A Risk Model and Cost Analysis of Incisional Hernia After Elective, Abdominal Surgery Based Upon 12,373 Cases

Abstract

Objectives:Incisional hernia (IH) remains a common, highly morbid, and costly complication. Modest progress has been realized in surgical technique and mesh technology; however, few advances have been achieved toward understanding risk and prevention. In light of the increasing emphasis on prevention in today's health care environment and the billions in costs for surgically treated IH, greater focus on predictive risk models is needed.Methods:All patients undergoing gastrointestinal or gynecologic procedures from January 1, 2005 to June 1, 2013, within the University of Pennsylvania Health System were identified. Comorbidities and operative characteristics were assessed. The primary outcome was surgically treated IH after index procedures. Patients with prior hernia, less than 1-year follow-up, or emergency surgical procedures were excluded. Cox hazard regression modeling with bootstrapped validation, risk factor stratification, and assessment of model performance were conducted.Results:A total of 12,373 patients with a 3.5% incidence of surgically treated IH (follow-up 32.2 ± 26.6 months) were identified. The cost of surgical treatment of IH and management of associated complications exceeded $17.5 million. Notable independent risk factors for IH were ostomy reversal (HR = 2.76), recent chemotherapy (HR = 2.04), bariatric surgery (HR = 1.78), smoking history (HR = 1.74), liver disease (HR = 1.60), and obesity (HR = 1.96). High-risk patients (20.6%) developed IH compared with 0.5% of low-risk patients (C-statistic = 0.78).Conclusions:This study demonstrates an internally validated preoperative risk model of surgically treated IH after 12,000 elective, intra-abdominal procedures to provide more individualized risk counseling and to better inform evidence-based algorithms for the role of prophylactic mesh.

External Validation of the HERNIAscore: An Observational Study

“…Our HERNIAscore models remain important scoring systems because they are among the few, if not only, models to include only preoperative and easily predictable intraoperative factors. Other scoring systems evaluate additional preoperative factors (chemotherapy, age, gender, thickness of subcutaneous fat, malnutrition, tobacco use, liver disease, ostomy reversal, acute gastrointestinal inflammatory process), operative factors (wound class, blood transfusion, suture type, continuous versus interrupted suture), and postoperative factors (surgical site infection) (1, 2, 4, 6, 7). These other scoring systems either use variables that are difficult to obtain or variables that cannot be easily determined prior to the operation.…”

“…The majority of models, however, use post-operative variables that limit their use for patient counseling and in implementing pre-operative or intra-operative interventions (1, 2, 4, 5, 6, 7). The HERNIAscore is a VIH risk assessment tool that utilizes only preoperative variables and predictable intra-operative variables: body mass index (BMI), chronic obstructive pulmonary disease (COPD), and incision length (laparoscopic, extended laparoscopy, or laparotomy) (8).…”

Systematic review of the stage of innovation of biological mesh for complex or contaminated abdominal wall closure

“…Incisional hernias carry a significant burden for both patients and the health service. They prevent return to normal activities and can be painful.…”

Robotic Versus Open Renal Transplantation in Obese Patients: Protocol for a Cost-Benefit Markov Model Analysis (Preprint)

“…In addition, due to the extra-adipose tissue in the subcuticular space, obese patiens are prone to develop seromas that often become infected because of the suboptimal vascularization of the adipose tissue [27][28][29][30]. In addition, obese patients require longer incisions and their surgeries are, most of the time longer with subsequent increased risk of tissue dissication and intraoperative contamination [1] that are predisposing factors for incisional hernias [31]. suggested that the lower rate of SSIs observed with the minimally invasive approach was due to the fact that the classical suprainguinal incision located in a highly colonized skin area was replaced with a 7 cm periumbilical incision that was much smaller and located in a more favorable area of the abdominal wall.…”