Laparoscopic ventral hernia repair reduces wound complications

Postoperative wound complications can be a source of significant morbidity after open ventral hernia repair. By using smaller incisions a laparoscopic approach may decrease this complication. To determine the rate of wound complications after laparoscopic ventral hernia repair prospectively collected data on morbidity in 54 consecutive patients undergoing ventral hernia repair were analyzed. Wound complications were classified as major if there was an open wound or treatment with intravenous antibiotics was required. Minor wound complications consisted of wound erythema or drainage that was treated on an outpatient basis. Eighteen patients underwent open ventral hernia repair. Thirty-six patients underwent attempted laparoscopic repair; five required conversion to an open procedure. Wound complications occurred in 28 and 16 per cent of patients undergoing open and successful laparoscopic repairs, respectively. However, only 3 per cent of patients undergoing laparoscopic repair had a major wound complication as compared with 22 per cent of patients undergoing open herniorrhaphy. Two-thirds of the major wound complications in the attempted laparoscopic group occurred in patients requiring conversion to an open procedure. Laparoscopic ventral hernia repair is a safe and effective alternative to conventional open ventral hernia repair. The main advantage of this minimally invasive approach is a decrease in the rate of major wound complications.     

Miles手术的结肠造瘘口并发症防治

目的 探讨Miles手术结肠痿口并发症的原因和防治措施。方法 回顾性分析126例Miles手术所出现的造口并发症。结果 造口并发症发生98例,其中造口坏死5例、造口回缩7例、造口脓肿、脱出各l例、造口狭窄9例、造口切口旁疝7例和造口周围皮肤炎症97例。结论 并发症常由于术中或术后处理不当引起。     

Intraoperative indocyanine green fluorescence angiography to predict wound complications in complex ventral hernia repair

Introduction

Complex ventral hernia repair (VHR) is associated with a greater than 30 % wound complication rate. Perfusion mapping using indocyanine green fluorescence angiography (ICG-FA) has been demonstrated to predict skin and soft tissue necrosis in many reconstructive procedures; however, it has yet to be evaluated in VHR.

Methods

Patients undergoing complex VHR involving component separation and/or extensive subcutaneous advancement flaps were included in a prospective, blinded study. Patients with active infection were excluded. ICG-FA was performed prior to incision and prior to closure, but the surgeon was not allowed to view it. An additional blinded surgeon documented wound complications and evaluated postoperative photographs. The operative ICG-FA was reviewed blinded, and investigators were then unblinded to determine its ability to predict wound complications.

Results

Fifteen consecutive patients were enrolled with mean age of 56.1 years and average BMI of 34.9, of which 60 % were female. Most (73.3 %) had prior hernia repairs (average of 1.8 prior repairs). Mean defect area was 210.4 cm², mean OR time was 206 min, 66.6 % of patients underwent concomitant panniculectomy, and 40 % had component separation. Mean follow-up was 7 months. Two patients developed wound breakdown requiring reoperation, while 1 had significant fat necrosis and another a wound infection, requiring operative intervention. ICG-FA was objectively reviewed and predicted all 4 wound complications. Of the 12 patients without complications, 1 had an area of low perfusion on ICG-FA. This study found a sensitivity of 100 % and specificity of 90.9 % for predicting wound complications using ICG-FA.

Conclusion

In complex VHR patients, subcutaneous perfusion mapping with ICG-FA is very sensitive and has the potential to reduce cost and improve patient quality of life by reducing wound complications and reoperation.

     

腹壁切口疝的发生及其预防措施

腹壁切口疝是外科剖腹术后的一种常见并发症,多见于腹主动脉瘤或肥胖症患者。切口疝的发生会给患者带来疼痛和不适,有时甚至可引起肠梗阻和肠绞窄,导致患者死亡,不仅严重损害了患者的生命健康,也给医疗保障体系带来了沉重的经济负担。近年来,通过选择适合的手术材料(缝线、补片等)和不断优化改良腹壁切口闭合手术技术,有效预防了患者术后切口疝的发生,减少了术后致残率,并节约了医疗成本。本文就腹壁切口疝的发生率、相关危险因素、治疗现状以及预防措施进行阐述。     

Correlation between early surgical complications and readmission rate after ventral hernia repair

Purpose

Postoperative surgical complications arising from ventral hernia repair have been assessed by a variety of outcome measures. The objective of this study was to correlate the Clavien Dindo Classification (CDC) graded complications with the 30-day readmission rate as early outcome measures in ventral hernia repair. Secondarily, we wanted to investigate whether the risk factors for Clavien Dindo class ≥1 and 30-day readmission were comparable.

Methods

Single-centre retrospective study including all patients (≥18 years) who underwent ventral hernia repair between January 1, 2009 and September 1, 2014 at Zealand University Hospital. Data were obtained from hospital files and the Danish National Patient Registry. A 100% follow-up was obtained.

Results

In total, the study included 700 patients (261 patients with incisional hernia repair and 439 patients with umbilical or epigastric hernia repair). There was a significant association between a complication graded by the CDC ≥1 and 30-day readmission for both incisional and umbilical/epigastric hernia repair (p < 0.001). In incisional hernia, larger hernia size was an independent risk factor for CDC ≥1. No independent risk was found for 30-day readmission. Recurrent (vs. primary) hernia repair was an independent risk factors for both CDC ≥1 and 30-day readmission in umbilical/epigastric hernia repair. Furthermore, hernia size 2–7 cm (vs. >2 cm) was a risk factor for CDC ≥1 but not for 30-day readmission in umbilical/epigastric hernia repair.

Conclusion

Reports on 30-day readmission can be used as a general outcome measure in ventral hernia repair, however CDC provides a more precise and detailed registration of postoperative complications.

     

Comparative study of wound complications: Isolated panniculectomy versus panniculectomy combined with ventral hernia repair

BackgroundThe resection of an abdominal pannus carries the risk of wound-related morbidity in obese patients. Surgeons often perform a panniculectomy (PAN) to gain better access to the abdomen to perform other operations. We evaluated the incidence of wound complications after PAN with and without a concomitant procedure (i.e., ventral hernia repair [VHR]).MethodsWe reviewed the prospective data from all patients who underwent PAN alone and PAN combined with VHR from 2007 to 2011 at a single institution. The demographic data, operative information, and postoperative wound complications and interventions were recorded and analyzed using standard statistical methods. Multivariate logistic regression analysis was performed to control for confounding factors.ResultsAfter excluding the patients who had undergone concomitant procedures involving the gastrointestinal or genitourinary tract, 185 patients were included in the present study (143 patients in the PAN-VHR group and 42 in the PAN group). The average patient age was 55.4 and 47.6 years in the two groups (P = 0.001). The average body mass index was 38.0 and 41.1 kg/m² (P = 0.69). Of the 143 patients in the PAN-VHR group, 81.1% were women. In the PAN group, 92.9% were women (P = 0.09). The mean length of follow-up was 6.5 and 3.3 mo in the PAN-VHR and PAN groups, respectively (P = 0.04). In the PAN-VHR group, 96.5% underwent hernia repair with mesh and 29% underwent component separation. Subcutaneous talc was used in 58.6% of the PAN-VHR patients and 38.1% of the PAN patients (P = 0.02). Wound pulse-a-vac irrigation with bacitracin solution was used in 37.1% of PAN-VHR patients and 19.1% of the PAN patients (P = 0.03). The rate of wound complications and interventions for the PAN-VHR and PAN groups were not significantly different statistically (P < 0.05) and included seroma, seroma drainage, wound breakdown or necrosis, cellulitis, wound interventions, including bedside debridement and vac placement, and reoperation. After controlling for age, gender, body mass index, talc use, and pulse-a-vac irrigation use in the multivariate logistic regression analysis, the PAN-VHR group were more likely to develop cellulitis than the PAN-alone group (P = 0.004). The rates of all other wound complications were not significantly different statistically between the two groups after adjusting for confounding factors.ConclusionsPAN is associated with a significant risk of wound-related complications. The risk of postoperative cellulitis is increased further in patients who undergo concomitant VHR. However, the risk of all other wound complications and the need for interventions was not increased by performing concomitant VHR.     

Predictors of wound infection in ventral hernia repair

BACKGROUND: Postoperative wound infection is a significant risk factor for recurrence after ventral hernia repair (VHR). The current study examines patient- and procedure-specific variables associated with wound infection. METHODS: A cohort of subjects undergoing VHR from 13 regional Veterans Health Administration (VHA) sites was identified. Patient-specific risk variables were obtained from National Surgical Quality Improvement Program (NSQIP) data. Operative variables were obtained from physician-abstracted operative notes. Univariate and multivariable logistic regression analysis was used to model predictors of postoperative wound infection. RESULTS: A total of 1505 VHR cases were used for analysis; wound infection occurred in 5% (n = 74). Best-fit logistic regression models demonstrated that steroid use, smoking, prolonged operative time, and use of absorbable mesh, acting as a surrogate marker for a more complex procedure, were significant independent predictors of wound infection. CONCLUSION: Permanent mesh placement was not associated with postoperative wound infection. Smoking was the only modifiable risk factor and preoperative smoking cessation may improve surgical outcomes in VHR.     

Influence of statins on postoperative wound complications after inguinal or ventral herniorrhaphy

The lipid-lowering agents, statins, are the most commonly prescribed class of drugs in the western world. Because of their widespread use, many patients undergo surgical procedures while on statins. Statins, in addition to cholesterol-lowering effects, also have anticoagulant, immunosuppressive, and antiproliferative properties that may affect the risk of local wound complications. This study investigated the relationship between statins and postoperative wound complications in a large cohort of patients undergoing inguinal or ventral hernia repair. Data mining was performed in the Veterans Integrated Service Network (VISN)16 Data Warehouse. This database contains clinical and demographic information about all veterans cared for at the ten VA Medical Centers that comprise the South Central VA Healthcare Network in the mid-south region of the US. Aggregate data (age, body mass index, smoking history, gender, race, history of diabetes, statin use, and postoperative wound complications) were obtained for all patients who underwent inguinal or ventral hernia repair during the period October 1, 1996–November 30, 2004. During the period of the query, 10,782 patients (10,676 male, 106 female), 1,242 (11.5%) of whom received statins, underwent herniorrhaphy. Statin use did not affect the risk of wound infection or delayed wound healing. Statin use was, however, associated with an increased rate of local postoperative bleeding complications (P=0.01). When the type of hernia, age, smoking, diabetes, and body mass index were included in a multivariate analysis, statins remained borderline significant as an independent predictor of wound hematoma/postoperative bleeding (P=0.04), odds ratio 1.6 (95% CI 1.03–2.44). Patients who undergo inguinal herniorrhaphy while on statins have an increased risk of postoperative wound hematoma/hemorrhage. Focus on additional factors that may affect the propensity to postoperative bleeding and on meticulous intraoperative hemostasis are particularly important in such patients.     

Long-term complications of laparoscopic ventral and incisional hernia repair

To date, there have been no long-term follow-up studies of the results of laparoscopic ventral and incisional hernia repair. We evaluated the long-term complications of these repairs over a mean follow-up period of 64 months. Between March 1993 and April 2000, we retrospectively evaluated 9 patients who underwent ventral or incisional hernia repair with prosthetic material and one patient who received laparoscopic primary closure of a hernia defect. The prosthetic material polypropylene was used in one patient and an expanded-polytetrafluoroethylene patch was used in the other 8. In one patient, the hernia was closed directly. In 7 patients, the prosthesis was fixed by stapling or tacking with no transfacial suture fixation and a 2-cm prosthesis overlap. In 2 later patients, we modified our technique by fixing the prosthesis by stapling or tacking with transfacial suture fixation and using prosthesis overlap of more than 3 cm. There were 2 episodes of hernia recurrence (20%), one of which required reoperation. Both occurred in patients in whom we used the unmodified repair technique. One of the patients in whom we used the unmodified technique developed a seroma which resolved spontaneously without antibiotic therapy. One patient in whom we used the modified technique developed infection (10%) requiring removal of the prosthetic material. The 2 episodes of hernia recurrence occurred 40 months after laparoscopic treatment, and the case of infection occurred 11 months after treatment. There were no episodes of recurrence in patients who received the unmodified surgery and had hernia defects less than 42 cm2. To perform safe and effective laparoscopic repair of ventral or incisional hernias, it is necessary to use a prosthetic overlap of more than 3 cm from the edge of the hernia gate and to use transfacial suture fixation with nonabsorbable sutures. In addition, patients who undergo laparoscopic ventral or incisional hernia repair should be observed for more than 5 years.     

Perioperative outcomes and complications of laparoscopic ventral hernia repair

BACKGROUND: Laparoscopic techniques are being used increasingly in the repair of ventral hernias and offer the potential benefits of a shorter hospital stay, decreased wound complications, and possibly a lower recurrence rate. Despite good results from high-volume centers, significant complications may occur with this approach and the morbidity of incisional hernia repair may be underestimated. The purpose of this study was to review our experience with laparoscopic ventral hernia repair (LVHR) since its inception at our institution. METHODS: Medical records of all patients who underwent LVHR at a single institution from May 2000 through December 2003 were reviewed. Preoperative and postoperative variables including complications were analyzed. Follow-up evaluation was by office visit and phone survey with assessment of patient satisfaction scores. Data are expressed as mean +/- SD. RESULTS: A total of 121 LVHR were performed in 116 patients (52 men, 64 women; mean age, 57 +/- 13 y; mean body mass index, 35 +/- 8). Hernias were recurrent in 35 cases (28.9%), with a mean of 1.4 prior repairs (range, 1-7). The mean defect size was 109 +/- 126 cm2 and the average mesh size used was 256 +/- 192 cm2. Operating time was 147 +/- 45 minutes, and the hospital stay averaged 1.7 +/- 1 days. Twelve cases (9.9%) were converted to open operation, most commonly because of extensive adhesions. Extensive laparoscopic adhesiolysis was necessary in 29 cases (26.6%). Overall, perioperative complications occurred in 33 cases (27.3%), 13 of which (39.3%) were persistent seromas. Major complications were seen in 9 cases (7.4%). There were 4 enterotomies (3.3%): 3 occurred as a result of adhesiolysis and 1 resulted from a trocar injury; 2 were detected intraoperatively and were converted to open operation and 2 presented postoperatively. One of these patients developed sepsis and died. Follow-up evaluation was available for 83.6% of cases at a mean interval of 22 +/- 16 months after repair. The hernia recurrence rate was 9.3% (9 cases) and was detected at a median of 6 months postoperatively. The overall patient satisfaction score was high at 4.3 +/- 1.1 (scale, 1-5). CONCLUSIONS: Laparoscopic repair is effective for the vast majority of patients with primary or recurrent ventral hernias and results in hernia recurrence rates of less than 10%, with high patient satisfaction scores. Although seroma is the most common complication, major morbidity occurred in 7.4% of the patients in our series. Enterotomy is the most common serious complication and may result in sepsis and death.     

腹壁切口疝修补术后腹壁膨出相关因素研究

目的探讨腹壁切口疝术后腹壁膨出（bulging）及复发的发生率及其相关危险因素。 方法回顾性分析2008年1月至2017年12月,复旦大学附属华东医院行腹壁切口疝修补术治疗的774例患者临床资料,观察腹壁膨出及疝复发的发生率与临床病例因素的关系。 结果术后平均住院时间（8.15±2.60）d,随访时间3～78个月。术后腹壁膨出58例（7.49%）,患者体质量指数（BMI）、是否急诊手术、是否使用补片、补片放置层次、手术入路、是否关闭腹壁缺损等与腹壁切口疝修补术后腹壁膨出有关。 结论影响腹壁切口疝术后腹壁膨出发生的独立危险因素为BMI、是否急诊手术、是否使用补片、补片放置的层次、手术入路、是否关闭腹壁缺损。临床应加强术前病例的筛选,减少急诊手术的同时,严格控制患者体重,选择合适的手术方式和植入修补、确实关闭腹壁缺损,并加强术后切口管理,以预防和减少腹壁切口疝术后腹壁膨出的发生。     

The use of indocyanine green angiography to prevent wound complications in ventral hernia repair with open components separation technique

Large ventral hernias can be managed with open components separation technique and onlay mesh reinforcement with low hernia recurrence rates. However, disruption of the perforating vessels to the medial skin flaps results in high rates of wound complications after the operation. An aggressive wound protocol including debridement of tissue with poor perfusion is needed to minimize complications. ICG angiography, a novel technology designed to detect tissue perfusion, can assist in this effort by identifying the ischemic areas to help guide the extent of debridement. This report presents a case in which ICG angiography–assisted open components separation was performed.     

Review of wound healing with reference to an unrepairable abdominal hernia.

A 58-year-old man has been under our care with an inguinal hernia that has recurred 8 times. This stimulated us to review the biochemistry of wound repair. We studied the composition of his collagen and tried to find out whether it was intrinsically faulty or whether its fault had been caused by the medication he was taken.