The effect of component separation technique on quality of life (QOL) and surgical outcomes in complex open ventral hernia repair (OVHR).

INTRODUCTION: Outcomes following OVHR may be affected by type of component separation. In this study, outcomes including QOL of patients undergoing OVHR were evaluated based on the utilization of transversus abdominis release (TAR), posterior rectus sheath release (PRSR) alone or in combination with external oblique release (EOR + PRSR). METHODS: A prospective, single-institution study following open ventral hernia repair involving component separation was performed from May 2005 to April 2015. Self-reported QOL outcomes were obtained preoperatively and at 1, 6 and 12 months postoperatively using the Carolinas Comfort Scale (CCS). A CCS of 2 (mild but bothersome discomfort) or greater was considered symptomatic. Comorbidities, complications, outcomes and CCS scores were reviewed. Univariate group comparisons were performed using Chi-square and Wilcoxon two-sample tests with statistical significance set at p < 0.05. RESULTS: During the study period, 292 OVHRs with CST met inclusion criteria. Single-sided, different releases on opposite sides, etc., were eliminated. Demographics included: average age-57.9 ± 11.9 years, BMI-34.0 ± 7.9 kgm2, 53.2% female, 69% at least one prior hernia repair and average defect size-291.2 ± 236.2 cm2. Preoperative discomfort (82 vs. 75 vs. 79%, p = 0.77) and movement limitation (94 vs. 70 vs. 78%, p = 0.1) in TAR, PRSR and EOR + PRSR were similar. Average follow-up was 16.4 months. At 1, 6 and 12 months postoperatively, there was no difference in reported CCS pain scores, movement limitation or mesh sensation among the groups (p > 0.05). Comparing OVHR patients outcomes by CST type, TAR was associated with decreased wound infections compared to others (3.2 vs. 16.1 vs. 20%, p = 0.07) while recurrence rates were increased in EOR + PRSR compared to TAR and PRSR alone(8.4 vs. 3 vs. 1.8%, p = 0.03). Eighty percent of recurrences had a biologic mesh secondary to contaminated field during hernia repair. The other two recurrences were one which occurred superior to the mesh at a suture site and one who developed a wound infection postoperatively. Mesh infection rates were low (0 vs. 1.5 vs. 2.6%, p > 0.05) even including contaminated cases (0 vs. 2 vs. 3.6%, p > 0.05) and were statistically equivalent among all three techniques. CONCLUSION: While QOL is not impacted by type of component separation on short- or long-term follow-up, the TAR may provide benefits such as decreased wound infection rates. Overall QOL had a significant improvement from preoperative regardless of type of component separation. When controlling for field contamination, there were no differences in recurrence or infection.

The cost of preventable comorbidities on wound complications in open ventral hernia repair.

BACKGROUND: Patients with complex ventral hernias may benefit from preoperative optimization. This study evaluates the financial impact of preventable comorbidities (PCM) in elective open ventral hernia repair. METHODS: In this single institution prospectively collected data from 2007-2011, hospital charges (included all hernia-related visits, interventions, or readmissions) and wound-related complications in patients with PCM-diabetes, tobacco use, and obesity-were compared to patients without such risks using standard statistical methods. RESULTS: Within the study period, there were 118 patients with no PCM; of those, 33 had complications, and 85 did not. In the 131 patients with two or more PCM, 81 had complications; 89 of 251 patients had complications in the group with only 1 PCM; groups with PCM were significantly more likely to have complications compared to the no PCM group (62% versus 35.4% versus 28%, P < 0.05). The majority of the patient population was female (57.2%) with a mean age of 57.8 y (range, 22-84 ys), and median defect size was 150 cm2 (interquartile range, 50-283 cm2). Body mass index was higher in PCM group with complications than in PCM without complications (40 versus 36 kg/m2, P < 0.05). For patients with complications, the average hospital charges were $80,660 in the PCM group compared to $55,444 in the no PCM group (P = 0.038). Hospital charges in those with PCM without complications compared to no PCM with complications were equivalent ($65,453 versus $55,444, P = 0.55). Even when no complications occurred, patients with PCM incurred higher charges than No PCM for inpatient ($61,269 versus $31,236, P < 0.02), outpatient ($4,185 versus $552, P < 0.04), and total hospital charges ($65,453 versus $31,788, P ≤ 0.001). Those patients without complications but with a single PCM incurred larger charges than those with no PCM during follow-up ($3578 versus $552, P = 0.04), but there was no difference in hospital or overall total charges (P > 0.05). Interestingly, patients without complications, both hospital ($38,333 versus $61,269, P = 0.02) and total charges ($41,911 versus $65,453, P = 0.01) were increased for patients with 2+ PCM compared to those with only a single PCM. If complications occurred, no difference between the single PCM group compared to the two or more PCM groups existed for hospital, follow-up, or overall charges (P > 0.05). CONCLUSIONS: Patients with PCM undergoing open ventral hernia repair are more likely to have complications than patients without comorbidities. Patients with PCM generate higher hospital charges than those without PCM even when no complications occur; furthermore, the more PCM, the patient has the more significant the impact. Interestingly, patients with multiple PCM and no complications had equivalent hospital costs compared to patients with no PCM and with complications. Aggressive risk reduction may translate into significant savings. Preoperative preparation of patients before elective surgery is indicated.

Nationwide variation in outcomes and cost of laparoscopic procedures.

INTRODUCTION: Healthcare systems and surgeons are under increasing pressure to provide high-quality care for the lowest possible cost . This study utilizes national data to examine the outcomes and costs of common laparoscopic procedures based on hospital type and location. METHODS: The National Inpatient Sample was queried from 2008 to 2011 for five laparoscopic procedures: colectomy (LC), inguinal hernia repair, ventral hernia repair (LVHR), Nissen fundoplication (NF), and cholecystectomy (LCh). Outcomes, including complication rate and inpatient mortality, were stratified by region and hospital type. Both univariate and multivariate regression analyses were performed using regression-based survey methods; risk-adjusted mean costs for hospital were calculated after adjusting for patient characteristics. RESULTS: In univariate analysis, the rates of minor complications varied significantly between geographic regions for LCh, LC, NF, and LVHR (p < 0.05). Though LCh and LVHR had statistical variation between regions for rates of major complications (p < 0.05), all regions were equivalent in rates of inpatient mortality for the procedures (p > 0.05). Rural and urban centers had similar rates of complications (p > 0.05), except for higher rates of major complications following IHR and LC in rural centers (p < 0.02) and following Nissen fundoplication in urban facilities(p < 0.0003). Though urban centers were more expensive for all procedures (p < 0.0001), mortality was similar between groups (p > 0.05). For hospital ownership, private investor-owned facilities were substantially more expensive (p < 0.0001), but had no significant differences in complications compared to other hospital types (p > 0.05). In multivariate analysis, while patient factors helped explain differences between outcome differences in different hospital types and locations, in general, the difference in cost remained statistically significant between hospitals. CONCLUSION: Though patient demographics and characteristics accounted for some differences in postoperative outcomes after common laparoscopic procedures, higher cost of care was not associated with better outcomes or more complex patients.

Acuity, outcomes, and trends in the transfer of surgical patients: a national study.

INTRODUCTION: With the regionalization of surgical care, reduction in the rural workforce, rising healthcare costs, and increasing focus on surgical outcomes, appropriate transfer of surgical patients is an increasingly important aspect of health care. This study examines patients transferred for surgical intervention through a national sample. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2005 to 2012 for surgery patients who were transferred from an outside hospital or emergency department (ED) and compared patients undergoing surgery without transfer. Patients were divided into two time periods (TP): 2005-2008 (TP1) and 2008-2012 (TP2) for analysis; patient characteristics and top CPT codes for each TP were collected. Univariate analysis and matched cohorts were used to compare the groups. RESULTS: Overall, 61,204 patients were transferred and underwent surgery. The rate of transferred surgery patients increased from 3.2% in TP1 to 4.5% in TP2 (p < 0.0001). Compared to non-transferred patients, transferred patients had higher rates of diabetes (23.4 vs. 17.6%, p < 0.0001), tobacco use (27.9 vs. 20.3%, p < 0.0001), Charlson comorbidity index (mean score 1.5 vs. 0.8, p < 0.0001), preoperative sepsis (32.0 vs. 9.4%, p < 0.0001), and need for emergent surgery (41.3 vs. 14.4%, p < 0.0001). From TP1 to TP2, there was an increase in transferred patients who were obese (33.9-36.4%, p < 0.0001) and had emergent transfers (39.6-41.8%, p < 0.0001), with a decrease in diabetic patients (24.7-23.1%, p < 0.0001). From TP1 to TP2, transferred patients had more minor complications (17.7-31.0%, p < 0.0001), but fewer major complications (32.1-23.9%, p < 0.0001) and lower 30-day mortality (11.8-8.1%, p < 0.0001). CONCLUSIONS: Patients transferred for surgery represent a higher acuity population than non-transferred patients, and the number of transfers continues to rise. Even when matched by comorbidities, transferred patients have worse outcomes. Surgical sub-specialization and physician tiering may complicate future transfer practices. Efficient transfers, effective physician communication, and ready availability of medical records are critical in improving patient transfers.

The Centers for Medicare and Medicaid Services (CMS) two midnight rule: policy at odds with reality.

INTRODUCTION: To reduce costs, the Centers for Medicare and Medicaid Services (CMS) implemented new policies governing which patients are automatically admitted as inpatients (staying greater than "two midnights") and which require additional justification with physician documentation to be admitted. This study examines procedures missing from the Medicare Inpatient Only (MIO) list and uses national data to evaluate its appropriateness. METHODS: Non-MIO procedures were identified from the current MIO list. Utilizing relevant billing codes, procedures were queried in the National Surgery Quality Improvement Program database for length of stay (LOS), percentage requiring >2 day stay, and inpatient status from 2005 to 2012. In addition, a separate analysis was performed for patients 65 years old or older who would qualify for Medicare. RESULTS: A majority of patients stayed more than 2 days for several procedures not included on the MIO list (% staying >2 days, mean LOS), including component separation (79.1%, 5.9 ± 12.3 days), diagnostic laparoscopy (64.2%, 5.5 ± 11.9 days), laparoscopic splenectomy (60.0%, 9.0 ± 13.6 days), open recurrent ventral hernia repair (58.2%, 6.3 ± 9.0 days), laparoscopic esophageal surgery (46.4%, 5.3 ± 13.3 days), and laparoscopic ventral hernia repair (24.7%, 2.5 ± 8.8 days). In patients ≥65 years, the average LOS was longer than the general population; for example, 40.2% of laparoscopic appendectomies and 38.7% of laparoscopic cholecystectomies in this older group required more than two nights in the hospital. In 92.3% of procedures examined, patients ≥65 years required greater than two nights in the hospital with an average LOS of 2.5-10.7 days. CONCLUSION: Commonly encountered non-MIO surgical procedures have national precedents for inpatient status. Before enacting policy, CMS and other regulatory bodies should consider current data to ensure rules are evidence-based and applicable.

Laparoscopic versus open peritoneal dialysis catheter placement.

BACKGROUND: Laparoscopy revolutionized many General Surgery procedures by decreasing hospital stay, minimizing recovery time, and reducing wound infection rates. This study evaluates the potential benefits of laparoscopic approach to peritoneal dialysis catheter (PDC) placement. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for laparoscopic and open PDC placement. We evaluated patient demographics, comorbidities, operative time, length of stay (LOS), and postoperative outcomes. Univariate comparison and multivariate logistic regression analysis (MVA) adjusting for confounding factors including age, body mass index (BMI), comorbidities, and preoperative conditions were performed. RESULTS: A total of 3134 patients undergoing PDC placement were recorded in the NSQIP database between 2005 and 2012, including 2412 laparoscopic cases (LPDC) (77%) and 722 open (OPDC). Overall, the majority of cases were performed by General Surgeons (81%) with most of the remainder completed by Vascular Surgeons (16.8%). Patients undergoing LPDC versus OPDC demonstrated no significant difference in gender (54 vs. 56% males, p = 0.4), smoking history (8.5 ± 18.3 vs. 7.2 ± 16.9 pack years, p = 0.06), diabetes (42 vs. 40%, p = 0.4), COPD (4.6 vs. 5%, p = 0.63), or preoperative dialysis requirement (72 vs. 73 %, p = 0.6), but they were younger (57.2 ± 14.8 vs. 60.5 ± 15.9 years, p = 0.05) and had a higher BMI (29.3 vs. 29 kg/m(2), p = 0.04). In univariate analysis of LPDC versus OPDC, overall wound complications (1.6 vs. 2.9 %, p = 0.02), deep surgical site infections (0.12 vs. 0.83%, p < 0.006), minor complications (3.8 vs. 6.5 %, p < 0.05), major complications (4.3 vs. 6.9%, p < 0.05), and LOS (1.8 ± 11.9 vs. 4.4 ± 10 days, p < 0.0001) favored the LPDC approach, but only operative time (57.6 ± 4.6 vs. 71.8 ± 5.3, p < 0.001) remained significant in MVA after controlling for confounding factors. Both LPDC and OPDC had equivalently low rates of catheter failure (0.21 vs. 0.14%, p = 0.7). CONCLUSION: Using univariate analysis, there appears to be a benefit from LPDC placement. However, after controlling for confounding variables, the techniques appear to have equal outcomes. Surgeons should perform a LPDC or OPDC according to the approach with which they are most familiar. However, continued adoption, dispersal, and refinement of the laparoscopic approach may further optimize patient outcomes.

Indocyanine Green: Historical Context, Current Applications, and Future Considerations.

BACKGROUND: Indocyanine green (ICG) is a dye used in medicine since the mid-1950s for a variety of applications in in cardiology, ophthalmology, and neurosurgery; however, its fluorescent properties have only recently been used in the intraoperative evaluation of tissue perfusion. METHOD: A literature review was conducted on the characterization and employment of ICG within the medical field. Historical and current context of ICG was examined while also considering implications for its future use. RESULTS: ICG is a relatively nontoxic, unstable compound bound by albumin in the intravascular space until rapid clearance by the liver. It has widespread uses in hepatic, cardiac, and ophthalmologic studies, and its use in analyzing tissue perfusion and identifying sentinel lymph nodes in cancer staging is gaining popularity. CONCLUSIONS: ICG has myriad applications and poses low risk to the patient. Its historical uses have contributed to medical knowledge, and it is now undergoing investigation for quantifying tissue perfusion, providing targeted therapies, and intraoperative identification of neurovascular anatomy, ophthalmic structures, and sentinel lymph nodes. New applications of ICG may lead to reduction in postoperative wound-related complications, more effective ophthalmologic procedures, and better detection and treatment of cancer cells.

Computed tomographic measurements predict component separation in ventral hernia repair.

BACKGROUND: Preoperative imaging with computed tomography (CT) scans can be useful in preoperative planning. We hypothesized that CT measurements of ventral hernia defect size and abdominal wall thickness (AWT) would correlate with postoperative complications and need for complex abdominal wall reconstruction (AWR). MATERIALS AND METHODS: Patients who underwent open ventral hernia repair and had preoperative abdominal CT imagining were identified from an institutional hernia-specific surgery outcomes database at our tertiary referral hernia center. Grade III and IV hernias and biologic mesh cases were excluded. CT measures of defect size and AWT were analyzed and correlated to complications and the need for AWR techniques using univariate, multivariate, and principal component (PC) analyses. PC1 and PC2 used five AWT measures, hernia defect width, and body mass index to create a new component variable. RESULTS: There were 151 open ventral hernia repairs included in the study. Preoperative findings included 37.7% male; age 55.3 ± 12.5 years; body mass index (BMI) 33.3 ± 7.8 kg/m(2); 60.3% were recurrent hernias with average defect width 8.5 ± 5.0 cm and area 178.3 ± 214 cm(2); AWT at umbilicus 3.5 ± 1.8 cm; and AWT at pubis 7.0 ± 3.2. Component separation was performed in 24.0% of patients and panniculectomy in 34.4%. Wound complications occurred in 13.3% patients, and 2.7% had hernia recurrence. Increasing defect width, length, and area as well as select AWT measurements were associated with increased need for component separation, concomitant panniculectomy, and higher rates of wound and total complications (all P < 0.05). Using multivariate regression, PC1 was associated with wound complications (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.01-1.16); PC2 (hernia defect width) was associated with the need for component separation (OR, 1.16; 95% CI, 1.03-1.30). Hernia recurrence was not predicted by AWT or defect size (OR, 1.00; 95%CI, 0.87-1.15). CONCLUSIONS: Preoperative CT measurements of hernia defects and AWT predict wound complications and the need for complex AWR techniques. Obtaining preoperative CT imaging should be a consideration in preoperative planning and may help with patient counseling.

Predictive modeling for chronic pain after ventral hernia repair.

BACKGROUND: Few studies predict which patients have dissolution of their postoperative discomfort or develop chronic pain after ventral hernia repair (VHR). This study develops a predictive model to determine which patients are at the greatest risk of chronic pain after VHR. METHODS: A prospective study of VHR patients was performed via the International Hernia Mesh Registry. Anonymous, self-reported, quality of life data using the Carolinas Comfort Scale (CCS) was recorded preoperatively, and 1,6, and 12 months postoperatively. Pain was identified as a score of 2 or more (mild but bothersome to severe) for any Carolinas Comfort Scale pain-specific questions. Logistic regression analyses were performed to determine statistically significant predictors of chronic pain. Univariate analysis selected potential predictors with a P value less than .15, and a subsequent multivariable model was built using backward elimination setting retention criterion at P < .15. Goodness-of-fit of the model was tested using Hosmer-Lemeshow test. A value of greater than 70% for the area under the curve (AUC) was considered most accurate diagnostically. The final model was then internally validated with bootstrap analysis. RESULTS: A total of 887 patients underwent VHR between 2007 and 2014. The patients had an average age of 57.2 ± 12.8 years, 52.4% were female, 17.0% were active smokers, and 13.2% used narcotics preoperatively. With 74% follow-up at 1 year, 26.0% of the patients reported chronic discomfort. After logistic regression model, independent predictors of pain at 6 months were preoperative pain score 2 or more (P < .0001), preoperative narcotic use (P = .06), and 1-month postoperative pain score 2 or more (P < .0001), AUC = .74. Baseline, 1-month, and 6-month predictors determined the final multivariate regression model for prediction of chronic pain at 1 year, AUC = .73. Older age was protective against chronic pain (odds ratio [OR] .98, 95%confidence interval [CI] = .96 to .998, P = .03), female sex increased risk with an OR of 1.7(CI = 1.1 to 2.7, P = .02); preoperative pain, and recurrent hernia repair nearly doubled the risk of developing chronic pain postoperatively (OR = 3.0, CI = 1.8 to 4.8, P < .0001 and 1.6, CI = .98 to 2.6, P = .06, respectively). Importantly, presence of pain at 1 month was a strong predictor of chronic pain at 1-year follow-up (OR = 2.6, CI = 1.7 to 4.2, P < .0001). CONCLUSIONS: Patients who have preoperative pain and at 1 month postoperatively are significantly more likely to have chronic pain. Both short- and long-term pain can be predicted from female sex, younger age, and repair of recurrent hernias. This predictive model may aid in preoperative counseling and when considering postoperative intervention for pain management in VHR patients.

Biologic mesh in ventral hernia repair: Outcomes, recurrence, and charge analysis.

BACKGROUND: Biologic mesh choice in ventral hernia repair is challenging due to lack of prospective data. This study examines long-term, single-center biologic mesh outcomes. METHODS: Prospective operative outcomes data was queried for open ventral hernia repair with biologic mesh. Univariate and multivariate analysis were used to compare mesh outcomes. RESULTS: In the study, 223 patients underwent open ventral hernia repair with biologic mesh, including 40 with Alloderm, 23 AlloMax, 70 FlexHD, 68 Strattice, and 22 Xenmatrix. Overall, 9.8% had an American Society of Anesthesiology classification of 4, 54.6% with a classification of 3, and 35.6% with a classification of 1 or 2. Operative time averaged 241 minutes with estimated blood loss of 202 mL. Hernia defects averaged 257 ± 245 cm2 with mesh size 384 cm2. Biologic mesh was used as a fascial bridge in 19.6%, component separation was performed in 47.5%, and 82% had concomitant procedure. Inpatient mortality was 1.4%. Hernia recurrence varied significantly by mesh type: 35% Alloderm, 34.5% AlloMax, 37.1% FlexHD, 14.7% Strattice, and 59.1% Xenmatrix (P = .001). The mean follow-up was 18.2 months. After multivariate analysis comparing to Strattice, AlloMax had a 3.4 higher odds ratio for recurrence, FlexHD a 2.9 odds ratio, and Xenmatrix a 7.8 odds ratio. The rate of mesh infections requiring explantation was <1%. Total hospital charges averaged $131,004 ± $143,320. Mean charges varied significantly between meshes; Xenmatrix was the most expensive and AlloMax was the least expensive (P < .05). CONCLUSION: In 223 ventral hernia repair performed with biologic mesh at a tertiary care institution, Strattice, a porcine acellular dermal mesh, had significantly lower odds of hernia recurrence compared with AlloMax, FlexHD, and Xenmatrix. Choice of biologic mesh affects long-term postoperative outcomes in ventral hernia repair.

Bone Anchor Fixation in Abdominal Wall Reconstruction: A Useful Adjunct in Suprapubic and Para-iliac Hernia Repair.

Suprapubic hernias, parailiac or flank hernias, and lumbar hernias are difficult to repair and are associated with high-recurrence rates owing to difficulty in obtaining substantive overlap and especially mesh fixation due to bone being a margin of the hernia. Orthopedic suture anchors used for ligament reconstruction have been used to attach prosthetic material to bony surfaces and can be used in the repair of these hernias where suture fixation was impossible. A prospective, single institution study of ventral hernia repairs involving bone anchor mesh fixation was performed. Demographics, operative details, and outcomes data were collected. Twenty patients were identified, with a mean age 53 (range: 35-70 years) and mean body mass index 28.4 kg/m(2) (range 21-38). Ten lumbar, seven suprapubic, and three parailiac hernias were studied. The majority were recurrent hernias (n = 13), with one to seven previously failed repairs. The mean hernia defect size was very large (270 cm(2); range: 56-832 cm(2)) with average mesh size of 1090 cm(2) (range 224-3640 cm(2)). Both Mitek GII (Depuy, Raynham, MA) and JuggerKnot 2.9-mm (Biomet, Biomedical Instruments, Warsaw, IN) anchors were used, with an average of four anchors/case (range: 1-16). Mean operative time was 218 minutes (120-495). There were three minor complications, no operative mortality, and no recurrences during an average follow-up of 24 months. Pelvic bone anchors permit mesh fixation in high-recurrence areas not amenable to traditional suture fixation. The ability to safely and effectively use bone anchor fixation is an essential tool in complex open ventral hernia repair.

Local Anesthesia in Open Inguinal Hernia Repair Improves Postoperative Quality of Life Compared to General Anesthesia: A Prospective, International Study.

The choice of general (GA) versus local anesthesia (LA) in open inguinal hernia repair (OIHR) has a substantial financial impact and may influence clinical outcomes. Our study compares postoperative quality of life (QOL) in patients undergoing OIHR under LA versus GA. A cooperative prospective study from centers in 10 countries was performed through the International Hernia Mesh Registry from 2007 to 2012. QOL was compared at one, six, 12, and 24 months for LA versus GA with univariate and multivariate analysis controlling for known confounding variables. Of 1128 patients who underwent OIHR, 585(52%) used GA and 533(48%) used LA. Most were male (92%) with unilateral (94%), primary (91%) repairs with a mean age 57 ± 16 years. There was no difference (P > 0.05) in age, gender, operative time, mesh size, length of stay, infection, recurrence, reoperation, or death. Multivariate analysis demonstrated significant QOL differences between groups: GA had higher odds of discomfort at one and six months [odds ratio (OR) 3.3, 2.0], movement limitation at one and six months (OR 3.5, 2.8), and mesh sensation at one and 12 months (OR 2.9, 1.8). Overall, patients undergoing OIHR under LA had improved postoperative QOL in the short and long term compared with GA.