Cirugía de las hernias: efectividad y coste para el sostenimiento del sistema sanitario / Hernia surgery: effectiveness and cost for the maintenance of the health system

Resumen Introducción: Las hernias son patologías muy frecuentes en un Servicio de Cirugía General (SCG); su tratamiento y costes son muy diferentes, dependiendo del cirujano, si hay hospitalización (CH) o cirugía mayor ambulatoria (CMA). Objetivo principal es el estudio de costes-resultados y de coste-efectividad de las hernias de pared abdominal (no pericolostómicas) realizadas por el SCG. Materiales y Método: Estudio descriptivo, longitudinal, observacional y retrospectivo. Intervenidas 370 hernias de pared abdominal, del 1 de octubre de 2015 al 30 de septiembre de 2016; seguimiento postquirúrgico hasta el 30 de octubre 2016 (1 a 12 meses). Resultados: 79,4% varones, media 59,95 años, 51,90% ASA II, 55,8% anestesia local, 59,72% hernias inguinales, 36,94% hernias inguinales unilaterales indirectas, 55,17 minutos por intervención, 54,44% por CMA, 4,77 días de estancia media en ingresados. Complicaciones perioperatorias 2,3%, tempranas 4,8% (5 reintervenciones) y tardías 12,8% (3 reintervenciones por recidiva). Altas 95,41%, tiempo medio 6,59 semanas. Coste de material de 109,87 € (hernia inguinal simple) hasta 370,41 € (eventración). Coste mediana quirófano 338,80 €. Coste/día CMA 807,30 € y con ingreso 1056,03 €. Mediana coste de hernia inguinal simple 422,69 € y de eventración 709,89 €. Mediana coste por complicación de hernia inguinal 1405,81 € y de eventración 8350,88 €. Mediana coste por proceso con CMA 1213,98 € y con ingreso 3689,80 €. Conclusión: Intervenciones de hernia inguinal unilateral simple, crural y umbilical, con técnica libre de tensión, material protésico, sin drenaje, CMA, anestesia local (con/sin sedación) y sin complicaciones resultan las más coste-efectivas (mejor relación coste-benefcio y coste-efectividad).

Introduction: Hernias are very frequent pathologies in a General Surgery Service (GSS); its treatment and costs are very different, depending on the surgeon, if there is admission (SH) or major outpatient surgery (MOS). A) Main objective. Study costs of (non-pericolostomic) abdominal wall hernia surgical procedures in the GSC (cost-outcome ratio and the cost-efectiveness). Materials and Method: Descriptive, longitudinal, observational and retrospective study. Abdominal wall hernias treated between 1st October, 2015 and 30th September, 2016; after surgery follow up until 30th October, 2016 (1 to 12 months). In total 370 hernia surgeries were performed. Results: 79.4% of males, mean 59.95 years, 51.90% of ASA II, 55.8% local anesthesia, 59.72% inguinal hernias, 36.94% indirect unilateral inguinal hernias, 55.17 minutes for surgeon, 54.44% for MOS, 4.77 days of average stay in admitted patients. Perioperative complications 2.3%, early 4.8% (with 5 reoperations) and late 12.8% (3 reinterventions due to relapse). 95.41% discharge, mean time 6.59 weeks. Material costs vary from €109.87 (simple inguinal hernia) to €370.41 (eventrations). Median surgery room cost €338.80. Cost/day MOS €807.30 and with income €1056.03. Median cost of simple inguinal hernia €422.69 and eventration €709.89. Median cost due to inguinal hernia complication €1405.81 and eventration €8350.88. Median cost per process MOS € 1213.98 and that of SH €3689.80. Conclusion: The interventions of simple unilateral inguinal hernia, crural and umbilical, using a tension-free technique, prosthetic material, without drainage, MOS, local anesthesia (with/without sedation) and without complications are the most cost-efective (better cost-beneft and cost-efectiveness ratio).

Use of commercial mesh for hernia repair in a low resource setting: experience after 500 cases.

BACKGROUND: The use of mesh has revolutionized the management of hernias in many parts of the world. There is, however, limited experience on its use in sub-Saharan Africa. This study describes a single hospital experience after 500 cases of mesh hernia repairs in a sub-Saharan African country. METHODS: We reviewed the records of the first 500 cases of abdominal wall hernia operations performed using commercial mesh since year 2007. Socio-demographic characteristics, hernia type, method of repair and outcome data were analyzed and presented as descriptive statistics. RESULTS: The first 500 cases of mesh hernia repairs were performed between 2007 and 2017 during which a total of 1,175 hernia operations were carried out, mesh repair accounting for 42.5% of the total. There was a progressive rise in the uptake of mesh repairs over time, with mesh repairs overtaking tissue based repairs in the last few years of the review. Inguinal hernia was by far the commonest indication for mesh use (80.4%), followed by incisional hernia (9%). Polypropylene mesh was the most common type of mesh used in about 96.2% of cases. Overall, there were seven recurrences (1.4%) at a mean follow-up period of 15.3 months (1-108 months) CONCLUSION: In spite of resource limitations, the use of mesh for hernia repairs continues to rise and has overtaken tissue-based repairs in a sub-Saharan African setting. Results show good outcomes justifying continued use.

Population-based rates of hernia surgery in Ghana.

PURPOSE: To estimate the population-based annual rate of hernia surgery in Ghana, so as to better define the met and unmet need and to identify opportunities to decrease the unmet need. METHODS: Data on operations performed from June 2014 to May 2015 were obtained from representative samples of 48 of 124 district (first-level) hospitals, 9 of 11 regional (referral) hospitals, and 3 of 5 tertiary hospitals, and scaled-up to nationwide estimates. Rates of hernia surgery were compared to previously published annual incidence of symptomatic hernia in Ghana (210/100,000 population) and to published annual rates of hernia surgery in high-income countries (120-275/100,000). RESULTS: Estimated 17,418 [95% uncertainty interval (UI) 8154-26,683] hernia operations were performed nationally. The annual rate of hernia operations was 65 operations/100,000 population (95% UI 30.2-99.0). The rate was considerably less than the annual incidence of new symptomatic hernia or rates of hernia surgery in high-income countries. Hernia operations represented 7.5% of all operations. Most hernia operations (74%) were performed at district hospitals. Most district hospitals (54%) did not have fully trained surgeons, but nonetheless performed 38% of district-level hernia operations. CONCLUSIONS: The rate of hernia operations fell short of estimated need. Most hernia repairs were performed at district hospitals, many without fully trained surgeons. Future global surgery benchmarking needs to address both overall surgical rates as well as rates for specific highly important operations. Countries can strengthen their planning for surgical care by defining their total, met, and unmet need for hernia surgery.

A direct comparison of robotic and laparoscopic hernia repair: patient-reported outcomes and cost analysis.

PURPOSE: Hernia repair is one of the most commonly performed surgeries in the United States. Since the introduction of the Da Vinci robot, robot-assisted hernia repairs have become more common. In this study we aim to directly compare robotic and laparoscopic hernia repairs as well as explore potential cost differences. We hypothesize that robot-assisted hernia repairs are associated with better patient-reported outcomes. METHODS: We conducted retrospective review to create a cohort study of 53 robotic (37 inguinal and 16 ventral) and 101 laparoscopic (68 inguinal and 33 ventral) hernia repairs. Patient-reported outcomes were measured using the Carolinas Comfort Scale (CCS). Operative details were examined, and a cost analysis was performed. RESULTS: Combining both hernia types together as well as looking at inguinal and ventral repairs separately, we found that there was no difference in hernia recurrence or 1-year CCS between robotic and laparoscopic hernia repair. For ventral hernia repairs alone, robotic procedure was associated with a decreased length of stay. We found that our robotic cases did have longer operative times and higher costs. The operative times did decrease to a length comparable to that of the laparoscopic cases as experience operating with the robot increased. CONCLUSION: In comparison to laparoscopic hernia repair, robotic hernia repair does not improve long-term patient-reported surgical outcomes. However, it does increase the cost of the operation and, in general, result in longer operative times.

Efficiency of care and cost for common emergency general surgery conditions: Comparison by surgeon training and practice.

BACKGROUND: Our institutional emergency general surgery service is staffed by both trauma and critical care-trained surgeons and other boarded general surgeons and subspecialists. We compared efficiency of care for common emergency general surgery conditions between trauma and critical care-trained surgeons and boarded general surgeons and subspecialists. METHODS: Adults admitted between February 2014 and May 2017 with acute appendicitis, acute cholecystitis, intestinal obstruction, incarcerated hernia, or other acute abdominal diagnoses seen by emergency general surgery service were included. Demographic characteristics, consulting surgeon, operations, outcomes, and cost data were obtained. RESULTS: A total of 1,363 patients were included: 384 (28.2%) with acute appendicitis, 477 (35.0%) with acute cholecystitis, 406 (29.8%) with intestinal obstruction, 22 (1.6%) with incarcerated hernia, and 74 (5.4%) with other acute abdominal diagnoses. Trauma and critical care-trained surgeons saw 836 (61.3%) patients. There was no difference in operative management between the two groups, however, trauma and critical care-trained surgeons had significantly less time to the operative room (7.0 vs 12.9 hours; P < .001), without a difference in duration of stay or costs. The subgroups of acute appendicitis and acute cholecystitis when treated by trauma and critical care-trained surgeons had less time to the operative room (8.4 vs 17.4 hours; P < .001), shorter hospital stay (2.5 vs 2.8 days; P = .021), and less emergency department cost ($822 vs $876; P = .012). CONCLUSION: Compared with boarded general surgeons and subspecialists, trauma and critical care-trained surgeons provide more efficient care for common emergency general surgery conditions, with less time from consultation to the operative room.

Incidence, etiology, management, and outcomes of flank hernia: review of published data.

PURPOSE: To review the published data describing the incidence, etiology, management, and outcomes of flank hernia. METHODS: A retrospective review of articles identified with an online search (using the terms "flank hernia", "flank bulge", "lateral hernia", "retroperitoneal aorta hernia", and "open radical nephrectomy") was performed. Studies exclusively on lumbar hernia or subcostal hernia were excluded. RESULTS: All articles retained for analysis (N = 26) were uncontrolled series or case reports; there were no controlled trials. The incidence of incisional hernia in the flank was ~ 17% (total patients analyzed = 1,061). Flank hernia repair was accomplished successfully with a variety of techniques, with overall mean rates of perioperative complications, chronic post-procedure pain, and recurrence equal to 20, 11, and 7%, respectively. Mesh utilization was universal. CONCLUSIONS: The available data of outcomes of flank hernia repair are not of high quality, and recommendations essentially consist of expert opinions. Operative approach (open vs. laparoscopic) and mesh insertion details have varied, but reasonable results appear possible with a number of techniques.

Adoption of robotics in a general surgery residency program: at what cost?

BACKGROUND: Robotic technology is increasingly being utilized by general surgeons. However, the impact of introducing robotics to surgical residency has not been examined. This study aims to assess the financial costs and training impact of introducing robotics at an academic general surgery residency program. METHODS: All patients who underwent laparoscopic or robotic cholecystectomy, ventral hernia repair (VHR), and inguinal hernia repair (IHR) at our institution from 2011-2015 were identified. The effect of robotic surgery on laparoscopic case volume was assessed with linear regression analysis. Resident participation, operative time, hospital costs, and patient charges were also evaluated. RESULTS: We identified 2260 laparoscopic and 139 robotic operations. As the volume of robotic cases increased, the number of laparoscopic cases steadily decreased. Residents participated in all laparoscopic cases and 70% of robotic cases but operated from the robot console in only 21% of cases. Mean operative time was increased for robotic cholecystectomy (+22%), IHR (+55%), and VHR (+61%). Financial analysis revealed higher median hospital costs per case for robotic cholecystectomy (+$411), IHR (+$887), and VHR (+$1124) as well as substantial associated fixed costs. CONCLUSIONS: Introduction of robotic surgery had considerable negative impact on laparoscopic case volume and significantly decreased resident participation. Increased operative time and hospital costs are substantial. An institution must be cognizant of these effects when considering implementing robotics in departments with a general surgery residency program.

Initial Experience With Biologic Polymer Scaffold (Poly-4-hydroxybuturate) in Complex Abdominal Wall Reconstruction.

OBJECTIVE: To evaluate the use of the new absorbable polymer scaffold poly-4-hydroxybutyrate (P4HB) in complex abdominal wall reconstruction. BACKGROUND: Complex abdominal wall reconstruction has witnessed tremendous success in the last decade after the introduction of cadaveric biologic scaffolds. However, the use of cadaveric biologic mesh has been expensive and plagued by complications such as seroma, infection, and recurrent hernia. Despite widespread application of cadaveric biologic mesh, little data exist on the superiority of these materials in the setting of high-risk wounds in patients. P4HB, an absorbable polymer scaffold, may present a new alternative to these cadaveric biologic grafts. METHODS: A retrospective analysis of our initial experience with the absorbable polymer scaffold P4HB compared with a consecutive contiguous group treated with porcine cadaveric mesh for complex abdominal wall reconstructions. Our analysis was performed using SAS 9.3 and Stata 12. RESULTS: The P4HB group (n = 31) experienced shorter drain time (10.0 vs 14.3 d; P < 0.002), fewer complications (22.6% vs 40.5%; P < 0.046), and reherniation (6.5% vs 23.8%; P < 0.049) than the porcine cadaveric mesh group (n = 42). Multivariate analysis for infection identified: porcine cadaveric mesh odds ratio 2.82, length of stay odds ratio 1.11; complications: drinker odds ratio 6.52, porcine cadaveric mesh odds ratio 4.03, African American odds ratio 3.08, length of stay odds ratio 1.11; and hernia recurrence: porcine cadaveric mesh odds ratio 5.18, drinker odds ratio 3.62, African American odds ratio 0.24. Cost analysis identified that P4HB had a $7328.91 financial advantage in initial hospitalization and $2241.17 in the 90-day postdischarge global period resulting in $9570.07 per case advantage over porcine cadaveric mesh. CONCLUSIONS: In our early clinical experience with the absorbable polymer matrix scaffold P4HB, it seemed to provide superior clinical performance and value-based benefit compared with porcine cadaveric biologic mesh.

If time matters: a multicenter review of minimally-invasive hernia repair in 7176 cases.

BACKGROUND: In endoscopic hernia repair totally extraperitoneal approach (TEP) and transabdominal preperitoneal approach (TAPP) are seen as equivalent surgical techniques in quality, but not in procedure-time. METHODS: We compared the two most common procedures in endoscopic hernia surgery. Focusing on the duration of the surgical procedure, we analyzed 7176 endoscopic hernia operations in 25 hospitals retrospectively and compared it to the literature. RESULTS: In our study TEP (N.=2799) took on average 59 minutes, TAPP (N.=4377) took 67.5 minutes, thus with a significant difference (P=0.043). In high volume centres this difference was even bigger. As there are few consistent advantages of one of the procedures in general, the procedure' s duration becomes more important. CONCLUSIONS: If time is the main reason, the TEP procedure takes on average 8.5 minutes less time, so it can be more cost-effective.

Surgically Treated Hernia following Abdominally Based Autologous Breast Reconstruction: Prevalence, Outcomes, and Expenditures.

BACKGROUND: Donor-site hernia is one of the most feared complications following abdominally based autologous breast reconstruction. The authors aim to assess the incidence of surgically repaired abdominal hernia across different types of abdominally based breast reconstruction, identify predictive perioperative factors, and estimate the health care charges associated with this morbidity. METHODS: Using inpatient and ambulatory surgery data from four states in the United States, the authors identified adult women who underwent pedicled transverse rectus abdominis muscle (TRAM), free TRAM, or deep inferior epigastric perforator (DIEP) flap breast reconstruction between 2008 and 2012. The primary outcome was surgical repair of abdominal hernia within 4 years. Multivariate Cox proportional hazards regression modeling was used to compare outcomes between groups. RESULTS: The final sample included 8246 women who underwent pedicled TRAM (29.2 percent), free TRAM (30.0 percent), or DIEP (40.8 percent) flap reconstruction. The frequency of surgically repaired abdominal hernia following breast reconstruction was highest among the pedicled TRAM flap group (pedicled TRAM, 7.0 percent; free TRAM, 5.7 percent; DIEP, 1.8 percent). A hospital encounter for hernia repair, whether inpatient or ambulatory, generated substantial health care charges (pedicled TRAM, $39,704; free TRAM, $48,378; DIEP, $46,481). On multivariate analysis, patients who developed a surgical-site infection within 30 days of discharge (incidence rate ratio, 1.99; 95 percent CI, 1.44 to 2.75) had a higher incidence of surgically repaired abdominal hernia. CONCLUSIONS: Surgically repaired abdominal hernia is common following abdominally based autologous breast reconstruction and is associated with significant health care expenditures. The authors demonstrate that the amount of rectus muscle sacrificed correlates to the likelihood of developing a surgically repaired abdominal hernia, and identify surgical-site infection as a predictive perioperative factor. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Biological Mesh Implants for Abdominal Hernia Repair: US Food and Drug Administration Approval Process and Systematic Review of Its Efficacy.

IMPORTANCE: Expensive biological mesh materials are increasingly used to reinforce abdominal wall hernia repairs. The clinical and cost benefit of these materials are unknown. OBJECTIVES: To review the published evidence on the use of biological mesh materials and to examine the US Food and Drug Administration (FDA) approval history for these devices. EVIDENCE ACQUISITION: Search of multiple electronic databases (Ovid, MEDLINE, EMBASE, Cochrane Systematic Reviews, Cochrane Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, and Cochrane National Health Service Economic Evaluation Database) to identify articles published between 1948 and June 30, 2015, on the use of biological mesh materials used to reinforce abdominal wall hernia repair. Keywords searched included surgical mesh, abdominal hernia, recurrence, infection, fistula, bioprosthesis, biocompatible materials, absorbable implants, dermis, and collagen. The FDA online database for 510(k) clearances was reviewed for all commercially available biological mesh materials. The median national price for mesh materials was established by a benchmarking query through several Integrated Delivery Network and Group Purchasing Organization tools. EVIDENCE SYNTHESIS: Of 274 screened articles, 20 met the search criteria. Most were case series that reported results of convenience samples of patients at single institutions with a variety of clinical problems. Only 3 of the 20 were comparative studies. There were no randomized clinical trials. In total, outcomes for 1033 patients were described. Studies varied widely in follow-up time, operative technique, meshes used, and patient selection criteria. Reported outcomes and clinical outcomes, such as fistula formation and infection, were inconsistently reported across studies. Conflicts of interest were not reported in 16 of the 20 studies. Recurrence rates ranged from 0% to 80%. All biological mesh devices were approved by the FDA based on substantial equivalence to a group of nonbiological predicate devices that, on average, were one-third less costly. CONCLUSIONS AND RELEVANCE: There is insufficient evidence to determine the extra costs associated with or the clinical efficacy of biological mesh materials for the repair of abdominal wall hernia.

The impact of healthcare rationing on elective and emergency hernia repair.

PURPOSE: In 2011 the local clinical commissioning group introduced a policy restricting funding for elective hernia repairs. Anecdotally, it was felt that this resulted in an increased number of emergency hernia repairs in our trust. Our primary objective was to assess whether this was actually the case. Our secondary objective was to quantify the risks of non-elective hernia repair. METHODS: We performed a retrospective cohort study, analysing all hernia surgeries performed between 2010 and 2013. The data were obtained from the trust Patient Information System. A total of 2556 patients underwent repair of inguinal, umbilical, incisional, femoral or ventral hernias over this time. RESULTS: As the policy intended, the number of elective hernia repairs reduced from 857 over 12 months before the funding restrictions to 606 in the same period afterwards (p < 0.001). Over the same time period, however, a significant rise in total emergency hernia repairs was demonstrated, increasing from 98 to 150 (p < 0.001). 30-day readmission rates also increased from 5.1 % before the policy introduction to 8.5 % afterwards (p = 0.006). In our data, the rate of bowel resection rises from 0.97 to 12.9 % for emergency operation compared to elective hernia repair (p < 0.001), while the median length of stay rises from less than 24 h to 3 days. CONCLUSIONS: Our data suggest that the funding restrictions introduced in 2011 were followed by a statistically significant and unintended increase in emergency hernia repairs in our trust, with associated increased risks to patient safety.

PREBIOUS trial: a multicenter randomized controlled trial of PREventive midline laparotomy closure with a BIOabsorbable mesh for the prevention of incisional hernia: rationale and design.

BACKGROUND: Development of an incisional hernia is one of the most frequent complications of midline laparotomies requiring reoperation. This paper presents the rationale, design, and study protocol for a randomized controlled trial, the aim of which is to evaluate the efficacy and safety of prophylactically placing a bioabsorbable synthetic mesh for reinforcement of a midline fascial closure. METHODS: The PREBIOUS trial (PREventive midline laparotomy closure with a BIOabsorbable mesh) is a multicenter randomized controlled trial in which adult patients undergoing elective or urgent open abdominal operations through a midline laparotomy incision are assigned to one of two groups based on the laparotomy closure procedure: an intervention group in which a continuous polydioxanone (PDS) suture is reinforced with a commercially available GORE® BIO-A® Tissue Reinforcement prosthesis (W.L. Gore & Associates, Flagstaff, AZ, USA), or a control group with continuous PDS suture only. Both groups are followed over 6 months. OUTCOMES: The primary outcome is the appearance of incisional hernias assessed by physical examination at clinical visits and radiologically (CT scan) performed at the end of follow-up. Secondary outcomes are the rate of complications, mainly infection, hematoma, burst abdomen, pain, and reoperation. The PREBIOUS trial has the potential to demonstrate that suture plus prosthetic mesh insertion for routine midline laparotomy closure is effective in preventing incisional hernias after open abdominal surgery, to avoid the effects on those affected, such as poor cosmesis, social embarrassment, or impaired quality of life, and to save costs potentially associated with incisional hernia surgical repair.

The economic analysis of two treatment procedures for incisional hernias - alloplastic versus tissular.

Incisional hernias are a common complication of abdominal surgery. Research shows that their incidence reaches 10%-11% of the total number of patients subject to laparotomy. Recurrent hernias are the main complication of eventrations and its rate ranges from 5 to 54%, depending on both the surgical procedure used and the follow-up methods. The goal of this study is the comparative cost analysis of two procedures used in the treatment of event rations, tissular versus alloplastic, the former, leading very often to recurrence requiring a new surgical intervention. The analysis comprised 156 cases of surgeries performed for incisional hernia in 2007 in the clinic of Surgery III, SUUB (Bucharest University Emergency Hospital). Tissular procedures were used in 42 cases and prosthetic procedures in 114 cases. The medium-term postoperative follow-up has revealed 17 relapses (40.4%) in the tissular batch and no relapse in the batch where parietal prosthesis was used. If the short-term costs of the tissular procedures are low as compared with the prosthetic procedures, on the medium-term the costs increase by 24.35% due to the high rate of relapses of tissular procedures. Therefore, the tissular procedure must be abandoned due to the high rate of relapse, as this drives additional costs required for the alloplastic repair of the abdominal parietal defects in a subsequent surgical intervention.

Abdominal wall reconstruction in the obese: an assessment of complications from the National Surgical Quality Improvement Program datasets.

BACKGROUND: This study utilizes the American College of Surgeons National Surgical Quality Improvement Program database to better understand the impact of obesity on perioperative surgical morbidity in abdominal wall reconstruction (AWR). METHODS: We reviewed the 2005 to 2010 American College of Surgeons National Surgical Quality Improvement Program databases, identifying cases of AWR and examining early complications in the context of obesity (body mass index > 30, World Health Organization classes 1 to 3). RESULTS: Of 1,695 patients undergoing AWR, 1,078 (63.2%) patients were obese (mean body mass index = 37.6 kg/m(2)). Major surgical complications (15.3% vs 10.1%, P = .003), wound complications (12.5% vs 8.1%, P = .006), medical complications (16.2% vs 11.2%, P = .005) and return to the operating room (9.1% vs 5.4%, P = .006) were significantly increased, while renal complications (1.9% vs .8%, P = .09) neared significance. On logistic regression, obesity only directly led to a significantly increased odds of having a renal complication (odds ratio = 4.4, P = .04). Complications were still noted to increase with World Health Organization classification, including a concerning incidence of venous thromboembolism. CONCLUSIONS: Although the incidence of complications increased with obesity, obesity itself does not appear to increase the odds of perioperative morbidity. Specific care should be given to VTE prophylaxis and to preventing renal complications.

[Assessment of the predisposing risk factors of the complicated postoperative course after combined operations].

Results of 335 combined operations were analyzed. Men were 89 (27%), women - 246 (73%), the majority of patients were of middle age. 285 (85%) operations included cholecystectomy. 195 (58%) patients had hernioplasty. The third place belonged to vascular operations - 76 (23%). Certain predisposing factors, correlating with the risk of the complicated postoperative course, were marked out. Indications and contraindications to the combined operation were assigned, based on the number of predisposing factors in a patient. Considering the increased risk of intraoperative complications during the combined operation (increased duration, blood loss), participation of highly experienced surgeons and use of modern high-tech equipment seem to be reasonable. The general results of the analysis prove that combined operations are effective, safe and economically beneficial.

Long-term outcome study in patients with abdominal wound dehiscence: a comparative study on quality of life, body image, and incisional hernia.

OBJECTIVE: Long-term quality of life and body image of patients with abdominal wound dehiscence were assessed. METHODS: Thirty-seven patients with abdominal wound dehiscence from a prospectively followed cohort of 967 patients (2007-2009) were reviewed. Patients completed the Short Form 36 quality of life questionnaire and Body Image Questionnaire and participated in semi-structured telephone interviews. For each patient, four controls were matched by age and gender. Analyses were adjusted for age, gender, comorbidity, and follow-up length. RESULTS: Of the 37 patients with abdominal wound dehiscence, 23 were alive after a mean follow-up of 40 months (range 33-49 months). Nineteen patients developed incisional hernias (83 %). Patients with abdominal wound dehiscence reported significantly lower scores for physical and mental component summaries (p = 0.038, p = 0.013), general health (p = 0.003), mental health (p = 0.011), social functioning (p = 0.002), and change (p = 0.034). No differences were found for physical functioning (p = 0.072), role physical (p = 0.361), bodily pain (p = 0.133), vitality (p = 0.150), and role emotional (p = 0.138). Patients with abdominal wound dehiscence reported lower body image scores (median 16.5 vs. 18, p = 0.087), cosmetic scores (median 13 vs. 16, p = 0.047), and total body image scores (median 30 vs. 34, p = 0.042). CONCLUSIONS: At long-term follow-up, patients with abdominal wound dehiscence demonstrated a high incidence of incisional hernia, low body image, and low quality of life.

Using patient-reported outcomes (PROs) to compare the providers of surgery: does the choice of measure matter?

BACKGROUND: Patient-reported outcomes (PROs) are being used to compare health care providers with little knowledge of how the choice of measure affects such comparisons. OBJECTIVES: To assess how much difference the choice of PRO makes to a provider's adjusted outcome and whether the choice affects a provider's rating. RESEARCH DESIGN: PROs collected in England from patients undergoing: hip replacement (243 providers; 52,692 patients); knee replacement (244; 60,118); varicose vein surgery (100; 11,163); and groin hernia repair (201; 31,714). Four case-mix-adjusted outcomes (mean postoperative disease-specific and generic PRO; proportion achieving a minimally important difference in disease-specific PRO; proportion reporting improvement on single transitional item). We calculated the associations between measures and for each measure, the proportion of providers rated as statistically above or below average and the level of agreement in ratings. RESULTS: For major surgery, disease-specific PROs were strongly correlated with the generic PRO (hip 0.90; knee 0.88), they rated high proportions of providers as above or below average (hip 25.1%; knee 19.3%) and there was agreement in ratings with the generic PRO. Even so, for a large proportion of providers (hip 30%; knee 16%) their rating depended on the choice of measure. For minor surgery, correlations between measures were mostly weak. The single transitional item identified the most outliers (varicose vein 20%, hernia 10%). CONCLUSIONS: Choice of outcome measure can determine a provider's rating. Measure selection depends on whether the priority is to avoid missing "poor" providers or avoid mislabeling average providers as "poor."