Faculty Bibliography

BACKGROUND:Prosthetic mesh infection (PMI) is a challenging complication of ventral hernia repair (VHR). The sparsity of data leaves only experience and judgment to guide surgical decision-making. METHODS:Retrospective review of patients diagnosed with PMI. Subsequent abdominal operation (SAO) constitutes any intraabdominal operation occurring after the index hernia repair prior to PMI presentation. Any mesh removal was considered salvage failure. Analysis was performed using Chi-square test, Fishers Exact, or Mann-Whitney U test. Analyses completed using R Version 3.0.2. RESULTS:We identified 213 instances of PMI. Most cases (58.7%) involved intraperitoneal mesh. Thirty-seven percent of patients had an SAO, only 25.3% of which were clean cases. Enteroprosthetic fistula occurred in 38 patients (17.8%). Mean time to presentation was 19.9 mos after index hernia repair or SAO for infection alone, and 48.1 mos when a fistula was present (p < 0.001). Percutaneous drainage was used to treat 29 cases, successfully in 10 (34.5%), 8 of which were macroporous polypropylene and 2 biologic mesh. Negative pressure wound therapy (NPWT) was used in 46 patients, but successful in only 16 (34.8%), all of which were macroporous polypropylene. Local wound care alone successfully salvaged only 16 of 85 meshes (18.8%), 13 of which were macroporous polypropylene. Macroporous polypropylene mesh was salvaged in 65% of cases overall, and 72.2% when in an extraperitoneal position. Mesh salvage was not possible in any case involving composite or PTFE mesh, and rarely for microporous polypropylene (7.7%) multifilament polyester (4.2%), or intraperitoneal mesh (2.4%). Closure of the defect after mesh removal significantly lowers recurrence rate (p < 0.001). CONCLUSION/CONCLUSIONS:PMI involving composite, PTFE, multifilament polyester, or microporous polypropylene mesh requires explantation in nearly all cases. Infected macroporous polypropylene mesh in an extraperitoneal position is salvageable in most cases. Furthermore, the risk of secondary mesh infection after SAO, particularly with intraperitoneal mesh, should be considered during index VHR.

BACKGROUND:Increased recognition of the dangers of opioid analgesia has led to significant focus on strategies for reducing use through multimodal analgesia, enhanced recovery protocols, and standardized guidelines for prescribing. Our institution implemented a standard protocol for prescribing analgesics at discharge after ventral hernia repair (VHR). We hypothesize that this strategy significantly reduces opioid use. METHODS:-test for continuous variables. RESULTS:= .141). Implementation of an evidence-based protocol significantly reduces opioid prescribing after VHR. DISCUSSION/CONCLUSIONS:A multimodal approach to postoperative pain management decreases the need for opioids. The additional implementation of an evidence-based prescribing protocol results in significant reduction of opioid use following VHR.

INTRODUCTION/BACKGROUND:Robotic hiatal hernia repair offers potential advantages over traditional laparoscopy, most notably enhanced visualization, improved ergonomics, and articulating instruments. The clinical outcomes, however, have not been adequately evaluated. We report outcomes of laparoscopic and robotic hiatal hernia repairs. METHODS:A retrospective observational cohort study was performed of all hiatal hernia repairs performed from 2006 through 2019. Operative, demographic, and outcomes data were compared between laparoscopic and robotic groups. Discrete variables were analyzed with Chi-square of Fisher's exact test. Continuous variables were analyzed with Student's t test (mean) or Wilcoxon rank sum (medians). All analyses were performed using R statistical software. RESULTS:< .001). DISCUSSION/CONCLUSIONS:Robotic hiatal hernia repair offers technical advantages over laparoscopic repair with similar clinical outcomes.

BACKGROUND:Recent data on opioid consumption indicate that patients typically require far less than is prescribed. Prisma Health Upstate Hernia Center adopted standardized postoperative prescribing after hernia repair and began tracking patient-reported opioid utilization. The aim of this study is to evaluate patient opioid use after hernia repair in order to guide future prescribing. METHODS:All patients who underwent primary ventral (umbilical and epigastric), incisional, and inguinal hernia repair between February and May 2019 were reviewed. Patients reported the number of opioid pills taken at their first postoperative visit and documented either in the progress note or in the Americas Hernia Society Quality Collaborative (AHSQC) patient-reported outcomes (PRO) questionnaire. All demographic, operative, and outcomes data were captured prospectively in the AHSQC. Opioid use reported as milligram morphine equivalents (MME). RESULTS:A total of 162 surgeries were performed during the study period, and 107 had patient-reported opioid use for analysis. Inguinal hernia repair was performed in 36 patients, 10 primary ventral hernia repairs, and 61 incisional hernia repairs. No opioid use was reported in 63.9% of inguinal hernias, 60% of primary ventral hernias, and 20% of incisional hernias. Inguinal hernia patients consumed a mean of 10.5 MME, primary ventral patients 11 MME, and incisional hernia patients 78.5 MME. CONCLUSION/CONCLUSIONS:Patients require little to no opioid after primary ventral or inguinal hernia repair and opioid-free surgery is feasible. Incisional hernia is more heterogenous, but the majority of patients still required less opioid than previously thought.

BACKGROUND:Controversy remains about appropriate mesh selection during ventral hernia repair (VHR) in a contaminated field. Fear of mesh infection has led to increased use of biologic and absorbable synthetic meshes rather than permanent synthetic mesh in these cases. We report the safety and efficacy of permanent synthetic mesh during contaminated VHR. STUDY DESIGN/METHODS:Retrospective review of our database identified all cases of contaminated VHR from July 2007 to May 2019. Student's t-test and Wilcoxon rank sum were used to analyze continuous variables, and discrete variables with Fisher's or Kruskal-Wallis test. RESULTS:There were 541 contaminated cases: 245 clean-contaminated, 214 contaminated, and 82 dirty cases. Suture repair was performed in 46 patients, biologic mesh was used in 38, absorbable synthetic mesh in 55, and permanent synthetic mesh in 402. Mesh was extraperitoneal in 97% of cases. Incidence of surgical site infection in each group was 17.4%, 36.8%, 32.7%, and 14.2%, respectively (p < 0.001). Multivariate analysis showed no effect of mesh selection on risk of surgical site infection. Mesh was removed in 7 patients; 5 were permanent synthetic (1.2%), 1 was absorbable synthetic (1.8%), and 1 was biologic (2.6%). In 4 patients there was mesh-specific complication and the remaining meshes were removed during exploration for indications unrelated to the mesh. At a median follow-up of 30.2 months, recurrence occurred in 15.2% of patients and was significantly lower with permanent synthetic mesh. CONCLUSIONS:Permanent synthetic mesh placed in an extraperitoneal position is not only safe for VHR in a contaminated field, but it confers a significantly lower rate of surgical site infection and recurrence compared with biologic or bioabsorbable meshes.

BACKGROUND:Major abdominal operations often requires postoperative opioid analgesia. However, there is growing recognition of the potential for abuse. We previously reported a significant reduction in opioid consumption after implementation of an Enhanced Recovery after Surgery protocol after ventral hernia repair focusing on opioid reduction. Epidural use was routine for postoperative pain control in this protocol. Recently, we have transitioned to transversus abdominis plane (TAP) block instead of epidural analgesia. We hypothesize that this modification reduces length of stay and lowers opioid use in ventral hernia repair. METHODS:All patients undergoing open ventral hernia repair were recorded prospectively in the Americas Hernia Society Quality Collaborative database. All patients receiving either TAP or epidural between February 2015 and March 2018 were identified. Additional review was performed to quantify opioid use in morphine milligram equivalents (MMEs). Primary outcomes were length of stay and opioid use. RESULTS:) and slightly smaller hernias (8.8 cm vs 10.8 cm). There was no difference in 30-day surgical site infections. Hospital length of stay was significantly shorter with TAP block (2.4 vs 4.5 days; p < 0.001). Total MME requirements for patients receiving TAP block were lower than those with epidural during postoperative days 1 and 2 (mean 40 vs 54.1 MMEs; p = 0.033 and 36.1 vs 52.5 MMEs; p = 0.018). CONCLUSIONS:Use of TAP block significantly reduces length of stay and decreases opioid dose requirements in the early postoperative period compared with epidural analgesia.

The use of mesh materials for reinforcement of the abdominal wall has revolutionized the approaches to hernia repair. Whether it's a permanent, synthetic mesh, a biologically derived collagen graft, or a synthetic, bioresorbable construct, data demonstrate improved outcomes with respect to recurrence with their use. Numerous advances and development of component separation techniques of the abdominal wall musculature have provided surgeons the ability to close large fascial defects and reestablish the linea alba for midline hernias. Augmentation of the these repairs with a mesh helps to offset the tension on the fascial closure and provide biomechanical strength to the native tissue. However, the use of mesh materials as either permanent or temporary scaffolds is not without potential complications. Abdominal wall surgeons must have knowledge of the mesh composition and structure in an effort to mitigate these concerns. This chapter will review the polymers and characteristics of the currently available synthetic meshes for abdominal wall reconstruction in an effort to provide guidance to surgeons.

Surgical site infections (SSI) are common complications after open ventral hernia repair (OVHR), potentially requiring further intervention. Antibiotic lavage before abdominal closure has been shown to lower the incidence in intra-abdominal and soft tissue SSI. A retrospective review of OVHR was performed with mesh at Greenville Health System Hernia Center between 2008 and 2017. Patients were divided into three groups, receiving no antibiotic irrigation (Grp 1, n = 260), gentamicin alone (Grp 2, n = 263), or gentamicin + clindamycin (G + C) irrigation (Grp 3, n = 299). Differences in categorical variables among the three groups were tested using chi-squared or Fischer's exact test (for n < 5). Analysis of continuous variables was performed using analysis of variance or Kruskal-Wallis test for differences in length of stay. Logistic regression was performed using all clinically relevant variables to determine the effects of irrigation on SSI. Incidence of surgical site occurrence was significantly lower after G + C irrigation (Grp 1, 28.1%; Grp 2, 35.4%; Grp 3, 19.7%; P < 0.001). Incidence of SSI was significantly lower after G + C irrigation, but not G alone (Grp 1, 16.5%; Grp 2, 15.2%; and Grp 3, 5.4%; P < 0.001). Multivariate logistic regression demonstrated significantly increased SSI with contaminated wounds (OR 2.96; 95% confidence interval (CI) 1.39-6.21), dirty wounds (OR 3.84; 95% CI 1.49-9.69), and chronic obstructive pulmonary disease (OR 3.70; 95% CI 2.16-6.38), as expected. Use of G + C was an independent predictor of decreased SSI (OR 0.33; 95% CI 0.16-0.67). Irrigation with a combined G + C antibiotic irrigation significantly reduces the incidence of surgical site infection after OVHR with mesh.