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Background: Umbilical hernias are highly prevalent in patients with liver dysfunction, ascites, and cirrhosis. This patient population carries significant perioperative risk and poses significant challenges because of their comorbidities. Literature suggests that elective repair of umbilical hernias can lead to better outcomes by reducing the risk of ascitic leak and compromised bowel. Medical optimization followed by open repair has been the standard approach; however, little is known about whether a laparoscopic approach may be equivalent or superior., Methods: We retrospectively analyzed the American College of Surgeons National Surgical Quality Improvement Program database from 2015 to 2021 for umbilical hernia repairs in patients with liver dysfunction, as defined per the aspartate aminotransferase to platelet ratio index ≥1. We compare operative outcomes for open and laparoscopic repair, adjusting for confounders using propensity score matching and stratifying by case acuity., Results: We identified 1,983 patients with liver dysfunction who underwent umbilical hernia repair. Most patients (86%) were operated via an open approach rather than laparoscopy. Operative outcomes between the laparoscopy and open group were comparable regarding mortality and serious complications. Notably, length of stay and need for blood transfusion intraoperatively or postoperatively were reduced in the laparoscopy group (P < .001). These findings remained significant after subgroup analysis with propensity matching stratified by elective and emergency case types., Conclusion: Minimally invasive umbilical hernia repair in liver dysfunction is as safe and, in some metrics, superior to open technique. We found no difference in mortality although hospital stays and the need for blood transfusions were lower in the laparoscopy groups. Prospective randomized trials are needed to validate these findings further., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Abdominal wall reconstruction requires extensive dissection of the abdominal wall, exposure of the retroperitoneum, and aggressive chemoprophylaxis to reduce the risk of thromboembolic complications. The need for early anticoagulation puts patients at risk for bleeding. We aimed to quantify postoperative blood loss, incidence of transfusion and reoperation, and associated risk factors in patients undergoing complex abdominal wall reconstruction., Methods: All patients underwent a posterior component separation with transversus abdominis release and placement of retromuscular mesh for ventral hernias <20 cm wide and were enrolled in a clinical trial assessing the utility of trans-fascial mesh fixation. A post hoc analysis was performed to quantify postoperative hemoglobin drop, blood transfusions, and procedural interventions for ongoing bleeding during the first 30 postoperative days. Multivariate logistic regression was used to identify predictors of transfusion., Results: In 325 patients, hemoglobin decreased by 3.61 (±1.58) g/dL postoperatively. Transfusion incidence was 9.5% (n = 31), and 3.1% (n = 10) required a surgical intervention for bleeding. Initiation of therapeutic anticoagulation postoperatively resulted in a higher likelihood of requiring surgical intervention for bleeding (odds ratio 10.4 [95% confidence interval 2.75-43.8], P < .01). Use of perioperative therapeutic anticoagulation was associated with higher rates of transfusion (odds ratio 3.51 [95% confidence interval 1.34-8.53], P < .01). Neither intraoperative blood loss nor operative times were associated with an increased transfusion requirement or need for operative intervention., Conclusion: Patients undergoing transversus abdominis release are at a high risk of postoperative bleeding that can require transfusion and reoperation. Patients requiring postoperative therapeutic anticoagulation are at particularly high risk., (Published by Elsevier Inc.)

Background: Patients from low socioeconomic backgrounds have greater rates of morbidity and mortality across disease processes. The Distressed Communities Index identified several socioeconomic components that were used to create a Distressed Communities Index score for every ZIP code, then broken into quintiles from prosperous to distressed. We aimed to explore whether socioeconomic distress as defined by the Distressed Communities Index affects the outcome of complex ventral hernia repair in the elderly population., Methods: Retrospective analysis was performed using the Abdominal Core Health Collaborative data. Included were adults aged 65+ years undergoing elective complex ventral hernia repair from 2013 to 2021. Primary outcomes were postoperative outcomes and composite hernia recurrence by Distressed Communities Index quintile. The Cox proportional hazards model was used for composite recurrence, and logistic regression was used for postoperative outcomes., Results: A total of 4,172 patients were included. Patients in distressed communities were more likely to identify as female or racial minority and had greater body mass index and American Society of Anesthesiologists class. Lower Distressed Communities Index quintile was associated with larger hernia (P = .012), open repair (P = .019), and 30-day complication (P = .05). There was no association between time to recurrence and Distressed Communities Index quintile (P = .24). After adjusted analysis, there was no significant difference for readmission, reoperation, recurrence, and complications., Conclusion: Patients from more distressed communities presented in worse clinical status with larger hernias. This likely contributed to greater rates of open repair and complications. However, when adjusted for these variables, outcomes were similar across Distressed Communities Index quintile. This supports the efficacy of complex hernia repair across socioeconomic classes., Competing Interests: Conflict of Interest/Disclosures Dr Poulose has received research support from Bard-Davol and Advanced Medical Solutions. He receives consulting fees from Ethicon and receives salary support from the Abdominal Core Health Collaborative (ACHQC) as the ACHQC Director of Quality and Outcomes. The ACHQC Foundation is supported by Bard-Davol, Allergan, Medtronic, W. L. Gore, Ethicon, and TelaBio. Dr Benjamin Poulose receives research grant support from BD Interventional and Advanced Medical Solutions. The ACHQC has contracted with Weill Cornell Medicine (WCM) to provide biostatistical support. The work for this manuscript was done under the ACHQC-WCM collaboration plan., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Ventral hernia repair is a common elective general surgery procedure among older patients, a population at greater risk of complications. Prior research has demonstrated improved quality of life in this population despite increased risk of complications. This study sought to assess the relationship between post-ventral hernia repair quality of life and patient frailty. We hypothesized that frail patients would report smaller gains in quality of life compared to the non-frail group., Methods: The Abdominal Core Health Quality Collaborative was used to identify a cohort of patients 65 years of age or older undergoing elective ventral hernia repair from 2018 to 2022. Patients were categorized based on their modified frailty index scores as not frail/prefrail, frail, and severely frail. Quality of life was assessed using a patient-reported 12-item scale preoperatively, 30 days, 6 months, and 1 year postoperatively., Results: A total of 3,479 patients were included: 30.93% non-frail, 47.17% frail, and 21.90% severely frail. Severely frail patients had lower quality of life scores at baseline (P = .001) but reported higher quality of life at both 30 days (1.24 points higher, 95% confidence interval (-1.51, 2.52), P = .010) and 6 months (0.92 points higher, 95% confidence interval (-2.29, 4.13), P = .005). Severely frail patients had higher rates of surgical site complications (P < .001) but no difference in 30-day readmissions., Conclusion: Our results found that frail patients reported the greatest increase in quality of life 1 year from baseline, showing that they, when selected appropriately, can gain equal benefits and have similar surgical outcomes as their non-frail counterparts., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Although the most durable method for ventral hernia repairs involves using mesh, whether to use biologic mesh versus synthetic mesh remains controversial. This study aimed to compare synthetic and biologic meshes with respect to patient-reported quality of life scores and costs after ventral hernia repair surgeries., Methods: This study is part of the Preventing Recurrence in Clean and Contaminated Hernias (PRICE) pragmatic randomized control trial conducted from March 2014 through October 2018. Patients were randomized 1:1 to undergo ventral hernia repair using either a biologic or synthetic mesh. The coprimary outcomes were 2-year changes in Visual Analog Scale, Activities Assessment Scale, Hernia-Related Quality-of-Life Survey, and Short-Form 36 Health Survey (SF-36) quality-of-life scores from repair. The secondary outcome was the overall cost per patient., Results: Among the 165 patients included in the study, 82 were randomized to biologic meshes and 83 to synthetic meshes. There were no significant differences in the performance between the 2 mesh types with regard to quality-of-life measures using a mixed model approach. This result was consistent even when performing subgroup analysis based on wound contamination. However, nonparametric tests comparing the differences in quality-of-life measures from preoperative to 24-month postoperative timepoints revealed that the synthetic mesh group showed a greater reduction in disability than biologic mesh for the SF-36 (median [interquartile range] of 20 [5-30] vs 6 [1-20], P = .025). This difference was due to reductions in the physical role limitations (62 [0-100] vs 0 [0-50], P = .018) and the pain (38 [12-50] vs 12 [0-25], P = .012) domains of the SF-36. Overall cost per patient was greater for biologic meshes (mean [95% confidence interval] of $80,420 [$66,485-$94,355] vs $61,036 [$48,946-$73,125], P = .038), regardless of insurance type., Conclusion: In this randomized clinical trial, there were no differences in changes in quality-of-life scores at the 2-year timepoint except for the SF-36, where the synthetic mesh may be associated with less pain and physical role limitations than the biologic mesh. Overall costs per patient were less for synthetic than biologic mesh., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Different unilateral groin hernia repair approaches have been developed in the last 2 decades. The most commonly done approaches are open inguinal hernia repair by the Lichenstein technique, laparoscopic approach by either total extraperitoneal or transabdominal preperitoneal, and robotic transabdominal preperitoneal approach. Hence, this study aimed to compare early and late postoperative outcomes in patients who underwent unilateral robotic transabdominal preperitoneal, laparoscopic transabdominal preperitoneal, and laparoscopic total extraperitoneal, and open groin hernia repair using a United States national hernia database, the Abdominal Core Health Quality Collaborative Database., Methods: Prospectively collected data from the Abdominal Core Health Quality Collaborative database was retrospectively reviewed, including all adult patients who underwent elective unilateral groin hernia repair from 2015 to 2022, with a 1:1 propensity score match analysis conducted for balanced groups. The univariate analysis compared the groups across the preoperative, intraoperative, and postoperative timeframes., Results: The Abdominal Core Health Quality Collaborative database identified 14,320 patients who underwent elective unilateral groin hernia repair and had documented 30 days of follow-up. Propensity score matching stratified 1,598 patients to each group (total of 6,392). The median age was 64 years (interquartile range 53-74) for open groin hernia repair, whereas 60 (interquartile range 47-69) for laparoscopic transabdominal preperitoneal, 62 (interquartile range 48-70) for laparoscopic total extraperitoneal, and 60 (interquartile range 47-70) for robotic transabdominal preperitoneal were noted. Open groin hernia repair had more American Society of Anesthesiologists score 4 (52, 3%) patients (P < .001). A painful bulge was the most common indication (>85%). Operating room time >2 hours was more significant in the robotic transabdominal preperitoneal group (123, 8%; P < .001). Seroma rate was higher in the laparoscopic transabdominal preperitoneal (134, 8%; P < .001). A 1-year analysis had 1,103 patients. Hematoma, surgical site infection, readmission, reoperation, and hernia recurrence at 30 days or 1 year did not differ, with an overall recurrence rate of 6% (n = 67) at 1 year (P = .33). In patients with body mass index ≥30 kg/m 2 , the robotic approach had lower rates of surgical site occurrence (n = 12, 4%; P = .002) and seroma (n = 5, 2%; P < .001) compared with the other groups. When evaluating recurrence 1 year after surgery, the robotic transabdominal preperitoneal group had 10% versus 18% open groin hernia repair, 11% laparoscopic transabdominal preperitoneal, and 18% laparoscopic total extraperitoneal, but it was not statistically significant (P = .53)., Conclusion: There was no difference in readmission, reoperation, and surgical site infection among the surgical techniques at 30 days. However, laparoscopic transabdominal preperitoneal was associated with more seromas. Hernia recurrence at 1 year was similar across groups; the robotic approach had the lowest recurrence rate among all 3 repairs but did not reach statistical significance. The robotic approach performed better in patients with a body mass index of 30 kg/m 2 for surgical site occurrence and seroma than in other surgical techniques., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Mesh has been the acceptable standard for incisional hernia repair regardless of hernia size. It is not clear whether there is a size of incisional hernias in whom repair would be best performed without mesh. This study aims to compare outcomes of mesh versus suture repairs for incisional hernias <2 cm in size., Methods: Incisional hernia repairs from 2012 to 2021 for hernias ≤2 cm in width were queried from the Abdominal Core Health Quality Collaborative. Those with 1-year follow up were considered. Hernia recurrence was defined using composite hernia recurrence, which combines both clinical and patient reported outcomes. Propensity score matching was performed between mesh and non-mesh using body mass index, smoking, diabetes, and drains as covariates., Results: A total of 352 patients met inclusion criteria. After propensity score matching, there were 132 repairs with mesh and 71 without. There was no difference in recurrence rates at 1 year between mesh and non-mesh repairs (15% vs 24%, P = .12). Mesh was associated with a higher rate of 30-day postoperative complications (11% vs 1%, P = .017). There were no differences in 1-year quality of life scores., Conclusion: The repair of incisional hernias ≤2 cm without mesh results in similar recurrence rates, similar quality of life scores, and lower postoperative early complications compared with repairs with mesh. Our findings suggest that there may be select patients with small incisional hernias that could reasonably undergo incisional hernia repair without mesh. Longer-term follow-up is needed to confirm ideal candidates and durability of these repairs., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Morbid obesity, with a body mass index 35 kg/m 2 , is a commonly used cutoff for denying elective transversus abdominis release. Although obesity is linked to short-term wound morbidity, its effect on long-term outcomes remains unknown, calling into question if a cutoff is justified. We sought to compare 1-year recurrence rates after transversus abdominis release based on body mass index and to evaluate short- and long-term outcomes., Methods: Patients undergoing open, clean transversus abdominis release from August 2014 to January 2022 at our institution with 1-year follow-up completed were identified. Univariate and multivariable analyses were performed to determine the association of body mass index with 90-day wound events, 1-year hernia recurrence, and hernia-specific quality of life. Covariates included body mass index, diabetes, recurrent hernia, hernia width, fascial closure, surgical site occurrence requiring procedural intervention, previous abdominal wall surgical site infection, inflammatory bowel disease, mesh weight, and mesh-to-hernia size ratio., Results: A total of 1,089 patients were included. Increasing body mass index was associated with surgical site infection (adjusted odds ratio = 1.59; 95% confidence interval, 1.14-1.77; P < .01) and surgical site occurrence (adjusted odds ratio = 1.42; 95% confidence interval, 1.13-1.74; P < .01) but was not associated with surgical site occurrence requiring procedural intervention. Hernia width was associated with surgical site occurrence (adjusted odds ratio = 1.4; 95% confidence interval, 1.08-1.82; P < .01) and surgical site occurrence requiring procedural intervention (adjusted odds ratio = 1.4; 95% confidence interval, 1.08-1.82; P = .01). Hernia recurrence rate at 1 year was lower for the body mass index ≥35 kg/m 2 group (7% vs 12%; P = .02). Hernia width (odds ratio = 1.33; 95% confidence interval, 1.02-1.74; P = .04) was associated with recurrence; body mass index was not (P = .11). Both groups experienced significant improvement in hernia-specific quality of life at 1 year., Conclusion: Morbid obesity is associated with 90-day wound morbidity; however, short-term complications did not translate to higher reoperation or long-term recurrence rates. The impact of body mass index on hernia recurrence is likely overstated. An arbitrary body mass index cutoff of 35 kg/m 2 should not be used to deny symptomatic patients abdominal wall reconstruction., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Open parastomal hernia repair can be performed using retromuscular synthetic mesh in a keyhole or Sugarbaker configuration. Relative morbidity and durability are unknown. Here, we present perioperative outcomes of a randomized controlled trial comparing these techniques, including 30-day patient-reported outcomes, reoperations, and wound complications in ≤90 days., Methods: This single-center randomized clinical trial compared open parastomal hernia repair with retromuscular medium-weight polypropylene mesh in the keyhole and Sugarbaker configuration for permanent stomas between April 2019 and April 2022. Adult patients with parastomal hernias requiring open repair with sufficient bowel length for either technique were included. Patient-reported outcomes were collected at 30 days; 90-day outcomes included initial hospital length of stay, readmission, wound morbidity, reoperation, and mesh- or stoma-related complications., Results: A total of 150 patients were randomized (75 keyhole and 75 Sugarbaker). There were no differences in length of stay, readmission, reoperation, recurrence, or wound complications. Twenty-four patients (16%) required procedural intervention for wound morbidity. Ten patients (6.7%) required abdominal reoperation in ≤90 days, 7 (4.7%) for wound morbidity, including 3 partial mesh excisions (1 keyhole compared with 2 Sugarbaker; P = 1). Four mesh-related stoma complications requiring reoperations occurred, including stoma necrosis (n = 1), bowel obstruction (n = 1), parastomal recurrence (n = 1), and mucocutaneous separation (n = 1), all in the Sugarbaker arm (P = .12). Patient-reported outcomes were similar between groups at 30 days., Conclusion: Open parastomal hernia repair with retromuscular mesh in the keyhole and Sugarbaker configurations had similar perioperative outcomes. Patients will be followed to determine long-term relative durability, which is critical to understanding each approach's risk-benefit ratio., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Outcomes for patients undergoing emergency thoracic operations have not been well described. This study was designed to compare postoperative outcomes among patients undergoing emergency versus nonemergency thoracic operations., Methods: We retrospectively analyzed the American College of Surgeons National Surgical Quality Improvement Program database (2005-2018). We identified patients who underwent emergency thoracic operations using current procedural technology codes. Patients were then sorted into 1 of 4 cohorts: lung and chest wall, hiatal hernia, esophagus, and pericardium. Emergency versus nonemergency outcomes were compared. Univariate logistic regression was performed with "emergency status" as the independent variable and 30-day postoperative outcomes as the dependent variables. Multiple logistic regression models were performed to control for preoperative factors., Results: Of 90,398 thoracic operations analyzed, 4,044 (4.5%) were emergency. Common emergency operations were pericardial window (n = 580, 10.2%), laparoscopic hiatal hernia repair (n = 366, 8.9%), thoracoscopic partial lung decortication (n = 334, 8.1%), thoracoscopic wedge resection (n = 301, 7.3%), thoracoscopic total lung decortication (n = 256, 6.2%), and open repair of hiatal hernia without mesh (n = 254, 6.2%). In all 4 cohorts, 30-day postoperative complications occurred more frequently after emergency surgery. After controlling for patient characteristics, 8 complications were more frequent after emergency lung and chest wall surgery, 5 complications were more frequent after emergency hiatal hernia surgery, and 3 complications were more frequent after emergency pericardium surgery. Risk-adjusted complications were not different after emergency esophageal surgery., Conclusion: Patients undergoing emergency thoracic operations have worse risk-adjusted outcomes than those undergoing nonemergency thoracic operations. Subset analysis is needed to determine what factors contribute to increased adverse outcomes in specific patient populations., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The objective was to compare the outcomes of open mesh repair versus suture repair for small (≤1 cm in diameter) umbilical hernia. The primary endpoint was the 30-day outcomes including pain, and secondary endpoints were the 2-year outcomes including recurrences and patient-reported outcomes., Methods: This propensity-matched, multicenter study was carried out on data collected prospectively in the Hernia-Club database between 2011 and 2021. A total of 590 mesh repairs and 590 suture repairs were propensity score matched (age, sex, body mass index) at a ratio of 1:1. Postoperative pain was assessed using the Verbal Rating Scale-4 and 0‒10 Numerical Rating Scale-11., Results: Mesh insertion was intraperitoneal in 331 patients (56.1%), extraperitoneal in 249 (42.2%), and onlay in 10 (1.7%). The rate of 30-day complications and Numerical Rating Scale-11 pain scores on postoperative days 8 and 30 were similar between the groups, including surgical site occurrences (2.2 vs 1.4% after suture repair). At 1 month, postoperative discomfort (sensation of something different from before) was significantly (P < .0001) more frequent after mesh repair, whereas the rate of relevant (moderate or severe) pain (mesh repair: 1.1% vs suture repair: 2.6%) and the distribution of Numerical Rating Scale-11 scores did not differ between the groups. At the 2-year follow-up, mesh repair patients had fewer reoperated recurrences (0.2% vs 1.7%; P = .035) and no more pain or discomfort than suture repair patients., Conclusion: Both techniques are effective and safe. Mesh repair is likely to reduce the rate of recurrences. Concerns about postoperative pain and infection might not prevent the use of mesh in smallest umbilical hernias., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: To compare the outcomes of sac invagination and sac ligation in patients undergoing open Lichtenstein repair of indirect inguinal hernia., Methods: A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards was conducted to identify all randomized controlled trials comparing the outcomes of sac invagination and sac ligation in patients undergoing open Lichtenstein repair of indirect inguinal hernia. Random effects modeling was applied to calculate pooled outcome data., Results: Analysis of 843 patients with 851 hernias from 6 randomized controlled trials suggested no difference between the sac invagination and sac ligation techniques in terms of recurrence (risk difference: 0.00, P = .91), chronic pain (risk difference: 0.00, P = .98), operative time (mean difference: -0.15, P = .89), hematoma (odds ratio: 0.93, P = .93), seroma (odds ratio: 1.00, P = 1.00), surgical site infection (odds ratio: 1.68, P = .40), or urinary retention (odds ratio: 0.85, P = .78); however, ligation of sac resulted in more early postoperative pain as measured by visual analog scale score at 6 hours postoperatively (mean difference: -0.92, P < .00001), at 12 hours postoperatively (mean difference: -0.94, P = .001), at 24 hours postoperatively (mean difference: -1.08, P < .00001), and on day 7 postoperatively (mean difference: -0.99, P = .009). The quality and certainty of the available evidence were moderate., Conclusion: Evidence from randomized controlled trials with moderate certainty suggests that ligation of indirect inguinal hernia sac during open Lichtenstein repair may not improve the outcomes regarding recurrence, chronic pain, or operative complications but may result in more early postoperative pain. Future randomized controlled trials with more robust statistical power and methodological quality would help improve the available evidence's certainty., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Hypoalbuminemia has been used as a surrogate for malnutrition and is associated with worse postoperative outcomes across major operations. Because patients with hiatal hernia often have inadequate caloric intake, we examined the association of serum albumin levels with outcomes after hiatal hernia repair., Methods: Adults undergoing elective and non-elective hiatal hernia repair via any approach were tabulated from the 2012 to 2019 National Surgical Quality Improvement Program. Patients were stratified into the Hypoalbuminemia cohort if serum albumin <3.5 mg/dL using restricted cubic spline analysis. Major adverse events were defined as a composite of all-cause mortality and major complications per the American College of Surgeons National Surgical Quality Improvement Program risk calculator. Entropy balancing was used to adjust for intergroup differences. Multivariable regression models were then constructed to assess the association of preoperative albumin with major adverse events, postoperative length of stay, and 30-day readmission., Results: Of 23,103 patients, 11.7% comprised the Hypoalbuminemia cohort. The Hypoalbuminemia group was older, less commonly of White race, and less likely to have an independent functional status than others. They were also more likely to undergo inpatient, non-elective surgery via laparotomy. After entropy balancing and adjustment, hypoalbuminemia remained associated with increased odds of major adverse events and multiple complications and longer adjusted postoperative length of stay. There was no significant difference in adjusted odds of readmission., Conclusion: We used a quantitative methodology to establish a serum albumin threshold of 3.5 mg/dL associated with increased adjusted odds of major adverse events, increased postoperative length of stay, and postoperative complications after hiatal hernia repair. These results may guide preoperative nutrition supplementation., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Ventral hernia repair is one of the most common operations performed worldwide, and using mesh is standard of care to decrease recurrence. Biologic meshes are increasingly used to minimize complications associated with synthetic mesh, but with significantly higher cost and unclear efficacy. Until recently, most of the evidence supporting the use of biologic meshes was from retrospective cohorts with high heterogeneity and risk of bias. We aimed to report a meta-analysis of randomized controlled trials comparing the outcomes of synthetic and biologic mesh in elective open ventral hernia repair., Methods: A literature search of PubMed, Embase, and Cochrane Library databases was performed to identify randomized controlled trials comparing biologic and synthetic mesh in elective open ventral hernia repairs. The postoperative outcomes were assessed by means of pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I 2 statistics., Results: A total of 1,090 studies were screened, and 22 were fully reviewed. Four randomized controlled trials and 632 patients were included in the meta-analysis. Fifty-eight percent of patients had contaminated wounds (Wound Classification II-IV). Hernia recurrence (odds ratio 2.75; 95% confidence interval 1.76-4.31; P < .00001; I 2  = 0%) and surgical site infections (odds ratio 1.53; 95% confidence interval 1.02-2.29; P = .04; I 2  = 0%) were significantly more common in patients with biologic mesh. The rates of seroma, hematoma, and mesh removal were similar in both groups., Conclusion: As compared to synthetic mesh, biologic meshes resulted in increased hernia recurrences and surgical site infections. Current evidence supports macroporous, uncoated synthetic mesh as the implant of choice for elective open ventral hernia repair, and its use should be considered even in contaminated cases., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Complete fascial closure significantly reduces recurrence rates and wound complications in abdominal wall reconstruction. While component separation techniques have clear effectiveness in closing large abdominal wall defects, preoperative botulinum toxin A has emerged as an adjunct to aid in fascial closure. Few data exist comparing preoperative botulinum toxin A to component separation techniques, and the aim was to do so in a matched study., Methods: A prospective, single-center, hernia-specific database was queried, and a 3:1 propensity-matched study of patients undergoing open abdominal wall reconstruction from 2016 to 2021 with botulinum toxin A versus component separation techniques was performed based on body mass index, defect width, hernia volume, and Centers for Disease Control and Prevention wound classification. Demographics, operative characteristics, and outcomes were evaluated., Results: Matched patients included 105 component separation techniques and 35 botulinum toxin A. There was no difference in tobacco use, diabetes, or body mass index (all P > .5). Hernia defects and volume were large for both the component separation techniques and botulinum toxin A groups (mean size: component separation techniques 286.2 ± 179.9 cm 2 vs botulinum toxin A 289.7 ± 162.4 cm 2 ; P = .73) (mean volume: 1,498.3 + 2,043.4 cm 3 vs 2,914.7 + 6,539.4 cm 3 ; P = .35). Centers for Disease Control and Prevention wound classifications were equivalent (CDC3 and 4%-39.1% vs 40.0%; P = .97). Component separation techniques were more frequently performed in European Hernia Society M1 hernias (21% vs 2.9%; P = .01). The botulinum toxin A group had fewer surgical site occurrences (32.4% vs 11.4%; P = .02) and surgical site infections (11.7% vs 0%; P = .04). In multivariate analysis, botulinum toxin A was associated with lower rates of surgical site occurrences (odds ratio = 5.3; 95% confidence interval [1.4-34.4]). There was no difference in fascial closure (90.5% vs 100%; P = .11) or recurrence (12.4% vs 2.9%; P = .10) with follow-up (22.8 + 29.7 vs 9.8 + 12.7 months; P = .13)., Conclusion: In a matched study comparing patients with botulinum toxin A versus component separation techniques, there was no difference in fascial closure rates or in hernia recurrence between the 2 groups. Preoperative botulinum toxin A can achieve similar outcomes as component separation techniques, while decreasing the frequency of surgical site occurrences., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Although ventral hernias are common in older adults and can impair quality of life, multiple barriers exist that preclude ventral hernia repair. The goal of this study was to determine if older adults with ventral hernias achieve surgeon-directed goals to progress to an elective ventral hernia repair., Methods: Patients ≥60 years evaluated for a ventral hernia in a specialty clinic from January 2018 to August 2021 were retrospectively reviewed. Nonoperative candidates with modifiable risk factors were included. Data collected included specific barriers to ventral hernia repair and recommendations to address these barriers for future ventral hernia repair eligibility. Patients lost to follow-up were contacted by phone., Results: In total, 559 patients were evaluated, with 182 (32.6%) deemed nonoperative candidates with modifiable risk factors (median age 68 years, body mass index 38.2). Surgeon-directed recommendations included weight loss (53.8%), comorbidity management by a medical specialist (44.0%), and smoking cessation (19.2%). Ultimately, 45/182 patients (24.7%) met preoperative goals and progressed to elective ventral hernia repair. Alternatively, 5 patients (2.7%) required urgent/emergency surgical intervention. Importantly, 106/182 patients (58.2%) did not return to clinic after initial consultation. Of those contacted (n = 62), 35.5% reported failure to achieve optimization goals. Initial body mass index ≥40 and surgeon-recommended weight loss were associated with lack of patient follow-up (P = .01, P = .02) and progression to elective ventral hernia repair (P = .009, P = .005)., Conclusion: Nearly one-third of older adults evaluated for ventral hernias were nonoperative candidates, most often due to obesity, and over half of these patients were lost to follow-up. An increase in structured support is needed for patients to achieve surgeon-specified preoperative goals., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Our center has adopted many evidence-based practices to improve outcomes for complex abdominal wall reconstruction with porcine dermal matrix. This study analyzed outcomes over time using porcine dermal matrix in complex abdominal wall reconstruction., Methods: Prospective, tertiary hernia center data was examined for patients undergoing complex abdominal wall reconstruction with porcine dermal matrix. Early (2008-2014) and Recent (2015-2021) cohorts were defined by dividing the study interval in half. Multivariable analyses of wound complications and recurrence were performed., Results: Comparing 117 Early vs 245 Recent patients, both groups had high rates of previously repaired hernias (76.1% vs 67.4%; P = .110), Centers for Disease Control and Prevention class 3 or 4 wounds (76.0% vs 66.6%; P = .002), and very large hernia defects (320 ± 317 vs 282 ± 164 cm 2 ; P = .640). Recent patients had higher rates of preoperative botulinum injection (0% vs 21.2%; P < .001), posterior component separation (15.4% vs 35.5%; P < .001), and delayed primary closure (23.1% vs 38.8%; P < .001), but lower rates of concurrent panniculectomy (32.3% vs 27.8%; P = .027) and similar anterior component separation (29.1% vs 18.2%; P = .060). Most mesh was placed preperitoneal (74.4% vs 93.3%; P < .001). Recent patients had less inlay (9.4% vs 2.1%; P < .01) and other mesh locations as fascial closure rate increased (88.0% vs 95.5%; P < .001). Over time, there was a decrease in wound complications (42.1% vs 14.3%; P < .001), length of stay (median [interquartile range]:8 [6-13] vs 7 [6-9]; P = .003), and 30-day readmissions (32.7% vs 10.3%; P < .001). Hernia recurrence decreased (10.3% vs 3.7%; P = .016) with mean follow-up of 2.8 ± 3.2 and 1.7 ± 1.7 years, respectively. Respective multivariable models(odds ratio, 95% confidence interval) demonstrated an increased risk of wound complications with diabetes (2.65, 1.16-5.98; P = .020), panniculectomy (2.63, 1.21-5.73; P = .014), and anterior component separation (5.1, 1.98-12.9; P < .001), with recurrence risk increased by wound complication (3.8, 1.4-2-7.62; P = .032)., Conclusion: Porcine dermal matrix in complex abdominal wall reconstruction performs well with low recurrence rates. Internal assessment and implementation of evidence-based practices improved outcomes such as length of stay, wound complications, and recurrence rate., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: This study aimed to describe progressive evidence-based changes in perioperative management of open preperitoneal ventral hernia repair and subsequent surgical outcomes and to analyze factors that affect recurrence and wound complications., Methods: Prospective, tertiary hernia center data (2004-2021) were examined for patients undergoing midline open preperitoneal ventral hernia repair with mesh. "Early" (2004-2012) and "Recent" (2013-2021) groups were based on surgery date., Results: Comparison of Early (n = 675) versus Recent (n = 1,167) groups showed that Recent patients were, on average, older (56.9 ± 12.6 vs 58.7 ± 12.1 years; P < .001) with a lower body mass index (33.5 ± 8.3 vs 32.0 ± 6.8 kg/m 2 ; P = .003) and a higher number of comorbidities (3.6 ± 2.2 vs 5.2 ± 2.6; P < .001). Recent patients had higher proportions of prior failed ventral hernia repair (46.5% vs 60.8%; P < .001), larger hernia defects (199.7 ± 232.8 vs 214.4 ± 170.5 cm 2 ; P < .001), more Center for Disease Control class 3 or 4 wounds (11.3% vs 18.6%; P < .001), and more component separations (22.5% vs 45.7%; P < .001). Hernia recurrence decreased over time (7.1% vs 2.4%; P < .001), as did wound complication rates (26.7% vs 13.2%; P < .001). Comparing respective multivariable analyses (Early versus Recent), wound complications were associated with panniculectomy (odds ratio [95% confidence interval]: 2.9 [1.9-4.5], P < .001 vs 2.1 [1.4-3.3], P < .01), contaminated wounds (2.1 [1.1-3.7], P = .02 vs 1.8 [1.1-3.1], P = .02), anterior component separation technique (1.8 [1.1-2.9], P = .02 vs 3.2[1.9-5.3], P < .01), and operative time (per minute: 1.01 [1.008-1.015], P < .01 vs 1.004 [1.001-1.007], P < .01). Diabetes (2.6 [1.7-4.0], P < .01) and tobacco (1.8 [1.1-2.9], P = .02) were only significant in the early group. In both groups, recurrence was associated with wound complication (8.9 [4.1-20.1], P < .01 vs 3.4 [1.3-8.2]. P < .01) and recurrent hernias (4.9 [2.3-11.5], P < .01 vs 2.1 [1.1-4.2], P = .036)., Conclusion: Despite significant increased patient complexity over time, detecting and implementing best practices as determined by recurring data analysis of a center's outcomes has significantly improved patient care results., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Perineal hernias are rare, underreported and poorly studied complications of extensive pelvic surgeries. Their management is challenging, with currently no treatment algorithm available., Method: MEDLINE, EMBASE, Cochrane Library, and Web of Science databases were searched. Studies comprising at least 3 patients who underwent surgical perineal hernia repair were included. The primary outcome was perineal hernia recurrence. The secondary outcomes were overall complications and surgical site occurrences., Results: Twenty-nine studies were included, comprising 325 patients undergoing 347 repairs. Overall complications were 33% (95% confidence interval 24%-43%) in the entire cohort, 31% (19%-44%) after perineal repair, 39% (14%-67%) after abdominal repair, and 36% (19%-53%) after mesh repair (20% with biological, 46% with synthetic mesh). The surgical site occurrence rate was 18% (8%-29%). The overall recurrence rate was 22% (15%-29%). Recurrence after perineal repair was 19% (10%-29%): 20% with mesh (25% with biological, 19% with synthetic), 24% with primary repair, and 39% with flap repair. Recurrence after an abdominal repair was 18% (11%-26%): 16% with laparoscopic, 12% with open, 16% with mesh (24% with biological, 16% with synthetic), 30% with primary, and 25% with flap repair. No significant differences could be found in the meta-analysis regarding overall complications and recurrence., Conclusion: Synthetic mesh repair seems to be associated with a lower recurrence rate than other techniques, especially after an abdominal approach. The perineal and abdominal approaches appear to be safe, with similar recurrence rates. The combined approach seems promising, but more evidence is needed., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Pain at sexual activity induced by an inguinal hernia or as a cause of its repair is not thoroughly studied. Reported frequencies are between 25% and 30% preoperatively and 10% and 15% postoperatively. The primary aim was to analyze pain at sexual activity at 1 year comparing total extraperitoneal with Lichtenstein repair in a randomized setting., Methods: Men, 30 to 60 years old, with a primary inguinal hernia were randomized to total extraperitoneal without mesh fixation or Lichtenstein repair. A questionnaire on pain prevalence, frequency, intensity, and impairment of sexual functions caused by pain at sexual activity was introduced. Clinical examination, a questionnaire on sexual function, and the 36-Item Short Form Survey were performed preoperatively and at 1 and 3 years postoperatively. A risk factor analysis for pain at sexual activity as performed., Results: A total of 243 patients (111 total extraperitoneal and 132 Lichtenstein) were included between 2008 and 2014; 97% remained for 1-year and 90% for 3-year analysis. Preoperative pain at sexual activity was reported in 35%, with a reduction to 5.9% in total extraperitoneal and 12.5% in Lichtenstein (P = .098) at 1 year and 7.0% in total extraperitoneal and 9.3% in Lichtenstein (P = .566) at 3 years. Quality of life preoperatively was markedly reduced in patients with pain at sexual activity but restored almost to norm levels at 1 and 3 years. New pain at sexual activity (harm) was seen in 8 patients (3.6%) at 1 year. Risk factors for having postoperative pain at sexual activity were preoperative pain and Lichtenstein technique., Conclusion: Pain at sexual activity in inguinal hernia patients is more common than suspected and reduces quality of life. Repair will markedly reduce pain at sexual activity and restore quality of life in most patients without difference between techniques. Patients should be informed on a potential relation between having an inguinal hernia and sexual impairment., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: The present study examined the association of nutrition status, as defined by preoperative serum albumin, with postoperative outcomes and resource use after groin hernia repair., Methods: The 2006 to 2019 American College of Surgeons National Surgical Quality Improvement Program database was queried for adults (≥18 years) undergoing open or laparoscopic repair of inguinal or femoral hernia. Patients were stratified based on the following preoperative serum albumin levels: &lt;2.5 g/dL (severe hypoalbuminemia), 2.5 to &lt;3.0 (moderate hypoalbuminemia), 3.0 to &lt;3.5 (mild), and ≥3.5 (normal albumin). Multivariable regression models were developed to assess the association of hypoalbuminemia with outcomes of interest, including 30-day mortality, postoperative complications, length of stay, and 30-day readmission., Results: Of the 261,052 patients meeting inclusion criteria, 0.3% had severe, 1.1% had moderate, and 7.4% had mild hypoalbuminemia, with 91.2% classified as normal albumin. After risk adjustment, mortality risk was greater for severe (5.8%, 95% confidence interval: 4.1-7.6), moderate (4.4%, 95% confidence interval: 3.4-5.3), and mild hypoalbuminemia (1.5%, 95% confidence interval: 1.2-1.8) relative to normal albumin (0.3%, 95% confidence interval: 0.2-0.3). Decreasing serum albumin levels were associated with a stepwise increase in risk of complications, length of stay, and 30-day readmission., Conclusion: Decreased preoperative serum albumin is associated with increased mortality and morbidity after open and laparoscopic groin hernia repair. Serum albumin remains a relevant predictor of postsurgical outcomes and can thus be used in shared decision-making and optimization of malnourished patients in need of groin hernia repair., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Optimal inguinal hernia repair timing remains controversial. It remains unclear how COVID-19 related elective surgery cancellations impacted timing of inguinal hernia repair and whether any delays led to complications. This study aims to determine whether elective surgery cancellations are safe in pediatric inguinal hernia., Methods: This multicenter retrospective cohort study at 14 children's hospitals included patients ≤18 years who underwent inguinal hernia repair between September 13, 2019, through September 13, 2020. Patients were categorized by whether their inguinal hernia repair occurred before or after their hospital's COVID-19 elective surgery cancellation date. Incarceration and emergency department encounters were compared between pre and postcancellation., Results: Of 1,404 patients, 604 (43.0%) underwent inguinal hernia repair during the postcancellation period, 92 (6.6%) experienced incarceration, and 213 (15.2%) had an emergency department encounter. The postcancellation period was not associated with incarceration (odds ratio 1.54; 95% confidence interval 0.88-2.71; P = .13) or emergency department encounters (odds ratio 1.53; 95% confidence interval 0.94-2.48; P = .09) despite longer median times to inguinal hernia repair (precancellation 29 days [interquartile range 13-55 days] versus postcancellation 31 days [interquartile range 14-73 days], P = .01). Infants were more likely to have the emergency department be their index presentation in the postcancellation period (odds ratio 1.69; 95% confidence interval 1.24-2.31; P < .01)., Conclusion: Overall, COVID-19 elective surgery cancellations do not appear to increase the likelihood of incarceration or emergency department encounters despite delays in inguinal hernia repair, suggesting that cancellations are safe in children with inguinal hernia. Assessment of elective surgery cancellation safety has important implications for health policy., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Hiatal hernia repair is commonly performed by both general and thoracic surgeons. The present study examined differences in approach, setting, and outcomes by specialty for hiatal hernia repair., Methods: Adults undergoing hiatal hernia repair were identified in the 2012-2019 American College of Surgeons National Surgical Quality Improvement Program. Patients were grouped by specialty of the operating surgeon (thoracic surgery vs general surgery). Generalized linear models were used to evaluate the effect of specialty on mortality, major morbidity, and 30-day readmission., Results: Among 46,739 patients, 5.0% were operated on by thoracic surgery. General surgery operated on younger patients (44.7 years vs 47.0, P < .001) with lesser systemic illness (American Society of Anesthesiologists class ≥3 50.4% vs 54.8%, P < .001) compared to thoracic surgery. General surgery more commonly used laparoscopy (95.0% vs 82.6%) and less commonly used thoracic approaches than thoracic surgery (0.6% vs 8.5%, P < .001). From 2012 to 2019, the proportion of cases performed as an outpatient by general surgery increased (28.1% to 46.4%, P < .001), but it remained stable for thoracic surgery (0.1% to 0.7%, P = .10). After risk adjustment, thoracic surgery specialty was not associated with mortality (odds ratio 0.9, 95% confidence interval 0.5-1.5), major morbidity (0.9, 95% confidence interval 0.7-1.1), or readmission (0.9, 95% confidence interval 0.8-1.1). Rather, factors including surgical approach (laparotomy 1.6, 95% confidence interval 1.4-1.9; thoracoscopy/thoracotomy 2.0, 95% confidence interval 1.5-2.7), inpatient case status (2.4, 95% confidence interval 2.2-2.7), increasing ASA class, and functional status more strongly influenced major morbidity., Conclusion: Operative factors, surgical approach, and patient comorbidities more strongly influence outcomes of hiatal hernia repair than does surgeon specialty, suggesting continued safety of hiatal hernia repair by both thoracic and general surgeons., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Whether to perform umbilical hernia repair in patients with cirrhosis is a common dilemma for surgeons. We aimed to determine the incidence, morbidity, and mortality associated with emergency and nonemergency umbilical hernia repair in patients with and without cirrhosis, and to explore opportunities for nonemergency repair., Methods: Veterans diagnosed with cirrhosis between 2001 and 2014 and a frequency-matched sample of veterans without cirrhosis were followed through September 2017. Veterans Affairs Surgical Quality Improvement Program data provided outcomes and risk factors for mortality after umbilical hernia repair. We performed chart review of a random sample of patients undergoing emergency umbilical hernia repair., Results: Among 119,605 veterans with cirrhosis and 118,125 matched veterans without cirrhosis, the Veterans Affairs Surgical Quality Improvement Program database included 1,475 and 552 open umbilical hernia repairs, respectively. In patients with cirrhosis, 30-day mortality was 1.2% after nonemergency umbilical hernia repair and 12.2% after emergency umbilical hernia repair, contrasting with zero deaths in patients without cirrhosis undergoing these repairs. In patients with cirrhosis but no ascites in the prior month, 30-day mortality after nonemergency umbilical hernia repair was 0.7%, compared to 2.2% in those with ascites. Chart review of patients requiring emergency umbilical hernia repair revealed that elective umbilical hernia repair may have been feasible in 30% of these patients in the prior year; fewer than half of those undergoing emergency umbilical hernia repair had received a general surgery consultation in the prior 2 years., Conclusions: Nonemergency open umbilical hernia repair was associated with relatively low perioperative mortality in patients with cirrhosis and no recent ascites. About 30% of patients undergoing emergency umbilical hernia repair may have been candidates for nonemergency repair in the prior year., (Published by Elsevier Inc.)

Background: The utility of preoperative computed tomography for urgent abdominal wall hernia repair is unclear. This study tests the hypothesis that there is no difference in patient outcomes for acutely incarcerated ventral or inguinal hernias diagnosed by preoperative computed tomography versus clinical assessment alone., Methods: This retrospective cohort analysis included 270 adult patients undergoing urgent repair of ventral or inguinal hernia. Demographics, risk factors for complications, operative management strategies, and 1-year outcomes were compared between patients with (n = 179) versus without (n = 91) preoperative computed tomography., Results: Among 179 preoperative computed tomography scans, 15 (8.4%) were ordered by surgeons, and all others were ordered by referring providers. The computed tomography and no computed tomography groups had similar age (58 vs 58 years, P = .77), body mass index (30.7 vs 30.6 kg/m 2 , P = .30), American Society of Anesthesiologists class (3.0 vs 3.0, P = .39), incidence of the systemic inflammatory response syndrome (19.0% vs 20.9%, P = .75), and incidence of recurrent hernia (16.8% vs 19.8%, P = .61). The interval between admission and incision was longer in the computed tomography group (11.2 hours vs 6.6 hours, P < .001). The computed tomography and no computed tomography groups had similar duration of surgery (125 minutes in both groups, P = .88), proportions of patients with biologic mesh (21.2% vs 17.6%, P = .52) and synthetic mesh (35.2% vs 46.2%, P = .09) placement, and 1-year outcomes including incidence of superficial (8.4% vs 6.6%, P = .81) and deep or organ/space surgical site infection (5.0% vs 6.6%, P = .59), mesh explant for infection (2.2% vs 3.3%, P = .69), reoperation for recurrent hernia (3.9% vs 1.1%, P = .27), and mortality (7.8% vs 4.4%, P = .44)., Conclusion: The performance of preoperative computed tomography was associated with a longer interval between admission and incision and no differences in mesh placement, mesh type, or 1-year patient outcomes. These results support the safety of performing urgent repair of acutely incarcerated ventral or inguinal hernias based on clinical assessment alone., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Major ventral hernia surgeries are commonly performed. Despite guideline recommendations for chemo-thromboprophylaxis in the perioperative period, the optimal timing for its initiation is unknown. We characterized the variability in perioperative chemoprophylaxis in elective major ventral hernia surgery and determine whether timing of chemoprophylaxis affects bleeding and symptomatic venous thromboembolism., Methods: Retrospective analysis of all elective major ventral hernia surgery undertaken between January 1, 2014, and December 31, 2019, at 14 hospitals across Australia. Major bleeding was defined as the need for blood transfusion, reoperation, or >20 g/L fall in hemoglobin. Clinical venous thromboembolism was defined as imaging-proven symptomatic disease <30 days postsurgery. Propensity score matched analysis was used to validate primary findings., Results: In the study, 3,384 hernia repairs were analyzed. Chemoprophylaxis was administered early (before skin closure), postoperatively, or not given in 856 (25.3%), 1,701 (50.3%), and 827 (24.4%) patients, respectively. This varied between surgeons, trainees, and institutions. Clinical venous thromboembolism occurred in 6 (0.2%) patients and was unrelated to chemoprophylaxis timing. 134 (4.0%) patients had postoperative bleeding, with 67 (50%) major bleeds, requiring surgical control in 41 (30.6%) cases. Bleeding extended duration of stay (mean [standard deviation], 7.0 (13.9) vs 2.6 (4.7) days, P < .001). Notably, compared with postoperative (odds ratio 1.98; 95% confidence interval, 1.36-2.88; P < .001) and no (odds ratio 2.83; 95% confidence interval, 1.70-4.89; P < .001) chemoprophylaxis, early initiation significantly increased bleeding risk and independently predicted its occurrence., Conclusion: The incidence of clinical venous thromboembolism after elective major ventral hernia repair is low. Variability in perioperative thromboprophylaxis is high. Early chemoprophylaxis increases bleeding risk without appreciable additional protection from venous thromboembolism., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: To explore the thoughts, feelings, and experiences of patients with mesh-related complications after hernia repair. The rate of long-term mesh-related complications requiring procedural intervention after abdominal core surgery, including hernia repair, is unknown. Determining this rate is challenging due to its anticipated low chance of occuring and historically poor systematic long-term follow-up in patients' hernia repair. The lived experience of these patients is also not well understood., Methods: Purposive sampling was used to identify patients who have experienced mesh-related complications after hernia repair, and semistructured interviews were conducted. Descriptive thematic analysis was used to identify, analyze, and report common patterns across the data set related to the patient experience of mesh-related complications., Results: Eight patients who had undergone a hernia repair with mesh and had at least 1 mesh-related complication after their repair requiring operation, an additional procedure, or medical treatment were included in the study and completed semistructured interviews over the phone. Five domains emerged from the interviews: indicators of mesh-related complications, knowledge of potential surgical complications, relationship/satisfcation with surgeon and/or surgical team, psychosocial impact of hernia repair and mesh-related complications, and function., Conclusion: Despite the widespread use of mesh in abdominal wall operations, little is known regarding the patient experience of mesh-related complications. The themes identified in the present study provide insight into the patient experience of mesh-related complications and can inform the future development of a patient-reported outcome measure to determine the true incidence of mesh-related complications and the impact of these complications on quality of life., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Recurrent hernias pose significant challenges due to violated anatomic planes, resultant scar, and potential prior mesh. Transversus abdominis release has been widely utilized for complex hernias. Transversus abdominis release can provide a novel plane for dissection and mesh placement for recurrent hernias. This study provides our institution's experience with transversus abdominis release in patients with recurrent ventral hernias., Methods: A retrospective chart review was conducted of patients with recurrent ventral hernias from January 2018 to September 2020 who underwent transversus abdominis release by 2 fellowship-trained abdominal wall surgeons. Combined procedures (ie, gynecological/urological), robotic totally extraperitoneal, and emergency cases were excluded. Demographics, perioperative, and postoperative outcomes were reviewed., Results: In total, 108 patients underwent open-transversus abdominis release and 25 had robotic-transversus abdominis release for recurrent ventral hernias. All patients received a lightweight to midweight nonabsorbable polypropylene synthetic mesh. Mean age was 59, mean body mass index was 34 kg/m 2 , with mean hernia defect area of 333 cm 2 . We noted 34 (25.6%) surgical site occurrences and 11 (8.3%) surgical site infections. Mean postoperative follow-up was 15.5 months, with 7 (5%) recurrences (6 open-transversus abdominis release, 1 robotic-transversus abdominis release). A minimum 12-month follow-up was available for 62% of patients, and minimum 6-month follow-up in 80% of patients., Conclusion: Recurrent hernias pose significant operative challenges for surgeons due to violated tissue planes and limited repair options. Our experience suggests that transversus abdominis release may provide a durable repair for difficult recurrent ventral hernias. However, long-term postoperative follow-up over multiple years is still needed to establish extended durability of transversus abdominis release in these patients., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Transversus abdominis release is an effective procedure for complex ventral hernias. As wound complications contribute to hernia recurrences, mitigating risk factors is vitally important for hernia surgeons. Although immunosuppression can impair wound healing, it has inconsistently predicted wound occurrences, and its effect on wound morbidity after a transversus abdominis release is unknown., Methods: Patients undergoing either an elective open or robotic bilateral transversus abdominis release with permanent synthetic mesh were retrospectively stratified by perioperative immunosuppression and secondarily by procedure type (open versus robotic) and immunosuppression., Results: A total of 321 patients were included for analysis. Overall, 63 (19.6%) patients were on chronic immunosuppression, with history of solid-organ transplant being the most common indication (43 patients). Patients stratified by perioperative immunosuppression were well-matched with similar defect size (P = .97), body mass index ≥30 (P = .32), diabetes (P = .09), history of surgical site infection (P = .53), surgical approach (P = .53), and tobacco use history (P = .33). No differences between cohorts were elicited for any wound event when stratified by immunosuppression use. Similarly, no differences were elicited when cohorts were further stratified also by procedure type., Conclusion: Chronic immunosuppression is often viewed as a notable risk factor for wound occurrences after surgery. However, our data suggest immunosuppression may not significantly increase the risk of perioperative wound morbidity follow transversus abdominis release as previously predicted., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The aim of this study was to assess whether the respective values of open and laparoscopic intraperitoneal repairs of umbilical hernias are related to the European Hernia Society diameter of defects., Methods: This registry-based study compared the early and 2-year outcomes of 776 open versus 1,019 consecutive laparoscopic intraperitoneal repairs performed from 2011 to 2019., Results: Intraperitoneal mesh repair, either laparoscopic or open, was found to be a safe procedure at the 2-year follow-up. The incidence of reoperated bowel obstructions was 0.3%. Compared with the open group: (1) postoperative surgical site occurrences in small (<2 cm) or medium (2-4 cm) hernias (0.3% vs 2.4%; P = .041; 1.4% vs 5.9%; P = .0002); (2) recurrence rates in large (≥4 cm) umbilical hernias (0.0% vs 8.6%; P = .0195); and (3) cumulative reoperation rates (0.9% vs 2.2%; P = .021) were significantly better in the laparoscopic group. Conversely, the rate of early pain on day 1 and 1 month postsurgery was higher in the laparoscopic group, for all hernia sizes (P < .001). The rate of moderate or severe chronic pain at 2 years was significantly higher in the laparoscopic group (8.1% vs 2.4%; P = .049) for small hernias., Conclusion: The respective benefit to drawback ratios for open versus laparoscopic intraperitoneal repairs were related to the European Hernia Society diameter of hernia defect. In medium-large hernias, the benefits of laparoscopic repair overrode its drawbacks. In small hernias, the low recurrence rate, reduced early and chronic pain, and better rate of ambulatory surgery suggest there is still a place for open repair., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Antibacterial meshes for hernia repair seek to avoid infection in the patient. As these biomaterials are especially prone to bacteria settling at their sutured borders, this study examines whether the use of a cyanoacrylate tissue adhesive could improve mesh behavior at the fixation zones., Methods: First, antibacterial polypropylene meshes were prepared by soaking in 0.05% chlorhexidine, and the response of n-hexyl cyanoacrylate to contamination with Staphylococcus aureus ATCC25923 was assessed in vitro. Then, in a preclinical model, partial defects (5 x 3 cm) were created in the abdominal wall of 18 New Zealand White rabbits and repaired with mesh to establish the following 3 study groups: (1) mesh without chlorhexidine fixed with cyanoacrylate, (2) antibacterial mesh fixed with sutures, and (3) antibacterial mesh fixed with cyanoacrylate (n = 6 each). The implants were inoculated with 10 6 CFU/mL of S aureus. At 14 days after surgery, bacterial adhesion to the implant and its integration within host tissue were determined through microbiological, histological and immunohistochemical procedures., Results: As observed in vitro, the cyanoacrylate gave rise to a 1.5-cm bacteria-free margin around the prosthetic mesh. In vivo, the tissue adhesive prevented bacterial adhesion to the fixation zones, reducing infection of chlorhexidine-free meshes and optimizing the efficacy of the antibacterial meshes compared with those fixed with sutures., Conclusion: These findings indicated that cyanoacrylate fixation does not affect mesh integration into the host tissue. Likewise, the antibacterial behavior and tissue response of a chlorhexidine-treated polypropylene mesh is improved when cyanoacrylate is used for its fixation., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: An increasing body of information suggests that preoperative physical activity level can impact postoperative outcomes. We sought to investigate this relationship in patients undergoing ventral hernia repair (VHR)., Methods: The Abdominal Core Health Quality Collaborative registry was used to identify patients undergoing a VHR between 2013 and 2019. Patient-reported preoperative exercise level was used to stratify the study population into 4 groups: none (no reported exercise), sporadic (once a month), moderate (once per week), and intense (more than once per week). Multi-variate logistic regression analyses were used to assess the impact of preoperative exercise frequency on postoperative outcomes, including complications, hospital readmissions and length of stay. Changes in quality of life and pain from baseline to 30-days postoperatively were assessed using the Hernia-Related Quality of Life Survey and National Institutes of Health Patient-Reported Outcomes Measurement Information System 3A Pain Scale., Results: A total of 2,994 patients were included in the study, out of which 1,519 (50.7%) patients reported no preoperative exercise, 662 (22.1%) sporadic exercise, 467 (15.6%) moderate exercise, and 346 (11.6%) intense exercise. A total of 1,253 patients (19.2%) experienced a postoperative complication, out of which 249 (3.8%) had a surgical site infection. After multi-variable analysis and adjusting for demographics, comorbidities, and hernia characteristics, increasing exercise frequency (versus no reported exercise) was associated with significantly lower odds of experiencing any postoperative complication (sporadic: odds ratio 0.70; P = .008; moderate: odds ratio 0.62, P = .006; intense: odds ratio 0.67, P = .04), as well as lower odds of readmission (sporadic: odds ratio 0.04; moderate: odds ratio 0.40; intense: odds ratio 0.03; P = .01). Exercise level was not associated with length of stay (sporadic: P = .36; moderate: P = .19; intense: P = .95). No significant differences were found in changes in quality of life or pain from baseline to 30-days after surgery (Hernia-Related Quality of Life Survey, P = .24; National Institutes of Health Patient-Reported Outcomes Measurement Information System 3A P = .14)., Conclusion: Patients reporting greater exercise frequency before surgery demonstrated decreased risk of complications and readmission after undergoing ventral hernia repair. Increasing preoperative exercise participation through targeted prehabilitation programs may be a viable way for patients to reduce complications associated with VHR and improve their postoperative recovery., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Surgical mesh and hernia repair have come under increasing scrutiny with large amounts of press, Internet, and social media reportage regarding ongoing mesh litigation, recalls, and patient testimonials. The aim of this study was to evaluate patient perceptions of mesh in hernia surgery., Methods: A 16-question survey was given to patients presenting for hernia surgery at a tertiary hernia center by trained data analysts before surgeon interaction., Results: Two hundred and two patients were surveyed. Patients believed mesh caused complications (45.1%) and reported concerns about mesh (38.2%). Those who performed their own research, females, and patients with recurrent hernias were more likely to have concerns about mesh (P ≤ 0.03). Most patients (81.7%) thought they were at average risk or less for complications; patients with recurrent hernias (versus primary hernias) and incisional hernias (compared with inguinal or umbilical hernias) had more negative outlooks on complications (all P < .05). Recovery expectations varied, but the failed repair and incisional hernia groups were more likely to expect prolonged recovery (>3 months) (all P < .05). After surgeon-directed education and a mesh education handout, all but one patient agreed to and underwent a mesh repair as indicated., Conclusion: Patients had concerns about mesh and were aware of mesh related complications. Patients performing their own research, as well as females and recurrent hernia patients, had worse perceptions of mesh. Recurrent and incisional hernia patients had greater concerns about complications, recurrence, and recovery. Preoperative education concerning mesh and mesh choice for each operation eased patient anxiety., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: While modern techniques allow midline fascial closure for most abdominal hernias, a bridge repair with mesh may be the only alternative in very large defects. When the risk of infection is high, the use of prosthetic mesh is controversial. We aim to examine outcomes after bridge repair of very large abdominal hernias at high risk for postoperative infection with a second-generation biologic mesh., Methods: Prospective, multicenter, single-arm study of patients with very large abdominal hernias who received bridge repair with a neonatal bovine dermis mesh. Primary outcome was hernia recurrence, as identified on computed tomography 1 year after the operation. Secondary outcomes included mesh laxity, surgical site occurrences, and any other mesh-related complications. Independent risk factors of the outcomes were determined by univariate and multivariable analyses., Results: A total of 117 bridge repair patients were enrolled with a mean defect size of 442.5 ± 254.2 cm 2 . The patients were predominantly obese (mean body mass index 36.5 ± 10.5) and with multiple comorbidities (Charlson comorbidity index 3 ± 2.5). Hernia recurrence was identified in 24 (20.5%) patients. An infected mesh at the index operation was an independent predictor of hernia recurrence, whereas obesity was an independent predictor of the pooled endpoint of recurrence and mesh laxity. Surgical site occurrences were recorded in 36.8% of the patients, and no independent risk factors were identified., Conclusion: In patients with very large abdominal hernias and at high risk for postoperative infection, who cannot undergo midline fascial closure, a bridge repair with neonatal bovine dermis mesh offers an acceptable profile in terms of hernia recurrence and wound occurrences., (Copyright © 2020. Published by Elsevier Inc.)

Objectives: To characterize regional variation in the age of patients undergoing umbilical hernia repair to determine costs and subsequent care., Study Design: We performed a cross-sectional descriptive study using a large convenience sample of US employer-based insurance claims from July 2012 to December 2015. We identified children younger than 18 years of age undergoing uncomplicated (not strangulated, incarcerated, or gangrenous) umbilical hernia repair as an isolated procedure (International Classification of Diseases, Ninth Revision procedure codes 53.41, 53.42, 53.43, or 53.49, International Classification of Diseases, Tenth Revision procedure code 0WQF0ZZ, or Current Procedural Terminology procedure codes 49580 or 49585)., Results: In all, 5212 children met criteria for inclusion. Children younger than age 2 years accounted for 9.7% of repairs, with significant variation by census region (6% to 14%, P < .001). Total payments for surgery varied by age; children younger than 2 years averaged $8219 and payments for older children were $6137. Postoperative admissions occurred at a rate of 73.1 per 1000 for children younger than age 2 years and 7.43 for older children; emergency department visits were 41.5 per 1000 for children younger than age 2 years vs 15.9 for older children (P < .001)., Conclusions: Umbilical hernias continue to be repaired at early ages with large regional variation. Umbilical hernia repair younger than age 2 years is associated with greater costs and greater frequency of postoperative hospitalization and emergency department visits., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Ventral hernias in patients with intra-abdominal metastases may not be addressed owing to other oncologic priorities, but they can affect quality of life and lead to sequelae necessitating an emergency operation. We compared the national trends and perioperative outcomes for elective and nonelective ventral hernia repairs for patients with intra-abdominal metastases., Methods: Patients were identified from the National Inpatient Sample (2003-2015). Temporal trends were described using average annual percent change. Perioperative outcomes between elective and nonelective ventral hernia repairs were compared using multivariable regressions., Results: An estimated 947,112 ventral hernia repairs were performed nationally, including 5,602 (0.6%) in patients with intra-abdominal metastases. Among patients with intra-abdominal metastases, 40.1% had a nonelective ventral hernia repair, mean (standard deviation) age was 64 (12) years, and 65.1% were women. Between 2003 and 2015, the total number of ventral hernia repairs performed nationally did not change (average annual percent change 0.062, P = .84). For patients with intra-abdominal metastases, although there was no change in the number of elective ventral hernia repairs (average annual percent change 0.65, P = .59), the number of nonelective ventral hernia repairs increased significantly (average annual percent change 2.7, P = .025). By multivariable analyses, patients with intra-abdominal metastases who underwent a nonelective repair were more likely to experience complications (odds ratio 1.76, P = .001), nonroutine discharge (odds ratio 1.93, P < .001), and mortality (odds ratio 2.27, P = .035). Nonelective ventral hernia repairs was also associated with a 38.5% (P < .001) longer hospital stay and 24.4% (P < .001) higher charges., Conclusion: The number of nonelective ventral hernia repairs, which is associated with substantial perioperative morbidity, has increased significantly among patients with intra-abdominal metastases. Surgeons should consider a nonemergency operation for select patients to mitigate the burden of nonelective ventral hernia repairs., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The best treatment for the combined defects of midline and lateral incisional hernia is not known. The aim of our multicenter study was to evaluate the operative and patient-reported outcomes using a modified posterior component separation in patients who present with the combination of midline and lateral incisional hernia., Methods: We identified patients from a prospective, multicenter database who underwent operative repairs of a midline and lateral incisional hernia at 4 centers with minimum 2-year follow-up. Hernias were divided into a main hernia based on the larger size and associated abdominal wall hernias. Outcomes reported were short- and long-term complications, including recurrence, pain, and bulging. Quality of life was assessed with the European Registry for Abdominal Wall Hernias Quality of Life score., Results: Fifty-eight patients were identified. Almost 70% of patients presented with a midline defect as the main incisional hernia. The operative technique was a transversus abdominis release in 26 patients (45%), a modification of transversus abdominis release 27 (47%), a reverse transversus abdominis release in 3 (5%), and a primary, lateral retromuscular preperitoneal approach in 2 (3%). Surgical site occurrences occurred in 22 patients (38%), with only 8 patients (14%) requiring procedural intervention. During a mean follow-up of 30.1 ± 14.4 months, 2 (3%) cases of recurrence were diagnosed and required reoperation. There were also 4 (7%) patients with asymptomatic but visible bulging. The European Registry for Abdominal Wall Hernias Quality of Life score showed a statistically significant decrease in the 3 domains (pain, restriction, and cosmetic) in the postoperative score compared with the preoperative score., Conclusion: The different techniques of posterior component separation in the treatment of combined midline and lateral incisional hernia show acceptable results, despite the associated high complexity. Patient-reported outcomes after measurement of the European Registry for Abdominal Wall Hernias Quality of Life score demonstrated a clinically important improvement in quality of life and pain., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Smoking and obesity are well-known risk factors for surgical site infection, but it is unknown whether these factors influence outcomes after repair of small umbilical and epigastric hernias with defects ≤2 cm. The aim of this study was to evaluate whether smoking and obesity are associated with readmission, reoperation for complications, and recurrence rates after elective repair of small umbilical and epigastric hernias., Methods: Data on hernia type, size, repair method, smoking status, and body mass index after elective repair were available from the Danish Hernia Database from January 2017 through December 2018. Data on 90-day readmission and reoperation were available from the Danish National Patients Registry., Results: A total of 1,965 patients were included for final analysis, of whom 85.1% (1,672 of 1,965) were repaired by open approach and 70.8% (1,391 of 1,965) with mesh reinforcement. A 100% follow-up was secured, and median follow-up time was 307 (138-432) days. Readmission was significantly higher in smokers (9.6% [34 of 353]) compared with nonsmokers (6.4% [103 of 1,612]), P = .030. The reoperation rate for complications was also significantly higher for smokers (4.0% [14 of 353])) compared with nonsmokers (2.0% [32 of 1,612]) (P = .026). Patients with a body mass index ≥35 kg/m 2 were more frequently readmitted (11.7%; 12 of 102) compared with 6.7% (125 of 1,965) of patients with body mass index ≤34.9 kg/m 2 (P = .046). In multivariate analyses adjusted for age, sex, presence of chronic obstructive pulmonary disease, diabetes, and cardiovascular disease, smoking (odds ratio = 1.52 [1.02-2.30]) and body mass index >40 kg/m 2 (odds ratio = 6.07 [2.03-18.10]) were independent risk factors for readmission., Conclusion: Smoking and obesity have a significantly negative impact on outcomes even after elective repair of small umbilical and epigastric hernias., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Little data exist to inform discharge opioid prescribing for patients undergoing abdominal wall reconstruction. The aim of this study was to evaluate postoperative, patient-reported opioid use after abdominal wall reconstruction. We hypothesized that the majority of patients undergoing open abdominal wall reconstruction would require between 16 and 30 opioid tablets after discharge., Methods: Postoperative, patient-reported opioid use was collected prospectively for all patients undergoing elective, open abdominal wall reconstruction at a single high-volume center. All opioid medications were converted to an equivalent number of 5 mg oxycodone tablets. The primary outcome was the total number of opioid tablets taken within 30 days of hospital discharge after abdominal wall reconstruction., Results: Ninety-eight patients were included. Median hernia width was 15 cm (interquartile range 12-19), 42% were recurrences, and all underwent transversus abdominis release. At the 30-day follow-up visit, 24% reported no postdischarge opioid use, and 76% reported taking 15 tablets or fewer. Of the 23 patients who used no opioids on the day before discharge, 16 (70%) reported taking no opioids after discharge., Conclusion: Most patients reported taking fewer opioid tablets than prescribed and fewer than our hypothesis within 30 days of abdominal wall reconstruction. Opioid use on the day before discharge may allow for prognostication of outpatient opioid requirements to prevent overprescribing., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Recurrence rates after ventral hernia repair vary widely and evidence about risk factors for recurrence are conflicting. There is little evidence for risk factors for long-term recurrence., Methods: Patients who underwent ventral hernia repair at our institution and were captured in the American College of Surgeons-National Surgical Quality Improvement Program database between 2002 and 2015 were included. We reviewed all demographic, procedural, and hernia-specific data., Results: Six hundred and thirty patients were included for analysis with a median follow-up of 4.9 years (inter-quartile range, 2-7.3 years). By univariate analysis, index hernia repairs were more likely to recur if defect size was ≥4 cm (P = .019), no mesh was used (P = .026), or if the repair was for a recurrent hernia (P = .001). Five-year cumulative incidence of recurrence and reoperation was 24.3% and 16.0%, respectively. Patients with a perioperative surgical site occurrence, which included superficial, deep-incisional, and organ space surgical site infections as well as wound disruption, had a 5-year cumulative incidence of recurrence of 54.9% compared with 22.6% for those without surgical site occurrence. By multivariable analysis, non-primary hernia repair (hazard ratio 1.7, 95% confidence interval 1.2-2.4, P = .005) and any postoperative surgical site occurrence (hazard ratio 1.9, 95% confidence interval 1.1-3.6, P = .02) were the only risk factors predictive of recurrence. Patient body mass index had no independent effect on recurrence., Conclusion: 1 in 4 patients undergoing an open ventral hernia repair will have a recurrence after 5 years, and this risk is doubled among patients who experience any perioperative surgical site occurrence. After controlling for patient comorbidities, including body mass index, hernia size, and mesh position, the most significant risk factor for recurrence after ventral hernia repair was a non-primary hernia and surgical site occurrence., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: A mesh-related intestinal fistula is an uncommon and challenging complication of ventral hernia repair. Optimal management is unclear owing to lack of prospective or long-term data., Methods: We reviewed our prospective data for mesh-related intestinal fistulas from 2004 to 2017and compared suture repair versus ventral hernia repair with mesh at the time of mesh-related intestinal fistula takedown., Results: Eighty-two mesh-related intestinal fistulas were treated; none of the fistulas had closed spontaneously, and all fistula persisted at the time of our treatment. Mean age was 61 ± 12 years with 33-month follow-up. Comorbidities were similar between groups. Defects were 2.5-times larger in ventral hernia repair with mesh (324 ± 392 cm 2 vs 1301 ± 133 cm 2 ; P = .044). Components separation (64% vs 21%; P = .0003) and panniculectomy (35% vs 7%; P = .0074) were more common in ventral hernia repair with mesh. Mortality occurred in 4 patients. Complications were similar. In patients undergoing ventral hernia repair with non-bridged, acellular, porcine dermal matrix, hernia recurrence was less than in patients without mesh (26% vs 66%; P = .0030). Only partial excision of the mesh involved with the fistula resulted in a substantial increase in developing another fistula (29% vs 6%; P < .05)., Conclusion: Patients undergoing preperitoneal ventral hernia repair with mesh for mesh-related intestinal fistula had a lesser rate of hernia recurrence and similar complications compared to suture repair despite larger hernias. Complete mesh excision decreases the risk of fistula recurrence. We maintain that ventral hernia repair with mesh during mesh-related intestinal fistula takedown represents the best opportunity for a durable herniorrhaphy., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The use of lightweight mesh for inguinal hernia repair has been suggested to be preferable compared with heavyweight mesh. Nevertheless, surgeons do not use lightweight mesh routinely, possibly owing to the higher price and lack of confidence in evaluation of previous evidence. The aim of this systematic review and meta-analysis is to update the available randomized controlled trials and provide a recommendation on the use of lightweight mesh or heavyweight mesh in open inguinal hernia repair., Methods: A literature search was conducted in May 2019 in MEDLINE, Embase and the Cochrane library for randomized controlled trials comparing lightweight (≤50 g/m 2 ) and heavyweight (>70 g/m 2 ) mesh in patients undergoing open (Lichtenstein) surgery for uncomplicated inguinal hernias. Outcomes were recurrences (overall, after direct or indirect repair), chronic pain (analyzing any and severe pain), and the feeling of a foreign body. The level of evidence was assessed using GRADE. Risk ratios and 95% confidence intervals were calculated by random effect meta-analyses., Results: Twenty-one randomized controlled trials involving 4,576 patients (lightweight mesh 2,257 vs heavyweight mesh 2,319) were included. Follow-up ranged from 3 to 60 months. No difference between lightweight mesh and heavyweight mesh was determined for recurrence rates (lightweight mesh 42 of 2,068 and heavyweight mesh 34 of 2,132; risk ratios 1.22; 95% confidence interval, 0.76-1.96) or severe pain (lightweight mesh 14 of 1,517 and heavyweight mesh 26 of 1,591; risk ratios 0.73; 95% confidence interval, 0.38-1.41). A significant reduction was seen for any pain after lightweight mesh (234 of 1,603) compared with heavyweight mesh (322 of 1,683; risk ratios 0.78; 95% confidence interval, 0.64-0.96) and for the feeling of a foreign body (lightweight mesh 130 of 1,053 and heavyweight mesh 209 of 1,035; risk ratios 0.64; 95% confidence interval, 0.51-0.80)., Conclusion: Lightweight mesh should be used in open (Lichtenstein) inguinal hernia repair., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Male and female hernia patients often have different surgical history, fat distribution, and medical comorbidities. Female surgical patients seemingly experience worse outcomes after open ventral hernia repair. This study evaluates the impact of sex and the distribution of abdominal adiposity on outcomes after open ventral hernia repair., Methods: A prospective hernia database was queried for patients from 2007 to 2018 with a computed tomography within 1 year of open ventral hernia repair. Three-dimensional volumetric analysis was performed. Demographics, abdominal fat distribution, operative characteristics, and outcomes were evaluated by sex using univariate and multivariate analysis., Results: A total of 1,178 patients were identified, 57.8% were female. Compared with males, females had higher mean body mass index (34.8 ± 8.5 vs 31.7 ± 6.4 kg/m 2 , P < .0001), previous abdominal operations (3.3 ± 1.5 vs 2.6 ± 1.3, P < .0001), and preoperative chronic pain (33.5 vs 26.4%, P = .009). There was no difference in history of recurrence, age, steroid use, smoking, diabetes, or hernia volume between sexes (P ≥ .17 all values). Males had larger defects (168.1 ± 148.2 vs 138.8 ± 126.8 cm 2 , P = .001) and intra-abdominal volume (intra-abdominal fat volume; 6,279 ± 2,614 vs 4,454 ± 2,196 cm 3 , P < .0001). Females had larger subcutaneous fat volume (subcutaneous fat volume; 7,453 ± 6,600 vs 5,708 ± 3,275 cm 3 , P < .0001), and ratio of hernia to intra-abdominal volume (hernia volume to intra-abdominal fat volume; 0.33 ± 0.52 vs 0.22 ± 0.42, P < .0001). On univariate analysis, females had higher rates of readmission, wound complication, and intervention for pain after open ventral hernia repair (P ≤ .02 all values). On multivariate analysis, females had shorter duration of stay (-1.36 day, standard error 0.49, P = .006) with higher readmission rate (odd ratio, 1.64; 95% confidence interval, 1.15-2.34)., Conclusion: Female hernia patients in our population are more comorbid, with higher body mass index, thicker subcutaneous fat volume and a higher ratio of hernia volume to intra-abdominal fat volume. These differences are associated with more extensive surgical intervention, such as panniculectomy and higher rates of adverse outcomes after open ventral hernia repair. However, these differences are not fully explained by identified comorbidities and warrant further investigation., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: In hernia surgery, soaking of meshes in antibiotics before implantation is a prophylactic strategy for minimizing the risk of infection while providing minimal, local, drug doses. This study describes the development and application of an antibacterial mesh coating comprising a carboxymethylcellulose gel loaded with rifampicin in a preclinical model of Staphylococcus aureus and S. epidermidis infection in rabbits., Methods: Antibacterial activity and cytocompatibility (with fibroblasts) of unloaded carboxymethylcellulose gel and 0.13 mg/mL rifampicin-carboxymethylcellulose gel were assessed in vitro. Then, partial abdominal wall defects (5 × 2 cm) were created in New Zealand white rabbits (n = 34), the wound inoculated with 0.25 mL of 10 6 CFU Staphylococcus aureus/ S. epidermidis (n = 17 each), and the defect then repaired with a lightweight, monofilament, large pore polypropylene mesh either uncoated (n = 3) or coated with carboxymethylcellulose gel (n = 7) or rifampicin-carboxymethylcellulose gel (n = 7). By postoperative day 14, coating performance was evaluated by determining bacterial adhesion (via sonication), host tissue incorporation (via histology), macrophage response via immunostaining), and bloodstream drug diffusion (via high-performance liquid chromatography)., Results: In vitro, rifampicin-carboxymethylcellulose gel demonstrated great activity against Staphylococcus aureus/S. epidermidis, while being innocuous for fibroblasts. In vivo, rifampicin-carboxymethylcellulose gel-coated implants displayed full bacterial clearance and optimal tissue integration, irrespective of the strain of Staphylococcus. In contrast, uncoated and carboxymethylcellulose gel-coated implants exhibited macro/microscopic signs of infection and impaired tissue integration. Macrophage responses were less in rifampicin-carboxymethylcellulose gel implants than in uncoated mesh (Staphylococcus aureus/S. epidermidis; P < .01) and carboxymethylcellulose gel (S. epidermidis; P < .05) implants. Bloodstream levels of rifampicin were undetectable., Conclusion: Soaking meshes in rifampicin-carboxymethylcellulose gel inhibited effectively the bacterial adhesion to the mesh without compromising the tissue repair. This antibiotic gel constitutes an easy-to-use and effective prophylactic strategy that potentially reduce the prevalence of postoperative mesh infection., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Improved recurrence rates after groin hernia surgery have led to chronic pain becoming the most troublesome postoperative complication. Self-gripping mesh was developed to decrease the risk for development of chronic pain. The aim of this nationwide cohort study was to compare recurrence rate and chronic pain 1 year after an open, anterior mesh repair of inguinal hernias with either a self-gripping mesh or other lightweight mesh., Method: All operations registered as open anterior mesh repair (Lichtenstein) in the Swedish Hernia Registry between September 2012 and October 2016 were selected. At 1 year after repair, patients were sent a pain questionnaire assessing chronic pain. We compared the prevalence of chronic pain and reoperation for recurrence using lightweight, sutured mesh or self-gripping mesh., Results: We analyzed the 1,803 repairs using self-gripping mesh and 16,567 repairs using lightweight mesh. We found no difference in the prevalence of chronic pain 1 year after the hernia repair between self-gripping mesh and sutured lightweight mesh (OR 0.92, CI 95% 0.80-1.06, P = .257). There was no increase in reoperation for recurrence when using self-gripping mesh (HR 0.71, CI 95% 0.45-1.14, P = .156). Mean operation time was considerably less when using self-gripping mesh (43 vs 70 minutes; P > .001)., Conclusion: The use of self-gripping mesh does not decrease the incidence of chronic pain and reoperation for recurrence compared with lightweight, sutured mesh for open anterior mesh repair of inguinal hernias. Furthermore, the use of self-gripping mesh is associated with a clinically important, lesser operation time., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Placement of paraesophageal type of "mesh" in paraesophageal hernia repair is controversial. This study examines the trends and outcomes of mesh placement in paraesophageal hernia repair., Methods: The American College of Surgeons National Surgical Quality Improvement Program was queried for patients who underwent paraesophageal hernia repair with or without mesh (2010-2017). Demographics, operative approach, and outcomes were compared over time., Results: Of 25,801, most paraesophageal hernia repair cases were elective (89.3%), without mesh (61.9%), and performed laparoscopically (91.3%).When compared with open paraesophageal hernia repair patients, the patients undergoing laparoscopic paraesophageal hernia repair had lesser rates of reoperation, readmission, mortality, overall complications and major complications (2.7% vs 4.8%, 6.2% vs 9.6%, 0.6% vs 2.9%, 7.1% vs 21.3%, 3.8% vs 11.1%, respectively; all P < .0001). Mesh placement was more common in laparoscopic paraesophageal hernia repair (38.9 vs 29.7, P < .0001) than opern paraesophageal hernia repair. During 2010-2017, mesh placement decreased from 46.2% to 35.2% of laparoscopic paraesophageal hernia repair (P < .0001). Operative times for laparoscopic paraesophageal hernia repair decreased over time, and laparoscpic paraesophageal hernia repair without mesh was consistently less (with mesh: 176.0 ± 71.0 to 149.9 ± 72.5 min, without mesh: 148.6 ± 71.4 to 134.6 ± 70.4). We observed no changes in comorbidities or adverse outcomes over time. Using multivariate analysis to control for potential confounding factors, chronic obstructive pulmonary disease was associated most strongly with adverse outcomes, including mortality (OR 2.53, CI 1.55-4.14), any complications (OR 1.80, CI 1.51-2.16), major complications (OR 1.80, CI 1.51-2.16), readmission (OR 1.63, CI 1.33-1.99) and reoperation (OR 1.49, CI 1.10-2.02). Mesh placement was not associated with adverse outcomes., Conclusion: The placement of mesh during laparoscopic paraesophageal hernia repair is not associated with adverse outcomes. Use of mesh with laparoscopic paraesophageal hernia repair is decreasing with no apparent adverse impact on short-term patient outcomes. Further research is needed to investigate patient factors not captured by this national database, such as characteristics of the hernia, patient symptoms, and hernia recurrence., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Pathways of enhanced recovery after surgery represent a standardized, multimodal approach to postoperative care with the goal of accelerating recovery without increasing morbidity. We hypothesized that implementation of an enhanced recovery after surgery pathway for abdominal wall reconstruction would result in a decreased duration of stay., Methods: We compared 100 historic controls to 100 consecutive patients undergoing abdominal wall reconstruction with use of a newly implemented, enhanced recovery after surgery pathway to detect a difference in duration of stay of 1 day. Groups were compared on demographics and clinical characteristics using χ 2 , Fisher exact, Mann-Whitney U test, and 2 sample t tests as appropriate for the data., Results: There was no change in duration of stay with the enhanced recovery after surgery protocol (median 5 vs 5 days, P = .78). There was no difference in time to regular diet (median 3 vs 3 days, P = .14). There was a trend toward decreased time epidurals or patient-controlled analgesia used (median 3 vs 3 day, P = .01). There was no increase in readmission rates. In a subgroup analysis, factors associated with a duration of stay <4 days were hernia width 9.5 ± 7.2 cm (P = .009), operative time 2.5 ± 0.9 hours (P = .001), and preoperative quality-of-life scores (HerQles) 59.5 ± 11.7 (P = .008)., Conclusion: Our enhanced recovery after surgery study group did not show a decrease in duration of stay. Although smaller hernia defects, lesser operative times, and better baseline quality-of-life scores were associated with shorter duration of stay, the benefits of enhanced recovery after surgery seem limited in patients with the more complex hernia repairs., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Open inguinal hernia repair is thought to cause worse postoperative pain than minimally invasive surgery, and thus patients are often prescribed more opioids at discharge. This study evaluates opioid use in inguinal hernia repair patients to optimize discharge prescribing practices for this common procedure., Methods: Opioid-naive adults undergoing open or minimally invasive surgery inguinal hernia repair were identified prospectively from 3 centers to complete a 29-question telephone interview after discharge as part of a larger initiative. Opioid prescription and consumption data were converted into morphine milligram equivalents and compared between minimally invasive surgery and open inguinal hernia repair. Univariate χ 2 , Fisher exact test, univariate, and multivariable logistic regression were used., Results: Of 249 contacted patients, 195 (74%) completed the survey (n = 97 open, n = 98 minimally invasive surgery). Patients undergoing open inguinal hernia repair were slightly older (71 vs 65 years, P < .001) and less likely to be female (3% vs 17%, P = .001) than minimally invasive surgery patients. Open patients were more likely to have a unilateral inguinal hernia repair (95% open vs 52% minimally invasive surgery, P < .001). Discharge pain scores using the 10-point, patient-reported Numeric Pain Rating scale were similar (open 2.3 ± 1.7 vs minimally invasive surgery 2.4 ± 1.6; P = .80), and most patients were satisfied with postoperative pain control (open 86% vs minimally invasive surgery 95%; P = .13). Open inguinal hernia repair patients were just as likely to receive opioids at discharge as those undergoing minimally invasive surgery inguinal hernia repair (98% vs 91% minimally invasive surgery; P = .06) and were prescribed similar amounts of opioids (open 155 [IQR 113, 225] morphine milligram equivalents vs 150 [IQR 100, 210] minimally invasive surgery; P = .08). There was no difference in opioid use by approach (open 15 [IQR 0, 60] morphine milligram equivalents vs 9 [IQR 0, 50] minimally invasive surgery; P = .33). More than one-third of patients used no opioids (open 38% vs minimally invasive surgery 44%; P = .42). Bilateral repair was not associated with increased opioid use (univariate odds ratio 1.23, P = .58). On multivariable analysis, low discharge pain and normal body mass index were independently associated with needing no opioids at discharge. Overall, 75% of prescribed opioids remained unused at time of survey, yet only 12% of patients had disposed of unused opioids at the time of survey., Conclusion: Postdischarge opioid utilization was clinically similar between patients undergoing open and minimally invasive surgery inguinal hernia repair and those requiring unilateral or bilateral repair. Given that more than one-third of patients required no opioids after discharge, 0 to 8 tablets of 5 mg oxycodone is sufficient for most opioid-naive patients undergoing inguinal hernia repair., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Our study aims were to evaluate factors that predict recurrence after open umbilical hernia repair with either mesh or primary closure., Methods: Consecutive patients (n = 1,125) undergoing open umbilical hernia repair from 2009 to 2018 were identified from a prospectively managed, quality database. Kaplan-Meier curves and log-rank tests were used to analyze recurrence-free survival for preoperative, intraoperative, and postoperative factors. Univariable and multivariable Cox regression was used to analyze recurrence-free survival by age, sex, body mass index, concurrent laparoscopic inguinal hernia repair, smoking status, diabetes, postoperative infection, hernia size in greatest dimension, and type of repair., Results: The overall recurrence rate was 3.3% with a median follow-up of 14 months. Univariable analysis revealed a difference in recurrence-free survival for current smoking (P = .039), diabetes (P = .007), higher body mass index (P = .057), and postoperative infection (P < .001). Multivariable analysis indicated higher body mass index (P = .007), concurrent laparoscopic inguinal hernia repair (P = .044), current smoking status (P = .020), diabetes (P = .021), and a primary closure repair of hernias ≥1.5 cm (P = .001) had a greater risk of recurrence. Postoperative infection showed an association with recurrence (P = .053)., Conclusion: Our results indicate higher body mass index, concurrent laparoscopic inguinal hernia repair, current smoking, diabetes, primary closure repair of hernias ≥1.5 cm, and postoperative infection were associated with a greater risk of recurrence after open umbilical hernia repair., (Copyright © 2019 Elsevier Inc. All rights reserved.)