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Background: We hypothesized that long-term quality of life (QoL) is improved among patients with ventral hernias (VHs) and comorbid conditions managed operatively than with non-operative management., Methods: This was the 3-year follow-up to a prospective observational study of patients with comorbid conditions and VHs. Primary outcome was change in QoL measured utilizing the modified Activities Assessment Scale (AAS), a validated, hernia-specific survey. Outcomes were compared using: (1)paired t-test on matched subset and (2)multivariable linear regression on the overall cohort., Results: In the matched cohort (n = 80; 40/group), the operative group experienced a significantly greater improvement in QoL compared to the non-operative group (28.4 ± 27.1 vs. 11.8 ± 23.8,p = 0.005). The operative group, had 10 (25.0%) reported recurrences while the non-operative group, reported 4/15 (26.7%) recurrences among the 15 (37.5%) patients that underwent repair. On multivariable analysis of the whole cohort (n = 137), operative management was associated with a 19.5 (95% CI7.0-31.9) point greater improvement in QoL compared to non-operative management., Conclusions: This is the first long term prospective study showing the benefits of operative as opposed to non-operative management of patients with comorbid conditions and VHs., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The modified Activities Assessment Scale (AAS) is a 13-question abdominal wall quality of life (AW-QOL) survey validated in patients undergoing ventral hernia repair (VHR). No studies have assessed AW-QOL among individuals without abdominal wall pathology. The minimal clinically important difference (MCID) of the modified AAS and its implications for the threshold at which VHR should be offered also remain unknown. Our objectives were to (1) establish the AW-QOL of patients with a clinical abdominal wall hernia versus those with no hernia, (2) determine the MCID of the modified AAS, and (3) identify the baseline quality of life (QOL) score at which patients derive little clinical benefit from VHR., Methods: Patient-centered outcomes data for all patients presenting to General Surgery and Hernia Clinics October-December 2016 at a single safety-net institution were collected via a prospective, cross-sectional observational study design. Primary outcome was QOL measured using the modified AAS. Secondary outcome was the MCID., Results: Patients with no hernia had modified AAS scores of 81.6 (50.4-94.4), while patients with a clinically apparent hernia had lower modified AAS scores of 31.4 (12.6-58.7) (p < 0.001). The MCID threshold was 7.6 for a "slight" change and 14.9 for "definite" change. Above a modified AAS score of 81, the risk of worsening a patient's QOL by surgery is higher than the chances of improvement., Conclusions: VHR can improve 1-year postsurgical AW-QOL to levels similar to that of the general population. The MCID of the modified AAS is 7.6 points. Patients with high baseline scores should be counseled about the lack of potential benefit in QOL from elective VHR.

Background: Surgical site infections (SSIs) remain prevalent after ventral hernia repair (VHR). In 2013-2014, a safety-net academic hospital initiated a two-pronged quality-improvement (QI) project: (1) Development and implementation of evidence-based guidelines; and (2) creation of a specialized hernia clinic to manage challenging patients and complex ventral hernias. Our objective was to decrease SSI rates after elective VHR., Methods: The primary outcome was SSI 30 days post-operatively, which was assessed in aggregate and with a stratified analysis based on case complexity using the χ 2 test., Results: A total of 399 patients in the pre-QI period and 390 patients in post-QI period (178 patients in general surgery clinics; 212 patients in the specialty hernia clinic) underwent VHR. Patients treated in the post-QI period were less likely to experience an SSI (13.5% vs. 1.5%; p < 0.001). On subgroup analysis of the post-QI clinics, specialty hernia clinic patients had an even lower risk of SSI than those in general surgery clinics (1.4% versus 1.7%)., Conclusions: The QI initiatives of evidence-based guidelines and the specialty hernia clinic were associated with lower SSI rates. Differences in peri-operative management included differences in patient selection and pre-operative preparation and increased use of synthetic mesh and laparoscopy. Future studies must investigate the long-term outcomes of these initiatives.

Background: From the patient's perspective, a ventral hernia (VH) can cause pain, adversely affect function, increase size, cosmetically distort the abdomen, and incarcerate/strangulate abdominal contents. The only known "cure" for a VH is surgical repair. The aim of this study was to review systematically the published randomized controlled trials (RCTs) of the surgical care of VH., Method: A search of the Ovid, MEDLINE, EMBASE, and Cochrane databases was performed to obtain reports of RCTs on the use of mesh reinforcement in abdominal wall hernia repair. The outcomes assessed were hernia recurrence and surgical site infection (SSI). The overall quality of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE). When feasible, based on assessment of heterogeneity, data were pooled and analyzed in a meta-analysis., Results: Of the 10,349 titles screened, 25 articles (23 studies) met the search criteria. Evidence indicates that mesh reinforcement in clean cases can decrease hernia recurrence (number needed to treat = 7.9) but increase risk of SSI (number needed to harm = 27.8). Placing mesh in the sublay position (as opposed to the onlay or underlay position) may decrease the risk of hernia recurrence and SSI., Conclusions: Mesh reinforcement is recommended for all VH repairs in a clean case (high grade of evidence). Sublay mesh location may result in fewer recurrences and SSIs than onlay or inlay placement, but further study is needed to confirm this hypothesis (moderate grade of evidence).

Background: The U.S. Centers for Disease Control requires 90 days after surgery using an implant to diagnose or show the absence of a surgical site infection (SSI). However, many databases only track outcomes up to 30 days. The cost and effort to increase follow-up to 90 days after surgery is high and the benefit is unclear. We hypothesize that the majority of SSIs after ventral hernia repair occur within 30 days of surgery., Patients and Methods: All patients who underwent ventral hernia repair (with or without mesh) from 2010-2015 at a single institution were evaluated for evidence of SSI. The duration between surgery and the diagnosis of a post-operative SSI was assessed. Baseline and operative characteristics were compared between patients with an early SSI (within 30 days of surgery) and those with a late SSI (more than 30 days after surgery)., Results: Among 1,635 patients who underwent ventral hernia repair, 117 (7.2%) developed an SSI. The median (range) of days between surgery and SSI was 15 days (range, 2-763). There were 20 (17.1%) late SSIs diagnosed; of these, 17 were diagnosed between 31-90 d and three were diagnosed later than 90 days. Patients with a late SSI were more likely to have had a prior ventral hernia repair and have had biologic mesh (p = 0.001)., Conclusions: Whereas the majority of SSIs after ventral hernia repair occurred within the first 30 days, a substantial number of late SSIs occurred. It is worthwhile to follow patients for at least 90 days post-operative in order to capture a more accurate picture of the true rate of SSI.

Background: Little is known about the clinical or patient-reported outcomes with non-operative management of ventral hernias. The aim of this prospective study is to determine the clinical and patient-reported outcomes of patients undergoing initial non-operative treatment of their ventral hernia., Study Design: This was a prospective observational study of patients undergoing non-operative management of ventral hernias. Primary outcome was rate of surgical repair of the ventral hernias. Secondary outcomes included rate of emergency repair, elective repair, and emergency room visits. In addition, validated measurement tools for patient satisfaction and cosmetic satisfaction with their abdomen, abdominal pain, and patient function (modified Activities Assessment Scale, AAS) were utilized., Results: Of 128 patients who underwent non-operative management of a ventral hernia, 99(77.3%) patients were followed for a median (interquartile range) of 12.2(10.4-13.5) months. Twenty (20.2%) patients had at least 1 emergency room visit associated with their hernia. One-quarter (n = 2323.2%) underwent ventral hernia repair following enrollment. Twenty (20.2%) underwent elective repair, and 3 (3.0%) underwent emergent repair. Based on the modified AAS survey, patients who were managed non-operatively experienced no change in patient centered outcomes, while patients converted to operative management had improved scores., Conclusions and Relevance: While the short-term risk of emergency surgery with non-operative management of ventral hernias is moderate, the chance of an emergency room visit and surgery is high. Patients who undergo non-operative management of their ventral hernias have no change in patient-reported outcomes at one year, while those converted to operative management experience improvement.

Objective: To achieve consensus on the best practices in the management of ventral hernias (VH)., Background: Management patterns for VH are heterogeneous, often with little supporting evidence or correlation with existing evidence., Methods: A systematic review identified the highest level of evidence available for each topic. A panel of expert hernia-surgeons was assembled. Email questionnaires, evidence review, panel discussion, and iterative voting was performed. Consensus was when all experts agreed on a management strategy., Results: Experts agreed that complications with VH repair (VHR) increase in obese patients (grade A), current smokers (grade A), and patients with glycosylated hemoglobin (HbA1C) ≥ 6.5% (grade B). Elective VHR was not recommended for patients with BMI ≥ 50 kg/m (grade C), current smokers (grade A), or patients with HbA1C ≥ 8.0% (grade B). Patients with BMI= 30-50 kg/m or HbA1C = 6.5-8.0% require individualized interventions to reduce surgical risk (grade C, grade B). Nonoperative management was considered to have a low-risk of short-term morbidity (grade C). Mesh reinforcement was recommended for repair of hernias ≥ 2 cm (grade A). There were several areas where high-quality data were limited, and no consensus could be reached, including mesh type, component separation technique, and management of complex patients., Conclusions: Although there was consensus, supported by grade A-C evidence, on patient selection, the safety of short-term nonoperative management, and mesh reinforcement, among experts; there was limited evidence and broad variability in practice patterns in all other areas of practice. The lack of strong evidence and expert consensus on these topics has identified gaps in knowledge where there is need of further evidence.

Objective: The aim of this study was to determine patient-centered outcomes of nonoperative treatment of a ventral hernia., Summary of Background Data: Nonoperative management of ventral hernias (VHs) is often recommended for patients at increased risk of complications; however, the impact of this management strategy on outcome and quality of life (QoL) is unknown. We hypothesize that QoL and function are better among patients with VHs managed operatively., Methods: Patients with a VH from a single-center hernia clinic were prospectively enrolled between June 2014 and June 2015. Nonoperative management was recommended if smoking, obesity, or poorly controlled diabetes was present. Primary outcomes were patient-centered outcomes, including QoL and function, which were measured using a validated, hernia-specific survey (modified Activities Assessment Scale) before surgeon' consultation and at 6 months. Other outcomes included surgical site infection (SSI) and recurrence. Risk-adjusted outcomes between nonoperative and operative groups were compared using: paired t test on a propensity score-matched subset and multivariable analysis on the overall cohort., Results: A total of 152 patients (nonoperative = 97, operative = 55) were enrolled. In the propensity-matched cohort (n = 90), both groups had similar baseline QoL and function scores, but only repaired patients had improved scores on 6-month follow-up. In the overall cohort, nonoperative management was strongly associated with lower function scores (log odds ratio = -26.5; 95% confidence interval = -35.0 to -18.0)., Conclusions: This is the first prospective study comparing management strategies in VH patients with comorbidities. Elective repair improves hernia-related QoL and function in low- to moderate-risk patients and should be considered in appropriately selected patients.

Background: The literature supporting ventral hernia management is growing; however, it is unclear whether the quality of work is improving. We hypothesize that the quality of clinical ventral hernia research has improved over the past 2.5 decades., Methods: A review of MEDLINE, Scopus, and Cochrane databases was conducted for all ventral hernia studies from January 1, 1980 to May 1, 2015. Relevant abstracts were assigned a level according to the Oxford Center for Evidence-Based Medicine. Reviews, and meta-analyses were graded using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Checklist and randomized controlled trials (RCTs) using the Consolidated Standards of Reporting Trials (CONSORT) checklist. Studies that did not fulfill at least 70% of the elements for the PRISMA (19/27) or CONSORT (26/37) checklists were considered to contain substantial methodological flaws., Results: Of 12,431 citations, 1336 met criteria for quality evaluation. Level 1 studies were sparse (n = 104, 7.8%), and most were level 2 or 3 (n = 463, 34.7%) or 4 (n = 769, 57.6%). Of the level 1 studies, 37 (35.6%) were RCTs, 61(58.7%) were reviews and/or meta-analyses, and 6 (5.8%) were consensus statements. Most RCTs and reviews and/or meta-analyses contained substantial methodological flaws (75.7%, 75.8%). Critical areas of weakness in RCTs were explaining losses and exclusions after randomization and/or allocation and reporting determination of sample size. For reviews and/or meta-analyses, areas of weakness were presenting an electronic search strategy and providing an assessment of risk of bias before pooling data. Linear regressions of PRISMA and CONSORT scores demonstrated improvement over time (PRISMA slope 0.95, R(2) = 0.24; CONSORT slope 0.34, R(2) = 0.08)., Conclusions: Although the quality of literature guiding ventral hernia management has improved over time, there is room for improvement., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Importance: Physical examination misses up to one-third of ventral hernia recurrences seen on radiologic imaging. However, tests such as computed tomographic (CT) imaging are subject to interpretation and require validation of interobserver reliability., Objective: To determine the interobserver reliability of CT scans for detecting a ventral hernia recurrence among surgeons and radiologists. We hypothesized there would be significant disagreement in the diagnosis of a ventral hernia recurrence among different observers. Our secondary aim was to determine reasons for disagreement in the interpretation of CT scans., Design, Setting, and Participants: One hundred patients who underwent ventral hernia repair from 2010-2011 at an academic health care center with a postoperative CT scan were randomly selected from a larger cohort. This study was conducted from July 2014 to March 2015. Prospective assessment of the presence or absence of a recurrent ventral hernia on CT scans was compared among 9 blinded reviewers and the radiology report. Five reviewers (consensus group) met to discuss all CT scans with disagreement. The discussion was assessed for keywords and key concepts. The remaining 4 reviewers (validation group) read the consensus group recommendations and reassessed the CT scans. Pre- and post-review κ were calculated; the post-review assessments were compared with clinical examination findings., Main Outcomes and Measures: Interobserver reliability in determining hernia recurrence radiographically., Results: Of 100 CT scans, there was disagreement among all 9 reviewers and the radiology report on the presence/absence of a ventral hernia in 73 cases (κ = 0.44; 95% CI, 0.35-0.54; P < .001). Following discussion among the consensus group, there remained disagreement in 10 cases (κ = 0.91; 95% CI, 0.83-0.95; P < .001). Among the validation group, the κ value had a slight improvement from 0.21 (95% CI, 0.12-0.33) to 0.34 (95% CI, 0.23-0.46) (P < .001) after reviewing the consensus group proposals. There was disagreement between clinical examination and the consensus group assessment of CT scans on the presence/absence of a ventral hernia in 25 cases. The concepts most frequently discussed were the absence of an accepted definition for a radiographic ventral hernia and differentiating pseudorecurrence from recurrence., Conclusions and Relevance: Owing to the high interobserver variability, CT scan was not associated with reliable diagnosing in ventral hernia recurrence. Consensus guidelines and improved communication between surgeon and radiologist may decrease interobserver variability.