Determining the Association Between Insurance Type and Myofascial Release in Large Ventral Hernias.

INTRODUCTION: Abdominal wall reconstruction (AWR) utilizes advanced myofascial releases to perform complex ventral hernia repair (VHR). The relationship between the performance of AWR and disparities in insurance type is unknown. METHODS: The Abdominal Core Health Quality Collaborative was queried for adults who had undergone an elective VHR between 2013 and 2020 with a hernia size ≥10 cm. Patients with missing insurance data were excluded. Comparison groups were divided by insurance type: favorable (private, Medicare, Veteran's Administration, Tricare) or unfavorable (Medicaid and self-pay). Propensity score matching compared the cumulative incidence of AWR between the favorable and unfavorable insurance comparison groups. RESULTS: In total, 26,447 subjects met inclusion criteria. The majority (89%, n = 23,617) had favorable insurance, while (11%, n = 2830) had unfavorable insurance. After propensity score matching, 2821 patients with unfavorable insurance were matched to 7875 patients with favorable insurance. The rate of AWR with external oblique release or transversus abdominis release was significantly higher (23%, n = 655) among the unfavorable insurance group compared to those with favorable insurance (21%, n = 1651; P = 0.013). CONCLUSIONS: This study provides evidence that patients with unfavorable insurance may undergo AWR with external oblique or transversus abdominis release at a greater rate than similar patients with favorable insurance. Understanding the mechanisms contributing to this difference and evaluating the financial implications of these trends represent important directions for future research in elective VHR.

End-Tidal CO2 During Enhanced-View Totally Extraperitoneal Hernia Repair: A Comparison of Retrorectus and Intraperitoneal Insufflation.

INTRODUCTION: Although the enhanced-view totally extraperitoneal (eTEP) approach has demonstrated safety, efficacy, and durability for small- to medium-sized hernia repairs, the relationships between retrorectus insufflation, intraoperative respiratory stability, and end-tidal CO2 (ETCO2) levels has not been appraised. METHODS: We conducted a retrospective chart review of patients undergoing elective robotic-assisted ventral hernia repairs at our quaternary academic center from July 2018 through December 2021. Patients were grouped by repair technique, either eTEP or robotic transversus abdominis release (r-TAR). Baseline demographics, intraoperative anesthesia records, and perioperative outcomes were reviewed. Anesthesia data were collected at intubation and 30-min time intervals thereafter. Operative time, length of stay, patient-controlled anesthesia use, and perioperative complications were compared. RESULTS: In total, 205 patients underwent an eTEP repair and 97 patients underwent an r-TAR repair. Intraoperatively, eTEP repairs had significantly higher ETCO2 at the beginning of the case (times 1-4, P < 0.05), and a higher peak ETCO2 (P < 0.05) when compared to r-TAR repairs. This difference in ETCO2 desisted as the case progressed, with a subsequent increase in respiratory rate (times 2-6, P < 0.05) in the eTEP procedures. The eTEP group demonstrated significantly shorter operative times, decreased patient-controlled anesthesia use, and a shorter length of stay. There was no significant difference in postoperative intensive care unit admission or respiratory distress. CONCLUSIONS: This study demonstrates that retrorectus insufflation during eTEP hernia repairs correlated with higher levels of ETCO2 compared to r-TAR repairs yet was not associated with any meaningful difference in perioperative outcomes. Communication of these respiratory differences with anesthesia is needed for proper ventilation adjustments.

Association of Race and Postoperative Outcomes in Ventral Hernia Repair With Component Separation.

INTRODUCTION: Hernia repairs are the most common surgical procedures in the United States, with a significant financial burden primarily attributed to emergent presentations and postsurgery complications. This study aimed to examine race differences on postoperative outcomes. METHODS: American College of Surgeons National Surgical Quality Improvement Program database was queried to identify ventral hernia repair (VHR) cases from 2016 to 2021, with a subgroup of patients undergoing component separation (CS). Statistical analysis utilized multinomial regression to compare outcomes across racial groups, generating weighted cohorts with balanced covariates to assess differences between groups. RESULTS: 288,515 patients were initially identified. Of these, 120,017 underwent VHR and 8732 VHR with CS. After weighting for the different groups, there were no differences in demographics or comorbidities between the racial groups for both cohorts. When evaluating postoperative complications after VHR, others (American Indian or Alaskan Native, Asian, Native Hawaiian, or Pacific Islander) had the highest rate of organ or space surgical site infection (SSI) (P < 0.001). Hospitalization >30 d was the lowest in Whites (0%), compared to Blacks (1%, P = 0.003) and others (1%, P < 0.001). For patients in the VHR with CS group, significant differences were noted in organ or space SSI (others 8%, P = 0.005), return to the operating room (others 13%, P = 0.015), hospitalizations >30 d (others 4% P = 0.002), and total LOS (others 5 [IQR 3,8], P = 0.004). CONCLUSIONS: Despite advancements in surgical techniques, racial differences in VHR outcomes persist. These include higher rates of complications such as SSIs, higher rates of return to the operating room, and extended hospital stays among racial groups.

Outcomes of Transversus Abdominis Release With Macroporous Polypropylene Mesh.

INTRODUCTION: Transversus abdominis release (TAR) is increasingly being performed for reconstruction of complex incisional and recurrent ventral hernias, with complication rates ranging from 17.4% to 33.3% after open TAR (oTAR) or robotic TAR (rTAR). The purpose of this study was to describe the outcomes of patients undergoing TAR with macroporous polypropylene mesh (MPM) and to compare outcomes between oTAR and rTAR. METHODS: A retrospective review of 183 consecutive patients undergoing TAR with MPM performed by a single surgeon at a single institution from 2015 to 2021 was performed. Patients with less than one year of follow-up were excluded. Univariate analysis was performed to compare outcomes between oTAR and rTAR patients. RESULTS: Average patient age was 59.4 y, median body mass index was 33.2 kg/m2, and median hernia width was 12.0 cm. Forty 2 (23%) patients underwent oTAR, 127 (69%) underwent rTAR, and 14 (8%) underwent laparoscopic TAR. Patients experienced 16.4%, 10.4%, 3.8%, and 6.0% rates of overall complications, surgical site occurrences, surgical site infections, and other complications, respectively. At average follow-up of 2.3 y, a 2.7% hernia recurrence rate was observed. In comparison to patients undergoing oTAR, rTAR patients required shorter operative times and length of stay, and were less likely to experience postoperative complications overall, and other complications. Recurrence rates were similar between oTAR and rTAR. CONCLUSIONS: Patients undergoing TAR with MPM experienced complication and recurrence rates in alignment with previously published results. In comparison to oTAR, rTAR was associated with more favorable perioperative outcomes and complication rates, but similar recurrence rates.

Classifying frailty in the ventral hernia population.

INTRODUCTION: Frailty is increasingly recognized as a preoperative predictor of adverse outcomes following various surgical procedures. Our study aims to compare validated frailty measures in the ventral hernia population, as this is a common elective procedure with a paucity of data regarding frailty prevalence. METHODS: Patients aged 18 years or older with planned ventral hernia repairs were prospectively enrolled in our single-institution study from January 2023 through June 2023. After obtaining informed consent, patients completed the Fried Frailty Index (FFI), the FRAIL Scale, and the Strength, Assistance walking, Rising from a chair, Climbing stairs, and Falls (SARC-F) questionnaires, as well as the standard completion of the Patient-Reported Outcomes Measurement Information System (PROMIS) measures at their preoperative clinic appointment. Chart review was performed for baseline demographics and comorbidities. The Modified Frailty Index (mFI-11) and the Charleston Comorbidity Index (CCI) were calculated. RESULTS: A total of 63 patients were enrolled in our study. On average, the population was 60 years old, with a BMI of 32.4 kg/m2, a CCI of 3, and on 10.5 medications preoperatively. Overall, 12 patients (19%) screened positive for frailty by the mFI-11, 17 patients (27%) by the FFI, 15 patients (23.8%) by the FRAIL Scale, and 15 patients (23.8%) screened positive for sarcopenia by SARC-F. The FFI and the FRAIL Scale were strongly correlated with the other measures by Spearman's rank-order correlation (p < 0.05). On multivariate regression analysis, a longer Timed Up and Go test was associated with screening positive for frailty or sarcopenia (OR 1.896, p = 0.016). CONCLUSION: In this study, we find that frailty is more prevalent than previously reported in the literature by any measure used. Both the FRAIL Scale and FFI strongly correlate with the other tools investigated. Surgeons should consider using these assessments preoperatively to estimate frailty and guide operative planning as well as shared decision-making.

Variability in surgical approaches to hernias in patients with ascites.

BACKGROUND: Hernias in patients with ascites are common, however we know very little about the surgical repair of hernias within this population. The study of these repairs has largely remained limited to single center and case studies, lacking a population-based study on the topic. STUDY DESIGN: The Michigan Surgical Quality Collaborative and its corresponding Core Optimization Hernia Registry (MSQC-COHR) which captures specific patient, hernia, and operative characteristics at a population level within the state was used to conduct a retrospective review of patients with ascites undergoing ventral or inguinal hernia repair between January 1, 2020 and May 3, 2022. The primary outcome observed was incidence and surgical approach for both ventral and inguinal hernia cohorts. Secondary outcomes included 30-day adverse clinical outcomes as listed here: (ED visits, readmission, reoperation and complications) and surgical priority (urgent/emergent vs elective). RESULTS: In a cohort of 176 patients with ascites, surgical repair of hernias in patients with ascites is a rare event (1.4% in ventral hernia cohort, 0.2% in inguinal hernia cohort). The post-operative 30-day adverse clinical outcomes in both cohorts were greatly increased compared to those without ascites (ventral: 32% inguinal: 30%). Readmission was the most common complication in both inguinal (n = 14, 15.9%) and ventral hernia (n = 17, 19.3%) groups. Although open repair was most common for both cohorts (ventral: 86%, open: 77%), minimally invasive (MIS) approaches were utilized. Ventral hernias presented most commonly urgently/emergently (60%), and in contrast many inguinal hernias presented electively (72%). CONCLUSION: A population-level, ventral and incisional hernia database capturing operative details for 176 patients with ascites. There was variation in the surgical approaches performed for this rare event and opportunities for optimization in patient selection and timing of repair.

Is weight trajectory a better marker of wound complication risk than BMI in hernia patients with obesity?

BACKGROUND: Complex ventral hernias are frequently repaired via an open transversus abdominis release (TAR). Obesity, particularly a BMI > 40, is a strong predictor of wound morbidity following this procedure. We aimed to determine if preoperative weight loss may still be beneficial in patients with persistently elevated BMIs. METHODS: A retrospective chart review of patients with obesity (BMI ≥ 30) who underwent open TAR at a tertiary academic medical center from January 2018 to December 2021 was completed. Demographics, medical history, operative details, and postoperative data were analyzed. Weight and BMI were recorded at three time points: > 6 months prior to initial surgical consultation, surgical consultation, and day of surgery. RESULTS: In total, 182 patients with obesity underwent an open TAR. Twenty-seven patients (14.8%) underwent surgery with a BMI > 40; they did not have any significant differences in surgical site occurrences (SSO, 48.1% vs 32.9%, p = 0.13) or surgical site infections (SSI, 25.9% vs 23.2%, p = 0.76) compared to those with a BMI ≤ 40. The average timeframe analyzed for preoperative weight loss was 592 days. Patients who had at least a 3% weight loss (n = 49, 26.9%) had decreased rates of SSI compared to those who did not have this weight loss (12.2% vs 27.8%, p = 0.03), despite the groups having similar BMIs at the time of surgery (36.4 vs 36.0, p = 0.50). Patients who only had a 1% weight loss did not see a decrease in SSI rate compared to those who did not (20.6% vs 25.4%, p = 0.45). CONCLUSION: Weight loss may be a better indicator of a patient's risk for wound morbidity following TAR than BMI alone, as weight loss of at least 3% resulted in fewer SSIs despite similar BMIs at time of surgery. Further research into optimal timing and amount of weight loss, as well as effects on long-term outcomes, is needed to confirm these findings.

Endoscopic-assisted repair of combined ventral hernias and diastasis recti: minimizing seroma incidence by quilting.

BACKGROUND: To reduce the incidence of seromas, we have adapted the quilting procedure used in open abdominoplasty to the endoscopic-assisted repair of concomitant ventral hernia (VH) and diastasis recti (DR). The aim of this study was to describe the technique and assess its efficacy by comparing two groups of patients operated on with the same repair technique before and after introducing the quilting. METHODS: This retrospective study included data prospectively registered in the French Club Hernie database from 176 consecutive patients who underwent surgery for concomitant VH and DR via the double-layer suturing technique. Patients were categorized into two groups: Group 1 comprised 102 patients operated before introducing the quilting procedure and Group 2 comprised 74 operated after introducing the quilting. To carry out comparisons between groups, seromas were classified into two types: type A included spontaneously resorbable seromas and seromas drained by a single puncture and type B included seromas requiring two or more punctures and complicated cases requiring reoperation. RESULTS: The global percentage of seromas was 24.4%. The percentage of seromas of any type was greater in Group 1 (27.5%) than in Group 2 (20.3%). The percentage of Type B seromas was greater in Group 1 (19.6%) than in Group 2 (5.4%), when the percentage of Type A seromas was greater in Group 2 (14.9) than in Group 1 (7.9%). Differences were significant (p = 0.014). The operation duration was longer in Group 2 (83.9 min) than in Group 1 (69.9 min). Four complications requiring reoperation were observed in Group 1: three persistent seromas requiring surgical drainage under general anesthesia and one encapsulated seroma. CONCLUSION: Adapting the quilting technique to the endoscopic-assisted bilayer suturing technique for combined VH and DR repair can significantly reduce the incidence and severity of postoperative seromas.

Robotic-assisted endoscopic onlay repair (R-ENDOR) for concomitant ventral hernias and diastasis recti: initial results and surgical technique.

BACKGROUND: The surgical management of midline ventral hernias complicated by concomitant diastasis recti presents a significant clinical challenge. The Endoscopic Onlay Repair (ENDOR) offers a minimally invasive solution, effectively addressing both conditions. This study focuses on describing the adaptation of ENDOR to a robotic platform, termed R-ENDOR, aiming to report initial outcomes along with other established robotic surgical approaches. METHODS: This retrospective case series study included consecutive adult patients who underwent R-ENDOR approach from October 2018 to April 2023, performed by a single surgeon. A comprehensive description of the surgical technique is included. Patient demographics, operative, and hernia-specific characteristics, as well as clinical outcomes are described. RESULTS: A total of 15 patients undergoing R-ENDOR for ventral hernia repair with diastasis recti plication were included. The median age was 59 years (IQR 42-63), with 60% (n = 9) female patients. The majority (86%, n = 13) had an ASA score of ≤ 2, and the median BMI was 24 kg/m2, with 20% (n = 3) classified as obese. Median hernia size was 2 cm (IQR 2-2.25), with a median diastasis length of 19 cm (IQR 15-21.5) and width of 4 cm (IQR 3-6). The median operative time was 129 min (IQR 113-166). Most repairs (93%, n = 14) were reinforced with mesh, predominantly self-fixating (73.3%, n = 11). Eighty percent of patients (n = 12) were discharged on the same day, with a median follow-up of 153 days (IQR 55-309). Notable complications included clinically significant seromas in 20% of patients (n = 3), long-term hypoesthesia in 40% (n = 6), and readmission in one patient (6.6%) for surgical site infection (SSI) requiring IV antibiotic therapy. CONCLUSION: Midline ventral hernias associated to diastasis recti can be managed robotically by ENDOR with safe and consistent 90-day outcomes in a carefully selected group of patients.

Robotic surgery for inguinal and ventral hernia repair: a systematic review and meta-analysis.

BACKGROUND: This systematic review and meta-analysis assessed the effectiveness of robotic surgery compared to laparoscopy or open surgery for inguinal (IHR) and ventral (VHR) hernia repair. METHODS: PubMed and EMBASE were searched up to July 2022. Meta-analyses were performed for postoperative complications, surgical site infections (SSI), seroma/hematoma, hernia recurrence, operating time (OT), intraoperative blood loss, intraoperative bowel injury, conversion to open surgery, length of stay (LOS), mortality, reoperation rate, readmission rate, use of opioids, time to return to work and time to return to normal activities. RESULTS: Overall, 64 studies were selected and 58 were used for pooled data analyses: 35 studies (227 242 patients) deal with IHR and 32 (158 384 patients) with VHR. Robotic IHR was associated with lower hernia recurrence (OR 0.54; 95%CI 0.29, 0.99; I2: 0%) compared to laparoscopic IHR, and lower use of opioids compared to open IHR (OR 0.46; 95%CI 0.25, 0.84; I2: 55.8%). Robotic VHR was associated with lower bowel injuries (OR 0.59; 95%CI 0.42, 0.85; I2: 0%) and less conversions to open surgery (OR 0.51; 95%CI 0.43, 0.60; I2: 0%) compared to laparoscopy. Compared to open surgery, robotic VHR was associated with lower postoperative complications (OR 0.61; 95%CI 0.39, 0.96; I2: 68%), less SSI (OR 0.47; 95%CI 0.31, 0.72; I2: 0%), less intraoperative blood loss (- 95 mL), shorter LOS (- 3.4 day), and less hospital readmissions (OR 0.66; 95%CI 0.44, 0.99; I2: 24.7%). However, both robotic IHR and VHR were associated with significantly longer OT compared to laparoscopy and open surgery. CONCLUSION: These results support robotic surgery as a safe, effective, and viable alternative for IHR and VHR as it can brings several intraoperative and postoperative advantages over laparoscopy and open surgery.

The current role of barbed sutures in fascial closure of ventral hernia repair: a multicenter study using the abdominal core health quality collaborative database.

BACKGROUND: Barbed sutures (BS) have been increasingly used in the last two decades across surgical disciplines but little is known about how widespread their adoption has been in ventral hernia repair (VHR). The aim of this study was to document the use of barbed sutures in VHR in a multicenter database with associated clinical and patient-reported outcomes. METHOD: Prospectively collected data from the Abdominal Core Health Quality Collaborative database was retrospectively reviewed, including all adult patients who underwent VHR with fascial closure from 2020 to 2022. A univariate analysis compared patients with BS against non-barbed sutures (NBS) across the preoperative, intraoperative, and postoperative timeframes including patient-reported outcomes concerning quality of life and pain scores. RESULTS: A total of 4054 patients that underwent ventral hernia repair with BS were compared with 6473 patients with non-barbed sutures (NBS). Overall, BS were used in 86.2% of minimally invasive ventral hernia repairs and about 92.2% of robotic surgery compared to only 9.6% of open procedures. Notable differences existed in patient selection, including a higher BMI (32 vs 30.5; p < 0.001), more incisional hernias (63.3% vs 51.1%; p < 0.001), wider hernias (4 cm vs 3 cm; p < 0.001), and higher ASA score (p < 0.001) in patients with BS. Outcomes in patients with BS included a shorter length of stay (mean days; 1.4 vs 2.4; p < 0.001), less SSI (1.5% vs 3.6%; p < 0.001), while having similar SSO (7.6% vs 7.3%; p = 0.657), readmission (3.0 vs 3.2; p = 0.691), and reoperation (1.5% vs 1.45%; p = 0.855), at a longer operative time (p < 0.001). Hernia-specific questionnaires for quality of life (HerQLes) and pain in patients with BS had a worse preoperative score that was later matched and favorable compared to NBS (p = 0.048). PRO concerning hernia recurrence suggest around 10% at two years of follow-up (p = 0.532). CONCLUSION: Use of barbed sutures in VHR is widespread and highly related to MIS. Outcomes from this multicenter database cannot be reported as superior but suggest that barbed sutures do not have a negative impact on outcomes.

Open versus robotic retromuscular ventral hernia repair: outcomes of the ORREO prospective randomized controlled trial.

BACKGROUND: Robotic retromuscular ventral hernia repair (rRMVHR) potentially combines the best features of open and minimally invasive VHR: myofascial release with abdominal wall reconstruction (AWR) with the lower wound morbidity of laparoscopic VHR. Proliferation of this technique has outpaced the data supporting this claim. We report 2-year outcomes of the first randomized controlled trial of oRMVHR vs rRMVHR. METHODS: Single-center randomized control trial of open vs rRMVHR. 100 patients were randomized (50 open, 50 robotic). We included patients > 18 y/o with hernias 7-15 cm with at least one of the following: diabetes, chronic obstructive pulmonary disease (COPD), body mass index (BMI) ≥ 30, or current smokers. Primary outcome was occurrence of a composite outcome of surgical site infection (SSI), non-seroma surgical site occurrence (SSO), readmission, or hernia recurrence. Secondary outcomes were length of stay, any SSI or SSO, SSI/SSOPI, operative time, patient reported quality of life, and cost. Analysis was performed in an intention-to-treat fashion. Study was funded by a grant from Society of American Gastrointestinal and Endoscopic Surgeons. RESULTS: 90 patients were available for 30-day and 62 for 2-year analysis (rRMVHR = 46 and 32, oRMVHR = 44 and 30). Hernias in the open group were slightly larger (10 vs 8 cm, p = 0.024) and more likely to have prior mesh (36.4 vs 15.2%; p = 0.030), but were similar in length, prior hernia repairs, mesh use, and myofascial release. There was no difference in primary composite outcome between oRMVHR and rRMVHR (20.5 vs 19.6%, p = 1.000). Median length of stay was shorter for rRMVHR (1 vs 2 days; p < 0.001). All patients had significant improvement in quality of life at 1 and 2 years. Other secondary outcomes were similar. CONCLUSION: There is no difference in a composite outcome including SSI, SSOPI, readmission, and hernia recurrence between open and robotic RMVHR.

Deep learning model utilizing clinical data alone outperforms image-based model for hernia recurrence following abdominal wall reconstruction with long-term follow up.

BACKGROUND: Deep learning models (DLMs) using preoperative computed tomography (CT) imaging have shown promise in predicting outcomes following abdominal wall reconstruction (AWR), including component separation, wound complications, and pulmonary failure. This study aimed to apply these methods in predicting hernia recurrence and to evaluate if incorporating additional clinical data would improve the DLM's predictive ability. METHODS: Patients were identified from a prospectively maintained single-institution database. Those who underwent AWR with available preoperative CTs were included, and those with < 18 months of follow up were excluded. Patients were separated into a training (80%) set and a testing (20%) set. A DLM was trained on the images only, and another DLM was trained on demographics only: age, sex, BMI, diabetes, and history of tobacco use. A mixed-value DLM incorporated data from both. The DLMs were evaluated by the area under the curve (AUC) in predicting recurrence. RESULTS: The models evaluated data from 190 AWR patients with a 14.7% recurrence rate after an average follow up of more than 7 years (mean ± SD: 86 ± 39 months; median [Q1, Q3]: 85.4 [56.1, 113.1]). Patients had a mean age of 57.5 ± 12.3 years and were majority (65.8%) female with a BMI of 34.2 ± 7.9 kg/m2. There were 28.9% with diabetes and 16.8% with a history of tobacco use. The AUCs for the imaging DLM, clinical DLM, and combined DLM were 0.500, 0.667, and 0.604, respectively. CONCLUSIONS: The clinical-only DLM outperformed both the image-only DLM and the mixed-value DLM in predicting recurrence. While all three models were poorly predictive of recurrence, the clinical-only DLM was the most predictive. These findings may indicate that imaging characteristics are not as useful for predicting recurrence as they have been for other AWR outcomes. Further research should focus on understanding the imaging characteristics that are identified by these DLMs and expanding the demographic information incorporated in the clinical-only DLM to further enhance the predictive ability of this model.

Drain vs no drain placement after retromuscular ventral hernia repair with mesh: an ACHQC analysis.

INTRODUCTION: Ventral hernia repair (VHR) is one of the most common procedures in the United States, and drains are used in over 50% of mesh repairs. The aim of this study is to investigate the impact of drains on surgical site occurrences (SSO) and infection (SSI) after open and minimally invasive retromuscular VHR with mesh. METHODS: A retrospective review of prospectively collected data from the ACHQC was performed to include adult patients who underwent elective VHR with retromuscular mesh placement. Univariate analysis was performed comparing drain and no-drain groups. A logistic regression was performed to identify factors independently associated with increased SSO, SSI, readmission, and length of stay (LOS). RESULTS: 6945 patients underwent elective VHR with sublay mesh. Most patients had M2 and M3 hernias in both groups (with Drain and no-drain). The median LOS was 4.7 (SD 8.3) in the drain group and 1.6 (SD 8.4) in the no-drain group (p < 0.001). 30-day SSI was higher in the drain group (176; 3.8% vs 25; 1.1%; p < 0.001). Despite lower SSO overall in the drain group (470; 10.0% vs 286; 12.7%; p < 0.001), SSO or SSI requiring intervention (SSOPI) was higher in the drain group (240; 5.1% vs 44; 1.9%; p < 0.001). Logistic regression identified diabetes (OR 1.3, CI 1.1-1.6; p < 0.001) and BMI (OR 1.04, CI 1.03-1.05; p < 0.001) as predictors of SSO, while the use of a drain was protective (OR 0.61; CI 0.5-0.8; p < 0.001). For SSI, logistic regression showed diabetes (OR 1.6, CI 1.2-2.3; p = 0.004) and open approach (OR 3.5, CI 2.1-5.9; p < 0.001) as predictors. CONCLUSIONS: Drain placement during retromuscular VHR with mesh was predictive of decreased postoperative SSO occurrence but associated with increased LOS. Diabetes and open approach, but not drain use, were predictors of SSI.

Variation in surgical approach and postoperative complication among older adults undergoing ventral hernia repair.

BACKGROUND: Surgical decision-making for preference-sensitive operations among older adults is understudied. Ventral hernia repair (VHR) is one operation where granular data are limited to guide preoperative decision-making. We aimed to determine risk for VHR in older adults given clinically nuanced data including surgical and hernia characteristics. METHODS: We performed a retrospective analysis of the Michigan Surgical Quality Collaborative Core Optimization Hernia Registry from January 2020 to March 2023. The primary outcome was postoperative complication across age groups: 18-64, 65-74, and ≥ 75 years, with secondary outcome of surgical approach. Mixed-effects logistic regression evaluated association between minimally invasive surgery (MIS) and 30-day complications, controlling for patient and hernia characteristics. RESULTS: Among 8,659 patients, only 7% were 75 or older. MIS rates varied across hospitals [Median = 31.4%, IQR: (14.8-51.6%)]. The overall complication rate was 2.2%. Complication risk for undergoing open versus MIS approach did not vary between age groups; however, patients over age 75 undergoing laparoscopic repair had increased risk (aOR = 4.58, 95% CI 1.13-18.67). Other factors associated with risk included female sex (aOR = 2.10, 95% CI 1.51-2.93), higher BMI (aOR = 1.18, 95% CI 1.03-1.34), hernia width ≥ 6 cm (aOR = 3.15, 95% CI 1.96-5.04), previous repair (aOR = 1.44, 95% CI 1.02-2.05), and component separation (aOR = 1.98, 95% CI 1.28-3.05). Patients most likely to undergo MIS were female (aOR = 1.21, 95% CI 1.09-1.34), black (aOR = 1.30, 95% CI 1.12-1.52), with larger hernias: 2-5.9 cm (aOR = 1.76, 95% CI 1.57-1.97), or intraoperative mesh placement (aOR = 14.4, 95% CI 11.68-17.79). There was no difference in likelihood to receive MIS across ages when accounting for hospital (SD of baseline likelihood = 1.53, 95% CI 1.14-2.05) and surgeon (SD of baseline likelihood = 2.77, 95% CI 2.46-3.11) variation. CONCLUSIONS: Our findings demonstrate that hernia, intraoperative, and patient characteristics other than age increase probability for complication following VHR. These findings can empower surgeons and older patients considering preoperative risk for VHR.

Evaluation of 30-day outcomes for open ventral hernia repair using self-gripping versus nonself-gripping mesh.

BACKGROUND: The use of mesh is standard of care for large ventral hernias repaired on an elective basis. The most used type of mesh includes synthetic polypropylene mesh; however, there has been an increase in the usage of a new polyester self-gripping mesh, and there are limited data regarding its efficacy for ventral hernia. The purpose of the study is to determine whether there is a difference in surgical site occurrence (SSO), surgical site infection (SSI), surgical site occurrence requiring procedural intervention (SSOPI), and recurrence at 30 days after ventral hernia repair (VHR) using self-gripping (SGM) versus non-self-gripping mesh (NSGM). METHODS: We performed a retrospective study from January 2014 to April 2022 using the Abdominal Core Health Quality Collaborative (ACHQC). We collected data on patients over 18 years of age who underwent elective open VHR using SGM or NSGM and whom had 30-day follow-up. Propensity matching was utilized to control for variables including hernia width, body mass index, age, ASA, and mesh location. Data were analyzed to identify differences in SSO, SSI, SSOPI, and recurrence at 30 days. RESULTS: 9038 patients were identified. After propensity matching, 1766 patients were included in the study population. Patients with SGM had similar demographic and clinical characteristics compared to NSGM. The mean hernia width to mesh width ratio was 8 cm:18 cm with NSGM and 7 cm:15 cm with SGM (p = 0.63). There was no difference in 30-day rates of recurrence, SSI or SSO. The rate of SSOPI was also found to be 5.4% in the nonself-gripping group compared to 3.1% in the self-gripping mesh group (p < .005). There was no difference in patient-reported outcomes at 30 days. CONCLUSIONS: In patients undergoing ventral hernia repair with mesh, self-gripping mesh is a safe type of mesh to use. Use of self-gripping mesh may be associated with lower rates of SSOPI when compared to nonself-gripping mesh.

Concurrent minimally invasive bariatric surgery and ventral hernia repair with mesh; Is it safe? Propensity score matching analysis using the 2015-2022 MBSAQIP database.

BACKGROUND: Obesity is a risk factor for the development of ventral hernias. Approximately eight percent of patients undergoing bariatric surgery have a concomitant ventral hernia. However, the optimal timing of hernia repair in these patients is debated. Concerns regarding mesh insertion in a potentially contaminated field are often cited by opponents of a combined approach. Our study compares 30-day outcomes of bariatric surgery with concurrent ventral hernia repair with mesh versus bariatric surgery alone. METHODS: Using the 2015-2022 MBSAQIP database, patients aged 18-65 years who underwent minimally invasive sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) with or without concurrent ventral hernia repair with mesh (VHR-M) were identified. 30-day postoperative outcomes were compared between patients who underwent SG or RYGB with VHR-M versus SG or RYGB alone. 1:1 propensity score matching was performed using 26 preoperative characteristics to adjust confounders. RESULTS: Among 1,236,644 patients who underwent SG (n = 871,326) or RYGB (n = 365,318), 3,121 underwent SG + VHR-M and 2,321 RYGB + VHR-M. The concurrent approach had longer operative times, in SG + VHR-M (86.06 ± 42.78 vs. 73.80 ± 38.45 min, p < 0.001), and in RYGB + VHR-M (141.91 ± 58.68 vs. 128.47 ± 62.37 min, p < 0.001). The RYGB + VHR-M cohort had higher rates of reoperations (3.2% vs. 2.1%, p = 0.024). Overall, 30-day outcomes, and bariatric-specific complications such as mortality, unplanned ICU admissions, surgical site complications, cardiac, pulmonary, renal complications, anastomotic leaks, postoperative bleeding, and intestinal obstruction were similar between SG + VHR-M or RYGB + VHR-M groups versus SG or RYGB alone. CONCLUSION: Bariatric surgery performed concurrently with VHR-M is safe and feasible and does not excessively prolong operative times. However, patients undergoing RYGB with VHR-M do have a higher rate of reoperations, therefore a staged VHR is recommended. On the other hand, concurrent SG and VHR-M may benefit after an appropriate individualized risk stratification assessment.

A comparison between robotic-assisted and open approaches for large ventral hernia repair-a multicenter analysis of 30 days outcomes using the ACHQC database.

INTRODUCTION: Over the last few decades, there has been an increase in the use of a minimally invasive (MIS) approach for complex hernias involving component separation. A robotic platform provides better visualization and mobilization of tissues for component separation. We aim to assess the outcomes of open and robotic-assisted approaches for large VHR utilizing the ACHQC national database. METHODS: A retrospective review of prospectively collected data from the Abdominal Core Health Quality Collaborative (ACHQC) was performed to include all adult patients who had primary and incisional midline ventral hernias larger than 10 cm and underwent elective open and robotic hernia repairs with mesh from January 2013 to March 2023. Univariate and multivariate analyses were performed comparing Open and Robotic approaches. RESULTS: The ACHQC database identified 5,516 patients with midline hernias larger than 10 cm who underwent VHR. The open group (OG) had 4,978 patients, and the robotic group (RG) had 538. The RG had a higher median BMI (33.3 kg/m2 (IQR 29.8-38.1) vs 32.7 (IQR 28.7-36.6) (p < 0.001). Median hernia width was 15 cm (IQR 12-18) in the OG and 12 cm in the RG (10-14) (p < 0.001). Sublay positioning of the mesh was the most common. The fascial closure was higher in the RG (524; 97% versus 4,708; 95%-p = 0.005). Median Length of Stay (LOS) was 5 days (IQR 4-7) in the OG and 2 days (IQR 1-3) in the RG (p < 0.001). The readmission rate was higher in the OG (n = 374; 7.5% vs n = 16; 3%; p < 0.001). 30-day SSI were higher in the OG (343; 6.9%% vs 14; 2.6%; p < 0.001). Logistic regression analysis identified diabetes (OR 1.6; CI 1.1-2.1; p = 0.006) and BMI (OR 1.04, CI 1.02-1.06; p < 0.001) as predictors of SSIs, while the robotic approach was protective (OR 0.35, CI 0.17-0.64; p = 0.002). For SSO, logistic regression showed BMI (OR 1.04, CI 1.03-1.06; p < 0.001) and smoking (OR 1.8, CI 1.3-2.4; p < 0.001) as predictors Robotic approach was associated with lower readmission rates (OR .04, CI 0.2-0.6; p < 0.001). CONCLUSION: A robotic approach improves early 30-day outcomes compared to an open technique for large VHR. There was no difference in SSO at 30 days.

Robotic approach for retromuscular ventral hernia repair may be associated with improved wound morbidity in high-risk patients: a propensity score analysis.

BACKGROUND: Retromuscular sublay (RMS) technique for repair of ventral hernias has gained popularity due to lower risk of recurrence and wound complications. Robotic approaches to RMS have been shown to decrease hospital stay; however, previous studies have failed to show a significant reduction in wound morbidity. Utilizing the Abdominal Core Health Quality Collaborative (ACHQC) database, this study sought to determine the effect of robotic approach on wound morbidity, while specifically focusing on a high-risk population. METHODS: A retrospective review of elective robotic and open RMS repairs in the ACHQC database was performed. Patients deemed to be high-risk for wound complications were included: adult patients with BMI greater than 35 and who were either current smokers or diabetics. A propensity score match was then done to balance covariates between the two groups. Main outcomes of concern were surgical site occurrences (SSO), surgical site infections (SSI), and surgical site occurrence requiring procedural intervention (SSOPI) at 30-day follow-up. RESULTS: A total of 917 patients met inclusion criteria. After propensity score matching, 211 patients matched for each approach. There was no difference in overall SSO (18% for Open vs 23% for Robotic, p = 0.23). Open repair was associated with higher rates of SSI (4% vs 1%, p = 0.032) and SSOPI (9% SSOPI vs 3%, p < 0. 015). As seen in previous studies, there was a higher rate of seroma associated with Robotic RMS repair (87% vs 48%, p < 0.001) in patients that developed an SSO. CONCLUSIONS: In this analysis, a robotic approach was associated with decreased rates of SSI and SSOPI in obese patients who were either current smokers or diabetics. In effort to reduce wound morbidity and the associated physical and economic costs, robotic approach for retromuscular ventral hernia repair should be considered in this patient population.

Causal relationship of obesity and adiposity distribution on risk of ventral hernia.

PURPOSE: Ventral hernia (VH) is a common surgical disease. Previous studies suggested that obesity is an important risk factor for VH. However, the causal relationship between fat distribution and the risk of VH is still unclear. This study used Mendelian randomization (MR) to evaluate their causal relationship. METHODS: We used the body mass index (BMI), body fat percentage, and body fat mass to represent general obesity and utilized the volume of abdominal subcutaneous adiposity tissue, visceral adiposity tissue, waist circumference, hip circumference, and waist-to-hip ratio to represent abdominal adiposity. The data were extracted from the large-scale genome-wide association study of European ancestry. We used two-sample MR to infer causality, using multivariate MR to correct the effects of confounding factors. RESULTS: Increased BMI, body fat percentage, body fat mass, visceral adiposity tissue, waist circumference, and hip circumference rather than subcutaneous adiposity tissue or waist-to-hip ratio, were causally associated with a higher risk of VH. The results of multivariate MR suggested that body fat percentage was causally associated with a higher risk of VH after adjusting for body mass index, diabetes, and smoking. CONCLUSION: General obesity, increased visceral adiposity tissue, waist circumference, and hip circumference rather than subcutaneous adiposity tissue or the waist-to-hip ratio were causally associated with a higher risk of VH. These findings provided a deeper understanding of the role that the distribution of adiposity plays in the mechanism of VH.