Absorbable mesh in a contaminated field: hernia repair outcomes.

Hernia repair mesh aids in the stability of incisional hernia repair and can reduce the need for subsequent operations. There is, however, debate among surgeons over which type of hernia mesh-synthetics, biologics, or biosynthetics-is indicated as best for specific patients. A retrospective case review comparing surgical outcomes based on wound class and mesh materials may provide insights into this question. This study evaluates patient outcomes using biosynthetic mesh based upon CDC wound classification. Following Institutional Review Board approval, the local National Surgery Quality Improvement (NSQIP) databases were queried for open ventral hernia repaired with absorbable mesh implants from January 2013-December 2017. Factors for comparison included patient demographics, operative details, and an analysis of clinical outcomes. Our study identified 112 ventral hernia repair cases with absorbable mesh placement, 32% (n = 36) were wound classes II-IV. Higher wound class correlated statistically with diabetes (33.3%), prior hernia repair (61.1%), and parastomal hernia (44.4%). Higher wound classes were associated with more emergent presentations, involved bowel resection more frequently, required larger mesh implants, increased post-operative surgical site infections, and wound disruption. Increasing wound class was also associated with longer hospital stays and greater need for readmission (38.9% vs. 11.8%). Compared to patients with clean wounds, biosynethic mesh repair patients with contaminated wounds exhibited more emergent presentations, increased incidence of bowel resection, increased mesh size, and more readmissions. Despite these peri-operative outcomes, hernia recurrence rates among biosynethic mesh hernia repair were similar in CDC class II-IV patients as class I.

Laparoscopic parastomal hernia repair delays recurrence relative to open repair.

BACKGROUND: Mesh repair of parastomal hernia is widely accepted as superior to non-mesh repair, yet the most favorable surgical approach is a subject of continued debate. The aim of this study was to compare the clinical outcomes of open versus laparoscopic parastomal hernia repair. METHODS: An IRB-approved retrospective review was conducted comparing laparoscopic (LPHR) or open (OPHR) parastomal hernia repair performed between 2009 and 2017 at our facilities. Patient demographics, preoperative characteristics, operative details, and clinical outcomes were compared by surgical approach. Subgroup analysis was performed by location of mesh placement. Repair longevity was measured using Kaplan-Meier method and Cox proportional hazards regression. Intention to treat analysis was used for this study based on initial approach to the repair. RESULTS: Sixty-two patients (average age of 61 years) underwent repair (31 LPHR, 31 OPHR). Patient age, gender, BMI, ASA Class, and comorbidity status were similar between OPHR and LPHR. Stoma relocation was more common in OPHR (32% vs 7%, p = .022). Open sublay subgroup was similar to LPHR in terms of wound class and relocation. Open "Other" and Sublay subgroups resulted in more wound complications compared to LPHR (70% and 48% vs 27%, p = .036). Operative duration and hospital length of stay were less with LPHR (p < .001). After adjustment for prior hernia repair, risk of recurrence was higher for OPHR (p = .022) and Open Sublay and Other subgroups compared to LPHR (p = .005 and p = .027, respectively). CONCLUSIONS: Laparoscopic repair of parastomal hernias is associated with shorter operative duration, decreased length of stay, fewer short-term wound complications, and increased longevity of repair compared to open repairs. Direct comparison of repair longevity between LPHR and OPHR with mesh using Kaplan-Meier estimate is unique to this study. Further study is warranted to better understand methods of parastomal hernia repair associated with fewer complications and increased durability.

Preoperative opioid use and incidence of surgical site infection after repair of ventral and incisional hernias.

BACKGROUND: Preoperative opioid use is a risk factor for complications after some surgical procedures. The purpose of this study was to investigate the influence of preoperative opiates on outcomes after ventral hernia repair. METHODS: With institutional review board approval, we conducted a retrospective review of consecutive ventral hernia repair cases during a 4-y period. RESULTS: A striking 48% of the total 234 patients met criteria for preoperative opioid use. Preoperative characteristics and operative details were similar between patient groups (preoperative opioid use versus no preoperative opioid use). Median duration of hospital stay trended toward an increase for opioid users versus nonopioid users (P = .06). Return of bowel function was delayed in opioid users compared with nonopioid users (P = .018). Incidence of superficial surgical site infection was increased among patients who used opioids preoperatively (27% vs 8.3%; P <.001) and remained so after multivariable logistic regression, (adjusted odds ratio 2.9, 95% confidence interval 1.2-6.7; P = .013). CONCLUSION: Among patients undergoing ventral hernia repair, those with preoperative opioid use experienced an increased incidence of superficial surgical site infection compared with patients without preoperative opioid use. Further study is needed to understand the relationship between opioid use and surgical site infection after ventral hernia repair.

Costs and Complications Associated with Infected Mesh for Ventral Hernia Repair.

Background: Mesh hernia repair is widely accepted because of the associated reduction in hernia recurrence compared with suture-based repair. Despite initiatives to reduce risk, mesh infection and mesh removal are a significant challenge. In an era of healthcare value, it is essential to understand the global cost of care, including the incidence and cost of complications. The purpose of this study was to identify the outcomes and costs of care of patients who required the removal of infected hernia mesh. Methods: A review of databases from 2006 through June 2018 identified patients who underwent both ventral hernia repair (VHR) and re-operation for infected mesh removal. Patient demographic and operative details for both procedures, including age, Body Mass Index, mesh type, amount of time between procedures, and information regarding interval procedures were obtained. Clinical outcome measures were the length of the hospital stay, hospital re-admission, incision/non-incision complications, and re-operation. Hospital cost data were obtained from the cost accounting system and were combined with the clinical data for a cost and clinical representation of the cases. Results: Thirty-four patients underwent both VHR and removal of infected mesh material over the 12-year time frame and were included in the analyses; the average age at VHR was 48 years, and 16 patients (47%) were female. Following VHR, 21 patients (62%) experienced incision complications within 90 days post-operatively, the complications ranging from superficial surgical site infection (SSI) to evisceration. A mean of 22.65 months passed between procedures. After mesh removal, 16 patients (47%) experienced further incisional complications; and 22 (65%) patients had at least one re-admission. Eighteen patients (53%) required a minimum of one additional related operative procedure after mesh removal. Median hospital costs nearly doubled (p < 0.001) for the mesh removal ($23,841 [interquartile range {IQR} $13,596-$42,148]) compared with the VHR admission ($13,394 [IQR $8,424-$22,161]) not accounting for re-admission costs. A majority experienced hernia recurrence subsequent to mesh removal. Conclusions: Mesh infection after hernia repair is associated with significant morbidity and costs. Hospital re-admission, re-operations, and recurrences are common among these patients, resulting in greater healthcare resource utilization. Development of strategies to prevent mesh infection, identify patients most likely to experience infectious complications, and define best practices for the care of patients with mesh infection are needed.

Hernia Repair Strength Enhanced With Antioxidants.

BACKGROUND: Incisional hernia is one of the most common complications of abdominal surgery, and repairs are associated with significant recurrence rates. Mesh repairs are associated with the best outcomes, but failures are not uncommon. Doxycycline has been demonstrated to enhance mesh hernia repair outcomes with associated increases in collagen deposition and improved tensiometric strength. This study compares the outcomes of incisional hernia repair with doxycycline administration and the antioxidant tempol. MATERIALS AND METHODS: Twenty-eight male Sprague Dawley rats underwent a midline hernia creation and an intraabdominal polypropylene mesh repair. The animals were administered saline, doxycycline, tempol, or both, daily for 8 wk. The abdominal wall was harvested at 8 wk and tensiometric strength and biochemical analysis was performed. RESULTS: The tensiometric strength of the repair was increased in all experimental groups. Collagen type 1 deposition was increased, and collagen type 3 deposition was decreased in each of the experimental groups relative to control. There was no difference in MMP-2 and MMP-9 levels between control and experimental groups. CONCLUSIONS: The hernia repair strength is equally enhanced with the administration of doxycycline or tempol. Dual therapy provided no benefit over treatment with either single agent. All treatment groups had an increase in collagen type 1:3 ratios, but the mechanism is not well understood. The benefits of antioxidant treatment following hernia repair are similar to treatment with doxycycline. Given the high frequency of incisional hernia repair failures, this study has implications for improving outcomes following ventral hernia repair through the use of either doxycycline or antioxidant therapy.

Polyester vs polypropylene, do mesh materials matter? A meta-analysis and systematic review.

PURPOSE: Controversy exists regarding the outcomes following ventral hernia repair with polypropylene (PP) or polyester (PET) mesh. Monofilament PP less frequently requires extraction in the setting of contamination compared to multifilament PET mesh. The purpose of this systematic review and meta-analysis was to analyze the clinical outcomes of ventral hernia repair with PP and PET mesh. PATIENTS AND METHODS: A comprehensive literature search was performed using the Ovid search platform. Criteria included ventral hernia repair publications using either PP or PET mesh with a minimum follow-up duration of one year. Included studies were subject to data extraction including mesh position, weight, recurrence rates, infection, and complications. Random effect meta-analysis was run to provide pooled event rate and 95% CI. RESULTS: Ninety-seven studies including a total of 10,022 patients were included in the final analysis. Hernia recurrence rates are similar (4.8%, 95% CI [3.5-6.5] vs 4.7%, 95% CI [3.7-6.0]) as well as mesh infection rates (3.5%, 95% CI [2.5-4.9] vs 5.0%, 95% CI [3.9-6.3]) between PET and PP, respectively. Mesh infections occurred less frequently in laparoscopic repair compared to open (1.6%, 95% CI [0.9-2.6] vs 5.2%, 95% CI [4.3-6.3]). CONCLUSION: This study suggests that mesh material does not affect recurrence or infection in ventral hernia repair and that surgery can be safely performed with both PP and PET mesh. A laparoscopic approach is associated with a decreased infection rate compared to open repair independent of mesh type.

Parastomal Hernia Repair Outcomes: A Nine-Year Experience.

Parastomal hernias (PHs) frequently complicate enterostomy creation. Decision for PH repair (PHR) is driven by patient symptoms due to the frequency of complications and recurrences. The European Hernia Society (EHS) PH classification is based on the PH defect size and the presence/absence of concomitant incisional hernia. The aim of this study was to evaluate PHR outcomes based on EHS classification. An Institutional Review Board-approved retrospective review of a prospective database between 2009 and 2017 was performed. Patient demographics, enterostomy type, EHS classification, operative technique, and clinical outcomes (postoperative complications, 30-day readmission, and PH recurrence) were obtained. Cases were analyzed by EHS classifications I and II (SmallPH) versus III and IV (LargePH). Sixty-two patients underwent PHR (35: SmallPH, 27: LargePH). Patient groups (SmallPH vs LargePH) were similar based on American Society of Anesthesiologists Class III and obesity. Hernia recurrence was seen in 26 per cent of repairs with no difference between groups. The median recurrence-free survival was 3.9 years. There was no difference in superficial SSI, deep SSI, nonwound complications, or readmission between SmallPH and LargePH. Both small and large PHs experience similar outcomes after repair. Strategies to improve outcomes should be developed and implemented universally across all EHS PH classes.

Early outcomes of an enhanced recovery protocol for open repair of ventral hernia.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols are evidence-based quality improvement pathways reported to be associated with improved patient outcomes. The purpose of this study was to compare short-term outcomes for open ventral hernia repair (VHR) before and after implementation of an ERAS protocol. METHODS: After obtaining IRB approval, surgical databases were searched for VHR cases for two years prior and eleven months after protocol implementation for retrospective review. Groups were compared on perioperative characteristics and clinical outcomes using chi-square, Fisher's exact, or Mann-Whitney U test, as appropriate. RESULTS: One hundred and seventy-one patients underwent VHR (46 patients with ERAS protocol in place and 125 historic controls). Age, gender, ASA Class, comorbidities, and smoking status were similar between the two groups. Body mass index was lower among ERAS patients (p = .038). ERAS patients had earlier return of bowel function (median 3 vs. 4 days) (p = .003) and decreased incidence of superficial surgical site infection (SSI) (7 vs. 25%) (p = .008) than controls. CONCLUSION: An ERAS protocol for VHR demonstrated improved patient outcomes. A system-wide culture focused on enhanced recovery is needed to ensure improved patient outcomes.

Compliance of the abdominal wall during laparoscopic insufflation.

BACKGROUND: To provide adequate workspace between the viscera and abdominal wall, insufflation with carbon dioxide is a common practice in laparoscopic surgeries. An insufflation pressure of 15 mmHg is considered to be safe in patients, but all insufflation pressures create perioperative and postoperative physiologic effects. As a composition of viscoelastic materials, the abdominal wall should distend in a predictable manner given the pressure of the pneumoperitoneum. The purpose of this study was to elucidate the relationship between degree of abdominal distention and the insufflation pressure, with the goal of determining factors which impact the compliance of the abdominal wall. METHODS: A prospective, IRB-approved study was conducted to video record the abdomens of patients undergoing insufflation prior to a laparoscopic surgery. Photo samples were taken every 5 s, and the strain of the patient's abdomen in the sagittal plane was determined, as well as the insufflator pressure (stress) at bedside. Patients were insufflated to 15 mmHg. The relationship between the stress and strain was determined in each sample, and compliance of the patient's abdominal wall was calculated. Subcutaneous fat thickness and rectus abdominus muscle thickness were obtained from computed tomography scans. Correlations between abdominal wall compliances and subcutaneous fat and muscle content were determined. RESULTS: Twenty-five patients were evaluated. An increased fat thickness in the abdominal wall had a direct exponential relationship with abdominal wall compliance (R 2 = 0.59, p < 0.05). There was no correlation between muscle and fat thickness. CONCLUSION: All insufflation pressures create perioperative and postoperative complications. The compliance of patients' abdominal body walls differs, and subcutaneous fat thickness has a direct exponential relationship with abdominal wall compliance. Thus, insufflation pressures can be better tailored per the patient. Future studies are needed to demonstrate the clinical impact of varying insufflation pressures.

Doxycycline alters collagen composition following ventral hernia repair.

BACKGROUND: Doxycycline, a nonspecific metalloproteinase (MMP) inhibitor, has been demonstrated to impact the strength of the polypropylene (PP) mesh-repaired hernia with an increase in the deposition of collagen type 1. The impact of doxycycline with porcine acellular dermal matrices (PADM) is unknown; therefore, we evaluated the impact of doxycycline administration upon hernia repair with PP and PADM mesh. METHODS: Sprague-Dawley rats weighing ~400 g underwent laparotomy with creation of a midline ventral hernia. After a 27-day recovery, animals were randomly assigned to four groups of eight and underwent intraperitoneal underlay hernia repair with either PP or PADM. Groups were assigned to daily normal saline (S) or daily doxycycline in normal saline 10 mg/kg (D) via oral gavage for 8 weeks beginning 24 h preoperatively. Animals were euthanized at 8 weeks and underwent tensiometric testing of the abdominal wall and western blot analyses for collagen subtypes and MMPs. RESULTS: Thirty-two animals underwent successful hernia creation and repair with either PADM or PP. At 8 weeks, 15 of 16 PP-implanted animals survived with only 12 of 16 PADM-implanted animals surviving. There were no differences in the mesh to fascial interface tensiometric strength between groups. Densitometric counts in the PADM-D group demonstrated increased collagen type 1 compared to PP-S (PADM-D [1286.5], PADM-S [906.9], PP-S [700.4], p = 0.037) and decreased collagen type 3 compared to PP-S (PADM-D [7446.9], PADM-S [8507.6], PP-S [11,297.1], p = 0.01). MMP-9 levels were increased in PADM-D (PP-S vs. PADM-D, p = 0.04), while MMP-2 levels were similar between PADM-D and PADM-S, respectively. CONCLUSIONS: Collagen type 1 deposition at the mesh to fascial interface is enhanced following administration of doxycycline in ventral hernia repairs with porcine acellular dermal matrices. Doxycycline administration may have implications for enhancing hernia repair outcomes using biologic mesh.

Cost of ventral hernia repair using biologic or synthetic mesh.

BACKGROUND: Patients undergoing ventral hernia repair (VHR) with biologic mesh (BioM) have higher hospital costs compared with synthetic mesh (SynM). This study compares 90-d pre- and post-VHR hospital costs (180-d) among BioM and SynM based on infection risk. METHODS: This retrospective National Surgical Quality Improvement Program study matched patient perioperative risk with resource utilization cost for a consecutive series of VHR repairs. Patient infection risks, clinical and financial outcomes were compared in unmatched SynM (n = 303) and BioM (n = 72) groups. Propensity scores were used to match 35 SynM and BioM pairs of cases with similar infection risk for outcomes analysis. RESULTS: BioM patients in the unmatched group were older with higher American Society of Anesthesiologists (ASA) and wound classification, and they more frequently underwent open repairs for recurrent hernias. Wound surgical site infections were more frequent in unmatched BioM patients (P = 0.001) as were 180-d costs ($43.8k versus $14.0k, P < 0.001). Propensity matching resulted in 31 clean cases. In these low-risk patients, wound occurrences and readmissions were identical, but 180-d costs remained higher ($31.8k versus $15.5k, P < 0.001). There were no differences in hospital 180-d diagnostic, emergency room, intensive care unit, floor, pharmacy, or therapeutic costs. However, 180-d operating room services and supply costs were higher in the BioM group ($21.1k versus $7.1k, P < 0.001). CONCLUSIONS: BioM is used more commonly in hernia repairs involving higher wound class and ASA scores and recurrent hernias. Clinical outcomes after low-risk VHRs are similar; SynM utilization in low-risk hernia repairs was more cost-effective.

Maternal and neonatal outcomes based on the gestational age of midtrimester preterm premature rupture of membranes.

OBJECTIVES: Determine neonatal and maternal outcomes based on the gestational age (GA) that midtrimester preterm premature rupture of membranes (mtPPROM) occurs. STUDY DESIGN: A retrospective chart review was conducted on pregnancies with mtPPROM between 180/7 and 236/7 weeks gestation from January 2000 to December 2007. Antenatal complications, maternal morbidity, and neonatal survival and morbidity were analysed by the specific GA of mtPPROM. Statistical analysis was performed using Chi-square, Fisher's Exact, and Kruskal-Wallis tests. RESULTS: A total of 105 patients met inclusion criteria. There was a trend for longer latency with earlier GA of mtPPROM (p=0.05). Neonatal survival to discharge was 26.6%, with an overall morbidity of 86%. Survival was significantly higher with mtPPROM at 22 0/7-23 6/7 weeks compared to 18 0/7-19 6/7 (p=0.01) and 20 0/7-21 6/7 weeks (p=0.01). There was no difference in neonatal morbidity based on the GA of mtPPROM. CONCLUSIONS: While neonatal survival improves at later GAs of mtPPROM, morbidity continues to be high.

Genetic loci for ventricular dilatation in the LEW/Jms rat with fetal-onset hydrocephalus are influenced by gender and genetic background.

BACKGROUND: The LEW/Jms rat strain has inherited hydrocephalus, with more males affected than females and an overall expression rate of 28%. This study aimed to determine chromosomal positions for genetic loci causing the hydrocephalus. METHODS: An F1 backcross was made to the parental LEW/Jms strain from a cross with non-hydrocephalic Fischer 344 rats. BC1 rats were generated for two specific crosses: the first with a male LEW/Jms rat as parent and grandparent, [(F x L) x L], designated B group, and the second with a female LEW/Jms rat as the parent and grandparent [L x (L x F)], designated C group. All hydrocephalic and a similar number of non-hydrocephalic rats from these two groups were genotyped with microsatellite markers and the data was analyzed separately for each sex by MAPMAKER. RESULTS: The frequency of hydrocephalus was not significantly different between the two groups (18.2 and 19.9 %), but there was a significant excess of males in the B group. The mean severity of hydrocephalus, measured as the ventricle-to-brain width ratio, was ranked as B group < C group < LEW/Jms. For the both rat groups, there were several chromosomes that showed possible regions with association between phenotype and genotype significant at the 5% or 1.0% level, but none of these had significant LOD scores. For the C group with a female LEW/Jms parent, there was a fully significant locus on Chr2 with a LOD score of 3.81 that was associated almost exclusively with male rats. Both groups showed possible linkage on Chr17 and the data combined produced a LOD score of 2.71, between suggestive and full significance. This locus was largely associated with male rats with a LEW/Jms male parent. CONCLUSION: Phenotypic expression of hydrocephalus in Lew/Jms, although not X-linked, has a strong male bias. One, and possibly two chromosomal regions are associated with the hydrocephalus.