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Lateral abdominal wall hernias are relatively rare and present unique challenges to repair. Our group has developed an algorithm for repair based on several anatomic characteristics identified on preoperative imaging. Herein, we report our algorithm and outcomes of a large series of open retromuscular lateral abdominal wall hernia repairs.Open retromuscular lateral abdominal wall hernia repairs performed at our institution from August 2014 through April 2021 were identified in the Abdominal Core Health Quality Collaborative (ACHQC). Hernia characteristics, etiology, operative techniques, postoperative outcomes, and long-term patient-reported outcomes were extracted from the ACHQC database, chart review, and telephone follow-up.Of 464 patients who underwent hernia repair, 121 with isolated lateral abdominal wall hernias (L1-4) and mean follow-up of 34 ± 24 months had a clinical recurrence rate of 0.9% (n=1) and bulge rate of 37% (n=42). The median HerQLes and PROMIS® pain intensity scores improved 37 and 9 points, respectively. Another 343 patients with lateral (L1-4) and midline (M1-5) abdominal wall hernias and mean follow-up of 29 ± 21 months had a clinical recurrence rate of 6% (n=20) and bulge rate of 35% (n=117). The median HerQLes and PROMIS® pain intensity scores improved by 43 and 16 points, respectively.We present an algorithm for open retromuscular lateral abdominal wall hernia repair with relatively low anatomic recurrence rates and substantial improvement in patient-reported quality of life and pain. Notably, postoperative bulging is commonly reported by patients, likely due to underlying denervation injuries from the original incision.

We aimed to report long-term clinical and patient-reported outcomes of transversus abdominis release (TAR) with permanent synthetic mesh performed in a high-volume abdominal wall reconstruction practice.Despite increasing utilization of TAR in abdominal wall reconstruction, long-term clinical and patient-reported outcomes remain uncertain.Prospectively collected registry data from the Cleveland Clinic Center for Abdominal Core Health were analyzed retrospectively. Patients undergoing elective, open VHR with TAR and permanent synthetic mesh implantation between August 2014 and March 2020 with 30-day clinical and ≥1 year clinical or patient-reported outcome follow-up were included. Outcomes included composite hernia recurrence, characterized by patient-reported bulges and recurrent hernias noted on physical exam or imaging, as well as hernia-specific quality of life and pain.A total of 1203 patients were included. Median age was 60 years [interquartile range (IQR): 52-67], median body mass index was 32 kg/m2 (IQR: 28-36), median hernia width was 15 cm (IQR: 12-19), and 57% of hernias were recurrent. Fascial reapproximation was achieved in 92%. At a median follow-up of 2 years (IQR: 1-4), the overall composite hernia recurrence rate was 26%, with sensitivity analysis yielding best-case and worst-case estimates of 5% and 28%, respectively. Patients experienced improved hernia-specific quality of life and pain regardless of recurrence outcome; however, those who did not recur experienced more substantial improvement.TAR with permanent synthetic mesh remains a valuable, versatile technique; however, surgeon and patient expectations should be tempered regarding long-term durability. Despite a high rate of recurrence, patients experience measurable improvements in quality of life.

Introduction We present our experience developing and embedding a registry-based module for resident feedback. Methods At our institution, entering operative data into the institutional quality collaborative registry is standard practice. In February 2019, a surgical education module was embedded into the registry to capture procedure-specific resident operative assessments. Faculty engagement with the sugical education module was assessed during its first year in existence (February 2019-February 2020). Results In total, 1074 of 1269 (85%) operative assessments were completed by 27 faculty via the surgical education registry module. Median faculty engagement rate with the module following resident-assisted procedures was 91% [IQR 76%-100%]. Residents received a median of 7 operative assessments [IQR 2-19] over the study period. Conclusion By embedding a surgical education module into an existing surgical quality collaborative registry, procedure-specific operative assessments can be routinely captured.

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. 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. 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. 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.

Transversus abdominis release (TAR) is increasingly used to address complex ventral hernias; consequently, associated complications are seen more frequently. Our hernia center has a growing experience with redo-transversus abdominis release (redo-TAR) to address large, complex hernia recurrences after failed TAR. Here, we describe our outcomes after abdominal wall reconstruction with redo-TAR. Adults undergoing elective open, redo-TAR at our institution from January 2015 to February 2021 were queried from a prospectively collected database in the Abdominal Core Health Quality Collaborative. The primary outcome was 30-day wound morbidity. Secondary outcomes were long-term composite hernia recurrence and patient-reported quality of life. Sixty-five patients underwent redo-TAR. Median age was 60 years, 50.8% were female, and median BMI 31.8 kg/m2. Median recurrent hernias were 16 cm wide by 25 cm long. Frequent mechanisms of recurrence included linea semilunaris injury (27.7%), mesh fracture (18.5%), infection (16.9%), and posterior sheath disruption (15.4%). Wound complications occurred in 33.8% and 16.9% required procedural intervention. With median clinical and PRO follow-up of 12 and 19 months, respectively, the composite hernia recurrence rate was 22.5% and patients reported significantly improved quality of life (HerQLes: median + 36.7, PROMIS: median – 9.5). Redo-TAR may be performed as a salvage procedure to reconstruct complex defects after failed TAR, however, in our center, it is associated with increased wound morbidity and fairly high composite recurrence rates. Despite this, patients report improvements in quality of life and pain. Tracking outcomes after TAR will facilitate understanding how to manage its failures.

Background The hernia sac to abdominal cavity volume ratio (VR) on abdominal CT was described previously as a way to predict which hernias would be less likely to achieve fascial closure. The aim of this study was to test the reliability of the previously described cutoff ratio in predicting fascial closure in a cohort of patients with large ventral hernias. Methods Patients who underwent elective, open incisional hernia repair of 18 cm or larger width at a single center were identified. The primary end point of interest was fascial closure for all patients. Secondary outcomes included operative details and abdominal wall-specific quality-of-life metrics. We used VR as a comparison variable and calculated the test characteristics (ie, sensitivity, specificity, and positive and negative predictive values). Results A total of 438 patients were included, of which 337 (77%) had complete fascial closure and 101 (23%) had incomplete fascial closure. The VR cutoff of 25% had a sensitivity of 76% (95% CI, 71% to 80%), specificity of 64% (95% CI, 54% to 74%), positive predictive value of 88% (95% CI, 83% to 91%), and negative predictive value of 45% (95% CI, 36% to 53%). The incomplete fascial closure group had significantly lower quality of life scores at 1 year (83.3 vs 52.5; p = 0.001), 2 years (85 vs 33.3; p = 0.003), and 3 years (86.7 vs 63.3; p = 0.049). Conclusions In our study, the VR cutoff of 25% was sensitive for predicting complete fascial closure for patients with ratios below this threshold. Although there is a higher likelihood of incomplete fascial closure when VR is ≥ 25%, this end point cannot be predicted reliably. Additional studies should be done to study this ratio in conjunction with other hernia-related variables to better predict this important surgical end point.

Laparoscopic and robotic ventral hernia repair with intraperitoneal mesh have been demonstrated previously to have comparable 30-day outcomes in the PROVE-IT randomized clinical trial. Here we report our 1-year follow-up of enrolled patients to examine exploratory outcomes.All patients enrolled in a previously published, registry-based, randomized trial investigating laparoscopic vs robotic ventral hernia repair with intraperitoneal mesh were reviewed. Several exploratory secondary outcomes were assessed: pain intensity (Patient-Reported Outcomes Measurement Information System [PROMIS 3a]), hernia-specific quality of life (Hernia-Specific Quality of Life Survey [HerQLes]), composite hernia recurrence, and reoperations.A total of 95% (71 of 75) follow-up was achieved: 33 laparoscopic repairs and 38 robotic repairs. Median follow-up time was 12 months [interquartile range 10 to 12 months]. Following regression analysis adjusting for baseline scores, there was no difference in postoperative pain intensity at 1 year (p = 0.94). However, HerQLes scores increased by 12.0 more points following robotic repairs compared to laparoscopic counterparts (95% CI 1.3 to 22.7, p = 0.03). Composite hernia recurrence was 6% (2 of 33) for the laparoscopic cohort and 24% (9 of 38) for the robotic group (p = 0.04). There was no difference in rates of reoperation (p = 0.61).Our exploratory analyses have identified potential differences in quality of life and recurrence, favoring the robotic and laparoscopic approaches, respectively. These findings warrant further study with larger patient cohorts to verify their potential significance.

An enterocutaneous fistula (ECF) with an associated large hernia defect poses a significant challenge for the reconstructive surgeon. We aim to describe operative details and 30-day outcomes of elective hernia repair with an ECF when performed by surgeons participating in the Abdominal Core Health Quality Collaborative (ACHQC). Patients undergoing concomitant hernia and ECF elective repair were identified within the ACHQC. Outcomes of interest were operative details and 30-day rates of surgical site infections (SSI), surgical site occurrences requiring procedural intervention (SSOPI), medical complications, and mortality. 170 patients were identified (mean age 60 years, 52.4% females, mean BMI 32.3 kg/m2). 106 patients (62%) had small-bowel ECFs, mostly managed with resection without diversion. 30 patients (18%) had colonic ECFs, which were managed with resection without diversion (14%) or resection with diversion (6%). 100 (59%) had a prior mesh in place, which was removed in 90% of patients. Hernias measured 14 cm ± 7 in width, and 68 (40%) had a myofascial release performed (41 TARs). Mesh was placed in 115 cases (68%), 72% as a sublay, and more frequently of biologic (44%) or permanent synthetic (34%) material. 30-day SSI was 18% (37% superficial, 40% deep), and 30-day SSOPI was 21%. 19 patients (11%) were re-operated: 8 (8%) due to a wound complication and 4 (2%) due to a missed enterotomy. Two infected meshes were removed, one biologic and one synthetic. Surgeons participating in the ACHQC predominantly resect ECFs and repair the associated hernias with sublay mesh with or without a myofascial release. Morbidity remains high, most closely related to wound complications, as such, concomitant definitive repairs should be entertained with caution.

Objective To study the efficacy of liposomal bupivacaine on postoperative opioid requirement and pain following abdominal wall reconstruction. Summary background data Despite the widespread use of liposomal bupivacaine in transversus abdominis plane block, there is inadequate evidence demonstrating its efficacy in open abdominal wall reconstruction. We hypothesized that liposomal bupivacaine plane block would result in decreased opioid requirements compared to placebo in the first 72 hours after surgery. Methods This was a single-center double-blind, placebo-controlled prospective study conducted between July 2018 and November 2019. Adult patients (at least 18 years of age) undergoing open, elective, ventral hernia repairs with mesh placed in the retromuscular position were enrolled. Patients were randomized to surgeon-performed transversus abdominis plane block with liposomal bupivacaine, simple bupivacaine, or normal saline (placebo). The main outcome was opioid requirements in the first 72 hours after surgery. Secondary outcomes included total inpatient opioid use, pain scores determined using a 100 mm visual analog scale, length of hospital stay, and patient-reported quality of life. Results Of the 164 patients that were included in the analysis, 57 patients received liposomal bupivacaine, 55 patients received simple bupivacaine and 52 received placebo. There were no differences in the total opioid used in the first 72 hours after surgery as measured by morphine milligram equivalents when liposomal bupivacaine was compared to simple bupivacaine and placebo (325 ± 225 vs. 350 ± 284 vs. 310 ± 272, respectively, p = 0.725). Similarly, there were no differences in total inpatient opioid use, pain scores, length of stay, and patient-reported quality of life. Conclusions There are no apparent clinical benefits to using liposomal bupivacaine transversus abdominis plane block when compared to simple bupivacaine and placebo for open abdominal wall reconstruction.

Resident operative involvement is an integral aspect of general surgery residency training. However, current data examining the effect of resident autonomy on perioperative outcomes remain limited. Patient and operator-specific data were collected from 344 adult laparoscopic cholecystectomies at a tertiary academic institution and its regional affiliates between 2018 and 2019. Multivariate modeling compared postoperative outcomes between cases completed with or without resident involvement and its effect modification by resident seniority and autonomy per Zwisch scale. Outcomes include 30-day postoperative complications, hospital readmission rate, and operative time. Multivariate analysis revealed resident involvement in laparoscopic cholecystectomy did not significantly change odds of 30-day postoperative complications (OR 2.52, p = 0.185, 95% CI 0.64–9.92) or hospital readmission (OR 1.61, p = 0.538, 95% CI 0.36–7.23). Operative time is significantly increased compared to faculty-only cases (IRR 1.37, p

Expert consensus recommends that all ventral hernias be repaired prior to, or concomitantly with, peritoneal dialysis (PD) catheter insertion. We examined the clinical outcomes of patients undergoing initial PD catheter insertion, with asymptomatic ventral hernias that were not repaired and rather managed using a watchful waiting approach. A single-center, retrospective review of patients undergoing PD catheter insertion from 2005–2019 was performed. Patients who did not undergo repair of a pre-existing ventral hernia at the time of their initial PD catheter insertion were included. The primary endpoint was ventral hernia repair following PD catheter insertion. Forty-one patients were included. Most patients presented with an umbilical hernia (78%). Six patients (15%) underwent ventral hernia repair at a median postoperative interval of 12 months [IQR 8–16], due to abdominal discomfort and hernia enlargement (n = 2) and incarceration (n = 2). Two patients remained asymptomatic, yet underwent ventral hernia repair at the time of renal transplantation. The cumulative incidence of ventral hernia repair within 12 and 24 months of PD catheter insertion was 13% and 21%, respectively. Watchful waiting may be an acceptable option for select patients with asymptomatic ventral hernias at the time of initial PD catheter placement. These findings highlight the need to better identify factors associated with asymptomatic ventral hernias that do not warrant concomitant repair to aid surgeons in the decision-making process.

The outcomes of utilizing anti-adhesive barrier-coated mesh in the retrorectus position during open ventral hernia repair are unknown. We compared the wound-related outcomes between non-coated (NCM) and coated mesh (CM) placed in the retrorectus space. Patients undergoing elective, open, clean ventral hernia repair with retrorectus mesh were retrospectively identified in the Americas Hernia Society Quality Collaborative. Propensity score matching was performed based on clinically relevant demographic and operative covariates. The primary outcome was wound morbidity, defined as surgical site infection (SSI), surgical site occurrence (SSO), and SSO requiring procedural intervention (SSOPI). 3609 patients were included (3281 NCM, 328 CM). Following 2:1 propensity score matching, rates of myofascial release remained the only statistically different matching parameter; external oblique releases were performed more frequently in the CM group (8% vs. 15%; p = 0.03). Rates of SSI (3% vs. 4%; p = 0.16) were similar between groups. Increased rates of SSO (13% vs. 18%; p = 0.045) and SSOPI (4% vs. 8%; p = 0.038) were observed in the CM group. The CM group had a higher rate of postoperative seroma (3% vs. 7%; p = 0.027) compared to the NCM group. Barrier-coated mesh in the retrorectus position was associated with increased wound morbidity requiring procedural intervention. Due to a lack of clinical benefit, the use of more costly barrier-coated mesh in the retrorectus position is not justified for routine, open ventral hernia repairs at this time.

The most common techniques used to repair umbilical hernias are open and laparoscopic. As the obesity epidemic in the United States is growing, it is essential to understand how this morbidity affects umbilical hernia repairs. This study compares laparoscopic versus open umbilical hernia repairs in obese patients. All patients with body mass index (BMI) ≥ 30 kg/m2 who underwent elective, open or laparoscopic repair of a primary umbilical hernia with mesh were identified from the Americas Hernia Society Quality Collaborative (AHSQC). A retrospective review of the prospectively collected data was conducted. Outcomes of interest included surgical site infections (SSI), surgical site occurrences requiring procedural intervention (SSOPI), hernia-related quality-of-life survey (HerQles), and long-term recurrence. A logistic regression model was used to generate propensity scores. Of 1507 patients who met the inclusion criteria, 322 were laparoscopic, and 1185 were open cases. The laparoscopic group had higher mean BMI (37 ± 6 vs. 35 ± 5 kg/m2 , P

Unlike routine ventral hernia repair, abdominal wall reconstruction (AWR) can results in large pieces of mesh and extensive manipulation of the intra-abdominal contents, rendering subsequent laparoscopic cholecystectomy challenging. This study addresses the additional wound morbidity of concomitant cholecystectomy. The Americas Hernia Society Quality Collaborative (AHSQC) was retrospectively reviewed and logistic regression modeling was used to control for multiple covariates. Patients that underwent open AWR with cholecystectomy were compared to a similar group of patients undergoing uncomplicated, open, clean, AWR alone. 130 patients undergoing concomitant cholecystectomy were compared to a control group of 6440 patients. The addition of a cholecystectomy did not cause a significant change in wound morbidity (SSI: p = 0.16; SSOPI: p = 0.65). This study noted that a concomitant cholecystectomy does not increase the wound morbidity as compared to an uncomplicated, clean, AWR. This provides support for consideration of routine cholecystectomy in patients with cholelithiasis undergoing AWR.

With increasing frequency, patients with idiopathic splenomegaly are referred to surgeons for splenectomy. We evaluated the diagnostic utility of splenectomy and feasibility of a minimally invasive approach in the face of idiopathic splenomegaly. We retrospectively reviewed 68 patients who underwent splenectomy for idiopathic splenomegaly. The primary endpoint was the rate of definitive diagnosis based on final surgical pathology of the removed spleen. Preoperative workup included a bone marrow biopsy and peripheral blood smear in 93% and 100% of patients, respectively, with none having lymphadenopathy warranting biopsy. Splenectomy provided a definitive diagnosis for 44 (64.7%) patients. Of these, 34 (50%) patients had an underlying malignancy, of which more than half were splenic marginal zone lymphoma. There were 33 (48.5%) laparoscopic, 23 (33.8%) open, 10 (14.7%) laparoscopic converted to open, and two (2.9%) laparoscopic hand-assist cases. Conversion to open was due to splenic size [median craniocaudal length 21.8 cm (cm)] in eight and staple line bleeding at the splenic hilum in two patients. Overall, the laparoscopic approach was completed in patients with a smaller splenic size compared to open (median craniocaudal length 15.2 vs. 26.0 cm, p

There has been increasing media coverage regarding the controversy of using mesh in various operations. At this time, there are no published studies evaluating the potential influence of this controversy on patients' perceptions. Therefore, our study aimed to assess patient perceptions of hernia repair surgery with mesh as well as factors that may influence patient opinions.A 16-item questionnaire evaluated each patient's perceptions of the use of mesh in their upcoming hernia repair. The primary outcomes of interest were their level of comfort regarding the possibility of hernia repair surgery with mesh, aversion to hernia surgery with mesh, and positive belief that mesh is a safe product in hernia repair surgery.We included 100 patients presenting for a hernia repair and 100 patients presenting for other operations. Both groups identified the media as their most common influence (37% and 40%, respectively). Factors leading to a high level of comfort regarding the possibility of mesh repair included believing mesh was a safe product (P.001) and hearing about the advantages of mesh (P = .012) from medical professionals (P = .001). Factors leading to a positive belief that mesh was a safe product included the male sex (P = .015), a high socioeconomic standing (P = .006), and their own personal experience (P = .013). Factors leading to aversion to mesh use included the female sex (P = .006) and hearing about meshes causing mesh-related (P = .028) and wound-related complications (P = .025) as well as chronic pain (.008).Despite the high penetration of non-medical information in the population before presentation for medical care, most patients overall do not seem to be opposed to the concept of the use of mesh in a hernia repair, but there are certain factors associated with aversion to the use of mesh that physicians should acknowledge and should address this potential issue.

Chronic postoperative inguinodynia is a challenging long-term complication after inguinal hernia repair. Surgery may be an option for patients who are refractory to non-operative measures. We aim to evaluate the short-term outcomes of surgical treatment for chronic inguinodynia at our institution.Consecutive patients undergoing surgical treatment for chronic groin pain were identified in a prospectively maintained database. Outcomes included operative details, intra- and postoperative complications, pain scores, and patient satisfaction.29 patients were included in the study. All patients were refractory to multimodal pain management. The median pain score on presentation was 8 (IQR 7-10), and after a median follow-up of 6 months (IQR 4-11), there was a statistically significant reduction in pain scores (median 2, IQR 2-6, p 0.001). Fifty-five percent of patient were pain free or almost pain free and 93 percent reported they would undergo the same operation again.Chronic groin pain is a complex problem with no universal solution. In our experience, surgical treatment significantly decreased short-term pain scores.

The association of postoperative patient-reported outcomes and type of mesh fixation during minimally invasive inguinal hernia repair has not been well characterized. We aimed to compare the 30-day quality of life outcomes between various mesh fixation techniques utilizing the AHSQC prospective registry. All minimally invasive inguinal hernias with completed 30-day follow-up were abstracted from the AHSQC, excluding patients with primary indication for surgery being chronic groin pain. Mesh fixation was categorized as (1) atraumatic fixation (AF) (2) traumatic non-suture (TNS), (3) traumatic suture (TS). Our outcomes of interest were pain at site at 30-day and EuraHS quality of life assessment. After applying inclusion and exclusion criteria, 864 patients had surgical site pain and quality of life outcomes reported; 253 (AF), 451 (TNS), and 160 (TS). After adjusting for identified confounders, there was no statistically significant difference between any fixation method when evaluating pain as a binary variable (Yes/No). However, when looking at the EuraHS evaluation for pain and quality of life outcomes, AF was associated with better scores than both TNS and TS fixation in the cosmetic, restrictions, and overall EuraHS domains. AF was only better than TS fixation in the pain domain. Our study suggests that AF had a significantly improved hernia-specific quality of life in all domains at 30-days postoperatively. We also identified that pain as a binary variable is inadequate for its states purpose. Thus, the overall well-being and morbidity should be taken into account when evaluating hernia patients postoperatively.

We investigate the prevalence of PTSD in patients with an incisional hernia presenting for evaluation at our institution.Study patients were screened for PTSD using the PCL-5 checklist for DSM-5. Patient-reported quality of life and pain scores were assessed using validated tools (HerQLes and PROMIS Pain Intensity 3a survey).The prevalence of PTSD in 131 patients was 32.1% [95% CI 24%-40%]. Patients screening positive (PTSD+) reported lower quality of life scores on HerQles (17.3 ± 14.3 vs. 47.7 ± 29.6, P 0.001), and higher pain scores on the PROMIS scale (54.2 ± 9.1 vs. 44.2 ± 10, p 0.001). PTSD + patients also reported significantly higher numbers of previous hernia repairs and abdominal operations, as well as a higher rate of a history of an open abdomen.Our study found a significant prevalence of positive screening for PTSD in patients seeking consultation regarding an incisional hernia. We have begun routine preoperative evaluations by a behavioral medicine specialist to address some of these complex issues in high-risk patients. Other high volume hernia programs caring for this challenging patient population should consider such assessments.

This was a retrospective analysis of a prospectively maintained database that objectively evaluated the benefit of preoperative chemical component separation with botulinum toxin A in complex hernia repairs. Continued evaluation.

Urinary catheters are commonly placed during laparoscopic inguinal hernia repair as a presumed protection against postoperative urinary retention (PUR), one of the most common complications following this operation. Data from randomized clinical trials evaluating the effect of catheters on PUR are lacking.To investigate the effect of intraoperative catheters on PUR after laparoscopic inguinal hernia repair.This 2-arm registry-based single-blinded randomized clinical trial was conducted at 6 academic and community hospitals in the US from March 2019 to March 2021 with a 30-day follow-up period following surgery. All patients who presented with inguinal hernias were assessed for eligibility, 534 in total. Inclusion criteria were adult patients undergoing laparoscopic, elective, unilateral, or bilateral inguinal hernia repair. Exclusion criteria were inability to tolerate general anesthesia and failure to understand and sign the written consent form. A total of 43 patients were excluded prior to intervention.Patients in the treatment arm had placement of a urinary catheter after induction of general anesthesia and removal at the end of procedure. Those in the control arm had no urinary catheter placement.PUR rate.Of the 491 patients enrolled, 241 were randomized to catheter placement, and 250 were randomized to no catheter placement. The median (IQR) age was 61 (51-68) years, and 465 participants (94.7%) were male. Overall, 44 patients (9.1%) developed PUR. There was no difference in the rate of PUR between the catheter and no-catheter groups (23 patients [9.6%] vs 21 patients [8.5%], respectively; P = .79). There were no intraoperative bladder injuries. In the catheter group, there was 1 incident of postoperative urethral trauma in a patient who presented to the emergency department with PUR leading to a suprapubic catheter placement.Intraoperative urinary catheters did not reduce the risk of PUR after laparoscopic inguinal hernia repair. While their use did not appear to be associated with a high rate of iatrogenic complications, there may be a low rate of catastrophic complications. In patients who voided urine preoperatively, catheter placement did not appear to confer any advantage and thus their use may be reconsidered.ClinicalTrials.gov Identifier: NCT03835351.

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. 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. 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

Laparoscopic totally extraperitoneal inguinal hernia repair (TEP) can be performed using either telescopic (TD) or balloon dissection (BD). The use of a disposable balloon dissector increases the cost of TEP. However, it remains unclear whether BD saves enough time to justify its cost. We hypothesized that BD would consistently save 15 min in operative time. To test this hypothesis, we designed a registry-based randomized controlled trial (RB-RCT) embedded into the Americas Hernia Society Quality Collaborative. A single-blinded, parallel, RB-RCT was conducted. Adults with inguinal hernias presenting for elective repair were screened. Patients with unilateral hernias deemed fit to undergo TEP were eligible; those with bilateral hernias (BIH) or undergoing open repair were excluded. Individuals were randomized to TD or BD with a disposable device. TEP was performed with synthetic mesh and tacks. Subjects were blinded and followed up for 30 day. Main outcome was operative time. 207 patients were screened: 166 were excluded and 41 were randomized (21 BD, 20 TD). One patient (TD group) was excluded due to the incidental finding of BIH. 40 patients were analyzed (median age 56, median BMI 26 kg/m2, 98% males). Hernias were 72% indirect, 17% direct, 10% pantaloon, and 8% recurrent. Other than obesity (26.5% vs. 0, p = 0.018), there were no baseline differences between the groups. Median operative times were similar (TD 43 min, IQR 33–63; BD 46 min, IQR 35–90, p = 0.490). There were 2 seromas and 2 hematomas in the BD group, and none in the TD (p = 0.108). BD does not consistently result in 15-min time saving during TEP. Use of a disposable balloon dissector can be deferred in the experienced hands. ClinicalTrials.gov (NCT03276871).

Background We aimed to assess the impact of modifiable comorbidities—obesity, diabetes, and smoking—and their aggregate effect on wound complications after incisional hernia repair. Methods Data on all open, elective, incisional hernia repair with permanent synthetic mesh in clean wounds were collected from the Americas Hernia Society Quality Collaborative and reviewed. Three groups were defined: those with 0, 1, or 2+ modifiable comorbidities, with associations described for each specific comorbid condition. Primary outcomes included surgical site occurrences, surgical site infections, and surgical site occurrences requiring procedural intervention. Results A total of 3,908 subjects met the inclusion criteria. Mean hernia width was 9.6 ± 6.5 cm, mean body mass index was 32.1 ± 6.6 kg/m2, 21% of patients had diabetes, and 9% were smokers. Of those, 31% had no modifiable comorbidities, 49% had 1 modifiable comorbidity, and 20% had 2+ modifiable comorbidities. Compared with having no modifiable comorbidities, having 1 modifiable comorbidity, or 2+ modifiable comorbidities significantly increased the odds of a surgical site occurrence (odds ratios 1.33 and 1.61, respectively). However, only patients with 2+ modifiable comorbidities had significantly increased odds of surgical site occurrences requiring procedural intervention compared with no modifiable comorbidities and 1 modifiable comorbidity (odds ratios 2.02 and 1.65, respectively). Patients with all 3 comorbidities had a two-fold increase in odds for all wound morbidity, followed similarly by obese patients with diabetes. Conclusion The presence of any number of comorbidities (1 modifiable comorbidity or 2+ modifiable comorbidities) increases the odds for wound events. However, having multiple comorbidities was associated with more procedural interventions for wound management. This was most evident in patients with all 3 comorbidities, and, in obese diabetics, underscoring the importance of preoperative counseling on expected recovery in such patients.

It is unclear whether a history of surgical site infection is associated with developing a new infection after subsequent operations. We aim to investigate the impact of an earlier abdominal wall surgical site infection on future 30-day infectious wound complications after open incisional hernia repair with mesh.Patients undergoing elective, clean open incisional hernia repair were identified within the Americas Hernia Society Quality Collaborative and were divided into those with and without a history of a surgical site infection. Predictors of a surgical site infection and a surgical site infection requiring a procedural intervention were investigated using logistic regression and propensity-matched analysis. A subgroup analysis was done to investigate whether an earlier methicillin-resistant Staphylococcus aureus surgical site infection specifically increases odds for infectious complications.Of 3,168 identified patients, 589 had a history of a surgical site infection and experienced higher rates of postoperative surgical site infection (6.5% vs 2.9%, P.001) and surgical site infections requiring procedural intervention (5.3% vs 1.9%, P.001). After adjusting for identified confounders, a previous surgical site infection was independently associated with developing another surgical site infection (odds ratio 2.04, 95% confidence interval 1.32-3.10, P.001) and a surgical site infection requiring procedural intervention (odds ratio 2.2, 95% confidence interval 1.35-3.55, P = .001). Propensity-matched analysis controlling for additional confounders confirmed the association of an earlier surgical site infection with the outcomes of interest (odds ratio 2.1 and 2.8, respectively). A subgroup analysis found that an earlier methicillin-resistant Staphylococcus aureus infection specifically did not incur higher rates of surgical site infection when compared with non-methicillin-resistant Staphylococcus aureus pathogens.History of a surgical site infection increases the odds for new infectious complications after open incisional hernia repair in a clean wound. Investigations on perioperative interventions to ameliorate the negative impact of such association are necessary.

Background Many studies implicate active smoking as a risk factor for postoperative wound complications and all 30-day morbidity, but the definitions of inclusion and exclusion criteria as well as outcome parameters are inconsistent. Critically, the ability of large databases and meta-analyses to generate statistically significant associations of active smoking with morbidity do not address whether those relationships are actually clinically meaningful. We investigated this relationship after open ventral hernia repair. Study Design Patients undergoing elective open ventral hernia repair in clean wounds with 30-day follow-up were extracted from the Americas Hernia Society Quality Collaborative. Current smokers (within 30 days of surgery) were 1:1 propensity matched to patients who had never smoked based on demographics, comorbidities, and operative characteristics. Wound complications and all 30-day morbidity were assessed. Results After matching 418 current smokers to 418 patients who had never smoked, the groups were similar with the exception of minor differences in body mass index (31.4 vs 33.3, P Conclusion Active smoking prior to elective clean OVHR is associated with clinically insignificant differences in wound morbidity. Surgeons allowing perioperative smoking should monitor their outcomes to assure these findings are replicable in their own practice.

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. 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. Fifty-nine patients met inclusion criteria. Mean BMI was 36.6 ± 8.9 kg/m2 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. 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.

IMPORTANCE: Despite rapid adoption of the robotic platform for ventral hernia repair with intraperitoneal mesh in the United States, there is no level I evidence comparing it with the traditional laparoscopic approach. This randomized clinical trial sought to demonstrate a clinical benefit to the robotic approach. OBJECTIVE: To determine whether robotic approach to ventral hernia repair with intraperitoneal mesh would result in less postoperative pain. DESIGN, SETTING, AND PARTICIPANTS: A registry-based, single-blinded, prospective randomized clinical trial at the Cleveland Clinic Center for Abdominal Core Health, Cleveland, Ohio, completed between September 2017 and January 2020, with a minimum follow-up duration of 30 days. Two surgeons at 1 academic tertiary care hospital. Patients with primary or incisional midline ventral hernias of an anticipated width of 7 cm or less presenting in the elective setting and able to tolerate a minimally invasive repair. INTERVENTIONS: Patients were randomized to a standardized laparoscopic or robotic ventral hernia repair with fascial closure and intraperitoneal mesh. MAIN OUTCOMES AND MEASURES: The trial was powered to detect a 30% difference in the Numerical Rating Scale (NRS-11) on the first postoperative day. Secondary end points included the Patient-Reported Outcomes Measurement Information System Pain Intensity short form (3a), hernia-specific quality of life, operative time, wound morbidity, recurrence, length of stay, and cost. RESULTS: Seventy-five patients completed their minimally invasive hernia repair: 36 laparoscopic and 39 robotic. Baseline demographics and hernia characteristics were comparable. Robotic operations had a longer median operative time (146 vs 94 minutes; P

Background Randomized controlled trials (RCTs) are the gold standard to establish evidence for surgical practice but can be hindered by high costs, complexity, and time requirements. Recently, observational registries have been leveraged as platforms for clinical trials to address these limitations, though few registry-based surgical RCTs have been conducted. Here, we present our group's approach to surgical registry-based RCTs and early results. Materials and methods To facilitate these trials, we focused on registry integration into surgeons' workflows, routine collection of patient-reported outcomes at clinic visits, and pragmatic trial design featuring broad inclusion criteria and standard of care follow-up. These features maximize generalizability and facilitate follow-up by minimizing visits and tests outside of normal practice. Results Since 2017, our group has completed enrollment in 4 registry-based RCTs with another 5 trials ongoing. Of these, 4 trials have been multicenter. Over 1000 patients have been enrolled in these studies, with follow-up rates of 90% or greater. Most of these trials are on track to complete enrollment in approximately 2 y from their start date. Beyond salary support, resource utilization is low. None of our trials has been terminated due to lack of resources or futility. Conclusions Registry-based RCTs allow for efficient conduct of pragmatic surgical trials. Thoughtful study design, registry integration into surgeons' routines, and a team culture embracing research are paramount. We believe registry-based trials are the future of affordable, high-level, prospective surgical research.

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.

Concern for chronic infection of a permanent synthetic material in contaminated and "high risk" ventral hernia repairs has led to the development and dissemination of slowly resorbable biosynthetic materials at a lower cost compared with biologic mesh counterparts. Here, we review the preclinical and clinical data available for each long-acting resorbable mesh, with a candid comparison to biologic and synthetic equivalents.