Incisional Hernia Incidence, Repair Techniques, and Outcomes Based on 1600 Consecutive Patients Receiving Abdominally Based Autologous Breast Reconstruction.

BACKGROUND: As the number of postmastectomy patients who receive abdominally based autologous breast reconstruction (ABABR) increases, the frequency of unique paramedian incisional hernias (IHs) at the donor site is increasing as well. We assessed incidence, repair techniques, and outcomes to determine the optimal treatment for this morbid condition. METHODS: A total of 1600 consecutive patients who underwent ABABR at the University of Pennsylvania between January 1, 2009, and August 31, 2016, were retrospectively identified. Preoperative and operative information was collected for these patients. Incisional hernia incidence was determined by flap type and donor site closure technique. Repair techniques and postoperative outcomes for all patients receiving IH repair (IHR) after ABABR at our institution were also determined. Univariate and multivariate analyses were conducted. RESULTS: The incidence of IH after ABABR in our health system was 3.6% (n = 61). Fifteen additional patients were referred from outside hospitals for a total of 76 patients who received IHR. At the time of IHR, mesh was used in 79% (n = 60) of cases (13 biologic and 47 synthetic), with synthetics having significantly lower recurrent IH incidence (10.6% vs 38.5%, P = 0.017) when compared with biologics. Mesh position did not have any statistically significant effect on outcomes; however, sublay mesh position had zero adverse outcomes. CONCLUSIONS: Mesh should be used in all cases when possible. Although retrorectus repair with mesh is optimal, this plane is often nonexistent or too scarred in after ABABR. Thus, intraperitoneal underlay mesh with primary fascial closure or primary closure with onlay mesh placement should then be considered.

The Abdominal Hernia-Q: Development, Psychometric Evaluation, and Prospective Testing.

OBJECTIVE: Our study completes the development and estimates the psychometric properties of a novel, ventral hernia-specific patient reported outcomes (PRO) tool-the Abdominal Hernia-Q (AHQ). SUMMARY BACKGROUND DATA: A standardized method for measuring hernia-related PRO has not been identified. There remains a need for a broadly applicable, hernia-specific tool that incorporates patient viewpoints and offers pre- and postoperative forms. METHODS: Concept elicitation interviews, focus groups, and cognitive debriefing interviews were completed to define content. The preoperative AHQ was administered to patients scheduled to have a ventral hernia repair (VHR). The postoperative AHQ was administered to patients within 24 months post-VHR. The SF-12 and HerQLes were concurrently administered. Psychometric evaluation was performed. Subsequently, the AHQ (pre: 8 items; post: 16 items) underwent prospective testing. RESULTS: Cross-sectional evaluations of patient responses to the AHQ (pre n = 104; post n = 261) demonstrated high internal consistency (Cronbach α pre = 0.86; post = 0.90) and moderate disattenuated correlations with the HerQLes (pre r = -0.71 and post r = -0.70) and the SF-12 domains (pre and post r ≥ 0.5 for 7 of 8 domains). Principal components analyses produced 2 factors preoperatively and 3 factors postoperatively. In prospective testing (n = 67), the AHQ scores replicated the cross-sectional psychometric results and suggested sensitivity to clinical outcomes. CONCLUSIONS: Through patient involvement and rigorous, iterative psychometric evaluation, we have produced substantial data to suggest the validity and reliability of AHQ scores in measuring hernia-specific PRO. The AHQ advances the clinical management and treatment of patients with abdominal hernias by providing a more complete understanding of patient-defined outcomes.

To Glue or Not to Glue? Analysis of Fibrin Glue for Split-thickness Skin Graft Fixation.

BACKGROUND: Split-thickness skin grafting (STSG) is a commonly used tool in the plastic surgeon's reconstructive armamentarium. Fibrin glue (FG) consists of a combination of clotting factors and thrombin whose key properties include adherence and hemostasis. This preliminary study aimed to assess clinical outcomes and cost of FG for STSG fixation in a general wound reconstruction. METHODS: A retrospective review was conducted in all patients undergoing STSG placement by a single surgeon (JPF) from January 2016 to March 2018. Twenty patients were identified and matched by wound location and wound size. Patients were then divided into 2 groups based on the method of STSG fixation: FG (n = 10) or suture only (SO) (n = 10). RESULTS: In patients with FG fixation, we observed trends of decreased adjusted operative times (34.9 versus 49.4 minutes, P = 0.612), a similar length of stay (2.8 versus 3.5 days, P = 0.306), and liberation from the use of negative pressure wound therapy (0 versus 10 wounds, P < 0.0001). There were no observed differences between the 2 groups in terms of graft-related complications at 180 days (1 complication FG versus 0 complications SO). Time to 100% graft take was also not different (20.2 versus 29.4 days, P = 0.405). Additionally, total direct cost ($16,542 FG versus $24,266 SO; P = 0.545) and total charges ($120,336 FG versus $183,750 SO; P = 0.496) were not statistically different between the FG and SO groups. CONCLUSIONS: In this preliminary comparative assessment, FG for STSG fixation has shown no difference in clinical outcomes to SO fixation, trends of decreased operative time, and afforded complete liberation from negative pressure wound therapy dressings.

Retromuscular Mesh Repair Using Fibrin Glue: Early Outcomes and Cost-effectiveness of an Evolving Technique.

BACKGROUND: Retromuscular hernia repairs (RHRs) decrease hernia recurrence and surgical site infections but can cause significant pain. We aimed to determine if pain and postoperative outcomes differed when comparing suture fixation (SF) of mesh to fibrin glue fixation (FGF). METHODS: Patients undergoing RHR (n = 87) between December 1, 2015 and December 31, 2017 were retrospectively identified. Patients received SF of mesh (n = 59, 67.8%) before the senior author changing his technique to FGF (n = 28, 32.2%). These 2 cohorts were matched (age, body mass index, number of prior repairs, mesh type, defect size, and wound class). Outcomes were analyzed using a matched pairs design with multivariable linear regression. RESULTS: Two matched groups (21 FGF and 21 SF) were analyzed (45.2% female, average age 56 years, average body mass index 34.7 kg/m2, and average defect size 330 cm2). Statistical significance was observed for FGF compared with SF: length of stay (3.7 versus 7.1 days, P = 0.032), time with a drain (17.2 versus 27.5 days, P = 0.012), 30-day postoperative visits (2 versus 3, P = 0.003), pain scores (5.2 versus 3.1, P = 0.019) and activity within the first 24 hours (walking versus sitting, P = 0.002). Operative time decreased by 23.1 minutes (P = 0.352) and postoperative narcotic represcription (3 versus. 8 patients, p=0.147) also decreased. Average cost for patients receiving SF was $36,152 compared to $21,782 for FGF (P = 0.035). CONCLUSIONS: Sutureless RHR using FGF may result in decreased pain when compared with a matched cohort receiving SF, translating to enhanced recovery time, shortened hospital stay, and decreased costs.