Comparative long-term effectiveness between ventral hernia repairs with biosynthetic and synthetic mesh.

BACKGROUND: Debate exists regarding the most appropriate type of mesh to use in ventral hernia repair (VHR). Meshes are broadly categorized as synthetic or biologic, each mesh with individual advantages and disadvantages. More recently developed biosynthetic mesh has characteristics of both mesh types. The current study aims to examine long-term follow-up data and directly compare outcomes-specifically hernia recurrence-of VHR with biosynthetic versus synthetic mesh. METHODS: With IRB approval, consecutive cases of VHR (CPT codes 49,560, 49,561, 49,565, and 49,566 with 49,568) performed between 2013 and 2018 at a single institution were reviewed. Local NSQIP data was utilized for patient demographics, perioperative characteristics, CDC Wound Class, comorbidities, and mesh type. A review of electronic medical records provided additional variables including hernia defect size, postoperative wound events to six months, duration of follow-up, and incidence of hernia recurrence. Longevity of repair was measured using Kaplan-Meier method and adjusted Cox proportional hazards regression. RESULTS: Biosynthetic mesh was used in 101 patients (23%) and synthetic mesh in 338 (77%). On average, patients repaired using biosynthetic mesh were older than those with synthetic mesh (57 vs. 52 years; p = .008). Also, ASA Class ≥ III was more common in biosynthetic mesh cases (70.3% vs. 55.1%; p = .016). Patients repaired with biosynthetic mesh were more likely than patients with synthetic mesh to have had a prior abdominal infection (30.7% vs. 19.8%; p = .029). Using a Kaplan-Meier analysis, there was not a significant difference in hernia recurrence between the two mesh types, with both types having Kaplan Meir 5-year recurrence-free survival rates of about 72%. CONCLUSION: Using Kaplan-Meier analysis, synthetic mesh and biosynthetic mesh result in comparable hernia recurrence rates and surgical site infection rates in abdominal wall reconstruction patients with follow-up to as long as five years.

Primary Fascial Closure During Laparoscopic Ventral Hernia Repair Improves Patient Quality of Life: A Multicenter, Blinded Randomized Controlled Trial.

BACKGROUND: Observational studies have reported conflicting results with primary fascial closure (PFC) versus bridged repair during laparoscopic ventral hernia repair (LVHR). OBJECTIVE: The aim of the study was to determine whether when evaluated in a randomized controlled trial (RCT), PFC compared to bridged repair would improve patient quality of life (QoL). METHODS: In this blinded, multicenter RCT, patients scheduled for elective LVHR (hernia defects 3 to 10 cm on computed tomography scan) were randomized to PFC versus bridged repair. Primary outcome was change in QoL after LVHR using a validated, hernia-specific survey (1 = poor QoL and 100 = perfect QoL) that measures pain, function, cosmesis, and satisfaction. Secondary outcomes were postoperative surgical site occurrences (including hematoma, seroma, surgical site infection, and wound dehiscence), abdominal eventration, and hernia recurrence. The trial was powered to detect a difference in change in QoL of 7 points between the study groups. Outcomes were compared with Mann-Whitney U test or chi-square. RESULTS: A total of 129 patients underwent LVHR and 107 (83%) completed follow-up at 2 years. Patients from both groups were similar at baseline. On median follow-up of 24 months (range: 9-42), patients treated with LVHR-PFC had on average a 12-point higher improvement in QoL compared to bridged repair (improvement in QoL, 41.3 ± 31.5 vs 29.7 ±â€Š28.7, P value = 0.047). There were no differences in surgical site occurrence, eventration, or hernia recurrence between groups. CONCLUSIONS: Among patients undergoing elective LVHR, the fascial defect should be closed. This is the first RCT demonstrating that PFC with LVHR significantly improves patient QoL. TRIAL REGISTRATION: This trial was registered with clinicaltrials.gov (NCT02363790).

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.

Doxycycline alters collagen composition following ventral hernia repair.

BACKGROUND: Doxycycline, a nonspecific metalloproteinase (MMP) inhibitor, has been demonstrated to impact the strength of the polypropylene (PP) mesh-repaired hernia with an increase in the deposition of collagen type 1. The impact of doxycycline with porcine acellular dermal matrices (PADM) is unknown; therefore, we evaluated the impact of doxycycline administration upon hernia repair with PP and PADM mesh. METHODS: Sprague-Dawley rats weighing ~400 g underwent laparotomy with creation of a midline ventral hernia. After a 27-day recovery, animals were randomly assigned to four groups of eight and underwent intraperitoneal underlay hernia repair with either PP or PADM. Groups were assigned to daily normal saline (S) or daily doxycycline in normal saline 10 mg/kg (D) via oral gavage for 8 weeks beginning 24 h preoperatively. Animals were euthanized at 8 weeks and underwent tensiometric testing of the abdominal wall and western blot analyses for collagen subtypes and MMPs. RESULTS: Thirty-two animals underwent successful hernia creation and repair with either PADM or PP. At 8 weeks, 15 of 16 PP-implanted animals survived with only 12 of 16 PADM-implanted animals surviving. There were no differences in the mesh to fascial interface tensiometric strength between groups. Densitometric counts in the PADM-D group demonstrated increased collagen type 1 compared to PP-S (PADM-D [1286.5], PADM-S [906.9], PP-S [700.4], p = 0.037) and decreased collagen type 3 compared to PP-S (PADM-D [7446.9], PADM-S [8507.6], PP-S [11,297.1], p = 0.01). MMP-9 levels were increased in PADM-D (PP-S vs. PADM-D, p = 0.04), while MMP-2 levels were similar between PADM-D and PADM-S, respectively. CONCLUSIONS: Collagen type 1 deposition at the mesh to fascial interface is enhanced following administration of doxycycline in ventral hernia repairs with porcine acellular dermal matrices. Doxycycline administration may have implications for enhancing hernia repair outcomes using biologic mesh.

Absorbable mesh in a contaminated field: hernia repair outcomes.

Hernia repair mesh aids in the stability of incisional hernia repair and can reduce the need for subsequent operations. There is, however, debate among surgeons over which type of hernia mesh-synthetics, biologics, or biosynthetics-is indicated as best for specific patients. A retrospective case review comparing surgical outcomes based on wound class and mesh materials may provide insights into this question. This study evaluates patient outcomes using biosynthetic mesh based upon CDC wound classification. Following Institutional Review Board approval, the local National Surgery Quality Improvement (NSQIP) databases were queried for open ventral hernia repaired with absorbable mesh implants from January 2013-December 2017. Factors for comparison included patient demographics, operative details, and an analysis of clinical outcomes. Our study identified 112 ventral hernia repair cases with absorbable mesh placement, 32% (n = 36) were wound classes II-IV. Higher wound class correlated statistically with diabetes (33.3%), prior hernia repair (61.1%), and parastomal hernia (44.4%). Higher wound classes were associated with more emergent presentations, involved bowel resection more frequently, required larger mesh implants, increased post-operative surgical site infections, and wound disruption. Increasing wound class was also associated with longer hospital stays and greater need for readmission (38.9% vs. 11.8%). Compared to patients with clean wounds, biosynethic mesh repair patients with contaminated wounds exhibited more emergent presentations, increased incidence of bowel resection, increased mesh size, and more readmissions. Despite these peri-operative outcomes, hernia recurrence rates among biosynethic mesh hernia repair were similar in CDC class II-IV patients as class I.

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.

Preoperative Glycosylated Hemoglobin and Postoperative Glucose Together Predict Major Complications after Abdominal Surgery.

BACKGROUND: Glycosylated hemoglobin (HbA1c) is diagnostic of and a measure of the quality of control of diabetes mellitus. Both HbA1c and perioperative hyperglycemia have been targeted as modifiable risk factors for postoperative complications. The HbA1c percent cutoff that best predicts major complications has not been defined. STUDY DESIGN: A prospective study of all abdominal operations from a single institution from 2007 to 2010 was performed. All patients with HbA1c within 3 months before surgery were included. The primary end point was major complication, using the Clavien-Dindo complication system, within 30 days of surgery. Stepwise, multivariate analysis was performed including clinically relevant variables chosen a priori. RESULTS: Among 438 patients who had a measured HbA1c, 96 (21.9%) experienced a major complication. On multivariate analysis, HbA1c ≥ 6.5% (odds ratio = 1.95; 95% CI, 1.17-3.24; p = 0.01) was found to be the most significant predictor of major complications. Glyosylated hemoglobin and glucose were strongly correlated (correlation coefficient 0.414, p < 0.01). Predicted probabilities demonstrated that both HbA1c and glucose together contributed to major complications; and HbA1c impacted the ability to achieve optimal perioperative glucose control. Patients with a BMI >30 kg/m(2), history of coronary artery disease, and nonwhite race were more likely to have a HbA1c ≥ 6.5%. CONCLUSIONS: Elevated HbA1c ≥ 6.5% and perioperative hyperglycemia were associated with an increased rate of major complications after abdominal surgery. Elevated peak postoperative glucose levels were correlated with elevated HbA1c and were independently associated with major complications. More liberal HbA1c testing should be considered in high-risk patients before elective surgery. Safe, feasible, and effective strategies to reduce both HbA1c and perioperative hyperglycemia need to be developed to optimize patient outcomes.

The component separation technique for hernia repair: a comparison of open and endoscopic techniques.

The open components separation technique (CST) for hernia repair allows for autologous tissue repair with approximation of the midline fascia in patients with complex hernias. CST requires creation of large undermining skin flaps, whereas the endoscopic component separation technique (ECST) is performed without division of the epigastric perforating vessels and may minimize wound morbidity. A review of patient demographics and outcome measures of patients undergoing CST and ECST between November 2008 and February 2010 was performed. Twenty-five patients were identified who underwent either CST (14 patients) or ECST (11 patients). There were no differences in body mass index (CST 34.8 kg/m(2), ECST 37.5 kg/m(2), P = 0.45), operating room times (CST 268 minutes, ECST 252 minutes, P = 0.54), or hospital length of stay (CST 5 days, ECST 5.8 days, P = 0.78). Wound complications occurred less with ECST (9 vs 57%, P = 0.03). The time to resolution of wound complications in ECST was reduced *1 vs 4 months). No recurrences were seen in either group with a mean follow-up of 4months (range, 1 to 12 months). ECST and CST require similar operative times and hospital lengths of stay. ECST is associated with reduced wound complications compared with CST. Short-term recurrence rates with CST and ECST are comparable.