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Purpose: Incisional hernias (IH) rates after diverting loop ileostomy reversal (DLI-R) have been reported up to 24%. We aimed to characterize the incidence rate and risk factors associated with DLI-R site IH formation within 1-year in a large patient cohort., Methods: A retrospective review at a single quaternary referral center hospital of adult patients who underwent DLI-R over a 5-year period and abdominal computerized tomography (CT) imaging performed within 1-year for any indication postoperatively was conducted. All CTs scans were independently reviewed by staff surgeons to determine the presence of a fascial defect at the DLI-R site., Results: 2,196 patients underwent DLI-R; of these, 569 (25.9%) underwent CT imaging for any indication. Mean patient age, 54.8 (± 14.9), BMI 27.6 kg/m 2 . 87 (15%) patients had a parastomal hernia at time of DLI-R. After median follow-up of 10 months, 203 patients (35.7%) had IH at the DLI-R site. Age (p = 0.14), sex (p = 0.39), race (p = 0.75), and smoking status (p = 0.82) weren't associated with IH after DLI-R. Comorbidities weren't significantly associated with IH following DLI-R. In univariate analysis, increased BMI (p < 0.001), presence of a parastomal hernia (p = 0.008), and suture type (p = 0.01) were associated with IH development. On multivariate analysis, BMI remained significant, and polyglyconate compared to polydioxanone suture were associated with higher rates of IH (p < 0.001)., Conclusion: We observed that the rate of incisional hernias within 1-year of diverting ileostomy reversal was indeed common at 36%. Granted, a high percentage of the population was excluded due to heterogeneity in radiographic evaluation that could be mitigated in future prospective studies. Our study suggests that IH preventative strategies include weight loss for overweight and obese patients prior to DLI-R and that the optimal suture for DLI-R is polydioxanone., (© 2024. The Author(s).)

Purpose: Abdominally based autologous breast reconstruction (ABABR) is common after mastectomy, but carries a risk of complex abdominal wall hernias. We report experience with posterior component separation (PCS) and transversus abdominis release (TAR) with permanent synthetic mesh repair of ABABR-related hernias., Methods: Patients at Cleveland Clinic Foundation and Penn State Health were identified retrospectively. Outcomes included postoperative complications, hernia recurrence, and patient-reported outcomes (PROs): Hernia Recurrence Inventory, HerQLes Summary Score, Patient-Reported Outcome Measurement Information System (PROMIS) Pain Intensity 3a Survey, and the Decision Regret Scale (DRS)., Results: Forty patients underwent PCS/TAR repair of hernias resulting from pedicled (35%), free (5%), muscle-sparing TRAMs (15%), and DIEPs (28%) from August 2014 to March 2021. Following PCS, 30-day complications included superficial surgical site infection (13%), seroma (8%), and superficial wound breakdown (5%). Five patients (20%) developed clinical hernia recurrence. At a minimum of 1 year, 17 (63%) reported a bulge, 12 (44%) reported pain, median HerQLes Quality Of Life Scores improved from 33 to 63/100 (p value < 0.01), PROMIS 3a Pain Intensity Scores improved from 52 to 38 (p value < 0.05), and DRS scores were consistent with low regret (20/100)., Conclusion: ABABR-related hernias are complex and technically challenging due to missing abdominal wall components and denervation injury. After repair with PCS/TAR, patients had high rates of recurrence and bulge, but reported improved quality of life and pain and low regret. Surgeons should set realistic expectations regarding postoperative bulge and risk of hernia recurrence., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Introduction: The optimal pain management strategy after open ventral hernia repair (VHR) with transversus abdominus release (TAR) is unknown. Opioids are known to have an inhibitory effect on the GI tract and cause postoperative ileus. Epidural analgesia is associated with lower postoperative ileus rates but may contribute to other postoperative complications. A propensity-matched retrospective review published by our group in 2018 found that epidural analgesia was associated with an increased length of stay and any postoperative complication after VHR. Epidural analgesia was therefore abandoned by our group following this publication. We aimed to determine if discontinuation of epidural analgesia affected ileus rates after open VHR., Methods: Patients who underwent open VHR with TAR from August 2014 to January 2022 ​at Cleveland Clinic Foundation with at least 30-day follow-up were retrospectively identified using the Abdominal Core Health Quality Collaborative registry. Patients with and without epidural analgesia were compared. The primary outcome was post-operative ileus. Additional outcomes included length of stay, deep venous thrombosis (DVT), pneumonia, wound complications and pain requiring intervention., Results: A total of 2570 patients were included: 420 had an epidural, 2150 did not. Preoperative patient and hernia characteristics were similar between both groups. Mean hernia width was 15.5 ​cm in the epidural group and 16.1 ​cm in the no epidural group. In the epidural group, ileus was seen in 9 of 420 (2.15%) of patients which was significantly less than in the no epidural group, 400 of 2150 (18.6%), p=>0.001. On multivariate analysis, epidurals were predictive of lower risk of ileus (OR 0.04, 95%CI 0.01-0.17, p ​= ​0.001) and pain requiring intervention (OR 0.02, 95%CI 0.00-0.71, p ​= ​0.02). Epidural analgesia was not associated with increased DVT rates, pneumonia, length of stay, SSI, or SSOPI., Discussion: Discontinuation of epidural analgesia was associated with a 9-fold increase in ileus rates after VHR with TAR. Epidurals may play an important role in limiting postoperative opioid use and therefore reducing risk of ileus. Other postoperative complications including pneumonia and venous thrombosis were not impacted by epidurals. Further prospective studies are needed to further define a ventral hernia patient population who will benefit from epidural analgesia., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: The most appropriate method of reconstructing the abdominal wall at the site of a simultaneous stoma takedown is controversial. The contaminated field, concomitant GI procedure being performed and presence of a hernia all complicate decision-making. We sought to describe the surgical approaches, mesh type and outcomes of concomitant abdominal wall reconstruction during stoma takedown in a large hernia registry., Methods and Procedures: All patients who underwent stoma takedown with simultaneous hernia repair with retromuscular mesh placement from January 2014 to May 2022 were identified within the Abdominal Core Health Quality Collaborative (ACHQC). Patients were stratified by mesh type including permanent synthetic (PS), resorbable synthetic (RS) and biologic mesh. Association of mesh type with 30-day wound events and other complications and 1-year outcomes were evaluated., Results: There were 368 patients who met inclusion criteria. Eighty-nine patients had ileostomies, 276 colostomies and 3 had both. Two hundred and seventy-nine (75.8%) patients received PS mesh, 46 (12.5%) biologic, and 43 (11.7%) RS. Seventy percent (259/368) had a parastomal hernia, 75% (285/368) had a midline incisional hernia, and 48% (178/368) had both. All groups had similar preoperative comorbidities and the majority had a transversus abdominus release. All mesh groups had similar thirty-day SSI (13.2-14.3%), SSO (10.5-17.8%) and SSOPI (7.9-14.1%), p = 0.6. Three patients with PS mesh developed infected synthetic mesh and one PS mesh required excision. Four patients with PS developed an enterocutaneous fistula. Of these, only one patient was recorded as having both an enterocutaneous fistula and mesh infection. Thirty-day reoperation and readmission were similar across all mesh groups. Recurrence at 1-year was similar between mesh groups. Quality of life measured using HerQLes scores were higher at one year compared to baseline in all groups indicating improvement in hernia-specific quality of life., Conclusion: Early complication rates associated with simultaneous stoma takedown and abdominal wall reconstruction are significant, regardless of mesh type utilized. Concomitant surgery should be weighed heavily and tailored to individual patients., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Prehospital chlorhexidine gluconate (CHG) skin washes are used to prevent wound complications, but little evidence supports this practice in hernia surgery. A propensity-matched retrospective review published by our group in 2016 found that prehospital CHG was associated with an increased risk of surgical site occurrences (SSO) and surgical site infections (SSI) after ventral hernia repair. Prehospital CHG was, therefore, abandoned by three of five surgeons at the Cleveland Clinic Foundation (CCF) by April 2017. We aimed to determine if discontinuation of prehospital CHG affected wound morbidity rates after incisional hernia repair., Methods: The Abdominal Core Health Quality Collaborative was queried for all patients who underwent open, clean incisional hernia repairs with 30-day follow-up from 2014 to 2019. Using an interrupted time series (ITS) analysis model adjusted for group and mean propensity score, wound morbidity before and after April 1, 2017 (start of Q2) was compared between three groups: CCF surgeons who abandoned prehospital CHG (Group 1), CCF surgeons who continued using prehospital CHG (Group 2), and non-CCF surgeons using prehospital CHG (Group 3). Outcomes included rates of SSOs, SSIs, and surgical site occurrences requiring procedural intervention (SSOPI) at 30 days., Results: In total, 4276 patients were included in the analysis (Group 1: 339 before Q2 vs 673 after Q2; Group 2: 211 before Q2 vs 175 after Q2; Group 3: 1312 before Q2 vs 1566 after Q2). Rates of SSO, SSIs, and SSOPIs at 30 days were similar across all three groups before and after prehospital CHG discontinuation., Conclusion: Stopping prehospital CHG wash did not result in increased wound morbidity after open, clean, incisional hernia repair. We have abandoned CHG use in this context., (© 2022. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: Incisional hernia is the most common complication of midline laparotomy. Although obesity is a known risk factor, the incidence of hernia formation in obese patients is not well defined. We sought to define the rate of incisional hernia formation in obese patients undergoing primary midline laparotomy in a large academic medical center., Methods: Obese patients (BMI ≥ 30 kg/m 2 ) who underwent an elective or urgent primary midline laparotomy from 2017 to 2021 at our institution were retrospectively identified. A blinded hernia surgeon reviewed imaging to assess for incisional hernia formation, defined as a midline fascial defect with intra-abdominal contents herniated outside of the peritoneal cavity., Results: A total of 2241 patients met inclusion criteria. Cross-sectional imaging was available for 914 (41%) of these patients. The median BMI for all patients was 34.3 kg/m 2 (range 30.0-59.1). Median time to follow-up imaging was 316 days (181-957, IQR = 185) for all patients and 316 days (201-903, IQR = 184) for patients with incisional hernia. In total, 474 (51.9%) had radiographic evidence of an incisional hernia. Colorectal and General Surgery demonstrated the highest rate of incisional hernia (p < 0.001). During the study period, 138 patients (15.1%) underwent surgical repair of their hernia at our institution, with the highest percentage being Colorectal Surgery patients., Conclusion: There is a high rate of hernia formation and subsequent hernia repair in obese patients undergoing midline laparotomy. Most importantly, these findings demonstrate an immediate and pressing need to identify the patient risk factors and technical issues related to this rate of hernia formation., (© 2022. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: Bowel injury during laparoscopic and robotic ventral hernia repair is a rare but potentially serious complication. We sought to compare bowel injury rates during minimally invasive approaches to ventral hernia repair using a national hernia registry., Methods: Patients undergoing elective laparoscopic and robotic ventral hernia repair (including cases converted-to-open) between 2013 and 2021 were retrospectively identified in the Abdominal Core Health Quality Collaborative registry. The primary outcome was bowel injury, which included partial- and full-thickness injuries and re-operations for missed enterotomies. Statistical analysis was performed using multivariate logistic regression., Results: Overall, 10,660 patients were included (4116 laparoscopic, 6544 robotic). The laparoscopic group included more incisional hernias (68% vs 62%, p &lt; 0.001) and similar rates of recurrent hernias (23% vs 22%, p = 0.26). A total of 109 bowel injuries were identified, with more occurring in the laparoscopic group (55 [1.3%] laparoscopic vs. 54 [0.8%] robotic; p = 0.01). Specifically, there were more full-thickness and missed enterotomies in the laparoscopic group (29 laparoscopic vs. 20 robotic; p = 0.012). Bowel injury resulted in higher rates of wound morbidity and major post-operative complications including sepsis, re-admission, and re-operation. Following adjustment for recurrent and incisional hernias, prior mesh, patient age, and hernia width, bowel injury during laparoscopic repair remained significantly more likely than bowel injury during robotic repair (OR 1.669 [95% C.I.: 1.141-2.440]; p = 0.008)., Conclusion: In a large registry, laparoscopic ventral hernia repair is associated with an increased risk of bowel injury compared to repairs utilizing the robotic platform. Knowing the limitations of retrospective research, large national registries are well suited to explore rare outcomes which cannot be feasibly assessed with randomized controlled trials., (© 2022. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: With the advancement of abdominal wall reconstruction, more complex hernia patients are undergoing repairs that may require a postoperative surgical intensive care unit (SICU) admission. The volume ratio (VR) of the hernia sac to the abdominal cavity is an easily applied method to quantify disease severity and the ensuing physiologic insult. This study aimed to predict postoperative SICU admission using VR and other preoperative variables., Methods: A single-center retrospective review was conducted for patients undergoing large abdominal hernias (width ≥ 18 cm) repaired from September 2014 to October 2019. Patient demographics, comorbidities, abdominal surgical history, and VR were analyzed through univariate and multivariable methods to identify predictors of SICU admission within the first two postoperative days. A predictive model was generated and validated., Results: Of 434 patients meeting inclusion criteria, 127(29%) required a SICU admission within the first two postoperative days. VR was significantly higher in SICU patients (Median 30.6% [IQR 14.4-59.0] vs. 10.6% [IQR 4.35-23.6], P < 0.001). Male sex, history of chronic obstructive pulmonary disease, prior component separation, recurrent incisional hernia, hernia grade 3, and VR showed higher odds of SICU admission. When validated on a testing dataset, these variables showed strong SICU admission predictions, with an area under the curve, sensitivity, and specificity of 0.82, 81.7% and 68.5%, respectively., Conclusions: The volume ratio in combination with preoperatively available variables can reliably predict postoperative SICU admission following abdominal wall reconstruction. Anticipating such events preoperatively allows for bed space allocation as well as optimizing postoperative care., (© 2022. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: While the use of synthetic mesh for incisional hernia repair reduces recurrence rates, little evidence exists regarding the impact of this practice on the disease burden of a Crohn's patient. We aimed to describe the post-operative outcomes and healthcare resource utilization following incisional hernia repair with synthetic mesh in patients with Crohn's disease., Methods: A retrospective review of adult patients with Crohn's disease who underwent elective open incisional hernia repair with extra-peritoneal synthetic mesh from 2014 to 2018 at a single large academic hospital with surgeons specializing in hernia repair was conducted. Primary outcomes included 30-day post-operative complications and long-term rates of fistula formation and hernia recurrence. The secondary outcome compared healthcare resource utilization during a standardized fourteen-month period before and after hernia repair., Results: Among the 40 patients included, six (15%) required readmission, 4 (10%) developed a surgical site occurrence, 3 (7.5%) developed a surgical site infection, and one (2.5%) required reoperation within the first 30 days. The overall median follow-up time was 42 months (IQR = 33-56), during which time one (2.5%) patient developed an enterocutaneous fistula and eight (20%) experienced hernia recurrence. Healthcare resource utilization remained unchanged or decreased across every category following repair., Conclusion: The use of extra-peritoneal synthetic mesh during incisional hernia repair in patients with Crohn's disease was not associated with a prohibitively high rate of post-operative complications or an increase in healthcare resource utilization to suggest worsening disease during the first 4 years after repair. Future studies exploring the long-term outcomes of this technique are needed., (© 2021. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: Incisional hernia repair with mesh improves long-term outcomes, but the ideal mesh position remains unclear. This study compared intraperitoneal versus retromuscular or preperitoneal sublay (RPS) mesh positions for open incisional hernia repairs., Methods: All patients who had elective open incisional hernia repairs were identified retrospectively in the Americas Hernia Society Quality Collaborative database. The primary outcome was the rate of 30-day surgical-site infection (SSI). Other outcomes of interest included 30-day surgical-site occurrences requiring procedural intervention (SSOPI), hernia-related quality-of-life survey (HerQLes) scores and long-term recurrence. A logistic model was used to generate propensity scores for mesh position using several clinically relevant co-variables. Regression models adjusting for propensity score and baseline characteristics were developed to assess the effect of mesh placement., Results: A total of 4211 patients were included in the study population: 587 had intraperitoneal mesh and 3624 had RPS mesh. Analysis with propensity score adjustment provided no evidence for differences in SSOPI (odds ratio (OR) 0·79, 95 per cent c.i. 0·49 to 1·26) and SSI (OR 0·91, 0·50 to 1·67) rates or HerQLes scores at 30 days (OR 1·20, 0·79 to 1·82), or recurrence rates (hazard ratio 1·28, 0·90 to 1·82)., Conclusion: Mesh position had no effect on short- or long-term outcomes, including SSOPI and SSI rates, HerQLes scores and long-term recurrence rates., (© 2020 BJS Society Ltd Published by John Wiley & Sons Ltd.)

Purpose: In a subset of patients with massive and multiply recurrent hernias, despite performing a transversus abdominis release (TAR), anterior fascial re-approximation is not feasible and a bridged repair is required. We aim to report on the outcomes of this patient population at our institution., Methods: Patients that underwent a TAR-bridged repair at the Cleveland Clinic were identified retrospectively within the Americas Hernia Society Quality Collaborative (AHSQC) database. Outcomes of interest were quality-of-life metrics measured through HerQLes and PROMIS pain intensity 3a and composite recurrence measured by patient-reported outcomes, physical examination, or CT imaging., Results: Ninety-six patients met inclusion criteria. The mean hernia width was 26 ± 8 cm. The majority (93%) were incisional hernias and 71% were recurrent with 21% having five prior hernia repairs. Of those eligible for recurrence and QoL analysis, 54 (70%) had data points available. HerQLes scores showed a steady improvement throughout postoperative recovery (26 ± 21 at baseline, 44 ± 26 at 30-day follow-up, and 60 ± 33 at 6 months-3 years; P < 0.001), as did the PROMIS Pain Intensity 3a scores (46 ± 11 at baseline, 45 ± 11 at 30-day follow-up, and 39 ± 11 at 6 months-3 years; P = 0.001). At a mean follow-up of 20 ± 10 months, a composite recurrence of 46% was reported, primarily from patients reporting a "bulge" at the site., Conclusion: Performing a bridged TAR repair with synthetic mesh in patients with complex hernias is associated with high rates of patient-reported bulge perception. Despite this, there was a significant improvement in quality-of-life metrics. When counseling these patients during preoperative evaluation, the results of our study should be shared in candor to aid in informed decision-making.

Background: Incisional hernias (IH) after orthotopic liver transplant (OLT) are challenging due to their concurrent midline and subcostal defects adjacent to bony prominences in the context of lifelong immunosuppression. To date, no studies evaluated the posterior component separation with transversus abdominis release (TAR) to repair complex IH after OLT. We aim to report the outcomes of TAR in this scenario., Study Design: OLT patients who underwent open, elective IH repair with TAR performed at two centers and with a minimum of 1-year follow-up were identified in the Americas Hernia Society Quality Collaborative (AHSQC). Outcomes included 30-day surgical site infections (SSI), surgical site occurrences requiring procedural intervention (SSOPI), unplanned readmissions, reoperations, and hernia recurrence., Results: Forty-four patients were identified (mean age 60 ± 8, 75% male, median BMI 30.7 kg/m 2 ) at two centers. Median hernia width was 20 cm [IQR 15-28] and 98% (43) were clean cases. Retromuscular synthetic mesh was used in all cases, and 93% (41) achieved fascial closure with no intraoperative complications. Postoperatively, there were 5 SSIs (4 deep, 1 superficial), 6 SSOPIs (4 wound opening, 1 debridement, 1 seroma drainage), four (9%) readmissions, and 3 (7%) reoperations. One patient developed a mesh infection that did not require mesh excision. After a median follow-up of 13 months [IQR 12-17], there were 11 (25%) recurrences; 8 due to central mesh fractures (CMF). Seven recurrences have been repaired either laparoscopically or using an onlay., Conclusions: In a challenging cohort of immunosuppressed patients with large IH, TAR was shown to have acceptable medium-term results, but high recurrence rate driven by CMF. Further studies investigating the mechanism of central mesh fractures are necessary to reduce these recurrences.

Purpose: Elective repair of large incisional hernias using posterior component separation with transversus abdominis release (TAR) has acceptable wound morbidity and long-term recurrence rates. The outcomes of using this reconstructive technique in the non-elective setting remains unknown. We aim to report 30-day outcomes of TAR in non-elective settings., Methods: All patients undergoing open TAR in non-elective settings were identified within the Americas Hernia Society Quality Collaborative (AHSQC). A retrospective review was conducted and outcomes of interest were 30-day Surgical Site Infections (SSI), Surgical Site Occurrences (SSO), SSOs requiring procedural intervention (SSOPI), medical complications, and unplanned readmissions and reoperations., Results: Fifty-nine patients met inclusion criteria. Mean BMI was 36.6 ± 8.9 kg/m 2 and mean hernia width was 14.4 ± 7.2 cm. Forty (67.8%) were recurrent hernias. Pain (88%) and bowel obstruction (79.7%) were the most frequent indications for surgery. Surgical field was classified as clean in 69.5% of cases, with an 88% use of permanent synthetic mesh and fascial closure achieved in 93.2% of cases. There were 15 (25.4%) total wound events, 8 (13.6%) were SSIs. There were 8 (13.6%) SSOPIs, 6 of which were wound opening, 1 wound debridement, and 1 percutaneous drainage. At least one wound or medical complication was reported for 37% of the patients. There were no mortalities., Conclusion: Not surprisingly, TAR in the non-elective setting is associated with increased wound morbidity requiring procedural interventions and reoperations compared to what has previously been reported for elective cases. The long-term consequences of this wound morbidity with regard to hernia recurrence are as of yet unknown.