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Patients undergoing emergency general surgery (EGS) and interhospital transfer (IHT) have increased mortality. Prior analyses of IHT have been limited by the inability to track post-discharge outcomes or have not included nonoperative EGS. We evaluated outcomes for IHT to our tertiary care facility compared with direct admission through the emergency department.Patients admitted directly (2015 to 2017) with a common EGS diagnosis (appendicitis, cholecystitis, choledocholithiasis, small bowel obstruction, and diverticulitis) were propensity score matched to patients transferred from another acute care hospital. Propensity score matching (PSM) was performed using patient characteristics, EGS diagnosis, comorbidities, and surgical critical care consultation. The primary outcome was inpatient mortality, and secondary outcomes were length of stay (LOS) 30-day hospital readmission.We identified 3,153 directly admitted patients and 1,272 IHT patients. IHT patients were older (mean 59.4 vs 51.5 years), had a higher Charlson comorbidity index (median 3 vs 1), White race (72% vs 49%), and BMI greater than 40 kg/m2 (11.6% vs 9.8%). After PSM, each group included 1,033 patients. IHT patients had a higher median LOS (5.5 days vs 3.8, p0.001), higher inpatient mortality (odds ratio [OR] 1.69, p = 0.03), and more complications (OR 1.57, p0.001). The rate of post-discharge 30-day hospital encounters was similar (OR 1.08, p = 0.460). However, IHT patients had more emergency department encounters (OR 1.35, p = 0.04) and fewer observation-status readmissions (OR 0.53, p = 0.01).After PSM to reduce confounding variables, patients with common EGS diagnoses transferred to a tertiary care facility have increased inpatient morbidity and mortality. The increased morbidity and resource utilization for these patients extends beyond the index hospital stay.

To define impact of missed ordering of venous thromboembolism (VTE) chemoprophylaxis in high-risk general surgery populations.The primary cause of preventable death in surgical patients is VTE. While guidelines and validated risk calculators assist in dosing recommendations, there remains considerable variability in ordering and adherence to recommended dosing.All adult inpatients who underwent a general surgery procedure between 2016 to 2019 and were entered into Atrium Health NSQIP registry were identified. Patients at high-risk for VTE (2010 Caprini score/=5) and without bleeding history and/or acute renal failure were included. Primary outcome was 30-day postoperative VTE. EMR identified compliance with 'perfect' VTE chemoprophylaxis orders (pVTE): no missed orders and no inadequate dose ordering. Multivariable analysis examined association between pVTE and 30-day VTE events.19,578 patients were identified of which 4,252 were high-risk inpatients. Hospital compliance of pVTE was present in 32.4%. pVTE was associated with shorter postoperative length of stay (LOS) and lower perioperative red blood cell (RBC) transfusions. There was 50% reduced odds of 30-day VTE event with pVTE (OR 0.50 95%CI 0.30-0.80) and 55% reduction in VTE event/mortality (OR 0.45 95%CI 0.31-0.63). After controlling for relevant covariates, pVTE remained significantly associated with decreased odds of VTE event and VTE event/mortality.Perfect VTE ordering in high-risk general surgery patients was associated with 42% reduction in odds of postoperative 30-day VTE. Comprehending factors contributing to missed or suboptimal ordering and development of quality improvement strategies to reduce them are critical to improving outcomes.

With health care expenditures continuing to increase rapidly, the need to understand and provide value has become more important than ever. In order to determine the value of care, the ability to accurately measure cost is essential. The acute care surgeon leader is an integral part of driving improvement by engaging in value increasing discussions. Different approaches to quantifying cost exist depending on the purpose of the analysis and available resources. Cost analysis methods range from detailed microcosting and time-driven activity-based costing to less complex gross and expenditure-based approaches. An overview of these methods and a practical approach to costing based on the needs of the acute care surgeon leader is presented.Study TypeRegular Review.

The aim of this study was to evaluate the use of laparoscopic surgery for common emergency general surgery (EGS) procedures within an integrated Acute Care Surgery (ACS) network. We hypothesized that laparoscopy would be associated with improved outcomes. Our integrated health care system’s EGS registry created from AAST EGS ICD-9 codes was queried from January 2013 to October 2015. Procedures were grouped as laparoscopic or open. Standard descriptive and univariate tests were performed, and a multivariable logistic regression controlling for open status, age, BMI, Charlson Comorbidity Index (CCI), trauma tier, and resuscitation diagnosis was performed. Laparoscopic procedures converted to open were identified and analyzed using concurrent procedure billing codes across episodes of care. Of 60,604 EGS patients identified over the 33-month period, 7280 (12.0%) had an operation and 6914 (11.4%) included AAST-defined EGS procedures. There were 4813 (69.6%) surgeries performed laparoscopically. Patients undergoing a laparoscopic procedure tended to be younger (45.7 ± 18.0 years vs. 57.2 ± 17.6, p

The Emergency General Surgery (EGS) population is particularly at high risk for readmission. Currently, no system exists to predict which EGS patients are most at risk. We hypothesized that a subset of EGS patients could be identified with increased 30-day unplanned readmission. We also hypothesized that a majority of readmissions occur sooner than the conventional 2-week follow-up period.National Surgical Quality Improvement Program (NSQIP) nonelective general surgery patients were analyzed. Multivariable logistic regression identified factors with increased odds of unplanned readmission. AAST EGS Diagnosis Categories were used to categorize postop ICD-9 codes, and the top 10 CPT codes in each group were analyzed. Readmission rate, the reason for unplanned readmission, and time to readmission were analyzed.A total of 383,726 patients were identified with a readmission rate of 8.1% within 30 d of their primary procedure. The top 50 CPT codes accounted for 84% of EGS readmissions. Increased readmission risk was demonstrated for underweight patients (OR = 1.15, P 0.05). High-risk hospital characteristics were LOS2 d, any inpatient pulmonary complications, and discharge to any facility or rehab (all P 0.05). Surgical site infections cause nearly 25% of readmissions. Intestinal procedures are most frequently readmitted (22% of EGS readmissions), with colorectal procedures having the higher odds of readmission. Most readmissions occur10 d after discharge.A high-risk subpopulation exists within EGS, and most readmissions occur sooner than a typical 2-week follow-up. Early interventions for high-risk EGS subpopulations may allow for early intervention and reduction of unnecessary healthcare utilization.

Emergency general surgery (EGS) patients have increased mortality risk compared with elective counterparts. Recent studies on risk factors have largely used national data sets limited to administrative data. Our aim was to examine risk factors in an integrated regional health system EGS database, including clinical and administrative data, hypothesizing that this novel process would identify clinical variables as important risk factors for mortality.Our nine-hospital health system's billing data were queried for EGS International Classification of Disease codes between 2013 and 2018. Codes were grouped by diagnosis, and urgent or emergent encounters were included and merged with electronic medical record clinical data. Outcomes assessed were inpatient and 1-year mortality. Standard and multivariable statistics evaluated factors associated with mortality.There were 253,331 EGS admissions with 3.6% inpatient mortality rate. Patients who suffered inpatient and 1-year mortality were older, more likely to be underweight, and have neutropenia or elevated lactate. On multivariable analysis for inpatient mortality: age (odds ratio [OR], 1.7-6.7), underweight body mass index (OR, 1.6), transfer admission (OR, 1.8), leukopenia (OR, 2.0), elevated lactate (OR, 1.8), and ventilator requirement (OR, 7.1) remained associated with increased risk. Adjusted analysis for 1-year mortality demonstrated similar findings, with highest risk associated with older age (OR, 2.8-14.6), underweight body mass index (OR, 2.3), neutropenia (OR, 2.0), and tachycardia (OR, 1.7).After controlling for patient and disease characteristics available in administrative databases, clinical variables remained significantly associated with mortality. This novel yet simple process allows for easy identification of clinical data points imperative to the study of EGS diagnoses that are critical in understanding factors that impact mortality.Prognostic and Epidemiologic; Level III.

Background Operative management of emergency general surgery (EGS) diagnoses involves a range of procedures which can carry high morbidity and mortality. Little is known about the impact of obesity on patient outcomes. The aim of this study was to examine the association between body mass index (BMI) >30 kg/m2 and mortality for EGS patients. We hypothesized that obese patients would have increased mortality rates. Methods A regional integrated health system EGS registry derived from The American Association for the Surgery of Trauma EGS ICD-9 codes was analyzed from January 2013 to October 2015. Patients were stratified into BMI categories based on WHO classifications. The primary outcome was 30-day mortality. Longer-term mortality with linkage to the Social Security Death Index was also examined. Univariate and multivariable analyses were performed. Results A total of 60 604 encounters were identified and 7183 (11.9%) underwent operative intervention. Patient characteristics include 53% women, mean age 58.2 ± 18.7 years, 64.2% >BMI 30 kg/m2, 30.2% with chronic obstructive pulmonary disease, 19% with congestive heart failure, and 31.1% with diabetes. The most common procedure was laparoscopic cholecystectomy (36.4%). Overall, 90-day mortality was 10.9%. In multivariable analysis, all classes of obesity were protective against mortality compared to normal BMI. Underweight patients had increased risk of inpatient (OR = 1.9, CI = 1.7-2.3), 30-day (OR = 1.9, CI = 1.7-2.1), 90-day (OR = 1.8, CI 1.6-2.0), 1-year (OR = 1.8, CI = 1.7-2.0), and 3-year mortality (OR = 1.7, CI = 1.6-1.9). Conclusions When stratified by BMI, underweight EGS patients have the highest odds of death. Paradoxically, obesity appears protective against death, even when controlling for potentially confounding factors. Increased rates of nonoperative management in the obese population may impact these findings.

Background The clinical significance of obtaining cardiac troponin (cTn) levels among trauma patients with new onset arrhythmias is unknown. We aimed to assess whether cTn levels actually influence clinical decision making or represent an inappropriate use of resources. Methods Trauma patients admitted from 2013 to 2014 diagnosed with atrial fibrillation (AF) were retrospectively reviewed using the institutional trauma database. Demographics, cTn levels, and myocardial infarction (MI) diagnosis data were recorded. Standard univariate tests were used to compare data between patients with and without cTn. Results There were 258 patients included of which 126 patients had cTn levels obtained (48.8%, TEST group). The remaining 132 patients (51.2%) were untested (noTEST group). Among TEST patients, use of echocardiography nearly doubled and cardiology consultations increased (all p Conclusions Obtaining cTn values in trauma patients with new-onset AF resulted in increased resource utilization without clinical utility.

The purpose of this study was to evaluate the safety and efficacy of early venous thromboembolism (VTE) chemoprophylaxis following blunt solid organ injury.A retrospective review of patients was performed for patients with blunt solid organ injury between 2009-2019. Enoxaparin was initiated when patients had1g/dl Hemoglobin decline over a 24 h period. These patients were then categorized by initiation: ≤48 h and48 h.There were 653 patients: 328 (50.2%)48 h and 325 (49.8%) ≥48 h. Twenty-nine (4.4%) developed VTE. Patients in ≥48 h group suffered more frequent VTE events (6.5% vs 2.4%, p = 0.021). Non-operative failure occurred in 6 patients (1.9%) in ≥48 h group, and 5 patients (1.5%)48 h group. Blood transfusion following chemophrophylaxis initiation was required in 69 (21.3%) in ≥48 h group, and 46 (14.0%) in48 h group, occurring similarly between groups (p=0.021).Stable hemoglobin in the first 24 h is an efficacious, objective measure that allows early initiation of VTE chemoprophylaxis in solid organ injury. This practice is associated with earlier initiation of and fewer VTE events.

Background The use of Gastrografin (GG) in the management of adhesive small bowel obstruction (SBO) has been shown to decrease the length of stay and operative intervention. Methods This retrospective cohort study examined patients with an SBO diagnosis prior to implementation (PRE, January 2017-January 2019) and following implementation (POST, January 2019-May 2021) of a GG challenge order set made available across 9 hospitals within a health care system. Primary outcomes were utilization of the order set across facilities and over time. Secondary outcomes included time to surgery for operative patients, rate of surgery, nonoperative length of stay, and 30-day readmission. Standard descriptive, univariate, and multivariable regression analyses were performed. Results PRE cohort had 1746 patients and POST had 1889. The utilization of GG increased from 14% to 49.5% following implementation. Significant variability existed within the hospital system with utilization at each individual hospital from 11.5% to 60%. There was an increase in surgical intervention (13.9% vs 16.4%, P = .04) and decrease in nonoperative LOS (65.6 vs 59.9 hours, P < .001) following implementation. For POST patients, multivariable linear regression showed significant reduction in nonoperative length of stay (−23.1 hours, P < .001) but no significant difference in time to surgery (−19.6 hours, P = .08). Discussion The availability of a standardized order set for SBO can result in increased Gastrografin administration across hospital settings. The implementation of a Gastrografin order set was associated with decreased length of stay in nonoperative patients.

The aim of this study was to evaluate the impact of the COVID-19 pandemic on volume and outcomes of Acute Care Surgery patients, and we hypothesized that inpatient mortality would increase due to COVID+ and resource constraints.An American College of Surgeons verified Level I Trauma Center's trauma and operative emergency general surgery (EGS) registries were queried for all patients from Jan. 2019 to Dec. 2020. April 1st, 2020, was the demarcation date for pre- and during COVID pandemic. Primary outcome was inpatient mortality.There were 14,460 trauma and 3091 EGS patients, and month-over-month volumes of both remained similar (p 0.05). Blunt trauma decreased by 7.4% and penetrating increased by 31%, with a concomitant 25% increase in initial operative management (p 0.001). Despite this, trauma (3.7%) and EGS (2.9-3.0%) mortality rates remained stable which was confirmed on multivariate analysis; p 0.05. COVID + mortality was 8.8% and 3.7% in trauma and EGS patients, respectively.Acute Care Surgeons provided high quality care to trauma and EGS patients during the pandemic without allowing excess mortality despite many hardships and resource constraints.

Interfacility transfers are necessary and valuable for the trauma system, but despite regional guidelines, many patients are inappropriately transferred. We evaluated over-triage at our Level I center and identified risk factors for over-triage.Retrospective analysis at our Level I urban trauma center assessed patients transferred from regional facilities during 2017. Over-triage was defined as patients discharged48 h without procedures. Exclusion criteria were leaving against medical advice or no outside records.Overall, 2352 patients met criteria. Nine hundred thirty (39.5%) with complete hospital records were discharged in48 h; 498 (53.5%) received no procedural intervention and 909 (97.7%) were ultimately discharged home.Many patients are inappropriately transferred to tertiary care centers without a definitive need for advanced services. Studies are needed to improve triage criteria without increasing under-triage.

Emergent surgeries have different causes and physiologic patient responses than the same elective surgery, many of which are due to infectious etiologies. Therefore, we hypothesized that emergency cases have a higher risk of postoperative SSI than their elective counterparts. The ACS NSQIP database was queried from 2005 to 2016 for all cholecystectomies, ventral hernia repairs, and partial colectomies to examine common emergency and elective general surgery operations. Thirty-day outcomes were compared by emergent status. Any SSI was the primary outcome. There were 863,164 surgeries: 416,497 cholecystectomies, 220,815 ventral hernia repairs, and 225,852 partial colectomies. SSIs developed in 38,865 (4.5%) patients. SSIs increased with emergencies (5.3% vs 3.6% for any SSI). Postoperative sepsis (5.8% vs 1.5%), septic shock (4.7% vs 0.6%), length of stay (8.1 vs 2.9 days), and mortality (3.6% vs 0.4%) were increased in emergent surgery; P < 0.001 for all. When controlling for age, gender, BMI, diabetes, smoking, wound classification, comorbidities, functional status, and procedure on multivariate analysis, emergency surgery (odds ratio 1.15, 95% confidence interval 1.11–1.19) was independently associated with the development of SSI. Patients undergoing emergency general surgery experience increased rates of SSI. Patients and their families should be appropriately counseled regarding these elevated risks when consenting for emergency surgery.

Despite advances in diagnostic imaging capabilities, little information exists concerning the impact of physical dimensions of a paraesophageal hernia (PEH) on intraoperative decision making. The authors hypothesized that computerized volumetric analysis and multidimensional visualization to measure hiatal defect area (HDA) and intrathoracic hernia sac volume (HSV) would correlate to operative findings and required surgical techniques performed. Using volumetric analysis software (Aquarius iNtuition, TeraRecon, Inc), HDA and HSV were measured in PEH patients with preoperative computerized tomography (CT) scans, and used to predict the likelihood of intraoperative variables. Multidimensional rotation of images enabled visualization of the entire hiatal defect in a plane mimicking the surgeon’s view during repair. The intrathoracic hernia sac was outlined producing volume measurements based on a summation of exact dimensions. A total of 213 PEHR patients had preoperative CT imaging, with 14.1% performed emergently. Primary cruroplasty was performed in 89.2%, salvage gastropexy in 10.3%, and diaphragmatic relaxing incisions in 4.2%. Median HDA was 25.7 cm2 (IQR17.8–35.6 cm2); median HSV was 365.0 cm3 (IQR150.0–611.0 cm3). Incremental 5 cm2 increase in HDA was associated with greater likelihood of presenting emergently (OR 1.27; 95%CI 1.124–1.428, p = 0.0001), incarceration (OR 1.27; 1.074–1.499, p = 0.005), gastric volvulus (OR 1.13; 1.021–1.248, p = 0.02), and requiring either relaxing incision (OR 1.43; 1.203–1.709, p

The role of prophylactic vena cava filters (pVCFs) in trauma patients remains controversial. After 20 years of data collection and experience, we reviewed our venous thromboembolism guideline for the efficacy of pVCFs in preventing pulmonary embolism (PE). A retrospective cohort study was performed using our Level I trauma center registry from January 1997 thru December 2016. This population was then divided by the presence of pVCFs. Univariate analysis was performed comparing the incidence of PEs, deep vein thrombosis, and mortality between those with and without a pVCF. There were 35,658 patients identified, of whom 2 per cent (n = 847) received pVCFs. The PE rate was 0.4 per cent in both groups. The deep vein thrombosis rate for pVCFs was 3.9 per cent compared with 0.6 per cent in the no-VCF group ( P < 0.0001). Given that there was no difference in the rates of PEs between the cohorts, the subset of patients with a PE were analyzed by their risk factors. Only ventilator days > 3 were associated with a higher risk in the no-pVCF group (0.2 vs 1.5%, P = 0.033). pVCFs did not confer benefit reducing PE rate. In addition, despite their intended purpose, pVCFs cannot eliminate PEs in high-risk trauma patients, suggesting a lack of utility for prophylaxis in this population.

BACKGROUND Geriatric Trauma Outcomes Score (GTOS) predicts in-patient mortality in geriatric trauma patients and has been validated in a prospective multicenter trial and expanded to predict adverse discharge (GTOS II). We hypothesized that these formulations actually underestimate the downstream sequelae of injury and sought to predict longer-term mortality in geriatric trauma patients. METHODS The Parkland Memorial Hospital Trauma registry was queried for patients 65 years or older from 2001 to 2013. Patients were then matched to the Social Security Death Index. The primary outcome was 1-year mortality. The original GTOS formula (variables of age, Injury Severity Score [ISS], 24-hour transfusion) was tested to predict 1-year mortality using receiver operator curves. Significant variables on univariate analysis were used to build an optimal multivariate model to predict 1-year mortality (GTOS III). RESULTS There were 3,262 patients who met inclusion. Inpatient mortality was 10.0% (324) and increased each year: 15.8%, 1 year; 17.8%, 2 years; and 22.6%, 5 years. The original GTOS equation had an area under the curve of 0.742 for 1-year mortality. Univariate analysis showed that patients with 1-year mortality had on average increased age (75.7 years vs. 79.5 years), ISS (11.1 vs. 19.1), lower GCS score (14.3 vs. 10.5), more likely to require transfusion within 24 hours (11.5% vs. 31.3%), and adverse discharge (19.5% vs. 78.2%; p < 0.0001 for all). Multivariate logistic regression was used to create the optimal equation to predict 1-year mortality: (GTOSIII = age + [0.806 × ISS] + 5.55 [if transfusion in first 24 hours] + 21.69 [if low GCS] + 34.36 [if adverse discharge]); area under the curve of 0.878. CONCLUSION Traumatic injury in geriatric patients is associated with high mortality rates at 1 year to 5 years. GTOS III has robust test characteristics to predict death at 1 year and can be used to guide patient centered goals discussions with objective data. LEVEL OF EVIDENCE Prognostic, level III.

Background/Objectives Older adults are at risk for adverse outcomes after trauma, but little is known about post-acute survival as state and national trauma registries collect only inpatient or 30-day outcomes. This study investigates long-term, out-of-hospital mortality in geriatric trauma patients. Methods Level I Trauma Center registry data were matched to the US Social Security Death Index (SSDI) to determine long-term and out-of-hospital outcomes of older patients. Blunt trauma patients aged ≥65 were identified from 2009 to 2015 in an American College of Surgeons Level 1 Trauma Center registry, n = 6289 patients with an age range 65-105 years, mean age 78.5 ± 8.4 years. Dates of death were queried using social security numbers and unique patient identifiers. Demographics, injury, treatments, and outcomes were compared using descriptive and univariate statistics. Results Of 6289 geriatric trauma patients, 505 (8.0%) died as an inpatient following trauma. Fall was the most common mechanism of injury (n = 4757, 76%) with mortality rate of 46.5% at long-term follow-up; motor vehicle crash (MVC) (n = 1212, 19%) had long-term mortality of 27.6%. Overall, 24.1% of patients died within 1 year of trauma. Only 8 of 488 patients who died between 1 and 6 months post-trauma were inpatient. Mortality rate varied by discharge location: 25.1% home, 36.4% acute rehabilitation, and 51.5% skilled nursing facility, P < .0001. Conclusion Inpatient and 30-day mortality rates in national outcome registries fail to fully capture the burden of trauma on older patients. Though 92% of geriatric trauma patients survived to discharge, almost one-quarter had died by 1 year following their injuries.

Background Emergency general surgery (EGS) patients presenting at tertiary care hospitals may bypass local hospitals with adequate resources. However, many tertiary care hospitals frequently operate at capacity. We hypothesized that understanding patient geographic origin could identify opportunities for enhanced system triage and optimization and be an important first step for EGS regionalization and care coordination that could potentially lead to improved utilization of resources. Methods We analyzed patient zip code and categorized EGS patients who were cared for at our tertiary care hospital as potentially divertible if the southern region hospital was geographically closer to their home, regional hospital admission (RHA) patients, or local admission (LA) patients if the tertiary care facility was closer. Baseline characteristics and outcomes were compared for RHA and LA patients. Results Of 14 714 EGS patients presenting to the tertiary care hospital, 30.2% were categorized as RHA patients. Overall, 1526 (10.4%) patients required an operation including 527 (34.5%) patients who were potentially divertible. Appendectomy and cholecystectomy comprised 66% of the operations for potentially divertible patients. Length of stay was not significantly different ( P = .06) for RHA patients, but they did have lower measured short-term and long-term mortality when compared to their LA counterparts ( P < .05). Conclusions EGS diagnoses and patient geocode analysis can identify opportunities to optimize regional operating room and bed utilization. Understanding where EGS patients are cared for and factors that influenced care facility will be critical for next steps in developing EGS regionalization within our system.

The aim of this study was to evaluate the use of laparoscopic surgery for common emergency general surgery (EGS) procedures within an integrated Acute Care Surgery (ACS) network. We hypothesized that laparoscopy would be associated with improved outcomes.Our integrated health care system's EGS registry created from AAST EGS ICD-9 codes was queried from January 2013 to October 2015. Procedures were grouped as laparoscopic or open. Standard descriptive and univariate tests were performed, and a multivariable logistic regression controlling for open status, age, BMI, Charlson Comorbidity Index (CCI), trauma tier, and resuscitation diagnosis was performed. Laparoscopic procedures converted to open were identified and analyzed using concurrent procedure billing codes across episodes of care.Of 60,604 EGS patients identified over the 33-month period, 7280 (12.0%) had an operation and 6914 (11.4%) included AAST-defined EGS procedures. There were 4813 (69.6%) surgeries performed laparoscopically. Patients undergoing a laparoscopic procedure tended to be younger (45.7 ± 18.0 years vs. 57.2 ± 17.6, p 0.001) with similar BMI (29.7 ± 9.0 kg/mUse of laparoscopy in EGS is common and associated with a decreased risk of all-cause mortality at all time points compared to open procedures. Conversion to open was protective at all time points compared to open procedures.

Background Surgical stabilization of rib fractures (SSRF) has been correlated with improved outcomes, including decreased length of stay (LOS). We hypothesized that an SSRF consultation service would increase the frequency of SSRF and improve outcomes. Methods A prospective observational study was performed to compare outcomes before and after implementing an SSRF service. Primary outcome was time from admission to surgery; secondary outcomes included LOS, mortality and morphine milligram equivalents (MME) prescribed at discharge. Results 1865 patients met consultation criteria and 128 patients underwent SSRF. Mortality decreased (6.3% vs. 3%) and patients were prescribed fewer MME at discharge (328 MME vs. 124 MME) following implementation. For the operative cohort, time from admission to surgery decreased by 1.72 days and ICU LOS decreased by 2.6 days. Conclusion Establishment of an SSRF service provides a mechanism to maximize capture and evaluation of operative candidates, provide earlier intervention, and improve patient outcomes. Additional study to determine which elements and techniques are most beneficial is warranted. Level of evidence III.

Hemorrhagic shock is a life-threatening and time-sensitive condition that can be mitigated and reversed by a number of techniques including transfusions to replace blood loss and reverse anticoagulation, direct pressure and tourniquets to mechanically reduce blood loss, surgical techniques to directly close vessels and wounds, and hemostatic agents to reduce blood loss by improving coagulation of blood on tissue surfaces. In this chapter, we will discuss two of these methods that are easily learned and readily available for the advanced practice provider. Direct pressure and tourniquet placement are vital to extremity injury management to prevent blood loss. Central wounds and specific sites not able to be compressed are also amendable to hemostatic materials impregnated with pro-coagulant agents or directly bound to thrombin and/or fibrin to stimulate clot formation. These are often used for surgery and can be valuable adjuncts at the bedside in the emergency room, wards, and ICU.

Background Admissions due to emergency general surgery (EGS) are on the rise, and patients who undergo emergency surgery are at increased risk of mortality. We hypothesized that utilization of palliative care and discharge to hospice in the EGS population have increased over time and that this is associated with a decrease in inpatient mortality. Methods Using the 2002-2011 nationwide inpatient sample and American Association for the Surgery of Trauma-defined EGS diagnosis codes, we identified patients ≥18 years old with an EGS admission. Demographics, hospitalization characteristics, mortality, use of palliative care services, and discharge to hospice were queried. All Patient Refined-Diagnosis Related Group risk of mortality was used to categorize those with an extreme likelihood of dying (ELD). Multivariable logistic regression was used to investigate the association between palliative care consult and discharge to hospice. Results Of the included patients, 0.3% received palliative care and 0.2% were discharged to hospice. Over time, rates of palliative care and hospice discharge increased while inpatient mortality decreased. In the 4% of patients with ELD, 3% received palliative care, 5% were transitioned to hospice care, and 22% suffered inpatient mortality. Controlling for patient characteristics, utilization of palliative care services was associated with increased odds of discharge to hospice compared to inpatient mortality (OR = 1.78 all patients and OR = 2.04 for ELD). Conclusions Despite the known increased risks associated with emergency surgical diagnoses, palliative care services remain infrequently utilized in the EGS population. This may be an opportunity for lessening suffering, improving patient-concordant care and outcomes, and reducing nonbeneficial and unwanted care.

Coagulopathy is a known sequela of traumatic brain injury (TBI) and can lead to increased morbidity and mortality. Platelet dysfunction has been identified as one of several etiologies of coagulopathy following TBI and has been associated with poor outcomes. Regardless of whether the platelet dysfunction occurs as a direct consequence of the injury or because of pre-existing medical comorbidities or medication use, accurate detection and monitoring of response to therapy is key to optimal patient care. Platelet transfusion has been proposed as a potential therapeutic intervention to treat platelet dysfunction, with several studies using platelet function assays to monitor response. The development of increasingly precise diagnostic testing is providing enhanced understanding of the specific derangement in the hemostatic process, allowing clinicians to provide patient-specific treatment plans. There is wide variability in the currently available literature on the incidence and clinical significance of platelet dysfunction following TBI, which creates challenges with developing evidence-based management guidelines. The relatively high prevalence of platelet inhibitor therapy serves as an additional confounding factor. In addition, the data are largely retrospective in nature. We performed a literature review to provide clarity on this clinical issue. We reviewed 348 abstracts, and included 97 manuscripts in our final literature review. Based on the currently available research, platelet dysfunction has been consistently demonstrated in patients with moderate-severe TBI. We recommend the use of platelet functional assays to evaluate patients with TBI. Platelet transfusion directed at platelet dysfunction may lead to improved clinical outcome. A randomized trial guided by implementation science could improve the applicability of these practices.

The concept of hemodilution after blood loss and crystalloid infusion is a surgical maxim that remains unproven in humans. We sought to quantify the effect of hemodilution after crystalloid administration in voluntary blood donors as a model for acute hemorrhage.A prospective, randomized control trial was conducted in conjunction with community blood drives. Donors were randomized to receive no IV fluid (noIVF), 2 liters of normal saline (NS), or 2 liters lactated Ringer's (LR) after blood donation. Blood samples were taken before donation of 500 mL of blood, immediately after donation, and after IV fluid administration. Hemoglobin (Hgb) was measured at each time point. Hemoglobin measurements between time points were compared between groups using standard statistical tests and the Bonferroni correction for multiple comparisons. Statistical significance was set at p ≤ 0.0167.Of 165 patients consented, 157 patients completed the study. Average pre-donation Hgb was 14.3 g/dL. There was no difference in the mean Hgb levels after blood donation between the 3 groups (p0.05). Compared with the control group, there was a significant drop in Hgb in the crystalloid infused groups from the post-donation level to post-resuscitation (13.2 vs 12.1 vs 12.2 g/dL, p0.0001). A formula was created to predict hemoglobin levels from a given estimated blood loss (EBL) and volume replacement (VR): Hemodilution Hgb = (mean pre-donation Hgb - hemorrhage Hgb drop - equilibration hemoglobin drop - resuscitation Hgb drop) = Mean pre-donation Hgb - [(EBL/TBV)*l] - [(EBL/TBV)*h] - [(VR/TBV)*r], l = 5.111g/dL = blood loss coefficient, h = 6.722 g/dL = equilibration coefficient, r = 2.617g/dL = resuscitation coefficient.This study proves the concept of hemodilution and derived a mathematical relationship between blood loss and resuscitation. These data may help to estimate response of hemoglobin levels to blood loss and fluid resuscitation in clinical practice.

Introduction: Early removal of urinary catheters is an effective strategy for catheter-associated urinary tract infection (CAUTI) prevention. We hypothesized that a nurse-directed catheter removal protocol would result in decreased catheter utilization and CAUTI rates in a surgical trauma intensive care unit (STICU). Methods: We performed a retrospective, cohort study following implementation of a multimodal CAUTI prevention bundle in the STICU of a large tertiary care center. Data from a 19-month historical control were compared to data from a 15-month intervention period. Pre- and postintervention indwelling catheter utilization and CAUTI rates were compared. Results: Catheter utilization decreased significantly with implementation of the nurse-driven protocol from 0.78 in the preintervention period to 0.70 in the postintervention period ( P < .05). As a result of the bundle, the CAUTI rate declined significantly, from 5.1 to 2.0 infections per 1000 catheter-days in the pre- vs postimplementation period (Incident Rate Ratio [IRR]: 0.38, 95% confidence interval: 0.21-0.65). Conclusions: Implementation of a nurse-driven protocol for early urinary catheter removal as part of a multimodal CAUTI intervention strategy can result in measurable decreases in both catheter utilization and CAUTI rates.

We hypothesized that a pH of7.0 on presentation would correlate with almost universal mortality in trauma patients.A retrospective cohort study was performed on a Level I trauma center registry from 2013 to 2014. Hospital mortality was the primary outcome, which was compared by pH cohort (7.0 or ≥7.0) using standard univariate statistics and multivariate logistic regression.There were 593 patients included in the analysis: 66 in7.0, 527 in ≥7.0. Mortality was 3× higher in the7.0 pH cohort (62.1 vs. 20.3%; p 0.0001), however there was no threshold for a pH below which there was 100% mortality. After controlling for these confounding variables, initial pH was found to be an independent predictor of inpatient mortality: pH 7.0 (OR 6.33, 3.29-12.19; p 0.0001).This data indicates that while patients with severe acidosis are at increased risk for mortality, a pH 7.0 is still recoverable in select cases.

Laparoscopic inguinal herniorrhaphy (LIH) has a relatively high risk of urinary retention. Bladder dysfunction may delay discharge after LIH. We hypothesized that filling the bladder before Foley catheter removal decreases time to discharge (TTD) after LIH. A secondary aim was to determine incidence of postoperative urinary retention (POUR) after bladder fill (BF). We reviewed a consecutive series of total extraperitoneal and transabdominal preperitoneal LIH procedures performed by a single surgeon at our institution from 2010 to 2013. All patients were catheterized during LIH, and selected patients received a 200-mL saline BF before Foley catheter removal. Patients were required to void >250 mL before discharge. TTD and incidence of POUR were compared between the BF and no-BF groups. A total of 161 LIH cases were reviewed. BF was performed in 89/161 (55%) of cases. TTD was significantly shorter in the BF versus the no-BF group (222 vs 286 minutes, respectively; P < 0.01). Patient and operative characteristics were similar between the BF and no-BF groups (P > 0.05). Incidence of POUR in the BF and the no-BF group was 10.1 and 16.7 per cent, respectively; however, this difference was not significant (P = 0.22). No postoperative urinary tract infection occurred in either group. In conclusions, postoperative BF significantly reduces TTD after LIH. Further studies may help to determine whether shorter postanesthesia care unit time and lower POUR rates associated with BF can lower LIH procedural costs and increase patient satisfaction.

Obese patients may have unique surgical needs. The goal of this study is to determine if there is an association between obesity and transfer in patients undergoing EGS.EGS patients were identified in the NSQIP 2011-2016 database. Outcome variables included interhospital transfer, days to surgery, SSI, postoperative LOS, discharge destination, and 30-day readmission. Descriptive statistics and multivariable regression were utilized.419,373 EGS patients were identified, and transfer status varied by obesity class. After controlling for other factors, obese patients had increased odds of interhospital transfer (OR = 1.07-1.53), SSI (OR = 1.22-1.69), and decreased odds of discharge to home (OR = 0.42-0.71, all p 0.01) but not of 30-day readmission or delay from admission to surgical intervention.Obese patients undergoing EGS procedures have an increased likelihood of transfer from an acute care hospital. As obese EGS patients are increasingly prevalent, determining best triage practices for this unique patient population warrants additional investigation.

Incisional and Ventral hernia repair (VHR) is one of the most common surgical procedures in the world, and over the last two decades this field has enjoyed exponentially advances thanks to improvements in operative technique and biomechanical science. Truly complex hernias which are multiply recurrent, have active infections, loss of domain, presence of stomas, require component separation or panniculectomy, or have other exacerbating factors are truly challenging to manage operatively, and the multidisciplinary operations to repair them have become known collectively as abdominal wall reconstruction (AWR). Herein, we describe the surgical history of AWR, the current state of surgical techniques and mesh science, as well as novel areas for advancement of the field in the future. In particular, a focus on patient specific clinical outcomes such as hernia recurrence, wound complications, and quality of life has been made with regards to mesh position and selection. Our goal is to provide a comprehensive review of the state of the literature and our recommendations for AWR, for the Plastic, General, and Hernia surgeon alike. This review contains 7 figures, 3 tables, and 79 references. Keywords: ventral hernia repair, incisional hernia, abdominal wall reconstruction, mesh, pre-peritoneal hernia repair, pre-operative optimization, clinical outcomes, mesh position, surgical site infection, robotic hernia repair

Truly complex hernias which are multiply recurrent, have active infections, loss of domain, presence of stomas, require component separation or panniculectomy, and/or have other exacerbating factors, are truly challenging to manage operatively, and the multidisciplinary operations to repair them have become known collectively as abdominal wall reconstruction (AWR). Component separation techniques and panniculectomy, to name a few, have become commonly used techniques for operative management for complex hernias. Herein, we describe the history and technical aspects of component separation, panniculectomy and other adjunct techniques in abdominal wall reconstruction. In particular, a focus on patient specific clinical outcomes such as hernia recurrence, wound complications, and quality of life has been made in regards to use and types of component separation. Our goal is to provide a comprehensive review of the state of the literature and our recommendations for AWR, for the Plastic, General, and Hernia surgeon alike. This review contains 7 figures, 1 video, 1 table, and 79 references. Keywords: ventral hernia repair, incisional hernia, abdominal wall reconstruction. component separation, transversus abdominis release (TAR), surgical site infection, advances in hernia repair, robotic hernia repair, robotic component separation, botulinum toxin

Background Emergency surgical services often encounter patients with generalized peritonitis. Difficult perioperative decisions impact morbidity, mortality, cost, and utilization of hospital resources. The ability to preoperatively predict patient nonsurvival despite surgical intervention using clinical physiologic indicators was the aim of this study and would be helpful in counseling patients/families. Methods A retrospective cohort from an institutional database was queried for nontrauma patients with peritonitis undergoing emergency laparotomy from 2012 to 2016. Time to mortality after surgery was compared: early (≤72 hours) versus late (>72 hours) and no death. Results After 534 emergency laparotomies, there were 74 (13.9%) mortalities. Of these, death occurred early (≤72 hours) after surgery in 28 (37.8%) patients and late (>72 hours) in 46 (62.2%). Early death patients had a significantly more deranged physiology, as evidenced by higher Acute Physiology and Chronic Health Evaluation II scores (mean 28.1 ± 8.4 vs 22.9 ± 8.7, P = .01), worse acute kidney injury (preoperative creatinine 3.7 ± 3.2 vs 1.9 ± 1.4, P = .001), and greater level of acidosis (pH 7.19 ± 0.12 vs 7.27 ± 0.13, P = .017). Additionally, preoperative lactate was significantly increased in patients with early mortality (6.8 ± 4.1 vs 5.1 ± 4.0, P = .045). Using logarithmic regression, a nomogram was constructed using age, Glasgow Coma Scale, lactate, creatinine, and pH. This nomogram had an area under the curve of 0.908 on receiver operator curve analysis. A score of 13 equates to greater than 50% risk of early mortality after surgery. Conclusion Early mortality (≤72 hours after emergency laparotomy) is associated with decreased pH, elevated creatinine, and elevated lactate. These factors combined into the nomogram constructed may assist surgical teams with patient and family discussions to prevent futile surgical interventions.

Emergent surgeries have different causes and physiologic patient responses than the same elective surgery, many of which are due to infectious etiologies. Therefore, we hypothesized that emergency cases have a higher risk of postoperative SSI than their elective counterparts. The ACS NSQIP database was queried from 2005 to 2016 for all cholecystectomies, ventral hernia repairs, and partial colectomies to examine common emergency and elective general surgery operations. Thirty-day outcomes were compared by emergent status. Any SSI was the primary outcome. There were 863,164 surgeries: 416,497 cholecystectomies, 220,815 ventral hernia repairs, and 225,852 partial colectomies. SSIs developed in 38,865 (4.5%) patients. SSIs increased with emergencies (5.3%

Minimally invasive surgery (MIS) has demonstrated superior outcomes in many elective procedures. However, its use in emergency general surgery (EGS) procedures is not well characterized. The purpose of this study was to examine the trends in utilization and outcomes of MIS techniques in EGS over the past decade. The 2007–2016 ACS-NSQIP database was utilized to identify patients undergoing emergency surgery for four common EGS diagnoses: appendicitis, cholecystitis/cholangitis, peptic ulcer disease, and small bowel obstruction. Trends over time were described. Preoperative risk factors, operative characteristics, outcomes, morbidity, and trends were compared between MIS and open approaches using univariate and multivariate analysis. During the 10-year study period, 190,264 patients were identified. The appendicitis group was the largest (166,559 patients) followed by gallbladder disease (9994), bowel obstruction (6256), and peptic ulcer disease (366). Utilization of MIS increased over time in all groups (p

Despite advances in diagnostic imaging capabilities, little information exists concerning the impact of physical dimensions of a paraesophageal hernia (PEH) on intraoperative decision making. The authors hypothesized that computerized volumetric analysis and multidimensional visualization to measure hiatal defect area (HDA) and intrathoracic hernia sac volume (HSV) would correlate to operative findings and required surgical techniques performed.Using volumetric analysis software (Aquarius iNtuition, TeraRecon, Inc), HDA and HSV were measured in PEH patients with preoperative computerized tomography (CT) scans, and used to predict the likelihood of intraoperative variables. Multidimensional rotation of images enabled visualization of the entire hiatal defect in a plane mimicking the surgeon's view during repair. The intrathoracic hernia sac was outlined producing volume measurements based on a summation of exact dimensions.A total of 213 PEHR patients had preoperative CT imaging, with 14.1% performed emergently. Primary cruroplasty was performed in 89.2%, salvage gastropexy in 10.3%, and diaphragmatic relaxing incisions in 4.2%. Median HDA was 25.7 cmUtilization of CT volumetric measurements is a valuable adjunct in preoperative planning, allowing the surgeon to anticipate complexity of repair and operative approach, as incremental increases in HSV by 100 cm

Transabdominal, preperitoneal (TAPP), laparoscopic inguinal hernia repair (IHR) requires the creation of a peritoneal flap (PF) that must be closed after mesh placement. Our previous study indicated that sutured PF closure resulted in less short-term postoperative pain at 2 and 4 weeks compared to tacks and staples. Therefore, the aim of this follow-up study was to compare short-term QOL with a greater sample size and long-term QOL at 2 years by method of PF closure.A prospective institutional hernia-specific database was assessed for all adult TAPP IHRs from July 2012 to May 2015. QOL outcomes were compared by PF closure method at 2 and 4 weeks and 6, 12, and 24 months as measured by the Carolinas Comfort Scale. Standard statistical tests were used for the whole population and then the Bonferroni Correction was used to compare groups (p 0.0167). Multivariate analysis controlling for age, gender, recurrent hernias, and preoperative symptomatic pain was used to compare QOL by PF closure method.A total of 679 TAPP IHRs in 466 patients were analyzed; 253 were unilateral, and 213 were bilateral. PF closure was performed using tacks in 36.7 %, suture in 24.3 %, and staples in 39.0 %. There was no difference in hernia recurrence (only 1 patient at 36 months). There were no statistical differences in QOL between 2 and 4 weeks and 6- to 24-month follow-up. When resolution of symptoms from preoperative levels was examined, there was no difference in the three groups at any time point (p 0.05). After controlling for confounding variables on multivariate analysis, there was no difference in QOL by PF closure method at any time point (p 0.05).Tacked, sutured, and stapled techniques for peritoneal flap closure following TAPP have no significant differences in operative outcomes, postoperative quality of life, or resolution of symptoms.

Background While the prevalence of HIV infection in the population is 0.5%, it is higher among trauma patients as are rates of unknown seropositivity. Routine HIV screening for all trauma evaluations was implemented at our urban level I center in 2009. We aimed to evaluate use and results of the program in our trauma population. Methods This was a retrospective analysis of all trauma evaluations between July 2015 and February 2018. After passage of legislation rescinding the requirement for consent to perform HIV testing, our trauma service instituted an order set which automatically tested for HIV unless the ordering physician opted out. Patients found to be infected with HIV were to be counseled and referred to specialty care. Results Of 6175 consecutive trauma evaluations during the study period, 449 (7.3%) patients had been screened within the prior year and were excluded. Of the remaining cohort, 2024 (35.3%) patients were screened with 27 (1.3%) testing positive. Among those testing positive for infection, 100% were male, 77% white, 63% non-Hispanic, and 70% lacked insurance. Twenty-five (92.6%) patients received counseling and 19 were referred to specialty care. Age, gender, race, ethnicity, Injury Severity Score, trauma activation level, and payor type were not significant predictors for positive HIV screen on logistic regression analysis. Conclusions Despite a significantly higher rate of HIV in the trauma population, only a third of patients are screened. Such high infection rates justify the existence of this screening program but steps must be taken to increase screening rate. Level of Evidence Level 3.

The novel coronavirus (COVID-19) was first diagnosed in Wuhan, China in December 2019 and has now spread throughout the world, being verified by the World Health Organization as a pandemic on March 11. This had led to the calling of a national emergency on March 13 in the US. Many hospitals, healthcare networks, and specifically, departments of surgery, are asking the same questions about how to cope and plan for surge capacity, personnel attrition, novel infrastructure utilization, and resource exhaustion. Herein, we present a tiered plan for surgical department planning based on incident command levels. This includes acute care surgeon deployment (given their critical care training and vertically integrated position in the hospital), recommended infrastructure and transfer utilization, triage principles, and faculty, resident, and advanced care practitioner deployment.

Trauma patients have an increased risk of venous thromboembolism (VTE), partly because of greater inflammation. However, it is unknown if this association is present in patients who undergo emergency general surgery (EGS).To investigate whether emergency case status is independently associated with VTE compared with elective case status and to test the hypothesis that emergency cases would have a higher risk of VTE.This retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program database from January 1, 2005, to December 31, 2016, for all cholecystectomies, ventral hernia repairs (VHRs), and partial colectomies (PCs) to obtain a sample of commonly encountered emergency procedures that have elective counterparts. Emergency surgeries were then compared with elective surgeries. The dates of analysis were January 1 to 31, 2019.The primary outcome was VTE at 30 days. A multivariable analysis controlling for age, sex, body mass index, bleeding disorder, disseminated cancer, laparoscopy approach, and surgery type was performed.There were 604 537 adults undergoing surgical procedures over 12 years (mean [SD] age, 55.3 [16.6] years; 61.4% women), including 285 847 cholecystectomies, 158 500 VHRs, and 160 190 PCs. The rate of VTE within 30 days was 1.9% for EGS and 0.8% for elective surgery, a statistically significant difference. Overall, 4607 patients (0.8%) had deep vein thrombosis, and 2648 patients (0.4%) had pulmonary embolism. A total of 6624 VTEs (1.1%) occurred in the cohort. As expected, when VTE risk was examined by surgery type, the risk increased with invasiveness (0.5% for cholecystectomy, 0.8% for VHR, and 2.4% for PC; P .001). On multivariable analysis, EGS was independently associated with VTE (odds ratio [OR], 1.70; 95% CI, 1.61-1.79). Also associated with VTE were open surgery (OR, 3.38; 95% CI, 3.15-3.63) and PC (OR, 1.86; 95% CI, 1.73-1.99).In this cohort study, emergency surgery and increased invasiveness appeared to be independently associated with VTE compared with elective surgery. Further study on methods to improve VTE chemoprophylaxis is highly recommended for emergency and more extensive operations to reduce the risk of potentially lethal VTE.

The field of hernia repair remains dynamic given the ongoing evolution of materials for hernia repair as well as surgical techniques. This chapter reviews the history and philosophy of hernia repair along with data supporting use of reinforcing materials. We review in detail the design and construction of permanent synthetic meshes, biologic grafts, and absorbable synthetic meshes used today in inguinal and ventral hernia repairs. Principles and techniques for mesh fixation, mesh specific complications, and the role of antiadhesive in antimicrobial coatings are discussed.

The aim of this study was to examine the outcomes of over a decade's experience utilizing preperitoneal ventral hernia repair (PP-VHR).PP-VHR was first described by our group in 2006, and there have been no subsequent reports of outcomes with this technique.A prospective study of all PP-VHR from January, 2004 to April, 2016 was performed. Multivariate stepwise logistic regression and Cox proportional-hazard models were used to identify predictors of wound complications and hernia recurrence, respectively.There were 1023 PP-VHRs. Mean age was 57.2 ± 12.6 years, BMI 33.7 ± 11.4 kg/m, defect size 210.0 ± 221.4 cm; 23.7% had diabetes, 13.9% were smokers, 68.7% were recurrent, and 23.6% incarcerated. Component separation was required in 43.6%, and a panniculectomy was performed in 30.0%. Wound complication was present in 27.3% of patients, with 1.7% having a mesh infection. In all, there were 53 (5.2%) hernia recurrences and 36 (3.9%) in the synthetic repairs, with a mean follow-up of 27.0 ± 26.4 months. On multivariate regression (odds ratio or hazard ratio, 95% confidence interval), diabetes (1.9, 1.4-3.0), panniculectomy (2.6, 1.8-3.9), and operations requiring biologic mesh were predictors of wound complications, whereas recurrent hernia repair (2.69, 1.14-6.35), biologic mesh (3.1, 1.67-5.75), and wound complications (3.01, 1.69-5.39) were predictors of hernia recurrence.An open PP-VHR is a very effective means to repair large, complex, and recurrent hernias resulting in a low recurrence rate. Mesh choice in VHR is important and was associated with hernia recurrence and wound complications in this population.

Intrahepatic cholangiocarcinoma (iCCA) is the second most common primary hepatic cancer in the United States. Currently, curative treatment involves aggressive surgery. Chemotherapy and radiation treatments have been used for unresectable tumors with some success. Optimizing the use of current and developing novel multimodality treatment for iCCA is essential to improving outcomes.

Our goal was to set criteria for massive ventral hernia and to compare surgical outcomes and quality of life after ventral hernia repair (VHR).The International Hernia Mesh Registry was queried for patients undergoing VHR from 2007 to 2013. Defect was categorized as massive if the width or length was greater than 15 cm or area greater than 150 cm(2). Massive VHR was compared to regular VHR.A total of 878 patients underwent VHR: 436 open, 442 laparoscopic with 13 deaths (1.5%) and 45 hernia recurrences (5.1%). Of those, 158 patients (18%) met criteria for massive VHR. Massive VHR patients had longer length of stay (LOS) and operative time and more hematomas, wound infections, wound complications, and pneumonias (P.05). On multivariate analysis, LOS was longer, and early postoperative pain and activity limitation were greater in massive VHRs (P.01). Massive VHR in the laparoscopic approach resulted in greater long-term mesh sensation (P.01).VHR in massive hernias have increased rates of complications and longer LOS.

Modern adjuncts to complex, open ventral hernia repair often include component separation (CS) and/or panniculectomy (PAN). This study examines nationwide data to determine how these techniques impact postoperative complications. The National Surgical Quality Improvement Program database was queried from 2005 to 2013 for inpatient, elective open ventral hernia repairs (OVHR). Cases were grouped by the need for and type of concomitant advancement flaps: OVHR alone (OVHRA), OVHR with CS, OVHR with panniculectomy (PAN), or both CS and PAN (BOTH). Multivariate regression to control for confounding factors was conducted. There were 58,845 OVHR: 51,494 OVHRA, 5,357 CS, 1,617 PAN, and 377 BOTH. Wound complications (OVHRA 8.2%, CS 12.8%, PAN 14.4%, BOTH 17.5%), general complications (15.2%, 24.9%, 25.2%, 31.6%), and major complications (6.9%, 11.4%, 7.2%, 13.5%) were different between groups ( P < 0.0001). There was no difference in mortality. Multivariate regression showed CS had higher odds of wound [odds ratio (OR) 1.7, 95% confidence interval (CI) 1.5–2.0], general (OR 1.5, 95% CI: 1.3–1.8), and major complications (OR 2.1, 95%, CI: 1.8–2.4), and longer length of stay by 2.3 days. PAN had higher odds of wound (OR 1.5, 95%, CI: 1.3–1.8) and general complications (OR 1.7, 95% CI: 1.5–2.0). Both CS and PAN had higher odds of wound (OR 2.2,95%, CI: 1.5–3.2), general (OR 2.5, 95%, CI: 1.8–3.4), and major complications (OR 2.2, 95%CI: 1.4–3.4), and two days longer length of stay. In conclusion, patients undergoing OVHR that require CS or PAN have a higher independent risk of complications, which increases when the procedures are combined.