Year-Over-Year Ventral Hernia Recurrence Rates and Risk Factors.

Importance: Recurrence is one of the most challenging adverse events after ventral hernia repair as it impacts quality of life, utilization of resources, and subsequent need for re-repair. Rates of recurrence range from 30% to 80% after ventral hernia repair. Objective: To determine the contemporary ventral hernia recurrence rate over time in patients with previous hernia repair and to determine risk factors associated with recurrence. Design, Setting, and Participants: This retrospective, population-based study used the Abdominal Core Health Quality Collaborative registry to evaluate year-over-year recurrence rates in patients with prior ventral hernia repair between January 2012 and August 2022. Patients who underwent at least 1 prior ventral hernia repair were included and categorized into 2 groups based on mesh or no-mesh use. There were 43 960 eligible patients; after exclusion criteria (patients with concurrent inguinal hernias as the primary diagnosis, nonstandard hernia procedure categories, American Society of Anesthesiologists class unassigned, or no follow-up), 29 834 patients were analyzed in the mesh group and 5599 in the no-mesh group. Main Outcomes and Measures: Ventral hernia recurrence rates. Risk factors analyzed include age, body mass index, sex, race, insurance type, medical comorbidities, American Society of Anesthesiologists class, smoking, indication for surgery, concomitant procedure, hernia procedure type, myofascial release, fascial closure, fixation type, number of prior repairs, hernia width, hernia length, mesh width, mesh length, operative approach, prior mesh placement, prior mesh infection, mesh location, mesh type, postoperative surgical site occurrence, postoperative surgical site infection, postoperative seroma, use of drains, and reoperation. Results: Among 29 834 patients with mesh, the mean (SD) age was 57.17 (13.36) years, and 14 331 participants (48.0%) were female. Among 5599 patients without mesh, the mean (SD) age was 51.9 (15.31) years, and 2458 participants (43.9%) were female. When comparing year-over-year hernia recurrence rates in patients with and without prior mesh repair, respectively, the Kaplan Meier analysis showed a recurrence rate of 201 cumulative events with 13 872 at risk (2.8%) vs 104 cumulative events with 1707 at risk (4.0%) at 6 months; 411 cumulative events with 4732 at risk (8.0%) vs 184 cumulative events with 427 at risk (32.6%) at 1 year; 640 cumulative events with 1518 at risk (19.7%) vs 243 cumulative events with 146 at risk (52.4%) at 2 years; 731 cumulative events with 670 at risk (29.3%) vs 258 cumulative events with 73 at risk (61.4%) at 3 years; 777 cumulative events with 337 at risk (38.5%) vs 267 cumulative events with 29 at risk (71.2%) at 4 years; and 798 cumulative events with 171 at risk (44.9%) vs 269 cumulative events with 19 at risk (73.7%) at 5 years. Higher body mass index; immunosuppressants; incisional and parastomal hernias; a robotic approach; greater hernia width; use of a biologic or resorbable synthetic mesh; and complications, such as surgical site infections and reoperation, were associated with higher odds of hernia recurrence. Conversely, greater mesh width, myofascial release, and fascial closure had lower odds of recurrence. Hernia type was the most important variable associated with recurrence. Conclusions and Relevance: In this study, the 5-year recurrence rate after ventral hernia repair was greater than 40% and 70% in patients with and without mesh, respectively. Rates of ventral hernia recurrence increased over time, underscoring the importance of close, long-term follow up in this population.

Parastomal Hernia Following Ileal Conduit: Incidence, Risk Factors, and Health-Related Quality of Life.

PURPOSE: The purpose of this study was to measure the incidence of parastomal hernia (PH) after radical cystectomy and ileal conduit. Secondary aims were the identification of risk factors for PH and to compare the health-related quality of life (QOL) between patients with and without PH. DESIGN: Retrospective review of medical records combined with cross-sectional administration of the QOL instrument and telephone follow-up. SUBJECTS AND SETTING: The study sample comprised 219 patients who underwent radical cystectomy and ileal conduit for urothelial cancer between February 2014 and December 2018. The study setting was Peking University First Hospital (Beijing, China). METHODS: Demographic and pertinent clinical data, including development of PH, were gathered via the retrospective review of medical records. Participants were also asked to complete the traditional Chinese language version of the City of Hope Quality of Life-Ostomy Questionnaire (C-COH). Multiple linear regression analysis was used to identify the effect of PH on C-COH scores. Logistic regression analysis was used to identify risk factors for PH development. RESULTS: At a median follow-up of 34 months (IQR = 21-48), 43 of 219 (19.63%) patients had developed a PH. A body mass index (BMI) indicating overweight (OR = 3.548; 95% CI, 1.562-8.061; P = .002), a prior history of hernia (OR = 5.147; 95% CI, 1.195-22.159; P = .028), and chronic high abdominal pressure postdischarge (CHAP-pd) (OR = 3.197; 95% CI, 1.445-7.075; P = .004) were predictors of PH after operation. There was no significant difference between C-COH scores of patients with or without PH. No significant differences were found when participants with PH were compared to those without PH on 4 factors of the C-COH: physical scores (ß= .347, P = .110), psychological scores (ß= .316, P = .070), spiritual scores (ß=-.125, P = .714), and social scores (ß= .054, P = .833). CONCLUSION: Parastomal hernia is prevalent in patients undergoing radical cystectomy and ileal conduit urinary diversion. Overweight, hernia history, and CHAP-pd were predictors of PH development. No significant differences in QOL were found when patients with PH were compared to those without PH.

Parastomal hernia repairs: A nationwide cohort study in the Republic of Ireland.

BACKGROUND: In the context of improving colorectal cancer outcomes, post-survivorship quality of life has become an important outcome measure. Parastomal hernias and their associated morbidity remain largely under-reported and under-appreciated. Despite their burden, conservative management is common. This study aims to provide a national overview on the current trends in parastomal hernia repairs (PHRs). METHODS: All PHRs performed in public hospitals across the country between 1/2017 to 7/2022 were identified retrospectively from the National Quality Assurance and Improvement System (NQAIS) database. Anonymised patient characteristics and quality indices were extracted for statistical analysis. RESULTS: A total of 565 PHRs, 64.1 % elective and the remainder emergent, were identified across 27 hospitals. The 8 national colorectal units performed 67.3 % of all repairs. While 42.3 % of PHRs were standalone procedures, reversal of Hartmann's procedure was the commonest simultaneous procedure in the remainder. The median age, ASA and Charlson Co-Morbidity Index were 64 years (19), 3(1) and 3(10) respectively. Mean length of stay (LOS) was 16.25 days (SD = 29.84). Linear regression analysis associated ASA (95 % CI 0.58-16.08, p < 0.035) and emergency admissions (95 % CI 5.86-25.55, P < 0.002) with a significantly longer LOS, with the latter also associated with more frequent emergency re-admissions (95 % CI 0.18-0.82, p < 0.002). CONCLUSION: Patients undergoing emergency PHR were older and significantly more comorbid. Consequently, these patients were subjected to longer hospital stays, more frequent readmissions and overall higher hospital costs. Multidisciplinary perioperative optimisation and standardised referral pathways should underpin the shift towards elective PHRs.

Impact of parastomal hernia on colostomy costs at 1 year: Secondary analysis of a randomized clinical trial (STOMAMESH).

BACKGROUND AND AIMS: Parastomal hernia (PSH) is a common complication after the creation of a colostomy, with a prevalence of approximately 50%. Despite the high frequency, little is known how PSH affects the cost of colostomy care.The hypothesis in this study was that PSH increases the cost of colostomy care compared with not having a PSH. METHODS: Two groups with (N = 61) and without (n = 147) PSH were compared regarding costs of stoma appliances and visits. The population from a large randomized trial comparing construction of colostomy with or without prophylactic mesh (STOMAMESH) was used and cross-matched with health economic data from the National Pharmaceutical Register, 1 year after initial surgery. RESULTS: Patients with and without a PSH were similar in basic demographic data. No difference in cost of stoma appliances (with PSH 2668.3 EUR versus no PSH 2724.5 EUR, p = 0.938) or number of visits to a stoma therapist (p = 0.987) was seen, regardless of the presence or not of a PSH. CONCLUSIONS: PSH appears not to affect costs due to colostomy appliances or the need to visit a stoma therapist, in the first year. The lesson to be learnt is that PSHs are not a driver for costs. Other factors may be determinants of the cost of a colostomy, including manufacturers' price and persuasion, means of procurement, and presence of guidelines.

Hernia Formation: Risk Factors and Biology.

The incidence of ventral hernias in the United States is in increasing. Herein, the author details the etiology of congenital and acquired ventral hernias as well as the risk factors associated with the development of each of these types of ventral hernias.

Association of Nicotine Cessation Time on the Incidence of Recurrent Incisional Hernia Repair and Postoperative Surgical Site Occurrences.

BACKGROUND: Nicotine products are believed to be associated with a higher incidence of incisional hernia (IH) recurrence and postoperative complications after IH repair. METHODS: A retrospective analysis of the Abdominal Core Health Quality Collaborative (ACHQC) database was performed. Outcomes included risk of IH recurrence, 30-day surgical site infection (SSI), and 30-day surgical site occurrence (SSO). RESULTS: We included 14,663 patients. Nicotine users who quit within 1 year of surgery had a 26% higher risk of IH recurrence compared to patients who quit more than a year before surgery or never users. Patients who quit using nicotine within 1 year of surgery had a 54% higher odds of SSI compared to former nicotine users who quit more than a year before surgery. CONCLUSION: Former nicotine users with less than 1 year of nicotine use cessation before surgery exhibited worse outcomes than those with more than a year of cessation or no prior use.

The impact of comorbidities on postoperative outcomes of ventral hernia repair: the patients' perspective.

INTRODUCTION: Ventral hernia repair (VHR) outcomes can be adversely affected by modifiable patient co-morbidities, such as diabetes, obesity, and smoking. Although this concept is well accepted among surgeons, the extent to which patients understand the significance of their co-morbidities is unknown, and a few studies have sought to determine patient perspectives regarding the impact of their modifiable co-morbidities on their post-operative outcomes. We attempted to determine how accurately patients predict their surgical outcomes after VHR compared to a surgical risk calculator while considering their modifiable co-morbidities. METHODS: This is a prospective, single-center, survey-based study evaluating patients' perceptions of how their modifiable risk factors affect outcomes after elective ventral hernia repair. Pre-operatively, after surgeon counseling, patients predicted the percentage of impact that they believed their modifiable co-morbidities (diabetes, obesity, and smoking) had on 30-day surgical site infections (SSI) and hospital readmissions. Their predictions were compared to the Outcomes Reporting App for CLinicians and Patient Engagement (ORACLE) surgical risk calculator. Results were analyzed using demographic information. RESULTS: 222 surveys were administered and 157 were included in the analysis after excluding for incomplete data. 21% had diabetes, 85% were either overweight with body mass index (BMI) 25-29.9 or obese (BMI ≥ 30), and 22% were smokers. The overall mean SSI rate was 10.8%, SSOPI rate was 12.7%, and 30-day readmission rate was 10.2%. ORACLE predictions correlated with observed SSI rates (OR 1.31, 95% CI 1.12-1.54, p < 0.001), but patient predictions did not (OR 1.00, 95% CI 0.98-1.03, p = 0.868). The correlation between patient predictions and ORACLE calculations was weak ([Formula: see text] = 0.17). Patient predictions were on average 10.1 ± 18.0% different than ORACLE, and 65% overestimated their SSI probability. Similarly, ORACLE predictions correlated with observed 30-day readmission rates (OR 1.10, 95% CI 1.00-1.21, p = 0.0459), but patient predictions did not (OR 1.00, 95% CI 0.975-1.03, p = 0.784). The correlation between patient predictions and ORACLE calculations for readmissions was weak ([Formula: see text] = 0.27). Patient predictions were on average 2.4 ± 14.6% different than ORACLE, and 56% underestimated their readmission probability. Additionally, a substantial proportion of the cohort believed that they had a 0% risk of SSI (28%) and a 0% risk of readmission (43%). Education, income and healthcare employment did not affect the accuracy of patient predictions. CONCLUSIONS: Despite surgeon counseling, patients do not accurately estimate their risks after VHR when compared to ORACLE. Most patients overestimate their SSI risk and underestimate their 30-day readmission risk. Furthermore, several patients believed that they had a 0% risk of SSI and readmission. These findings persisted regardless of level of education, income level, or healthcare employment. Additional attention should be directed toward setting expectations prior to surgery and using applications such as ORACLE to assist in this process.

The incidence and impact of enterotomy during laparoscopic and robotic ventral hernia repair: a nationwide readmissions analysis.

INTRODUCTION: Our aim was to define the national incidence of enterotomy (ENT) during minimally invasive ventral hernia repair (MIS-VHR) and evaluate impact on short-term outcomes. METHODS: The 2016-2018 Nationwide Readmissions Database was queried using ICD-10 codes for MIS-VHR and enterotomy. All patients had 3-months follow-up. Patients were stratified by elective status; patients without ENT (No-ENT) were compared against ENT patients. RESULTS: In total, 30,025 patients underwent LVHR and ENT occurred in 388 (1.3%) patients; 19,188 (63.9%) cases were elective including 244 elective-ENT patients. Incidence was similar between elective versus non-elective cohorts (1.27% vs 1.33%; p = 0.674). Compared to laparoscopy, ENT was more common during robotic procedures (1.2% vs 1.7%; p = 0.004). Comparison of elective-No-ENT vs elective-ENT showed that elective-ENT patients had a longer median LOS (2 vs 5 days; p < 0.001), higher mean hospital cost ($51,656 vs $76,466; p < 0.001), increased rates of mortality (0.3% vs 2.9%; p < 0.001), and higher 3-month readmission (10.1% vs 13.9%; p = 0.048). Non-elective cohort comparison demonstrated non-elective-ENT patients had a longer median LOS (4 vs 7 days; p < 0.001), higher mean hospital cost ($58,379 vs $87,850; p < 0.001), increased rates of mortality (0.7% vs 2.1%;p < 0.001), and higher 3-month readmission (13.6% vs 22.2%; p < 0.001). In multivariable analysis (odds ratio, 95% CI), higher odds of enterotomy were associated with robotic-assisted procedures (1.386, 1.095-1.754; p = 0.007) and older age (1.014, 1.004-1.024; p = 0.006). Lower odds of ENT were associated with BMI > 25 kg/m2 (0.784, 0.624-0.984; p = 0.036) and metropolitan teaching vs metropolitan non-teaching (0.784, 0.622-0.987; p = 0.044). ENT patients (n = 388) were more likely to be readmitted with post-operative infection (1.9% vs 4.1%; p = 0.002) or bowel obstruction (1.0% vs 5.2%;p < 0.001) and more likely to undergo reoperation for intestinal adhesions (0.3% vs 1.0%; p = 0.036). CONCLUSION: Inadvertent ENT occurred in 1.3% of MIS-VHRs, had similar rates between elective and urgent cases, but was more common for robotic procedures. ENT patients had a longer LOS, and increased cost and infection, readmission, re-operation and mortality rates.

Mediumweight polypropylene mesh fractures after open retromuscular ventral hernia repair: incidence and associated risk factors.

PURPOSE: Mediumweight (MW) and heavyweight (HW) polypropylene have demonstrated similar clinical and patient-reported outcomes in the setting of open retromuscular ventral hernia repair (VHR). While MW mesh has an anecdotal risk of central mesh fracture, that phenomenon is not well-characterized. We sought to assess the incidence of and risk factors for MW polypropylene mesh fractures after VHR. METHODS: The ACHQC registry was queried for patients with CT-documented hernia recurrence after open retromuscular VHR with MW polypropylene mesh at our institution with 1-year follow-up between January 2014 and April 2022. Images were reviewed by five blinded surgeons at Cleveland Clinic to reach consensus that hernia recurrence mechanism was central mesh fracture. Patients without clinical recurrence or patient-reported bulge were used as a comparator group. RESULTS: Eighty patients were identified with radiographically documented recurrence; 28 had recurrence from mesh fractures and these were compared to 644 patients without recurrence. Incidence of MW fracture was 4.2%. Bridging of anterior fascia was more common in the group with the central mesh fracture (33.3% vs 3.3%, p < 0.001); the incidence of fracture was 30% (9/30) in patients requiring a bridged closure. Mesh fracture was associated with larger hernias (median width: 20 cm [16-26] vs 15 cm [12-18], p < 0.001,), length (25 cm [23-30] vs 23 cm [19-26], p = 0.004). CONCLUSION: MW polypropylene mechanical failures are surprisingly common, particularly in settings of bridged fascial closure and larger hernias. Use of HW polypropylene should be considered in this setting, and industry should be encouraged to create larger pieces of HW polypropylene mesh.

Prophylactic Mesh Placement During Formation of an End-colostomy: Long-term Randomized Controlled Trial on Effectiveness and Safety.

OBJECTIVE: The aim of this study was to determine if prophylactic mesh placement is an effective, safe, and cost-effective procedure to prevent parastomal hernia (PSH) formation in the long term. BACKGROUND: A PSH is the most frequent complication after stoma formation. Prophylactic placement of a mesh has been suggested to prevent PSH, but long-term evidence to support this approach is scarce. METHODS: In this multicentre superiority trial patients undergoing the formation of a permanent colostomy were randomly assigned to either retromuscular polypropylene mesh reinforcement or conventional colostomy formation. Primary endpoint was the incidence of a PSH after 5 years. Secondary endpoints were morbidity, mortality, quality of life, and cost-effectiveness. RESULTS: A total of 150 patients were randomly assigned to the mesh group (n = 72) or nonmesh group (n = 78). For the long-term follow-up, 113 patients were analyzed, and 37 patients were lost to follow-up. After a median follow-up of 60 months (interquartile range: 48.6-64.4), 49 patients developed a PSH, 20 (27.8%) in the mesh group and 29 (37.2%) in the nonmesh group ( P = 0.22; RD: -9.4%; 95% CI: -24, 5.5). The cost related to the meshing strategy was € 2.239 lower than the nonmesh strategy (95% CI: 491.18, 3985.49), and quality-adjusted life years did not differ significantly between groups ( P = 0.959; 95% CI: -0.066, 0.070). CONCLUSIONS: Prophylactic mesh placement during the formation of an end-colostomy is a safe procedure but does not reduce the incidence of PSH after 5 years of follow-up. It does, however, delay the onset of PSH without a significant difference in morbidity, mortality, or quality of life, and seems to be cost-effective.

Variation of ventral and incisional hernia repairs in kidney transplant recipients.

INTRODUCTION: As survivorship following kidney transplant continues to improve, so does the probability of intervening on common surgical conditions, such as ventral or incisional hernia, in this population. Ventral hernia management is known to vary across institutions and this variation has an impact on patient outcomes. We sought to evaluate hospital level variation of ventral or incisional hernia repair (VIHR) in the kidney transplant population. METHODS: We performed a retrospective review of 100% inpatient Medicare claims to identify patients who underwent kidney transplant between 2007 and 2018. The primary outcome was 1- and 3-year ventral or incisional risk- and reliability-adjusted VIHR rates. Patient and hospital characteristics were evaluated across risk- and reliability-adjusted VIHR rate tertiles. Models were adjusted for age, sex, race, and Elixhauser comorbidities. RESULTS: Overall, 139,741 patients underwent kidney transplant during the study period with a mean age (SD) of 51.6 (13.7) years. 84,717 (60.6%) were male, and 72,657 (52.0%) were white. Median follow up time was 5.4 years. 2098 (1.50%) patients underwent VIHR. the 1 year risk- and reliability-adjusted hernia repair rates were 0.49% (95% Conf idence Interval (CI) 0.48-0.51, range 0.31-0.59) in tertile 1, 0.63% (95% CI 0.62-0.63, range 0.59-0.68) in tertile 2, and 0.98 (95% CI 0.91-1.05, range 0.68-2.94) in tertile 3. Accordingly, compared to hospitals in tertile 1, the odds of post-transplant hernia repair tertile 2 hospitals were 1.78 (95% CI 1.37-2.31) and at tertile 3 hospitals 3.53 (95% CI 2.87-4.33). CONCLUSIONS: In a large cohort of Medicare patients undergoing kidney transplant, the overall cumulative incidence of hernia repair varied substantially across hospital tertiles. Patient and hospital characteristics varied across tertile, most notably in diabetes and obesity. Future research is needed to understand if program and surgeon level factors are contributing to the observed variation in treatment of this common disease.

Trends in Surgical Technique and Outcomes of Ventral Hernia Repair in The United States.

OBJECTIVE: To describe national trends in surgical technique and rates of reoperation for recurrence for patients undergoing ventral hernia repair (VHR) in the United States. BACKGROUND: Surgical options for VHR, including minimally invasive approaches, mesh implantation, and myofascial release, have expanded considerably over the past 2 decades. Their dissemination and impact on population-level outcomes is not well characterized. METHODS: We conducted a retrospective cohort study of Medicare beneficiaries undergoing elective, inpatient umbilical, ventral, or incisional hernia repair between 2007 and 2015. Cox proportional hazards models were used to estimate the adjusted proportion of patients who remained free from reoperation for hernia recurrence up to 5 years after surgery. RESULTS: One hundred fort-one thousand two hundred sixty-one patients underwent VHR during the study period. Between 2007 and 2018, the use of minimally invasive surgery increased from 2.1% to 22.2%, mesh use increased from 63.2% to 72.5%, and myofascial release increased from 1.8% to 16.3%. Overall, the 5-year incidence of reoperation for recurrence was 14.1% [95% confidence interval (CI) 14.0%-14.1%]. Over time, patients were more likely to remain free from reoperation for hernia recurrence 5 years after surgery [2007-2009 reoperation-free survival: 84.9% (95% CI 84.8%-84.9%); 2010-2012 reoperation-free survival: 85.7% (95% CI 85.6%-85.7%); 2013-2015 reoperation-free survival: 87.8% (95% CI 87.7%-87.9%)]. CONCLUSIONS: The surgical treatment of ventral and incisional hernias has evolved in recent decades, with more patients undergoing minimally invasive repair, receiving mesh, and undergoing myofascial release. Although our analysis does not address causality, rates of reoperation for hernia recurrence improved slightly contemporaneous with changes in surgical technique.

Impact of race and ethnicity on rates of emergent ventral hernia repair (VHR): has anything changed?

BACKGROUND: Non-white patients have been shown to have higher rates of emergent VHR, though no study to date has characterized these disparities over time. METHODS: National Surgical Quality Improvement Program (NSQIP) database was queried for VHR patients between 2008 and 2019. White, black, and hispanic patients were included for analysis. Older (2008-2011) versus New (2016-2019) time-periods were compared. The primary outcome was emergent VHR proportion. Multivariable analysis identified predictors of emergent VHR, then patients in each time-period were propensity matched (PSM) to control for confounders. RESULTS: The 665,809 VHRs between 2008 and 2019 consisted of 69.2% white, 9.7% black, and 8.1% hispanic patients. Emergent VHR rates were higher (all p < 0.001) for black (6.8%) and hispanic (5.6%) patients compared to White (4.1%). Emergent VHR rates between white vs black and white vs hispanic for both old (4.6% vs 7.4% and 4.6% vs 7.4%) and new (3.6% vs 5.8% and 3.6% vs 5.1%) groups demonstrated lower rates in White patients (all p < 0.001). Ratios of emergent VHR rates over time (old to new) remained similar (black:white 1.61-1.61; hispanic:white 1.43-1.42). Multivariable analysis showed older age, higher BMI, smoking, female sex, and increasing ASA class increased odds for emergent VHR. Comparison of PSM-groups (white-PSM vs black-PSM and white-PSM vs hispanic-PSM) for both old (5.0% vs 7.0% and 3.6% vs 6.3%) and new (3.2% vs 4.8% and 3.8% vs 5.5%) time-periods showed lower emergent VHR rates in white patients (all p < 0.001). Ratios of emergent VHR rates over time increased for black patients and decreased for Hispanic patients (black:white:1.4 to 1.5, and hispanic:white:1.75 to 1.45). CONCLUSION: Black and Hispanic patients have higher rates of emergent VHR compared to White patients, and this has not improved over time. After PSM to control for confounding variables, disparities in emergent VHR rates have increased for Black patients and decreased for Hispanic patients.

Abdominal wall hernia and mental health: patients lived experiences and implications for patient care.

BACKGROUND: Abdominal wall hernia (AWH) affects mental health and mental health questions are frequently included within Patient-Reported Outcome Measures (PROMS) for this patient population. However, these questions have not been informed by the subjective lived experiences of mental health in AWH patients. This study is the first to qualitatively examine how AWH affects patients' mental health. METHODS: Fifteen patients were interviewed from a purposive sample of AWH patients until no new themes emerged. Interviews explored patient thoughts and experiences of AWH and mental health. Data were examined using Interpretative Phenomenological Analysis (IPA). RESULTS: Three key themes pertaining to mental health were identified: "psychological and emotional distress", "identity disruption" and "coping mechanisms and support systems". CONCLUSION: Our findings illustrate that AWH is a pathology that can have a significant detrimental impact on people's mental health. This impact has implications for patient care and can be treated and managed through better psychological support. This support may positively affect AWH patient's experience and outcomes in terms of quality of life. This paper provides recommendations for improved AWH patient care in regard to mental health.

Impact of COVID-19 on volume of elective and nonelective ventral hernia repair.

BACKGROUND: The significant decrease in elective surgery during the COVID-19 pandemic prompted fears that there would be an increase in emergency or urgent operations for certain disease states. The impact of COVID-19 on ventral hernia repair is unknown. This study aimed to compare volumes of elective and nonelective ventral hernia repairs performed pre-COVID-19 with those performed during the COVID-19 pandemic. METHODS: An analysis of a prospective database from 8 hospitals capturing patient admissions with the International Classification of Diseases, Tenth Revision Procedure Coding System for ventral hernia repair from January 2017 through June 2021 were included. During, COVID-19 was defined as on or after March 2020. RESULTS: Comparing 3,558 ventral hernia repairs pre-COVID-19 with 1,228 during COVID-19, there was a significant decrease in the mean number of elective ventral hernia repairs per month during COVID-19 (pre-COVID-19: 61 ± 5 vs during COVID-19 19: 39 ± 11; P < .001), and this persisted after excluding the initial 3-month COVID-19 surge (61 ± 5 vs 42 ± 9; P < .001). There were fewer nonelective cases during the initial 3-month COVID-19 surge (32 ± 9 vs 24 ± 4; P = .031), but, excluding the initial surge, there was no difference in nonelective volume (32 ± 9 vs 33 ± 8; P = .560). During COVID-19, patients had lower rates of congestive heart failure (elective: 9.0% vs 6.6%; P = .0047; nonelective: 17.7% vs 11.6%; P < .001) and chronic obstructive pulmonary disease (elective: 13.7% vs 10.2%; P = .017; nonelective: 17.9% vs 12.0%; P < .001) and underwent fewer component separations (10.2% vs 6.4%; P ≤ .001). Intensive care unit admissions decreased for elective ventral hernia repairs (7.7% vs 5.0%; P = .016). Length of stay, cost, and readmission were similar between groups. CONCLUSION: Elective ventral hernia repair volume decreased during COVID-19 whereas nonelective ventral hernia repairs transiently decreased before returning to baseline. During COVID-19, patients appeared to be lower risk and less complex. The possible impact of the more complex patients delaying surgery is yet to be seen.

Umbilical Fascial Defects are Common and Predict Trocar Site Hernias After Laparoscopic Appendectomy.

INTRODUCTION: Investigations have demonstrated that trocar site hernia (TSH) is an under-appreciated complication of laparoscopic surgery, occurring in as many as 31%. We determined the incidence of fascial defects prior to laparoscopic appendectomy and its impact relative to other risk factors upon the development of TSH. METHODS: TSH was defined as a fascial separation of ≥ 1 cm in the abdominal wall umbilical region on abdominal computerized tomography scan (CT) following laparoscopic appendectomy. Patients admitted to our medical center who had both a preoperative CT and postoperative CT for any reason (greater than 30 days after surgery) were reviewed for the presence of TSH from May 2010 to December 2018. CT scans were measured for fascial defects, while investigators were blinded to film timing (preoperative or postoperative) and patient identity. Demographic information was collected. RESULTS: 241 patients undergoing laparoscopic appendectomy had both preoperative and late postoperative CT. TSH was identified in 49 (20.3%) patients. Mean preoperative fascial gap was 3.3 ± 4.3 mm in those not developing a postoperative hernia versus 14.8 ± 7.3 mm in those with a postoperative hernia (P < .0001). Preoperative fascial defect on CT was predictive of TSH (P < .001, OR = 1.44), with an Area Under the Curve (AUC) of .921 (95%CI: .88-.92). Other major risk factors for TSH were: age greater than 59 years (P < .031, OR = 2.48); and obesity, BMI > 30 (P < .012, OR = 2.14). CONCLUSIONS: The incidence of trocar site hernia was one in five following laparoscopic appendectomy. The presence of a pre-existing fascial defect, advanced age, and obesity were strong predictors for the development of trocar site hernia.

How Often Occult Inguinal or Spigelian Hernias Detected During Laparoscopy of Other Reasons Are Later Operated?

BACKGROUND: The incidence of occult inguinal or Spigelian hernias found in other laparoscopies is seldom studied and their development to symptomatic hernias is unknown. MATERIALS AND METHODS: The orifices of all inguinal and Spigelian hernias at linea semilunaris were carefully recorded prospectively in the laparoscopic surgery during the years 2003-2004 (104 cholecystectomies, 55 fundoplications, 36 diagnostic, and 6 miscellaneous). The patients were followed up over 15 years to find out how often the detected occult hernias at index laparoscopy become later symptomatic and were repaired. RESULTS: The index laparoscopic operation was performed to 201 patients with a mean age of 53±14 years. The overall frequency of unexpected hernias was 21% including 36 (18%) inguinal hernias, 5 (2.5%) Spigelian hernias, and 2 (1.0%) ventral hernias. At the index laparoscopy, only 5/201 inguinal and 2 Spigelian hernioplasties were concomitantly undertaken. After 15 years, data of 169 patients were available and new hernia repairs were performed only in 8 (4.7%) patients (2 inguinal, 4 umbilical, and 2 ventral hernias). CONCLUSIONS: Asymptomatic occult hernias detected during laparoscopic surgery of other reason evolve very seldom (<5%) to symptomatic and need to be repaired.

Emergency repair and smoking predict recurrence in a large cohort of ventral hernia patients.

PURPOSE: Ventral hernias are frequent and hernia repair is regularly performed by general surgeons. Emergency repair is less frequent and can be challenging. Long-term data comparing outcomes of emergency- vs. elective ventral hernia repair are scarce. METHODS: Consecutive patients undergoing emergency and elective ventral hernia repair at our institution were prospectively entered in our HerniaMed database between August 2013 and February 2020. Patients were contacted after 1 and 5 years to assess long-term complications. Risk factors for emergency repair and hernia recurrence were assessed by univariate and multivariate analysis. RESULTS: We included 1307 patients. Emergency and elective hernia repair were performed in 11% and 89% of patients with 1-year follow-up rates of 94% and 92%. Female gender, BMI > 40 kg/m2, ASA class 3 and 4, large size umbilical herniation (> 4 cm) and epigastric herniation were more frequent in emergency hernia repair. Binary logistic regression analysis identified emergency repair and smoking as predictors of recurrence (Odds ratio: 4.04 and 95% confidence interval: 1.67-14.21, p = 0.004; Odds ratio: 2.94 and 95% confidence interval: 1.33-9.15, p = 0.011). Furthermore, female gender and significant comorbidity (ASA class 3 and 4) were risk factors for emergency repair (Odds ratio: 1.98 and 95% confidence interval: 01.05-3.74, p = 0.034; Odds ratio: 3.54 and 95% confidence interval: 1.79-6.98, p < 0.001). CONCLUSIONS: Emergency repair and smoking predicted hernia recurrence. Females and highly comorbid patients are at increased risk for emergency repair and should be prioritized for early elective hernia repair.

Obesity Stratification Predicts Short-Term Complications After Parastomal Hernia Repair.

INTRODUCTION: While previous studies have documented adverse outcomes among obese patients undergoing ventral and inguinal hernia repairs, there is a lack of literature regarding the impact of obesity on parastomal hernia (PSH) repair. This retrospective study aims to determine the value of obesity stratification in predicting postoperative complications in patients undergoing PSH repair. MATERIALS AND METHODS: Outcomes of elective PSH repairs from 2010 to 2020 in the American College of Surgeons National Surgical Quality Improvement Program database were analyzed. Patient demographics, preoperative characteristics, and postoperative outcomes were compared using bivariate analysis and multivariable regression models. RESULTS: A total of 2972 patients were retrospectively analyzed. Multivariable regression found, compared to nonobese patients, patients of obesity class ≥ II were 1.37 times more likely to develop complications overall (P = 0.006) and 1.55 times more likely to develop wound complications (P < 0.001). This group also yielded a 1.60 times higher risk of developing superficial wound infection (P = 0.007) and a 1.63 times greater risk of developing postoperative sepsis (P = 0.044). Total length of stay was longer for patients of obesity class ≥ II but not for obesity class I when compared to patients with body mass index <30.0 kg/m2. CONCLUSIONS: Patients with a body mass index ≥35.0 kg/m2 are more susceptible to an increased rate of complications after PSH repairs. The findings of this study will allow surgeons to stratify obese patients who would benefit from preoperative weight loss interventions prior to PSH repair and discuss associated risks with patients to facilitate informed consent.

Incidence and trends of decision regret following elective hernia repair.

BACKGROUND: One approach to evaluate decision-making is using the concept of decision regret, which measures patient remorse after a healthcare decision. This is particularly important for elective, preference-sensitive conditions with multiple treatment options, such as ventral and inguinal hernia repair. In this study, we assessed decision regret among patients who pursued surgical management of ventral and inguinal hernias. METHODS: We retrospectively reviewed a statewide registry of adult patients who underwent elective ventral and inguinal hernia repair between January 2017 and March 2020 and completed a validated survey measuring decision regret. 30-day outcomes included complications, emergency department (ED) utilization, readmission, and reoperation. Multivariable logistic regression examined the association of regret with age, sex, race, insurance status, ASA, tobacco use, diabetes, admission status, surgical approach (open vs. laparoscopic vs. robotic), year, and outcomes. RESULTS: 8315 patients underwent surgery during the study period with a mean age of 60.5 (14.7) years and 1812 (22%) female patients. Among 2159 patients who underwent ventral hernia repair, 248 (11%) reported regret to undergo surgery, 64 (3%) experienced a complication, 160 (7%) visited an ED, 86 (4%) were readmitted, and 29 (1%) underwent reoperation. Outcomes associated with regret after ventral hernia repair included complications (OR 2.33, 95% CI 1.26-4.29) and readmission (OR 2.67, 95% CI 1.51-4.71). Among 6,156 patients who underwent inguinal hernia repair, 533 (9%) reported regret to undergo surgery, 41 (1%) experienced a complication, 304 (5%) visited an ED, 72 (1%) were readmitted, and 63 (1%) underwent reoperation. Outcomes associated with regret after inguinal hernia repair included ED visits (OR 2.03, 95% CI 1.44-2.87) and readmission (OR 4.23, 95% CI 2.35-7.61). CONCLUSION: Roughly 1 in 10 patients undergoing hernia repair report regret with their decision to undergo surgery. Developing a better understanding of the factors associated with decision regret after hernia repair may better inform both patients and surgeon decision-making.