|Year : 2021 | Volume
| Issue : 4 | Page : 188-194
Clinical outcomes vary for emergent and elective ventral hernia repair
Rachel M Whittaker1, Zachary E Lewis1, Margaret A Plymale2, Michael J Nisiewicz3, Ebunoluwa Ajadi3, Daniel L Davenport4, Jessica K Reynolds5, John Scott Roth2
1 University of Kentucky College of Medicine, Bowling Green, USA
2 Department of Surgery, Division of General, Endocrine & Metabolic Surgery, University of Kentucky, Lexington, USA
3 University of Kentucky College of Medicine, Lexington, USA
4 Department of Surgery, Division of Healthcare Outcomes and Optimal Patient Services, University of Kentucky, Lexington, USA
5 Department of Surgery, Division of Trauma & Acute Care, University of Kentucky, Lexington, Kentucky, USA
|Date of Submission||11-Jun-2021|
|Date of Decision||04-Nov-2021|
|Date of Acceptance||11-Nov-2021|
|Date of Web Publication||31-Dec-2021|
Dr. John Scott Roth
Department of Surgery, University of Kentucky, Division Chief General, Endocrine and Metabolic Surgery, 800 Rose Street, C 240, Lexington, KY 40536.
Source of Support: None, Conflict of Interest: None
PURPOSE: Elective ventral hernia repair (ELVHR) is generally performed for chronic symptoms, including pain, increasing size, intermittent obstruction, and cosmesis. Emergent ventral hernia repair (EMVHR) indications include acute symptoms that are often concerning for strangulation. The study objective included identifying variations in perioperative characteristics as well as clinical and cost outcomes in patients who underwent ELVHR vs. EMVHR. MATERIALS AND METHODS: An IRB-approved retrospective review of ELVHR and EMVHR cases was conducted, exclusive of incidental hernias. Due to the retrospective nature of the study, patient consent was deemed unnecessary by the IRB. Demographics, perioperative characteristics, operative details, clinical outcomes, and hospital costs were included in the analyses. RESULTS: Five-hundred forty-nine patients (453 ELVHR, 96 EMVHR) underwent repair. The EMVHR characteristics included more females (P = 0.009), class 3 obesity (P < 0.001), diabetes (P < 0.001), and bleeding disorder (P = 0.009). The EMVHR indications included incarceration (69%), strangulation (12%), and perforation (2%). Fifty-six percent of EMVHR underwent repair without mesh vs. 3.5% of ELVHR. Six-month wound events and ER visits were similar between groups; hernia recurrence was noted in 4% of ELVHR and 17% of EMVHR (P < 0.001). Pharmacy, ICU, lab, ancillary services, floor, and imaging costs varied significantly between groups. Supply, OR, and total hospital costs were similar. CONCLUSIONS: The EMVHR occurs in a unique patient population with more frequent comorbidities. Incarceration and obstruction are the most common indications for repair. Costs were similar despite more frequent non-mesh repairs and four-fold increase early recurrence rates in EMVHR. Strategies to improve outcomes in EMVHR require further investigation.
Keywords: Elective ventral hernia repair, emergency ventral hernia repair, hernia recurrence, hospital costs
|How to cite this article:|
Whittaker RM, Lewis ZE, Plymale MA, Nisiewicz MJ, Ajadi E, Davenport DL, Reynolds JK, Roth JS. Clinical outcomes vary for emergent and elective ventral hernia repair. Int J Abdom Wall Hernia Surg 2021;4:188-94
|How to cite this URL:|
Whittaker RM, Lewis ZE, Plymale MA, Nisiewicz MJ, Ajadi E, Davenport DL, Reynolds JK, Roth JS. Clinical outcomes vary for emergent and elective ventral hernia repair. Int J Abdom Wall Hernia Surg [serial online] 2021 [cited 2022 Jan 20];4:188-94. Available from: http://www.herniasurgeryjournal.org/text.asp?2021/4/4/188/334561
| Introduction|| |
Ventral hernia repair (VHR), either elective or emergent, is among the most frequently performed general surgical procedures, with more than 365,000 laparoscopic and open hernia repairs in the United States annually. Common indications for elective repair include patient symptoms such as pain, increasing size, intermittent obstruction management, cosmesis, and avoidance of acute presentation. Although most patients undergo elective ELVHR, surgeons are often faced with a clinical dilemma when considering surgical vs. nonoperative management for patients deemed at high risk due to comorbidity status. The economic impact of risk factors on outcomes following ELVHR has been explored,, whereas the economic impact of EMVHR has received little attention.
To better understand the presenting factors and clinical and cost outcomes of ELVHR vs. EMVHR, this study evaluated cases of VHR performed by general surgeons at a single academic medical center over five years. The study objective was to compare the incidence of postoperative complications, mortality, hernia recurrence, and hospital costs in patients who underwent ELVHR vs. EMVHR while accounting for perioperative comorbidities.
| Materials and Methods|| |
With Institutional Review Board approval, consecutive cases of open ventral incisional hernia repair, Current Procedural Terminology (CPT) codes 49560, 49561, 49565, or 49566, performed by general surgeons at a single tertiary care referral center, from January 1, 2013 to December 31, 2017, were identified by reviewing surgical databases. Laparoscopic hernia repair cases were not included in this study. Due to the retrospective nature of the study, patient consent was deemed unnecessary by the IRB. Patient demographics, perioperative characteristics, elective vs. urgent/emergent status of a repair, and 30-day clinical outcomes data were extracted from the local American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Review of electronic medical records provided additional patient variables, including indication for repair and 6-month postoperative outcomes, including wound events, number of surgical office visits, emergency department (ED) visits, and incidence of hernia recurrence.
A query of the hospital cost accounting system was carried out to obtain direct hospital costs. Cost categories included pharmacy, intensive care unit, laboratory, ancillary services such as respiratory therapy and physical therapy, floor costs, and imaging costs. Information obtained from the NSQIP database, medical record review, and cost accounting system query was combined.
The NSQIP preoperative and operative risk factors were compared between the ELVHR and EMVHR groups using t tests, chi-square, or Fisher’s exact tests as appropriate. Hospital costs and 6-month outcomes were similarly compared. Statistical calculations were performed using SPSS version 24 (IBM, Armonk, New York). Significance was set at P < 0.05.
| Results|| |
A total of 549 patients underwent VHR during the time period described; 453 (82.5%) cases were performed on an elective basis, and 96 (17.5%) cases were categorized as EMVHR. Across all patients, the average age was 53 years (±13), and 47.7% were male (n = 262). The two patient cohorts varied significantly in preoperative characteristics, including gender, body mass index (BMI) category, the American Society of Anesthesiologists (ASA) Class, bleeding disorders, and sepsis, as shown in [Table 1]. Preoperative patient characteristics that did not differ by repair status included dyspnea (9.3%), functional partial dependence (0.9%), history of severe COPD (8.0%), ascites (0.7%), CHF (0.4%), treated hypertension (54.6%), dialysis (0.7%), disseminated cancer (1.6%), preoperative open wound (2.7%), steroid use/immunosuppression (4.4%), and recent weight loss (0.7%).
|Table 1: Patient characteristics that differed between presentation groups|
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Indications for EMVHR included incarceration (68.8%), strangulation (11.5%), enterocutaneous fistula (2.1%), and perforation (2.1%); indications for ELVHR included patient symptoms such as pain, unwanted bulge, and avoidance of acute presentation. The majority of patients with EMVHR who were transferred from an outside facility were transferred from another ED to our facility [n = 50 (52%)]. Nearly nine of the ten ELVHR cases were Wound Class I (clean), as opposed to only six among ten EMVHR cases (P < 0.001). Mesh use varied by group in that no mesh was utilized in 54 (56.3%) emergent repairs compared with 16 (3.5%) elective cases (P < 0.001). Hernia and operative characteristics comparing ELVHR and EMVHR are depicted in [Table 2].
The mean length of hospital stay was shorter for elective cases (4.6 days) compared with 6.5 days in the emergent group (SD = 3.6 and 4.3, respectively; P < 0.001). On discharge, 439 (96.9%) patients in the elective cohort were sent home compared with 89 (92.7%) patients in the emergent cohort. No differences were found between the elective and emergent cohorts in 6-month postoperative wound complications or 6-month ED visits. However, office visits within 6 months of surgery were more frequent in the ELVHR group (37.1% > 2 visits vs. 22.9%, P = 0.001). Hernia recurrence occurred in 16 patients (16.7%) in the emergent group compared with 20 patients (4.4%) in the elective group (P < 0.001). Clinical outcomes in the ELVHR and EMVHR groups are presented in [Table 3].
Total hospital costs, medical and surgical supplies including mesh, pharmacy services, and operating room services were similar between the two groups. Hospital floor costs were significantly higher in emergent repairs when compared with elective repairs ($4,135, SD = $2,966 and $3,446, SD = $2,608, respectively; P = 0.025). Similarly, ICU costs were greater in EMVHR (P = 0.002). Laboratory, imaging, miscellaneous, and ancillary services were each significantly higher in the emergent groups. The breakdown of mean hospital costs between ELVHR and EMVHR is presented in [Table 4].
| Discussion|| |
The patients with EMVHR represent a unique group that differs significantly from those patients undergoing elective repair. The rationale for these differences is speculative but may be partially related to surgeon concerns for increased morbidity due to underlying medical conditions, lack of symptomatology of the hernia, or limited access to elective care. The elective, poorly optimized patient may present to the emergency room with symptom progression, ultimately necessitating an untimely operation. A great deal has been written regarding prehabilitation and optimization before hernia repair to improve elective hernia outcomes. However, little is understood about the patients who struggle to achieve preoperative goals and are not deemed appropriate candidates for elective hernia repair. This study attempts to provide some insight into the characteristics of those patients who present more acutely and require operative intervention. Understanding this population is an important step in developing strategies to reduce the presentation of acutely incarcerated or strangulated hernias. Although not answered in this study, an important question to answer in the future is whether patients would be better served to undergo elective repair without appropriate optimization as compared with those undergoing urgent or emergent repair.
Modifiable risk factors are known to be associated with increased adverse clinical and cost outcomes after VHR., Optimization for modifiable risk factors, such as morbid obesity, current smoking, and uncontrolled blood glucose levels, is considered necessary to prevent postoperative complications that lead to an increased risk of recurrence and prohibitive cost outcomes.,, The VHR is associated with low mortality, especially when performed laparoscopically. However, in patients undergoing ELVHR, increased age and comorbidities (including congestive heart failure [CHF], pulmonary circulation disorders, coagulopathy, liver disease, metastatic cancer, neurological disorders, and paralysis) are associated with increased mortality. Although optimization of these comorbidities is desirable, some patients present with acute symptoms before achieving goals with the potential for less optimal outcomes.
EMVHR is most frequently performed due to evidence or suspicion of incarceration and strangulation to minimize the risk of intestinal ischemia and perforation. Although ELVHR is believed to pose less risk than an emergent repair, 10% of all VHR are done on an emergent basis, and the rates of emergency incisional hernia repair in the United States, particularly among older men, are increasing. Non-elective VHR is considered to be associated with an increase in morbidity and mortality compared with ELVHR; therefore, elective repair may be encouraged to avoid the need for emergent repair.
In this study, class III obesity, ASA class, and insulin-independent diabetes were more frequent in the emergent cohort of patients with VHR compared with elective cases. Khorgami et al. studied 103,635 elective (57.9%) and emergent (42.1%) VHR, noting that morbid obesity can be challenging in patients with ventral hernias due to a greater risk of complications and recurrence in this population subset. As a result, many surgeons recommend weight loss before ELVHR, although the threshold BMI needed before repair is often debated.,, In a study by Plymale et al., which evaluated a cohort of more than 350 patients with a ventral hernia for an initial consultation, 70% had BMI greater than 30 kg/m2. Despite the recommended weight loss, a few patients attained their goal weight, and accordingly, an elective repair was not performed. Due to the increased surgical morbidity associated with ventral repair in the obese patient population, special consideration should be given to obese patients considering VHR in order to stratify surgical risk, although tools for predicting progression to emergent repair have not been reported. However, our practice is to offer repair to unoptimized patients with crescendo-type symptoms with concerning radiographic findings such as partial obstruction or inflammatory changes or to those with small hernia defects with large volumes of incarcerated intestines that could require significant intestinal resection in the event of strangulation. Paradoxically, patients with higher ASA at the highest risk for elective repair more frequently undergo EMVHR, a finding similar to the current study results (P < 0.001).,,
Unexpectedly, this study’s findings demonstrated that females were more likely to undergo EMVHR than males (P = 0.009). In a study of ventral hernias, Helgstrand et al. reported female gender to be an independent variable for an emergency repair in umbilical and epigastric hernias (OR = 1.65, 95% CI: 1.40–1.94). Beadles et al. studied trends of emergent hernia repair in the United States and found that women have higher rates of emergent incisional ventral hernia repairs. Despite the extensive literature demonstrating that women develop more femoral hernias on average than men,, we have been unable to find any definitive explanation for gender differences in EMVHR. In our study, the impact of race on outcomes in emergent and elective cohorts demonstrated no racial disparities (P = 0.187). However, these data contradict other studies reporting racial minority as an independent factor contributing to higher rates of emergent repair., Despite our findings, we feel that disparities in health-care access impact hernia care, and efforts to improve access in vulnerable populations are needed.
Laparoscopic VHR was excluded from the current study, the focus of which was on open repair of ventral incisional hernia comparing emergent and elective repair outcomes. Although not all incisional hernias are amenable to laparoscopic repair, in the carefully selected patient population laparoscopy is considered to be associated with decreased use of health-care resources without increased risk of complications or hernia recurrence. [Zolin]. However, as few as 9% of emergent VHR cases are performed laparoscopically. [Pechman]. Laparoscopic repair remains underutilized in the non-emergent population, too. Future study is warranted to better appreciate the clinical outcomes of laparoscopic emergent VHR as compared with the open approach, taking into account long-term follow-up and resultant hernia recurrence.
The current study demonstrated a nearly fourfold increase in ventral hernia recurrences in the emergent cohorts (P < 0.001). This may be partially explained by the technique differences in which the emergent group was less likely to have component separation (P < 0.001) or mesh implantation (P < 0.001). Although we are unable to ascertain the rationale for the reduced utilization of mesh or component separation techniques, we would postulate that surgeons are utilizing minimalistic techniques, often sutures alone, to avoid additional soft tissue dissection or the risk of mesh infection in potentially contaminated situations with incarcerated viscera. In addition, the higher medical complexity of the emergent hernia repair patient likely impacts surgical decision making. In a study by Kaoutzanis et al., of more than 25,000 ventral incisional hernia repairs, high ASA class (III/IV) led to greater postoperative wound infections. In addition, in a cohort of 122 patients undergoing EMVHR, Emile et al. identified the following factors as significant predictors of surgical site infection: diabetes mellitus, recurrent hernias, and intestinal resection. However, in the current study, we did not find any increase in surgical site infection rates between EMVHR and ELVHR (P = 0.369), despite having a significantly higher representation of high ASA class and insulin-independent diabetics in the emergent cohort (P < 0.001). Further, our study found no impact of higher wound class II–IV (P < 0.001) in the emergent group on surgical site infection rates. As the risk of surgical site infection in the emergent repair is not increased, the current study suggests that mesh utilization is likely safe in the emergent setting. Although we appreciate the challenges associated with changing practice patterns, we are optimistic that the comparable surgical site infection rate in emergent and elective hernia repairs will compel surgeons to utilize mesh in the emergent setting, which should translate into improved long-term hernia outcomes. Elective ventral hernia surgical site occurrence (SSO) rates based on wound classification have been studied far more extensively than emergent cases. In a study of elective cases, Baucom et al. found wound classification to be a nonsignificant risk factor in predicting SSO two years after ventral hernia repair. We hypothesize that enhanced recovery protocols, meticulous surgical technique, and antibiotic prophylaxis have contributed to these findings and would recommend utilization of best practices in the emergent setting wherever feasible.
Total hospital costs were similar for EMVHR and ELVHR (P = 0.125), although intensive care unit (ICU) and floor costs were significantly higher in the emergent cohort (P = 0.002 and P = 0.025, respectively). Given that EMVHR has significantly higher rates of hernia recurrence (P < 0.001) compared with ELVHR, the increased hernia recurrence rates are likely to create a greater financial burden in the long term due to the likely need for future surgical procedures. Conservative estimates suggest that a 1% reduction in hernia recurrence would result in financial savings of $32 million per year. Understanding long-term health care costs in the United States remains a significant challenge, but efforts to understand the impact of hernia recurrence on total health care costs are necessary to appreciate the financial burden associated with hernia recurrence.
Although this longitudinal single-institutional study provides insight into the EMVHR population and postoperative outcomes, this retrospective study is not without limitations. Selection biases inherent to any retrospective study likely impacted not only surgical decisions to operate but also the techniques employed. Although difficult, a prospective randomized trial of suture compared with mesh-based hernia repairs in the emergent, incarcerated, and strangulated hernia population would provide additional insight into the risks and benefits of mesh in the emergent setting. This study describes the outcomes of all hernia repairs at a single tertiary care institution, with more than half of all emergent repairs resulting from interfacility patient transfers. Although we feel these data are representative of the general population, local factors may have impacted our results, and the applicability of these data to other populations should be carefully considered. Study parameters were limited to 6-month outcomes due to challenges with longer-term follow-up in our rural population with broad referral patterns. As a result, the long-term incidence of postoperative complications and hernia recurrence in this population is not known, and long-term mesh complications may have occurred outside the study period. We appreciate the limitation in reporting on 6-month hernia outcomes, but the fact that the recurrence rate is fourfold increased at this early time point suggests there are significant differences that need to be addressed. Limitations of our cost analysis are related to difficulties in obtaining costs for patients transferred from other institutions, which represented more than half of the emergent group. Nevertheless, this cost analysis provides valuable insights into the hospital costs associated with providing care for the ventral hernia population. An understanding of these costs may be valuable to facilities when negotiating contracts for hernia care with payers.
| Conclusion|| |
Patients with incarcerated or strangulated ventral hernias present with more frequent comorbidities, including a higher incidence of obesity, diabetes, ASA class, and hypoalbuminemia. EMVHRs utilize mesh and component separation techniques less often; they are associated with a similar incidence of surgical site infections and a higher incidence of hernia recurrence than elective repairs. Hospital length of stay is longer in the emergent hernia repair population, although total hospital costs were similar between elective and emergent hernia repairs. An understanding of the emergent ventral hernia population and outcomes serves as a starting point in developing strategies to improve outcomes in these patients.
The authors acknowledge and thank the University of Kentucky, College of Medicine, Professional Student Mentored Research Fellowship Program for their contributions to this project.
Financial support and sponsorship
Conflicts of interest
Outside the scope of the present work, Dr. Roth has grants from Becton Dickinson, Advanced Medical Solutions, and Davol; receives consulting fees from Miromatrix and Johnson and Johnson; and has stock options from Miromatrix. The other authors have no conflicts to report.
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[Table 1], [Table 2], [Table 3], [Table 4]