Prescription opioid use increases resource utilization following ventral hernia repair.

BACKGROUND: Previous studies showed that preoperative opioid use is associated with increased postoperative opioid use and surgical site infection (SSI) in patients undergoing ventral hernia repair (VHR). Orthopedic surgery literature cites increased resource utilization with opioid use. This study aimed to determine the effect of preoperative opioid use on resource utilization after open VHR. METHODS: A retrospective institutional review board-approved study of VHRs from a single tertiary care practice between 2013 and 2020 was performed. Medical records, the National Surgical Quality Improvement Program database, and Kentucky All Schedule Prescription Electronic Reporting data were reviewed for patient demographics, comorbidities, dispensed opiate prescriptions, hernia characteristics, and outcomes. Univariate logistic regression analyses assessed the effect of each patient's demographic and clinical characteristics. Multivariate logistic regression models analyzed significant factors from the univariate analyses. The primary outcome was resource utilization measured as readmission, emergency department visit, or >2 postoperative clinic visits within 45 days after VHR. RESULTS: Overall, 381 patients who underwent VHR were identified; of which 101 patients had preoperative dispensed opioids. Multivariate analysis demonstrated that patient gender at birth, any new-onset SSI, and any preoperative opioid use were associated with increased postoperative resource utilization (odds ratio, 1.76; P = .026). CONCLUSION: Preoperative opioid use was determined as a risk factor that increased resource utilization after open VHR. An understanding of the drivers of the increased use of resources is essential in developing strategies to improve healthcare value. Future research will focus on strategies to reduce the utilization of resources among patients who use opioids.

Predictors of postoperative opioid use in ventral and incisional hernia repair.

BACKGROUND: One in two ventral and incisional hernia repair (VIHR) patients have preoperative opioid prescription within a year before procedure. The study's aim was to investigate risk factors of increased postoperative prescription filling in patients with or without preoperative opioid prescription. METHODS: VIHR cases from 2013 to 2017 were reviewed. State prescription drug monitoring program data were linked to patient records. The primary endpoint was cumulative opioid dose dispensed through post-discharge day 45. Morphine milligram equivalent (MME) was used for uniform comparison. RESULTS: 205 patients were included in the study (average age 53.5 years; 50.7% female). Over 35% met criteria for preoperative opioid use. Preoperative opioid tolerance, superficial wound infection, current smoking status, and any dispensed opioids within 45 days of admission were independent predictors for increased postoperative opioid utilization (p < 0.001). CONCLUSION: Preoperative opioid use during 45-day pre-admission correlated strongly with postoperative prescription filling in VIHR patients, and several independent risk factors were identified.

Emergent and urgent ventral hernia repair: comparing recurrence rates amongst procedures utilizing mesh versus no mesh.

BACKGROUND: The decision for emergent and urgent ventral hernia repair (VHR) is driven by acute symptomatology, concern for incarceration and strangulation, and perforation. Although mesh has been established to reduce hernia recurrences, the potential for mesh complications may impact the decision for utilization in emergent repairs. This study evaluates hernia repair outcomes in the emergent setting with/without mesh. METHODS: An IRB-approved review of NSQIP and retrospective chart review data of emergent/urgent VHRs performed between 2013 and 2017 was conducted at a single academic institution. Six-month postoperative emergency department and surgery clinic visits, hospital readmissions, and hernia recurrences were recorded. Patients were grouped based on mesh utilization. Perioperative and outcome variables were compared using Chi-square, Fisher's exact, and t-tests. RESULTS: Among 94 patients, 41 (44%) received mesh; 53 (56%) did not. Synthetic mesh was used in 27 cases (65.9%); bioresorbable or biologic mesh was used in 14 cases (34.1%). ASA class (p = 0.016) was higher in the no-mesh group, as were emergent vs. urgent cases (p ≤ 0.001). Preoperative SIRS/Sepsis, COPD, and diabetes were increased in the no-mesh group. Hernia recurrence was significantly higher in the no-mesh group vs. the mesh group (24.5% vs. 7.3%, p = 0.03). No difference was found in wound complications between groups. ED visits occurred almost twice as often in the mesh group (42% vs. 23%, p = 0.071). Postoperative surgery clinic visits were more frequent among the mesh group (> 1 visit 61% vs. 24%, p = 0.004). CONCLUSIONS: Mesh-based hernia repairs in the urgent/emergent patient population are performed in fewer than half of patients in our tertiary care referral center. Repairs without mesh were associated with over a three-fold increase in recurrence without a difference in the risk of infectious complications. Efforts to understand the rationale for suture-based repair compared to mesh repair are needed to reduce hernia recurrences in the emergent population.

Laparoscopic parastomal hernia repair delays recurrence relative to open repair.

BACKGROUND: Mesh repair of parastomal hernia is widely accepted as superior to non-mesh repair, yet the most favorable surgical approach is a subject of continued debate. The aim of this study was to compare the clinical outcomes of open versus laparoscopic parastomal hernia repair. METHODS: An IRB-approved retrospective review was conducted comparing laparoscopic (LPHR) or open (OPHR) parastomal hernia repair performed between 2009 and 2017 at our facilities. Patient demographics, preoperative characteristics, operative details, and clinical outcomes were compared by surgical approach. Subgroup analysis was performed by location of mesh placement. Repair longevity was measured using Kaplan-Meier method and Cox proportional hazards regression. Intention to treat analysis was used for this study based on initial approach to the repair. RESULTS: Sixty-two patients (average age of 61 years) underwent repair (31 LPHR, 31 OPHR). Patient age, gender, BMI, ASA Class, and comorbidity status were similar between OPHR and LPHR. Stoma relocation was more common in OPHR (32% vs 7%, p = .022). Open sublay subgroup was similar to LPHR in terms of wound class and relocation. Open "Other" and Sublay subgroups resulted in more wound complications compared to LPHR (70% and 48% vs 27%, p = .036). Operative duration and hospital length of stay were less with LPHR (p < .001). After adjustment for prior hernia repair, risk of recurrence was higher for OPHR (p = .022) and Open Sublay and Other subgroups compared to LPHR (p = .005 and p = .027, respectively). CONCLUSIONS: Laparoscopic repair of parastomal hernias is associated with shorter operative duration, decreased length of stay, fewer short-term wound complications, and increased longevity of repair compared to open repairs. Direct comparison of repair longevity between LPHR and OPHR with mesh using Kaplan-Meier estimate is unique to this study. Further study is warranted to better understand methods of parastomal hernia repair associated with fewer complications and increased durability.

Totally extraperitoneal approach for open complex abdominal wall reconstruction.

BACKGROUND: Ventral hernia repair is typically performed via a transabdominal approach and the peritoneal cavity is opened and explored. Totally extraperitoneal ventral hernia repair (TEVHR) facilitates dissection of the hernia sac without entering the peritoneal cavity. This study evaluates our experience of TEVHR, addressing technique, decision-making, and outcomes. METHODS: This is an IRB-approved retrospective review of open TEVHR performed between January 2012 and December 2016. Medical records were reviewed for patient demographics, operative details, postoperative outcomes, hospital readmissions, and reoperations. RESULTS: One hundred sixty-six patients underwent TEVHR (84 males, 82 females) with a mean BMI range of 30-39. Eighty-six percent of patients underwent repair for primary or first-time recurrent hernia, and 89% CDC wound class I. Median hernia defect size was 135 cm2. Hernia repair techniques included Rives-Stoppa (34%) or transversus abdominis release (57%). Median operative time was 175 min, median blood loss 100 mL, and median length of stay 4 days. There were no unplanned bowel resections or enterotomies. Four cases required intraperitoneal entry to explant prior mesh. Wound complication rate was 27%: 9% seroma drainage, 18% superficial surgical site infection (SSI), and 2% deep space SSI. Five patients (3%) required reoperation for wound or mesh complications. Over the study, four patients were hospitalized for postoperative small bowel obstruction and managed non-operatively. Of the 166 patients, 96%, 54%, and 44% were seen at 3-month, 6-month, and 12-month follow-ups, respectively. Recurrences were observed in 2% of patients at 12-month follow-up. One patient developed an enterocutaneous fistula 28 months postoperatively. CONCLUSIONS: TEVHR is a safe alternative to traditional transabdominal approaches to ventral hernia repair. The extraperitoneal dissection facilitates hernia repair, avoiding peritoneal entry and adhesiolysis, resulting in decreased operative times. In our study, there was low risk for postoperative bowel obstruction and enterotomy. Future prospective studies with long-term follow-up are required to draw definitive conclusions.

Preoperative opioid use and incidence of surgical site infection after repair of ventral and incisional hernias.

BACKGROUND: Preoperative opioid use is a risk factor for complications after some surgical procedures. The purpose of this study was to investigate the influence of preoperative opiates on outcomes after ventral hernia repair. METHODS: With institutional review board approval, we conducted a retrospective review of consecutive ventral hernia repair cases during a 4-y period. RESULTS: A striking 48% of the total 234 patients met criteria for preoperative opioid use. Preoperative characteristics and operative details were similar between patient groups (preoperative opioid use versus no preoperative opioid use). Median duration of hospital stay trended toward an increase for opioid users versus nonopioid users (P = .06). Return of bowel function was delayed in opioid users compared with nonopioid users (P = .018). Incidence of superficial surgical site infection was increased among patients who used opioids preoperatively (27% vs 8.3%; P <.001) and remained so after multivariable logistic regression, (adjusted odds ratio 2.9, 95% confidence interval 1.2-6.7; P = .013). CONCLUSION: Among patients undergoing ventral hernia repair, those with preoperative opioid use experienced an increased incidence of superficial surgical site infection compared with patients without preoperative opioid use. Further study is needed to understand the relationship between opioid use and surgical site infection after ventral hernia repair.

The contribution of specific enhanced recovery after surgery (ERAS) protocol elements to reduced length of hospital stay after ventral hernia repair.

BACKGROUND: Ventral hernia repair (VHR) is a commonly performed procedure that may be associated with prolonged hospitalization. Enhanced recovery after surgery (ERAS) protocols are intended to decrease hospital length of stay (LOS) and improve outcomes. This study evaluated the impact of compliance with individual VHR ERAS elements on LOS. METHODS: With IRB approval, a medical record review (perioperative characteristics, clinical outcomes, compliance with ERAS elements) was conducted of open VHR consecutive cases performed in August 2013-July 2017. The ERAS protocol was implemented in August 2015; elements in place prior to implementation were accounted for in compliance review. Clinical predictors of LOS were determined through forward regression of log-transformed LOS. The effects of specific ERAS elements on LOS were assessed by adding them to the model in the presence of the clinical predictors. RESULTS: Two-hundred and thirty-four patients underwent VHR (109 ERAS, 125 pre-ERAS). Across all patients, the mean LOS was 5.4 days (SD = 3.3). Independent perioperative predictors (P's < 0.05) of increased LOS were CDC Wound Class III/IV (38% increase above the mean), COPD (35%), prior infected mesh (21%), concomitant procedure (14%), mesh size (3% per 100 cm2), and age (8% increase per 10 years from mean age). Formal ERAS implementation was associated with a 15% or about 0.7 days (95% CI 6%-24%) reduction in mean LOS after adjustment. Compliance with acceleration of intestinal recovery was low (25.6%) as many patients were not eligible for alvimopan use due to preoperative opioids, yet when achieved, provided the greatest reduction in LOS (- 36%). CONCLUSIONS: Implementation of an ERAS protocol for VHR results in decreased hospital LOS. Evaluation of the impact of specific ERAS element compliance to LOS is unique to this study. Compliance with acceleration of intestinal recovery, early postoperative mobilization, and multimodal pain management standards provided the greatest LOS reduction.

Costs and Complications Associated with Infected Mesh for Ventral Hernia Repair.

Background: Mesh hernia repair is widely accepted because of the associated reduction in hernia recurrence compared with suture-based repair. Despite initiatives to reduce risk, mesh infection and mesh removal are a significant challenge. In an era of healthcare value, it is essential to understand the global cost of care, including the incidence and cost of complications. The purpose of this study was to identify the outcomes and costs of care of patients who required the removal of infected hernia mesh. Methods: A review of databases from 2006 through June 2018 identified patients who underwent both ventral hernia repair (VHR) and re-operation for infected mesh removal. Patient demographic and operative details for both procedures, including age, Body Mass Index, mesh type, amount of time between procedures, and information regarding interval procedures were obtained. Clinical outcome measures were the length of the hospital stay, hospital re-admission, incision/non-incision complications, and re-operation. Hospital cost data were obtained from the cost accounting system and were combined with the clinical data for a cost and clinical representation of the cases. Results: Thirty-four patients underwent both VHR and removal of infected mesh material over the 12-year time frame and were included in the analyses; the average age at VHR was 48 years, and 16 patients (47%) were female. Following VHR, 21 patients (62%) experienced incision complications within 90 days post-operatively, the complications ranging from superficial surgical site infection (SSI) to evisceration. A mean of 22.65 months passed between procedures. After mesh removal, 16 patients (47%) experienced further incisional complications; and 22 (65%) patients had at least one re-admission. Eighteen patients (53%) required a minimum of one additional related operative procedure after mesh removal. Median hospital costs nearly doubled (p < 0.001) for the mesh removal ($23,841 [interquartile range {IQR} $13,596-$42,148]) compared with the VHR admission ($13,394 [IQR $8,424-$22,161]) not accounting for re-admission costs. A majority experienced hernia recurrence subsequent to mesh removal. Conclusions: Mesh infection after hernia repair is associated with significant morbidity and costs. Hospital re-admission, re-operations, and recurrences are common among these patients, resulting in greater healthcare resource utilization. Development of strategies to prevent mesh infection, identify patients most likely to experience infectious complications, and define best practices for the care of patients with mesh infection are needed.

Enhanced value with implementation of an ERAS protocol for ventral hernia repair.

BACKGROUND: Open ventral hernia repair (VHR) is associated with postoperative complications and hospital readmissions. A comprehensive Enhanced Recovery after Surgery (ERAS) protocol for VHR contributes to improved clinical outcomes including the rapid return of bowel function and reduced infections. The purpose of this study was to compare hospital costs for patients cared for prior to ERAS implementation with patients cared for with an ERAS protocol. METHODS: With IRB approval, clinical characteristics and postoperative outcomes data were obtained via retrospective review of consecutive VHR patients 2 years prior to and 14 months post ERAS implementation. Hospital cost data were obtained from the cost accounting system inclusive of index hospitalization. Clinical data and hospital costs were compared between groups. RESULTS: Data for 178 patients (127 pre-ERAS, 51 post-ERAS) were analyzed. Preoperative and operative characteristics including gender, ASA class, comorbidities, and BMI were similar between groups. ERAS patients had faster return of bowel function (p = 0.001) and decreased incidence of superficial surgical site infection (p = 0.003). Hospital length of stay did not vary significantly pre and post ERAS implementation. Inpatient pharmacy costs were increased in ERAS group ($2673 vs. $1176 p < 0.001), but total hospital costs (14,692 vs. 15,151, p = 0.538) were similar between groups. CONCLUSIONS: Standardization of hernia care via ERAS protocol improves clinical outcomes without impacting total costs.

Clinical and Quality of Life Assessment of Patients Undergoing Laparoscopic Hiatal Hernia Repair.

Hiatal hernia repair (HHR) and fundoplication are similarly performed among all hiatal hernia types with similar techniques. This study evaluates the effect of HHR using a standardized technique for cruroplasty with a reinforcing polyglycolic acid and trimethylene carbonate mesh (PGA/TMC) on patient symptoms and outcomes. A retrospective review of patient perioperative characteristics and postoperative outcomes was conducted for cases of laparoscopic hiatal hernia repair (LHHR) using a PGA/TMC mesh performed over 21 months. Gastroesophageal reflux disease symptom questionnaire responses were compared between preoperative and three postoperative time points. Ninety-six patients underwent LHHR with a PGA/TMC mesh. Postoperatively, the number of overall symptoms reported by patients decreased across all postoperative periods (P < 0.001). Patients reported a significant reduction in antacid use long term (P < 0.001). Laryngeal and regurgitation symptoms decreased at all time points (P < 0.05). There was no difference in dysphagia preoperatively and postoperatively at any time point. Individuals undergoing HHR with PGA/TMC mesh experienced improved regurgitation and laryngeal symptoms, and decreased use of antacid medication.

Validation and Extension of the Ventral Hernia Repair Cost Prediction Model.

BACKGROUND: Repair of ventral and incisional hernias remains a costly challenge for health care systems. In a previous study of a single surgeon's elective open ventral hernia repair (VHR) practice, a cost model was developed, which predicted over 70% of hospital cost variation. The purpose of the present study was to evaluate the ventral hernia cost model with multiple surgeons' elective open VHR cases and extending to include nonelective and laparoscopic VHR. MATERIALS AND METHODS: With the University of Kentucky Institutional Review Board approval, elective and emergent cases of open and laparoscopic VHR performed by multiple surgeons over 3 y were identified. Perioperative variables were obtained from the local American College of Surgeons National Surgery Quality Improvement Program database and electronic medical record review. Hospital cost data were obtained from the hospital cost accounting system. Forward multivariable regression of log-transformed costs identified independent cost drivers (P for entry < 0.05, and P for exit > 0.10). RESULTS: Of the 387 VHRs, 74% were open repairs; mean age was 55 y, and 52% of patients were female. For open, elective cases (n = 211; mean cost of $19,145), the previously reported six-factor cost model predicted 45% of the total cost variation. With all VHRs included, additional variables were found to independently drive costs, predicting 59% of the total cost variation from the base cost. The biggest cost drivers were inpatient status (+$1013), use of biologic mesh (+$1131), preoperative systemic inflammatory response syndrome/sepsis (+$894), and preoperative open wound (+$786). CONCLUSIONS: Ventral hernia repair cost variability is predictable. Understanding the independent drivers of cost may be helpful in controlling costs and in negotiating appropriate reimbursement with payers.

Long-term efficacy of laparoscopic Nissen versus Toupet fundoplication for the management of types III and IV hiatal hernias.

BACKGROUND: Laparoscopic hiatal hernia repair via Toupet or Nissen fundoplication remains the most commonly performed procedures for management of large hiatal hernia. Few studies have compared the procedures' long-term effectiveness. This study sought to characterize the efficacy of laparoscopic Toupet versus Nissen fundoplication for types III and IV hiatal hernia. METHODS: With IRB approval, a review of all laparoscopic hiatal hernia repairs with mesh reinforcement performed over 7 years at a single center by one surgeon was conducted. Hiatal hernias were classified as type III or IV using operative reports and preoperative imaging. Patients with type I, II, or recurrent hiatal hernia and patients receiving concomitant procedures were excluded. The GERD-Health Related Quality of Life Survey was administered by telephone no earlier than 18 months postoperatively. RESULTS: A total of 473 patients underwent laparoscopic fundoplication; 179 having type III or IV hiatal hernia met inclusion criteria; 62 underwent Toupet, 117 underwent Nissen fundoplication. Average patient age was 64 years; 63% of patients were female. Cohorts were similar in demographics, comorbidities, and intraoperative factors. Survey was completed by 77 patients (43%): 50 having Nissen and 27 Toupet. Median time of survey completion after surgery was 54 months (Nissen) and 25 months (Toupet). Median survey responses across all items for both groups were 0 (no symptoms) with no significant variation between groups. Of patients that had Nissen, 26% reported current proton-pump inhibitor use versus 31% of Toupet patients (p = 0.486). Patient-reported satisfaction with current condition was similar between groups (67% Toupet, 72% Nissen, p = 0.351). CONCLUSIONS: Patient-reported symptoms and satisfaction did not vary for patients receiving laparoscopic Nissen versus Toupet fundoplication, which may indicate that patients with large type III and IV hiatal hernia undergoing either procedure have similar long-term postoperative symptom control.

A comparison of short-term outcomes between laparoscopic and open emergent repair of perforated peptic ulcers.

BACKGROUND: We compared 30-day outcomes in patients undergoing emergent open and laparoscopic repair of perforated peptic ulcers in a large multicenter cohort. METHODS: Prospectively obtained data in the American College of Surgeons National Surgical Quality Improvement Program public use files from 2010 to 2016 were reviewed. Perioperative risks and outcomes were compared in unmatched and propensity-matched groups using parametric/non-parametric statistical tests as appropriate. RESULTS: A total of 4210 procedures were identified 345 (8.2%) laparoscopic and 3865 (91.8%) open. Laparoscopic repairs increased from 4.5% of 2010 cases to 11.4% of 2016 cases (p < .001). Open repair patients had more acute presentation including higher rates of ASA class, hypoalbuminemia, preoperative septic shock, dyspnea, and mechanical ventilation (all p < .01). Laparoscopic operations were longer than open procedures (p < .001). Mortality (8.5 vs. 3.5%), median length of stay (7 vs. 5 days), transfusion rates (13.7 vs. 7.0%), renal failure (3.7 vs. 1.2%), and respiratory failure (15.5 vs. 5.2%) were all worse in the unmatched open group (all p < .01). Propensity matching resulted in 342 laparoscopic and 626 open cases of similar ulcer type, demographics, ASA class, preoperative SIRS/sepsis, hypoalbuminemia, and wound class. Mortality was similar between matched groups (5.0 vs. 3.5%, p = .331). Median length of stay was longer in the open group (6 vs. 5 days, p < .001), which also had higher rates of prolonged ventilation/reintubation (9.6 vs. 5.3%, p = .019) and abdominal wall wound occurrences (6.2 vs. 2.3%, p = .042). Return to the operating room and 30-day readmissions did not differ between the matched groups. CONCLUSIONS: Emergent laparoscopic repair of perforated peptic ulcer is increasingly being performed, is safe relative to open repair (in patients without preoperative septic shock), and confers a modest benefit in terms of length of stay, respiratory, and abdominal wall wound complications.

Risk-Assessment Score and Patient Optimization as Cost Predictors for Ventral Hernia Repair.

BACKGROUND: Ventral hernia repair (VHR) is associated with complications that significantly increase healthcare costs. This study explores the associations between hospital costs for VHR and surgical complication risk-assessment scores, need for cardiac or pulmonary evaluation, and smoking or obesity counseling. STUDY DESIGN: An IRB-approved retrospective study of patients having undergone open VHR over 3 years was performed. Ventral Hernia Risk Score (VHRS) for surgical site occurrence and surgical site infection, and the Ventral Hernia Working Group grade were calculated for each case. Also recorded were preoperative cardiology or pulmonary evaluations, smoking cessation and weight reduction counseling, and patient goal achievement. Hospital costs were obtained from the cost accounting system for the VHR hospitalization stratified by major clinical cost drivers. Univariate regression analyses were used to compare the predictive power of the risk scores. Multivariable analysis was performed to develop a cost prediction model. RESULTS: The mean cost of index VHR hospitalization was $20,700. Total and operating room costs correlated with increasing CDC wound class, VHRS surgical site infection score, VHRS surgical site occurrence score, American Society of Anesthesiologists class, and Ventral Hernia Working Group (all p < 0.01). The VHRS surgical site infection scores correlated negatively with contribution margin (-280; p < 0.01). Multivariable predictors of total hospital costs for the index hospitalization included wound class, hernia defect size, age, American Society of Anesthesiologists class 3 or 4, use of biologic mesh, and 2+ mesh pieces; explaining 73% of the variance in costs (p < 0.001). Weight optimization significantly reduced direct and operating room costs (p < 0.05). Cardiac evaluation was associated with increased costs. CONCLUSIONS: Ventral hernia repair hospital costs are more accurately predicted by CDC wound class than VHR risk scores. A straightforward 6-factor model predicted most cost variation for VHR.

Early outcomes of an enhanced recovery protocol for open repair of ventral hernia.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols are evidence-based quality improvement pathways reported to be associated with improved patient outcomes. The purpose of this study was to compare short-term outcomes for open ventral hernia repair (VHR) before and after implementation of an ERAS protocol. METHODS: After obtaining IRB approval, surgical databases were searched for VHR cases for two years prior and eleven months after protocol implementation for retrospective review. Groups were compared on perioperative characteristics and clinical outcomes using chi-square, Fisher's exact, or Mann-Whitney U test, as appropriate. RESULTS: One hundred and seventy-one patients underwent VHR (46 patients with ERAS protocol in place and 125 historic controls). Age, gender, ASA Class, comorbidities, and smoking status were similar between the two groups. Body mass index was lower among ERAS patients (p = .038). ERAS patients had earlier return of bowel function (median 3 vs. 4 days) (p = .003) and decreased incidence of superficial surgical site infection (SSI) (7 vs. 25%) (p = .008) than controls. CONCLUSION: An ERAS protocol for VHR demonstrated improved patient outcomes. A system-wide culture focused on enhanced recovery is needed to ensure improved patient outcomes.

Predictors of outpatient resource utilization following ventral and incisional hernia repair.

INTRODUCTION: Little is known about the predictors of increased ambulatory costs following open ventral and incisional hernia repair (VIHR); however, postoperative complications would be expected to be associated with an increased burden on outpatient resources. The purpose of this study is to evaluate the impact of perioperative factors on outpatient resource utilization following VIHR. METHODS: With IRB approval, the surgery scheduling system was queried to identify all cases of VIHR done at our institution over 3 years. Cases with other procedures done at time of VIHR were excluded. National Surgical Quality Improvement Program clinical data, physician billing data which included market and payor across cases, and medical record review data were combined and evaluated in order to quantify care and predictors of usage during the 6 months postoperatively. RESULTS: Data were analyzed for 308 patients. Median patient age was 52 years (SD = 13.3), and over half were female. The number of outpatient visits to the surgical office varied from 0 to 18 [median = 2; interquartile range (IQR) = 1-3]. CDC Wound Class >1 was associated with increase of mean 1.4 visits (IQR: 0.5-2.3); p = 0.003. Component separation, longer duration of operation, and increased mesh size were also predictive of increased number of office visits (p < 0.01). Postoperative infected seroma/seroma requiring drainage added a mean 2.3 visits (IQR: 1.3-3.3), (p < 0.001); and deep wound infection added a mean 3.9 visits (IQR: 1.9-5.9) (p < 0.001). CONCLUSIONS: Postoperative complications confer a significant burden for patients and to the outpatient surgical office. In an era in which improved quality and cost-efficiency has become imperative, measures to decrease risk of postoperative complications particularly for more complex VIHR would be expected to decrease resource utilization and increase value of care.

Concomitant open ventral hernia repair: what is the financial impact of performing open ventral hernia with other abdominal procedures concomitantly?

BACKGROUND: Open ventral hernia repair (VHR) is often performed in conjunction with other abdominal procedures. Clinical outcomes and financial implications of VHR are becoming better understood; however, financial implications of concomitant VHR during other abdominal procedures are unknown. This study aimed to evaluate the financial implications of adding VHR to open abdominal procedures. METHODS: This IRB-approved study retrospectively reviewed hospital costs to 180-day post-discharge of standalone VHRs, isolated open abdominal surgeries (bowel resection or stoma closure, removal of infected mesh, hysterectomy or oophorectomy, panniculectomy or abdominoplasty, open appendectomy or cholecystectomy), performed at our institution from October 1, 2011 to September 30, 2014. The perioperative risk data were obtained from the local National Surgery Quality Improvement Program (NSQIP) database, and resource utilization data were obtained from the hospital cost accounting system. RESULTS: 345 VHRs, 1389 open abdominal procedures as described, and 104 concomitant open abdominal and VHR cases were analyzed. The VHR-only group had lower ASA Class, shorter operative duration, and a higher percentage of hernias repaired via separation of components than the concomitant group (p < 0.001). The median hospital cost for VHR-alone was $12,900 (IQR: $9500-$20,700). There were significant increases to in-hospital costs when VHR was combined with removing an infected mesh (63%) or with bowel resections or stoma closures (0.7%). The addition of VHR did not cause a significant change in 180-day post-discharge costs for any of the procedures. CONCLUSIONS: This study noted decreased costs when combining VHR with panniculectomy or abdominoplasty and hysterectomy or oophorectomy. For removal of infected mesh and bowel resection or stoma closure, waiting, when feasible, is recommended. Given the impending changes in financial reimbursements in healthcare in the United States, it is prudent that future studies evaluate further the clinical and fiscal benefit of concomitant procedures.

Ventral and incisional hernia: the cost of comorbidities and complications.

INTRODUCTION: Ventral and incisional hernia repair (VIHR) is among the most frequently performed abdominal operations with significant incidence of postoperative complications and readmissions. Payers are targeting increased "value" of care through improved outcomes and reduced costs. Cost data in clinically relevant terms is still rare. This study aims to identify hospital costs associated with clinically relevant factors in order to facilitate strategies by surgeons to enhance the value of VIHR. METHODS: An IRB-approved retrospective review of VIHRs performed at the University of Kentucky from April 2009 through September 2013 was conducted. NSQIP clinical data and hospital cost data were matched. Operating room (ORC), total encounter (TEC), and 90-day postdischarge (90PDC) hospital costs were analyzed relative to clinical variables using non-parametric tests. RESULTS: In total 385 patients that underwent VIHR during the time period were included in the analyses. Considering all VIHRs, median [interquartile range (IQR)] ORC was $6900 ($5600-$10,000); TEC was $10,700 ($7500-$18,600); and 90PDC was $0 ($0-$800). Compared to all VIHRs, ASA Class ≥ 3 was associated with increased ORC and TEC (p < .001), and 90PDC (p < .01). Preoperative open wound was associated with increased ORC and TEC (p < .001). Numerous operative variables were associated with both increased ORC and TEC. Wound Class > 1 was associated with increased ORC and TEC (p < .001) and 90PDC (p < .01). Inpatient occurrence of any complication was associated with increased TEC and 90PDC (p < .001). CONCLUSIONS: ASA Class ≥ 3, Wound Class > 1, open abdominal wound, and postoperative complications significantly increase costs. Although the hospital encounter represents the majority of the cost associated with VIHR, additional costs are incurred during the 90-day postoperative period. An appreciation of global costs is essential in developing alternative payment models for hernia in order to provide the greatest value in hernia care.

Compliance of the abdominal wall during laparoscopic insufflation.

BACKGROUND: To provide adequate workspace between the viscera and abdominal wall, insufflation with carbon dioxide is a common practice in laparoscopic surgeries. An insufflation pressure of 15 mmHg is considered to be safe in patients, but all insufflation pressures create perioperative and postoperative physiologic effects. As a composition of viscoelastic materials, the abdominal wall should distend in a predictable manner given the pressure of the pneumoperitoneum. The purpose of this study was to elucidate the relationship between degree of abdominal distention and the insufflation pressure, with the goal of determining factors which impact the compliance of the abdominal wall. METHODS: A prospective, IRB-approved study was conducted to video record the abdomens of patients undergoing insufflation prior to a laparoscopic surgery. Photo samples were taken every 5 s, and the strain of the patient's abdomen in the sagittal plane was determined, as well as the insufflator pressure (stress) at bedside. Patients were insufflated to 15 mmHg. The relationship between the stress and strain was determined in each sample, and compliance of the patient's abdominal wall was calculated. Subcutaneous fat thickness and rectus abdominus muscle thickness were obtained from computed tomography scans. Correlations between abdominal wall compliances and subcutaneous fat and muscle content were determined. RESULTS: Twenty-five patients were evaluated. An increased fat thickness in the abdominal wall had a direct exponential relationship with abdominal wall compliance (R 2 = 0.59, p < 0.05). There was no correlation between muscle and fat thickness. CONCLUSION: All insufflation pressures create perioperative and postoperative complications. The compliance of patients' abdominal body walls differs, and subcutaneous fat thickness has a direct exponential relationship with abdominal wall compliance. Thus, insufflation pressures can be better tailored per the patient. Future studies are needed to demonstrate the clinical impact of varying insufflation pressures.