Tanushree Prasad

Computed tomographic measurements predict component separation in ventral hernia repair

BACKGROUND Preoperative imaging with computed tomography (CT) scans can be useful in preoperative planning. We hypothesized that CT measurements of ventral hernia defect size and abdominal wall thickness (AWT) would correlate with postoperative complications and need for complex abdominal wall reconstruction (AWR). MATERIALS AND METHODS Patients who underwent open ventral hernia repair and had preoperative abdominal CT imagining were identified from an institutional hernia-specific surgery outcomes database at our tertiary referral hernia center. Grade III and IV hernias and biologic mesh cases were excluded. CT measures of defect size and AWT were analyzed and correlated to complications and the need for AWR techniques using univariate, multivariate, and principal component (PC) analyses. PC1 and PC2 used five AWT measures, hernia defect width, and body mass index to create a new component variable. RESULTS There were 151 open ventral hernia repairs included in the study. Preoperative findings included 37.7% male; age 55.3 ± 12.5 years; body mass index (BMI) 33.3 ± 7.8 kg/m(2); 60.3% were recurrent hernias with average defect width 8.5 ± 5.0 cm and area 178.3 ± 214 cm(2); AWT at umbilicus 3.5 ± 1.8 cm; and AWT at pubis 7.0 ± 3.2. Component separation was performed in 24.0% of patients and panniculectomy in 34.4%. Wound complications occurred in 13.3% patients, and 2.7% had hernia recurrence. Increasing defect width, length, and area as well as select AWT measurements were associated with increased need for component separation, concomitant panniculectomy, and higher rates of wound and total complications (all P < 0.05). Using multivariate regression, PC1 was associated with wound complications (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.01-1.16); PC2 (hernia defect width) was associated with the need for component separation (OR, 1.16; 95% CI, 1.03-1.30). Hernia recurrence was not predicted by AWT or defect size (OR, 1.00; 95%CI, 0.87-1.15). CONCLUSIONS Preoperative CT measurements of hernia defects and AWT predict wound complications and the need for complex AWR techniques. Obtaining preoperative CT imaging should be a consideration in preoperative planning and may help with patient counseling.

A nationwide evaluation of robotic ventral hernia surgery

BACKGROUND The purpose of this study was to examine outcomes of robotic ventral hernia repair(RVHR) versus laparoscopic ventral hernia repair(LVHR). METHODS The Nationwide Inpatient Sample was queried from October 2008 to December 2013 for ventral hernia repairs. Demographics, morbidity, mortality, and charges were compared between RVHR and LVHR. RESULTS From 2008-2013, 149,622 ventral hernia surgeries were identified; 117,028 open, 32,243 laparoscopic, and 351 robotic. Open repairs were excluded. RVHR rose annually with 2013 containing 47.9% of all RVHRs. RVHR patients were more likely to be older and have more chronic conditions. There was no difference between length of stay. Pneumonia rates were higher with RVHR; however, after controlling for confounding variables, there was no difference in pneumonia rates. Mortality and other major complications were similar. Total charges were increased for RVHR in univariate and multivariate analysis. RVHR was more common in teaching hospitals and wealthier zip codes. CONCLUSION RVHR demonstrates comparable safety to the laparoscopic technique, with increased charges and increased volume in urban teaching hospitals and patients from areas of higher median income.

Prospective, International Comparison of Quality of Life Outcomes After Laparoscopic vs Open Ventral Hernia Repair

RESULTS: A total of 1,221 repairs were performed, 578 LVHR and 643 OVHR, with a mean age of 56.9 years. Laparoscopic VHR was more frequently associated with females (57.2% vs 48.1%; p 1⁄4 0.002) and higher BMI (32.6 kg/m vs 31.0 kg/m; p < 0.0001), but other comorbidities were similar. Laparoscopic VHR had shorter length of stay (LOS, 2.8 2.4 days vs 4.3 5.1 days; p < 0.0001). Recurrences did not differ (5.7% vs 7.2%; p 1⁄4 0.3056). Wound complications were higher in OVHR (4.1% vs 0.4%; p < 0.0001), however, abdominal wall seromas and hematomas were increased in LVHR (16.6% vs 10.6%; p 1⁄4 0.002). The QOL at 1 month was worse for LVHR with regard to pain (odds ratio [OR], 1.98; 95% CI, 1.336-2.936), movement limitation (OR, 1.61; 95% CI, 1.076-2.402), and overall QOL (OR, 1.69; 95% CI, 1.1402.497). At 1 year, LVHR remained independently associated with increased pain (OR, 1.64; 95% CI, 1.025-2.624). No differences in QOL outcomes were noted at 2 years. Increased defect size was independently associated with worse overall postoperative QOL.

Deciding on Optimal Approach for Ventral Hernia Repair: Laparoscopic or Open

BACKGROUND The decision to perform laparoscopic or open ventral hernia repair (VHR) is multifactorial. This study evaluates the impact of operative approach, BMI, and hernia size on outcomes after VHR. STUDY DESIGN The International Hernia Mesh Registry was queried for VHR (2007-2017). A predictive algorithm was constructed, factoring the impact of BMI, hernia size, age, sex, diabetes, and operative approach on outcomes. RESULTS Of the 1,906 VHRs, 58.8% were performed open, patient mean age was 54.9 ± 13.5 years, BMI was 31.2 ± 6.8 kg/m2, and defect area was 44.8 ± 88.1 cm2. Patients undergoing open VHRs were more likely to have an infection develop (3.1% vs 0.3%; p < 0.0001), but less likely to have a seroma develop (6.8% vs 15.3%; p < 0.0001) at mean follow-up 23.2 ± 12.0 months. With multivariate regression controlling for confounding variables, patients undergoing laparoscopic VHR had increased risk of seroma (odds ratio [OR] 1.78; 95% CI 1.05 to 3.03), a decreased risk of infection (OR 0.05; 95% CI 0.01 to 0.42), and had worse quality of life at 1, 6, 12, and 24 months postoperatively compared with patients undergoing open repair. Recurrent hernias were associated with subsequent recurrence (OR 2.69; 95% CI 1.24 to 5.81) and need for reoperation (OR 4.93; 95% CI 2.24 to 10.87). Multivariate predictive models demonstrated independent predictors of infection, including open approach, recurrent hernias, and low ratio of BMI to defect size. CONCLUSIONS Ideal outcomes are dependent on both patient and operative factors. Open repair in thin patients with large defects should be considered due to reduced complications and improved quality of life. Laparoscopic repair in obese patients and recurrent hernias can decrease the associated risk of infection.

Long-Term Quality of Life Outcomes in Laparoscopic and Open Repair of the Flank Hernia: A Prospective, International Study

RESULTS: Sixty-seven flank hernia repairs, 25 laparoscopic and 42 open, were examined. Patients undergoing laparoscopic vs open repair were similar in age (58.9 vs 61.8 years, p1⁄40.42), BMI (30.2 vs 30.5 kg/m, p1⁄40.78), operative time (97.7 vs 118.1 minutes, p<0.21), and percentage of primary hernias (72.0% vs 76.2%, p<0.70). Open repairs had larger defects (136.0 vs 41.7cm, p<0.068) and longer length of stay (LOS, 5.6 vs 3.0 days, p<0.0012). There were no mesh or wound infections reported in the study population. There was 1 recurrence in each group (3.0% overall). One-year follow-up rates were 84% for laparoscopic and 74% for open; overall mean follow-up was 22.1 months. At 1 year, mesh sensation, pain, and movement limitation were persistent in nearly 30% of patients regardless of operative approach (Table). Overall, of patients endorsing preoperative pain, 56.5% improved, 39.1% stayed the same, and 4.3% worsened by 1 year.