Clayton C. Petro

Functional abdominal wall reconstruction improves core physiology and quality-of-life

INTRODUCTION One of the goals of modern ventral hernia repair (VHR) is restoring the linea alba by returning the rectus muscles to the midline. Although this practice presumably restores native abdominal wall function, improvement of abdominal wall function has never been measured in a scientific fashion. We hypothesized that a dynamometer could be used to demonstrate an improvement in rectus muscle function after open VHR with restoration of the midline, and that this improvement would be associated with a better quality-of-life. METHODS Thirteen patients agreed to dynamometric analysis before and 6 months after an open posterior component separation (Rives-Stoppa technique complimented with a transversus abdominis muscle release) and mesh sublay. Analysis done using a dynamometer (Biodex 3, Corp, Shirley, NY) included measurement of peak torque (PT; N*m) and PT per bodyweight (BW; %) generated during abdominal flexion in 5 settings: Isokinetic analysis at 45°/s and 60°/s as well as isometric analysis at 0°, -15°, and +15°. Power (W) was calculated during isokinetic settings. Quality-of-life was measured using our validated HerQles survey at the time of each dynamometric analysis. RESULTS Thirteen patients (mean age, 54 ± 9 years; mean body mass index, 31 ± 7 kg/m(2)) underwent repair with restoration of the midline using the aforementioned technique. Mean hernia width was 12.5 cm (range, 5-19). Improvements in PT and PT/BW were significant in all 5 settings (P < .05). Improvement in power during isokinetic analyses at 45°/s and 60°/s was also significant (P < .05). All patients reported an improvement in quality-of-life, which was associated positively with each dynamometric parameter. CONCLUSION Restoration of the linea alba during VHR is associated with improved abdominal wall functionality. Analysis of rectus muscle function using a dynamometer showed statistical improvement by isokinetic and isometric measurements, all of which were associated with an improvement in quality-of-life.

Enhanced recovery after surgery pathway for abdominal wall reconstruction: pilot study and preliminary outcomes.

Summary: Enhanced recovery after surgery (ERAS) pathways represent a multimodal approach to improve the quality of postoperative care by diminishing the stress response to the trauma of an operation, thereby minimizing hospital length of stay and potentially complications. At a time when healthcare costs are being intensely scrutinized, efforts to reduce patient morbidity and hospital stay are imperative and timely. The success of ERAS fast-track surgery pathways—thoroughly studied in the colorectal literature—has led to their application in other fields. Herein, we present our ERAS pathway for patients undergoing abdominal wall repairs, including the rationale and supporting evidence behind each of its components and our early clinical results after implementation. Although hastened patient recovery is clearly multifactorial, our pathway, incorporating alvimopan, early feeding strategies, and multimodal pain therapy with an emphasis on the reduction of opiate usage as well as precise intraoperative nerve block with novel longer-acting local anesthetic Exparel, appears to provide significant improvement in postoperative pain, bowel function recovery, and shorter hospital stay. Although a prospective evaluation of the entire ERAS pathway as well as contribution of its various components is currently ongoing at our Hernia Center, we believe ours or similar ERAS pathways will soon become standard for the vast majority of patients undergoing abdominal wall surgery.

Posterior component separation and transversus abdominis muscle release for complex incisional hernia repair in patients with a history of an open abdomen

BACKGROUND The best reconstructive approach for large fascial defects precipitated from a previous open abdomen has not been elucidated to date. We use a posterior component separation with transversus abdominis muscle release (TAR) in this scenario. METHODS Patients with a history of an open abdomen who ultimately underwent complex hernia repair with TAR from 2010 to 2013 at Case Medical Center were identified in our prospective database and analyzed. RESULTS Of 34 patients (mean [SD] age, 54 [11.3] years; mean [SD] body mass index, 32.5 [7.2]) with a history of an open abdomen, the fascia was closed primarily in 11 and skin alone closed primarily in 4 patients after a mean (SD) of 5.9 (6.7) days. Those unable to achieve primary closure either received a skin graft (n = 16) or healed by secondary intention (n = 3). Patients presented to our institution a mean (SD) of 25.1 (26.5) months after their initial operation, eight having already undergone at least one hernia repair, including four anterior component separations. Operations consisted of 21 (61.8%) contaminated cases, including 7 enterocutaneous fistula takedowns, 2 stoma revisions, 2 stoma reversals, and 3 excisions of infected mesh. Wound morbidity consisted of 12 (35%) surgical site occurrences: 1 wound dehiscence, 2 hematomas, 1 seroma, 8 surgical site infections (23.5%; 3 superficial, 3 deep, and 2 organ space), and no enterocutaneous fistulas or chronic mesh infections. One reoperation was necessary for debridement of a hematoma and deep surgical site infection. With a mean follow-up of 18 months (range, 3–42 months), two (5.9%) new parastomal hernias and three (8.8%) midline recurrences have been documented. CONCLUSION To our knowledge, this is the first report describing the use of TAR in patients with a history of an open abdomen for definitive abdominal wall reconstruction. We have demonstrated that this approach is associated with low significant perioperative morbidity and recurrence. LEVEL OF EVIDENCE Therapeutic study, level V.

Risk factors for wound morbidity after open retromuscular (sublay) hernia repair

BACKGROUND Retrorectus repairs (RR) of abdominal wall hernias are growing in popularity, yet wound morbidity and predictors in this context have been characterized poorly. Models aimed at predicting wound morbidity typically do not control for technique and/or location of mesh. Our aim was to describe wound morbidity and risk factors specifically in the context of RR hernia repair. Our hypothesis was that the incidence of wound morbidity with mesh sublay would be less than predicted by a model that does not control for mesh position. METHODS Consecutive RR hernia repairs with at least a 90-day follow-up were identified in our prospective database and analyzed. The primary outcome measures were the incidence of surgical-site occurrence (SSO) and surgical-site infection (SSI) via modern, standardized definitions. For predictors of SSO, statistical analysis was performed with univariate analysis, χ(2), and logistic regression as well as multivariate regression. RESULTS A total of 306 patients met the inclusion criteria. Eighty-four SSOs identified in 72 (23.5%) patients included 48 (15.7%) SSIs, 14 (4.6%) instances of wound cellulitis, 12 (3.9%) skin dehiscences, 6 (2.0%) seromas, and 4 (1.3%) hematomas but no instances of mesh excision or fistula formation. Treatment entailed antibiotics alone in 30 patients, 14 bedside drainage procedures, 9 radiographically assisted drainage procedures, and 10 returns to the operating room for debridement. After multivariate analysis, diabetes (OR 2.41), hernia width >20 cm (OR 2.49), and use of biologic mesh (OR 2.93) were statistically associated with the development of a SSO (P < .05). Notably, the mere presence of contamination was not independently associated with wound morbidity (OR 1.83, P = .11). SSO and SSI rates anticipated by a recent risk prediction model were 50-80% and 17-83%, respectively, compared with our actual rates of 20-46% and 7-32%. CONCLUSION Based on a large cohort of patients, we identified factors contributing to SSOs specifically for RR hernia repairs. Paradoxically, biologic mesh was an independent predictor of wound morbidity. The development of clinically important mesh complications and rates of wound morbidity less than anticipated by recent predictive models suggest that the retromuscular (sublay) mesh position may be more advantageous.

Using Modified Frailty Index to Predict Safe Discharge Within 48 Hours of Ileostomy Closure

BACKGROUND: Enhanced recovery pathways allow for safe discharge and optimal outcomes within 48 hours after ileostomy closure. Unfortunately, some patients undergoing ileostomy closure have prolonged hospital stays. We have shown previously that the Modified Frailty Index can help predict patients who will fail early discharge after laparoscopic colorectal surgery. OBJECTIVE: The purpose of this study was to use the Modified Frailty Index to identify patients who were safe for early discharge after ileostomy closure. DESIGN: This was a retrospective review. SETTINGS: The study was conducted at a tertiary referral center. PATIENTS: Patients who underwent ileostomy closure (2006–2015) were stratified into early (⩽48 hours) and late discharge groups. MAIN OUTCOME MEASURES: The Modified Frailty Index, morbidity, and readmission rates were measured. RESULTS: A total of 272 patients undergoing ileostomy closure were evaluated. Overall length of stay was 3.64 days (±3.23 days), with 114 patients (42%) discharged within 48 hours. Sex, age, and ASA scores were similar between early and later discharge groups (p > 0.2). Univariate logistic regression demonstrated that a Modified Frailty Index score of 0 was associated with early discharge (p = 0.03), whereas a Modified Frailty Index score ⩽1 and ⩽2 were not. There was no significant association between the Modified Frailty Index and complication or readmission rates. Postoperative complications occurred in 39 patients (14.3%), and 1 patient died secondary to an anastomotic leak. Fifteen patients (5.5%) were readmitted within 30 days. Readmission rate within 30 days was 3.2%, with a Modified Frailty Index score of 0, 6.1% for a Modified Frailty Index score of <1, and 5.9% for a Modified Frailty Index score of <2, for which there was not an association based on univariate logistic regression (Modified Frailty Index = 0, p = 0.13; <1, p = 0.55; <2, p = 0.53). LIMITATIONS: The study was limited by nature of being a retrospective review. CONCLUSIONS: Patients undergoing ileostomy closure with a Modified Frailty Index score of 0 are associated with higher rates of discharge within 48 hours of ileostomy closure surgery than those with a higher Modified Frailty Index, without higher readmission rates. This information can be helpful to better manage patient and resource use expectations for the duration of inpatient recovery.

Classification of Hernias

While incisional hernia repair is one of the most common operations performed by general surgeons, little standardization exists in regards to accurately describing a patient’s preoperative state. The absence of a universal classification system has hindered comparisons within the literature and at meetings, indirectly delaying meaningful conversations regarding repair techniques. Standardized definitions of outcome measures have been a useful foundation on which to build. Here we summarize previous efforts—including our own—to standardize hernia classification.

Preoperative Planning and Patient Optimization

This article reviews the literature that supports routine expectations for smoking cessation; weight loss; diabetic, nutritional, or metabolic optimization; and decolonization techniques before ventral hernia repair. These methods diminish postoperative complications. In an era of value-centric care, an upfront investment in patient optimization can improve the quality of the repair by reducing wound morbidity and hernia recurrence, naturally translating to a reduction in cost. The adoption of these practices and further study aimed at identifying other effective optimization techniques are encouraged.

Does active smoking really matter before ventral hernia repair? An AHSQC analysis

Background: Many studies implicate active smoking as a risk factor for postoperative wound complications and all 30‐day morbidity, but the definitions of inclusion and exclusion criteria as well as outcome parameters are inconsistent. Critically, the ability of large databases and meta‐analyses to generate statistically significant associations of active smoking with morbidity do not address whether those relationships are actually clinically meaningful. We investigated this relationship after open ventral hernia repair. Study Design: Patients undergoing elective open ventral hernia repair in clean wounds with 30‐day follow‐up were extracted from the Americas Hernia Society Quality Collaborative. Current smokers (within 30 days of surgery) were 1:1 propensity matched to patients who had never smoked based on demographics, comorbidities, and operative characteristics. Wound complications and all 30‐day morbidity were assessed. Results: After matching 418 current smokers to 418 patients who had never smoked, the groups were similar with the exception of minor differences in body mass index (31.4 vs 33.3, P < .001) and incidence of chronic obstructive pulmonary disease (18% vs 6%, P < .001). Rates of surgical site occurrence were greater in active smokers (12.0% vs 7.4%, P = .03) driven by increased rates of wound cellulitis (2.4% vs 1.2%) and seroma (5.5% vs 1.2%); however, rates of surgical site infection (4.1 vs 4.1, P = .98), surgical site occurrences requiring a procedural intervention (6.2% vs 5.0%, P = .43), reoperation (1.9% vs 1.2%, P = .39), and all 30‐day morbidity (7.5 vs 6.6, P = .60) were not significantly increased in active smokers. There were no instances of mesh excision. Conclusion: Active smoking prior to elective clean OVHR is associated with clinically insignificant differences in wound morbidity. Surgeons allowing perioperative smoking should monitor their outcomes to assure these findings are replicable in their own practice.

Robotic Component Separation

Component separation techniques to address large ventral hernias have dramatically evolved during the past decade. The touted benefits of a posterior component separation with transversus abdominis release (TAR), with its broad adaptability and favorable wound morbidity/recurrence profile, have led to its wide adoption for large, complex, and multiply-recurrent repairs. Concurrent development of the robotic platform and surgeon ingenuity have more recently culminated in the evolution of a minimally invasive TAR technique made practical and adaptable by robotic technology (rTAR). Here, we provide a detailed explanation of the benefits this technique offers in the context of alternative repairs described during the past 30 years. Though the operation is actively evolving, we will also provide a detailed depiction of our approach. While early retrospective reviews tout a shortened length of hospital stay compared to modern open and laparoscopic counterparts in order to justify the increased cost of the robotic platform, improved patient outcomes unique to the approach may ultimately provide enough value to substantiate the vitality of the operative approach.

Hernia repair in patients with chronic liver disease - A 15-year single-center experience

BACKGROUND Elective hernia repairs in chronic liver disease (CLD) patients are often avoided due to the fear of hepatic decompensation and mortality, leaving the patient susceptible to an emergent presentation. METHODS CLD patients undergoing ventral or inguinal hernia repair in emergent and non-emergent settings at our institution (2001-2015) were analyzed. Predictors of 30-day morbidity and mortality (M&M) were determined using univariate analysis and multivariate logistic regression. RESULTS A total of 186 non-emergent repairs identified acceptable rates of M&M (27%) and 90-day mortality (3.7%, 0/21 for MELD≥15). Meanwhile, 67 emergent repairs had higher rates of M&M (60%) and 90-day mortality (10%; 25% for MELD≥15). M&M was associated with elevated MELD scores in emergent cases (14 ± 6 vs 11 ± 4; p = 0.01) and intraoperative drain placement in non-emergent cases (OR1.31,p < 0.01). CONCLUSION In patients with advanced CLD, non-emergent hernia repairs carry acceptable rates of M&M, while emergent repairs have increased M&M rates associated with higher MELD scores.