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INTRODUCTION: In the Transversus Abdominis Release (TAR) procedure, ideally, the posterior sheath is completely reapproximated to establish an interface isolating the polypropylene mesh from visceral contents. When primary closure of the posterior sheath is unachievable, Vicryl mesh is commonly used to supplement the posterior sheath closure and an uncoated polypropylene mesh is placed superficial to the Vicryl mesh. The long-term implications of utilizing Vicryl mesh as an antiadhesive barrier are poorly understood. In this study, we aimed to assess our outcomes when utilizing Vicryl mesh to supplement the posterior sheath defects when placed underneath polypropylene mesh in patients undergoing posterior component separation. METHODS: Adult patients who underwent VHR with concurrent TAR procedure with a permanent synthetic mesh and posterior sheath supplementation with Vicryl mesh in the Cleveland Clinic Center for Abdominal Core Health between January 2014 and December 2022 were queried retrospectively from a prospectively collected database in the Abdominal Core Health Quality Collaborative. We evaluated 30-day wound morbidity, perioperative complications, long-term mesh-related complications, and pragmatic hernia recurrence. RESULTS: 53 patients who underwent TAR procedure with posterior sheath supplementation using Vicryl mesh and had a minimum 12-month follow-up were identified. Of the 53 patients, 94.3% presented with recurrent hernias, 73.6% had a midline hernia, 7.5% had a flank hernia, and 18.9% had concurrent parastomal hernia. The mean hernia width was 24.9 cm (± 8.8 cm). No Vicryl mesh-related operative complications were identified in our study, with no instances of mesh erosion, fistulas, or interventions for small bowel obstruction. Skin necrosis requiring reoperations was observed in three patients (5.7%), leading to permanent mesh excision in two cases (3.8%) without intraabdominal visceral involvement. Throughout the 12-month follow-up, 23 incidences (43.4%) of surgical site occurrences (SSOs) and surgical site occurrences requiring procedural intervention (SSOPI) were documented. CONCLUSIONS: Our findings suggest that posterior sheath supplementation with Vicryl mesh is a feasible approach to achieve posterior sheath closure in challenging abdominal wall reconstruction cases. Given the absence of notable mesh-related complications and a similar hernia recurrence rate to cases without posterior sheath supplementation, Vicryl mesh can be used to safely achieve posterior sheath closure in complex reconstructions with insufficient native tissue.
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Poliglactina 910 , Telas Cirúrgicas , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Estudos Retrospectivos , Idoso , Herniorrafia/métodos , Complicações Pós-Operatórias/etiologia , Músculos Abdominais , Hérnia Ventral/cirurgia , Recidiva , AdultoRESUMO
BACKGROUND: Managing patients with abdominal wall hernias and multiple comorbidities can be challenging because these patients are at increased risk for postoperative complications. Preoperative optimization has been used to identify and intervene upon modifiable risk factors to improve hernia repair outcomes, however, waiting to achieve optimization may cause unnecessary delays. METHODS: We describe our approach to preoperative optimization in hernia and we review the current evidence for preoperative optimization. CONCLUSION: Modifying risk factors before undergoing elective hernia repair can improve the overall health of patients with multiple comorbidities. However, when considering the hernia-specific data, prolonging waiting times for patients to achieve full optimization is not justified. Surgeons should take a nuanced approach to balance achieving patient optimization without unnecessarily delaying surgical care.
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Herniorrafia , Complicações Pós-Operatórias , Cuidados Pré-Operatórios , Humanos , Cuidados Pré-Operatórios/métodos , Fatores de Risco , Complicações Pós-Operatórias/prevenção & controle , Hérnia Abdominal/cirurgia , ComorbidadeRESUMO
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: Despite increasing use of cannabis, literature on perioperative effects is lagging. We compared active cannabis-smokers versus non-smokers and postoperative wound morbidity and reoperations following open abdominal wall reconstruction (AWR). METHODS: Patients who underwent open, clean, AWR with transversus abdominis release and retromuscular synthetic mesh placement at our institution between January 2014 and May 2022 were identified using the Abdominal Core Health Quality Collaborative database. Active cannabis-smokers were 1:3 propensity matched to non-smokers based on demographics and comorbidities. Wound complications, 30 day morbidity, pain (PROMIS 3a-Pain Intensity), and hernia-specific quality of life (HerQles) were compared. RESULTS: Seventy-two cannabis-smokers were matched to 216 non-smokers. SSO (18% vs 17% p = 0.86), SSI (11.1% vs 9.3%, p = 0.65), SSOPI (12% vs 12%, p = 0.92), and all postoperative complications (46% vs 43%, p = 0.63) were similar between cannabis-smokers and non-smokers. Reoperations were more common in the cannabis-smoker group (8.3% vs 2.8%, p = 0.041), driven by major wound complications (6.9% vs 3.2%, p = 0.004). No mesh excisions occurred. HerQles scores were similar at baseline (22 [11, 41] vs 35 [14, 55], p = 0.06), and were worse for cannabis-smokers compared to non-smokers at 30 days (30 [12, 50] vs 38 [20, 67], p = 0.032), but not significantly different at 1 year postoperatively (72 [53, 90] vs 78 [57, 92], p = 0.39). Pain scores were worse for cannabis-smokers compared to non-smokers at 30 days postoperatively (52 [46, 58] vs 49 [44, 54], p = 0.01), but there were no differences at 6 months or 1 year postoperatively (p > 0.05 for all). CONCLUSION: Cannabis smokers will likely experience similar complication rates after clean, open AWR, but should be counseled that despite similar wound complication rates, the severity of their wound complications may be greater than non-smokers.
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Herniorrafia , Fumar Maconha , Pontuação de Propensão , Telas Cirúrgicas , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Herniorrafia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Parede Abdominal/cirurgia , Qualidade de Vida , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Adulto , Hérnia Ventral/cirurgia , Idoso , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/tratamento farmacológicoRESUMO
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
PURPOSE: Radical resections for abdominal wall tumors are rare, thus yielding limited data on reconstruction of defects. We describe surgical management and long-term outcomes following radical tumor resection. METHODS: This was a single-center retrospective review of patients between January 2010 and December 2022. Variables included operative characteristics, wound complications, hernia development, tumor recurrence, and reoperation. A multivariable analysis compared wound morbidity for suture and mesh repairs while adjusting for defect width, fascial closure, and CDC wound class. RESULTS: 120 patients were identified. Mean follow-up was 3.9 ± 3.4 years. Seventy-five (62.5%) of the masses were primary; most commonly desmoid (n = 25) and endometrioma (n = 27). Forty-five masses were metastases. Mean tumor width was 6.2 ± 3.4 cm; mean defect width was 8.1 ± 4.1 cm. Sixty-one patients (50.8%) had mesh placed, with variation in technique. Postoperative CT scans were available for 88 (73.3%) patients. Forty SSOs (33.3%), 11 SSIs (9.2%), and 18 (15%) SSOPIs occurred within 30 days. On multivariable analysis, increased defect width was associated with SSOPI (OR 1.17, p = 0.041) and CDC wound class II-III was associated with SSI (OR 8.38 and 49.1, p < 0.05) and SSOPI (OR 5.77 and 17.4, p < 0.05); mesh was not associated with these outcomes. Seven patients (5.8%) underwent 30-day reoperations and 35 (20.8%) required additional operations after 30 days. Thirteen percent developed abdominal wall (n = 8) or intra-abdominal tumor recurrence (n = 8) requiring reoperation. Twenty-seven (22.5%) patients developed hernias with a mean fascial defect width of 9.8 ± 7.2 cm. CONCLUSION: Abdominal wall mass resections are morbid, often contaminated cases with high postoperative complication rates. Risks and benefits of mesh implantation should be tailored on an individual basis.
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Parede Abdominal , Hérnia Ventral , Humanos , Parede Abdominal/cirurgia , Hérnia Ventral/cirurgia , Resultado do Tratamento , Herniorrafia/métodos , Recidiva Local de Neoplasia/cirurgia , Fáscia , Estudos Retrospectivos , Telas Cirúrgicas/efeitos adversos , RecidivaRESUMO
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.
Assuntos
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.
Assuntos
Hérnia Incisional , Humanos , Hérnia Incisional/etiologia , Hérnia Incisional/epidemiologia , Estudos Retrospectivos , Laparotomia/efeitos adversos , Herniorrafia/efeitos adversos , Obesidade/complicaçõesRESUMO
PURPOSE: Postoperative ileus (POI) is the paralytic disruption of gastrointestinal motility, a common complication following abdominal wall reconstruction that often leads to increased patient morbidity and length of stay (LOS). We reviewed two randomized clinical trials to determine POI rates, predictive factors, LOS, and associated cost. METHODS: Two randomized trials were performed from 2017-2019 with all patients receiving elective open abdominal wall reconstruction with retromuscular mesh. Using multivariate logistic regression, we performed a retrospective analysis including demographics and operative details from patients at a single site to determine predictive factors for POI. All medical costs encompassing surgery and the 30-day postoperative period were compared between ileus and non-ileus groups. RESULTS: Four hundred and seventy patients were reviewed with a POI rate of 13.0% (N = 61). There were no differences in age, body mass index (BMI), history of abdominal surgery, or comorbidities between patients with and without POI. Logistic regression showed no association with POI and age, BMI, hernia width, or operative time lasting longer than 4 h. Median LOS was 8 days for patients with POI compared to five for those without (p < 0.001). Relative median 30-day costs were 1.19 in patients with ileus and 1.0 in those without (p < 0.001). CONCLUSION: We identified a 13% rate of POI in patients undergoing open abdominal wall reconstruction with mesh with no clearly identified predisposing factors. This resulted in a 3 days increase in median LOS and 19% additional costs. Further efforts should be devoted to investigating interventions that may reduce postoperative ileus after abdominal wall reconstruction.
Assuntos
Parede Abdominal , Íleus , Humanos , Parede Abdominal/cirurgia , Herniorrafia/efeitos adversos , Íleus/etiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Ensaios Clínicos como AssuntoRESUMO
PURPOSE: Prescribing and consumption of opioids remain highly variable. Using a national hernia registry, we aimed to identify patient and surgery specific factors associated with low and high opioid tablet consumption after inguinal hernia repair. METHODS: This was a retrospective cross-sectional study evaluating patients undergoing elective inguinal hernia repair with 30-day follow-up and patient-reported opioid consumption from March 2019 to March 2021 using the Abdominal Core Health Quality Collaborative. Clinically significant patient demographics, comorbidities, operative details, quality-of-life measurements, and surgeon prescribing data were entered into a multivariable logistic regression model to identify statistically significant predictors of patients who took no opioid tablets or >10 tablets. RESULTS: A total of 1937 patients were analyzed. Operations included 59% laparoscopic or robotic, 35% open mesh, and 6% open non-mesh repairs. Of these patients, 50% reported taking zero, 42% took 1-10, and 8% took ≥10 opioid tablets at 30-day follow-up. Patients who were older (OR 1.55, 95% CI 1.34-1.79, p-value <0.001), ASA ≤ 2 (OR 1.56, 95% CI 1.2-2.01, p-value <0.001), had no preoperative opioid use at baseline (OR 2.29, 95% CI 1.31-4.03, p-value = 0.004), had local anesthetic with general anesthesia (OR 1.39, 95% CI 1.0.5-1.85, p-value = 0.022), or prescribed <7 opioid tablets (OR 2.27, 95% CI 1.96-2.62, p-value <0.001) were more likely to take no opioid tablets. CONCLUSION: Older, healthier, opioid naïve patients with local anesthetic administered during elective inguinal hernia repair are most likely to not require opioids. Surgeon prescribing-arguably the most modifiable factor-independently correlates with both low and high opioid consumption.
Assuntos
Hérnia Inguinal , Laparoscopia , Humanos , Hérnia Inguinal/cirurgia , Analgésicos Opioides/uso terapêutico , Herniorrafia/efeitos adversos , Estudos Retrospectivos , Anestésicos Locais , Estudos Transversais , Comprimidos , Telas CirúrgicasRESUMO
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.
Assuntos
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.