surgeon, a sonographer and radiologist, and a behavioral medicine psychologist. Patient psychological history and treatment, Depression Anxiety and Stress Scale (DASS) scores, pain catastrophizing, and trauma or abuse history were captured. RESULTS: From January 2018 to January 2022, 61 patients were evaluated and included in the study. Psychological treatment had been provided to 37 (61%) patients (present: 16 (27%), past: 21 (35%)). The most common psychological disorders represented were depression (N = 13, 22%), anxiety (N = 10, 17%), and post-traumatic stress disorder (N = 5, 8%). DASS scores indicated that 20 (33%) patients were reporting symptoms of depression and 16 (27%) patients were reporting symptoms of anxiety. Of the 40 patients assessed for pain catastrophizing, 28 (70%) reported rumination, 9 (23%) reported magnification, and 23 (58%) reported feelings of helplessness. A childhood history of emotional or physical abuse was reported by 11 (18%) patients. CONCLUSION: An inter-disciplinary groin pain clinic has revealed that patients with CPIP frequently have pre-existing complex psychosocial issues. A multi-specialty approach to CPIP may improve preoperative assessments and identify patients who may benefit from further psychological evaluation and treatment.
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Dor Crônica , Hérnia Inguinal , Humanos , Criança , Virilha/cirurgia , Estudos Retrospectivos , Dor Crônica/epidemiologia , Dor Crônica/etiologia , Herniorrafia/efeitos adversos , Dor Pós-Operatória/epidemiologia , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/diagnóstico , Hérnia Inguinal/complicaçõesRESUMO
PURPOSE: Seromas can occur after ventral hernia repairs (VHR), but little is known about their relevance to short- and long-term outcomes. We aimed to determine if there is a correlation between seroma occurrence after clean VHR with mesh and patient-reported and clinical outcomes. METHODS: Patients with and without seromas in the Abdominal Core Health Quality Collaborative registry were compared using a propensity score-matched analysis. Outcomes included hospital readmissions, postoperative antibiotics use, and procedural interventions. Pain and hernia-related quality of life were assessed at 30 days and 1 year. Composite hernia recurrence rates were compared at 1 year. RESULTS: Propensity score matching compared 218 patients with a seroma to 649 without a seroma. At 30 days, patients with seromas were more likely to be readmitted (27 (12%) vs 28 (4%), respectively; P < 0.001), receive postoperative antibiotics (25 (12%) vs 18 (3%), respectively; P < 0.001), and undergo procedural interventions (41 (19%) vs 23 (4%), respectively; P < 0.001) than patients without seromas. Surgical site occurrences were more common in patients with seromas than those without seromas at 1 year (12 (11%) vs 12 (4%), respectively; P = 0.01).Pain and hernia-related quality of life were similar for both groups at 30 days and 1 year. Composite hernia recurrence rates were similar for both groups at 1 year (37 seroma (17%) vs 115 no seroma (18%); P = 0.80). CONCLUSION: Seromas after clean VHR with mesh were associated with short- and long-term morbidity, but they did not significantly impact quality of life or hernia recurrences at 1 year.
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Hérnia Ventral , Complicações Pós-Operatórias , Humanos , Complicações Pós-Operatórias/epidemiologia , Pontuação de Propensão , Qualidade de Vida , Herniorrafia , Telas Cirúrgicas , Hérnia Ventral/cirurgia , Seroma , Antibacterianos , Recidiva , Estudos RetrospectivosRESUMO
BACKGROUND: Drains may be placed during robotic retromuscular ventral hernia repair (rVHR) to decrease wound morbidity, but their use is controversial. We aimed to assess the impact of retromuscular drain placement on wound morbidity after robotic rVHR. METHODS: Patients with and without drains after robotic rVHR in the Abdominal Core Health Quality Collaborative (ACHQC) registry were compared using a propensity score-matched analysis. Outcomes included surgical site occurrences (SSO), surgical site infections (SSI), and surgical site occurrences requiring procedural interventions (SSOPI) at 30 days. RESULTS: Propensity score matching compared 580 patients with drains to 580 without drains. The groups were well matched with respect to hernia width (drain: 8.0 cm [IQR 6.0; 10.0] vs no drain: 8.0 cm [IQR 5.0; 10.0]; P = 0.399) and transversus abdominis release (drain: 409 (70.5%) vs no drain: 408 (70.3%); P = 0.949). At 30 days, patients with drains had fewer seromas than those without drains (22 (3.8%) vs 88 (15.2%); P < 0.0001). Rates of SSIs and SSOPIs were similar between the two groups at 30 days. Logistic regression analysis showed drain placement lowered the risk of an SSO compared to no drain placement (OR 0.32, CI 0.21-0.47; P < 0.0001). Hospital stay was longer for patients with drains than those without drains (2.0 days [IQR 1.0; 3.0] vs 1.0 day [IQR 1.0; 2.0], respectively; P < .0001). CONCLUSION: Drain placement during robotic rVHR is associated with decreased postoperative seroma occurrence.
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Hérnia Ventral , Procedimentos Cirúrgicos Robóticos , Humanos , Procedimentos Cirúrgicos Robóticos/métodos , Pontuação de Propensão , Herniorrafia/métodos , Telas Cirúrgicas , Hérnia Ventral/cirurgia , Seroma , Estudos RetrospectivosRESUMO
PURPOSE: Incisional hernia is the most common complication of midline laparotomy. Although obesity is a known risk factor, the incidence of hernia formation in obese patients is not well defined. We sought to define the rate of incisional hernia formation in obese patients undergoing primary midline laparotomy in a large academic medical center. METHODS: Obese patients (BMI ≥ 30 kg/m2) who underwent an elective or urgent primary midline laparotomy from 2017 to 2021 at our institution were retrospectively identified. A blinded hernia surgeon reviewed imaging to assess for incisional hernia formation, defined as a midline fascial defect with intra-abdominal contents herniated outside of the peritoneal cavity. RESULTS: A total of 2241 patients met inclusion criteria. Cross-sectional imaging was available for 914 (41%) of these patients. The median BMI for all patients was 34.3 kg/m2 (range 30.0-59.1). Median time to follow-up imaging was 316 days (181-957, IQR = 185) for all patients and 316 days (201-903, IQR = 184) for patients with incisional hernia. In total, 474 (51.9%) had radiographic evidence of an incisional hernia. Colorectal and General Surgery demonstrated the highest rate of incisional hernia (p < 0.001). During the study period, 138 patients (15.1%) underwent surgical repair of their hernia at our institution, with the highest percentage being Colorectal Surgery patients. CONCLUSION: There is a high rate of hernia formation and subsequent hernia repair in obese patients undergoing midline laparotomy. Most importantly, these findings demonstrate an immediate and pressing need to identify the patient risk factors and technical issues related to this rate of hernia formation.
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Hérnia Incisional , Humanos , Hérnia Incisional/etiologia , Hérnia Incisional/epidemiologia , Estudos Retrospectivos , Laparotomia/efeitos adversos , Herniorrafia/efeitos adversos , Obesidade/complicaçõesRESUMO
BACKGROUND: More than half of patients undergoing paraesophageal hernia repair (PEHR) will have radiographic hernia recurrence at 5 years after surgery. Gastropexy is a relatively low-risk intervention that may decrease recurrence rates, but it has not been studied in a prospective manner. Our study aims to evaluate the effect of anterior gastropexy on recurrence rates after PEHR, compared to no anterior gastropexy. METHODS: This is a two-armed, single-blinded, registry-based, randomized controlled trial comparing anterior gastropexy to no anterior gastropexy in PEHR. Adult patients (≥18 years) with a symptomatic paraesophageal hernia measuring at least 5 cm in height on computed tomography, upper gastrointestinal series, or endoscopy undergoing elective minimally invasive repair are eligible for recruitment. Patients will be blinded to their arm of the trial. All patients will undergo laparoscopic or robotic PEHR, where some operative techniques (crural closure techniques and fundoplication use or avoidance) are left to the discretion of the operating surgeon. During the operation, after closure of the diaphragmatic crura, participants are randomized to receive either no anterior gastropexy (control arm) or anterior gastropexy (treatment arm). Two hundred forty participants will be recruited and followed for 1 year after surgery. The primary outcome is radiographic PEH recurrence at 1 year. Secondary outcomes are symptoms of gastroesophageal reflux disease, dysphagia, odynophagia, gas bloat, regurgitation, chest pain, abdominal pain, nausea, vomiting, postprandial pain, cardiovascular, and pulmonary symptoms as well as patient satisfaction in the immediate postoperative period and at 1-year follow-up. Outcome assessors will be blinded to the patients' intervention. DISCUSSION: This randomized controlled trial will examine the effect of anterior gastropexy on radiographic PEH recurrence and patient-reported outcomes. Anterior gastropexy has a theoretical benefit of decreasing PEH recurrence; however, this has not been proven beyond a suggestion of effectiveness in retrospective series. If anterior gastropexy reduces recurrence rates, it would likely become a routine component of surgical PEH management. If it does not reduce PEH recurrence, it will likely be abandoned. TRIAL REGISTRATION: ClinicalTrials.gov NCT04007952 . Registered on July 5, 2019.
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Gastropexia , Hérnia Hiatal , Laparoscopia , Adulto , Gastropexia/efeitos adversos , Hérnia Hiatal/complicações , Hérnia Hiatal/diagnóstico por imagem , Hérnia Hiatal/cirurgia , Herniorrafia/efeitos adversos , Herniorrafia/métodos , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Retrospectivos , Resultado do TratamentoRESUMO
PURPOSE: Obesity is known to result in increased morbidity and risk of hernia recurrence after ventral hernia repair; however, many patients lack the resources to pursue guided weight loss. We sought to evaluate the effectiveness of a free Weight Management Navigator (WMN) program on preoperative weight loss for patients with Class 2 or 3 obesity and complex ventral hernias seeking surgical repair. METHODS: From September 2019 and December 2020, all patients with BMI ≥ 35 kg/m2 and ventral hernias seeking surgical care were identified in outpatient clinics at a high-volume hernia center and were offered participation in a free WMN program by the attending surgeon. Descriptive analysis was performed to analyze participation in the program and average weight loss during study period. RESULTS: One hundred ninety one patients were identified. Most patients declined to participate in a weight loss program, were unable to be reached, or did not respond to the WMN (58.1%). Eighty patients enrolled in a WMN program, forty-four of which were lost to follow-up (55%). Seventeen patients underwent hernia repair, nine of which were enrolled in a WMN program. Mean weight loss for those enrolled in a program was 5.97 kg compared to 1.8 kg for those who did not participate (p = 0.01). CONCLUSION: Enrollment in weight loss programs was low despite encouragement from surgeons, free programs, and accessible platforms. Participation in the WMN correlated with more successful weight loss. Our findings suggest that inability to lose weight may be multifactorial. Further study should be devoted to determining other common barriers to weight loss.
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Hérnia Ventral , Programas de Redução de Peso , Hérnia Ventral/cirurgia , Herniorrafia/efeitos adversos , Humanos , Obesidade/complicações , Projetos Piloto , Estudos Retrospectivos , Resultado do Tratamento , Redução de PesoRESUMO
PURPOSE: Bowel injury during laparoscopic and robotic ventral hernia repair is a rare but potentially serious complication. We sought to compare bowel injury rates during minimally invasive approaches to ventral hernia repair using a national hernia registry. METHODS: Patients undergoing elective laparoscopic and robotic ventral hernia repair (including cases converted-to-open) between 2013 and 2021 were retrospectively identified in the Abdominal Core Health Quality Collaborative registry. The primary outcome was bowel injury, which included partial- and full-thickness injuries and re-operations for missed enterotomies. Statistical analysis was performed using multivariate logistic regression. RESULTS: Overall, 10,660 patients were included (4116 laparoscopic, 6544 robotic). The laparoscopic group included more incisional hernias (68% vs 62%, p < 0.001) and similar rates of recurrent hernias (23% vs 22%, p = 0.26). A total of 109 bowel injuries were identified, with more occurring in the laparoscopic group (55 [1.3%] laparoscopic vs. 54 [0.8%] robotic; p = 0.01). Specifically, there were more full-thickness and missed enterotomies in the laparoscopic group (29 laparoscopic vs. 20 robotic; p = 0.012). Bowel injury resulted in higher rates of wound morbidity and major post-operative complications including sepsis, re-admission, and re-operation. Following adjustment for recurrent and incisional hernias, prior mesh, patient age, and hernia width, bowel injury during laparoscopic repair remained significantly more likely than bowel injury during robotic repair (OR 1.669 [95% C.I.: 1.141-2.440]; p = 0.008). CONCLUSION: In a large registry, laparoscopic ventral hernia repair is associated with an increased risk of bowel injury compared to repairs utilizing the robotic platform. Knowing the limitations of retrospective research, large national registries are well suited to explore rare outcomes which cannot be feasibly assessed with randomized controlled trials.
Assuntos
Traumatismos Abdominais , Hérnia Ventral , Hérnia Incisional , Laparoscopia , Procedimentos Cirúrgicos Robóticos , Centro Abdominal , Traumatismos Abdominais/cirurgia , Hérnia Ventral/etiologia , Hérnia Ventral/cirurgia , Herniorrafia/efeitos adversos , Herniorrafia/métodos , Humanos , Hérnia Incisional/cirurgia , Laparoscopia/efeitos adversos , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Telas CirúrgicasRESUMO
PURPOSE: While the use of synthetic mesh for incisional hernia repair reduces recurrence rates, little evidence exists regarding the impact of this practice on the disease burden of a Crohn's patient. We aimed to describe the post-operative outcomes and healthcare resource utilization following incisional hernia repair with synthetic mesh in patients with Crohn's disease. METHODS: A retrospective review of adult patients with Crohn's disease who underwent elective open incisional hernia repair with extra-peritoneal synthetic mesh from 2014 to 2018 at a single large academic hospital with surgeons specializing in hernia repair was conducted. Primary outcomes included 30-day post-operative complications and long-term rates of fistula formation and hernia recurrence. The secondary outcome compared healthcare resource utilization during a standardized fourteen-month period before and after hernia repair. RESULTS: Among the 40 patients included, six (15%) required readmission, 4 (10%) developed a surgical site occurrence, 3 (7.5%) developed a surgical site infection, and one (2.5%) required reoperation within the first 30 days. The overall median follow-up time was 42 months (IQR = 33-56), during which time one (2.5%) patient developed an enterocutaneous fistula and eight (20%) experienced hernia recurrence. Healthcare resource utilization remained unchanged or decreased across every category following repair. CONCLUSION: The use of extra-peritoneal synthetic mesh during incisional hernia repair in patients with Crohn's disease was not associated with a prohibitively high rate of post-operative complications or an increase in healthcare resource utilization to suggest worsening disease during the first 4 years after repair. Future studies exploring the long-term outcomes of this technique are needed.
Assuntos
Doença de Crohn , Hérnia Ventral , Hérnia Incisional , Adulto , Doença de Crohn/complicações , Doença de Crohn/cirurgia , Atenção à Saúde , Hérnia Ventral/cirurgia , Herniorrafia/efeitos adversos , Herniorrafia/métodos , Humanos , Hérnia Incisional/etiologia , Hérnia Incisional/cirurgia , Recidiva , Estudos Retrospectivos , Telas Cirúrgicas/efeitos adversos , Resultado do TratamentoRESUMO
BACKGROUND: Transversus abdominis release (TAR) is increasingly used to address complex ventral hernias; consequently, associated complications are seen more frequently. Our hernia center has a growing experience with redo-transversus abdominis release (redo-TAR) to address large, complex hernia recurrences after failed TAR. Here, we describe our outcomes after abdominal wall reconstruction with redo-TAR. STUDY DESIGN: Adults undergoing elective open, redo-TAR at our institution from January 2015 to February 2021 were queried from a prospectively collected database in the Abdominal Core Health Quality Collaborative. The primary outcome was 30-day wound morbidity. Secondary outcomes were long-term composite hernia recurrence and patient-reported quality of life. RESULTS: Sixty-five patients underwent redo-TAR. Median age was 60 years, 50.8% were female, and median BMI 31.8 kg/m2. Median recurrent hernias were 16 cm wide by 25 cm long. Frequent mechanisms of recurrence included linea semilunaris injury (27.7%), mesh fracture (18.5%), infection (16.9%), and posterior sheath disruption (15.4%). Wound complications occurred in 33.8% and 16.9% required procedural intervention. With median clinical and PRO follow-up of 12 and 19 months, respectively, the composite hernia recurrence rate was 22.5% and patients reported significantly improved quality of life (HerQLes: median + 36.7, PROMIS: median - 9.5). CONCLUSION: Redo-TAR may be performed as a salvage procedure to reconstruct complex defects after failed TAR, however, in our center, it is associated with increased wound morbidity and fairly high composite recurrence rates. Despite this, patients report improvements in quality of life and pain. Tracking outcomes after TAR will facilitate understanding how to manage its failures.
Assuntos
Parede Abdominal , Hérnia Ventral , Músculos Abdominais/cirurgia , Parede Abdominal/cirurgia , Adulto , Feminino , Hérnia Ventral/cirurgia , Herniorrafia/efeitos adversos , Herniorrafia/métodos , Humanos , Pessoa de Meia-Idade , Qualidade de Vida , Recidiva , Telas Cirúrgicas , Resultado do TratamentoRESUMO
BACKGROUND: An enterocutaneous fistula (ECF) with an associated large hernia defect poses a significant challenge for the reconstructive surgeon. We aim to describe operative details and 30-day outcomes of elective hernia repair with an ECF when performed by surgeons participating in the Abdominal Core Health Quality Collaborative (ACHQC). STUDY DESIGN: Patients undergoing concomitant hernia and ECF elective repair were identified within the ACHQC. Outcomes of interest were operative details and 30-day rates of surgical site infections (SSI), surgical site occurrences requiring procedural intervention (SSOPI), medical complications, and mortality. RESULTS: 170 patients were identified (mean age 60 years, 52.4% females, mean BMI 32.3 kg/m2). 106 patients (62%) had small-bowel ECFs, mostly managed with resection without diversion. 30 patients (18%) had colonic ECFs, which were managed with resection without diversion (14%) or resection with diversion (6%). 100 (59%) had a prior mesh in place, which was removed in 90% of patients. Hernias measured 14 cm ± 7 in width, and 68 (40%) had a myofascial release performed (41 TARs). Mesh was placed in 115 cases (68%), 72% as a sublay, and more frequently of biologic (44%) or permanent synthetic (34%) material. 30-day SSI was 18% (37% superficial, 40% deep), and 30-day SSOPI was 21%. 19 patients (11%) were re-operated: 8 (8%) due to a wound complication and 4 (2%) due to a missed enterotomy. Two infected meshes were removed, one biologic and one synthetic. CONCLUSIONS: Surgeons participating in the ACHQC predominantly resect ECFs and repair the associated hernias with sublay mesh with or without a myofascial release. Morbidity remains high, most closely related to wound complications, as such, concomitant definitive repairs should be entertained with caution.
Assuntos
Parede Abdominal , Hérnia Ventral , Fístula Intestinal , Parede Abdominal/cirurgia , Feminino , Hérnia Ventral/cirurgia , Herniorrafia/efeitos adversos , Humanos , Fístula Intestinal/etiologia , Fístula Intestinal/cirurgia , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Telas Cirúrgicas , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/etiologia , Resultado do TratamentoRESUMO
PURPOSE: The outcomes of utilizing anti-adhesive barrier-coated mesh in the retrorectus position during open ventral hernia repair are unknown. We compared the wound-related outcomes between non-coated (NCM) and coated mesh (CM) placed in the retrorectus space. METHODS: Patients undergoing elective, open, clean ventral hernia repair with retrorectus mesh were retrospectively identified in the Americas Hernia Society Quality Collaborative. Propensity score matching was performed based on clinically relevant demographic and operative covariates. The primary outcome was wound morbidity, defined as surgical site infection (SSI), surgical site occurrence (SSO), and SSO requiring procedural intervention (SSOPI). RESULTS: 3609 patients were included (3281 NCM, 328 CM). Following 2:1 propensity score matching, rates of myofascial release remained the only statistically different matching parameter; external oblique releases were performed more frequently in the CM group (8% vs. 15%; p = 0.03). Rates of SSI (3% vs. 4%; p = 0.16) were similar between groups. Increased rates of SSO (13% vs. 18%; p = 0.045) and SSOPI (4% vs. 8%; p = 0.038) were observed in the CM group. The CM group had a higher rate of postoperative seroma (3% vs. 7%; p = 0.027) compared to the NCM group. CONCLUSION: Barrier-coated mesh in the retrorectus position was associated with increased wound morbidity requiring procedural intervention. Due to a lack of clinical benefit, the use of more costly barrier-coated mesh in the retrorectus position is not justified for routine, open ventral hernia repairs at this time.