Hernia

Giant incisional hernia repair outcomes were similar for full thickness skin graft (FTSG) and synthetic mesh, according to findings published in Hernia.

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In a prospective, randomized study of 52 patients (24 who received FTSG and 28 who received synthetic mesh), two recurrences were found at 1-year follow up in each group. Results for pain, patient satisfaction, and aesthetic outcome did not differ significantly between the groups, reported Viktor Holmdahl of the department of surgery and perioperative sciences at Umeå (Sweden) University and his coauthors.

Patients were aged 18 years or older, with symptomatic giant (greater than 10 cm) ventral incisional hernia. All patients had computerized tomography (CT) imaging of the abdominal wall, and were assessed for abdominal wall muscle strength via the Biodex Multi-Joint System-4.

The synthetic mesh used was a polypropylene mesh overlapping the repaired hernia defect by at least 5 cm. The FTSG was always placed in an onlay position, and was taken from excess skin adjacent to the midline incision made for the hernia repair. Postoperative care was identical for both groups, Dr. Holmdahl and his colleagues reported.

At 1 year, all patients received a follow-up Biodex assessment and were evaluated for recurrence. Aesthetic outcomes such as scar appearance and wound healing were assessed. Patients self-reported pain levels using a visual analogue scale.

Two patients in both the FTSG group (8.3%) and the synthetic mesh group (7.1%) had recurrence (P = 1.000). Differences between groups for the other measures were not significant, including for well-healed scars (91.3% for FTSG vs. 96.4% for synthetic mesh) and excess skin (60.9% vs. 57.1%). Biodex results also did not differ significantly between the groups.

The similarities in results between the two techniques “indicate that FTSG possibly has a future role in hernia repair, but more research is needed,” the authors concluded.

The study was supported by the Swedish Research Council and by a regional agreement between Umeå University and Västerbotten County Council. The investigators declared no conflicts of interest.

SOURCE: Holmdahl V et al. Hernia 2019 Feb 8. doi: 10.1007/s10029-019-01900-4.

Giant incisional hernia repair outcomes were similar for full thickness skin graft (FTSG) and synthetic mesh, according to findings published in Hernia.

castillodominici/Thinkstock

In a prospective, randomized study of 52 patients (24 who received FTSG and 28 who received synthetic mesh), two recurrences were found at 1-year follow up in each group. Results for pain, patient satisfaction, and aesthetic outcome did not differ significantly between the groups, reported Viktor Holmdahl of the department of surgery and perioperative sciences at Umeå (Sweden) University and his coauthors.

Patients were aged 18 years or older, with symptomatic giant (greater than 10 cm) ventral incisional hernia. All patients had computerized tomography (CT) imaging of the abdominal wall, and were assessed for abdominal wall muscle strength via the Biodex Multi-Joint System-4.

The synthetic mesh used was a polypropylene mesh overlapping the repaired hernia defect by at least 5 cm. The FTSG was always placed in an onlay position, and was taken from excess skin adjacent to the midline incision made for the hernia repair. Postoperative care was identical for both groups, Dr. Holmdahl and his colleagues reported.

At 1 year, all patients received a follow-up Biodex assessment and were evaluated for recurrence. Aesthetic outcomes such as scar appearance and wound healing were assessed. Patients self-reported pain levels using a visual analogue scale.

Two patients in both the FTSG group (8.3%) and the synthetic mesh group (7.1%) had recurrence (P = 1.000). Differences between groups for the other measures were not significant, including for well-healed scars (91.3% for FTSG vs. 96.4% for synthetic mesh) and excess skin (60.9% vs. 57.1%). Biodex results also did not differ significantly between the groups.

The similarities in results between the two techniques “indicate that FTSG possibly has a future role in hernia repair, but more research is needed,” the authors concluded.

The study was supported by the Swedish Research Council and by a regional agreement between Umeå University and Västerbotten County Council. The investigators declared no conflicts of interest.

SOURCE: Holmdahl V et al. Hernia 2019 Feb 8. doi: 10.1007/s10029-019-01900-4.

Giant incisional hernia repair outcomes were similar for full thickness skin graft (FTSG) and synthetic mesh, according to findings published in Hernia.

castillodominici/Thinkstock

In a prospective, randomized study of 52 patients (24 who received FTSG and 28 who received synthetic mesh), two recurrences were found at 1-year follow up in each group. Results for pain, patient satisfaction, and aesthetic outcome did not differ significantly between the groups, reported Viktor Holmdahl of the department of surgery and perioperative sciences at Umeå (Sweden) University and his coauthors.

Patients were aged 18 years or older, with symptomatic giant (greater than 10 cm) ventral incisional hernia. All patients had computerized tomography (CT) imaging of the abdominal wall, and were assessed for abdominal wall muscle strength via the Biodex Multi-Joint System-4.

The synthetic mesh used was a polypropylene mesh overlapping the repaired hernia defect by at least 5 cm. The FTSG was always placed in an onlay position, and was taken from excess skin adjacent to the midline incision made for the hernia repair. Postoperative care was identical for both groups, Dr. Holmdahl and his colleagues reported.

At 1 year, all patients received a follow-up Biodex assessment and were evaluated for recurrence. Aesthetic outcomes such as scar appearance and wound healing were assessed. Patients self-reported pain levels using a visual analogue scale.

Two patients in both the FTSG group (8.3%) and the synthetic mesh group (7.1%) had recurrence (P = 1.000). Differences between groups for the other measures were not significant, including for well-healed scars (91.3% for FTSG vs. 96.4% for synthetic mesh) and excess skin (60.9% vs. 57.1%). Biodex results also did not differ significantly between the groups.

The similarities in results between the two techniques “indicate that FTSG possibly has a future role in hernia repair, but more research is needed,” the authors concluded.

The study was supported by the Swedish Research Council and by a regional agreement between Umeå University and Västerbotten County Council. The investigators declared no conflicts of interest.

SOURCE: Holmdahl V et al. Hernia 2019 Feb 8. doi: 10.1007/s10029-019-01900-4.

A multicenter, randomized study comparing laparoscopic and robotic assisted surgical approaches is being conducted to examine outcomes for ventral hernia repairs.

In the trial precis, the researchers wrote, “The robotic platform in surgery is growing exponentially. Despite this, the evidence supporting robotics remains limited. Studies demonstrating benefit, such as improved outcomes or decreased hospital length of stay, are largely cohort studies subject to substantial bias. Among randomized controlled trials, none have demonstrated benefit with robotic surgery.”

Study participants will be randomized to two arms, one for laparoscopic hernia repair and the other for robotic repair. Patients in both arms will be treated with a mid-density polypropylene mesh with a one-sided adhesion barrier.

The primary outcomes studied are length of stay in the hospital and readmissions out to 90 days. Secondary outcomes include the occurrence of surgical-site infection, hematoma, seroma, dehiscence, necrosis, nonhealing wound, hernia recurrence, and several cost and quality-of-life measures.

Patients included must be over age 18 and undergoing elective ventral hernia repair deemed appropriate for minimally invasive repair. Exclusions include those unlikely to survive beyond 2 years based on surgeon judgment or are unlikely to follow up. In addition, patients are excluded if they have advanced COPD or heart failure, a history of open abdomen or extensive lysis of adhesions for bowel obstruction, ascites caused by cirrhosis or malignancy, active infection, or a large hernia larger than 12 cm. Estimated enrollment is 120 patients, and the researchers expect the study to end in 2023.

For more details on the study (NT03490266), go to clinicaltrials.gov.

A multicenter, randomized study comparing laparoscopic and robotic assisted surgical approaches is being conducted to examine outcomes for ventral hernia repairs.

In the trial precis, the researchers wrote, “The robotic platform in surgery is growing exponentially. Despite this, the evidence supporting robotics remains limited. Studies demonstrating benefit, such as improved outcomes or decreased hospital length of stay, are largely cohort studies subject to substantial bias. Among randomized controlled trials, none have demonstrated benefit with robotic surgery.”

Study participants will be randomized to two arms, one for laparoscopic hernia repair and the other for robotic repair. Patients in both arms will be treated with a mid-density polypropylene mesh with a one-sided adhesion barrier.

The primary outcomes studied are length of stay in the hospital and readmissions out to 90 days. Secondary outcomes include the occurrence of surgical-site infection, hematoma, seroma, dehiscence, necrosis, nonhealing wound, hernia recurrence, and several cost and quality-of-life measures.

Patients included must be over age 18 and undergoing elective ventral hernia repair deemed appropriate for minimally invasive repair. Exclusions include those unlikely to survive beyond 2 years based on surgeon judgment or are unlikely to follow up. In addition, patients are excluded if they have advanced COPD or heart failure, a history of open abdomen or extensive lysis of adhesions for bowel obstruction, ascites caused by cirrhosis or malignancy, active infection, or a large hernia larger than 12 cm. Estimated enrollment is 120 patients, and the researchers expect the study to end in 2023.

For more details on the study (NT03490266), go to clinicaltrials.gov.

A multicenter, randomized study comparing laparoscopic and robotic assisted surgical approaches is being conducted to examine outcomes for ventral hernia repairs.

In the trial precis, the researchers wrote, “The robotic platform in surgery is growing exponentially. Despite this, the evidence supporting robotics remains limited. Studies demonstrating benefit, such as improved outcomes or decreased hospital length of stay, are largely cohort studies subject to substantial bias. Among randomized controlled trials, none have demonstrated benefit with robotic surgery.”

Study participants will be randomized to two arms, one for laparoscopic hernia repair and the other for robotic repair. Patients in both arms will be treated with a mid-density polypropylene mesh with a one-sided adhesion barrier.

The primary outcomes studied are length of stay in the hospital and readmissions out to 90 days. Secondary outcomes include the occurrence of surgical-site infection, hematoma, seroma, dehiscence, necrosis, nonhealing wound, hernia recurrence, and several cost and quality-of-life measures.

Patients included must be over age 18 and undergoing elective ventral hernia repair deemed appropriate for minimally invasive repair. Exclusions include those unlikely to survive beyond 2 years based on surgeon judgment or are unlikely to follow up. In addition, patients are excluded if they have advanced COPD or heart failure, a history of open abdomen or extensive lysis of adhesions for bowel obstruction, ascites caused by cirrhosis or malignancy, active infection, or a large hernia larger than 12 cm. Estimated enrollment is 120 patients, and the researchers expect the study to end in 2023.

For more details on the study (NT03490266), go to clinicaltrials.gov.

Elective hernia repair in patients with chronic liver disease was far safer than emergent repair and carried an acceptable level of morbidity and mortality, according to an analysis of all cases performed at the Cleveland Clinic from 2001-2015.

In a chart review of 253 patients with chronic liver disease (CLD) who underwent hernia repair between January 2001 and December 2015, the rate of postoperative 30-day morbidity and mortality was 27% for nonemergent repairs, compared with 60% in emergent repairs.

The 90-day mortality rate also was higher for emergent repairs (10%) than for nonemergent repairs (3.7%), reported Clayton C. Petro, MD, of the Cleveland Clinic, and his coauthors.

Thirty-day morbidity and mortality was defined as incidence of surgical-site infection (SSI), wound dehiscence, bacterial peritonitis, decompensated liver failure, postoperative admission to the intensive care unit, unplanned hospital readmission, unplanned reoperation, and 30-day mortality. CLD severity was determined using the Charlson Comorbidity Index (CCI), age-adjusted CCI, Child-Turcott-Pugh Score, laboratory values, and Model for End-Stage Liver Disease (MELD) Score.

Of the 253 patients, 186 (74%) had nonemergent repairs and 67 (26%) had emergent repairs; 91 patients (36%) experienced a total of 159 morbidity and mortality events, Dr. Petro and coauthors said.

Emergent repairs had significantly higher rates of postoperative ICU admission than nonemergent repairs (27% vs. 5%; P less than .0001). Emergent repairs also had higher rates of bacterial peritonitis (10% vs 3%; P = .02), unplanned reoperation (9% vs 1%; P = .005), and unplanned readmission (27% vs 14%, P = .02).

“This large single-center cohort of 253 CLD patients suggests that non-emergent hernia repairs have relatively acceptable rates of [morbidity and mortality], even with advanced liver disease,” the authors wrote. “The dramatic increase in postoperative complications and 90-day mortality in the emergent setting supports the practice of elective repair when possible.”

No disclosures or conflicts of interest were reported.

SOURCE: Petro C et al. Am J Surg. 2019:217;59-65.

Elective hernia repair in patients with chronic liver disease was far safer than emergent repair and carried an acceptable level of morbidity and mortality, according to an analysis of all cases performed at the Cleveland Clinic from 2001-2015.

In a chart review of 253 patients with chronic liver disease (CLD) who underwent hernia repair between January 2001 and December 2015, the rate of postoperative 30-day morbidity and mortality was 27% for nonemergent repairs, compared with 60% in emergent repairs.

The 90-day mortality rate also was higher for emergent repairs (10%) than for nonemergent repairs (3.7%), reported Clayton C. Petro, MD, of the Cleveland Clinic, and his coauthors.

Thirty-day morbidity and mortality was defined as incidence of surgical-site infection (SSI), wound dehiscence, bacterial peritonitis, decompensated liver failure, postoperative admission to the intensive care unit, unplanned hospital readmission, unplanned reoperation, and 30-day mortality. CLD severity was determined using the Charlson Comorbidity Index (CCI), age-adjusted CCI, Child-Turcott-Pugh Score, laboratory values, and Model for End-Stage Liver Disease (MELD) Score.

Of the 253 patients, 186 (74%) had nonemergent repairs and 67 (26%) had emergent repairs; 91 patients (36%) experienced a total of 159 morbidity and mortality events, Dr. Petro and coauthors said.

Emergent repairs had significantly higher rates of postoperative ICU admission than nonemergent repairs (27% vs. 5%; P less than .0001). Emergent repairs also had higher rates of bacterial peritonitis (10% vs 3%; P = .02), unplanned reoperation (9% vs 1%; P = .005), and unplanned readmission (27% vs 14%, P = .02).

“This large single-center cohort of 253 CLD patients suggests that non-emergent hernia repairs have relatively acceptable rates of [morbidity and mortality], even with advanced liver disease,” the authors wrote. “The dramatic increase in postoperative complications and 90-day mortality in the emergent setting supports the practice of elective repair when possible.”

No disclosures or conflicts of interest were reported.

SOURCE: Petro C et al. Am J Surg. 2019:217;59-65.

Elective hernia repair in patients with chronic liver disease was far safer than emergent repair and carried an acceptable level of morbidity and mortality, according to an analysis of all cases performed at the Cleveland Clinic from 2001-2015.

In a chart review of 253 patients with chronic liver disease (CLD) who underwent hernia repair between January 2001 and December 2015, the rate of postoperative 30-day morbidity and mortality was 27% for nonemergent repairs, compared with 60% in emergent repairs.

The 90-day mortality rate also was higher for emergent repairs (10%) than for nonemergent repairs (3.7%), reported Clayton C. Petro, MD, of the Cleveland Clinic, and his coauthors.

Thirty-day morbidity and mortality was defined as incidence of surgical-site infection (SSI), wound dehiscence, bacterial peritonitis, decompensated liver failure, postoperative admission to the intensive care unit, unplanned hospital readmission, unplanned reoperation, and 30-day mortality. CLD severity was determined using the Charlson Comorbidity Index (CCI), age-adjusted CCI, Child-Turcott-Pugh Score, laboratory values, and Model for End-Stage Liver Disease (MELD) Score.

Of the 253 patients, 186 (74%) had nonemergent repairs and 67 (26%) had emergent repairs; 91 patients (36%) experienced a total of 159 morbidity and mortality events, Dr. Petro and coauthors said.

Emergent repairs had significantly higher rates of postoperative ICU admission than nonemergent repairs (27% vs. 5%; P less than .0001). Emergent repairs also had higher rates of bacterial peritonitis (10% vs 3%; P = .02), unplanned reoperation (9% vs 1%; P = .005), and unplanned readmission (27% vs 14%, P = .02).

“This large single-center cohort of 253 CLD patients suggests that non-emergent hernia repairs have relatively acceptable rates of [morbidity and mortality], even with advanced liver disease,” the authors wrote. “The dramatic increase in postoperative complications and 90-day mortality in the emergent setting supports the practice of elective repair when possible.”

No disclosures or conflicts of interest were reported.

SOURCE: Petro C et al. Am J Surg. 2019:217;59-65.

Herniorrhaphy may be appropriate in compensated cirrhosis but only when accompanied by careful selection of patients, operative timing, and technique, according to a literature review of studies on hernia management in cirrhosis.

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“Hernia management in cirrhosis continues to be restricted by lack of high-quality evidence and heterogeneity in expert opinion,” wrote lead author Sara P. Myers, MD, of the University of Pittsburgh, and her coauthors, adding that “there is, however, convincing evidence to advocate for elective ventral, umbilical, or inguinal hernia repair in compensated cirrhosis.” The study was published in the Journal of Surgical Research.

After reviewing 51 articles – including 7 prospective observational studies, 26 retrospective observational studies, 2 randomized controlled trials, 15 review articles, and 1 case report – Dr. Myers and her colleagues organized their data into three categories: preoperative, intraoperative, or postoperative considerations.

From a preoperative standpoint, decompensated cirrhosis was recognized as a “harbinger of poor outcomes.” Signs of decompensated cirrhosis include ascites, variceal bleeding, spontaneous bacterial peritonitis, hepatic encephalopathy, and hepatorenal syndrome. A 2006 study found that patients with decompensated cirrhosis survive for a median of less than 2 years, while those with compensated cirrhosis has a median survival of more than 12 years.

Intraoperative considerations leaned on studies of cholecystectomy; the evidence suggested that patients with mild to moderate cirrhosis can undergo laparoscopic surgery, even showing decreased risk of mortality, pneumonia, sepsis, and reoperation as a result. And although most laparoscopic procedures involve an intraperitoneal onlay mesh repair and the “use of mesh for hernia repair in patients with cirrhosis has been debated,” a 2007 study showed that synthetic mesh is safe for elective herniorrhaphy.

Finally, they shared specific postoperative risks, including encephalopathy and ascites, along with the fact that cirrhosis itself “precipitates immune dysfunction and deficiency and promotes systemic inflammation.” At the same time, they highlighted a 2008 study in which a cohort of 32 patients with cirrhosis underwent elective Lichtenstein repair with no major complications and an overall improved quality of life.

The coauthors noted that, although many surgeons will avoid hernia repair in patients with severe liver disease because of the associations with high morbidity and mortality, dissent fades when an emergency means abstaining will lead to a prognosis worse than intervention. That said, when it comes to preemptive elective repair there are also “no clear guidelines with regard to severity of cirrhosis and thresholds that would preclude herniorrhaphy.” Regardless of the choices made, “recognizing and managing complications in cirrhotic patients who have undergone hernia repair is crucial,” they wrote.

The authors reported no conflicts of interest.

SOURCE: Myers SP et al. J Surg Res. 2018 Oct 23. doi: doi: 10.1016/j.jss.2018.09.052.

Herniorrhaphy may be appropriate in compensated cirrhosis but only when accompanied by careful selection of patients, operative timing, and technique, according to a literature review of studies on hernia management in cirrhosis.

monkeybusinessimages/Thinkstock

“Hernia management in cirrhosis continues to be restricted by lack of high-quality evidence and heterogeneity in expert opinion,” wrote lead author Sara P. Myers, MD, of the University of Pittsburgh, and her coauthors, adding that “there is, however, convincing evidence to advocate for elective ventral, umbilical, or inguinal hernia repair in compensated cirrhosis.” The study was published in the Journal of Surgical Research.

After reviewing 51 articles – including 7 prospective observational studies, 26 retrospective observational studies, 2 randomized controlled trials, 15 review articles, and 1 case report – Dr. Myers and her colleagues organized their data into three categories: preoperative, intraoperative, or postoperative considerations.

From a preoperative standpoint, decompensated cirrhosis was recognized as a “harbinger of poor outcomes.” Signs of decompensated cirrhosis include ascites, variceal bleeding, spontaneous bacterial peritonitis, hepatic encephalopathy, and hepatorenal syndrome. A 2006 study found that patients with decompensated cirrhosis survive for a median of less than 2 years, while those with compensated cirrhosis has a median survival of more than 12 years.

Intraoperative considerations leaned on studies of cholecystectomy; the evidence suggested that patients with mild to moderate cirrhosis can undergo laparoscopic surgery, even showing decreased risk of mortality, pneumonia, sepsis, and reoperation as a result. And although most laparoscopic procedures involve an intraperitoneal onlay mesh repair and the “use of mesh for hernia repair in patients with cirrhosis has been debated,” a 2007 study showed that synthetic mesh is safe for elective herniorrhaphy.

Finally, they shared specific postoperative risks, including encephalopathy and ascites, along with the fact that cirrhosis itself “precipitates immune dysfunction and deficiency and promotes systemic inflammation.” At the same time, they highlighted a 2008 study in which a cohort of 32 patients with cirrhosis underwent elective Lichtenstein repair with no major complications and an overall improved quality of life.

The coauthors noted that, although many surgeons will avoid hernia repair in patients with severe liver disease because of the associations with high morbidity and mortality, dissent fades when an emergency means abstaining will lead to a prognosis worse than intervention. That said, when it comes to preemptive elective repair there are also “no clear guidelines with regard to severity of cirrhosis and thresholds that would preclude herniorrhaphy.” Regardless of the choices made, “recognizing and managing complications in cirrhotic patients who have undergone hernia repair is crucial,” they wrote.

The authors reported no conflicts of interest.

SOURCE: Myers SP et al. J Surg Res. 2018 Oct 23. doi: doi: 10.1016/j.jss.2018.09.052.

Herniorrhaphy may be appropriate in compensated cirrhosis but only when accompanied by careful selection of patients, operative timing, and technique, according to a literature review of studies on hernia management in cirrhosis.

monkeybusinessimages/Thinkstock

“Hernia management in cirrhosis continues to be restricted by lack of high-quality evidence and heterogeneity in expert opinion,” wrote lead author Sara P. Myers, MD, of the University of Pittsburgh, and her coauthors, adding that “there is, however, convincing evidence to advocate for elective ventral, umbilical, or inguinal hernia repair in compensated cirrhosis.” The study was published in the Journal of Surgical Research.

After reviewing 51 articles – including 7 prospective observational studies, 26 retrospective observational studies, 2 randomized controlled trials, 15 review articles, and 1 case report – Dr. Myers and her colleagues organized their data into three categories: preoperative, intraoperative, or postoperative considerations.

From a preoperative standpoint, decompensated cirrhosis was recognized as a “harbinger of poor outcomes.” Signs of decompensated cirrhosis include ascites, variceal bleeding, spontaneous bacterial peritonitis, hepatic encephalopathy, and hepatorenal syndrome. A 2006 study found that patients with decompensated cirrhosis survive for a median of less than 2 years, while those with compensated cirrhosis has a median survival of more than 12 years.

Intraoperative considerations leaned on studies of cholecystectomy; the evidence suggested that patients with mild to moderate cirrhosis can undergo laparoscopic surgery, even showing decreased risk of mortality, pneumonia, sepsis, and reoperation as a result. And although most laparoscopic procedures involve an intraperitoneal onlay mesh repair and the “use of mesh for hernia repair in patients with cirrhosis has been debated,” a 2007 study showed that synthetic mesh is safe for elective herniorrhaphy.

Finally, they shared specific postoperative risks, including encephalopathy and ascites, along with the fact that cirrhosis itself “precipitates immune dysfunction and deficiency and promotes systemic inflammation.” At the same time, they highlighted a 2008 study in which a cohort of 32 patients with cirrhosis underwent elective Lichtenstein repair with no major complications and an overall improved quality of life.

The coauthors noted that, although many surgeons will avoid hernia repair in patients with severe liver disease because of the associations with high morbidity and mortality, dissent fades when an emergency means abstaining will lead to a prognosis worse than intervention. That said, when it comes to preemptive elective repair there are also “no clear guidelines with regard to severity of cirrhosis and thresholds that would preclude herniorrhaphy.” Regardless of the choices made, “recognizing and managing complications in cirrhotic patients who have undergone hernia repair is crucial,” they wrote.

The authors reported no conflicts of interest.

SOURCE: Myers SP et al. J Surg Res. 2018 Oct 23. doi: doi: 10.1016/j.jss.2018.09.052.

Smoking before elective clean open ventral hernia repair (OVHR) was not associated with significant differences in postoperative wound morbidity or all 30-day morbidity, according to results published in Surgery.

castillodominici/Thinkstock

The question of the impact of smoking on infection risk and wound healing has been studied in a variety of surgical procedures. While some associations have been established (JAMA Surg. 2017;152[5]:476-83; Infect Immun. 2015;83[6]:2443-52), the data have not been strong enough to lead to recommendations that surgeons delay procedures until a patient stops smoking.

In a study of 418 active smokers and 418 matched patients who had never smoked, the rate of surgical site infection (SSI) was 4.1% in both groups (P = .98). The total 30-day complication rates were 7.5% for current smokers and 6.6% for nonsmokers (P = .60), reported Clayton C. Petro, MD, of the department of general surgery at the Cleveland Clinic Comprehensive Hernia Center, and his coauthors.

Patient data were obtained from the Americas Hernia Society Quality Collaborative (AHSQC), and included those who had undergone OVHR in a Centers for Disease Control and Prevention class 1 wound with 30-day follow-up.

Participants were grouped according to smoking status: those who had never smoked, those who had smoked within 30 days of operation (“current smokers”), and patients who had quit smoking more than 1 month before operation (“former smokers”). Current smokers were matched with never smokers by characteristics including age, sex, and body mass index, and conditions such as diabetes and hypertension. Former smokers were excluded.

The investigators collected data from both groups on SSI, surgical site occurrence (SSO), surgical site occurrence requiring a procedural intervention (SSOPI), and all 30-day morbidity (any morbidity event entered into the AHSQC database within 30 days of operation), the authors said.

Rates of SSI were 4.1% for both smokers and nonsmokers (P = .98). Rates of SSO were greater in current smokers (12.0% vs. 7.4%, P = .03). SSOPI and reoperation rates were similar in current and never smokers (6.2% vs. 5.0%, P = .43; 1.9% vs. 1.2%, P = .39, respectively).

The results suggest that “active smoking before an elective OVHR in a CDC class I wound has a clinically negligible impact on postoperative wound morbidity and all 30-day morbidity,” wrote Dr. Petro and his colleagues.

“Surgeons allowing perioperative smoking should monitor their outcomes to [ensure that] these findings are replicable in their own practice,” they concluded.

The study authors disclosed financial relationships with Medtronic, Ariste Medical, and other companies.

SOURCE: Petro CC et al. Surgery. 2019 Feb;165(2):406-11.

Smoking before elective clean open ventral hernia repair (OVHR) was not associated with significant differences in postoperative wound morbidity or all 30-day morbidity, according to results published in Surgery.

castillodominici/Thinkstock

The question of the impact of smoking on infection risk and wound healing has been studied in a variety of surgical procedures. While some associations have been established (JAMA Surg. 2017;152[5]:476-83; Infect Immun. 2015;83[6]:2443-52), the data have not been strong enough to lead to recommendations that surgeons delay procedures until a patient stops smoking.

In a study of 418 active smokers and 418 matched patients who had never smoked, the rate of surgical site infection (SSI) was 4.1% in both groups (P = .98). The total 30-day complication rates were 7.5% for current smokers and 6.6% for nonsmokers (P = .60), reported Clayton C. Petro, MD, of the department of general surgery at the Cleveland Clinic Comprehensive Hernia Center, and his coauthors.

Patient data were obtained from the Americas Hernia Society Quality Collaborative (AHSQC), and included those who had undergone OVHR in a Centers for Disease Control and Prevention class 1 wound with 30-day follow-up.

Participants were grouped according to smoking status: those who had never smoked, those who had smoked within 30 days of operation (“current smokers”), and patients who had quit smoking more than 1 month before operation (“former smokers”). Current smokers were matched with never smokers by characteristics including age, sex, and body mass index, and conditions such as diabetes and hypertension. Former smokers were excluded.

The investigators collected data from both groups on SSI, surgical site occurrence (SSO), surgical site occurrence requiring a procedural intervention (SSOPI), and all 30-day morbidity (any morbidity event entered into the AHSQC database within 30 days of operation), the authors said.

Rates of SSI were 4.1% for both smokers and nonsmokers (P = .98). Rates of SSO were greater in current smokers (12.0% vs. 7.4%, P = .03). SSOPI and reoperation rates were similar in current and never smokers (6.2% vs. 5.0%, P = .43; 1.9% vs. 1.2%, P = .39, respectively).

The results suggest that “active smoking before an elective OVHR in a CDC class I wound has a clinically negligible impact on postoperative wound morbidity and all 30-day morbidity,” wrote Dr. Petro and his colleagues.

“Surgeons allowing perioperative smoking should monitor their outcomes to [ensure that] these findings are replicable in their own practice,” they concluded.

The study authors disclosed financial relationships with Medtronic, Ariste Medical, and other companies.

SOURCE: Petro CC et al. Surgery. 2019 Feb;165(2):406-11.

Smoking before elective clean open ventral hernia repair (OVHR) was not associated with significant differences in postoperative wound morbidity or all 30-day morbidity, according to results published in Surgery.

castillodominici/Thinkstock

The question of the impact of smoking on infection risk and wound healing has been studied in a variety of surgical procedures. While some associations have been established (JAMA Surg. 2017;152[5]:476-83; Infect Immun. 2015;83[6]:2443-52), the data have not been strong enough to lead to recommendations that surgeons delay procedures until a patient stops smoking.

In a study of 418 active smokers and 418 matched patients who had never smoked, the rate of surgical site infection (SSI) was 4.1% in both groups (P = .98). The total 30-day complication rates were 7.5% for current smokers and 6.6% for nonsmokers (P = .60), reported Clayton C. Petro, MD, of the department of general surgery at the Cleveland Clinic Comprehensive Hernia Center, and his coauthors.

Patient data were obtained from the Americas Hernia Society Quality Collaborative (AHSQC), and included those who had undergone OVHR in a Centers for Disease Control and Prevention class 1 wound with 30-day follow-up.

Participants were grouped according to smoking status: those who had never smoked, those who had smoked within 30 days of operation (“current smokers”), and patients who had quit smoking more than 1 month before operation (“former smokers”). Current smokers were matched with never smokers by characteristics including age, sex, and body mass index, and conditions such as diabetes and hypertension. Former smokers were excluded.

The investigators collected data from both groups on SSI, surgical site occurrence (SSO), surgical site occurrence requiring a procedural intervention (SSOPI), and all 30-day morbidity (any morbidity event entered into the AHSQC database within 30 days of operation), the authors said.

Rates of SSI were 4.1% for both smokers and nonsmokers (P = .98). Rates of SSO were greater in current smokers (12.0% vs. 7.4%, P = .03). SSOPI and reoperation rates were similar in current and never smokers (6.2% vs. 5.0%, P = .43; 1.9% vs. 1.2%, P = .39, respectively).

The results suggest that “active smoking before an elective OVHR in a CDC class I wound has a clinically negligible impact on postoperative wound morbidity and all 30-day morbidity,” wrote Dr. Petro and his colleagues.

“Surgeons allowing perioperative smoking should monitor their outcomes to [ensure that] these findings are replicable in their own practice,” they concluded.

The study authors disclosed financial relationships with Medtronic, Ariste Medical, and other companies.

SOURCE: Petro CC et al. Surgery. 2019 Feb;165(2):406-11.

Patients use fewer opioids and have shorter hospital stays when they had transversus abdominis plane (TAP) blocks instead of epidurals for pain control after ventral hernia repair, according to a review of 246 cases at the Greenville Health System, in South Carolina.

“Regional anesthesia using TAP block[s] provides an effective alternative to epidural analgesia or opioid use alone for perioperative pain control ... In light of these findings, use of TAP block should be strongly considered as an adjunct to abdominal surgery,” wrote investigators led by general surgeon Jeremy Warren, MD, of the University of South Carolina School of Medicine, Greenville, in the Journal of the American College of Surgeons.

Prompted by favorable reports in the literature, the team switched from epidural analgesia to TAP blocks in early 2017. To see how it’s worked out, they reviewed all patients who had ventral hernia repairs at the Greenville Health System from Feb. 2015 to March 2018. They were all mesh cases, without parastomal hernias or enterostomy reversal.

Seventy-four patients had TAP blocks, which were placed in the OR after anesthesia induction and consisted of 200 mg ropivacaine, 100 mcg epinephrine, and 100 mcg clonidine in 60 ml saline, with 30 ml injected on each side under ultrasound guidance.

Their outcomes were compared with 172 patients who received epidurals, which were placed preoperatively and consisted of 0.125% bupivacaine initiated shortly before patients came out of anesthesia, at a rate of 8-12 ml/hr.

Hospital lengths of stay were significantly shorter in the TAP group, a median of 2.4 versus 4.5 days (P less than .001), and TAP patients received fewer opioids, a mean of 40 versus 54.1 morphine milligram equivalents (MME) on postop day 1, and 36.1 versus 52.5 MME on postop day 2 (P = .018).

There were no differences in the rates of surgical site infections or other wound complications. The mean duration of epidural infusion was 49.5 hours.

The shorter length of stay with TAP block was probably related to side effects of epidurals, which can include leg paresthesias, hypotension, and urinary retention, all of which get in the way of early ambulation. “Additionally, the decision of when to discontinue epidural analgesia in our series was left to the judgment of the pain management and surgical team based on reporting of patient pain, rather than duration determined by a protocol,” which may have also played a role, the study team said.

Overall, the results mirror outcomes from previous TAP block studies, but there were caveats. Epidural patients had wider hernias (median 10.8 cm versus 8.8 cm); required more myofascial releases; and had longer operative times, “indicating a higher degree of complexity that may influence the need for longer hospitalization and greater opioid use,” the investigators said.

Also, a greater number of TAP block patients received non-opioid pain killers, including ketorolac and acetaminophen.

The study was conducted within the health system’s enhanced recovery after surgery protocol, which includes a preoperative cocktail of pregabalin 75 mg, celecoxib 400 mg, and acetaminophen 1,000 mg, given within 1-2 hours of surgery. Post-operative management includes intravenous ketamine infusions at sub-anesthetic doses, NSAIDs, and acetaminophen, among other measures. The approach has pretty much eliminated patient-controlled analgesia.

There were slightly more men than women in the review. Study participants, on average, were in their late 50s. There were no significant differences in comorbidities.

No funding was reported, and the investigators didn’t have any relevant disclosures.
 

aotto@mdedge.com

SOURCE: Warren JA et al., J Am Coll Surg. 2019 Jan 7. pii: S1072-7515(19)30014-6. doi: 10.1016/j.jamcollsurg.2018.12.017

Patients use fewer opioids and have shorter hospital stays when they had transversus abdominis plane (TAP) blocks instead of epidurals for pain control after ventral hernia repair, according to a review of 246 cases at the Greenville Health System, in South Carolina.

“Regional anesthesia using TAP block[s] provides an effective alternative to epidural analgesia or opioid use alone for perioperative pain control ... In light of these findings, use of TAP block should be strongly considered as an adjunct to abdominal surgery,” wrote investigators led by general surgeon Jeremy Warren, MD, of the University of South Carolina School of Medicine, Greenville, in the Journal of the American College of Surgeons.

Prompted by favorable reports in the literature, the team switched from epidural analgesia to TAP blocks in early 2017. To see how it’s worked out, they reviewed all patients who had ventral hernia repairs at the Greenville Health System from Feb. 2015 to March 2018. They were all mesh cases, without parastomal hernias or enterostomy reversal.

Seventy-four patients had TAP blocks, which were placed in the OR after anesthesia induction and consisted of 200 mg ropivacaine, 100 mcg epinephrine, and 100 mcg clonidine in 60 ml saline, with 30 ml injected on each side under ultrasound guidance.

Their outcomes were compared with 172 patients who received epidurals, which were placed preoperatively and consisted of 0.125% bupivacaine initiated shortly before patients came out of anesthesia, at a rate of 8-12 ml/hr.

Hospital lengths of stay were significantly shorter in the TAP group, a median of 2.4 versus 4.5 days (P less than .001), and TAP patients received fewer opioids, a mean of 40 versus 54.1 morphine milligram equivalents (MME) on postop day 1, and 36.1 versus 52.5 MME on postop day 2 (P = .018).

There were no differences in the rates of surgical site infections or other wound complications. The mean duration of epidural infusion was 49.5 hours.

The shorter length of stay with TAP block was probably related to side effects of epidurals, which can include leg paresthesias, hypotension, and urinary retention, all of which get in the way of early ambulation. “Additionally, the decision of when to discontinue epidural analgesia in our series was left to the judgment of the pain management and surgical team based on reporting of patient pain, rather than duration determined by a protocol,” which may have also played a role, the study team said.

Overall, the results mirror outcomes from previous TAP block studies, but there were caveats. Epidural patients had wider hernias (median 10.8 cm versus 8.8 cm); required more myofascial releases; and had longer operative times, “indicating a higher degree of complexity that may influence the need for longer hospitalization and greater opioid use,” the investigators said.

Also, a greater number of TAP block patients received non-opioid pain killers, including ketorolac and acetaminophen.

The study was conducted within the health system’s enhanced recovery after surgery protocol, which includes a preoperative cocktail of pregabalin 75 mg, celecoxib 400 mg, and acetaminophen 1,000 mg, given within 1-2 hours of surgery. Post-operative management includes intravenous ketamine infusions at sub-anesthetic doses, NSAIDs, and acetaminophen, among other measures. The approach has pretty much eliminated patient-controlled analgesia.

There were slightly more men than women in the review. Study participants, on average, were in their late 50s. There were no significant differences in comorbidities.

No funding was reported, and the investigators didn’t have any relevant disclosures.
 

aotto@mdedge.com

SOURCE: Warren JA et al., J Am Coll Surg. 2019 Jan 7. pii: S1072-7515(19)30014-6. doi: 10.1016/j.jamcollsurg.2018.12.017

Patients use fewer opioids and have shorter hospital stays when they had transversus abdominis plane (TAP) blocks instead of epidurals for pain control after ventral hernia repair, according to a review of 246 cases at the Greenville Health System, in South Carolina.

“Regional anesthesia using TAP block[s] provides an effective alternative to epidural analgesia or opioid use alone for perioperative pain control ... In light of these findings, use of TAP block should be strongly considered as an adjunct to abdominal surgery,” wrote investigators led by general surgeon Jeremy Warren, MD, of the University of South Carolina School of Medicine, Greenville, in the Journal of the American College of Surgeons.

Prompted by favorable reports in the literature, the team switched from epidural analgesia to TAP blocks in early 2017. To see how it’s worked out, they reviewed all patients who had ventral hernia repairs at the Greenville Health System from Feb. 2015 to March 2018. They were all mesh cases, without parastomal hernias or enterostomy reversal.

Seventy-four patients had TAP blocks, which were placed in the OR after anesthesia induction and consisted of 200 mg ropivacaine, 100 mcg epinephrine, and 100 mcg clonidine in 60 ml saline, with 30 ml injected on each side under ultrasound guidance.

Their outcomes were compared with 172 patients who received epidurals, which were placed preoperatively and consisted of 0.125% bupivacaine initiated shortly before patients came out of anesthesia, at a rate of 8-12 ml/hr.

Hospital lengths of stay were significantly shorter in the TAP group, a median of 2.4 versus 4.5 days (P less than .001), and TAP patients received fewer opioids, a mean of 40 versus 54.1 morphine milligram equivalents (MME) on postop day 1, and 36.1 versus 52.5 MME on postop day 2 (P = .018).

There were no differences in the rates of surgical site infections or other wound complications. The mean duration of epidural infusion was 49.5 hours.

The shorter length of stay with TAP block was probably related to side effects of epidurals, which can include leg paresthesias, hypotension, and urinary retention, all of which get in the way of early ambulation. “Additionally, the decision of when to discontinue epidural analgesia in our series was left to the judgment of the pain management and surgical team based on reporting of patient pain, rather than duration determined by a protocol,” which may have also played a role, the study team said.

Overall, the results mirror outcomes from previous TAP block studies, but there were caveats. Epidural patients had wider hernias (median 10.8 cm versus 8.8 cm); required more myofascial releases; and had longer operative times, “indicating a higher degree of complexity that may influence the need for longer hospitalization and greater opioid use,” the investigators said.

Also, a greater number of TAP block patients received non-opioid pain killers, including ketorolac and acetaminophen.

The study was conducted within the health system’s enhanced recovery after surgery protocol, which includes a preoperative cocktail of pregabalin 75 mg, celecoxib 400 mg, and acetaminophen 1,000 mg, given within 1-2 hours of surgery. Post-operative management includes intravenous ketamine infusions at sub-anesthetic doses, NSAIDs, and acetaminophen, among other measures. The approach has pretty much eliminated patient-controlled analgesia.

There were slightly more men than women in the review. Study participants, on average, were in their late 50s. There were no significant differences in comorbidities.

No funding was reported, and the investigators didn’t have any relevant disclosures.
 

aotto@mdedge.com

SOURCE: Warren JA et al., J Am Coll Surg. 2019 Jan 7. pii: S1072-7515(19)30014-6. doi: 10.1016/j.jamcollsurg.2018.12.017

A observational, prospective trial is underway to study the use of surgical glue for hernia repair. Cyanoacrylate Fixation for Laparoscopic Repair of Inguinal Hernias, a multicenter registry, is currently enrolling patients for laparoscopic inguinal hernia repair using surgical tissue glue for mesh fixation.

The trial expects to enroll 1,000 patients and to be completed by December 2019. The primary outcome is postoperative pain evaluated by patient self-assessment using a visual analog scale. Secondary outcomes include intraoperative and postoperative complications, analgesic intake, postoperative quality of life, recurrences, and longer-term complications.

Included in the participant group are adult patients of both sexes with primary inguinal hernia. Exclusions include patients with recurrent inguinal hernia, patients previously treated with Lichtenstein technique, those allergic to the components of the tissue glue, and those whose life expectancy is under 1 year. The patients will be followed up to 1 year.

For further information about to the study, go to clinicaltrials.gov (NCT01669837).

tborden@mdedge.com

A observational, prospective trial is underway to study the use of surgical glue for hernia repair. Cyanoacrylate Fixation for Laparoscopic Repair of Inguinal Hernias, a multicenter registry, is currently enrolling patients for laparoscopic inguinal hernia repair using surgical tissue glue for mesh fixation.

The trial expects to enroll 1,000 patients and to be completed by December 2019. The primary outcome is postoperative pain evaluated by patient self-assessment using a visual analog scale. Secondary outcomes include intraoperative and postoperative complications, analgesic intake, postoperative quality of life, recurrences, and longer-term complications.

Included in the participant group are adult patients of both sexes with primary inguinal hernia. Exclusions include patients with recurrent inguinal hernia, patients previously treated with Lichtenstein technique, those allergic to the components of the tissue glue, and those whose life expectancy is under 1 year. The patients will be followed up to 1 year.

For further information about to the study, go to clinicaltrials.gov (NCT01669837).

tborden@mdedge.com

A observational, prospective trial is underway to study the use of surgical glue for hernia repair. Cyanoacrylate Fixation for Laparoscopic Repair of Inguinal Hernias, a multicenter registry, is currently enrolling patients for laparoscopic inguinal hernia repair using surgical tissue glue for mesh fixation.

The trial expects to enroll 1,000 patients and to be completed by December 2019. The primary outcome is postoperative pain evaluated by patient self-assessment using a visual analog scale. Secondary outcomes include intraoperative and postoperative complications, analgesic intake, postoperative quality of life, recurrences, and longer-term complications.

Included in the participant group are adult patients of both sexes with primary inguinal hernia. Exclusions include patients with recurrent inguinal hernia, patients previously treated with Lichtenstein technique, those allergic to the components of the tissue glue, and those whose life expectancy is under 1 year. The patients will be followed up to 1 year.

For further information about to the study, go to clinicaltrials.gov (NCT01669837).

tborden@mdedge.com

Recurrence of inguinal hernia in women was lower after laparoscopic repair, compared with open repair, according to findings published in JAMA Surgery.

Courtesy Wikimedia Commons/Samuel Bendet, US Air Force/Creative Commons License

In a systematic review of 43,870 female patients in 55 studies, the recurrence rate was 1.2% after laparoscopic repair, compared with 2.4% after open repair. The recurrent hernia was a femoral hernia in 40.9% of patients after open repair, compared with no recurrences after laparoscopic repair, reported Line Schmidt of the department of surgery at Herlev (Denmark) Hospital, and coauthors.

Patients were women aged 18 years and older who had repair of a primary unilateral or bilateral inguinal hernia. The review included all retrospective cohort studies, prospective cohort studies, prospective clinical trials, and retrospective cohort studies with 20 or more women with inguinal hernias. PubMed, Embase, and the Cochrane Library databases were searched. The primary outcome was recurrence rate after primary laparoscopic and open repairs, with or without mesh.

The overall recurrence rate among women was 2.6%. The overall crude recurrence rate for studies with low risk of bias was 3.9%, the authors wrote. A femoral hernia was found in 43% of reoperations, though in one study including both open and laparoscopic repairs in women, the rate of detection of incidental femoral hernia was only 2%.

The results “support the recommendation that women with inguinal hernias should undergo laparoscopic repair, unless there are concerns where an open repair might be more clinically appropriate,” the authors wrote. “A substantial number of recurrences after open repair were femoral hernias that may have been overlooked at the primary operation.”

Authors reported receiving personal fees from Bard and Merck. No other disclosures were reported.

SOURCE: Schmidt L et al. JAMA Surg. 2018;153(12):1135-42.

Recurrence of inguinal hernia in women was lower after laparoscopic repair, compared with open repair, according to findings published in JAMA Surgery.

Courtesy Wikimedia Commons/Samuel Bendet, US Air Force/Creative Commons License

In a systematic review of 43,870 female patients in 55 studies, the recurrence rate was 1.2% after laparoscopic repair, compared with 2.4% after open repair. The recurrent hernia was a femoral hernia in 40.9% of patients after open repair, compared with no recurrences after laparoscopic repair, reported Line Schmidt of the department of surgery at Herlev (Denmark) Hospital, and coauthors.

Patients were women aged 18 years and older who had repair of a primary unilateral or bilateral inguinal hernia. The review included all retrospective cohort studies, prospective cohort studies, prospective clinical trials, and retrospective cohort studies with 20 or more women with inguinal hernias. PubMed, Embase, and the Cochrane Library databases were searched. The primary outcome was recurrence rate after primary laparoscopic and open repairs, with or without mesh.

The overall recurrence rate among women was 2.6%. The overall crude recurrence rate for studies with low risk of bias was 3.9%, the authors wrote. A femoral hernia was found in 43% of reoperations, though in one study including both open and laparoscopic repairs in women, the rate of detection of incidental femoral hernia was only 2%.

The results “support the recommendation that women with inguinal hernias should undergo laparoscopic repair, unless there are concerns where an open repair might be more clinically appropriate,” the authors wrote. “A substantial number of recurrences after open repair were femoral hernias that may have been overlooked at the primary operation.”

Authors reported receiving personal fees from Bard and Merck. No other disclosures were reported.

SOURCE: Schmidt L et al. JAMA Surg. 2018;153(12):1135-42.

Recurrence of inguinal hernia in women was lower after laparoscopic repair, compared with open repair, according to findings published in JAMA Surgery.

Courtesy Wikimedia Commons/Samuel Bendet, US Air Force/Creative Commons License

In a systematic review of 43,870 female patients in 55 studies, the recurrence rate was 1.2% after laparoscopic repair, compared with 2.4% after open repair. The recurrent hernia was a femoral hernia in 40.9% of patients after open repair, compared with no recurrences after laparoscopic repair, reported Line Schmidt of the department of surgery at Herlev (Denmark) Hospital, and coauthors.

Patients were women aged 18 years and older who had repair of a primary unilateral or bilateral inguinal hernia. The review included all retrospective cohort studies, prospective cohort studies, prospective clinical trials, and retrospective cohort studies with 20 or more women with inguinal hernias. PubMed, Embase, and the Cochrane Library databases were searched. The primary outcome was recurrence rate after primary laparoscopic and open repairs, with or without mesh.

The overall recurrence rate among women was 2.6%. The overall crude recurrence rate for studies with low risk of bias was 3.9%, the authors wrote. A femoral hernia was found in 43% of reoperations, though in one study including both open and laparoscopic repairs in women, the rate of detection of incidental femoral hernia was only 2%.

The results “support the recommendation that women with inguinal hernias should undergo laparoscopic repair, unless there are concerns where an open repair might be more clinically appropriate,” the authors wrote. “A substantial number of recurrences after open repair were femoral hernias that may have been overlooked at the primary operation.”

Authors reported receiving personal fees from Bard and Merck. No other disclosures were reported.

SOURCE: Schmidt L et al. JAMA Surg. 2018;153(12):1135-42.

Smaller inguinal hernias are associated with a greater risk of chronic postoperative inguinal pain than larger hernias, according to a study published in Annals of Surgery.

castillodominici/Thinkstock

Researchers used data from the European Herniamed registry to look at 1-year outcomes in 57,999 male patients who underwent primary unilateral inguinal hernia repair.

While patients with larger hernias showed significantly longer operation times and had a significantly larger body mass index, those with smaller hernias had significantly higher rates of pain at rest or on exertion, and chronic pain requiring treatment.

Individuals with smaller hernias (EHS I) had a 35% higher odds of pain at rest, compared with those with medium-sized hernias (EHS II), and 84% higher odds, compared with individuals with large hernias (EHS III). Smaller hernias were also associated with a 100% higher odds of pain on exertion and greater than 100% higher odds of chronic postoperative pain requiring treatment, compared with large hernias.

“CPIP [chronic postoperative inguinal pain] has become one of the most important surgical quality parameters after elective inguinal hernia repair with significant consequences affecting patient productivity, employment, and quality of life,” wrote Henry Hoffmann, MD, of the clinic for visceral surgery at the University Hospital Basel in Switzerland, and his coauthors. “With our findings we contribute to the important discussion of prevention, risk factors, and treatment of CPIP identifying smaller inguinal hernias [EHS I-II] as a new independent, patient-related risk factor for the development of CPIP.”

Noting that an association between smaller hernias and increased postoperative pain seems counterintuitive, the authors suggested that patients’ expectations of outcomes may be higher in those with smaller hernias than in patients with larger hernias. While larger hernias are likely more bothersome rather than painful or uncomfortable, smaller hernias may be associated more with pain and discomfort. As such, patients with smaller hernias may have higher hopes for relief from surgery, and therefore may be more likely to experience disappointment.

“Based on a cognitive information processing model it has been suggested that a greater discrepancy between expected and actual pain after surgery leads to significant postoperative distress,” the authors wrote.

The study also found patients aged younger than 55 years were also at greater risk of pain at rest, pain on exertion, and chronic pain requiring treatment.

Overall, around half the patients in the study underwent transabdominal preperitoneal repair, 35.6% underwent totally extraperitoneal repair, 10.1% had Lichtenstein repair, and 3.8% had Shouldice repair.

Lichtenstein was associated with more postoperative pain at rest and on exertion, compared with other surgical methods, and there was a trend toward an increased odds for developing pain requiring treatment in patients with smaller hernias.

The Herniamed Registry is supported by Johnson & Johnson, Karl Storz, pfm medical Cologne, Dahlhausen Cologne, B. Braun Tuttlingen, MenkeMed, and Bard. No conflicts of interest were reported.
 

SOURCE: Hoffmann H et al. Ann Surg. 2018 Oct 10. doi: 10.1097/SLA.0000000000003065.

Smaller inguinal hernias are associated with a greater risk of chronic postoperative inguinal pain than larger hernias, according to a study published in Annals of Surgery.

castillodominici/Thinkstock

Researchers used data from the European Herniamed registry to look at 1-year outcomes in 57,999 male patients who underwent primary unilateral inguinal hernia repair.

While patients with larger hernias showed significantly longer operation times and had a significantly larger body mass index, those with smaller hernias had significantly higher rates of pain at rest or on exertion, and chronic pain requiring treatment.

Individuals with smaller hernias (EHS I) had a 35% higher odds of pain at rest, compared with those with medium-sized hernias (EHS II), and 84% higher odds, compared with individuals with large hernias (EHS III). Smaller hernias were also associated with a 100% higher odds of pain on exertion and greater than 100% higher odds of chronic postoperative pain requiring treatment, compared with large hernias.

“CPIP [chronic postoperative inguinal pain] has become one of the most important surgical quality parameters after elective inguinal hernia repair with significant consequences affecting patient productivity, employment, and quality of life,” wrote Henry Hoffmann, MD, of the clinic for visceral surgery at the University Hospital Basel in Switzerland, and his coauthors. “With our findings we contribute to the important discussion of prevention, risk factors, and treatment of CPIP identifying smaller inguinal hernias [EHS I-II] as a new independent, patient-related risk factor for the development of CPIP.”

Noting that an association between smaller hernias and increased postoperative pain seems counterintuitive, the authors suggested that patients’ expectations of outcomes may be higher in those with smaller hernias than in patients with larger hernias. While larger hernias are likely more bothersome rather than painful or uncomfortable, smaller hernias may be associated more with pain and discomfort. As such, patients with smaller hernias may have higher hopes for relief from surgery, and therefore may be more likely to experience disappointment.

“Based on a cognitive information processing model it has been suggested that a greater discrepancy between expected and actual pain after surgery leads to significant postoperative distress,” the authors wrote.

The study also found patients aged younger than 55 years were also at greater risk of pain at rest, pain on exertion, and chronic pain requiring treatment.

Overall, around half the patients in the study underwent transabdominal preperitoneal repair, 35.6% underwent totally extraperitoneal repair, 10.1% had Lichtenstein repair, and 3.8% had Shouldice repair.

Lichtenstein was associated with more postoperative pain at rest and on exertion, compared with other surgical methods, and there was a trend toward an increased odds for developing pain requiring treatment in patients with smaller hernias.

The Herniamed Registry is supported by Johnson & Johnson, Karl Storz, pfm medical Cologne, Dahlhausen Cologne, B. Braun Tuttlingen, MenkeMed, and Bard. No conflicts of interest were reported.
 

SOURCE: Hoffmann H et al. Ann Surg. 2018 Oct 10. doi: 10.1097/SLA.0000000000003065.

Smaller inguinal hernias are associated with a greater risk of chronic postoperative inguinal pain than larger hernias, according to a study published in Annals of Surgery.

castillodominici/Thinkstock

Researchers used data from the European Herniamed registry to look at 1-year outcomes in 57,999 male patients who underwent primary unilateral inguinal hernia repair.

While patients with larger hernias showed significantly longer operation times and had a significantly larger body mass index, those with smaller hernias had significantly higher rates of pain at rest or on exertion, and chronic pain requiring treatment.

Individuals with smaller hernias (EHS I) had a 35% higher odds of pain at rest, compared with those with medium-sized hernias (EHS II), and 84% higher odds, compared with individuals with large hernias (EHS III). Smaller hernias were also associated with a 100% higher odds of pain on exertion and greater than 100% higher odds of chronic postoperative pain requiring treatment, compared with large hernias.

“CPIP [chronic postoperative inguinal pain] has become one of the most important surgical quality parameters after elective inguinal hernia repair with significant consequences affecting patient productivity, employment, and quality of life,” wrote Henry Hoffmann, MD, of the clinic for visceral surgery at the University Hospital Basel in Switzerland, and his coauthors. “With our findings we contribute to the important discussion of prevention, risk factors, and treatment of CPIP identifying smaller inguinal hernias [EHS I-II] as a new independent, patient-related risk factor for the development of CPIP.”

Noting that an association between smaller hernias and increased postoperative pain seems counterintuitive, the authors suggested that patients’ expectations of outcomes may be higher in those with smaller hernias than in patients with larger hernias. While larger hernias are likely more bothersome rather than painful or uncomfortable, smaller hernias may be associated more with pain and discomfort. As such, patients with smaller hernias may have higher hopes for relief from surgery, and therefore may be more likely to experience disappointment.

“Based on a cognitive information processing model it has been suggested that a greater discrepancy between expected and actual pain after surgery leads to significant postoperative distress,” the authors wrote.

The study also found patients aged younger than 55 years were also at greater risk of pain at rest, pain on exertion, and chronic pain requiring treatment.

Overall, around half the patients in the study underwent transabdominal preperitoneal repair, 35.6% underwent totally extraperitoneal repair, 10.1% had Lichtenstein repair, and 3.8% had Shouldice repair.

Lichtenstein was associated with more postoperative pain at rest and on exertion, compared with other surgical methods, and there was a trend toward an increased odds for developing pain requiring treatment in patients with smaller hernias.

The Herniamed Registry is supported by Johnson & Johnson, Karl Storz, pfm medical Cologne, Dahlhausen Cologne, B. Braun Tuttlingen, MenkeMed, and Bard. No conflicts of interest were reported.
 

SOURCE: Hoffmann H et al. Ann Surg. 2018 Oct 10. doi: 10.1097/SLA.0000000000003065.

BOSTON – Deep surgical site infections after retrorectus ventral hernia repair do not necessarily require mesh excision, according to Cleveland Clinic investigators.

When infected mesh is removed, however, there’s a novel approach that avoids the pitfalls of both immediate and staged abdominal wall reconstruction, according to a second team from the Georgetown University, Washington.

The two approaches were offered at the annual clinical congress of the American College of Surgery as alternatives to usual care. Infected ventral hernia mesh is a well-known headache for general surgeons, and management isn’t standardized. Surgeons are keenly alert for new approaches to improve outcomes; the presenters said they hoped their talks would help.

The work “is really pushing this forward, and giving us new data to manage a really vexing problem,” said an audience member.
 

Almost 80% salvageable

Infected meshes are usually removed, but the Cleveland Clinic investigators found that that’s often not necessary.

They reviewed 905 elective ventral hernia repairs at the clinic with synthetic sublay mesh in the retrorectus space. The median hernia width was about 15 cm, and the implanted mesh – usually medium- or heavy-weight polypropylene – had a mean area of 900 cm², “so these were big hernias with a lot of mesh. [Patients] often come to us as a last resort because they’ve been told no elsewhere,” said lead investigator Dominykas Burneikis, MD.

Twenty-four patients (2.7%) developed deep surgical site infections below the anterior rectus fascia. Instead of returning to the OR for new mesh, the team opened, drained, and debrided the wounds, and patients received antibiotics plus negative pressure wound therapy.

Those measures were enough for all but one patient. Mesh was generally found to be granulating well into surrounding tissue, so it was left completely intact in 19 cases (79%), and just trimmed a bit in four others. One man had an excision after his skin flap died and the hernia recurred. At 8 months, 11 patients were completely healed, and 12 had granulating wounds with no visible mesh. There were no cutaneous fistulas.

In short, “we had an 80% mesh salvage rate at 8 months, [which] led us to conclude that most synthetic mesh infections after retrorectus sublay repair do not require explanation,” Dr. Burneikis said.


 

A hybrid approach

When infected mesh does need to come out, abdominal wall reconstruction is either done in the same procedure or months later. Immediate reconstruction generally means operating in a contaminated field, with subsequent rates of wound infection of up to 48%. Delayed closure, meanwhile, means long-term wound care and temporary hernia recurrence, among other problems.

The Georgetown team reported good outcomes with a hybrid approach that combines the benefits of both procedures while avoiding their pitfalls. In the first step, mesh is removed, the abdominal wall debrided, fistulas taken down, and cultures obtained, explained lead investigator and surgery resident Kieranjeet Nijhar, MD.

The wound is temporarily closed with a sterile plastic liner under negative pressure, and patients are taken to the floor for IV antibiotics based on culture results. Three days later, after the infection has been knocked down, the patient is returned to the OR for debridement to healthy tissue and definitive reconstruction with biologic mesh. It’s all done during the same hospitalization.

Dr. Nijhar reviewed 53 cases at Georgetown since 2009. Patients were a mean age of 58 years, with an average body mass index of 35.1 kg/m². Infected mesh was most commonly underlain or retrorectus; mean defect size was 206 cm². Patients spent an average of 11 days in the hospital.

During a mean follow-up of about 9 months, 17 patients (32%) had surgical site problems – infection, dehiscence, hematoma, or seroma – and hernia recurred in six (11.3%); the results compare favorably with especially immediate reconstruction. As in prior studies, higher age and bridge repair were associated with recurrence and methicillin-resistant Staphylococcus aureus (MRSA) infection with surgical site problems.

“We propose this as a potential alternative for” repairs of ventral hernias with infected mesh, Dr. Nijhar said.

Dr. Nijhar and Dr. Burneikis had no relevant disclosures. There was no external funding for the work.
 

aotto@mdedge.com

BOSTON – Deep surgical site infections after retrorectus ventral hernia repair do not necessarily require mesh excision, according to Cleveland Clinic investigators.

When infected mesh is removed, however, there’s a novel approach that avoids the pitfalls of both immediate and staged abdominal wall reconstruction, according to a second team from the Georgetown University, Washington.

The two approaches were offered at the annual clinical congress of the American College of Surgery as alternatives to usual care. Infected ventral hernia mesh is a well-known headache for general surgeons, and management isn’t standardized. Surgeons are keenly alert for new approaches to improve outcomes; the presenters said they hoped their talks would help.

The work “is really pushing this forward, and giving us new data to manage a really vexing problem,” said an audience member.
 

Almost 80% salvageable

Infected meshes are usually removed, but the Cleveland Clinic investigators found that that’s often not necessary.

They reviewed 905 elective ventral hernia repairs at the clinic with synthetic sublay mesh in the retrorectus space. The median hernia width was about 15 cm, and the implanted mesh – usually medium- or heavy-weight polypropylene – had a mean area of 900 cm², “so these were big hernias with a lot of mesh. [Patients] often come to us as a last resort because they’ve been told no elsewhere,” said lead investigator Dominykas Burneikis, MD.

Twenty-four patients (2.7%) developed deep surgical site infections below the anterior rectus fascia. Instead of returning to the OR for new mesh, the team opened, drained, and debrided the wounds, and patients received antibiotics plus negative pressure wound therapy.

Those measures were enough for all but one patient. Mesh was generally found to be granulating well into surrounding tissue, so it was left completely intact in 19 cases (79%), and just trimmed a bit in four others. One man had an excision after his skin flap died and the hernia recurred. At 8 months, 11 patients were completely healed, and 12 had granulating wounds with no visible mesh. There were no cutaneous fistulas.

In short, “we had an 80% mesh salvage rate at 8 months, [which] led us to conclude that most synthetic mesh infections after retrorectus sublay repair do not require explanation,” Dr. Burneikis said.


 

A hybrid approach

When infected mesh does need to come out, abdominal wall reconstruction is either done in the same procedure or months later. Immediate reconstruction generally means operating in a contaminated field, with subsequent rates of wound infection of up to 48%. Delayed closure, meanwhile, means long-term wound care and temporary hernia recurrence, among other problems.

The Georgetown team reported good outcomes with a hybrid approach that combines the benefits of both procedures while avoiding their pitfalls. In the first step, mesh is removed, the abdominal wall debrided, fistulas taken down, and cultures obtained, explained lead investigator and surgery resident Kieranjeet Nijhar, MD.

The wound is temporarily closed with a sterile plastic liner under negative pressure, and patients are taken to the floor for IV antibiotics based on culture results. Three days later, after the infection has been knocked down, the patient is returned to the OR for debridement to healthy tissue and definitive reconstruction with biologic mesh. It’s all done during the same hospitalization.

Dr. Nijhar reviewed 53 cases at Georgetown since 2009. Patients were a mean age of 58 years, with an average body mass index of 35.1 kg/m². Infected mesh was most commonly underlain or retrorectus; mean defect size was 206 cm². Patients spent an average of 11 days in the hospital.

During a mean follow-up of about 9 months, 17 patients (32%) had surgical site problems – infection, dehiscence, hematoma, or seroma – and hernia recurred in six (11.3%); the results compare favorably with especially immediate reconstruction. As in prior studies, higher age and bridge repair were associated with recurrence and methicillin-resistant Staphylococcus aureus (MRSA) infection with surgical site problems.

“We propose this as a potential alternative for” repairs of ventral hernias with infected mesh, Dr. Nijhar said.

Dr. Nijhar and Dr. Burneikis had no relevant disclosures. There was no external funding for the work.
 

aotto@mdedge.com

BOSTON – Deep surgical site infections after retrorectus ventral hernia repair do not necessarily require mesh excision, according to Cleveland Clinic investigators.

When infected mesh is removed, however, there’s a novel approach that avoids the pitfalls of both immediate and staged abdominal wall reconstruction, according to a second team from the Georgetown University, Washington.

The two approaches were offered at the annual clinical congress of the American College of Surgery as alternatives to usual care. Infected ventral hernia mesh is a well-known headache for general surgeons, and management isn’t standardized. Surgeons are keenly alert for new approaches to improve outcomes; the presenters said they hoped their talks would help.

The work “is really pushing this forward, and giving us new data to manage a really vexing problem,” said an audience member.
 

Almost 80% salvageable

Infected meshes are usually removed, but the Cleveland Clinic investigators found that that’s often not necessary.

They reviewed 905 elective ventral hernia repairs at the clinic with synthetic sublay mesh in the retrorectus space. The median hernia width was about 15 cm, and the implanted mesh – usually medium- or heavy-weight polypropylene – had a mean area of 900 cm², “so these were big hernias with a lot of mesh. [Patients] often come to us as a last resort because they’ve been told no elsewhere,” said lead investigator Dominykas Burneikis, MD.

Twenty-four patients (2.7%) developed deep surgical site infections below the anterior rectus fascia. Instead of returning to the OR for new mesh, the team opened, drained, and debrided the wounds, and patients received antibiotics plus negative pressure wound therapy.

Those measures were enough for all but one patient. Mesh was generally found to be granulating well into surrounding tissue, so it was left completely intact in 19 cases (79%), and just trimmed a bit in four others. One man had an excision after his skin flap died and the hernia recurred. At 8 months, 11 patients were completely healed, and 12 had granulating wounds with no visible mesh. There were no cutaneous fistulas.

In short, “we had an 80% mesh salvage rate at 8 months, [which] led us to conclude that most synthetic mesh infections after retrorectus sublay repair do not require explanation,” Dr. Burneikis said.


 

A hybrid approach

When infected mesh does need to come out, abdominal wall reconstruction is either done in the same procedure or months later. Immediate reconstruction generally means operating in a contaminated field, with subsequent rates of wound infection of up to 48%. Delayed closure, meanwhile, means long-term wound care and temporary hernia recurrence, among other problems.

The Georgetown team reported good outcomes with a hybrid approach that combines the benefits of both procedures while avoiding their pitfalls. In the first step, mesh is removed, the abdominal wall debrided, fistulas taken down, and cultures obtained, explained lead investigator and surgery resident Kieranjeet Nijhar, MD.

The wound is temporarily closed with a sterile plastic liner under negative pressure, and patients are taken to the floor for IV antibiotics based on culture results. Three days later, after the infection has been knocked down, the patient is returned to the OR for debridement to healthy tissue and definitive reconstruction with biologic mesh. It’s all done during the same hospitalization.

Dr. Nijhar reviewed 53 cases at Georgetown since 2009. Patients were a mean age of 58 years, with an average body mass index of 35.1 kg/m². Infected mesh was most commonly underlain or retrorectus; mean defect size was 206 cm². Patients spent an average of 11 days in the hospital.

During a mean follow-up of about 9 months, 17 patients (32%) had surgical site problems – infection, dehiscence, hematoma, or seroma – and hernia recurred in six (11.3%); the results compare favorably with especially immediate reconstruction. As in prior studies, higher age and bridge repair were associated with recurrence and methicillin-resistant Staphylococcus aureus (MRSA) infection with surgical site problems.

“We propose this as a potential alternative for” repairs of ventral hernias with infected mesh, Dr. Nijhar said.

Dr. Nijhar and Dr. Burneikis had no relevant disclosures. There was no external funding for the work.
 

aotto@mdedge.com