Preoperative Risk Reduction

Martindale, Robert G.; Deveney, Clifford W.

doi:10.1016/j.suc.2013.06.015

Cited by 56 publications

(12 citation statements)

References 104 publications

(104 reference statements)

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“…Each major complication following the surgical management of a ventral hernia repair costs the healthcare system $30,000 to $210,000 to address. 6 …”

Section: Introductionmentioning

confidence: 99%

Development and Validation of a Risk Stratification Score for Ventral Incisional Hernia after Abdominal Surgery: Hernia Expectation Rates in Intra-Abdominal Surgery (The HERNIA Project)

Goodenough

Kao

et al. 2015

Journal of the American College of Surgeons

167

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Background Ventral incisional hernias (VIH) develop in up to 20% of patients following abdominal surgery. No widely applicable pre-operative risk-assessment tool exists. We aim to develop and validate a risk-assessment tool to predict VIH following abdominal surgery. Study Design A prospective study of all patients undergoing abdominal surgery was conducted at a single institution from 2008-2010. Variables were defined in accordance with the National Surgical Quality Improvement Project. VIH was determined through clinical and radiographic evaluation. A multivariate Cox proportional hazard model was built from a development cohort (2008-2009) to identify predictors of VIH. The HERNIAscore was created by converting the hazards ratios (HR) to points. The predictive accuracy was assessed on the validation cohort (2010) using a receiver operator characteristic curve and calculating the area under the curve (AUC). Results Of 625 patients followed for a median of 41(0.3-64 months), 93(13.9%) developed a VIH. The training cohort (n=428, VIH=70,16.4%) identified four independent predictors: laparotomy (HR 4.77, 95%CI 2.61-8.70) or hand-assisted laparoscopy (HR=4.00, 95% CI 2.08-7.70), COPD (HR=2.35; 95%CI 1.44-3.83), and BMI≥25 (HR=1.74; 95% CI 1.04-2.91). Factors that were not predictive included age, gender, ASA score, albumin, immunosuppression, prior surgery, and suture material/technique. The predictive score had an AUC=0.77(95%CI0.68-0.86) using the validation cohort (n=197, VIH=23,11.6%). Using the HERNIAscore--HERNIAscore=4*Laparotomy+3*HAL+1*COPD+1* BMI≥25--three classes stratified the risk of VIH: Class I (0-3 points):5.2%, Class II (4-5 points):19.6%, and Class III (6 points):55.0%. Conclusions The HERNIAscore accurately identifies patients at increased risk for VIH. While external validation is needed, this provides a starting point to counsel patients and guide clinical decisions. Increasing the use of laparoscopy, weight-loss programs, community smoking prevention programs, and incisional reinforcement may help reduce rates of VIH.

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“…Each major complication following the surgical management of a ventral hernia repair costs the healthcare system $30,000 to $210,000 to address. 6 …”

Section: Introductionmentioning

confidence: 99%

Development and Validation of a Risk Stratification Score for Ventral Incisional Hernia after Abdominal Surgery: Hernia Expectation Rates in Intra-Abdominal Surgery (The HERNIA Project)

Goodenough

Kao

et al. 2015

Journal of the American College of Surgeons

167

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“…12 Numerous studies have additionally demonstrated that the rate of recurrence for incisional hernias directly correlates with BMI. [13][14][15] In colorectal patients, increased BMI has also been associated with increased costs of care. 11 The increased risk associated with operating on obese hernia patients and the fact that perioperative weight loss has been demonstrated to improve surgical outcomes prior to other procedures reveal the need to develop an effective perioperative weight loss strategy for hernia patients.…”

Section: Introductionmentioning

confidence: 99%

A Multidisciplinary Approach to Medical Weight Loss Prior to Complex Abdominal Wall Reconstruction: Is it Feasible?

Rosen

Aydogdu

Grafmiller

et al. 2015

Journal of Gastrointestinal Surgery

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Obesity is a major risk factor for perioperative morbidity, especially for patients undergoing complex incisional hernia repair. The feasibility and effectiveness of medical weight loss programs prior to complex abdominal wall reconstruction have not been well characterized. Here, we report our experience collaborating with a medical weight loss specialist utilizing a protein sparing modified fast in order to optimize weight loss prior to complex abdominal wall reconstruction. Morbidly obese patients (body mass index (BMI) > 35 kg/m(2)) evaluated by our medical weight loss specialist prior to complex ventral hernia repair were identified within our prospective database. Our primary outcome measure was the amount of weight lost prior to surgical intervention. Our secondary outcome measure was to determine the maintenance of weight loss during long-term follow-up after the surgical intervention. A total of 25 patients with a BMI > 35 kg/m(2) were evaluated by our medical weight loss specialist prior to undergoing a planned incisional hernia repair. The mean weight of the patients preoperatively was 128 kg ± 25 (range 96-205 kg) (mean ± standard deviation), and the mean BMI was 49 kg/m(2) ± 10 (range 36-85). After completion of the preoperative modified protein sparing fast, the mean preoperative weight loss of the group was 24 kg ± 21 (range 2-80 kg). The overall change in BMI for the group prior to surgery was 9 kg/m(2) ± 8 (0.6 to 33). The percentage of excess BMI loss and total BMI loss preoperatively was 37 % ± 23 (2 to 83) and 18 % ± 12 (1 to 43), respectively. Of the 24 patients that initially lost weight in the program preoperatively, 22 (88 %) successfully maintained their weight loss for the entire study period for an average of 18 months. Collaboration with a medical weight loss specialist and a surgeon with a structured approach using a modified protein sparing fast can successfully result in meaningful weight loss prior to complex abdominal wall reconstruction. The majority of patients in this study were able to maintain their weight loss during long-term follow-up. Utilization of a protein sparing modified fast in collaboration with a medical weight loss specialist is a valuable resource for guiding weight loss in patients with morbid obesity prior to elective complex surgical procedures.

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“…Perhaps a valuable method in the treatment of medical conditions such as hypertension, our data indicate that the approach may be misguided in this context, where big data may not adequately account for the profound effect that surgical technique may have on patient outcomes. We do not attempt to refute literature that supports a role of patient factors such as BMI, 11,17,18 smoking, 11 diet, 11 COPD, 17 kidney disease necessitating dialysis, 17 American Society of Anesthesiologists score, 17,18 incision class, 18 and blood glucose/diabetes, 11,17 which impact outcomes in hernia repair. Rather, we posit that the generalizations made by risk scores such as those evaluated here cannot be accurately made until surgical technique has been optimized.…”

Section: Discussionmentioning

confidence: 99%

“…Hernia repairs with surgical site occurrences (SSOs) are, at a minimum, 3 times more likely to recur than those without. 11 …”

Section: Introductionmentioning

confidence: 99%

Current Risk Stratification Systems Are Not Generalizable across Surgical Technique in Midline Ventral Hernia Repair

Fligor

Lanier

Dumanian

2017

Plastic and Reconstructive Surgery - Global Open

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Background:Current ventral hernia repair risk estimation tools focus on patient comorbidities with the goal of improving clinical outcomes through improved patient selection. However, their predictive value remains unproven.Methods:Outcomes of patients who underwent midline ventral hernia repair with retrorectus placement of mid-weight soft polypropylene mesh between 2010 and 2015 were retrospectively reviewed and compared with predicted wound-related complication risk from 3 tools in the literature: Carolinas Equation for Determining Associated Risk, the Ventral Hernia Working Group (VHWG) grade, and a modified VHWG grade.Results:A total of 101 patients underwent hernia repair. Mean age was 56 years and mean body mass index was 29 m/kg2 (range, 18–51 m/kg2). We found no significant relationship between the risk estimated by Carolinas Equation for Determining Associated Risk (B = 1.45, P = 0.61) and actual wound-related complications. VHWG grades >1 were not statistically different with regard to rate of wound complication compared with VHWG grade 1 (grade 2: B = 0.05, P = 0.95; grade 3: B = −0.21, P = 0.86; grade 4: B = 2.57, P = 0.10). Modified VHWG grades >1 were not statistically different with regard to rate of wound complication compared with modified VHWG grade 1 (grade 2: B = 0.20, P = 0.80; grade 3: B = 1.03, P = 0.41).Conclusions:Current risk stratification tools overemphasize patient factors, ignoring the importance of technique in minimizing complications and recurrence. We attribute our low complication rate to retrorectus placement of a narrow, macroporous polypropylene mesh with up to 45 suture fixation points for force distribution in contrast to current strategies that employ wide meshes with minimal fixation.

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Preoperative Risk Reduction

Cited by 56 publications

References 104 publications

Development and Validation of a Risk Stratification Score for Ventral Incisional Hernia after Abdominal Surgery: Hernia Expectation Rates in Intra-Abdominal Surgery (The HERNIA Project)

Development and Validation of a Risk Stratification Score for Ventral Incisional Hernia after Abdominal Surgery: Hernia Expectation Rates in Intra-Abdominal Surgery (The HERNIA Project)

A Multidisciplinary Approach to Medical Weight Loss Prior to Complex Abdominal Wall Reconstruction: Is it Feasible?

Current Risk Stratification Systems Are Not Generalizable across Surgical Technique in Midline Ventral Hernia Repair

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