A single institutional comparison of endoscopic and open abdominal component separation

Background

The authors analyzed surgical factors and outcomes data in the largest single institutional study comparing endoscopic (ECS) and open component separation (OCS) in ventral hernia repairs (VHR).

Methods

A prospectively maintained database was reviewed, identifying 76 patients who underwent component separation for VHR with mesh from 2010 to 2013: 34 OCS and 42 ECS. Comparisons were made for demographics, surgical risk factors, and peri-operative outcomes. Wound complications and hernia occurrence post-operatively were reviewed. Risk analyses were performed to determine the association of pre-operative risk factors with surgical site occurrences.

Results

Twenty-five ECS patients underwent subsequent laparoscopic hernia repair, and 17 underwent open repair. Operative time for ECS was longer than OCS (334 vs. 239 min; P < 0.001); however, there was no difference in length of stay (4 days in both groups, P = 0.64) and estimated blood loss (ECS: 97 vs. OCS: 93 cc, P = 0.847). In a sub-analysis of ECS patients, those who underwent laparoscopic hernia repair had a 96 min shorter operative time (P < 0.001) and lower EBL (63 vs. 147 cc, P < 0.001) than open repair. Wound complications were 24 % in the ECS (n = 10) and 32 % in OCS group (n = 11). There was one midline hernia recurrence in the ECS group (mean follow-up of 8 months, range 0.5–34.5 months) and no hernia recurrences in the OCS group (mean follow-up 10 months, range 0.5–30 months). Three of the patients in the ECS group developed new lateral abdominal wall hernias post-operatively.

Conclusions

The ECS group had a significantly longer operative time than the OCS group. Post-operative wound complications were similar between ECS and OCS groups. Patients in the ECS group who underwent subsequent laparoscopic VHR had a shorter operative time and blood loss than open repair.     

Current national practice patterns for inpatient management of ventral abdominal wall hernia in the United States

Background

The health-care burden related to ventral hernia management is substantial, with more than 3 billion dollars in expenditures annually in the US. Previous studies have suggested that the utilization of laparoscopic repair remains relatively low although national volume estimates have not been reported. We sought to estimate the inpatient national volume of elective ventral hernia surgery and characterize the proportion of laparoscopic versus open operations.

Methods

We analyzed data from the Nationwide Inpatient Sample to identify adults with a diagnosis of an umbilical, incisional, or ventral hernia who underwent an elective inpatient repair between 2009 and 2010. Cases that involved other major abdominal or pelvic operations were excluded. Covariates included patient demographics, surgical approach, and use of mesh. National surgical volume estimates were generated and length of stay and total hospital charges were compared for laparoscopic versus open repairs.

Results

A total of 112,070 ventral hernia repairs were included in the analysis: 72.1 % (n = 80,793) were incisional hernia repairs, while umbilical hernia repairs comprised only 6.9 % (n = 7,788). Laparoscopy was utilized in 26.6 % (n = 29,870) of cases. Mesh was placed in 85.8 % (n = 96,265) of cases, including 49.3 % (n = 3,841) of umbilical hernia repairs and 90.1 % (n = 72,973) of incisional hernia repairs. Length of stay and total hospital charges were significantly lower for laparoscopic umbilical, incisional, and “other” ventral hernia repairs (p values all <0.001). Total hospital charges during this 2-year period approached 4 billion dollars ($746 million for laparoscopic repair; $3 billion for open repair).

Conclusions

Utilization of laparoscopy for elective abdominal wall hernia repair remains relatively low in the US despite its excellent outcomes. Given the substantial financial burden associated with these hernias, future research focused on preventing the development and optimizing the surgical treatment of ventral abdominal wall hernias is warranted.     

Fifteen-year experience in managing obturator hernia: from open to laparoscopic approach

Purpose

Obturator hernia is a rare disease and preoperative diagnosis is always difficult. There are increasing reports employing laparoscopic approach in the recent literature. Our aim was to review and compare the open and laparoscopic approach in repairing obturator hernia.

Methods

All patients with obturator hernia from 1997 to 2011 were recruited. Patient’s demographics, presentation, operative details, morbidity, and mortality were retrospectively collected and reviewed.

Results

There were 36 patients during the 15-year period. All of them were elderly ladies (median 83). Nineteen underwent open surgery while 16 received laparoscopic surgery. Both age and ASA were comparable. The median operative time was 68 and 65 min for laparoscopic and open group, respectively (p = 0.690). The median hospital stay was significantly longer in the open group (19 vs 5 days, p = 0.007). There were less major complications (p = 0.004) and mortality (p = 0.049) in the laparoscopic group. Two recurrences were reported in the laparoscopic group, although statistically not significant (p = 0.202).

Conclusions

Laparoscopic repair can achieve a shorter hospital stay and has lesser major complications and mortality in selected patients.     

Endoscopic component separation for ventral hernia causes fewer wound complications compared to open components separation: a systematic review and meta-analysis

Background

Open component separation (OCS) for tension-free approximation of fascial borders is increasingly used for repair of large midline ventral hernias. Recent studies suggested lower complication rates following a modified version of this technique with an endoscopic approach (ECS). The aim of this meta-analysis was to compare the outcomes after ECS and OCS.

Methods

A literature search was performed in PubMed and Embase in order to identify studies comparing ECS and OCS as a supplementary procedure for surgical repair of ventral hernia. The included studies were independently assessed using the Newcastle Ottawa Scale. Outcomes analyzed were wound complications, hernia recurrence and length of stay. A meta-analysis on the pooled data was performed.

Results

The literature search identified 222 articles, of which five retrospective comparative cohort studies were included in the review and meta-analysis reporting on a total of 163 patients. Patient demography and the rates of mesh repair were comparable between the ECS and OCS patient groups. The incidence of wound complications comprising surgical site infection, skin necrosis, subcutaneous abscess, seroma, skin dehiscence, cellulitis, and fistula was significantly less after ECS (odds ratio [OR] 0.27, 95 % confidence interval [CI] 0.12–0.58, p < 0.001). The incidence of recurrent hernia was 13 % after ECS and 16 % after OCS (OR 0.76, 95 % CI 0.29–1.98, p = 0.57). Four studies reported length of stay that was comparable between the groups (mean difference ?0.14 days, 95 % CI ?1.49 to 1.21, p = 0.84).

Conclusions

ECS causes fewer wound complications compared with OCS.     

Short- and mid-term outcome after laparoscopic repair of large incisional hernia

Purpose

To compare the outcome after laparoscopic incisional and ventral herniorrhaphy (LIVH) for fascial defect larger or equal than 15 cm in width with the outcome after LIVH in patients with hernia defect smaller than 15 cm.

Methods

From 2003 through 2010, 350 patients were submitted to LIVH. In 70 cases, hernia defect was ≥15 cm in width and in 280 was <15 cm. Incisional hernias were often recurrent, double or multiorificial. In the group of larger hernias, the rate of obesity, recurrent hernia and multiorificial hernia was 27.1, 24.2 and 12.8 %, respectively, and in the group of smaller hernias 27.3, 16.1 and 2.8 %, respectively. Patients were interviewed using McGill pain score test to measure postoperative quality of life (QoL) in the mid-term.

Results

LIVH for hernia ≥15 cm required longer surgical time (p = 0.034) and postoperative hospital stay (p = 0.0001). Besides, there were higher rate of postoperative prolonged ileus (p = 0.035) and polmonitis (p = 0.001). Overall recurrence rate was 2.6, 8.6 % for larger and 1.1 % for smaller incisional hernias, p = 0.045. Mc Gill pain test revealed no significant difference in the two groups of patients in postoperative QoL within 36 months.

Conclusions

Laparoscopic approach seems safe and effective even to repair large incisional hernia, the rate of recurrence was higher, but acceptable, if compared to smaller hernias. To the best of our knowledge, this is the largest reported series of incisional hernias ≥15 cm managed by laparoscopy.     

One-Year Follow-up After Open Abdomen Therapy With Vacuum-Assisted Wound Closure and Mesh-Mediated Fascial Traction

Background

Open abdomen (OA) therapy frequently results in a giant planned ventral hernia. Vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) enables delayed primary fascial closure in most patients, even after prolonged OA treatment. Our aim was to study the incidence of hernia and abdominal wall discomfort 1 year after abdominal closure.

Methods

A prospective multicenter cohort study of 111 patients undergoing OA/VAWCM was performed during 2006–2009. Surviving patients underwent clinical examination, computed tomography (CT), and chart review at 1 year. Incisional and parastomal hernias and abdominal wall symptoms were noted.

Results

The median age for the 70 surviving patients was 68 years, 77 % of whom were male. Indications for OA were visceral pathology (n = 40), vascular pathology (n = 22), or trauma (n = 8). Median length of OA therapy was 14 days. Among 64 survivors who had delayed primary fascial closure, 23 (36 %) had a clinically detectable hernia and another 19 (30 %) had hernias that were detected on CT (n = 18) or at laparotomy (n = 1). Symptomatic hernias were found in 14 (22 %), 7 of them underwent repair. The median hernia widths in symptomatic and asymptomatic patients were 7.3 and 4.8 cm, respectively (p = 0.031) with median areas of 81.0 and 42.9 cm², respectively (p = 0.025). Of 31 patients with a stoma, 18 (58 %) had a parastomal hernia. Parastomal hernia (odds ratio 8.9; 95 % confidence interval 1.2–68.8) was the only independent factor associated with an incisional hernia.

Conclusions

Incisional hernia incidence 1 year after OA therapy with VAWCM was high. Most hernias were small and asymptomatic, unlike the giant planned ventral hernias of the past.     

Planned ventral hernia following damage control laparotomy in trauma: an added year of recovery but equal long-term outcome

Purpose

Significantly injured trauma patients commonly require damage control laparotomy (DCL). These patients undergo either primary fascial closure during the index hospitalization or are discharged with a planned ventral hernia. Hospital and long-term outcomes of these patients have not been extensively studied.

Methods

Patients who underwent DCL for trauma from 2003 to 2012 at a regional Level I trauma center were identified and a comparison was made between those who had primary fascial closure and planned ventral hernia.

Results

DCL was performed in 154 patients, 47 % of whom sustained penetrating injuries. The mean age and injury severity score (ISS) were 40 and 25, respectively. Hospital mortality was 19 %. Primary fascial closure was performed in 115 (75 %) of those undergoing DCL during the index hospitalization. Of these, 11 (9 %) had reopening of the fascia. Of the surviving patients, 22 (19 %) never had primary fascial closure and were discharged with a planned ventral hernia. Patients with primary fascial closure and those with planned ventral hernia were similar in age, gender, ISS, and mechanism. Those with planned ventral hernias underwent more subsequent laparotomies (3.0 vs 1.3, p < 0.001), and had more enteric fistulas (18.2 vs 4.3 %, p = 0.041) and intra-abdominal infections (46 vs 15 %, p = 0.007), and had a greater number of hospital days (38 vs 25, p = 0.007) during the index hospitalization. Sixteen (73 %) patients with a planned ventral hernia had definitive reconstruction (mean days = 266). Once definitive abdominal wall closure was achieved, the two groups achieved similar rates of return to work and usual activity (71 vs 70 %, p = NS).

Conclusions

Following DCL for trauma, patients with a planned ventral hernia have definitive reconstruction nearly 9 months after the initial injury. Once definitive abdominal wall closure has been achieved; patients with primary fascial closure and those with planned ventral hernia have similar rates of return to usual activity.

     

Direct and Recurrent Inguinal Hernias Are Associated with Ventral Hernia Repair: A Database Study

Background

A systemically altered connective tissue metabolism has been demonstrated in patients with abdominal wall hernias. The most pronounced connective tissue changes are found in patients with direct or recurrent inguinal hernias as opposed to patients with indirect inguinal hernias. The aim of the present study was to assess whether direct or recurrent inguinal hernias are associated with an elevated rate of ventral hernia surgery.

Methods

In the nationwide Danish Hernia Database, a cohort of 92,457 patients operated on for inguinal hernias was recorded from January 1998 until June 2010. Eight-hundred forty-three (0.91 %) of these patients underwent a ventral hernia operation between January 2007 and June 2010. A multivariate logistic regression analysis was applied to assess an association between inguinal and ventral hernia repair.

Results

Direct (Odds Ratio [OR] = 1.28 [95 % CI, 1.08–1.51]) and recurrent (OR = 1.76, [95 % CI, 1.39–2.23]) inguinal hernias were significantly associated with ventral hernia repair after adjustment for age, gender, and surgical approach (open or laparoscopic).

Conclusions

Patients with direct and recurrent inguinal herniation are more prone to ventral hernia repair than patients with indirect inguinal herniation. This is the first study to show that herniogenesis is associated with type of inguinal hernia.     

Laparoscopic versus open hernia repair: outcomes and sociodemographic utilization results from the nationwide inpatient sample

Introduction

The differences and advantages of laparoscopic (LVHR) and open ventral hernia repair (OVHR) have been debated since laparoscopic hernia repair was first described. The purpose of this study is to compare LVHR and OVHR with mesh in the United States using the Nationwide Inpatient Sample (NIS).

Methods

The NIS, a representative sample of approximately 20 % of all inpatient encounters in the United States, was queried for all ventral hernia repairs with graft or prosthesis in 2009 using ICD-9-CM codes. The patients were stratified into LVHR and OVHR groups. Sociodemographic data, comorbidities, complications, and outcomes were compared between groups.

Results

A total of 18,223 cases were documented in the NIS sample after inclusion and exclusion criteria were met. LVHR was performed in 27.6 % of cases. There were no statistically significant differences in gender or mean income by zip code of residence. Mean age (58.8 years in open group vs. 58.1 years, p = 0.014) and mean Charlson score (0.97 vs. 0.77, p < 0.0001) differed significantly between groups. OVHR more often was associated with emergent admissions (21.7 vs. 15.2 %, p < 0.0001). There were significant differences comparing outcomes between groups: complication rate (OVHR: 8.24 vs. LVHR: 3.97 %, p < 0.0001), average length of stay (5.2 vs. 3.5 days, p < 0.0001), total charge ($45,708 vs. $35,947, p < 0.0001), frequency of routine discharge (80.8 vs. 91.1 %, p < 0.0001), and mortality rate (0.88 vs. 0.36 %, p = 0.0002). After controlling for confounding variables with multivariate regression, all outcomes remained significant between groups.

Conclusions

Patients who have undergone LVHR with mesh had fewer complications, shorter length of stay, lower hospital charges, more frequent routine discharge, and decreased mortality compared with those who received open repair. Patient comorbidities, selection bias, and emergency operations may limit the number of patients who receive laparoscopic ventral hernia repair. Regionalization studies may better illuminate the low rates of laparoscopic surgery.     

Infected large pore meshes may be salvaged by topical negative pressure therapy

Purpose

To evaluate the efficacy of negative pressure therapy for superficial and deep mesh infections after ventral and incisional hernia repair by a prospective monocentric observational study.

Methods

During a 6-year period, 724 consecutive open ventral and incisional hernia repairs were performed. Pre- and intraoperative data as well as postoperative complications were prospectively recorded. In case of wound infection, negative pressure therapy (NPT) was our primary treatment.

Results

Sixty-three patients (8.7 %) were treated using negative pressure therapy after primary ventral and incisional hernia repair. Infectious complications needing NPT occurred in 54 patients in the retromuscular group (54/523; 10.3 %), none when laparoscopically treated and in 9 patients (9/143; 6.3 %) treated by an open intraperitoneal mesh technique. Considering outcome, all meshes were completely salvaged in the retromuscular mesh group after a median of 5 dressing changes (range, 2–9), while in the intraperitoneal mesh, group 3 meshes needed complete (n = 2) or partial (n = 1) excision. Mean duration to complete wound closure was 44 days (range, 26–63 days).

Conclusion

NPT is a useful adjunct for salvage of deep infected meshes, particularly when large pore monofilament mesh is used.     

Comparison of open and laparoscopic preperitoneal repair of groin hernia

Background

Compared with laparoscopic groin herniorrhaphy, the open procedure used in most former studies was Lichtenstein repair. However, unlike the totally extraperitoneal (TEP) or transabdominal preperitoneal (TAPP) laparoscopic techniques, Lichtenstein procedure is a premuscular but not preperitoneal repair. This retrospective study compared the outcomes between laparoscopic preperitoneal and open preperitoneal procedure—modified Kugel (MK) herniorrhaphy.

Methods

Groin hernia patients older than 18 years who underwent open MK or laparoscopic preperitoneal herniorrhaphy in our hospitals between January 2008 and December 2010 were enrolled. Baseline characteristics, recurrence, and intraoperative, short-term, and long-term postoperative complications were recorded.

Results

Among the 1,760 included patients (530 open and 1,230 laparoscopic), 96.08 % completed the follow-up (24–60 months). The patients in the open group were older than laparoscopic group (p < 0.001). More bilateral (91.45 %) and recurrent (82.12 %) hernia patients underwent laparoscopic procedures (p < 0.001 and p = 0.004, respectively). The overall recurrence rate was 0.71 %, with no significant difference between the two approaches (p = 0.227). The overall complication rate was lower for the laparoscopic than the open approach (14.47 vs. 19.25 %, p = 0.012), whereas the rates of life-threatening complications were similar (1.51 vs. 0.98 %, p = 0.332). The laparoscopic group had significantly lower incidence rates of wound infection and chronic pain (p = 0.016 and p < 0.001, respectively), shorter operative time, lower visual analogue scale scores, and faster recovery than the open group (p < 0.001).

Conclusions

As preperitoneal herniorrhaphy, both MK and laparoscopic (TEP/TAPP) procedures are safe and effective, with low incidence rates of life-threatening complications and recurrence. The laparoscopic approach is superior in terms of lower incidence rates of infection and chronic pain, shorter operative time, and faster recovery; however, careful surgical procedure selection and implementation of technical details are required.     

Laparoscopic versus open ventral hernia repair: longitudinal outcomes and cost analysis using statewide claims data

Background

There is still considerable debate regarding the best operative approach to ventral hernia repair. Using two large statewide databases, this study sought to evaluate the longitudinal outcomes and associated costs of laparoscopic and open ventral hernia repair.

Methods

All patients undergoing elective ventral hernia repair from 2007–2011 were identified from inpatient discharge data from California and New York. In-hospital morbidity, in-hospital mortality, incidence of readmission, and incidence of revisional ventral hernia repair were evaluated as a function of surgical technique. The associated costs of medical care for laparoscopic versus open ventral hernia repair were evaluate for both the index procedure and all subsequent admissions and procedures within the study period.

Results

A total of 13,567 patients underwent elective ventral hernia repair with mesh; 9228 (69 %) underwent OVHR and 4339 (31 %) underwent LVHR. At time of the index procedure, LVHR was associated with a lower incidence of reoperation (OR 0.29, CI 0.12–0.58, p = 0.001), wound disruption (OR 0.35, CI 0.16–0.78, p = 0.01), wound infection (OR 0.50, CI 0.25–0.70, p < 0.001), blood transfusion (OR 0.47, CI 0.36–0.61, p < 0.001), ARDS (OR 0.74, CI 0.54–0.99, p < 0.05), and total index visit complications (OR 0.72, CI 0.64–0.80, p < 0.001). LVHR was associated with significantly fewer readmissions (OR 0.81, CI 0.75–0.88, p < 0.001) and a lower risk for revisional VHR (OR 0.75, CI 0.64–0.88, p < 0.001).

Conclusions

Open ventral hernia repair was associated with a higher incidence of perioperative complications, postoperative readmissions and need for revisional hernia repair when compared to laparoscopic ventral hernia repair, even when controlling for patient sociodemographics. In congruence, open ventral hernia repair was associated with higher costs for both the index hernia repair and tallied over the length of follow-up for readmissions and revisional hernia repair.

     

Closing the gap between the laparoscopic and open approaches to abdominal wall hernia repair: a trend and outcomes analysis of the ACS-NSQIP database

Objective

To assess trends in utilization and perioperative outcomes of laparoscopic and open abdominal wall hernia repair.

Methods

Using the ACS-NSQIP database between 2009 and 2012, patients were identified as having an ICD-9 diagnosis of an umbilical, ventral, or incisional hernia as well as a CPT code for a laparoscopic or open abdominal wall hernia repair. A coarsened exact matching procedure was utilized to create a matched cohort to mitigate selection bias. Thirty-day outcomes analysis was done for the aggregate and matched cohorts. Subcategory analysis was performed for inpatient/outpatient status, strangulated/incarcerated hernias, initial/recurrent repairs, and hernia type (umbilical, ventral, incisional). Chi-square analysis was performed to determine the statistical significance of each comparison.

Results

In total, 112,074 qualifying patients were identified, 86,566 (77.24 %) open and 25,508 (22.76 %) laparoscopic. Patients undergoing laparoscopic repair were more likely to have preexisting comorbidities, but less likely to experience any postoperative morbidity (11.74 vs. 7.25 %, P < 0.0001), serious morbidity (4.55 vs. 3.02 %, P < 0.0001), or mortality (0.36 vs. 0.24 %, P = 0.0030). Creation of the matched cohort produced 17,394 patients in both the laparoscopic and open groups and resulted in a loss of advantage for the laparoscopic approach in terms of morbidity associated with umbilical hernia repairs (P = 0.0082 vs. P = 0.3172). Patients undergoing laparoscopic repair were still less likely to experience any postoperative (9.57 vs. 4.92 %, P < 0.0001) or serious morbidity (3.37 vs. 1.70 %, P < 0.0001). Hospital length of stay in the matched cohort supported initial primary repairs done by an open approach.

Conclusion

The laparoscopic approach is used in a minority of abdominal wall hernia repairs, though utilization increased by 40 % from 2009 to 2012. The laparoscopic approach continues to be safer on many fronts, but not all, and is arguably not better for umbilical or primary hernia repairs on the basis of overall morbidity and length of stay.

     

Randomized clinical trial of mesh fixation with “double crown” versus “sutures and tackers” in laparoscopic ventral hernia repair

Background

Although laparoscopic intra-peritoneal mesh repair (LVHR) is a well-established treatment option to repair ventral and incisional hernias, no consensus in the literature can be found on the best method of fixation of the mesh to the abdominal wall.

Methods

Between December 2004 and July 2008, 76 patients undergoing a LVHR were randomized between mesh fixation using a double row of spiral tackers (DC) (n = 33) and mesh fixation with transfascial sutures combined with one row of spiral tackers (S&T) (n = 43), in the WoW trial (with or without sutures). Patients were clinically examined and evaluated using a visual analog scale for pain (VAS) in rest and after coughing 4 h post-operatively, after 4 weeks and 3 months after surgery. Primary endpoint of the study was abdominal wall pain, defined as a VAS score of at least 1.0 cm, at 3 months post-operative. Quality of life was quantified with the SF-36 questionnaire preoperatively and after 3 months. Secondary endpoint was the recurrence rate at 24-month follow-up.

Results

The DC and S&T group were comparable in age, gender, ASA score, BMI, indication, hernia, and mesh variables. The DC group had a significant shorter operating time compared with the S&T group (74 vs 96 min; p = 0.014) and a significant lower mean VAS score 4 h post-operatively (in rest; p = 0.028/coughing; p = 0.013). At 3 months, there were significant more patients in the S&T group with VAS score ≥1.0 cm (31.4 vs 8.3 %; p = 0.036). Clinical follow-up at 24 months was obtained in 63 patients (82.9 %). The recurrence rate at 24 months was 7.9 % overall (5/63). There were more recurrences in the S&T group (4/36) than in the DC group (1/27), but this difference was not significant (11.1 vs 3.7 %; p = 0.381).

Conclusion

We found that double-crown fixation of intra-peritoneal mesh during laparoscopic ventral hernia repair was quicker, was less painful immediately post-operative and after 3 months, and did not increase the recurrence rate at 24 months. In hernias at a distance from the bony borders of the abdomen, transfascial sutures can be omitted if a double crown of tackers is placed.     

Onlay ventral hernia repairs using porcine non-cross-linked dermal biologic mesh

Introduction

Ventral hernias are common and repair with mesh has been shown to reduce recurrence. However, synthetic mesh is associated with a risk of infection. Biologic mesh is an alternative that may be less susceptible to infection. Typically, the sublay position is preferred for mesh placement but this technique takes longer and has not been shown to have a lower recurrence rate than an onlay mesh. The aim of this study was to evaluate the outcome of complex ventral hernia repair using a porcine non-cross-linked biologic mesh onlay.

Methods

A retrospective chart review was performed of all patients that had a ventral hernia repair with biologic mesh from January 2009 to March 2012. The operative procedure in all patients was an open repair with primary fascial closure (if possible) with or without external oblique component separation and porcine biologic mesh onlay.

Results

There were 22 patients that had a ventral hernia repair, 19 primary and 3 recurrent. The majority were men, had hernia grade 3 or 4, and developed the hernia after an esophagectomy or gastrectomy for cancer. All but one had primary closure with a porcine biologic mesh onlay. One patient was bridged for loss of domain. A bilateral external oblique component separation was added in 16 patients (73 %). The median hospital stay was 7 days. There were two superficial wound infections, one with exposed mesh, but no patient required mesh removal. A seroma requiring intervention developed in 6 patients (27 %) and resolved with pig-tail drainage. At a median follow-up of 7 months, there has been no hernia recurrence apart from the patient that was bridged.

Conclusions

Porcine non-cross-linked biologic mesh overlay has excellent short-term results in patients at increased risk for mesh infection. No patient required mesh removal, and there have been no recurrent hernias in patients with primary fascial closure. Biologic bridging is not effective for long-term abdominal wall reconstruction.     

Same day discharge, surgical training and early complications after open and laparoscopic repair of primary paraumbilical hernia

Aims

The aims of this study were to compare same day discharges and early complications after open and laparoscopic primary paraumbilical hernia (PUH) repair, including the procedures performed by surgical trainees (STs).

Methods

All patients who had open (suture or mesh) and laparoscopic repair of primary PUH in the Day Surgery Unit (DSU) between January 2007 and June 2009 were identified from the hospital database. The database was questioned regarding the grade of operating surgeon, type of surgical repair, day of admission and discharge from the DSU, and a patient’s return to surgical services. Data were stored in Microsoft Excel^® (TM 2007). Statistical significance was determined using Fisher’s exact test.

Results

PUH was repaired in 337 patients: 252/337 (74.8 %) had open and 85/337 (25.2 %) had laparoscopic repair. Significantly, more patients were discharged home on the day of surgery after an open repair compared to the laparoscopic repair: open repair 187/252 (74.2 %), laparoscopic repair 35/85 (41.17 %), P = 0.0001. Overall early complications such as wound complications and hospital re-visits were similar in both groups: open repair 6.3 % (16/252), laparoscopic repair 11.7 % (10/85), P = 0.1554. STs performed 142/337 (42.1 %) of the PUH repairs with similar same day discharges from the DSU: STs 64.7 % (92/142), consultant surgeons 66.7 % (130/195), P = 0.7285. The difference in hernia recurrence between open repair 7/252 (2.78 %) and laparoscopic group 0/85 was not significant (P = 0.1985).

Conclusion

Patients with PUH repair were more likely to go home on the day of surgery after open than after laparoscopic repair. This was not affected by the grade of the operating surgeon. Early complications were similar following open and laparoscopic repair of primary PUH.     

The increased cost of ventral hernia recurrence: a cost analysis

Purpose

Over 300,000 ventral hernia repairs (VHRs) are performed each year in the US. We sought to assess the economic burden related to ventral hernia recurrences with a focused comparison of those with the initial open versus laparoscopic surgery.

Methods

The Premier Alliance database from 2009 to 2014 was utilized to obtain patient demographics and comorbid indices, including the Charlson comorbidity index (CCI). Total hospital cost and resource expenses during index laparoscopic and open VHRs and subsequent recurrent repairs were also obtained. The sample was separated into laparoscopic and open repair groups from the initial operation. Adjusted and propensity score matched cost outcome data were then compared amongst groups.

Results

One thousand and seventy-seven patients were used for the analysis with a recurrence rate of 3.78 %. For the combined sample, costs were significantly higher during recurrent hernia repair hospitalization ($21,726 versus $19,484, p < 0.0001). However, for index laparoscopic repairs, both the adjusted total hospital cost and department level costs were similar during the index and the recurrent visit. The costs and resource utilization did not go up due to recurrence, even though these patients had greater severity during the recurrent visit (CCI score 0.92 versus 1.06; p = 0.0092). Using a matched sample, the total hospital recurrence cost was higher for the initial open group compared to laparoscopic group ($14,520 versus $12,649; p = 0.0454).

Conclusions

Based on our analysis, need for recurrent VHR adds substantially to total hospital costs and resource utilization. Following initial laparoscopic repair, however, the total cost of recurrent repair is not significantly increased, as it is following initial open repair. When comparing the initial laparoscopic repair versus open, the cost of recurrence was higher for the prior open repair group.

     

Transvaginal natural orifice transluminal endoscopic surgery in the morbidly obese

Background

The objective of this study is to assess the safety and efficacy of transvaginal (TV) natural orifice transluminal endoscopic surgery (NOTES) operations in morbidly obese patients.

Methods

One hundred seven NOTES operations have been performed at our institution to date, of which 17 were completed in patients with body mass index (BMI) between 35 and 45 kg/m². These included 14 cholecystectomies, one appendectomy, and two ventral hernia repairs. The patients had average age of 36.2 years (range 19–62 years) and average BMI of 38.9 kg/m² (range 35.2–44.9 kg/m²). The mean number of previous abdominal operations was 1. The TV cholecystectomies were hybrid NOTES procedures, while TV appendectomy and ventral hernia repair were pure NOTES. All operations were completed with standard straight laparoscopic instruments.

Results

The mean operative time was 60 min for cholecystectomy, 41 min for TV appendectomy, and 90 min for ventral hernia repair. No significant difference was encountered between the operative time for NOTES cholecystectomies in obese versus nonobese (60 vs. 61 min, p = 0.86). No conversions to traditional laparoscopy or open surgery were made, and no major complications were encountered.

Conclusions

NOTES is an attractive alternative to laparoscopy in female patients with morbid obesity. The procedures are safe and have short operative times, good postoperative outcomes, and improved cosmesis compared with laparoscopy.