Elective Hernia Repair Research Articles

Long-Term Outcomes After Epigastric Hernia Repair in Women-A Nationwide Database Study.

Aim: Women have the highest prevalence of epigastric hernia repair. Outcomes after epigastric hernia repair are rarely reported independently, although pathology and surgical techniques may be different than for other primary ventral hernias. The aim of this study was to evaluate long-term outcomes after epigastric hernia repairs in women on a nationwide basis. Methods: Nationwide cohort study from the Danish Hernia Database. Complete data from women undergoing elective epigastric hernia repair during a 12years period (2007-2018) was extracted. A 100% follow-up was obtained by combining data from the National Civil Register. The primary outcome was operation for recurrence, secondary outcomes were readmission and operation for complications. Outcomes for open sutured repair, open mesh repair mesh, and laparoscopic repairs were compared. Results: In total, 3,031 women underwent elective epigastric hernia repair during the study period. Some 1,671 (55.1%) women underwent open sutured repair, 796 (26.3%) underwent open mesh repair, and 564 (18.6%) underwent laparoscopic repair. Follow-up was median 4.8years. Operation for recurrence was higher after sutured repairs than after open mesh and laparoscopic repairs (7.7% vs. 3.3%, vs. 6.2%, p < 0.001). The risk of operation for complications was slightly higher after open mesh repair compared with sutured repair and laparoscopic repair (2.6% vs. 1.2%, vs. 2.0%, p = 0.032), with more operations for wound complications in the open mesh group (2.0%, p = 0.006). Conclusion: More than half of the women underwent a suture-based repair, although mesh repair reduces risk of recurrence. Open mesh repair had the lowest risk of recurrence, but on the expense of slightly increased risk of wound-related complications.

The effect of frailty and age on outcomes in elective paraesophageal hernia repair.

Paraesophageal hernia repair (PEHR) is a safe and effective operation. Previous studies have described risk factors for poor peri-operative outcomes such as emergent operations or advanced patient age, and pre-operative frailty is a known risk factor in other major surgery. The goal of this retrospective cohort study was to determine if markers of frailty were predictive of poor peri-operative outcomes in elective paraesophageal hernia repair. Patients who underwent elective PEHR between 1/2011 and 6/2022 at a single university-based institution were identified. Patient demographics, modified frailty index (mFI), and post-operative outcomes were recorded. A composite peri-operative morbidity outcome indicating the incidence of any of the following: prolonged length of stay (≥ 3days), increased discharge level of care, and 30-day complications or readmissions was utilized for statistical analysis. Descriptive statistics and logistic regression were used to analyze the data. Of 547 patients who underwent elective PEHR, the mean age was 66.0 ± 12.3, and 77.1% (n = 422) were female. Median length of stay was 1 [IQR 1, 2]. ASA was 3-4 in 65.8% (n = 360) of patients. The composite outcome occurred in 32.4% (n = 177) of patients. On multivariate analysis, increasing age (OR 1.021, p = 0.02), high frailty (OR 2.02, p < 0.01), ASA 3-4 (OR 1.544, p = 0.05), and redo-PEHR (OR 1.72, p = 0.02) were each independently associated with the incidence of the composite outcome. On a regression of age for the composite outcome, a cutoff point of increased risk is identified at age 72years old (OR 2.25, p < 0.01). High frailty and age over 72years old each independently confer double the odds of a composite morbidity outcome that includes prolonged post-operative stay, peri-operative complications, the need for a higher level of care after elective paraesophageal hernia repair, and 30-day readmission. This provides additional information to counsel patients pre-operatively, as well as a potential opportunity for targeted pre-habilitation.

Slowly absorbable mesh in sublay ventral hernia repair in contaminated fields.

In the past years, there has been increasing evidence that supports the use of permanent mesh in contaminated wounds. Given this increased evidence, the indications to opt for slowly absorbable "biosynthetic" prostheses have been questioned. To address this, we compared the outcomes of slowly absorbable mesh in contaminated cases in a well-matched multicentric cohort. The Abdominal Core Health Quality Collaborative (ACHQC) database was queried for patients undergoing elective ventral hernia repair in Centers for Disease Control (CDC)-III operations (2013-2022). We compared demographics, hernia characteristics, and postoperative outcomes among types of mesh. We used propensity score matching to adjust for sex, diabetes, body mass index, smoking status, and operative time between mesh groups. Patients within other CDC classes and those with mesh positioned elsewhere than retro-rectus/preperitoneal space were excluded. A total of 760 patients were included in the analysis. Slowly absorbable synthetic mesh (SA) was utilized in only 7% of the cases, while permanent (P) and biologic (B) mesh in 77% and 16%, respectively. After matching, 255 patients were studied. There was no difference in surgical site occurrence (8% SA, 16% P, 10% B, p = 0.27), surgical site infection (20% SA, 17% P, 12% B p = 0.54), surgical site occurrence requiring intervention (18% SA, 13% P, 14% B p = 0.72), readmission (12% SA, 14% P, 12% B, p = 0.90), or reoperation (8% SA, 2% P, 4% B, p = 0.14) at 30days. In patients with 1-year follow-up, there was no difference in recurrence among groups (20% SA, 26% P, 24% B p = 0.90). Based on our findings, SA has comparable outcomes to other types of mesh, particularly when an optimal retro-rectus repair is performed.

Gender, racial, and socioeconomic disparity of preoperative optimization goals in ventral hernia repair.

Preoperative optimization cut-offs are frequently utilized to determine eligibility for elective ventral hernia repair. Our objective was to assess the relationship between gender, race, and socioeconomic status and preoperative optimization goals. We queried our institutional database for adults with ventral hernia diagnoses between 2016 and 2021. Demographics, comorbidities, laboratory, and operative data were collected and analyzed. The following cut-offs were used to determine eligibility for elective repair: body mass index (BMI) < 40kg/m2, no active smoking, and glycated hemoglobin (HbA1c) < 8%. Socioeconomic status was assessed using the Distressed Communities Index. A total of 5638 patients were included [Whites = 4321 (77%), Blacks = 794 (14%), Hispanics = 318 (6%), and other/unknown 205 (4%)]. Median age was 61years and 50% were male. Most common hernia types were umbilical (36%) and incisional (20%). 10% had BMI > 40kg/m2, 9% were active smokers and 4% had HbA1c > 8%. 21% of all patients did not meet the preoperative optimization cut-offs at time of diagnosis and those were less likely to undergo hernia repair during the study timeframe compared to those who did (OR 0.50; 95% CI [0.42-0.60]). There was a higher proportion of females (21%) and Blacks (22%) with BMI > 40kg/m2 compared to males (11%) and other races (11-15%), p = 0.002. As the level of socioeconomic distress increased, there was a corresponding increase in the proportion of patients who did not meet preoperative optimization cut-offs from 16% in prosperous communities to 25% in distressed communities (p < 0.0001). Nearly 1 of 5 patients with ventral hernias is affected by commonly used arbitrary preoperative optimization cut-offs. These cut-offs disproportionately impact females, Black patients and those with higher socioeconomic distress. These disparities need to be considered when planning preoperative optimization protocols and resource allocation to ensure equitable access to elective ventral hernia repair.

933 Inguinal Bladder Hernia: Case Report and Literature Review

Abstract Background Partial bladder herniation into the inguinal canal has an incidence of 1-3%. Most patients are asymptomatic, and diagnosis is made incidentally upon imaging or during surgical repairs. Complete herniation of the bladder and distal ureters is rare, and few cases of resultant acute kidney injury or hyperkalaemia have been reported. This case presentation includes preoperative and intra-operative images, and literature review. Case presentation A 73-year-old gentleman with longstanding bilateral inguinal hernia, benign prostatic hyperplasia, type 2 diabetes mellitus, and obesity presented with new-onset lower urinary tract symptoms and intermittent pain over his right inguinal hernia. His PSA (Prostate-Specific Antigen) was raised, and imaging identified bilateral hydronephrosis, and right inguinal hernia containing distal ureters and bladder. He was added to the waiting list for elective hernia repair. Whilst awaiting repair, he was admitted with acute kidney injury and hyperkalaemia, which was managed with cardiac protection, urethral catheterisation, hydration, and serial blood tests. After stabilization, he underwent an open right inguinal hernia repair with mesh. His acute kidney injury resolved; however he failed trial without catheter (TWOC), and was discharged with a catheter pending TWOC clinic review. General Surgical Follow up is planned to discuss left inguinal hernia repair. Conclusion Awareness of bladder herniation into the inguinal canal is essential to avoid iatrogenic injury. Careful pre-operative planning and correction of physiological abnormalities is vital to ensure good surgical outcome. More unusual sequelae of untreated hernias are likely to become more frequent, if fewer elective hernias are performed.

Modified Frailty Index Predicts Postoperative Complications Following Parastomal Hernia Repair.

The 5-factor frailty index (5-mFI), validated frailty index with Spearmen rho correlation of .95 and C statistic >.7 for predicting postoperative complications, can be preoperatively used to stratify patients prior to parastomal hernia repairs. Retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database identified patients from 2015 to 2020. 5-mFI scores were calculated by adding one point for each comorbidity present: diabetes mellitus, congestive heart failure (CHF), hypertension requiring medication, severe chronic obstructive pulmonary disease (COPD), non-independent functional status. Primary endpoint was 30-day overall complications; secondary endpoints were 30-day readmission, reoperation, and discharge to care facility. 2924 (52.2% female) patients underwent elective parastomal hernia repair. Univariate analysis showed 5-mFI > 2 had higher rates of overall (P = .008), pulmonary (P = .002), cardiovascular (P = .003)), hematologic (P = .003), and renal (P = .002) complications and higher rates of readmission (P = .009), reoperation (P = .001), discharge to care facility (P < .001), and death (P < .001). Multivariate analysis identified a 5-mFI of 2 or more as an independent risk factor for overall complications [OR: 1.40, 1.03-1.78; P = .032], pulmonary complications [2.97, 1.63-5.39; P < .001], hematological complications [1.60, 1.03-2.47; P = .035], renal complications [2.04, 1.19-3.46; P = .009], readmission [1.54, 1.19-1.99; P < .001], and discharge to facility [2.50, 1.66-3.77; P < .001]. Reoperation was not signification on multivariate analysis. Parastomal hernia repair patients with 5-mFI score of >2 had higher risk of renal, cardiovascular, pulmonary, and hematologic complications, readmissions, longer hospitalization, discharge to care facility, and mortality, and can be useful during preoperative risk stratification.

Impact of consensus guideline publication on the timing of elective pediatric umbilical hernia repair

BackgroundThe American Academy of Pediatrics published consensus guidelines advising observation of asymptomatic umbilical hernias until age 4 or 5, given unnecessary risks of early intervention and substantial practice variation. Yet, the impact of guidelines on early repair (age <4) or if certain groups remain at risk for avoidable intervention is unclear. MethodsThis retrospective study used data from children’s hospitals participating in the Pediatric Health Information System database. Children aged 17 years and younger who underwent umbilical hernia repair from July 2017 to August 2022 were eligible for inclusion. Children with recurrent hernias, an emergency, or urgent presentation were excluded. An interrupted time series using segmented multivariable logistic regression estimated the association of guideline publication in November 2019 with the odds of guideline-adherent repair (age ≥4) after adjusting for sociodemographic characteristics and hospital-level random effects. Results16,544 children underwent repair, of which 3,115 (18.8%) were children <4 years old. After adjustment, guideline publication was associated with an immediate increase in guideline-adherent repairs (odds ratio = 1.25 95% confidence interval = 1.05–1.49). The interrupted time series found that each month after publication was associated with a 2% increase in the odds of guideline-adherent repair (odds ratio = 1.02, 95% confidence interval = 1.01–1.03). Children with public insurance were nearly 20% less likely to receive guideline-adherent repair than privately insured children (odds ratio = 0.82, 95% confidence interval = 0.74–0.91). Children in the Midwest had lower odds of guideline-adherent repair (Midwest versus Northeast: odds ratio = 0.45. 95% confidence interval = 0.24–0.84). ConclusionGuideline publication was associated with greater odds of guideline-adherent repair, yet public insurance coverage and Midwest location remain significant predictors of early repair against recommendations.

Life after "no": barriers to behavior change for persons declined hernia repair due to high-risk features.

Delaying an elective operation to mitigate risk factors improves patient outcomes. Elective ventral hernia repair is one such example. To address this issue, we developed a pre-operative optimization clinic to support high-risk patients seeking elective ventral hernia repair. Unfortunately, few patients progressed to surgery. Within this context, we sought to understand the barriers to behavior change among these patients with the goal of improving care for patients undergoing elective surgery. We performed semi-structured, qualitative interviews with 20 patients who were declined ventral hernia repair due to either active tobacco use or obesity. Patients were recruited from a pre-operative optimization clinic at an academic hospital. Interviews sought to characterize patients' perceived barriers to behavior change. Interviews were concluded once thematic saturation was reached. We used an inductive thematic analysis to analyze the data. All data analysis was performed using MAXQDA software. Among 20 patients (mean age 50, 65% female, 65% White), none had yet undergone ventral hernia repair. While most patients had a positive experience in the clinic, among those who did not, we found three dominant themes around behavior change: (1) Patient's role in behavior change: how the patient perceived their role in making behavior changes optimize their health for surgery; (2) Obtainability of offered resources: the need for more support for patients to access the recommended healthcare; and (3) Patient-provider concordance: the extent to which patients and providers agree on the relative importance of different attributes of their care. Behavior change prior to elective surgery is complex and multifaceted. While improving access to tobacco cessation resources and obesity management may improve outcomes for some, patients may benefit from increased on-site facilitation to promote access to resources as well as the use of patient-facing decision support tools to promote patient-provider concordance.

Are we following guidelines in inguinal hernia repair? An evaluation of practice patterns in the abdominal core health quality collaborative

Aim : The HerniaSurge Group established inguinal hernia repair guidelines to reduce recurrence and chronic pain. We evaluated whether the surgeons of the Abdominal Core Health Quality Collaborative (ACHQC) follow these guidelines and identify areas for improvement. Methods : A retrospective evaluation of data from the ACHQC database between 2013-2021 using 18,641 eligible subjects undergoing elective and emergent hernia repair with 30-day follow-up. Compliance with a given guideline was defined as following the recommendation in 70% of cases. Results : Twelve of 19 questions with available data met recommendations based on our above criteria. Eight recommendations with strong evidence and four recommendations with weak evidence were met. The recommendations not met were using the Shouldice technique for any non-mesh open inguinal herniorrhaphy, using local anesthesia for open repair of reducible inguinal hernias, using lightweight mesh, and avoiding the use of prophylactic antibiotics in laparoscopic herniorrhaphy. Conclusion : Despite varied techniques for inguinal hernia repair, surgeons of the ACHQC follow the majority of the recently published guidelines on the subject. While further research is needed to strengthen the existing guidelines, a standardized approach will facilitate this effort while aiming to reduce negative patient outcomes.

Poor accessibility to consumer pricing exists for elective hernia repair surgery

BackgroundHospital price transparency is federally mandated to improve consumer accessibility. We aimed to evaluate how hospitals were complying with these regulations for elective hernia repairs. MethodsSearches were performed for different hospital systems in attempt to find a price for the procedure using author's own health insurance. Data collected included time to reach the cost estimate tool, time to obtain price estimates, and price ranges. With prices for inguinal and ventral hernia repairs varying across the state's medical centers. ResultsFourteen medical centers across the country were included, all had a cost estimate calculator. The average success rate of obtaining a cost for inguinal hernia was 48%. Comparatively, the average success rate of obtaining a cost for ventral hernia was 12%. Of the successful searches for price, significant variation exists amongst the accessed hernia procedure cost. ConclusionDespite federal mandates for hospital price transparency, online cost-estimate calculators are underperforming, thus exposing a need for more accessible cost-estimates for patients undergoing elective hernia repair.

The impact of comorbidities on postoperative outcomes of ventral hernia repair: the patients' perspective.

Ventral hernia repair (VHR) outcomes can be adversely affected by modifiable patient co-morbidities, such as diabetes, obesity, and smoking. Although this concept is well accepted among surgeons, the extent to which patients understand the significance of their co-morbidities is unknown, and a few studies have sought to determine patient perspectives regarding the impact of their modifiable co-morbidities on their post-operative outcomes. We attempted to determine how accurately patients predict their surgical outcomes after VHR compared to a surgical risk calculator while considering their modifiable co-morbidities. This is a prospective, single-center, survey-based study evaluating patients' perceptions of how their modifiable risk factors affect outcomes after elective ventral hernia repair. Pre-operatively, after surgeon counseling, patients predicted the percentage of impact that they believed their modifiable co-morbidities (diabetes, obesity, and smoking) had on 30-day surgical site infections (SSI) and hospital readmissions. Their predictions were compared to the Outcomes Reporting App for CLinicians and Patient Engagement (ORACLE) surgical risk calculator. Results were analyzed using demographic information. 222 surveys were administered and 157 were included in the analysis after excluding for incomplete data. 21% had diabetes, 85% were either overweight with body mass index (BMI) 25-29.9 or obese (BMI ≥ 30), and 22% were smokers. The overall mean SSI rate was 10.8%, SSOPI rate was 12.7%, and 30-day readmission rate was 10.2%. ORACLE predictions correlated with observed SSI rates (OR 1.31, 95% CI 1.12-1.54, p < 0.001), but patient predictions did not (OR 1.00, 95% CI 0.98-1.03, p = 0.868). The correlation between patient predictions and ORACLE calculations was weak ([Formula: see text] = 0.17). Patient predictions were on average 10.1 ± 18.0% different than ORACLE, and 65% overestimated their SSI probability. Similarly, ORACLE predictions correlated with observed 30-day readmission rates (OR 1.10, 95% CI 1.00-1.21, p = 0.0459), but patient predictions did not (OR 1.00, 95% CI 0.975-1.03, p = 0.784). The correlation between patient predictions and ORACLE calculations for readmissions was weak ([Formula: see text] = 0.27). Patient predictions were on average 2.4 ± 14.6% different than ORACLE, and 56% underestimated their readmission probability. Additionally, a substantial proportion of the cohort believed that they had a 0% risk of SSI (28%) and a 0% risk of readmission (43%). Education, income and healthcare employment did not affect the accuracy of patient predictions. Despite surgeon counseling, patients do not accurately estimate their risks after VHR when compared to ORACLE. Most patients overestimate their SSI risk and underestimate their 30-day readmission risk. Furthermore, several patients believed that they had a 0% risk of SSI and readmission. These findings persisted regardless of level of education, income level, or healthcare employment. Additional attention should be directed toward setting expectations prior to surgery and using applications such as ORACLE to assist in this process.

Transverse versus vertical incision approach in elective ventral hernia repair - A comparative study

Background: Ventral hernias are commonly associated with not infrequent complications and significant recurrence rates, often resulting in future procedures. The relative merits and disadvantages of vertical versus transverse incisions remain subjects of active debate. Aims and Objectives: The study aims to compare the relative merits, demerits, and outcomes between patients of ventral hernia who have undergone open mesh repair through a transverse incision and a vertical incision. Materials and Methods: In this prospective study, 100 patients were admitted to Government Rajaji Hospital for ventral hernia repair and those satisfying the inclusion criteria were divided into two groups, A and B, 50 each. In group A, open mesh repair was done through a transverse incision; in group B, open mesh repair was done via a vertical incision. The study compared the incidence of surgical site infection (SSI), flap necrosis, wound dehiscence, pain, and mean hospital stay. Results: On comparing the groups, it has been seen that the incidence of significant pain (taken as a visual analog scale score of 3.5 or more) was 16% in group A (transverse incision) compared to 34% in group B (vertical incision), which is statistically significant. The incidence of SSI, flap necrosis, wound dehiscence, and mean hospital stay were more or less the same and statistically insignificant. Conclusion: The group in which a transverse incision was used for ventral hernia repair showed significantly less post-operative pain than the group in which a vertical incision was used. Hence, the use of transverse incision in elective open mesh repair for ventral hernias should be considered.

Losing weight to achieve joint or hernia surgery: is the intragastric balloon the answer?

Obesity is an epidemic, with its accompanying medical conditions putting patients at increased risk of postoperative complications. For patients undergoing elective surgery, preoperative weight loss provides an opportunity to decrease complications. We sought to evaluate the safety and efficacy of an intragastric balloon in achieving a body mass index (BMI) < 35kg/m2 prior to elective joint replacement or hernia repair. Retrospective review of all patients who had intragastric balloon placement at a level 1A VA medical center from 1/2019 to 1/2023. Patients who had a scheduled qualifying procedure (knee/hip replacement or hernia repair) and had a BMI > 35kg/m2 were offered intragastric balloon placement to achieve 30-50lbs (13-28kg) weight loss prior to surgery. Participation in a standardized weight loss program for 12months was required. Balloons were removed 6months after placement, preferentially concomitant with the qualifying procedure. Baseline demographics, duration of balloon therapy, weight loss and progression to qualifying procedure were recorded. Twenty patients completed intragastric balloon therapy and had balloon removal. Mean age 54 (34-71years), majority (95%) male. Mean balloon duration was 200 ± 37days. Mean weight loss was 30.8 ± 17.7lbs (14.0 ± 8.0kg) with an average BMI reduction of 4.4 ± 2.9. Seventeen (85%) patients were successful, 15 (75%) underwent elective surgery and 2 (10%) were no longer symptomatic after weight loss. Three patients (15%) did not lose sufficient weight to qualify or were too ill to undergo surgery. Nausea was the most frequent side effect. One (5%) patient was readmitted within 30days for pneumonia. Intragastric balloon placement resulted in an average 30lbs (14kg) weight loss over 6months allowing more than 75% of patients to undergo joint replacement or hernia repair at an optimal weight. Intragastric balloons should be considered in patients requiring 30-50lbs (13-28kg) weight loss prior to elective surgery. More study is needed to determine the long-term benefit of preoperative weight loss prior to elective surgery.

Evaluating the Natural History of Groin Hernia from an "Unplanned" Watchful Waiting Strategy.

Groin hernia is one of the most common surgical diagnoses worldwide. The indication for surgery in asymptomatic or mildly symptomatic patients is discussed. Some trials have demonstrated the safety of a watchful waiting strategy. During the pandemic, waiting lists for hernia surgery dramatically increased the opportunity to evaluate the natural history of groin hernias. The present study aimed to evaluate the incidence of emergency hernia surgery in a large cohort of patients that were selected and were waiting for elective surgery. This is a retrospective cross-sectional cohort study including all patients evaluated and selected for elective groin hernia surgery at San Gerardo Hospital between 2017 and 2020. Elective and emergency hernia surgeries were recorded for all patients. The incidence of adverse events was also evaluated. Overall, 1423 patients were evaluated, and 964 selected patients (80.3%) underwent elective hernia surgery, while 17 patients (1.4%) required an emergency operation while waiting for an elective operation. A total of 220 (18.3%) patients were still awaiting surgery in March 2022. The overall cumulative risk levels for emergency hernia surgeries were 1%, 2%, 3.2%, and 5% at 12, 24, 36, and 48 months, respectively. There was no association between longer waiting periods and an increased need for emergency surgery. Our study indicates that up to 5% of patients with groin hernia require emergency surgery at 48 months from the evaluation; the increased waiting time for surgery for elective groin hernia repair was not associated with an increased incidence of adverse events.

Association of body mass index with morbidity following elective ventral hernia repair

BackgroundPrior work has linked body mass index (BMI) with postoperative outcomes of ventral hernia repair (VHR), though recent data characterizing this association are limited. This study used a contemporary national cohort to investigate the association between BMI and VHR outcomes. MethodsAdults ≥ 18 years undergoing isolated, elective, primary VHR were identified using the 2016–2020 American College of Surgeons National Surgical Quality Improvement Program database. Patients were stratified by BMI. Restricted cubic splines were utilized to ascertain the BMI threshold for significantly increased morbidity. Multivariable models were developed to evaluate the association of BMI with outcomes of interest. ResultsOf ~89,924 patients, 0.5 % were considered Underweight, 12.9 % Normal Weight, 29.5 % Overweight, 29.1 % Class I, 16.6 % Class II, 9.7 % Class III, and 1.7 % Superobese. After risk adjustment, class I (Adjusted Odds Ratio [AOR] 1.22, 95 % Confidence Interval [95%CI]: 1.06–1.41), class II (AOR 1.42, 95%CI: 1.21–1.66), class III obesity (AOR 1.76, 95%CI: 1.49–2.09) and superobesity (AOR 2.25, 95 % CI: 1.71–2.95) remained associated with increased odds of overall morbidity relative to normal BMI following open, but not laparoscopic, VHR. A BMI of 32 was identified as the threshold for the most significant increase in predicted rate of morbidity. Increasing BMI was linked to a stepwise rise in operative time and postoperative length of stay. ConclusionBMI ≥ 32 is associated with greater morbidity following open, but not laparoscopic VHR. The relevance of BMI may be more pronounced in open VHR and must be considered for stratifying risk, improving outcomes, and optimizing care. Key messageBody mass index (BMI) continues to be a relevant factor in morbidity and resource use for elective open ventral hernia repair (VHR). A BMI of 32 serves as the threshold for significant increase in overall complications following open VHR, though this association is not observed in operations performed laparoscopically.

Contemporary association of preoperative malnutrition and outcomes of hiatal hernia repairs in the United States

BackgroundHypoalbuminemia has been used as a surrogate for malnutrition and is associated with worse postoperative outcomes across major operations. Because patients with hiatal hernia often have inadequate caloric intake, we examined the association of serum albumin levels with outcomes after hiatal hernia repair. MethodsAdults undergoing elective and non-elective hiatal hernia repair via any approach were tabulated from the 2012 to 2019 National Surgical Quality Improvement Program. Patients were stratified into the Hypoalbuminemia cohort if serum albumin <3.5 mg/dL using restricted cubic spline analysis. Major adverse events were defined as a composite of all-cause mortality and major complications per the American College of Surgeons National Surgical Quality Improvement Program risk calculator. Entropy balancing was used to adjust for intergroup differences. Multivariable regression models were then constructed to assess the association of preoperative albumin with major adverse events, postoperative length of stay, and 30-day readmission. ResultsOf 23,103 patients, 11.7% comprised the Hypoalbuminemia cohort. The Hypoalbuminemia group was older, less commonly of White race, and less likely to have an independent functional status than others. They were also more likely to undergo inpatient, non-elective surgery via laparotomy. After entropy balancing and adjustment, hypoalbuminemia remained associated with increased odds of major adverse events and multiple complications and longer adjusted postoperative length of stay. There was no significant difference in adjusted odds of readmission. ConclusionWe used a quantitative methodology to establish a serum albumin threshold of 3.5 mg/dL associated with increased adjusted odds of major adverse events, increased postoperative length of stay, and postoperative complications after hiatal hernia repair. These results may guide preoperative nutrition supplementation.

OC-026 LONG-TERM OUTCOMES AFTER EPIGASTRIC HERNIA REPAIR IN WOMEN – A NATIONWIDE DATABASE STUDY

Abstract Aim Outcomes after epigastric hernia repair are rarely reported independently. Repair of an epigastric hernia is more frequently performed in women. The aim of this study was to evaluate long-term outcomes after epigastric hernia repairs in women on a nationwide basis. Methods Nationwide database cohort study using prospectively recorded data from the Danish Hernia Database of women undergoing elective repair for epigastric hernias, during a 4-year period (2018–2021). A 100% follow-up was obtained by combining intra-operative data with data from the National Civil Register (NRC). The primary outcome was operation for recurrence, secondary outcomes were readmission and operation for complications. Results In total, 3031 women underwent elective epigastric hernia repair during the study period. Some 2462 were performed as open repairs and 569 underwent laparoscopic repair. Follow-up was median 4.8 years. The cumulative operation rate for recurrence for open mesh repairs was 3.3% vs. 7.7% for sutured repair (P=0.002). The risk of operation for complications was significantly higher after mesh repair vs. sutured repair (2.0% vs. 3.6%, P = 0.014) with more operations for surgical site infection in the mesh group. In multivariable analyses, risk factors for recurrence were operation for complications and sutured repair. For open vs. laparoscopic repairs there were no differences in recurrence rates (6.3% vs. 6.3%, P=0.915), but the readmission rate was higher for laparoscopic repairs 10.9% vs. 6.1 (P&amp;lt;0.001). Conclusion Mesh repair reduces the risk of operation for recurrence but at the expense of an increased risk of operation for superficial wound infection.

P-059 FEASIBILITY OF A SMARTPHONE APPLICATION FOR INGUINAL HERNIA CARE: A PROSPECTIVE PILOT STUDY

Abstract Aim The Inguinal Hernia Application (IHAPP) is designed to overcome current limitations of regular follow-up after inguinal hernia surgery. It has two goals: Minimizing unnecessary healthcare consumption by supplying patient information and facilitating registration of patient reported outcome measures (PROMs) by offering simple questionnaires. In this study we evaluated the usability and validity of the app. Material &amp; Methods In this prospective cohort study patients (&amp;gt;=18 years) scheduled for elective hernia repair were assessed for eligibility. Feasibility of the app was evaluated by measuring patient satisfaction about utilization. Validity (internal consistency and convergent validity) was tested by comparing answers in the app to the scores of the standardized EuraHS-Quality of Life instrument. Furthermore, test-retest reliability was analyzed correlating scores obtained at 6 weeks to outcomes after 44 days (6 weeks and 2 days). Results During a 3-month period, a total of 100 patients were included. Median age was 56 years and 98% were male. Most respondents (68%) valued the application as a supplementary tool to their treatment. The pre-operative information was reported as useful by 77% and the app was regarded user-friendly by 71%. Patient adherence was mediocre, 47% completed all questionnaires during follow-up. Reliability of the app was considered excellent (α &amp;gt; 0.90) and convergent validity was significant (p = 0.01). The same applies to test-retest reliability (p = 0.01). Conclusions The IHAPP is a useful tool for reliable data registration and serves as patient information platform. However, further improvements are necessary to increase patient compliance in recording PROMs.

Effects of Novel Multimodal Transversus Abdominis Plane Block on Postoperative Opioid Usage and Hospital Length of Stay Following Elective Ventral Hernia Repair.

Background and objective Traditional transversus abdominis plane (TAP) blocks consisting of a local anesthetic, typically bupivacaine, have previously been shown to reduce postoperative pain following gastrointestinal surgery, including hernia repair. However, elective abdominal wall reconstructions for the repair of large ventral hernias continue to cause patients significant postoperative pain, resulting in prolonged hospital stays and need for opioid pain medication. This study aimed to analyze the postoperative opioid pain medication usage and hospital length of stay (LOS) in patients who received a nontraditional multimodal TAP block of ropivacaine (local anesthetic), ketorolac (non-steroidal anti-inflammatory), and epinephrine following elective ventral hernia repair. Methods A retrospective review of medical records for patients who underwent elective robotic ventral hernia repair by a single surgeon was conducted. Postoperative hospital LOS and opioid usage for patients with the multimodal TAP block were compared to those without. Results A total of 334 patients met the inclusion criteria for LOS analysis: 235 received the TAP block and 109 did not. Patients who received the TAP block had a statistically significant shorter LOS compared to patients who had no TAP block (1.09 ± 1.22 days vs. 2.53 ± 1.57 days; P<0.001). Medical records for 281 patients, 214 with the TAP block and 67 without the TAP block, contained information and were analyzed for postoperative opioid usage. A statistically significantly fewer number of patients who had the TAP block required hydromorphone patient-controlled analgesia pump (3.3% vs. 36%; P<0.001) and oral opioids (29% vs. 78%; P<0.001) postoperatively. Those with TAP block required intravenous opioids more frequently (50% vs 10%; P<0.001) although at much less dosages than those without TAP block (4.86 ± 2.62 mg vs. 10.29 ±3.90 mg; P<0.001). Conclusion In conclusion, this multimodal TAP block of ropivacaine, ketorolac, and epinephrine may represents an effective method to improve hospital LOS and postoperative opioid usage in patients undergoing robotic abdominal wall reconstruction for ventral hernia repair.

Biologic versus synthetic mesh in open ventral hernia repair: A systematic review and meta-analysis of randomized controlled trials.

Ventral hernia repair is one of the most common operations performed worldwide, and using mesh is standard of care to decrease recurrence. Biologic meshes are increasingly used to minimize complications associated with synthetic mesh, but with significantly higher cost and unclear efficacy. Until recently, most of the evidence supporting the use of biologic meshes was from retrospective cohorts with high heterogeneity and risk of bias. We aimed to report a meta-analysis of randomized controlled trials comparing the outcomes of synthetic and biologic mesh in elective open ventral hernia repair. A literature search of PubMed, Embase, and Cochrane Library databases was performed to identify randomized controlled trials comparing biologic and synthetic mesh in elective open ventral hernia repairs. The postoperative outcomes were assessed by means of pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I2 statistics. A total of 1,090 studies were screened, and 22 were fully reviewed. Four randomized controlled trials and 632 patients were included in the meta-analysis. Fifty-eight percent of patients had contaminated wounds (Wound Classification II-IV). Hernia recurrence (odds ratio 2.75; 95% confidence interval 1.76-4.31; P < .00001; I2= 0%) and surgical site infections (odds ratio 1.53; 95% confidence interval 1.02-2.29; P= .04; I2= 0%) were significantly more common in patients with biologic mesh. The rates of seroma, hematoma, and mesh removal were similar in both groups. As compared to synthetic mesh, biologic meshes resulted in increased hernia recurrences and surgical site infections. Current evidence supports macroporous, uncoated synthetic mesh as the implant of choice for elective open ventral hernia repair, and its use should be considered even in contaminated cases.