Open repair of flank and lumbar hernias: 142 consecutive repairs at a high-volume hernia center.

BACKGROUND: Flank and lumbar hernias (FLH) are challenging to repair. This study aimed to establish a reproducible management strategy and analyze elective flank and lumbar repair (FLHR) outcomes from a single institution. METHODS: A prospective analysis using a hernia-specific database was performed examining patients undergoing open FLHR between 2004 and 2021. Variables included patient demographics and operative characteristics. RESULTS: Of 142 patients, 106 presented with flank hernias, and 36 with lumbar hernias. Patients, primarily ASA Class 2 or 3, exhibited a mean age of 57.0 â€‹± â€‹13.4 years and BMI of 30.2 â€‹± â€‹5.7 â€‹kg/m2. Repairs predominantly utilized synthetic mesh in the preperitoneal space (95.1 â€‹%). After 29.9 â€‹± â€‹13.1 months follow-up, wound infections occurred in 8.3 â€‹%; hernia recurrence was 3.5 â€‹%. At 6 months postoperatively, 21.2 â€‹% of patients reported chronic pain with two-thirds of these individuals having preoperative pain. CONCLUSIONS: Open preperitoneal FLHR provides a durable repair with low complication and hernia recurrence rates over 2.5 years of follow-up.

The Utilization of Laparoscopic Ventral Hernia Repair (LVHR) in Incarcerated and Strangulated Cases: A National Trend in Outcomes.

INTRODUCTION: Early after its adoption, minimally invasive surgery had limited usefulness in emergent cases. However, with improvements in equipment, techniques, and skills, laparoscopy in complex and emergency operations expanded substantially. This study aimed to examine the trend of laparoscopy in incarcerated or strangulated ventral hernia repair (VHR) over time. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for laparoscopic repair of incarcerated and strangulated hernias (LIS-VHR) and compared over 2 time periods, 2014-2016 and 2017-2019. RESULTS: The utilization of laparoscopy in all incarcerated or strangulated VHR increased over time (2014-2016: 39.9% (n = 14 075) vs 2017-2019: 46.3% (n = 18 369), P < .001). Though likely not clinically significant, demographics and comorbidities statistically differed between groups (female: 51.7% vs 50.0%, P = .003; age 54.5 ± 13.7 vs 55.4 ± 13.8 years, P < .001; BMI 34.9 ± 8.0 vs 34.6 ± 7.8 kg/m2, P < .001). Patients from 2017 to 2019 were less comorbid (18.9% vs 16.8% smokers, P < .001; 18.2% vs 17.3% diabetic, P = .036; 4.6% vs 4.1% COPD, P = .021) but had higher ASA classification (III: 43.3% vs 45.7%; IV: 2.5% vs 2.7%, P < .001). Hernia types (primary, incisional, recurrent) were similar in each group. Operative time (89.7 ± 59.3 vs 97.4 ± 63.4 min, P < .001) became longer but length-of-stay (1.4 ± 3.3 vs 1.1 ± 2.6 days, P < .001) decreased. There was no statistical difference in surgical complications, medical complications, reoperation, or readmission rates between periods. CONCLUSION: Laparoscopic VHR has become a routine method for treating incarcerated and strangulated hernias, and its utilization continues to increase over time. Clinical outcomes have remained the same while hospital stays have decreased.

Disparate potential for readmission prevention exists among inpatient and outpatient procedures in a minimally invasive surgery practice.

BACKGROUND: Administrators have focused on decreasing postoperative readmissions for cost reduction without fully understanding their preventability. This study describes the development and implementation of a surgeon-led readmission review process that assessed preventability. METHODS: A gastrointestinal surgical group at a tertiary referral hospital developed and implemented a template to analyze inpatient and outpatient readmissions. Monthly stakeholder assessments reviewed and categorized readmissions as potentially preventable or not preventable. Continuous variables were examined by the Student's t test and reported as means and standard deviations. Categorical variables were examined by the Pearson χ2 statistic and Fisher's exact test. RESULTS: There were 61 readmission events after 849 inpatient operations (7.2%) and 16 after 856 outpatient operations (1.9%), the latter of which were all classified as potentially preventable. Colorectal procedures represented 65.6% of readmissions despite being only 37.2% of all cases. The majority (67.2%) of readmission events were not preventable. Compared to the not-preventable group, the potentially preventable group experienced more dehydration (30.0% vs 9.8%, P = .045) and ileostomy creation (78.6% vs 33.3%, P = .017). The potential for outpatient management to prevent readmission was significantly higher in the potentially preventable group (40.0% vs 0.0%, P < .001), as was premature discharge prevention (35.0% vs 0.0%, P < .001). CONCLUSION: The use of the standardized template developed for analyzing readmission events after inpatient and outpatient procedures identified a disparate potential for readmission prevention. This finding suggests that a singular focus on readmission reduction is misguided, with further work needed to evaluate and implement appropriate quality-based strategies.

Open preperitoneal ventral hernia repair: Prospective observational study of quality improvement outcomes over 18 years and 1,842 patients.

BACKGROUND: This study aimed to describe progressive evidence-based changes in perioperative management of open preperitoneal ventral hernia repair and subsequent surgical outcomes and to analyze factors that affect recurrence and wound complications. METHODS: Prospective, tertiary hernia center data (2004-2021) were examined for patients undergoing midline open preperitoneal ventral hernia repair with mesh. "Early" (2004-2012) and "Recent" (2013-2021) groups were based on surgery date. RESULTS: Comparison of Early (n = 675) versus Recent (n = 1,167) groups showed that Recent patients were, on average, older (56.9 ± 12.6 vs 58.7 ± 12.1 years; P < .001) with a lower body mass index (33.5 ± 8.3 vs 32.0 ± 6.8 kg/m2; P = .003) and a higher number of comorbidities (3.6 ± 2.2 vs 5.2 ± 2.6; P < .001). Recent patients had higher proportions of prior failed ventral hernia repair (46.5% vs 60.8%; P < .001), larger hernia defects (199.7 ± 232.8 vs 214.4 ± 170.5 cm2; P < .001), more Center for Disease Control class 3 or 4 wounds (11.3% vs 18.6%; P < .001), and more component separations (22.5% vs 45.7%; P < .001). Hernia recurrence decreased over time (7.1% vs 2.4%; P < .001), as did wound complication rates (26.7% vs 13.2%; P < .001). Comparing respective multivariable analyses (Early versus Recent), wound complications were associated with panniculectomy (odds ratio [95% confidence interval]: 2.9 [1.9-4.5], P < .001 vs 2.1 [1.4-3.3], P < .01), contaminated wounds (2.1 [1.1-3.7], P = .02 vs 1.8 [1.1-3.1], P = .02), anterior component separation technique (1.8 [1.1-2.9], P = .02 vs 3.2[1.9-5.3], P < .01), and operative time (per minute: 1.01 [1.008-1.015], P < .01 vs 1.004 [1.001-1.007], P < .01). Diabetes (2.6 [1.7-4.0], P < .01) and tobacco (1.8 [1.1-2.9], P = .02) were only significant in the early group. In both groups, recurrence was associated with wound complication (8.9 [4.1-20.1], P < .01 vs 3.4 [1.3-8.2]. P < .01) and recurrent hernias (4.9 [2.3-11.5], P < .01 vs 2.1 [1.1-4.2], P = .036). CONCLUSION: Despite significant increased patient complexity over time, detecting and implementing best practices as determined by recurring data analysis of a center's outcomes has significantly improved patient care results.

Factors Predicting Increased Length of Stay in Abdominal Wall Reconstruction.

BACKGROUND: Enhanced recovery after surgery (ERAS) programs have become increasingly popular in general surgery, yet no guidelines exist for an abdominal wall reconstruction (AWR)-specific program. We aimed to evaluate predictors of increased length of stay (LOS) in the AWR population to aid in creating an AWR-specific ERAS protocol. METHODS: A prospective, single institution hernia center database was queried for all patients undergoing open AWR (1999-2019). Standard statistical methods and linear and logistic regression were used to evaluate for predictors of increased LOS. Groups were compared based on LOS below or above the median LOS of 6 days (IQR = 4-8). RESULTS: Inclusion criteria were met by 2,505 patients. On average, the high LOS group was older, with higher rates of CAD, COPD, diabetes, obesity, and pre-operative narcotic use (all P < .05). Longer LOS patients had more complex hernias with larger defects, higher rates of mesh infection/fistula, and more often required a component separation (all P < .05). Multivariate analysis identified age (ß0.04,SE0.02), BMI (ß0.06,SE0.03), hernia defect size (ß0.003,SE0.001), active mesh infection or mesh fistula (ß1.8,SE0.72), operative time (ß0.02,SE0.002), and ASA score >4 (ß3.6,SE1.7) as independently associated factors for increased LOS (all P < .05). Logistic regression showed that an increased length of stay trended toward an increased risk of hernia recurrence (P = .06). CONCLUSIONS: Multiple patient and hernia characteristics are shown to significantly affect LOS, which, in turn, increases the odds of AWR failure. Weight loss, peri-operative geriatric optimization, prehabilitation of comorbidities, and operating room efficiency can enhance recovery and shorten LOS following AWR.

Outcomes of biologic versus synthetic mesh in CDC class 3 and 4 open abdominal wall reconstruction.

INTRODUCTION: Abdominal wall reconstruction (AWR) in a contaminated field is associated with an increased risk of wound complications, infection, and reoperation. The best method of repair and mesh choice in these operations have generated marked controversy. Our aim was to compare outcomes of patients who underwent AWR with biologic versus synthetic mesh in CDC class 3 and 4 wounds. METHODS: A prospective, single-institution database was queried for AWR using biologic or synthetic mesh in CDC Class 3 and 4 wounds. Hernia recurrence and complications were measured. Multivariable logistic regression was performed to identify factors predicting both. RESULTS: In total, 386 patients with contaminated wounds underwent AWR, 335 with biologic and 51 with synthetic mesh. Groups were similar in age, sex, BMI, and rate of diabetes. Biologic mesh patients had larger hernia defects (298 ± 233cm2 vs. 208 ± 155cm2; p = 0.004) and a higher rate of recurrent hernias (72.2% vs 47.1%; p < 0.001), comorbidities(5.8 ± 2.7 vs. 4.2 ± 2.4, p < 0.01), and a nearly fivefold increase in Class 4 wounds (47.8% vs. 9.8%, p < 0.001), while fascial closure trended to being less common (90.7% vs 96.1%; p = 0.078). Hernia recurrence was comparable between biologic and synthetic mesh (10.4% vs. 17.6%, p = 0.132). Wound complication rates were similar (36.1% vs. 33.3%, p = 0.699), but synthetic mesh had higher rates of mesh infection (1.2% vs 11.8%; p < 0.001) and infection-related resection (0% vs 7.8%, p < 0.001), with 66% of those synthetic mesh infections requiring excision. On logistic regression, wound complications (OR 5.96 [CI 1.60-22.17]; p = 0.008) and bridging mesh (OR 13.10 [CI 2.71-63.42];p = 0.030) predicted of hernia recurrence (p < 0.05), while synthetic mesh (OR 18.6 [CI 2.35-260.4] p = 0.012) and wound complications (OR 20.6 [CI 3.15-417.7] p = 0.008) predicted mesh infection. CONCLUSIONS: Wound complications in AWR with CDC class 3 and 4 wounds significantly increased mesh infection and hernia recurrence; failure to achieve fascial closure also increased hernia recurrence. Use of synthetic versus biologic mesh increased the mesh infection rate by 18.6 times.

Coated Polypropylene Mesh Is Associated With Increased Infection in Abdominal Wall Reconstruction.

BACKGROUND: Barrier-coated meshes were designed to reduce adhesion formation between mesh and the surrounding viscera. There have been questions raised but little data to determine if rapidly absorbable coatings pose an increased risk of infection. The objective of this study was to determine if a difference exists in wound and mesh infection rates between coated and uncoated polypropylene mesh in patients undergoing open ventral hernia repair. METHODS: A prospective, institutional database at a tertiary hernia center identified patients undergoing open preperitoneal ventral hernia repair (OPPVHR) with polypropylene mesh in CDC class 1 and 2 wounds. Using propensity score matching, an absorbable, coated and uncoated group were matched based on age, comorbidities, wound class, defect size, and mesh size. RESULTS: There were 265 patients each in the matched coated and uncoated mesh groups for a total of 530 patients. Postoperative wound infections (10.9% versus 4.6%, P = 0.01) and need for IV antibiotics (10.5% versus 4.3%, P = 0.01) were significantly higher in the coated group. There was an increase in mesh infection for the coated group (3.4% versus 0.4%, P = 0.02), and of those developing a mesh infection, 60.0% eventually required mesh excision. CONCLUSIONS: Coated mesh was associated with increased postoperative wound and mesh infection following OPPVHR. An uncoated mesh should be strongly considered when placed in an extraperitoneal location.

Closed-Incision Negative Pressure Therapy Decreases Wound Morbidity in Open Abdominal Wall Reconstruction With Concomitant Panniculectomy.

INTRODUCTION: Patients undergoing abdominal wall reconstruction (AWR) with concomitant panniculectomy (CP) may be at higher risk for wound complications due to the need for large incisions and tissue undermining. The aim of this study was to evaluate whether the use of closed-incision negative pressure therapy (ciNPT) decreases wound complications in AWR patients undergoing CP. METHODS: Beginning in February 2018, all patients at this institution who underwent AWR with CP received ciNPT. These patients were identified from a prospectively maintained institutional database. A standard dressing (non-NPT) group was then created in a 1:1 fashion by identifying patients who had AWR with CP immediately before the beginning of ciNPT use (2016-2018). A univariate comparison was made between the ciNPT and non-NPT groups. The primary outcome was wound complication rate; however, other perioperative outcomes, such as requirement for reoperation, were also tracked. Standard statistical methods and logistic regression were used. RESULTS: In total, 134 patients met criteria, with 67 patients each in the ciNPT and non-NPT groups. When comparing patients in the ciNPT and non-NPT groups, they were demographically similar, including body mass index, smoking, and diabetes (P < 0.05). Hernias was large on average (289.5 ± 158.2 vs 315.3 ± 197.3 cm2, P = 0.92) and predominantly recurrent (58.5% vs 72.6%, P = 0.14). Wound complications were much lower in the ciNPT group (15.6% vs 35.5%, P = 0.01), which was mainly driven by a decrease in superficial wound breakdown (3.1% vs 19.7%, P < 0.01). Patients in the ciNPT group were less likely to require a return trip to the operating room for wound complications (0.0% vs 13.3%, P < 0.01). In logistic regression, the use of ciNPT continued to correlate with reduced wound complication rates (P = 0.02). CONCLUSIONS: In AWR with CP, the use of ciNPT significantly decreased the risk of postoperative wound complications, particularly superficial wound breakdown, and lessened the need for wound-related reoperation.

Delayed primary closure (DPC) of the skin and subcutaneous tissues following complex, contaminated abdominal wall reconstruction (AWR): a propensity-matched study.

BACKGROUND: Wound complications following abdominal wall reconstruction (AWR) in a contaminated setting are common and significantly increase the risk of hernia recurrence. The purpose of this study was to examine the effect of short-term negative pressure wound therapy (NPWT) followed by operative delayed primary closure (DPC) of the skin and subcutaneous tissue after AWR in a contaminated setting. METHODS: A prospective institutional hernia database was queried for patients who underwent NPWT-assisted DPC after contaminated AWR between 2008 and 2020. Primary outcomes included wound complication rate and reopening of the incision. A non-DPC group was created using propensity-matching. Standard descriptive statistics were used, and a univariate analysis was performed between the DPC and non-DPC groups. RESULTS: In total, 110 patients underwent DPC following AWR. The hernias were on average large (188 ± 133.6 cm2), often recurrent (81.5%), and 60.5% required a components separation. All patients had CDC Class 3 (14.5%) or 4 (85.5%) wounds and biologic mesh placed. Using CeDAR, the wound complication rate was estimated to be 66.3%. Postoperatively, 26.4% patients developed a wound complication, but only 5.5% patients required reopening of the wound. The rate of recurrence was 5.5% with mean follow-up of 22.6 ± 27.1 months. After propensity-matching, there were 73 patients each in the DPC and non-DPC groups. DPC patients had fewer overall wound complications (23.0% vs 43.9%, p = 0.02). While 4.1% of the DPC group required reopening of the incision, 20.5% of patients in the non-DPC required reopening of the incision (p = 0.005) with an average time to healing of 150 days. Hernia recurrence remained low overall (2.7% vs 5.4%, p = 0.17). CONCLUSIONS: DPC can be performed with a high rate of success in complex, contaminated AWR patients by reducing the rate of wound complications and avoiding prolonged healing times. In patients undergoing AWR in a contaminated setting, a NPWT-assisted DPC should be considered.

Are laparoscopic and open ventral hernia repairs truly comparable?: A propensity-matched study in large ventral hernias.

BACKGROUND: The merits of laparoscopic (LVHR) and open preperitoneal ventral hernia repair (OPPVHR) have been debated for more than 2 decades. Our aim was to determine peri-operative and long-term outcomes in large hernias. METHODS: A prospective, institutional database at a tertiary hernia center was queried for patients undergoing LVHR and OPPVHR. One-to-one propensity score matching was performed for hernia defect size and follow-up. RESULTS: Three hundred and fifty-two LVHR and OPPVHR patients were identified with defect sizes closely matched between laparoscopic (182.0 ± 110.0 cm2) and open repairs (178.3 ± 99.8 cm2), p = 0.64. LVHR and OPPVHR patients were comparable: mean age 57.2 ± 12.1 vs 56.6 ± 12.0 years (p = 0.52), BMI: 32.9 ± 6.6 vs 32.0 ± 7.4 kg/m2 (p = 0.16), diabetes 19.0% vs 19.7% (p = 0.87), and smoking history 8.7% vs 23.0% (p < 0.001), respectively. OPPVHR had higher number of recurrent hernias (14.2% vs 44.9%, p < 0.001), longer operative time (168.1 ± 64.3 vs 186.7 ± 67.7 min, p = 0.006), and more components separation (0% vs 20.3%, p < 0.001). Mean mesh size was larger (p < 0.001) in the open group (634.4 ± 243.4 cm2 vs 841.8 ± 277.6 cm2). The hernia recurrence rates were similar (10.8% vs 9.2%, p = 0.62), with average follow-up of 39.3 ± 32.5 vs 40.0 ± 35.0 months (p = 0.89). Length of stay was higher in the OVHR cohort (5.4 ± 3.0 vs 6.3 ± 3.6 days, p < 0.001), but 30-day readmission rates (4.0% vs 6.4%, p = 0.31) were similar. Overall wound infection rate (2.9% vs 8.4%, p = 0.03) was higher in the OPPVHR group, but the mesh infection rate was similar between LVHR (1.7%) and OPPVHR (0.6%) (p = 0.33). Postoperative pain (41.1% vs 41.4%, p = 0.95) and overall QOL based on the Carolinas Comfort Scale at 6 months (p = 0.73) and 5-years (p = 0.36) were similar. CONCLUSION: Laparoscopic and open preperitoneal repair for large ventral hernias have equivalent hernia recurrence rates, postoperative pain, and QOL on long-term follow-up. Patients undergoing OPPVHR were more likely to be recurrent, complex, require components separation, and more likely to develop postoperative wound complications.

Impact of panniculectomy in complex abdominal wall reconstruction: a propensity matched analysis in 624 patients.

INTRODUCTION: In complex abdominal wall reconstruction (AWR), the role of concomitant panniculectomy has been debated due to concern for increased wound complications that impact outcomes; however, long-term outcomes and quality of life (QOL) have not been well described. The aim of our study was to evaluate the outcomes and QOL in patients undergoing AWR with panniculectomy utilizing 3D volumetric-based propensity match. METHODS: A prospective database from a tertiary referral hernia center was queried for patients undergoing open AWR. 3D CT volumetrics were analyzed and a propensity match comparing AWR patients with and without panniculectomy was created including subcutaneous fat volume (SFV). QOL was analyzed using the Carolinas Comfort Scale. RESULTS: Propensity match yielded 312 pairs, all with adequate CT imaging for volumetric analysis. The panniculectomy group had a higher BMI (p = 0.03) and were more likely female (p < 0.0001), but all other demographics and comorbidities were similar. The panniculectomy group was more likely to have undergone prior hernia repair (77% vs 64%, p < 0.001), but hernia area, SFV, and CDC wound class were similar (all p > 0.05). Requirement of component separation (61% vs 50%, p = 0.01) and mesh excision (44% vs 35%, p = 0.02) were higher in the panniculectomy group, but operative time were similar (all p ≥ 0.05). Panniculectomy patients had a higher overall wound occurrence rate (45% vs 32%, p = 0.002) which was differentiated only by a higher rate of wound breakdown (24% vs 14%, p = 0.003); all other specific wound complications were equal (all p ≥ 0.05). Hernia recurrence rates were similar (8% vs 9%, p = 0.65) with an average follow-up of 28 months. Overall QOL was equal at 2 weeks, and 1, 6, and 12 months (all p ≥ 0.05). CONCLUSIONS: Despite panniculectomy patients and their hernias being more complex, concomitant panniculectomy increased wound complications but did not negatively impact infection rates or long-term outcomes. Concomitant panniculectomy should be considered in appropriate patients to avoid two procedures.

Impact of perforator sparing on anterior component separation outcomes in open abdominal wall reconstruction.

INTRODUCTION: Anterior component separation (ACS) is a well-established, highly functional technique to achieve fascial closure in complex abdominal wall reconstruction (AWR). Unfortunately, ACS is also associated with an increased risk of wound complications. Perforator sparing ACS (PS-ACS) has more recently been introduced to maintain the subcutaneous perforators derived from the deep epigastric vessels. The aim of this study is to evaluate wound-related outcomes in patients undergoing open AWR after implementation of a PS-ACS technique. METHODS: A prospectively collected database were queried for patients who underwent open AWR and an ACS from 2006 to 2018. Patients who underwent PS-ACS were compared to patients undergoing ACS using standard statistical methods. Patients undergoing concomitant panniculectomy were included in the standard ACS group. RESULTS: In total, 252 patients underwent ACS, with 24 (9.5%) undergoing PS-ACS. Age and specific comorbidities were similar between groups (all p > 0.05) except for the PS-ACS groups having a higher rate of prior tobacco use (45.8% vs 19.6%, p = 0.003). Mean hernia defect area was 381.6 ± 267.0 cm2 with 64.3% recurrent hernias, and both were similar between groups (all p > 0.05). The PS-ACS group did have more complex wounds with more Ventral Hernia Working Group Grade 3 and 4 hernias (p = 0.04). OR time and length of stay were similar between groups (all p > 0.05). Despite increased complexity, wound complication rates were much lower in the PS-ACS group (20.8% vs 46.1%, p = 0.02), and all specific wound complications were lower but not statistically different. Hernia recurrence rate was similar between PS-ACS and ACS groups (4.2% vs 7.0%, p > 0.99) with mean follow-up of 27.7 ± 26.9 months. CONCLUSIONS: In complex AWR, preservation of the deep epigastric perforating vessels during ACS significantly lowers the rates of wound complications, despite its performance in more complex patients with an increased risk of infection. PS-ACS should be performed preferentially over a standard ACS whenever possible.

Recurrent incisional hernia repairs at a tertiary hernia center: Are outcomes really inferior to initial repairs?

BACKGROUND: Recurrent ventral hernia repairs are reported to have higher recurrence and complication rates than initial ventral hernia repairs. This is the largest analysis of outcomes for initial versus recurrent open ventral hernia repairs reported in the literature. METHODS: A prospective, institutional database at a tertiary hernia center was queried for patients undergoing open ventral hernia repairs with complete fascial closure and synthetic mesh placement. RESULTS: A total of 1,694 open ventral hernia repairs patients were identified, including 896 (52.9%) initial ventral hernia repairs and 798 (47.1%)recurrent ventral hernia repairs. Recurrent ventral hernia repair patients were more complex: older (P = .003), higher body mass index (P < .001), higher American Society of Anesthesiologists class (P < .001), incidence of diabetics (P = .003), comorbidities (P < .001), and larger hernia defects (133.3 ± 171.9 vs 220.2 ± 210.0; P < .001). Recurrent ventral hernia repairs also had longer operative times (161.6 ± 82.4 vs 188.2 ± 68.9 minutes; P < .001), increased use of preoperative botulinum toxin A injection (4.3% vs 10.1%; P = .01), components separation (19.2% vs 39.5%; P < .001), and panniculectomy (20.3% vs 35.8%; P < .001). The overall hernia recurrence rate was 4.4% at a mean follow-up of 36.6 ± 45.5 months. Between the initial ventral hernia repairs and recurrent ventral hernia repairs, the hernia recurrence rates were equivalent (4.2% vs 4.7%, P = .63). Rates of wound infection, seromas, hematomas, mesh infections, and wound related reoperations (P > .05) were nonsignificant. CONCLUSION: At a tertiary hernia center, despite higher-risk patients, larger hernia defects, and increased components separation in recurrent ventral hernia repairs, early recurrence rates, wound complications, and reoperations are similar to initial ventral hernia repairs.

Laparoscopic Ventral Hernia Repair in the Geriatric Population : An Assessment of Long-Term Outcomes and Quality of Life.

OBJECTIVES: Laparoscopic ventral hernia repair (LVHR) has been shown to decrease wound complications and length of stay (LOS) but results in more postoperative discomfort. The benefits of LVHR for the growing geriatric population are unclear. The aim of our study is to evaluate long-term outcomes and quality of life (QOL) after LVHR in the geriatric population. METHODS: A prospectively collected single-center database was queried for all patients who underwent LVHR (1999-2019). Age groups were defined as <40 (young), 40-64 (middle age), and ≥65 years (geriatric). QOL was assessed with the Carolinas Comfort Scale. RESULTS: LVHR was performed in 1181 patients, of which 13.4% were young, 61.6% middle aged, and 25.0% geriatric. Hernia defect size (64.2 ± 94.4 vs 79.9 ± 102.4 vs 84.7 ± 110.0 cm2) and number of comorbidities (2.2 ± 2.1 vs 3.2 ± 2.2 vs 4.3 ± 2.2) increased with age (all P < .05). LOS increased with age (2.9 ± 2.5 vs 3.8 ± 2.9 vs 5.2 ± 5.3 days, P < .0001). Rates of postoperative cardiac events, pneumonia, respiratory failure, wound complication, reoperation, and death were similar (P > .05). Geriatric patients had increased rate of ileus and urinary retention (all P < .05). Overall recurrence rate was 5.7% with an average follow-up of 43.5 months, with no differences in recurrence between groups (P > .05). Geriatric patients had better overall QOL at 2 weeks (P = .0008) and similar QOL at 1, 6, and 12 months. DISCUSSION: LVHR offers excellent results in the geriatric population. Despite having increased rates of comorbidities and larger hernia defects, which may relate to LOS, rates of complications and recurrence were similar compared with younger cohorts, with better short-term QOL.

Preperitoneal Ventral Hernia Repair: A Decade Long Prospective Observational Study With Analysis of 1023 Patient Outcomes.

OBJECTIVES: The aim of this study was to examine the outcomes of over a decade's experience utilizing preperitoneal ventral hernia repair (PP-VHR). BACKGROUND: PP-VHR was first described by our group in 2006, and there have been no subsequent reports of outcomes with this technique. METHODS: A prospective study of all PP-VHR from January, 2004 to April, 2016 was performed. Multivariate stepwise logistic regression and Cox proportional-hazard models were used to identify predictors of wound complications and hernia recurrence, respectively. RESULTS: There were 1023 PP-VHRs. Mean age was 57.2 ±â€Š12.6 years, BMI 33.7 ±â€Š11.4 kg/m, defect size 210.0 ±â€Š221.4 cm; 23.7% had diabetes, 13.9% were smokers, 68.7% were recurrent, and 23.6% incarcerated. Component separation was required in 43.6%, and a panniculectomy was performed in 30.0%. Wound complication was present in 27.3% of patients, with 1.7% having a mesh infection. In all, there were 53 (5.2%) hernia recurrences and 36 (3.9%) in the synthetic repairs, with a mean follow-up of 27.0 ±â€Š26.4 months. On multivariate regression (odds ratio or hazard ratio, 95% confidence interval), diabetes (1.9, 1.4-3.0), panniculectomy (2.6, 1.8-3.9), and operations requiring biologic mesh were predictors of wound complications, whereas recurrent hernia repair (2.69, 1.14-6.35), biologic mesh (3.1, 1.67-5.75), and wound complications (3.01, 1.69-5.39) were predictors of hernia recurrence. CONCLUSIONS: An open PP-VHR is a very effective means to repair large, complex, and recurrent hernias resulting in a low recurrence rate. Mesh choice in VHR is important and was associated with hernia recurrence and wound complications in this population.

The impact of component separation technique versus no component separation technique on complications and quality of life in the repair of large ventral hernias.

BACKGROUND: Component Separation (CST) typically involves incision of one or more fascial planes to generate myofascial advancement flaps to assist with fascial closure in ventral hernia repair (VHR). The aim of this study was to compare peri-operative outcomes and quality of life (QOL) after CST versus patients without CST (No-CST) in large, preperitoneal VHR (PPVHR). METHODS: A prospective, single institution hernia study examined all patients undergoing PPVHR with synthetic mesh. Emergency and contaminated operations were excluded. A case-control cohort was identified using propensity score matching for CST and No-CST. QOL was assessed using the Carolinas Comfort Scale. RESULTS: The algorithm matched 113 CST cases to 113 No-CST cases. The groups (CST vs No-CST) were similar regarding age, BMI, diabetes, smoking, defect size, mesh size, and follow-up. In univariate analysis, there was no difference in recurrence between the CST and no-CST groups (0.9% vs 0.9%, p = 1.0) or mesh infection (0.9% vs 0.0%, p = 1.0). CST did have more wound complications (29.2% vs 16.1%, p = 0.019). When controlling for panniculectomy and diabetes with multivariate logistic regression, CST continued to have had an increased risk for wound complications (OR 2.27, CI 1.16-4.47). QOL was routinely assessed. The groups were similar pre-operatively with 76.3% of CST patients and 77.8% of No-CST patients having pain (p = 1.0). At 1, 6, 12, 24, and 36 months post-operatively, the groups had equal QOL. CONCLUSION: The use of CST versus No-CST in the repair of large VHs results in an increased risk of wound complications but does not increase the hernia recurrence rate. In the largest QOL comparative study to date, CST's generation of myofascial advancement flaps does not negatively impact patient QOL in the repair of large ventral hernias in the short or long term.

The use of component separation during abdominal wall reconstruction in contaminated fields: A case-control analysis.

BACKGROUND: Component separation technique (CST) allows fascial medialization during abdominal wall reconstruction (AWR). Wound contamination increases the incidence of wound complications, which multiplies the incidence of repair failure. The aim of this study was to compare the impact of CST on AWR outcomes in contaminated fields in comparison to those operations without CST. METHODS: A prospective, single institution hernia database was queried for patients undergoing AWR with CST and contamination. A case control cohort was identified using propensity score matching. RESULTS: There were 286 CSTs performed in contaminated cases. After propensity score matching, 61 CSTs were compared to 61 No-CSTs. These groups were matched by defect area (CST:287.1 ±â€¯150.4 vs No-CST:277.6 ±â€¯218.4 cm2, p = 0.156), BMI (32.0 ±â€¯7.0 vs 32.2 ±â€¯6.0 kg/m2, p = 0.767), diabetes (26.2% vs 32.8%, p = 0.427), and panniculectomy (52.5% vs 36.1%, p = 0.068). Groups had similar rates of wound complications (42.6% vs 40.7%, p = 0.829) and recurrence (4.9% vs 13.1%, p = 0.114). CONCLUSIONS: The use of CST in the face of contamination is not associated with an increase in wound complications, mesh complications, or recurrence.

Sarcopenia in Patients Undergoing Open Ventral Hernia Repair.

Radiologic indicators of sarcopenia have been associated with adverse operative outcomes in some surgical populations. This study assesses the association of radiologic indicators of frailty with outcomes after open ventral hernia repair (OVHR). A prospective, institutional, hernia-specific database was queried for patients undergoing OVHR from 2007 to 2018 with preoperative CT. Psoas muscle cross-sectional area at L3 was measured and adjusted for height (skeletal muscle index (SMI)). L3 vertebral body density (L3 VBD) was measured. Demographics and outcomes were evaluated as related to SMI and L3 VBD. Of 1178 patients, 9.7 per cent of females and 15.8 per cent of males had sarcopenia and 11.6 per cent of females and 9.2 per cent of males had osteopenia. Neither sarcopenia nor osteopenia were associated with outcomes of wound infection, readmission, reoperation, hernia recurrence, or major complications. When examined as continuous variables or by quartile, SMI and L3 VBD were not associated with adverse outcomes, including in subsets of male or female patients, the elderly, contaminated cases, and the obese. Radiologic markers of sarcopenia and osteopenia are not associated with adverse outcomes after OVHR. Further study should examine age or other potential predictors of outcomes in this patient population, such as independent status.

Twelve years of component separation technique in abdominal wall reconstruction.

BACKGROUND: Component separation technique involves incision of abdominal muscle and its aponeurosis, which generates a myofascial advancement flap to assist with fascial closure in abdominal wall reconstructions. This tissue mobilization allows for musculo-fascial approximation of much larger abdominal wall defects than would otherwise be possible. With extensive tissue mobilization, however, there is concern for significant wound and systemic complications. METHODS: A prospective, single institution hernia database was queried for patients undergoing component separation from January 2006 to May 2018. Emergency operations were excluded. Anterior component separation (external oblique release with posterior rectus sheath release) and posterior component separation (transversus abdominus release and posterior rectus sheath release) were examined. RESULTS: Of the 775 component separation, 33.4% included anterior component separation and 66.6% posterior component separation. Mean age was 58.8 ± 11.5 years, mean body mass index was 33.6 ± 7.1 (kg/m2), and 27.9% of patients were diabetic. Hernias were large (280.0 ± 220.9 cm2) and often complex (recurrent: 62.6%, incarcerated: 41.5%, concomitant panniculectomy: 39.1%, and contaminated: 37.0%). Defect size was larger in anterior component separation group compared with posterior component separation (379.5 ± 265.2 vs 230.0 ± 175.0 cm2, P < .001). There was a 35.1% wound complication rate with 32 recurrences (4.1%) during a mean follow-up of 23.3 ± 25.1 months. Complete fascial closure and lack of wound complications significantly improved outcomes (P < .01). Patients undergoing anterior component separation demonstrated more wound complications (42.9% vs 31.2%, P < .001) and recurrences (7.0% vs 2.7%, P = .005). In multivariate analysis, anterior component separation was associated with increased risk of wound complications (odds ratio 1.660; confidence interval, 1.125-2.450), but not recurrence (odds ratio 2.95; confidence interval, 0.72-12.19). Since 2013, prehabilitation and perforator sparing techniques reduced anterior component separation wound complications to 19.6% (P = .008). CONCLUSION: Both anterior component separation and posterior component separation are associated with low recurrence rates, but anterior component separation is associated with higher wound complications. Prehabilitation and operative techniques improve outcomes of component separation.

Long-term assessment of surgical and quality-of-life outcomes between lightweight and standard (heavyweight) three-dimensional contoured mesh in laparoscopic inguinal hernia repair.

BACKGROUND: Mesh weight is a possible contributor to quality-of-life outcomes after inguinal hernia repair. This study compares lightweight mesh versus heavyweight mesh in laparoscopic inguinal hernia repair. METHODS: A prospective, single-center, hernia-specific database was queried for all adult laparoscopic inguinal hernia repair with three-dimensional contoured mesh (3-D Max, Bard, Inc, New Providence, NJ) from 1999 to June 2016. Demographics and outcomes were analyzed. Quality of life was evaluated preoperatively and after 2 weeks, 4 weeks, 6 months, 12 months, and 24 months, using the Carolinas Comfort Scale. Univariate analysis and multivariate logistic regression were performed. RESULTS: A total of 1,424 laparoscopic inguinal hernia repair were performed with three-dimensional contoured mesh, with 804 patients receiving lightweight mesh and 620 receiving heavyweight mesh. Patients receiving lightweight mesh were somewhat younger (52.6 ± 14.8 years vs 56.3 ± 13.7 years, P < .0001), with slightly lower body mass indices (26.4 ± 9.9 vs 27.1 ± 4.3, P < .0001). Lightweight mesh was used less often in incarcerated hernias (12.5% vs 16.8%, P = .02). There were a total of 3 surgical site infections. There were no differences in complications between groups except for seroma. Although on univariate analysis, seromas appeared to occur more frequently with heavyweight mesh (21.5% vs 7.9%). On multivariate analysis, heavyweight mesh was not independently associated with seroma formation. Average follow-up was 20 months. Recurrence rates were similar between lightweight mesh and heavyweight mesh (0.7 vs 0.6% P > .05). At all points of follow-up (4 week to 3 years), quality-of-life outcomes of discomfort, mesh sensation, and movement limitation scores were similar between lightweight mesh and heavyweight mesh. CONCLUSION: Contoured lightweight mesh and heavyweight mesh in laparoscopic inguinal hernia repair yield excellent recurrence rates and no difference in postoperative complications or quality of life. Considering the lack of outcome difference with long-term follow-up, heavyweight mesh may be considered for use in laparoscopic inguinal hernia repair patients.