Long-term outcomes of seromas after ventral hernia repair: a propensity score-matched analysis of the Abdominal Core Health Quality Collaborative.

PURPOSE: Seromas can occur after ventral hernia repairs (VHR), but little is known about their relevance to short- and long-term outcomes. We aimed to determine if there is a correlation between seroma occurrence after clean VHR with mesh and patient-reported and clinical outcomes. METHODS: Patients with and without seromas in the Abdominal Core Health Quality Collaborative registry were compared using a propensity score-matched analysis. Outcomes included hospital readmissions, postoperative antibiotics use, and procedural interventions. Pain and hernia-related quality of life were assessed at 30 days and 1 year. Composite hernia recurrence rates were compared at 1 year. RESULTS: Propensity score matching compared 218 patients with a seroma to 649 without a seroma. At 30 days, patients with seromas were more likely to be readmitted (27 (12%) vs 28 (4%), respectively; P < 0.001), receive postoperative antibiotics (25 (12%) vs 18 (3%), respectively; P < 0.001), and undergo procedural interventions (41 (19%) vs 23 (4%), respectively; P < 0.001) than patients without seromas. Surgical site occurrences were more common in patients with seromas than those without seromas at 1 year (12 (11%) vs 12 (4%), respectively; P = 0.01).Pain and hernia-related quality of life were similar for both groups at 30 days and 1 year. Composite hernia recurrence rates were similar for both groups at 1 year (37 seroma (17%) vs 115 no seroma (18%); P = 0.80). CONCLUSION: Seromas after clean VHR with mesh were associated with short- and long-term morbidity, but they did not significantly impact quality of life or hernia recurrences at 1 year.

Ileus rate after abdominal wall reconstruction: a retrospective analysis of two clinical trials.

PURPOSE: Postoperative ileus (POI) is the paralytic disruption of gastrointestinal motility, a common complication following abdominal wall reconstruction that often leads to increased patient morbidity and length of stay (LOS). We reviewed two randomized clinical trials to determine POI rates, predictive factors, LOS, and associated cost. METHODS: Two randomized trials were performed from 2017-2019 with all patients receiving elective open abdominal wall reconstruction with retromuscular mesh. Using multivariate logistic regression, we performed a retrospective analysis including demographics and operative details from patients at a single site to determine predictive factors for POI. All medical costs encompassing surgery and the 30-day postoperative period were compared between ileus and non-ileus groups. RESULTS: Four hundred and seventy patients were reviewed with a POI rate of 13.0% (N = 61). There were no differences in age, body mass index (BMI), history of abdominal surgery, or comorbidities between patients with and without POI. Logistic regression showed no association with POI and age, BMI, hernia width, or operative time lasting longer than 4 h. Median LOS was 8 days for patients with POI compared to five for those without (p < 0.001). Relative median 30-day costs were 1.19 in patients with ileus and 1.0 in those without (p < 0.001). CONCLUSION: We identified a 13% rate of POI in patients undergoing open abdominal wall reconstruction with mesh with no clearly identified predisposing factors. This resulted in a 3 days increase in median LOS and 19% additional costs. Further efforts should be devoted to investigating interventions that may reduce postoperative ileus after abdominal wall reconstruction.

Comparing anterior gastropexy to no anterior gastropexy for paraesophageal hernia repair: a study protocol for a randomized control trial.

BACKGROUND: More than half of patients undergoing paraesophageal hernia repair (PEHR) will have radiographic hernia recurrence at 5 years after surgery. Gastropexy is a relatively low-risk intervention that may decrease recurrence rates, but it has not been studied in a prospective manner. Our study aims to evaluate the effect of anterior gastropexy on recurrence rates after PEHR, compared to no anterior gastropexy. METHODS: This is a two-armed, single-blinded, registry-based, randomized controlled trial comparing anterior gastropexy to no anterior gastropexy in PEHR. Adult patients (≥18 years) with a symptomatic paraesophageal hernia measuring at least 5 cm in height on computed tomography, upper gastrointestinal series, or endoscopy undergoing elective minimally invasive repair are eligible for recruitment. Patients will be blinded to their arm of the trial. All patients will undergo laparoscopic or robotic PEHR, where some operative techniques (crural closure techniques and fundoplication use or avoidance) are left to the discretion of the operating surgeon. During the operation, after closure of the diaphragmatic crura, participants are randomized to receive either no anterior gastropexy (control arm) or anterior gastropexy (treatment arm). Two hundred forty participants will be recruited and followed for 1 year after surgery. The primary outcome is radiographic PEH recurrence at 1 year. Secondary outcomes are symptoms of gastroesophageal reflux disease, dysphagia, odynophagia, gas bloat, regurgitation, chest pain, abdominal pain, nausea, vomiting, postprandial pain, cardiovascular, and pulmonary symptoms as well as patient satisfaction in the immediate postoperative period and at 1-year follow-up. Outcome assessors will be blinded to the patients' intervention. DISCUSSION: This randomized controlled trial will examine the effect of anterior gastropexy on radiographic PEH recurrence and patient-reported outcomes. Anterior gastropexy has a theoretical benefit of decreasing PEH recurrence; however, this has not been proven beyond a suggestion of effectiveness in retrospective series. If anterior gastropexy reduces recurrence rates, it would likely become a routine component of surgical PEH management. If it does not reduce PEH recurrence, it will likely be abandoned. TRIAL REGISTRATION: ClinicalTrials.gov NCT04007952 . Registered on July 5, 2019.

Comparing rates of bowel injury for laparoscopic and robotic ventral hernia repair: a retrospective analysis of the abdominal core health quality collaborative.

PURPOSE: Bowel injury during laparoscopic and robotic ventral hernia repair is a rare but potentially serious complication. We sought to compare bowel injury rates during minimally invasive approaches to ventral hernia repair using a national hernia registry. METHODS: Patients undergoing elective laparoscopic and robotic ventral hernia repair (including cases converted-to-open) between 2013 and 2021 were retrospectively identified in the Abdominal Core Health Quality Collaborative registry. The primary outcome was bowel injury, which included partial- and full-thickness injuries and re-operations for missed enterotomies. Statistical analysis was performed using multivariate logistic regression. RESULTS: Overall, 10,660 patients were included (4116 laparoscopic, 6544 robotic). The laparoscopic group included more incisional hernias (68% vs 62%, p < 0.001) and similar rates of recurrent hernias (23% vs 22%, p = 0.26). A total of 109 bowel injuries were identified, with more occurring in the laparoscopic group (55 [1.3%] laparoscopic vs. 54 [0.8%] robotic; p = 0.01). Specifically, there were more full-thickness and missed enterotomies in the laparoscopic group (29 laparoscopic vs. 20 robotic; p = 0.012). Bowel injury resulted in higher rates of wound morbidity and major post-operative complications including sepsis, re-admission, and re-operation. Following adjustment for recurrent and incisional hernias, prior mesh, patient age, and hernia width, bowel injury during laparoscopic repair remained significantly more likely than bowel injury during robotic repair (OR 1.669 [95% C.I.: 1.141-2.440]; p = 0.008). CONCLUSION: In a large registry, laparoscopic ventral hernia repair is associated with an increased risk of bowel injury compared to repairs utilizing the robotic platform. Knowing the limitations of retrospective research, large national registries are well suited to explore rare outcomes which cannot be feasibly assessed with randomized controlled trials.

Short-term outcomes and healthcare resource utilization following incisional hernia repair with synthetic mesh in patients with Crohn's disease.

PURPOSE: While the use of synthetic mesh for incisional hernia repair reduces recurrence rates, little evidence exists regarding the impact of this practice on the disease burden of a Crohn's patient. We aimed to describe the post-operative outcomes and healthcare resource utilization following incisional hernia repair with synthetic mesh in patients with Crohn's disease. METHODS: A retrospective review of adult patients with Crohn's disease who underwent elective open incisional hernia repair with extra-peritoneal synthetic mesh from 2014 to 2018 at a single large academic hospital with surgeons specializing in hernia repair was conducted. Primary outcomes included 30-day post-operative complications and long-term rates of fistula formation and hernia recurrence. The secondary outcome compared healthcare resource utilization during a standardized fourteen-month period before and after hernia repair. RESULTS: Among the 40 patients included, six (15%) required readmission, 4 (10%) developed a surgical site occurrence, 3 (7.5%) developed a surgical site infection, and one (2.5%) required reoperation within the first 30 days. The overall median follow-up time was 42 months (IQR = 33-56), during which time one (2.5%) patient developed an enterocutaneous fistula and eight (20%) experienced hernia recurrence. Healthcare resource utilization remained unchanged or decreased across every category following repair. CONCLUSION: The use of extra-peritoneal synthetic mesh during incisional hernia repair in patients with Crohn's disease was not associated with a prohibitively high rate of post-operative complications or an increase in healthcare resource utilization to suggest worsening disease during the first 4 years after repair. Future studies exploring the long-term outcomes of this technique are needed.

Outcomes of redo-transversus abdominis release for abdominal wall reconstruction.

BACKGROUND: Transversus abdominis release (TAR) is increasingly used to address complex ventral hernias; consequently, associated complications are seen more frequently. Our hernia center has a growing experience with redo-transversus abdominis release (redo-TAR) to address large, complex hernia recurrences after failed TAR. Here, we describe our outcomes after abdominal wall reconstruction with redo-TAR. STUDY DESIGN: Adults undergoing elective open, redo-TAR at our institution from January 2015 to February 2021 were queried from a prospectively collected database in the Abdominal Core Health Quality Collaborative. The primary outcome was 30-day wound morbidity. Secondary outcomes were long-term composite hernia recurrence and patient-reported quality of life. RESULTS: Sixty-five patients underwent redo-TAR. Median age was 60 years, 50.8% were female, and median BMI 31.8 kg/m2. Median recurrent hernias were 16 cm wide by 25 cm long. Frequent mechanisms of recurrence included linea semilunaris injury (27.7%), mesh fracture (18.5%), infection (16.9%), and posterior sheath disruption (15.4%). Wound complications occurred in 33.8% and 16.9% required procedural intervention. With median clinical and PRO follow-up of 12 and 19 months, respectively, the composite hernia recurrence rate was 22.5% and patients reported significantly improved quality of life (HerQLes: median + 36.7, PROMIS: median - 9.5). CONCLUSION: Redo-TAR may be performed as a salvage procedure to reconstruct complex defects after failed TAR, however, in our center, it is associated with increased wound morbidity and fairly high composite recurrence rates. Despite this, patients report improvements in quality of life and pain. Tracking outcomes after TAR will facilitate understanding how to manage its failures.

Management of ventral hernia defect during enterocutaneous fistula takedown: practice patterns and short-term outcomes from the Abdominal Core Health Quality Collaborative.

BACKGROUND: An enterocutaneous fistula (ECF) with an associated large hernia defect poses a significant challenge for the reconstructive surgeon. We aim to describe operative details and 30-day outcomes of elective hernia repair with an ECF when performed by surgeons participating in the Abdominal Core Health Quality Collaborative (ACHQC). STUDY DESIGN: Patients undergoing concomitant hernia and ECF elective repair were identified within the ACHQC. Outcomes of interest were operative details and 30-day rates of surgical site infections (SSI), surgical site occurrences requiring procedural intervention (SSOPI), medical complications, and mortality. RESULTS: 170 patients were identified (mean age 60 years, 52.4% females, mean BMI 32.3 kg/m2). 106 patients (62%) had small-bowel ECFs, mostly managed with resection without diversion. 30 patients (18%) had colonic ECFs, which were managed with resection without diversion (14%) or resection with diversion (6%). 100 (59%) had a prior mesh in place, which was removed in 90% of patients. Hernias measured 14 cm ± 7 in width, and 68 (40%) had a myofascial release performed (41 TARs). Mesh was placed in 115 cases (68%), 72% as a sublay, and more frequently of biologic (44%) or permanent synthetic (34%) material. 30-day SSI was 18% (37% superficial, 40% deep), and 30-day SSOPI was 21%. 19 patients (11%) were re-operated: 8 (8%) due to a wound complication and 4 (2%) due to a missed enterotomy. Two infected meshes were removed, one biologic and one synthetic. CONCLUSIONS: Surgeons participating in the ACHQC predominantly resect ECFs and repair the associated hernias with sublay mesh with or without a myofascial release. Morbidity remains high, most closely related to wound complications, as such, concomitant definitive repairs should be entertained with caution.

Watchful waiting is an appropriate option for peritoneal dialysis candidates with an asymptomatic ventral hernia.

PURPOSE: Expert consensus recommends that all ventral hernias be repaired prior to, or concomitantly with, peritoneal dialysis (PD) catheter insertion. We examined the clinical outcomes of patients undergoing initial PD catheter insertion, with asymptomatic ventral hernias that were not repaired and rather managed using a watchful waiting approach. METHODS: A single-center, retrospective review of patients undergoing PD catheter insertion from 2005-2019 was performed. Patients who did not undergo repair of a pre-existing ventral hernia at the time of their initial PD catheter insertion were included. The primary endpoint was ventral hernia repair following PD catheter insertion. RESULTS: Forty-one patients were included. Most patients presented with an umbilical hernia (78%). Six patients (15%) underwent ventral hernia repair at a median postoperative interval of 12 months [IQR 8-16], due to abdominal discomfort and hernia enlargement (n = 2) and incarceration (n = 2). Two patients remained asymptomatic, yet underwent ventral hernia repair at the time of renal transplantation. The cumulative incidence of ventral hernia repair within 12 and 24 months of PD catheter insertion was 13% and 21%, respectively. CONCLUSION: Watchful waiting may be an acceptable option for select patients with asymptomatic ventral hernias at the time of initial PD catheter placement. These findings highlight the need to better identify factors associated with asymptomatic ventral hernias that do not warrant concomitant repair to aid surgeons in the decision-making process.

Non-coated versus coated mesh for retrorectus ventral hernia repair: a propensity score-matched analysis of the Americas Hernia Society Quality Collaborative (AHSQC).

PURPOSE: The outcomes of utilizing anti-adhesive barrier-coated mesh in the retrorectus position during open ventral hernia repair are unknown. We compared the wound-related outcomes between non-coated (NCM) and coated mesh (CM) placed in the retrorectus space. METHODS: Patients undergoing elective, open, clean ventral hernia repair with retrorectus mesh were retrospectively identified in the Americas Hernia Society Quality Collaborative. Propensity score matching was performed based on clinically relevant demographic and operative covariates. The primary outcome was wound morbidity, defined as surgical site infection (SSI), surgical site occurrence (SSO), and SSO requiring procedural intervention (SSOPI). RESULTS: 3609 patients were included (3281 NCM, 328 CM). Following 2:1 propensity score matching, rates of myofascial release remained the only statistically different matching parameter; external oblique releases were performed more frequently in the CM group (8% vs. 15%; p = 0.03). Rates of SSI (3% vs. 4%; p = 0.16) were similar between groups. Increased rates of SSO (13% vs. 18%; p = 0.045) and SSOPI (4% vs. 8%; p = 0.038) were observed in the CM group. The CM group had a higher rate of postoperative seroma (3% vs. 7%; p = 0.027) compared to the NCM group. CONCLUSION: Barrier-coated mesh in the retrorectus position was associated with increased wound morbidity requiring procedural intervention. Due to a lack of clinical benefit, the use of more costly barrier-coated mesh in the retrorectus position is not justified for routine, open ventral hernia repairs at this time.

Transversus abdominis release (TAR): what are the real indications and where is the limit?

PURPOSE: To review literature surrounding transversus abdominis release (TAR) for incisional hernia repair, with the aim of describing key preoperative and technical considerations for this procedure. METHODS: Existing literature on TAR was reviewed and synthesized with the clinical experience and approach to TAR from a high-volume hernia center. RESULTS: Recommendations regarding patient selection, optimization and technique for TAR are presented. CONCLUSIONS: While published outcomes of TAR from expert centers are favorable, potentially devastating complications may result when TAR is performed incorrectly or in suboptimal clinical situations. Appropriate patient selection, optimization, and surgeon expertise are necessary if TAR is to be performed.

Open retromuscular versus laparoscopic ventral hernia repair for medium-sized defects: where is the value?

PURPOSE: There is increasing emphasis on value in health care, defined as quality over cost required to deliver care. We analyzed outcomes and costs of repairing medium-sized ventral hernias to identify whether an open retromuscular or laparoscopic intraperitoneal onlay approach would provide superior value to the patient and healthcare system. METHODS: A retrospective analysis of prospectively collected data from the Americas Hernia Society Quality Collaborative was performed for patients undergoing clean, elective repair of ventral hernias between 4 and 8 cm in width at our institution between 4/2013 and 12/2016 for whom at least 1-year follow-up was available. Recurrence rates, wound complications, length of stay, patient-reported outcomes, and perioperative costs were compared. RESULTS: One hundred and eighty-six patients met criteria (105 open, 81 laparoscopic) with 93.5% having ≥ 2-year follow-up. Patients undergoing laparoscopic repair had higher BMI, lower ASA classification, slightly lower prevalence of recurrent hernias and less prior mesh utilization, and slightly smaller hernias. Length of stay was shorter in the laparoscopic group (median 1 vs. 3 days, p < 0.001), without increased readmissions. Recurrence rates, wound complications, and patient-reported outcomes were similar. Laparoscopic repair had higher up-front surgical costs, yet equivalent total perioperative costs. CONCLUSION: Both laparoscopic and open approaches for elective repair of medium-sized ventral hernias offer similar clinical outcomes, patient-reported outcomes, and total perioperative costs. Laparoscopic repair appears to offer superior value based on a significantly reduced postoperative length of stay.

Comparing 30-day outcomes between different mesh fixation techniques in minimally invasive inguinal hernia repair.

PURPOSE: The association of postoperative patient-reported outcomes and type of mesh fixation during minimally invasive inguinal hernia repair has not been well characterized. We aimed to compare the 30-day quality of life outcomes between various mesh fixation techniques utilizing the AHSQC prospective registry. METHODS: All minimally invasive inguinal hernias with completed 30-day follow-up were abstracted from the AHSQC, excluding patients with primary indication for surgery being chronic groin pain. Mesh fixation was categorized as (1) atraumatic fixation (AF) (2) traumatic non-suture (TNS), (3) traumatic suture (TS). Our outcomes of interest were pain at site at 30-day and EuraHS quality of life assessment. RESULTS: After applying inclusion and exclusion criteria, 864 patients had surgical site pain and quality of life outcomes reported; 253 (AF), 451 (TNS), and 160 (TS). After adjusting for identified confounders, there was no statistically significant difference between any fixation method when evaluating pain as a binary variable (Yes/No). However, when looking at the EuraHS evaluation for pain and quality of life outcomes, AF was associated with better scores than both TNS and TS fixation in the cosmetic, restrictions, and overall EuraHS domains. AF was only better than TS fixation in the pain domain. CONCLUSION: Our study suggests that AF had a significantly improved hernia-specific quality of life in all domains at 30-days postoperatively. We also identified that pain as a binary variable is inadequate for its states purpose. Thus, the overall well-being and morbidity should be taken into account when evaluating hernia patients postoperatively.