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.

Operative dictations in surgical trainees: an underutilized educational resource?

INTRODUCTION: Accurate operative notes are imperative to patient care and are used for communication, billing, quality assurance, and medical-legal conflicts. However, operative note quality often varies and many lack critical details. Unfortunately, no standardized training exists in operative dictations for surgical trainees. This pilot study sought to determine resident ability to dictate a comprehensive operative note and to determine a need for a formal operative dictation curriculum. METHODS: Thirty-eight surgical residents between post-graduate years (PGY) one to four participated in a ventral hernia repair simulation. One senior (PGY3/4) resident coached two junior residents (PGY1/2). Residents completed an informal needs assessment regarding operative dictations. Post-simulation, residents completed an operative dictation. Notes were graded using a modified validated rubric. RESULTS: Thirty-five residents completed the needs assessment, and 38 residents submitted an operative note. Eighty-two percent of this group have completed ≤ 25 operative dictations in training and 77% have received minimal feedback on operative dictations. Out of 33 total points, mean overall score was 18.9 ± 5.4 (Junior resident: 17.9 ± 5.4; Senior resident: 20.9 ± 4.8) Total mean scores did not significantly differ between junior and senior residents (p = 0.10). Senior and junior residents scored similarly on the procedural details component (p = 0.29). Senior residents scored higher on relevant patient history and operative note headers (p = 0.04). CONCLUSION: Standard surgical training may not provide enough teaching and feedback to residents on operative note dictations. A formal residency training curriculum may bolster trainee ability to learn the components of an effective operative note.

Laparoscopic versus robotic inguinal hernia repair: 1- and 2-year outcomes from the RIVAL trial.

INTRODUCTION: Robotic inguinal hernia repair is growing in popularity among general surgeons despite little high-quality evidence supporting short- or long-term advantages over traditional laparoscopic inguinal hernia repair. The original RIVAL trial showed increased operative time, cost, and surgeon frustration for the robotic approach without advantages over laparoscopy. Here we report the 1- and 2-year outcomes of the trial. METHODS: This is a multi-center, patient-blinded, randomized clinical study conducted at six sites from 2016 to 2019, comparing laparoscopic versus robotic transabdominal preperitoneal (TAPP) inguinal hernia repair with follow-up at 1 and 2 years. Outcomes include pain (visual analog scale), neuropathic pain (Leeds assessment of neuropathic symptoms and signs pain scale), wound morbidity, composite hernia recurrence (patient-reported and clinical exam), health-related quality of life (36-item short-form health survey), and physical activity (physical activity assessment tool). RESULTS: Early trial participation included 102 patients; 83 (81%) completed 1-year follow-up (45 laparoscopic vs. 38 robotic) and 77 (75%) completed 2-year follow-up (43 laparoscopic vs. 34 robotic). At 1 and 2 years, pain was similar for both groups. No patients in either treatment arm experienced neuropathic pain. Health-related quality of life and physical activity were similar for both groups at 1 and 2 years. No long-term wound morbidity was seen for either repair type. At 2 years, there was no difference in hernia recurrence (1 laparoscopic vs. 1 robotic; P = 1.0). CONCLUSIONS: Laparoscopic and robotic inguinal hernia repairs have similar long-term outcomes when performed by surgeons with experience in minimally invasive inguinal hernia repairs.

Chronological age does not predict postoperative outcomes following transversus abdominis release (TAR).

BACKGROUND: Transversus abdominis release (TAR) is an effective procedure for the repair of complex ventral hernias. However, TAR is not a low risk operation, particularly in older adults who are disproportionately affected by multiple age-related risk factors. While past studies have suggested that age alone inconsistently predicts patient outcomes, data regarding age's effect on postoperative outcomes and wound complications following a TAR are lacking. METHODS: Patients who underwent either an open or robotic bilateral TAR from 1/2018 to 9/2020 were eligible for the study. Patients were stratified by age groups (≥ 60 years vs. < 60 years and < 60, 60-70, and ≥ 70) and by both age and operative approach. The rates of key postoperative outcomes and wound morbidity were compared between the various cohorts. RESULTS: A total of 300 patients were included: 165 patients were ≥ 60 and 135 patients were < 60. Cohorts stratified by age were well-matched for important hernia factors: defect size (p = 0.31), BMI ≥ 30 (p = 0.46), OR time (p = 0.25), percent open TAR (p = 0.42), diabetes (p = 0.45) and history of prior surgical site infection (p = 0.40). The older cohort had significantly higher rates of coronary artery disease, hypertension, and COPD. On univariate analysis, cohorts stratified by age had similar rates of key postoperative and wound complications including in-hospital complications (p = 0.62), length of stay (p = 0.47), readmissions (p = 0.66), and surgical site occurrences (p = 0.68). Additionally, cohorts stratified by both age and operative approach also had similar outcomes. Multivariate analysis showed that chronological age was not independently associated with surgical site occurrences (p = 0.22), readmissions (p = 0.99), in-hospital complications (p = 0.15), or severe complications (p = 0.79). CONCLUSION: Open and robotic TARs can be safely performed in older adults and chronological age alone is a poor predictor of patient morbidity following TAR. Further investigation of alternative preoperative screening tools that do not rely solely on age are needed to better optimize surgical outcomes in older adults following TAR.

Examination of abdominal wall perfusion using varying suture techniques for midline abdominal laparotomy closure.

BACKGROUND: With a growing interest in the primary prevention of incisional hernias, it has been hypothesized that different suturing techniques may cause various levels of tissue ischemia. Using ICG laser-induced fluorescence angiography (ICG-FA), we studied the effect of different suture materials and closure techniques on abdominal wall perfusion. METHODS: Fifteen porcine subjects underwent midline laparotomy, bilateral skin flap creation, and three separate 7 cm midline fascial incisions. Animals underwent fascial closure with 5 different techniques: (1) Running 0-PDS® II (polydioxanone) Suture with large bites; (2) Running 0-PDS II Suture with small bites; (3) Interrupted figure-of-eight (8) PDS II Suture, (4) Running 0-barbed STRATAFIX™ Symmetric PDS™ Plus Knotless Tissue Control Device large bite; (5) Running 0-STRATAFIX Symmetric PDS Plus Device small bites. ICG-FA signal intensity was recorded prior to fascial incision (baseline), immediately following fascial closure (closure), and at one-week (1-week.). Post-mortem, the abdominal walls were analyzed for inflammation, neovascularity, and necrosis. RESULTS: PDS II Suture with small bites, fascial closure at the caudal 1/3 of the abdominal wall, and the 1-week time period were all independently associated with increased tissue perfusion. There was also a significant increase in tissue perfusion from closure to 1-week when using small bites PDS II Suture compared to PDS II Suture figure-of-8 (p < 0.001) and a trend towards significance when compared with large bites PDS II Suture (p = 0.056). Additionally, the change in perfusion from baseline to 1 week with small bites was higher than with figure of 8 (p = 0.002). Across all locations, small bite PDS II Suture has greater total inflammation than figure of 8 (p < 0.001). CONCLUSIONS: The results suggest that the small bite technique increases abdominal wall perfusion and ICG-FA technology can reliably map abdominal wall perfusion. This finding may help explain the reduced incisional hernia rates seen in clinical studies with the small bite closure technique.

A Practical Guideline for the Implementation of Shared Decision-making in Complex Ventral Incisional Hernia Repair.

BACKGROUND: Although obtaining preoperative procedural consent is required to meet legal and ethical obligations, consent is often relegated to a unidirectional conversation between surgeons and patients. In contrast, shared decision-making (SDM) is a collaborative dialog that elicits patient preferences. Despite emerging interest in SDM, there is a paucity of literature on its application to ventral incisional hernia repair (VIHR). The various surgical techniques and mesh types available, the potential impact on functional outcomes and quality of life, the largely elective nature of the operation, and the significant risk of perioperative patient complications render VIHR an ideal field for SDM implementation. METHODS: The authors reviewed the current literature and drew on their own practice experience to describe evidence-based practical guidelines for implementing the SDM into VIHR care. RESULTS: We summarized the evidence basis for SDM in surgery and discussed how this model can be applied to VIHR given the multiple, complex factors that influence surgical decision-making. We outlined an example of using an SDM framework, "SHARE," with a patient with a large, recurrent ventral hernia. CONCLUSIONS: SDM has the potential to improve patient-centered and preference-concordant care among individuals being considered for VIHR to ensure that treatment interventions meet a patient's goals, rather than solely treating the underlying disease process.

The impact of internet-based patient self-education of surgical mesh on patient attitudes and healthcare decisions prior to hernia surgery.

BACKGROUND: As internet access improves, patient self-education continues to increase. However, patient surgical background, e-literacy, and media exposure potentially influence what information patients search online. This impacts patient concern, healthcare decisions, and subsequent patient-physician interactions. The purpose of this pilot study is to characterize hernia patients' use and the impact of internet self-education regarding surgical mesh. METHODS: The target population included patients presenting for evaluation of hernia repair with mesh. A total of 30 patients were enrolled. Patients took surveys before and after the initial surgical consult. The surveys evaluated internet use, mesh research completed, the impact on patient opinions/decisions, and the impact of research on the patient-physician interaction. RESULTS: The average age of the patients was 58.7 years; sixteen had prior surgery with surgical mesh. 93% of patients were aware of surgical mesh through the media, and 60% were motivated by the media to conduct research. 90% of patients conducted research, and 67% used the internet. Patients with negative attitudes toward mesh had more media exposure in comparison to those with neutral or positive attitudes (p = 0.046), and they were more likely to have researched surgical mesh because of media influence (p = 0.033). This group had the highest rate of perceived knowledge on mesh risks and the lowest regarding benefits (p = 0.013). Patients who had prior surgery without complication had the most positive attitude toward surgical mesh (p = 0.010) and were less likely to plan to do future internet research (p = 0.041) in comparison to patients who had surgery with complications or no prior surgery. CONCLUSIONS: Patients' attitudes and perceived knowledge regarding surgical mesh are associated with media exposure and internet research. These attributes along with prior surgical experience impact the patient-physician relationship and shared decision-making model regarding patient care.

Combined in vivo and ex vivo analysis of mesh mechanics in a porcine hernia model.

BACKGROUND: Hernia meshes exhibit variability in mechanical properties, and their mechanical match to tissue has not been comprehensively studied. We used an innovative imaging model of in vivo strain tracking and ex vivo mechanical analysis to assess effects of mesh properties on repaired abdominal walls in a porcine model. We hypothesized that meshes with dissimilar mechanical properties compared to native tissue would alter abdominal wall mechanics more than better-matched meshes. METHODS: Seven mini-pigs underwent ventral hernia creation and subsequent open repair with one of two heavyweight polypropylene meshes. Following mesh implantation with attached radio-opaque beads, fluoroscopic images were taken at insufflation pressures from 5 to 30 mmHg on postoperative days 0, 7, and 28. At 28 days, animals were euthanized and ex vivo mechanical testing performed on full-thickness samples across repaired abdominal walls. Testing was conducted on 13 mini-pig controls, and on meshes separately. Stiffness and anisotropy (the ratio of stiffness in the transverse versus craniocaudal directions) were assessed. RESULTS: 3D reconstructions of repaired abdominal walls showed stretch patterns. As pressure increased, both meshes expanded, with no differences between groups. Over time, meshes contracted 17.65% (Mesh A) and 0.12% (Mesh B; p = 0.06). Mesh mechanics showed that Mesh A deviated from anisotropic native tissue more than Mesh B. Compared to native tissue, Mesh A was stiffer both transversely and craniocaudally. Explanted repaired abdominal walls of both treatment groups were stiffer than native tissue. Repaired tissue became less anisotropic over time, as mesh properties prevailed over native abdominal wall properties. CONCLUSIONS: This technique assessed 3D stretch at the mesh level in vivo in a porcine model. While the abdominal wall expanded, mesh-ingrown areas contracted, potentially indicating stresses at mesh edges. Ex vivo mechanics demonstrate that repaired tissue adopts mesh properties, suggesting that a better-matched mesh could reduce changes to abdominal wall mechanics.

Infection prevention using affinity polymer-coated, synthetic meshes in a pig hernia model.

BACKGROUND: Given concern for hernia mesh infection, surgeons often use biologic mesh which may provide reduced risk of infection but at the cost of decreased repair durability. We evaluated mesh coating to provide sustained release of antibiotics to prevent prosthetic mesh infection and also allow a durable repair. MATERIALS AND METHODS: Cyclodextrin-based polymer was crosslinked onto multifilament polyester mesh and loaded with vancomycin (1.75 mg/cm2). Pigs received modified meshes (n = 6) or normal, untreated meshes (n = 4), which were implanted into acute 10 × 5 cm ventral hernia, then directly inoculated with 106 colony-forming unit (CFU) of methicillin-resistant Staphylococcus aureus (MRSA). These were compared to animals receiving normal, uninfected mesh. All mesh was secured in an underlay bridge manner, and after 30 d, the abdominal wall was removed for quantitative bacterial culture and biomechanical analysis. RESULTS: All animals survived 30 d. All six animals with coated mesh cleared MRSA infection. The four control animals did not clear MRSA (P = 0.005). Quantitative bacterial load was higher in standard mesh versus drug-delivery mesh group (2.34 × 104versus 80.9 CFU/gm). These data were log10-transformed and analyzed by Welch's t-test (P = 0.001). Minimum number of CFUs detectable by assay (300) was used instead of zero. Biomechanical analysis of controls (1.82 N/mm infected; 1.71 N/mm uninfected) showed no difference to the modified meshes (1.31 N/mm) in tissue integration (P = 0.15). CONCLUSIONS: We successfully prevented synthetic mesh infection in a pig model using a cyclodextrin-based polymer to locally deliver vancomycin to the hernia repair site and clearing antibiotic-resistant bacteria. Polymer coating did not impact the strength of the hernia repair.

Validation of Single C-Arm Fluoroscopic Technique for Measuring In Vivo Abdominal Wall Deformation.

Hernia meshes significantly reduce the recurrence rates in hernia repair. It is known that they affect the abdominal wall postimplantation, yet the understanding of in vivo mechanics in the mesh placement area is lacking. We established a single C-arm biplane fluoroscopic system to study strains at the interface between the mesh and repaired abdominal tissues. We aimed to validate this system for future porcine hernia repair studies. Custom matlab programs were written to correct for pincushion distortion, and direct linear transformation (DLT) reconstructed objects in 3D. Using a custom biplane-trough setup, image sets were acquired throughout the calibrated volume to evaluate a radio-opaque test piece with known distances between adjacent beads. Distances were measured postprocessing and compared to known measurements. Repeatability testing was conducted by taking image sets of the test piece in a fixed location to determine system movement. The error in areal stretch tracking was evaluated by imaging a square plate with fixed radio-opaque beads and using matlab programs to compare the measured areal stretch to known bead positions. Minor differences between measured and known distances in the test piece were not statistically different, and the system yielded a 0.01 mm bias in the XY plane and a precision of 0.61 mm. The measured areal stretch was 0.996, which was not significantly different than the expected value of 1. In addition, preliminary stretch data for a hernia mesh in a porcine model demonstrated technique feasibility to measure in vivo porcine abdominal mechanics.

Stoma Complications.

When created properly, an ileostomy or colostomy can dramatically improve a patient's quality of life. Conversely, when a patient develops complications related to their stoma, the impact on physical and mental health can be profound. Unfortunately, significant morbidity is associated with stoma creation conveying high rates of both early and late-term complications. Early complications include stomal ischemia/necrosis, retraction, mucocutaneous separation, and parastomal abscess. Late complications include parastomal hernia, prolapse, retraction, and varices. This review will discuss commonly occurring nondermatological stoma complications and detail management strategies for the ostomate and the surgeon.

A 5-year clinical experience with single-staged repairs of infected and contaminated abdominal wall defects utilizing biologic mesh.

OBJECTIVE: Our objective was to evaluate the safety and durability of biologic mesh for single-staged reconstruction of contaminated fields. INTRODUCTION: The presence of contamination during ventral hernia repair (VHR) poses a significant challenge. Some advocate for a multistaged reconstructive approach with delayed definitive repair, whereas others perform definitive repair at the initial operation. METHODS: Patients undergoing single-staged VHR in a contaminated field with biologic mesh over a 5-year period were retrospectively reviewed from a prospectively maintained database. Outcome measures included wound complication and hernia recurrence. RESULTS: A total of 128 patients (76 F, 52 M) were identified, with a mean age of 58.2 years, mean American Society of Anesthesiologist (ASA) score 3.1, and mean body mass index (BMI) 34.1 ± 9.7 kg/m2. Comorbidities included COPD (n = 29), diabetes (n = 65), smoking (n = 29), and immunosuppression (n = 8). Mean hernia defect size was 431 cm2 (range 40-2450 cm2). Reasons for contamination included the presence of infected mesh (n = 45), stoma (n = 24), concomitant gastrointestinal (GI) surgery (n = 17), enterocutaneous fistula (n = 25), open nonhealing wound(s) (n = 6), enterotomy/colotomy (n = 5), and chronic draining sinus (n = 6). Postoperative wound complications were identified in 61 (47.7%) patients. Predictors of wound complications included ASA score, diabetes, smoking, number of previous abdominal surgeries or hernia repairs, hernia defect size, and operative time. With a mean follow-up time of 21.7 months, hernia recurrence was identified in 40 (31.3%) patients. The majority of recurrent hernias were asymptomatic and 7 patients underwent repair. CONCLUSIONS: Despite the high rate of wound morbidity associated with single-staged reconstruction of contaminated fields, it can safely be performed with biologic mesh reinforcement. Although biologic mesh in these situations is safe, the long-term durability seems to be less favorable.

A novel over-the-scope deployment method for enteral stent placement.

BACKGROUND: Over the last two decades, self-expanding enteral stents have gained popularity and shown therapeutic potential for strictures, obstructions, fistulae, and perforations of the gastrointestinal (GI) tract. Currently available stent delivery systems make deployment in many locations in the GI tract difficult due to the inability to traverse curves or impossible due to the size requirements of the deployment systems. METHODS: A 67-year-old male presented to our hospital with severe gallstone pancreatitis, requiring a prolonged intensive care unit course. Two days after discharge to a rehabilitation facility he developed acute abdominal pain and pneumoperitoneum. Operative exploration failed to identify a perforation. Subsequently, a left-upper-quadrant abscess developed that was drained percutaneously, yielding coliform bacteria. The drain produced several hundred milliliters of stool a day. A barium enema demonstrated a perforation in the descending colon from an old colo-colic anastomosis site. We proposed a novel over-the-scope (OTS) stent deployment method. Utilizing a heat-activated polymer sheath, the stent was affixed to the endoscope. A modified speed-banding attachment was created to permit release of the polymer sheath once endoscopic and fluoroscopic confirmation of the correct position was obtained. RESULTS: Utilizing this method of OTS stent deployment, a fully covered 23 × 155 mm self-expanding metal stent (WallFlex, Boston Scientific, Natick, MA) was placed in the colon. Endoscopic and fluoroscopic evaluation following stent placement confirmed stent coverage of the perforation with no ongoing evidence of leak. The patient was discharged to his home state 2 weeks after stent placement in stable condition. CONCLUSION: We have developed a novel method of OTS stent placement that permits deployment of a variety of enteral stents on any available endoscope. This method permits placement of fully covered stents in locations in the GI tract not reachable with currently available delivery systems.

Evaluation of fibrin sealant for biologic mesh fixation at the hiatus in a porcine model.

BACKGROUND: The ideal method to secure biologic mesh during laparoscopic hiatal hernia repair remains uncertain. Suture or tack fixation can be technically difficult, and serious cardiovascular complications have been reported. Fibrin sealant (FS) offers a potential solution to this problem. We hypothesized that FS provides comparable mesh fixation to suture repair during laparoscopic mesh hiatoplasty. STUDY DESIGN: Using a porcine model, laparoscopic hiatal hernia repair was performed with suture reapproximation of the crura and reinforcement with an acellular porcine dermal matrix. Prior to repair, animals were randomized to mesh fixation with sutures (S) or FS. After 30-day survival, an esophagram was performed, the diaphragm harvested, and mesh position, fixation, and incorporation were evaluated histologically and biomechanically using a T-peel test. RESULTS: Twenty (10 S and 10 FS) laparoscopic hiatal hernia repairs were performed. Total operative time was significantly less in the FS group (74.7 versus 127.0 min, p < 0.01). There were no instances of mesh migration in any animal. Mean peel force did not differ significantly between the S and FS groups (0.21 vs. 0.18 N/mm, respectively; p = 0.49). There was no significant difference in cellular repopularization or inflammatory changes around the mesh. CONCLUSIONS: Fibrin sealant offers a reasonable alternative to suturing biologic mesh during laparoscopic hiatal hernia repair with equivalent mesh fixation. At 30 days it provides adhesive strength similar to suture fixation, while significantly reducing operative time.

Evaluation of information on the Internet regarding surgical mesh for hernia repair: analysis of websites found through three popular search engines.

PURPOSE: Hernia repair remains one of the most common surgical procedures. Surgical mesh usage has been highlighted in the media due to recent lawsuits and recalls. Patients can read potentially biased information on the Internet and this can influence a patient's healthcare decisions. The purpose of this study is to evaluate search engine listings and respective website content of surgical mesh for hernia repair. METHODS: Websites evaluated were derived from four keyword searches targeting surgical mesh with Google, Yahoo, and Bing. Websites from the first two pages of each search were evaluated for content comprehensiveness. RESULTS: The largest category of websites from search engine results was legal advertisements, accounting for 20% of all results. These websites also held the first position on every results page. Legal advertisements and blog/forum websites were the most skewed toward surgical mesh risks and complications vs. benefits. There was a reduction in advertisements in 2020 vs. 2018. The most comprehensive non-advertisement websites were found more frequently. Overall, only 44% of websites presented references and 50% cited supporting data. Finally, 46% of 'recommended search terms' displayed on the search engine results page had a risk, complication, or legal bias. CONCLUSIONS: These results emphasize the challenges of using an Internet search engine to find comprehensive and appropriate information regarding surgical mesh. This manuscript underscores the importance for physicians to direct patients toward specific websites to mitigate their exposure to websites that are biased and not appropriate for patients searching for an accurate and comprehensive overview of surgical mesh.

Transversus abdominis release with posterior component separation in patients with previously recurrent ventral hernias: A single institution experience.

BACKGROUND: Recurrent hernias pose significant challenges due to violated anatomic planes, resultant scar, and potential prior mesh. Transversus abdominis release has been widely utilized for complex hernias. Transversus abdominis release can provide a novel plane for dissection and mesh placement for recurrent hernias. This study provides our institution's experience with transversus abdominis release in patients with recurrent ventral hernias. METHODS: A retrospective chart review was conducted of patients with recurrent ventral hernias from January 2018 to September 2020 who underwent transversus abdominis release by 2 fellowship-trained abdominal wall surgeons. Combined procedures (ie, gynecological/urological), robotic totally extraperitoneal, and emergency cases were excluded. Demographics, perioperative, and postoperative outcomes were reviewed. RESULTS: In total, 108 patients underwent open-transversus abdominis release and 25 had robotic-transversus abdominis release for recurrent ventral hernias. All patients received a lightweight to midweight nonabsorbable polypropylene synthetic mesh. Mean age was 59, mean body mass index was 34 kg/m2, with mean hernia defect area of 333 cm2. We noted 34 (25.6%) surgical site occurrences and 11 (8.3%) surgical site infections. Mean postoperative follow-up was 15.5 months, with 7 (5%) recurrences (6 open-transversus abdominis release, 1 robotic-transversus abdominis release). A minimum 12-month follow-up was available for 62% of patients, and minimum 6-month follow-up in 80% of patients. CONCLUSION: Recurrent hernias pose significant operative challenges for surgeons due to violated tissue planes and limited repair options. Our experience suggests that transversus abdominis release may provide a durable repair for difficult recurrent ventral hernias. However, long-term postoperative follow-up over multiple years is still needed to establish extended durability of transversus abdominis release in these patients.

Does immunosuppression increase perioperative wound morbidity in patients undergoing transversus abdominis release?

BACKGROUND: Transversus abdominis release is an effective procedure for complex ventral hernias. As wound complications contribute to hernia recurrences, mitigating risk factors is vitally important for hernia surgeons. Although immunosuppression can impair wound healing, it has inconsistently predicted wound occurrences, and its effect on wound morbidity after a transversus abdominis release is unknown. METHODS: Patients undergoing either an elective open or robotic bilateral transversus abdominis release with permanent synthetic mesh were retrospectively stratified by perioperative immunosuppression and secondarily by procedure type (open versus robotic) and immunosuppression. RESULTS: A total of 321 patients were included for analysis. Overall, 63 (19.6%) patients were on chronic immunosuppression, with history of solid-organ transplant being the most common indication (43 patients). Patients stratified by perioperative immunosuppression were well-matched with similar defect size (P = .97), body mass index ≥30 (P = .32), diabetes (P = .09), history of surgical site infection (P = .53), surgical approach (P = .53), and tobacco use history (P = .33). No differences between cohorts were elicited for any wound event when stratified by immunosuppression use. Similarly, no differences were elicited when cohorts were further stratified also by procedure type. CONCLUSION: Chronic immunosuppression is often viewed as a notable risk factor for wound occurrences after surgery. However, our data suggest immunosuppression may not significantly increase the risk of perioperative wound morbidity follow transversus abdominis release as previously predicted.

Biologic vs Synthetic Mesh for Single-stage Repair of Contaminated Ventral Hernias: A Randomized Clinical Trial.

IMPORTANCE: Biologic mesh is widely used for reinforcing contaminated ventral hernia repairs; however, it is expensive and has been associated with high rates of long-term hernia recurrence. Synthetic mesh is a lower-cost alternative but its efficacy has not been rigorously studied in individuals with contaminated hernias. OBJECTIVE: To determine whether synthetic mesh results in superior reduction in risk of hernia recurrence compared with biologic mesh during the single-stage repair of clean-contaminated and contaminated ventral hernias. DESIGN, SETTING, AND PARTICIPANTS: This multicenter, single-blinded randomized clinical trial was conducted from December 2012 to April 2019 with a follow-up duration of 2 years. The trial was completed at 5 academic medical centers in the US with specialized units for abdominal wall reconstruction. A total of 253 adult patients with clean-contaminated or contaminated ventral hernias were enrolled in this trial. Follow-up was completed in April 2021. INTERVENTIONS: Retromuscular synthetic or biologic mesh at the time of fascial closure. MAIN OUTCOMES AND MEASURES: The primary outcome was the superiority of synthetic mesh vs biologic mesh at reducing risk of hernia recurrence at 2 years based on intent-to-treat analysis. Secondary outcomes included mesh safety, defined as the rate of surgical site occurrence requiring a procedural intervention, and 30-day hospital direct costs and prosthetic costs. RESULTS: A total of 253 patients (median [IQR] age, 64 [55-70] years; 117 [46%] male) were randomized (126 to synthetic mesh and 127 to biologic mesh) and the follow-up rate was 92% at 2 years. Compared with biologic mesh, synthetic mesh significantly reduced the risk of hernia recurrence (hazard ratio, 0.31; 95% CI, 0.23-0.42; P < .001). The overall intent-to-treat hernia recurrence risk at 2 years was 13% (33 of 253 patients). Recurrence risk with biologic mesh was 20.5% (26 of 127 patients) and with synthetic mesh was 5.6% (7 of 126 patients), with an absolute risk reduction of 14.9% with the use of synthetic mesh (95% CI, -23.8% to -6.1%; P = .001). There was no significant difference in overall 2-year risk of surgical site occurrence requiring a procedural intervention between the groups (odds ratio, 1.22; 95% CI, 0.60-2.44; P = .58). Median (IQR) 30-day hospital direct costs were significantly greater in the biologic group vs the synthetic group ($44 936 [$35 877-$52 656] vs $17 289 [$14 643-$22 901], respectively; P < .001). There was also a significant difference in the price of the prosthetic device between the 2 groups (median [IQR] cost biologic, $21 539 [$20 285-$23 332] vs synthetic, $105 [$105-$118]; P < .001). CONCLUSIONS AND RELEVANCE: Synthetic mesh demonstrated superior 2-year hernia recurrence risk compared with biologic mesh in patients undergoing single-stage repair of contaminated ventral hernias, and both meshes demonstrated similar safety profiles. The price of biologic mesh was over 200 times that of synthetic mesh for these outcomes. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02451176.

A prospective, multicenter trial of a long-term bioabsorbable mesh with Sepra technology in cohort of challenging laparoscopic ventral or incisional hernia repairs (ATLAS trial).

BACKGROUND: This prospective, multicenter, single-arm, open-label study evaluated P4HB-ST mesh in laparoscopic ventral or incisional hernia repair (LVIHR) in patients with Class I (clean) wounds at high risk for Surgical Site Occurrence (SSO). METHODS: Primary endpoint was SSO requiring intervention <45 days. Secondary endpoints included: surgical procedure time, length of stay, SSO >45 days, hernia recurrence, device-related adverse events, reoperation, and Quality of Life at 1, 3, 6, 12, 18, and 24-months. RESULTS: 120 patients (52.5% male), mean age of 55.0 ± 14.9 years, and BMI of 33.2 ± 4.5 kg/m2 received P4HB-ST mesh. Patient-reported comorbid conditions included: obesity (86.7%), active smoker (45.0%), COPD (5.0%), diabetes (16.7%), immunosuppression (2.5%), coronary artery disease (7.5%), chronic corticosteroid use (2.5%), hypoalbuminemia (0.8%), advanced age (10.0%), and renal insufficiency (0.8%). Hernia types were primary ventral (44.2%), primary incisional (37.5%), recurrent ventral (5.8%), and recurrent incisional (12.5%). Patients underwent LVIHR in laparoscopic (55.8%) or robotic-assisted cases (44.2%), mean defect size 15.7 ± 28.3 cm2, mean procedure time 85.9 ± 43.0 min, and mean length of stay 1.0 ± 1.4 days. There were no SSOs requiring intervention beyond 45 days, n = 38 (31.7%) recurrences, n = 22 (18.3%) reoperations, and n = 2 (1.7%) device-related adverse events (excluding recurrence). CONCLUSION: P4HB-ST mesh demonstrated low rates of SSO and device-related complications, with improved quality of life scores, and reoperation rate comparable to other published studies. Recurrence rate was higher than expected at 31.7%. However, when analyzed by hernia defect size, recurrence was disproportionately high in defects ≥7.1 cm2 (43.3%) compared to defects <7.1 cm2 (18.6%). Thus, in LVIHR, P4HB-ST may be better suited for small defects. Caution is warranted when utilizing P4HB-ST in laparoscopic IPOM repair of larger defects until additional studies can further investigate outcomes.

Thirty-day readmission after ventral hernia repair: predictable or preventable?

INTRODUCTION: Thirty-day readmission has become an increasingly scrutinized event in the field of surgery, especially in light of projected cuts in reimbursement. Although studies have evaluated large populations, little work has been done on procedure-specific populations. Our objective is to determine if any factors are predictive of 30-day readmission in patients undergoing ventral hernia repair. METHODS: We retrospectively reviewed the charts of all patients who underwent laparoscopic or open ventral hernia repair over a 4-year period. We evaluated patients based on demographic, preoperative, and operative variables. The primary outcome measure was all-cause 30-day readmission. RESULTS: There were 420 patients identified for evaluation. Fifty-one (12%) patients required readmission to the hospital within 30 days. The most common indications for readmission were wound infection (57%; n=29) and gastrointestinal (GI) complication (19%; n=10). On analysis, demographic variables were similar between the two groups. However, patients who were readmitted were more likely to have had more prior abdominal surgeries (4 vs. 2; p<0.0001), more previous hernia repairs (2 vs. 1; p=0.006), open repair (76% vs. 46%; p<0.0001), and active abdominal infection (37% vs. 12%; p<0.0001). In addition, patients also had longer procedures (235 vs. 150 min; p<0.0001) and larger defects (350 vs. 96 cm2; p<0.0001). On multivariate analysis, independent predictors of readmission included presence of fistula [odds ratio (OR)=8.55; 95% confidence interval (CI) 3.21-22.72], defect size>300 cm2 (OR=5.35; 95% CI 2.59-11.05), active abdominal infection (OR=4.37; 95% CI 2.28-8.37), and open repair (OR=4.27; 95% CI 2.17-8.42). CONCLUSIONS: Patients undergoing ventral hernia repair can represent a complex group. In our practice, enterocutaneous fistula, defect size>300 cm2, active abdominal infection, and open repair were all independent risk factors (OR>4) for 30-day readmission after ventral hernia repair. Recognition of these high-risk patients can help focus resources to increase surveillance and possible early intervention to reduce readmissions.