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Purpose: Despite increasing use of cannabis, literature on perioperative effects is lagging. We compared active cannabis-smokers versus non-smokers and postoperative wound morbidity and reoperations following open abdominal wall reconstruction (AWR). Methods: Patients who underwent open, clean, AWR with transversus abdominis release and retromuscular synthetic mesh placement at our institution between January 2014 and May 2022 were identified using the Abdominal Core Health Quality Collaborative database. Active cannabis-smokers were 1:3 propensity matched to non-smokers based on demographics and comorbidities. Wound complications, 30 day morbidity, pain (PROMIS 3a-Pain Intensity), and hernia-specific quality of life (HerQles) were compared. Results: Seventy-two cannabis-smokers were matched to 216 non-smokers. SSO (18% vs 17% p = 0.86), SSI (11.1% vs 9.3%, p = 0.65), SSOPI (12% vs 12%, p = 0.92), and all postoperative complications (46% vs 43%, p = 0.63) were similar between cannabis-smokers and non-smokers. Reoperations were more common in the cannabis-smoker group (8.3% vs 2.8%, p = 0.041), driven by major wound complications (6.9% vs 3.2%, p = 0.004). No mesh excisions occurred. HerQles scores were similar at baseline (22 [11, 41] vs 35 [14, 55], p = 0.06), and were worse for cannabis-smokers compared to non-smokers at 30 days (30 [12, 50] vs 38 [20, 67], p = 0.032), but not significantly different at 1 year postoperatively (72 [53, 90] vs 78 [57, 92], p = 0.39). Pain scores were worse for cannabis-smokers compared to non-smokers at 30 days postoperatively (52 [46, 58] vs 49 [44, 54], p = 0.01), but there were no differences at 6 months or 1 year postoperatively (p > 0.05 for all). Conclusion: Cannabis smokers will likely experience similar complication rates after clean, open AWR, but should be counseled that despite similar wound complication rates, the severity of their wound complications may be greater than non-smokers. [ABSTRACT FROM AUTHOR]

Background: To date, there is limited data on the association of active smoking and 30-day wound events following inguinal hernia repair (IHR) with mesh. We aimed to determine if active smoking at the time of IHR with mesh was associated with worse 30-days wound events and additional morbidity outcomes using the Abdominal Core Health Quality Collaborative (ACHQC) database. Methods: All adult patients undergoing elective, IHR with mesh who had 30-day follow-up data available were identified within the ACHQC database. Smokers were defined as having used nicotine within the 30 days prior to surgery. A 1:1 propensity score matched analysis was performed comparing smokers to non-smokers, controlling for factors previously shown to be associated with postoperative wound events. The effect of smoking on 30-day wound events and additional morbidity outcomes following IHR with mesh was investigated using Chi-square or Fisher's exact test for categorical data and Wilcoxon ranked test for continuous data. Results: A total of 17,543 patients met inclusion criteria; 1855 (11%) were active smokers at the time of minimally invasive IHR with mesh. A total of 3694 patients were used for the matched analysis. There were no statistically significant differences between the non-smokers and smokers with respect to the incidence of surgical site infection (p = 0.10), surgical site occurrences (p = 0.22), or surgical site occurrences requiring procedural intervention (p = 0.64). Non-smokers were significantly more likely to be readmitted to the hospital and had significantly less improvement in all pain domains following IHR with mesh. Conclusions: Active smoking at the time of IHR with mesh is not associated with worse 30-day wound or additional morbidity and mortality outcomes. Based on these results, preoperative smoking cessation for all patients undergoing IHR may not reduce 30-day morbidity. [ABSTRACT FROM AUTHOR]

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

Purpose: Seromas can occur after ventral hernia repairs (VHR), but little is known about their relevance to short- and long-term outcomes. We aimed to determine if there is a correlation between seroma occurrence after clean VHR with mesh and patient-reported and clinical outcomes. Methods: Patients with and without seromas in the Abdominal Core Health Quality Collaborative registry were compared using a propensity score-matched analysis. Outcomes included hospital readmissions, postoperative antibiotics use, and procedural interventions. Pain and hernia-related quality of life were assessed at 30 days and 1 year. Composite hernia recurrence rates were compared at 1 year. Results: Propensity score matching compared 218 patients with a seroma to 649 without a seroma. At 30 days, patients with seromas were more likely to be readmitted (27 (12%) vs 28 (4%), respectively; P < 0.001), receive postoperative antibiotics (25 (12%) vs 18 (3%), respectively; P < 0.001), and undergo procedural interventions (41 (19%) vs 23 (4%), respectively; P < 0.001) than patients without seromas. Surgical site occurrences were more common in patients with seromas than those without seromas at 1 year (12 (11%) vs 12 (4%), respectively; P = 0.01).Pain and hernia-related quality of life were similar for both groups at 30 days and 1 year. Composite hernia recurrence rates were similar for both groups at 1 year (37 seroma (17%) vs 115 no seroma (18%); P = 0.80). Conclusion: Seromas after clean VHR with mesh were associated with short- and long-term morbidity, but they did not significantly impact quality of life or hernia recurrences at 1 year. [ABSTRACT FROM AUTHOR]

Purpose: Ambiguity exists defining abdominal wall reconstruction (AWR) and associated Current Procedural Terminology code usage in the context of ventral hernia repair (VHR), especially with recent adoption of laparoscopic and robotic-assisted AWR techniques. Current guidelines have not accounted for the spectrum of repair complexity and have relied on expert opinion. This study aimed to develop an evidence-based definition and coding algorithm for AWR based on myofascial releases performed. Methods: Three vignettes and associated outcomes were evaluated in adult patients who underwent elecive VHR with mesh between 2013 and 2020 in the Abdominal Core Health Quality Collaborative including: (1) no myofascial release (NR), (2) posterior rectus sheath myofascial release (PRS), and (3) PRS with transversus abdominis release or external oblique release (PRS-TA/EO). The primary outcome measure was operative time based on the following categories (min): 0–59, 60–119, 120–179, 180–239, and 240 + ; secondary outcomes included disease severity measures and 30-day postoperative outcomes. Results: 15,246 patients were included: 7287(NR), 2425(PRS), and 5534(PRS-TA/EO). Operative time increased based on myofascial releases performed: 180–239 min (p < 0.05): NR(5%), PRS(23%), PRS-TA/EO(28%) and greater than 240 min (p < 0.05): NR (4%), PRS (17%), PRS-TA/EO(44%). A dose–response effect was observed for all secondary outcome measures indicative of three distinct levels of patient complexity and outcomes for each of the three vignettes. Conclusion: AWR is defined as VHR including myofascial release. Coding for AWR should reflect the actual effort used to manage these patients. We propose an evidence-based approach to AWR coding that focuses on myofascial release and is inclusive of minimally invasive techniques. [ABSTRACT FROM AUTHOR]

Purpose: 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.Methods: 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).Results: 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.Conclusion: 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. [ABSTRACT FROM AUTHOR]

Purpose: The approach to repairing an initial umbilical hernia (IUH) varies substantially, and this likely depends on hernia size, patient age, sex, BMI, comorbidities including diabetes mellitus, and surgeon preference. Of these, only hernia size has been widely studied. This cross-sectional study aims to look at the practice pattern of umbilical hernia repair in the United States.Methods: A retrospective study was performed using data from the America Hernia Society Quality Collaborative. Patient characteristics included age, sex, hernia width, BMI, smoking status, and diabetes. Outcomes were use of mesh for repair, as well as surgical approach (open vs minimally invasive). Multivariate logistic regression was performed to assess the independent effect of age, sex, hernia width, BMI, smoking status, and diabetes on use of mesh and approach to repair.Results: 3475 patients were included. 74% were men. Mesh use was more common in men (67% vs 60%, P < 0.001). Mesh was used in 33% of repairs ≤ 1 cm, and 82% of repairs > 1 cm (P < 0.001). Younger patients were less likely to receive a mesh repair (54% if age ≤ 35 vs 67% for age > 35, P < 0.001). However, on multivariate analysis, mesh use was associated with increasing hernia width (OR 5.474, 95% CI 4.7-6.3) as well as BMI (OR 1.8, 95% CI 1.5-2.1) but not with age or sex.Conclusion: The majority of IUH are performed open. Patient BMI and hernia defect size contribute to choice of surgical technique including use of mesh. The use of mesh in 33% of hernias below 1 cm demonstrates a gap between evidence and practice. Patient factors including patient age and sex had no impact on operative approach or use of mesh. [ABSTRACT FROM AUTHOR]

Purpose: Recent work has shown that over 40% of patients undergoing surgery for abdominal malignancy develop ventral incisional hernias (VIH) within 2 years. We hypothesized that early repair of VIH for cancer survivors could improve long-term quality of life (QoL).Methods: All patients presenting with a history of surgery for abdominal malignancy and a VIH were prospectively enrolled. QoL was assessed at baseline and 3-, 6-, 12-, 18-, and 24-month follow-up using abdominal wall-specific (HerQLes) and cancer-specific (FACT-G) instruments. At the study's conclusion, patients were divided into 2 groups-those that underwent VIH repair during the study's course (Repair Group) and those that did not (Control Group). Categorical variables were analyzed using Pearson's Chi-square and continuous variables with Wilcoxon rank sum test.Results: Eighty-four patients were enrolled. Overall, 46 patients (55%) underwent VIH repair, with 36 repairs (78%) occurring within 3 months of initial evaluation. Sixty-six (79%) had complete 1-year follow-up data, and 30 (36%) had 2-year data, with a median follow-up duration of 15.6 months. At baseline, both groups were similar with respect to demographics, cancer stage, and HerQLes/FACT-G scores. Compared to the Controls, the Repair Group showed greater improvements over baseline HerQLes Summary Scores at the 3-, 6-, 12-, and 18-month time points (median increase, 37 vs. 26 points), and in FACT-G total scores at the 3-, 6-, and 12-month time points (median increase, 6 vs. 4 points).Conclusions: Repair of VIH after surgery for abdominal malignancy may improve abdominal wall-specific and cancer-specific QoL, making post-resection abdominal wall reconstruction an important aspect of cancer survivorship. [ABSTRACT FROM AUTHOR]

Purpose: Previous work demonstrated that prior MRSA infection [MRSA(+)] is associated with 30-day surgical site infection (SSI) following ventral hernia repair (VHR). We aimed to determine the impact of MRSA(+) on long-term wound outcomes after VHR.Participants: A retrospective cohort study was performed at a tertiary center between July 11, 2005, and May 18, 2012, of patients undergoing elective VHR with class I wounds. Patients with documented preoperative MRSA infection at any site (urinary, bloodstream, SSI, etc.) were considered MRSA(+). Primary outcome was 2-year surgical site occurrence (SSO), defined as SSI, cellulitis, necrosis, nonhealing wound, seroma, hematoma, dehiscence, or fistula. SSOs were subdivided into those that required procedural intervention (SSOPI) and those that did not.Results: Among 632 patients, 46 % were female with average age 53 ± 13 years. There were 368 SSOs in 193 patients (31 %); an SSOPI occurred in 9.8 % (n = 62). The most common SSOs were cellulitis (91/632), seroma (91/632), and serous drainage (58/632). The rate of 2-year SSO was higher with MRSA(+) compared to those without (46 vs. 29 %, p = 0.023), attributed to increased soft tissue necrosis, purulent drainage, serous drainage, cellulitis, and fistula. In multivariable analysis, MRSA(+) was not associated with 2-year SSO (HR 1.5, 95 % CI 0.91-2.55, p = 0.113); factors associated with SSO included obesity, immunosuppression, mesh repair, and operative times.Conclusions: This study is the first to evaluate long-term SSOs and SSOPIs after VHR, highlighting the importance of long-term follow-up. Though not independently associated with SSOs, MRSA(+) may be a marker of hernia complexity. [ABSTRACT FROM AUTHOR]

Purpose: Ventral hernia repair (VHR) lacks standardization of care and exhibits variation in delivery. Complications of VHR, notably recurrence and infection, increase costs. Efforts at obtaining federal funding for VHR research are frequently unsuccessful, in part due to misperceptions that VHR is not a clinical challenge and has minimal impact on healthcare resources. We analyzed national trends for VHR performance and associated costs to demonstrate potential savings resulting from an improvement in outcomes. Methods: Inpatient non-federal discharges for VHR were identified from the 2001-2006 Healthcare Cost and Utilization Project, supplemented by the Center for Disease Control 2006 National Survey of Ambulatory Surgery for outpatient estimates. The total number of VHRs performed in the US was estimated along with associated costs. Costs were standardized to 2010 US dollars using the Consumer Price Index and reported as mean with 95% confidence intervals (95% CI). Results: The number of inpatient VHRs increased from 126,548 in 2001 to 154,278 in 2006. Including 193,543 outpatient operations, an estimated 348,000 VHRs were performed for 2006. Inpatient costs consistently rose with 2006 costs estimated at US $15,899 (95% CI $15,394-$16,404) per operation. Estimated cost for outpatient VHR was US $3,873 (95% CI $2,788-$4,958). The total cost of VHR for 2006 was US $3.2 billion. Conclusions: VHRs continue to rise in incidence and cost. By reducing recurrence rate alone, a cost saving of US $32 million dollars for each 1% reduction in operations would result. Further research is necessary for improved understanding of ventral hernia etiology and treatment and is critical to cost effective healthcare. [ABSTRACT FROM AUTHOR]