A Pilot Study to Determine the Impact of Adipose Tissue Attachment to Polypropylene Fibers In Hernia Mesh.

INTRODUCTION: Prior publications have demonstrated chemical and physical alteration of hernia mesh analyzed after explantation from the body. The specific alteration documented is oxidative degradation of polypropylene mesh fibers. An animal study recently published has demonstrated that adipose tissue attachment is present instead of reparative fibrous tissue infiltration in an average of 10.9-18.9% of the intramesh healing for a variety of clinically used knitted polypropylene mesh products; 8.0% for knitted polyester meshes. This study also found that in comparison to the knitted mesh products, non-woven polypropylene mesh reduced adipose tissue attachment to 1% or less, which was a statistically significant difference. MATERIALS AND METHODS: Samples of explanted polypropylene mesh from eight patients were analyzed for the presence of adipose tissue attachment, reparative fibrous tissue infiltration, and oxidative changes. Greater adipose tissue attachment areas were compared with areas of greater reparative fibrous tissue infiltration for evidence of oxidative changes in the mesh to determine if the areas of higher adipose tissue attachment correlated with an increase in oxidative changes. RESULTS: Intra mesh healing of clinically explanted knitted meshes demonstrated adipose tissue content from 0.0% to 49.1% per analyzed segment. The oxidation index, a measure of the degree of oxidative degradation in that portion of the mesh, was higher in seven of the eight areas of greater adipose tissue attachment than areas of greater reparative fibrous tissue infiltration. CONCLUSION: Adipose tissue attachment does occur in knitted and woven polypropylene hernia meshes. The presence of adipose tissue may contribute to an increase in oxidative changes in knitted polypropylene hernia mesh fibers.

Evaluating effectiveness of cognitive behavioral therapy within multimodal treatment for chronic groin pain after inguinal hernia repair.

INTRODUCTION: The development of chronic groin pain after inguinal hernia repair is a complex problem with many potential factors contributing to its development. Surgical options for alleviation of symptoms are limited and only performed by a few centers dedicated to its treatment. Opportunities to apply the principles of a prehabilitation program, including Cognitive Behavioral Therapy (CBT), aim to improve the surgical outcomes for this condition. METHODS AND PROCEDURES: A multi-disciplinary hernia team has implemented a clinical quality improvement (CQI) effort in an attempt to better measure and improve outcomes for patients suffering with chronic groin pain after inguinal hernia repair. Between April 2011 and August 2018, 129 patients (157 groins) underwent surgical treatment for chronic groin pain after inguinal hernia repair. Data were collected to compare outcomes for those undergoing preoperative CBT and patients who did not have CBT prior to their operation. RESULTS: Of 129 total patients, baseline demographics were similar in terms of gender, age, and BMI. In total, 27 patients (32 groins) underwent prehabilitation with CBT (20.93%). We found none of the patients who underwent preoperative CBT had new postoperative pain and all patient procedures were able to be performed on an outpatient basis. Overall, 15 (14.7%) patients had no improvement in symptoms after surgery from the non-CBT group, whereas there was improvement in chronic pain for all patients who underwent CBT. CONCLUSION: This attempt at process improvement demonstrated beneficial effects for patients who had CBT as part of a prehabilitation program prior to a surgical procedure to attempt to relieve groin pain after inguinal hernia repair. As with any CQI analysis, other factors may have contributed to these outcomes and these results may be different in another local environment.

Laparoscopic Ventral Hernia Repair with a Non-Woven Hernia Mesh.

INTRODUCTION: Laparoscopic ventral hernia repair is a commonly performed procedure with a variety of mesh options. A relatively new mesh option is a non-woven polypropylene mesh with a silicone barrier designed for intraabdominal placement. This non-woven randomly oriented polypropylene microfiber hernia mesh may have benefits with potentially better biocompatibility compared with other ventral hernia repair mesh options. MATERIALS AND METHODS: A clinical quality improvement (CQI) program was initiated for ventral hernia patients to better measure and improve outcomes. From March 2013 to September 2015, 62 laparoscopic ventral hernia repairs were performed with this non-woven polypropylene mesh on 61 patients (one patient had two separate hernia repairs). Attempts were made to obtain long-term (> 2 years) follow up. RESULTS: There were 36 females and 25 males. The average age was 58.7 years (range 21-85). The average body mass index (BMI) was 36.2 (range 21.4-62.4). There were 51 (82%) incisional hernias and 11 (18%) primary hernias. There were 29 (47%) recurrent hernias. Mean hernia size was 83.4cm2 (range 1-400) and mean mesh size was 508.5cm2 (range 144-936). The mean operating room (OR) time was 108.2 minutes (range 38-418). The mean length of hospital stay was 2.7 days (range 0-13). There was one intraoperative complication-an injury to an inferior epigastric vessel that had a minor postoperative bleed that was self-limiting and required no treatment. There was one postoperative death due to aspiration on postoperative day #4. There has been one recurrence (1.6%) with long-term follow up. There were two patients (3.2%) with suture site pain postoperatively that resolved with suture site injections of local anesthetic in the clinic. There were no patients that required rehospitalization within 30 days after surgery. There were no mesh-related complications and no incidence of mesh removal was required. CONCLUSION: The results for laparoscopic ventral hernia repair, using a relatively new non-woven randomly oriented polypropylene microfiber mesh, are good with long-term follow up completed in the majority of patients. More experience with this type of mesh could generate evidence for the benefits of this mesh material in laparoscopic ventral hernia repair.

The Value Proposition for Complex Abdominal Wall Reconstruction: How to Make It Work.

BACKGROUND: The challenge for health care in the 21st century is to understand how to measure and improve value in the context of each patient care process for the entire cycle of care. For patients who undergo an abdominal wall reconstruction, there is a great opportunity to improve value because of the high cost and variability in outcomes for this complex operation. METHODS: For almost a decade, our hernia team has been applying the principles of systems and data science to actual patient care. Tools from systems and data science applied to patient care include clinical quality improvement and nonlinear analytical methods such as factor analysis. The most important outcome to measure and improve is the value of care provided for the entire cycle of care. RESULTS: Many measurement and improvement ideas have been applied to the abdominal wall reconstruction process in our hernia program, including the use of a less costly long-term resorbable mesh, multimodal pain management and enhanced recovery process improvement ideas, and surgical technique improvements that have led to decreased wound complications and the elimination of abdominal wall drains. More recently, the data analysis has shown an opportunity to improve outcomes through a robust prehabilitation program, including cognitive therapy to induce neural rewiring before surgery. CONCLUSIONS: Improving value for patients who undergo abdominal wall reconstruction and for all patients in our global health care system should be a unifying goal. Understanding and applying systems and data science tools appropriately are necessary to achieve this goal.

Laparoscopic approach for the treatment of chronic groin pain after inguinal hernia repair : Laparoscopic approach for inguinodynia.

BACKGROUND: Traditional methods of clinical research may not be adequate to improve the value of care for patients with complex medical problems such as chronic pain after inguinal hernia repair. This problem is very complex with many potential factors contributing to the development of this complication. METHODS: We have implemented a clinical quality improvement (CQI) effort in an attempt to better measure and improve outcomes for patients suffering with chronic groin pain (inguinodynia) after inguinal hernia repair. Between April 2011 and June 2016, there were 93 patients who underwent 94 operations in an attempt to relieve pain (1 patient had two separate unilateral procedures). Patients who had prior laparoscopic inguinal hernia repair (26) had their procedure completed laparoscopically. Patients who had open inguinal hernia repair (68) had a combination of a laparoscopic and open procedure in an attempt to relieve pain. Initiatives to attempt to improve measurement and outcomes during this period included the administration of pre-operative bilateral transversus abdominis plane and intra-operative inguinal nerve blocks using long-acting local anesthetic as a part of a multimodal regimen, the introduction of a low pressure pneumoperitoneum system, and the expansion of a pre-operative questionnaire to assess emotional health pre-operatively. RESULTS: The results included the assessment of how much improvement was achieved after recovery from the operation. Forty-five patients (48%) reported significant improvement, 39 patients (41%) reported moderate improvement, and 10 patients (11%) reported little or no improvement. There were 3 (3%) complications, 13 (11%) hernia recurrences, and 15 patients (13%) developed a new pain in the inguinal region after the initial pain had resolved. CONCLUSIONS: The principles of CQI can be applied to a group of patients suffering from chronic pain after inguinal hernia repair. Based on these results additional process improvement ideas will be implemented in an attempt to improve outcomes.

Real-World Clinical Quality Improvement for Complex Abdominal Wall Reconstruction.

INTRODUCTION: Traditional methods of clinical research may not be adequate to improve the value of care for patients undergoing abdominal wall reconstruction (AWR). These patients are prone to high complication rates and high costs. Here, we describe a clinical quality improvement (CQI) effort to enhance outcomes for patients undergoing AWR. MATERIALS AND METHODS: CQI was applied for the entire care cycle for consecutive patients who underwent AWR from August 2011-September 2015. Initiatives for improving value during this period included use of long-term resorbable synthetic mesh as well as administration of preoperative bilateral transversus abdominus plane (TAP), and intraoperative abdominal wall blocks using long-acting bupivacaine as a part of a multimodal regimen. Outcomes data that measure value in the context of AWR were collected to compare outcomes for the patients who received TAP blocks only, TAP and intraoperative blocks, and those who received no block. RESULTS: One hundred and two patients who had AWR for abdominal wall pathology were included. Outcomes including total opioid use, duration of stay and opioid use in the postanesthesia care unit (PACU), length of hospital stay (LOS), major wound complications, and costs, all improved over time. Specifically, PACU opioid use, total opioid use, and LOS were decreased in the two groups that received blocks versus a group that did not have any type of block. CONCLUSIONS: CQI program implementation in patients undergoing AWR resulted in measurable improvement of value-based outcomes over time. A CQI effort applied to the entire patient cycle of care should be routinely utilized.

A Clinical Quality Improvement (CQI) Project to Improve Pain After Laparoscopic Ventral Hernia Repair.

Patients who undergo laparoscopic ventral hernia repair can have significant post-operative pain and discomfort from both somatic pain due to mesh fixation and visceral pain due to CO2 insufflation pressure. In an attempt to improve outcomes, a Clinical Quality Improvement (CQI) project was implemented by a multi-disciplinary hernia team. CQI tools were applied for consecutive patients who underwent laparoscopic ventral hernia repair from June 2012 through September 2015 (39 months). Initiatives for improved patient outcomes during this period included the administration of a transversus abdominis plane (TAP) block and/or an intra-operative block with long-acting local anesthetic first, and then a low pressure pneumoperitoneum (LPP) system was implemented later in the project. One-hundred-twenty patients who underwent a laparoscopic ventral/incisional hernia repair were included in the analysis. Fifty-three patients had no block and had conventional insufflation at 15 mmHg (No Block-No LPP group). Outcomes for this group included a median time in the Post-Anesthesia Care Unit (PACU) of 126 minutes, a median length of stay of 4.0 days, a median use of opioid morphine equivalents (MEQ) in the PACU of 10.0, and a total use of opioid MEQ for the entire hospital stay of 100.0. Thirty-seven patients had blocks with a long-acting local anesthetic and conventional insufflation at 15 mmHg (Block only group). Outcomes for this group showed improvement for all outcomes, but none were statistically significant. Thirty patients had blocks with a long-acting local anesthetic and a low pressure pneumoperitoneum system with a standard pressure of 8 mmHg. Outcomes for this group included a median time in PACU of 83.6 minutes, a median length of stay of 1.5 days, a median amount of opioid use in the PACU of 5.0 MEQ, and a median use of opioid use for the entire hospital stay of 26.0 MEQ. All of these outcomes were statistically significant improvements compared with the No Block-No LPP and Block only groups. Implementation of a CQI program, including long-acting local anesthetic blocks and a low pressure pneumoperitoneum system as part of a multi-modal pain strategy for patients who underwent laparoscopic ventral hernia repair, was associated with decreased PACU time, decreased length of stay, and less opioid use in the PACU and for the entire hospital stay.

Can Abdominal Wall Reconstruction Be Safely Performed Without Drains?

The use of closed suction drains in the abdominal wall is a common practice in abdominal wall reconstruction (AWR) operations. Drains can be a conduit for bacteria and can cause pain and discomfort for patients after surgery. A single hernia program has implemented the principles of clinical quality improvement in an attempt to improve outcomes for hernia patients. An attempt at a process improvement was implemented to eliminate the use of drains in AWR by adapting the technique. A total of 102 patients undergoing AWR were included between 8/11 and 9/15 (49 months). Compared with the group before the attempt at eliminating the use of abdominal wall drains (8/11-9/13), the group of patients after the implementation of the attempted process improvement (9/13-9/15) had less wound and pulmonary complications, a shorter hospital stay, less time in the postanesthesia care unit, and less opioid use in the postanesthesia care unit as well as for the entire hospital stay. In this group of AWR patients, an attempt at process improvement that eliminated the use of drains led to improved outcomes. Abdominal wall drains may be able to be safely eliminated with appropriate technique adaptation for AWR.

Value-based Clinical Quality Improvement (CQI) for Patients Undergoing Abdominal Wall Reconstruction.

Patients with complex ventral/incisional hernias often undergo an abdominal wall reconstruction (AWR). These operations have a high cost of care and often result in a long hospital stay and high complication rates. Using the principles of clinical quality improvement (CQI), several attempts at process improvement were implemented in one hernia program over a 3-year period. For consecutive cases of patients undergoing abdominal wall reconstruction, process improvement attempts included the use of a long-term resorbable synthetic mesh (TIGR® Resorbable Matrix, Novus Scientific, Uppsala, Sweden) in place of a biologic mesh, the use of the transversus abdominis release approach in place of an open or endoscopic component separation (external oblique release) technique, and the use of a preoperative transversus abdominis plane (TAP) block using a long-acting local anesthetic (Exparel®, Pacira Pharmaceutical, Parsippany, NJ) as a part of perioperative multi-modal pain management and an enhanced recovery program. After over 60 cases, improvement in materials costs and postoperative outcomes were documented. No mesh-related complications occurred and no mesh removal was required. In this real-world, value-based application of CQI, several attempts at process improvement led to decreased costs and improved outcomes for patients who underwent abdominal wall reconstruction for complex ventral/incisional hernias. Value-based CQI could be a tool for improved health care value globally.