Reducing the incidence of surgical site infection after ventral hernia repair: Outcomes from the RINSE randomized control trial.

BACKGROUND: The clinical and financial impact of surgical site infection after ventral hernia repair is significant. Here we investigate the impact of dual antibiotic irrigation on SSI after VHR. METHODS: This was a multicenter, prospective randomized control trial of open retromuscular VHR with mesh. Patients were randomized to gentamicin â€‹+ â€‹clindamycin (G â€‹+ â€‹C) (n â€‹= â€‹125) vs saline (n â€‹= â€‹125) irrigation at time of mesh placement. Primary outcome was 30-day SSI. RESULTS: No significant difference was seen in SSI between control and antibiotic irrigation (9.91 vs 9.09 â€‹%; p â€‹= â€‹0.836). No differences were seen in secondary outcomes: SSO (11.71 vs 13.64 â€‹%; p â€‹= â€‹0.667); 90-day SSO (11.1 vs 13.9 â€‹%; p â€‹= â€‹0.603); 90-day SSI (6.9 vs 3.8 â€‹%; p â€‹= â€‹0.389); SSIPI (7.21 vs 7.27 â€‹%, p â€‹= â€‹0.985); SSOPI (3.6 vs 3.64 â€‹%; p â€‹= â€‹0.990); 30-day readmission (9.91 vs 6.36 â€‹%; p â€‹= â€‹0.335); reoperation (5.41 vs 0.91 â€‹%; p â€‹= â€‹0.056). CONCLUSION: Dual antibiotic irrigation with G â€‹+ â€‹C did not reduce the risk of surgical site infection during open retromuscular ventral hernia repair.

Hernia Mesh Complications: Management of Mesh Infections and Enteroprosthetic Fistula.

The potential consequences of mesh infection mandate careful consideration of surgical approach, mesh selection, and preoperative patient optimization when planning for ventral hernia repair. Intraperitoneal mesh, microporous or laminar mesh, and multifilament mesh typically require explantation, whereas macroporous, monofilament mesh in an extraperitoneal position is often salvageable. Delayed presentation of mesh infection should raise the suspicion for enteroprosthetic fistula when intraperitoneal mesh is present. When mesh excision is necessary, the surgeon must carefully consider both the risk of recurrent infection as well as hernia recurrence when deciding on single-stage definitive reconstruction versus primary closure with delayed reconstruction.

Outcomes of subsequent abdominal operations after an initial ventral hernia repair.

INTRODUCTION: Nearly 20% of ventral hernia repair (VHR) patients require a subsequent abdominal operation (SAO), and mesh position may impact the complexity and outcome of the SAO. METHODS: Retrospective review of VHR with mesh from 2006 to 2020 from an internal database and the ACHQC. Primary outcomes measured incidence, complexity, and complications of SAO relative to mesh position. RESULTS: SAO was required in 433 of 2539 (17.1%) patients, totaling 671 operations; 197/893 (22.1%) with intraperitoneal mesh (IPM) and 236/1646 (14.3%) with extraperitoneal mesh (EPM; p â€‹< â€‹0.001). SAO was directly related to VHR in 180 (232 total SAOs) and unrelated in 253 (439 total SAOs). There were no significant differences in complications after SAO between IPM and EPM, nor any difference in adhesion complexity. CONCLUSION: Incidence of SAO is higher with IPM, but surgical outcomes are similar. Due to the risk of secondary mesh infection with IPM, significantly more of these were removed at the time of SAO.

Impact of methocarbamol on opioid use after ventral incisional hernia repair.

BACKGROUND: Alternatives to opioid analgesia are needed to reduce the risk of abuse, misuse, and diversion. Musculoskeletal pain is a significant contributor to postoperative pain after ventral hernia repair (VHR). We report the impact of methocarbamol on opioid prescribing after VHR. METHODS: Review of all robotic and open VHR, Jan 2020-July 2022. Data was collected in the Abdominal Core Health Quality Collaborative (ACHQC) with additional chart review to assess for opioid refills. A 2:1 propensity score match was performed comparing opioid prescribing in patients prescribed vs not prescribed methocarbamol. RESULTS: 101 patients received methocarbamol compared with 202 without. Similar number of patients received an opioid prescription (87.1 vs 86.6%; p = 0.904). Study patients received significantly lower MME prescription at discharge (60 v 75; p = 0.021) with no difference in refills (12.5 vs 16.6%; p = 0.386). CONCLUSION: Addition of methocarbamol to a multimodal analgesic regimen after VHR facilitates reduction in prescribed opioid with no increase in refills.

Impact of methocarbamol on opioid use after primary ventral and inguinal hernia repair.

BACKGROUND: Multimodal analgesia is now a mainstay of perioperative care. Our aim is to assess the impact of adding methocarbamol on opioid use for patients undergoing primary ventral (umbilical and epigastric) hernia repair (PVHR) and inguinal hernia repair (IHR). METHODS: Retrospective review of patients undergoing PVHR and IHR who received methocarbamol, propensity score matched in a 2:1 fashion to patients not receiving methocarbamol. RESULTS: Fifty-two PVHR patients receiving methocarbamol were matched to 104 control patients. Study patients were prescribed fewer opioids (55.8 vs 90.4%; p < 0.001) and received lower MME (20 vs 50; p < 0.001), with no difference in refills or rescue opioids. For IHR, study patients received fewer prescriptions (67.3 vs 87.5%; p < 0.001) and received lower MME (25 vs 40; p < 0.001), with no difference in rescue opioid (5.9 vs 0%; p = 0.374). CONCLUSIONS: Methocarbamol significantly reduced opioid prescribing in patients undergoing PVHR and IHR without increasing the risk of refill or rescue opioid.

A Standardized Protocol for Opioid Prescribing After Surgery Decreases Total Morphine Equivalents Prescribed.

INTRODUCTION: Perioperative opioid analgesia has been extensively reexamined during the opioid epidemic. Multiple studies have demonstrated over prescription of opioids, demonstrating the need for change in prescribing practices. A standard opioid prescribing protocol was implemented to evaluate opioid prescribing trends and practices. OBJECTIVES: To evaluate opioid use after primary ventral, inguinal, and incisional hernia repair and to assess clinical factors that may impact opioid prescribing and consumption. Secondary outcomes include the number of refills, patients without opioid requirement, difference in opioid use based on patient characteristics and adherence to prescribing protocol. METHODS: This is a prospective observational study examining patients undergoing inguinal, primary ventral and incisional hernias between February and November 2019. A standardized prescribing protocol was implemented and utilized for postoperative prescribing. All data was captured in the abdominal core health quality collaborative (ACHQC) and opioid use was standardized via morphine milligram equivalents (MME). RESULTS: 389 patients underwent primary ventral, incisional, and inguinal hernia repair, with a total of 285 included in the final analysis. 170 (59.6%) of patients reported zero opioid use postoperatively. Total opioid MME prescribed and high MME consumption were significantly higher after incisional hernia repair with a greater number of refills were required. Compliance with prescribing protocol resulted in lower MME prescription, but not actual lower MME consumption. CONCLUSIONS: Implementation of a standardized protocol for opioid prescribing after surgery decreases the total MME prescribed. Compliance with our protocol significantly reduced this disparity, which has the potential for decreasing abuse, misuse, and diversion of opioids by better estimating actual postoperative analgesic requirements.

Robotic repair of non-midline hernias.

Non-midline abdominal wall hernias present unique anatomic challenges, making repair more complex. The constraints of the peritoneal cavity, pelvis, and costal margin limit the utility of intraperitoneal mesh repair, and extra-peritoneal repairs have traditionally been performed using open techniques, often resulting in higher wound morbidity. Advances in minimally invasive surgery make visualization and dissection of such complex cases feasible, with all the attendant benefits of a minimally invasive over an open approach. In this study, we examined the use of the robotic platform to repair non-midline hernias. Retrospective review of all non-midline abdominal wall hernias was performed robotically at Prisma Health, excluding parastomal hernias. Study conducted and outcomes reported according to STROBE statement. Repair was performed in the retro-rectus (n = 3) or retro-rectus + transversus abdominis release (TAR) (n = 39), pre-peritoneal (n = 22), and intraperitoneal (n = 1). Mean hernia width was 9.4 cm, permanent synthetic mesh used for all repairs. Mean LOS was 1.5 days. Surgical-site occurrence (SSO) occurred in 49.2%, 78% of which were simple seroma. Three patients (4.6%) developed surgical-site infection (SSI). Two recurrences were identified with a mean follow-up of 11 mos. The robotic platform facilitates complex dissection to allow minimally invasive, extra-peritoneal repair of complex non-midline hernias. This approach overcomes the anatomic constraints of intraperitoneal mesh repair and the wound morbidity of open repair.

Implementation of a Patient-Tailored Opioid Prescribing Guideline in Ventral Hernia Surgery.

INTRODUCTION: Opioids are commonly prescribed beyond what is necessary to adequately manage postoperative pain, increasing the likelihood of chronic opioid use, pill diversion, and misuse. We sought to assess opioid utilization and patient-reported outcomes (PROs) in patients undergoing ventral hernia repair (VHR) following the implementation of a patient-tailored opioid prescribing guideline. METHODS: A patient-tailored opioid prescribing guideline was implemented in March of 2018 for patients undergoing inpatient VHR in a large regional healthcare system. We retrospectively assessed opioid utilization and patient-reported outcomes among patients who did (n = 42) and did not receive guideline-based care (n = 121) between March 2018 and December 2019. PROs, operative details, and patient characteristics were extracted from the Abdominal Core Health Quality Collaborative (ACHQC) registry data, and length-of-stay and prescription information were extracted from the electronic health record system at the healthcare institution. RESULTS: The milligram morphine equivalents (MME) prescribed at discharge was lower for patients receiving guideline-based care (Median = 65, interquartile range [IQR] = 50-75) than patients receiving standard care (Median = 100, IQR = 60-150). After adjusting for patient characteristics, the odds of receiving an opioid refill after discharge did not significantly differ between patient groups (P = 0.43). Patient Reported Outcomes Measurement Information System (PROMIS) pain scores and hernia-specific quality-of-life (HerQLes) scores at follow-up also did not differ between patients receiving guideline-based care (Mean PROMIS = 57.3; Mean HerQLes = 53.1) versus those that did not (Mean PROMIS = 56.7; Mean HerQLes = 46.6). CONCLUSIONS: Patients who received tailored, guideline-based opioid prescriptions were discharged with lower opioid dosages and did not require more opioid refills than patients receiving standard opioid prescriptions. Additionally, we found no differences in pain or quality-of-life scores after discharge, indicating the opioids prescribed under the guideline were sufficient for patients.

Effect of stapled versus layered skin closure on surgical site occurrences after abdominal wall reconstruction.

BACKGROUND: The effect of skin closure technique on surgical site occurrences (SSO) after open abdominal wall reconstruction (AWR) with retromuscular polypropylene mesh placement is largely unknown. We hypothesize that layered subcuticular skin closure with cyanoacrylate skin adhesive is protective of surgical site infection compared to standard stapled closure. METHODS: A retrospective review utilizing the Abdominal Core Health Quality Collaborative (ACHQC) database of all patients at Prisma Health-Upstate. All patients with open abdominal wall reconstruction (AWR) of midline incisional hernia defects with retromuscular polypropylene mesh placement from January 2013 to February 2020 were included. Patient demographics, comorbidities, type of hernia repair with mesh location, method of skin closure, and SSOs were collected. Skin closure method was divided into two groups, reflecting a temporal change in practice: staples (historical control group) versus subcuticular suture with cyanoacrylate skin adhesive with/without polymer mesh tape (study group). Primary endpoint was SSI and SSO. Secondary endpoints were SSO or SSI requiring procedural intervention (SSOPI/SSIPI). Standard statistical methods were utilized. RESULTS: A total of 834 patients were analyzed, with 263 treated with stapled skin closure and 571 with subcuticular and adhesive closure. On univariate analysis, the incidence of SSI was significantly lower in the study group (11.8 vs 6.8%; p = 0.002), as was the need for SSIPI (11.8 vs 6.7%; p = 0.015). Rate of SSO was not significantly different between groups (28.1 vs 27.2%), but the rate of SSO requiring intervention was lower in the study group (14.1 vs 9.3%; p = 0.045). CONCLUSION: Layered skin closure technique, including subcuticular closure and adhesive, may reduce the risk of surgical site infection after open AWR. A prospective randomized trial is planned to confirm these findings.

Biologic vs Synthetic Mesh for Parastomal Hernia Repair: Post Hoc Analysis of a Multicenter Randomized Controlled Trial.

BACKGROUND: Parastomal hernias are often repaired with mesh to reduce recurrences, but the presence of an ostomy increases the wound class from clean to clean-contaminated/contaminated and makes the choice of mesh more controversial than in a strictly clean case. We aimed to compare the outcomes of biologic and synthetic mesh for parastomal hernia repair. STUDY DESIGN: This is a post hoc analysis of parastomal hernia repairs in a randomized trial comparing biologic and synthetic mesh in contaminated ventral hernia repairs. Outcomes included rates of surgical site occurrences requiring procedural intervention (SSOPI), reoperations, stoma/mesh-related adverse events, parastomal hernia recurrence rates (clinical, patient-reported, and radiographic) at 2 years, quality of life (EQ-5D, EQ-5D Visual Analog Scale, and Hernia-Related Quality of Life Survey), and hospital costs up to 30 days. RESULTS: A total of 108 patients underwent parastomal hernia repair (57 biologic [53%] and 51 synthetic [47%]). Demographic and hernia characteristics were similar between the two groups. No significant differences in SSOPI rates or reoperations were observed between mesh types. Four mesh erosions into an ostomy requiring reoperations (2 biologic vs 2 synthetic) occurred. At 2 years, parastomal hernia recurrence rates were similar for biologic and synthetic mesh (17 [29.8%] vs 13 [25.5%], respectively; p = .77). Overall and hernia-related quality of life improved from baseline and were similar between the two groups at 2 years. Median total hospital cost and median mesh cost were higher for biologic compared with synthetic mesh. CONCLUSION: Biologic and synthetic mesh have similar wound morbidity, reoperations, 2-year hernia recurrence rates, and quality of life in parastomal hernia repairs. Cost should be considered in mesh choice for parastomal hernia repairs.

One and done? Repair of recurrent hernias after prior Myofascial release.

BACKGROUND: Myofascial release (MFR) techniques, including retromuscular hernia repair, are often considered one-time repairs. We report recurrent ventral hernia repair (RVHR) in patients with prior MFR, focusing on redo-RM repair. METHODS: Retrospective analysis of all patients undergoing RVHR after prior MFR. Primary outcomes were operative time, surgical site infection (SSI), surgical site occurrence (SSO), and 20-month recurrence. RESULTS: 111 RVHR were performed after MFR. For patients with prior external oblique release (EOR, n = 31), transversus abdominis release (TAR) was used for repair in 13. For patients with prior TAR/PCS (posterior component separation) (n = 22), EOR (n = 2) and redo-TAR (n = 3) were employed with comparable results. Prior retromuscular (RM) repair was performed in 92 patients. Redo-RM (n = 32) and intraperitoneal onlay mesh (IPOM; n = 38) were most common. Operative time was longer for redo-RM. SSI (12.5 vs 7.9%), SSO (40.1 vs 39.5%), and recurrence (18.8 vs 16.2%) were similar for redo-RM and IPOM repair. CONCLUSION: RVHR after prior MFR does not preclude additional MFR. Redo-RM VHR outcomes are similar to those repaired with other techniques.

Effect of Hernia Mesh Weights on Postoperative Patient-Related and Clinical Outcomes After Open Ventral Hernia Repair: A Randomized Clinical Trial.

Importance: Although multiple versions of polypropylene mesh devices are currently available on the market for hernia repair, few comparisons exist to guide surgeons as to which device may be preferable for certain indications. Mesh density is believed to impact patient outcomes, including rates of chronic pain and perception of mesh in the abdominal wall. Objective: To examine whether medium-weight polypropylene is associated with less pain at 1 year compared with heavy-weight mesh. Design, Setting, and Participants: This multicenter randomized clinical trial was performed from March 14, 2017, to April 17, 2019, with 1-year follow-up. Patients undergoing clean, open ventral hernia repairs with a width 20 cm or less were studied. Patients were blinded to the intervention. Interventions: Patients were randomized to receive medium-weight or heavy-weight polypropylene mesh during open ventral hernia repair. Main Outcomes and Measures: The primary outcome was pain measured with the National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Intensity Short Form 3a. Secondary outcomes included quality of life and pain measured at 30 days, quality of life measured at 1 year, 30-day postoperative morbidity, and 1-year hernia recurrence. Results: A total of 350 patients participated in the study, with 173 randomized to receive heavy-weight polypropylene mesh (84 [48.6%] female; mean [SD] age, 59.2 [11.4] years) and 177 randomized to receive medium-weight polypropylene mesh (91 [51.4%] female; mean [SD] age, 59.3 [11.4] years). No significant differences were found in demographic characteristics (mean [SD] body mass index of 32.0 [5.4] in both groups [calculated as weight in kilograms divided by height in meters squared] and American Society of Anesthesiologists classes of 2-4 in both groups), comorbidities (122 [70.5%] vs 93 [52.5%] with hypertension, 44 [25.4%] vs 43 [24.3%] with diabetes, 17 [9.8%] vs 12 [6.8%] with chronic obstructive pulmonary disease), or operative characteristics (modified hernia grade of 2 in 130 [75.1] vs 140 [79.1] in the heavy-weight vs medium-weight mesh groups). Pain scores for patients in the heavy-weight vs medium-weight mesh groups at 30 days (46.3 vs 46.3, P = .89) and 1 year (30.7 vs 30.7, P = .59) were identical. No significant differences in quality of life (median [interquartile range] hernia-specific quality of life score at 1 year of 90.0 [67.9-96.7] vs 86.7 [65.0-93.3]; median [interquartile range] hernia-specific quality of life score at 30 days, 45.0 [24.6-73.8] vs 43.3 [28.3-65.0]) were found for the heavy-weight mesh vs medium-weight mesh groups. Composite 1-year recurrence rates for patients in the heavy-weight vs medium-weight polypropylene groups were similar (8% vs 7%, P = .79). Conclusions and Relevance: Medium-weight polypropylene did not demonstrate any patient-perceived or clinical benefit over heavy-weight polypropylene after open retromuscular ventral hernia repair. Long-term follow-up of these comparable groups will elucidate any potential differences in durability that have yet to be identified. Trial Registration: ClinicalTrials.gov Identifier: NCT03082391.

Ventral Hernia Management in Obese Patients.

Ventral and incisional hernias in obese patients are particularly challenging. Suboptimal outcomes are reported for elective repair in this population. Preoperative weight loss is ideal but is not achievable in all patients for a variety of reasons, including access to bariatric surgery, poor quality of life, and risk of incarceration. Surgeons must carefully weigh the risk of complications from ventral hernia repair with patient symptoms, the ability to achieve adequate weight loss, and the risks of emergency hernia repair in obese patients.

Robotic Versus Laparoscopic Approach to Hiatal Hernia Repair: Results After 7 Years of Robotic Experience.

INTRODUCTION: Robotic hiatal hernia repair offers potential advantages over traditional laparoscopy, most notably enhanced visualization, improved ergonomics, and articulating instruments. The clinical outcomes, however, have not been adequately evaluated. We report outcomes of laparoscopic and robotic hiatal hernia repairs. METHODS: A retrospective observational cohort study was performed of all hiatal hernia repairs performed from 2006 through 2019. Operative, demographic, and outcomes data were compared between laparoscopic and robotic groups. Discrete variables were analyzed with Chi-square of Fisher's exact test. Continuous variables were analyzed with Student's t test (mean) or Wilcoxon rank sum (medians). All analyses were performed using R statistical software. RESULTS: Laparoscopic repair was performed in 278 patients and robotic repair in 114. More recurrent hernias were repaired robotically (24.5% vs 12.9%, P = .08). Operative times were no different between groups (175 vs 179 minutes; P = .681). Robotic repair resulted in significantly shorter length of stay (LOS; 2.3 vs 3.3 days; P = .003). Rate of readmission was no different, and there were no differences in acute complications. For patients with at least 1 year of follow-up, recurrence rates were lower after robotic repair (13.3% vs 32.8%; P = .008); however, mean follow-up is significantly longer after laparoscopic repair (23.7 ± 28.4 vs 15.1 ± 14.9 months; P < .001). DISCUSSION: Robotic hiatal hernia repair offers technical advantages over laparoscopic repair with similar clinical outcomes.

Opioid Use After Inguinal and Ventral Hernia Repair.

BACKGROUND: Recent data on opioid consumption indicate that patients typically require far less than is prescribed. Prisma Health Upstate Hernia Center adopted standardized postoperative prescribing after hernia repair and began tracking patient-reported opioid utilization. The aim of this study is to evaluate patient opioid use after hernia repair in order to guide future prescribing. METHODS: All patients who underwent primary ventral (umbilical and epigastric), incisional, and inguinal hernia repair between February and May 2019 were reviewed. Patients reported the number of opioid pills taken at their first postoperative visit and documented either in the progress note or in the Americas Hernia Society Quality Collaborative (AHSQC) patient-reported outcomes (PRO) questionnaire. All demographic, operative, and outcomes data were captured prospectively in the AHSQC. Opioid use reported as milligram morphine equivalents (MME). RESULTS: A total of 162 surgeries were performed during the study period, and 107 had patient-reported opioid use for analysis. Inguinal hernia repair was performed in 36 patients, 10 primary ventral hernia repairs, and 61 incisional hernia repairs. No opioid use was reported in 63.9% of inguinal hernias, 60% of primary ventral hernias, and 20% of incisional hernias. Inguinal hernia patients consumed a mean of 10.5 MME, primary ventral patients 11 MME, and incisional hernia patients 78.5 MME. CONCLUSION: Patients require little to no opioid after primary ventral or inguinal hernia repair and opioid-free surgery is feasible. Incisional hernia is more heterogenous, but the majority of patients still required less opioid than previously thought.

Implementation of an Evidence-Based Protocol Significantly Reduces Opioid Prescribing After Ventral Hernia Repair.

BACKGROUND: Increased recognition of the dangers of opioid analgesia has led to significant focus on strategies for reducing use through multimodal analgesia, enhanced recovery protocols, and standardized guidelines for prescribing. Our institution implemented a standard protocol for prescribing analgesics at discharge after ventral hernia repair (VHR). We hypothesize that this strategy significantly reduces opioid use. METHODS: A standardized protocol for discharge prescribing was implemented in March 2018. Patients were prescribed ibuprofen, acetaminophen, and opioids based on milligram morphine equivalent (MME) use the 24 hours prior to discharge. We retrospectively reviewed prescriptions of opioids for two 6-month periods-July-December 2017 (PRE) and July-December 2018 (POST)-for comparison using EPIC report and the South Carolina Prescription Monitoring Program. Analysis performed included Mann-Kendall linear trend test and Student's t-test for continuous variables. RESULTS: VHR was performed in 105 patients in the PRE and 75 patients in the POST group. Total MME prescribed decreased significantly from mean 322.7 + 261.3/median 225 (IQR 150-400) MME to 141.6 + 150.4/median 100 (50-184) MME (P < .001). This represents a 57% reduction in mean opioid MME prescriptions. Acetaminophen prescribing increased from 10% to 65%, and ibuprofen from 7.6% to 61.3%. Refills were prescribed in 21 patients (20%) during the PRE period, which decreased to 10.7% during the POST group (P = .141). Implementation of an evidence-based protocol significantly reduces opioid prescribing after VHR. DISCUSSION: A multimodal approach to postoperative pain management decreases the need for opioids. The additional implementation of an evidence-based prescribing protocol results in significant reduction of opioid use following VHR.

Factors affecting salvage rate of infected prosthetic mesh.

BACKGROUND: Prosthetic mesh infection (PMI) is a challenging complication of ventral hernia repair (VHR). The sparsity of data leaves only experience and judgment to guide surgical decision-making. METHODS: Retrospective review of patients diagnosed with PMI. Subsequent abdominal operation (SAO) constitutes any intraabdominal operation occurring after the index hernia repair prior to PMI presentation. Any mesh removal was considered salvage failure. Analysis was performed using Chi-square test, Fishers Exact, or Mann-Whitney U test. Analyses completed using R Version 3.0.2. RESULTS: We identified 213 instances of PMI. Most cases (58.7%) involved intraperitoneal mesh. Thirty-seven percent of patients had an SAO, only 25.3% of which were clean cases. Enteroprosthetic fistula occurred in 38 patients (17.8%). Mean time to presentation was 19.9 mos after index hernia repair or SAO for infection alone, and 48.1 mos when a fistula was present (p < 0.001). Percutaneous drainage was used to treat 29 cases, successfully in 10 (34.5%), 8 of which were macroporous polypropylene and 2 biologic mesh. Negative pressure wound therapy (NPWT) was used in 46 patients, but successful in only 16 (34.8%), all of which were macroporous polypropylene. Local wound care alone successfully salvaged only 16 of 85 meshes (18.8%), 13 of which were macroporous polypropylene. Macroporous polypropylene mesh was salvaged in 65% of cases overall, and 72.2% when in an extraperitoneal position. Mesh salvage was not possible in any case involving composite or PTFE mesh, and rarely for microporous polypropylene (7.7%) multifilament polyester (4.2%), or intraperitoneal mesh (2.4%). Closure of the defect after mesh removal significantly lowers recurrence rate (p < 0.001). CONCLUSION: PMI involving composite, PTFE, multifilament polyester, or microporous polypropylene mesh requires explantation in nearly all cases. Infected macroporous polypropylene mesh in an extraperitoneal position is salvageable in most cases. Furthermore, the risk of secondary mesh infection after SAO, particularly with intraperitoneal mesh, should be considered during index VHR.

Length of Stay and Opioid Dose Requirement with Transversus Abdominis Plane Block vs Epidural Analgesia for Ventral Hernia Repair.

BACKGROUND: Major abdominal operations often requires postoperative opioid analgesia. However, there is growing recognition of the potential for abuse. We previously reported a significant reduction in opioid consumption after implementation of an Enhanced Recovery after Surgery protocol after ventral hernia repair focusing on opioid reduction. Epidural use was routine for postoperative pain control in this protocol. Recently, we have transitioned to transversus abdominis plane (TAP) block instead of epidural analgesia. We hypothesize that this modification reduces length of stay and lowers opioid use in ventral hernia repair. METHODS: All patients undergoing open ventral hernia repair were recorded prospectively in the Americas Hernia Society Quality Collaborative database. All patients receiving either TAP or epidural between February 2015 and March 2018 were identified. Additional review was performed to quantify opioid use in morphine milligram equivalents (MMEs). Primary outcomes were length of stay and opioid use. RESULTS: Epidural was used in 172 patients and TAP block in 74. There were no significant comorbidity differences between groups. The TAP group had a slightly higher BMI (33.6 kg/m2 vs 28.3 kg/m2) and slightly smaller hernias (8.8 cm vs 10.8 cm). There was no difference in 30-day surgical site infections. Hospital length of stay was significantly shorter with TAP block (2.4 vs 4.5 days; p < 0.001). Total MME requirements for patients receiving TAP block were lower than those with epidural during postoperative days 1 and 2 (mean 40 vs 54.1 MMEs; p = 0.033 and 36.1 vs 52.5 MMEs; p = 0.018). CONCLUSIONS: Use of TAP block significantly reduces length of stay and decreases opioid dose requirements in the early postoperative period compared with epidural analgesia.