Quality of life (QOL) has become an important focus of hernia repair outcomes. This study aims to identify factors which lead to ideal outcomes (asymptomatic and without recurrence) in large umbilical hernias (defect size ≥9 cm2). Review of the prospective International Hernia Mesh Registry was performed. The Carolinas Comfort Scale was used to measure QOL at 1-, 6-, and 12-month follow-up. Demographics, operative details, complications, and QOL data were evaluated using standard statistical methods. Forty-four large umbilical hernia repairs were analyzed. Demographics included: average age 53.6 ± 12.0 and body mass index 34.9 ± 7.2 kg/m2. The mean defect size was 21.7 ± 16.9 cm2, and 72.7 per cent were performed laparoscopically. Complications included hematoma (2.3%), seroma (12.6%), and recurrence (9.1%). Follow-up and ideal outcomes were one month = 28.2 per cent, six months = 42.9 per cent, one year = 55.6 per cent. All patients who remained symptomatic at one and two years were significantly symptomatic before surgery. Symptomatic preoperative activity limitation was a significant predictor of nonideal outcomes at one year ( P = 0.02). Symptomatic preoperative pain was associated with nonideal outcomes at one year, though the difference was not statistically significant ( P = 0.06). Operative technique, mesh choice, and fixation technique did not impact recurrence or QOL. Repair of umbilical hernia with defects ≥9 cm2 had a surprising low rate of ideal outcomes (asymptomatic and no recurrence). All patients with nonideal long-term outcomes had preoperative pain and activity limitations. These data may suggest that umbilical hernia should be repaired when they are small and asymptomatic.
High-reliability organizations standardize processes to deliver consistent results. Unplanned visits (UV) to emergency department (ED) or urgent care (UC) settings after ambulatory surgery (AS) are costly and disruptive. Therefore, we implemented a collaborative, multidisciplinary, standardized care protocol to improve postoperative outcomes after AS for open inguinal hernia repair (OIHR). METHODS: A quality improvement intervention composed of 9 perioperative elements was implemented across 14 hospitals as a collaborative effort between surgery, anesthesia, and nursing. Data on patient factors, protocol adherence, post-anesthesia care unit, and post-discharge outcomes were collected. Bivariate comparisons assessed outcome differences by adherence to protocol elements. Multivariate models controlling for patient factors and hospital clustering examined the effect of specific intervention elements on outcomes. RESULTS: Data were collected for 2,390 patients undergoing AS for OIHR over a 14-month period. Rates of UV were 6.3% (for any cause) and 2.8% (for avoidable causes: pain/urinary retention/constipation/nausea/vomiting). Adherence varied across the 9 elements (24% to 95%). Preoperative education reduced UV for any cause, for avoidable causes, and for nausea/vomiting; giving prescriptions preoperatively reduced UV for avoidable causes and constipation. Use of monitored anesthesia care (MAC) instead of general anesthesia reduced postoperative pain scores. Patients receiving all elements (3%) were older and riskier, but had lower postoperative pain (p ¼ 0.01). CONCLUSIONS: A multidisciplinary, multihospital intervention to standardize best practices for AS significantly reduced postoperative pain and unplanned visits to emergency care. Preoperative education and preferential use of MAC contributed most strongly to these changes. Further refinement of this protocol may yield additional improvements.
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