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Introduction: Wound complications (WC) after abdominal wall reconstruction (AWR) are associated with increased cost, recurrence, and mesh infection. Operative closing protocols (CP) have been studied in other surgical disciplines but not in AWR. Our aim was to study the effect of a CP on WC after AWR., Methods: The CP consists of antibiotic wound irrigation, glove and complete instrument exchange, and re-draping of the sterile field to cover the skin entirely prior to mesh implantation. A prospective institutional database at a tertiary hernia center was queried for patients who underwent open AWR with mesh. Standard descriptive and inferential statistics are reported. A Bayesian structured time-series analysis was performed to evaluate rates of wound infection (WI) and WC before and after implementation of a CP in late 2016., Results: A total of 2541 AWR patients were examined. Mean age and BMI were 57.9 ± 12.6 years and 32.9 ± 9.8 kg/m 2 , 56.7% were female, and 24.2% were diabetic. Significantly more CP patients had contaminated wounds. Mean defect size was 203.1 ± 205.8 cm 2 . Average follow-up was 31.5 ± 41.4 months. WI rate before CP (preCP) was 14.5% compared to 2.6% after CP (P < 0.001). WC rate was higher before CP (29.3% vs 10.3%, P < 0.001). Specifically, wound cellulitis (9.7% vs 2.7%, P < 0.001), wound infection (13.8 vs 1.8%, P < 0.001), and mesh infection (2.1% vs 0.6%, P < 0.004) rates were reduced after CP implementation. For WI, Bayesian Structured time-series analysis showed that the implementation of CP had an effect of 83% (± 2%, 95% CI - 87%, - 78%; P < 0.001) reduction in WI compared to counterfactual. For WC, the Bayesian analysis revealed a reduction compared to counterfactual for WC of - 67% (± 3%, 95% CI - 60%, - 72%; P < 0.001)., Conclusions: Introduction of a CP for open AWR with mesh has reduced overall WI and WC rates. The use of a CP should be strongly considered in AWR., Competing Interests: Declarations. Disclosures: Kercher received speaking honoraria from WL Gore. Augenstein received speaking honoraria from Allergan, Pacira, and Bard, and is a consultant for Medtronic and Vicarious Surgical. Heniford received a surgical education grant and honoraria from WL Gore. Lorenz, Ricker, Holland, Polcz, and Scarola have no conflict of interest or financial ties to disclose., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Active smoking is related to wound and respiratory complications following abdominal wall reconstruction (AWR), but no AWR studies directly compare outcomes of abstinent-smokers (AS), fulfilling four-weeks of smoking cessation, to non-smokers (NS)., Methods: Prospectively maintained institutional database was queried for all AWR between 2012 and 2019. AS and NS were included. Primary outcomes were wound and respiratory complications; secondary outcome was recurrence. Standard statistical analyses were performed., Results: Evaluation included 1088 patients, 305 AS and 783 NS. AS had a lower BMI (31.3 vs 32.7 ​kg/m 2 ; P ​= ​0.004) but increased ASA Class III (51.5% vs 34.5 ​%, P ​= ​0.009), COPD (8.9% vs 4.0 ​%, P ​= ​0.001), comorbidities (6.3 vs 4.7, P < 0.001), and wound class (Class III/IV: 25.3% vs 15.8 ​%, P ​= ​0.003). AS had increased defect size (229 vs 209.1 ​cm 2 ; P ​= ​0.023), use of component separation (CST) (52.5% vs 43.8 ​%; P ​= ​0.010) and hospital stay (6.6 vs 6.2 days, P ​= ​0.015). Postoperative wound, mesh, and pulmonary infection, respiratory failure, and recurrence were similar. On multivariable regression, wound class and complications predicted recurrence. BMI, panniculectomy and CST predicted wound complications. BMI, CST, and wound class predicted respiratory complications., Conclusion: Despite greater patient and hernia complexity, smoking cessation appears to result in similar outcomes to never-smokers in this AWR population., Competing Interests: Declaration of competing interest Dr. Kercher received speaking honoraria from WL Gore. Dr. Augenstein received speaking honoraria from Allergan, Pacira and Bard, and is a consultant for Medtronic and Vicarious Surgical. Dr. Heniford received a surgical education grant and honoraria from WL Gore. Drs. Lorenz, Holland, Kerr, Mead, and Mr. Scarola have no disclosures. We did not receive outside funding for this work. Generative AI software was not used in the evaluation of data or drafting of the manuscript., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Open parastomal hernia repairs (OPHR) are complex with high recurrence rates and no clear optimal technique. This report summarizes long-term OPHR outcomes at a high-volume hernia center., Methods: OPHRs were identified from a prospectively maintained institutional database. Recurrence and wound complication rates were compared across operative techniques using standard statistical analysis., Results: Of 97 OPHR patients, mean age was 61.9 ± 12.6 years, 56.7% were female, 24.7% were diabetic, and average BMI was 31.3 ± 6.5 kg/m 2 . Mean defect size was 125.3 ± 130.0cm 2 and 41.2% were recurrent. Stomas included colostomies (56.7%), ileostomies (30.9%), and urostomies (12.4%). Patients underwent concurrent ventral hernia repair (56.7%), panniculectomy (22.7%), and component separation (30.9%). Patients either had their stoma reversed (13.4%), resited (25.8%), or repaired in situ (60.8%) with suture (11.9%) or mesh (88.1%) in a Sugarbaker (65.4%), keyhole (19.2%), or onlay (15.4%) configuration. Over a mean follow-up of 31.6 ± 35.9 months, wound complications occurred in 18.6% and recurrences in 20.6%. There were no significant differences in recurrence by ostomy type. Recurrence rates were highest after in situ suture repair (42.9%), followed by resiting with mesh (34.8%), in situ with mesh (17.3%), and reversal (0.0%)(p = 0.042). When stomas were resited, prophylactic mesh compared to no mesh did not significantly impact recurrence (28.6%vs.50.0%;p = 0.570). Recurrence rates for in situ repairs were not statistically different by mesh technique (onlay 25.0%, Sugarbaker 17.7%, keyhole 10.0%;p = 0.751), but differed by location(retrorectus 50.0%, intraperitoneal 36.4%, onlay 25.0%, preperitoneal 6.5%;p = 0.035). Multivariable analysis did not demonstrate any independent predictors of recurrence or wound complications., Conclusion: This study represents the largest series to date describing long-term OPHR outcomes with a variety of techniques. Recurrence was greatest after in situ primary repair. There were no recurrences after stoma reversal. After ostomy resiting, all recurrences occurred at the new stoma site, independent of prophylactic mesh use. When the stoma was repaired in situ, preperitoneal mesh placement had the lowest recurrence. Optimal technique for OPHR remains unclear, but these results may inform preoperative discussions and surgical planning., Competing Interests: Declarations Disclosures Dr. Heniford is a speaker and surgical research grant recipient for WL Gore. Dr. Augenstein is a consultant for Medtronic and Vicarious Surgical and is a speaker for Allergan, Bard, and Pacira. Dr. Polcz, Dr. Holland, Dr. Lorenz, Dr. Mead, and Mr. Scarola have no conflicts of interest or financial ties to disclose., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Conflicting literature suggests that larger defects in abdominal wall reconstruction both increase the risk of recurrence and have no impact on recurrence. In our prior work, hernias with defect areas ≥100 cm 2 were associated with increased discomfort, operative time, and length of stay but not recurrence or reoperation. Our goal was to determine if defect size, even in giant hernias, would impact recurrence after mesh repair with complete fascial closure., Methods: A prospectively maintained hernia database was reviewed for clean, abdominal wall reconstruction with fascial closure and synthetic mesh. Patients were grouped and compared by defect area: moderate hernias <200 cm 2 (LT200) and giant hernias ≥200 cm 2 (GT200)., Results: Of 984 patients, 607 LT200 (average area: 92.8 ± 60.8 cm 2 ) were compared with 377 GT200 (average area: 363.2 ± 196.7 cm 2 ). LT200 and GT200 had similar mean age, body mass index, and smoking rate, but GT200 had higher rates of diabetes (22.1% vs 27.9%; P = .040), recurrent hernias (52.7% vs 63.4%; P = .001), preoperative Botox (0.7% vs 8.8%; P < .001), component separation (23.4% vs 59.9%; P < .001), panniculectomy (8.7% vs 15.4%; P = .001), and negative-pressure incisional vacuum placement (5.9% vs 13.5%; P < .001). GT200 had increased mesh size (753.5 ± 367.1 vs 1168.2 ± 412.0 cm 2 ; P < .001), operative time (147.8 ± 55.7 vs 205.3 ± 59.9 minutes; P < .001), and length of stay (5.1 ± 3.2 vs 6.9 ± 4.4 days; P < .001). GT200 had more wound complications (24.7% vs 36.1%; P < .001) and readmissions (9.1% vs 15.1%; P = .004) but similar recurrence rates (3.0% vs 3.7%; P = .520) over the mean follow-up of 30.1 ± 38.9 and 23.0 ± 33.6 months for LT200 and GT200, respectively. On multivariable regression, previous abdominal wall reconstruction, lightweight mesh, and wound complications independently predicted recurrence; component separation was protective, but defect size was not predictive of recurrence., Conclusion: GT200 required more complex measures to achieve fascial closure and resulted in increased length of stay, wound complications, and readmissions; however, GT200 had the same recurrence rate as smaller defects when fascial closure was achieved., Competing Interests: Conflict of Interest/Disclosure Alexis M. Heniford is a surgical research grant recipient and speaking honorarium for WL Gore. Vedra A. Augenstein is a consultant for Medtronic and Vicarious Surgical and is a speaker for Allergan, Bard, and Pacira. The other authors have indicated that they have no conflicts of interest regarding the content of this article., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Inguinal hernia repair is one of the most common surgical procedures in the world. Each repair technique, open, laparoscopic, and robotic, has its advantages and advocates. Prior studies have compared 2 techniques, but there are little data comparing all 3 approaches with long-term follow-up., Methods: Prospectively collected data for unilateral inguinal hernia repair between 2007 and 2022 were reviewed. Using more than 3,300 inguinal hernia repairs, a 1:1:1 propensity score match was performed for open inguinal hernia repair, laparoscopic inguinal hernia repair, and robotic inguinal hernia repair based on patient age, sex, body mass index, and laterality. Standard descriptive and comparative statistics were performed. Data below is reported consistently as open inguinal hernia repair versus laparoscopic inguinal hernia repair versus robotic inguinal hernia repair., Results: A total of 420 patients were matched, with 140 in each group. There was no difference in age, body mass index, or smoking status between groups. Open inguinal hernia repair had significantly more comorbidities (2.8 vs 2.6 vs 2.3; P = .035), including higher rates of chronic obstructive pulmonary disease (5.0% vs 0.0% vs 1.4%; P = .013), cirrhosis (4.3% vs 0.0% vs 1.4%; P = .032), and congestive heart failure (5.0% vs 0.7% vs 0.7%; P = .023). American Society of Anesthesiologists scores differed significantly between groups (stage III and IV: 35.0% vs 20.0% vs 28.6%; P = .004). Open inguinal hernia repair were more often recurrent (48.6% vs 27.9% vs 17.1%; P < .001). The mean operative time was significantly different between groups (88.0 vs 86.1 vs 101.4 minutes; P < .001). There was no difference in wound infection (0.7% vs 0.0% vs 0.0%; P > .99), hematoma (1.4% vs 0.7% vs 1.4%; P > .99), seroma requiring intervention (2.9% vs 0.7% vs 0.7%; P = .377), or readmission (0.0% vs 2.1% vs 1.4%; P = .378). The rate of prolonged discomfort, requiring more than 2 pain medication refills, was similar between groups (2.9% vs 2.1% vs 2.1%; P = .903). Robotic inguinal hernia repair was significantly more expensive than laparoscopic inguinal hernia repair and open inguinal hernia repair ($10,005 ± $7,050 vs $17,155 ± $6,702 vs $31,173 ± $8,474; P < .001). With follow-up of at least 2.4 years in each group (3.6 vs 4.8 vs 2.4 years; P < .001), the recurrence rate was comparable (3.6% vs 0.7% vs 0.7%; P = .226)., Conclusions: All techniques are safe and effective in qualified hands. Open inguinal hernia repair was more commonly used in comorbid patients and recurrent hernias, but the techniques had comparable rates of wound complications, postoperative prolonged discomfort, and recurrence., Competing Interests: Conflict of Interest/Disclosure Drs Lorenz, Holland, Mead, Kercher, Ms Adams, and Mr Scarola have no financial ties or conflicts of interest to disclose. Dr Augenstein is a consultant for Medtronic and Vicarious Surgical and is a speaker for Allergan, Bard, and Pacira. Dr Heniford is a speaker and surgical research grant recipient for WL Gore., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: The choice of biologic compared with synthetic mesh in abdominal wall reconstruction remains controversial, especially in Centers for Disease Control and Prevention class 1 and 2 wounds. This study evaluated wound complications and hernia recurrence with a 2:1 propensity-matched sample and extended follow-up., Methods and Procedures: A prospectively maintained abdominal wall reconstruction database was queried for patients undergoing open abdominal wall reconstruction using biologic or synthetic mesh in Centers for Disease Control and Prevention class 1 and 2 wounds. Patients receiving synthetic or biologic mesh were propensity score matched in a 2:1 fashion. Univariate, bivariate, and inferential analyses were conducted. Unless stated, data are reported as biologic compared with synthetic., Results: In total, 519 patients were compared, 173 with biologic and 346 with synthetic mesh. Defect size (215.2 ± 153.6 cm 2 vs 251.5 ± 284.3 cm 2 ), body mass index (33.6 ± 9 kg/m 2 vs 34 ±17.7 kg/m 2 ), and comorbidities were well matched (all P > .05). Although Centers for Disease Control and Prevention wound class was used in the match, it was significantly different between groups (Centers for Disease Control and Prevention 1:43.4% vs 81.2%, Centers for Disease Control and Prevention 2:56.6% vs 18.8%; P < .001). The rate of component separation (40.1% vs 44.2%; P = .397), fascial closure (97.7% vs 98.3%; P = .738), and panniculectomy (33.5% vs 29.2%; P = .315) were similar. Mesh size was also similar (816.4 ± 555.5 vs 892.2 ± 487.8 cm 2 ; P = .112). Wound complications were equal, including wound breakdown (10.5% vs 7.5%; P = .315), wound cellulitis (5.2% vs 5.8%; P = .843), wound infection (7.5% vs 4.6%; P = .223), seroma requiring intervention (6.4% vs 7.8%; P = .597), and mesh infection (1.2% vs 0.9%; P > .999). The biologic group had an increased length of stay (6.8 ± 5.5 days vs 5.4 ± 2.3 days; P < .001) and greater hospital charges ($82,181 ± 50,356 vs $62,221 ± 26,817 USD; P < .001). Mean follow-up after biologic repair was longer (33.9 ± 36.6 months vs 23.3 ± 32.3 months; P < .001). Hernia recurrence between the biologic and synthetic groups was not significantly different (2.9% vs 1.4%; P = .313). On multivariable regression, wound complications were predictive of recurrence, and panniculectomy was predictive of wound complications., Conclusion: In a 2:1 matched analysis of Centers for Disease Control and Prevention 1 and 2 wounds with nearly 3-years of follow-up, biologic and synthetic mesh had similar rates of wound complications and recurrence in abdominal wall reconstruction., Competing Interests: Conflict of Interest/Disclosure Dr Heniford is a speaker and surgical research grant recipient for WL Gore. Dr Augenstein is a consultant for Medtronic and Vicarious Surgical and is a speaker for Allergan, Bard, and Pacira. Drs Lorenz, Holland, Kerr, Ayuso, Polcz, Kercher, and Mr Scarola have no financial ties or conflicts of interest to disclose., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: Beta-lactam prophylaxis is the first-line preoperative antibiotic in open abdominal wall reconstruction. However, of the 11% patients reporting a penicillin allergy (PA), most receive second-line, non-β-lactam prophylaxis. Previously, abdominal wall reconstruction research from our institution demonstrated increased wound complications, readmissions, and reoperations with non-β-lactam prophylaxis. Therefore, a collaborative quality improvement initiative was developed with the infectious disease service, and a penicillin allergy protocol was instituted that stratified patients' risk of allergic reaction with a goal to increase β-lactam prophylaxis use. The effect of the penicillin allergy protocol on open abdominal wall reconstruction outcomes was prospectively evaluated., Methods: Patients with penicillin allergy undergoing open abdominal wall reconstruction were identified and grouped according to penicillin allergy protocol implementation. Pre-penicillin allergy protocol underwent open abdominal wall reconstruction before January 1, 2020, predominantly receiving non-β-lactam prophylaxis; post-penicillin allergy protocol underwent open abdominal wall reconstruction between January 1, 2020-November 1, 2023, predominantly receiving β-lactam prophylaxis. Incidence of surgical site infection was the primary outcome. Standard and inferential statistical analyses were performed., Results: Of 315 patients with penicillin allergy, 250 underwent open abdominal wall reconstruction pre-penicillin allergy protocol and 65 post-penicillin allergy protocol. Pre- and post-penicillin allergy protocol were similar in allergic reaction severity history, sex, race, age, diabetes, American Society of Anesthesiologists score, hernia defect size, and mesh type (P > .05). Post-penicillin allergy protocol had lower body mass index (33.4 ± 7.9 vs 29.8 ± 5.3 kg/m 2 ; P = .002) and fewer active smokers (12.4% vs 1.5%; P = .019). Expectedly, post-penicillin allergy protocol received more β-lactam prophylaxis (22.8% vs 83.1%; P < .001) and no antibiotic-induced allergic reactions. Post-penicillin allergy protocol had significantly fewer surgical site infections (24.4% vs 3.1%; P < .001), wound breakdown (16.0% vs 3.1%; P = .004), reoperations (19.2% vs 0.0%; P < .001), and readmissions (25.3% vs 9.2%; P = .006) but no statistically significant reduction in recurrence (8.4% vs 1.5%; P = .057)., Conclusions: The penicillin allergy protocol safely increased the number of patients with penicillin allergy undergoing open abdominal wall reconstruction receiving β-lactam prophylaxis and decreased the rate of surgical site infections, wound complications, reoperations, and readmissions. These data supported the systemwide implementation of the penicillin allergy protocol for both general and orthopedic surgery, which has been incorporated into the electronic medical record of 13 hospitals within the system., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Early after its adoption, minimally invasive surgery had limited usefulness in emergent cases. However, with improvements in equipment, techniques, and skills, laparoscopy in complex and emergency operations expanded substantially. This study aimed to examine the trend of laparoscopy in incarcerated or strangulated ventral hernia repair (VHR) over time., Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for laparoscopic repair of incarcerated and strangulated hernias (LIS-VHR) and compared over 2 time periods, 2014-2016 and 2017-2019., Results: The utilization of laparoscopy in all incarcerated or strangulated VHR increased over time (2014-2016: 39.9% (n = 14 075) vs 2017-2019: 46.3% (n = 18 369), P < .001). Though likely not clinically significant, demographics and comorbidities statistically differed between groups (female: 51.7% vs 50.0%, P = .003; age 54.5 ± 13.7 vs 55.4 ± 13.8 years, P < .001; BMI 34.9 ± 8.0 vs 34.6 ± 7.8 kg/m 2 , P < .001). Patients from 2017 to 2019 were less comorbid (18.9% vs 16.8% smokers, P < .001; 18.2% vs 17.3% diabetic, P = .036; 4.6% vs 4.1% COPD, P = .021) but had higher ASA classification (III: 43.3% vs 45.7%; IV: 2.5% vs 2.7%, P < .001). Hernia types (primary, incisional, recurrent) were similar in each group. Operative time (89.7 ± 59.3 vs 97.4 ± 63.4 min, P < .001) became longer but length-of-stay (1.4 ± 3.3 vs 1.1 ± 2.6 days, P < .001) decreased. There was no statistical difference in surgical complications, medical complications, reoperation, or readmission rates between periods., Conclusion: Laparoscopic VHR has become a routine method for treating incarcerated and strangulated hernias, and its utilization continues to increase over time. Clinical outcomes have remained the same while hospital stays have decreased., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Flank and lumbar hernias (FLH) are challenging to repair. This study aimed to establish a reproducible management strategy and analyze elective flank and lumbar repair (FLHR) outcomes from a single institution., Methods: A prospective analysis using a hernia-specific database was performed examining patients undergoing open FLHR between 2004 and 2021. Variables included patient demographics and operative characteristics., Results: Of 142 patients, 106 presented with flank hernias, and 36 with lumbar hernias. Patients, primarily ASA Class 2 or 3, exhibited a mean age of 57.0 ​± ​13.4 years and BMI of 30.2 ​± ​5.7 ​kg/m 2 . Repairs predominantly utilized synthetic mesh in the preperitoneal space (95.1 ​%). After 29.9 ​± ​13.1 months follow-up, wound infections occurred in 8.3 ​%; hernia recurrence was 3.5 ​%. At 6 months postoperatively, 21.2 ​% of patients reported chronic pain with two-thirds of these individuals having preoperative pain., Conclusions: Open preperitoneal FLHR provides a durable repair with low complication and hernia recurrence rates over 2.5 years of follow-up., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: B. Todd Heniford reports a relationship with WL Gore that includes: funding grants and speaking and lecture fees. Vedra A. Augenstein reports a relationship with Allergan that includes: speaking and lecture fees. Vedra A. Augenstein reports a relationship with Pacira that includes: speaking and lecture fees. Vedra A. Augenstein reports a relationship with Bard that includes: speaking and lecture fees. Vedra A. Augenstein reports a relationship with Medtronic that includes: consulting or advisory. Vedra A. Augenstein reports a relationship with Vicarious Surgical that includes: consulting or advisory. Kent W. Kercher reports a relationship with WL Gore that includes: speaking and lecture fees. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

An analysis of ACS-NSQIP open ventral hernia repair (OVHR) data (2017-2019) was performed. Respiratory failure (RF) occurred in 643 patients (1%) and not in 63,213 (99%) (nRF). Respiratory failure patients were older (63.7 vs 57 years, P < .001) and more comorbid: insulin-dependent diabetes (14.7% vs 5.8%, P < .001), COPD (19.4% vs 5.2%, P < .001), BMI (36.0 vs 32.8, P < .001), and current tobacco use (24.9% vs 17.6%, P < .001). Respiratory failure patients had greater ASA scores (ASA 3: 63.3% vs 47.8%, P < .001), bowel resection (8.2% vs 1.3%, P < .001), component separation (20.1% vs 9.0%, P < .001), operative times (178.4 vs 98.8 minutes, P < .001), complications (deep wound infections 3.6% vs 1.0%, organ space infections 13.2% vs 1.0%, wound dehiscence 3.1% vs 0.6%, acute renal failure 11.7% vs 0.1%), and hospital stay (13.7 vs 2.3 days), with fewer home discharges (44.3% vs 96.4%) (all P < .001). Respiratory failure patients had higher mortality compared to nRF (20.2% vs 0.1%, P < .001). Respiratory failure after OVHR is rare but correlates closely with significant wound, systemic, and social complications. Preoperative management of risk factors would be appropriate in high-risk patients., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Deep learning models (DLMs) using preoperative computed tomography (CT) imaging have shown promise in predicting outcomes following abdominal wall reconstruction (AWR), including component separation, wound complications, and pulmonary failure. This study aimed to apply these methods in predicting hernia recurrence and to evaluate if incorporating additional clinical data would improve the DLM's predictive ability., Methods: Patients were identified from a prospectively maintained single-institution database. Those who underwent AWR with available preoperative CTs were included, and those with < 18 months of follow up were excluded. Patients were separated into a training (80%) set and a testing (20%) set. A DLM was trained on the images only, and another DLM was trained on demographics only: age, sex, BMI, diabetes, and history of tobacco use. A mixed-value DLM incorporated data from both. The DLMs were evaluated by the area under the curve (AUC) in predicting recurrence., Results: The models evaluated data from 190 AWR patients with a 14.7% recurrence rate after an average follow up of more than 7 years (mean ± SD: 86 ± 39 months; median [Q1, Q3]: 85.4 [56.1, 113.1]). Patients had a mean age of 57.5 ± 12.3 years and were majority (65.8%) female with a BMI of 34.2 ± 7.9 kg/m 2 . There were 28.9% with diabetes and 16.8% with a history of tobacco use. The AUCs for the imaging DLM, clinical DLM, and combined DLM were 0.500, 0.667, and 0.604, respectively., Conclusions: The clinical-only DLM outperformed both the image-only DLM and the mixed-value DLM in predicting recurrence. While all three models were poorly predictive of recurrence, the clinical-only DLM was the most predictive. These findings may indicate that imaging characteristics are not as useful for predicting recurrence as they have been for other AWR outcomes. Further research should focus on understanding the imaging characteristics that are identified by these DLMs and expanding the demographic information incorporated in the clinical-only DLM to further enhance the predictive ability of this model., (© 2024. The Author(s).)

Background: Health disparities are pervasive in surgical care. Particularly racial and socioeconomic inequalities have been demonstrated in emergency general surgery outcomes, but less so in elective abdominal wall reconstruction (AWR). The goal of this study was to evaluate the disparities in referrals to a tertiary hernia center. Methods: A prospectively maintained hernia database was queried for patients who underwent open ventral hernia (OVHR) or minimally invasive surgical (MISR) repair from 2011 to 2022 with complete insurance and address information. Patients were divided by home address into in-state (IS) and out-of-state (OOS) referrals as well as by operative technique. Demographic data and outcomes were compared. Standard and inferential statistical analyses were performed. Results: Of 554 patients, most were IS (59.0%); 334 underwent OVHR, and 220 underwent MISR. IS patients were more likely to undergo MISR (OVHR: 45.6% vs. 81.5%, laparoscopic: 38.2% vs. 14.1%, robotic: 16.2% vs. 4.4%; p < 0.001) when compared to OOS referrals. Of OVHR patients, 44.6% were IS and 55.4% were OOS. Patients' average age and BMI, sex, ASA score, and insurance payer were similar between IS and OOS groups. IS patients were more often Black (White: 77.9% vs. 93.5%, Black: 16.8% vs. 4.3%; p < 0.001). IS patients had more smokers (12.1% vs. 3.2%; p = 0.001), fewer recurrent hernias (45.0% vs. 69.7%; p < 0.001), and smaller defects (155.7 ± 142.2 vs. 256.4 ± 202.9 cm 2 ; p < 0.001). Wound class, mesh type, and rate of fascial closure were similar, but IS patients underwent fewer panniculectomies (13.4% vs. 34.1%; p < 0.001), component separations (26.2% vs. 51.4%; p < 0.001), received smaller mesh (744.2 ± 495.6 vs. 975.7 ± 442.3 cm 2 ; p < 0.001), and had shorter length-of-stay (4.8 ± 2.0 vs. 7.0 ± 5.5 days; p < 0.001). There was no difference in wound breakdown, seroma requiring intervention, hematoma, mesh infection, or recurrence; however, IS patients had decreased wound infections (2.0% vs. 8.6%; p = 0.009), overall wound complications (11.4% vs. 21.1%; p = 0.016), readmissions (2.7% vs. 13.0%; p = 0.001), and reoperations (3.4% vs. 11.4%; p = 0.007). Of MISR patients, 80.9% were IS and 19.1% were OOS. In contrast to OVHR, MISR IS and OOS patients had similar demographics, preoperative characteristics, intraoperative details, and postoperative outcomes. Conclusion: Although there were no differences in referred patients for MISR, this study demonstrates the racial disparities that exist among our IS and OOS complex, open AWR patients. Awareness of these disparities can help clinicians work towards equitable access to care and equal referrals to tertiary hernia centers., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Holland, Mead, Lorenz, Scarola and Augenstein.)

Background: Administrators have focused on decreasing postoperative readmissions for cost reduction without fully understanding their preventability. This study describes the development and implementation of a surgeon-led readmission review process that assessed preventability., Methods: A gastrointestinal surgical group at a tertiary referral hospital developed and implemented a template to analyze inpatient and outpatient readmissions. Monthly stakeholder assessments reviewed and categorized readmissions as potentially preventable or not preventable. Continuous variables were examined by the Student's t test and reported as means and standard deviations. Categorical variables were examined by the Pearson χ2 statistic and Fisher's exact test., Results: There were 61 readmission events after 849 inpatient operations (7.2%) and 16 after 856 outpatient operations (1.9%), the latter of which were all classified as potentially preventable. Colorectal procedures represented 65.6% of readmissions despite being only 37.2% of all cases. The majority (67.2%) of readmission events were not preventable. Compared to the not-preventable group, the potentially preventable group experienced more dehydration (30.0% vs 9.8%, P = .045) and ileostomy creation (78.6% vs 33.3%, P = .017). The potential for outpatient management to prevent readmission was significantly higher in the potentially preventable group (40.0% vs 0.0%, P < .001), as was premature discharge prevention (35.0% vs 0.0%, P < .001)., Conclusion: The use of the standardized template developed for analyzing readmission events after inpatient and outpatient procedures identified a disparate potential for readmission prevention. This finding suggests that a singular focus on readmission reduction is misguided, with further work needed to evaluate and implement appropriate quality-based strategies., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Quality of life (QOL) has become a key outcome measure following ventral hernia repair (VHR), but recurrent and primary VHR have not been compared in this context previously., Methods: The International Hernia Mesh Registry (2008-2019) was used to identify patients with QOL data scored by the Carolinas Comfort Scale preoperatively and postoperatively at 1 year., Results: Repairs were performed in 227 recurrent and 1,122 primary VHs. Recurrent patients had a higher BMI, larger defects, and were more likely to have preoperative pain, but other comorbidities were equal. Recurrence rates at 1 year were equivalent. Recurrent patients had a greater improvement in pain (-6.3 ± 10.2 vs -4.3 ± 8.3,p = 0.002) and movement limitation (-5.5 ± 10.0 vs -3.2 ± 7.2,p < 0.001) compared to primary patients, but they had increased postoperative mesh sensation (4.6 ± 7.7 vs 2.7 ± 5.5,p < 0.001)., Conclusions: Recurrent VHRs led to improved pain and movement limitation, but increased mesh sensation. These findings may be useful for preoperative counseling in the elective setting., Competing Interests: Declaration of competing interest Dr. Colavita has an investigator-sponsored agreement with Medtronic. Dr. Augenstein receives speaking honoraria from Medtronic, Allergan, Intuitive, Acelity, and Bard. Dr. Heniford receives surgical research and education grants and speaking honoraria from Allergan and WL Gore. The remaining authors have no disclosures to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: With an aging population, the utility of surgery in elderly patients, particularly octogenarians, is of increasing interest. The goal of this study was to analyze outcomes of octogenarians versus non-octogenarians undergoing paraesophageal hernia repair (PEHR)., Methods: The Nationwide Readmission Database was queried for patients > 18 years old who underwent PEHR from 2016 to 2018. Exclusion criteria included a diagnosis of gastrointestinal malignancy or a concurrent bariatric procedure. Patients ≥ 80 were compared to those 18-79 years old using standard statistical methods, and subgroup analyses of elective and non-elective PEHRs were performed., Results: From 2016 to 2018, 46,450 patients were identified with 5425 (11.7%) octogenarians and 41,025 (88.3%) non-octogenarians. Octogenarians were more likely to have a non-elective operation (46.3% vs 18.2%, p < 0.001), and those undergoing non-elective PEHR had a higher mortality (5.5% vs 1.2%, p < 0.001). Outcomes were improved with elective PEHR, but octogenarians still had higher mortality (1.3% vs 0.2%, p < 0.001), longer LOS (3[2, 5] vs 2[1, 3] days, p < 0.001), and higher readmission rates within 30 days (11.1% vs 6.5%, p < 0.001) compared to non-octogenarian elective patients. Multivariable logistic regression showed that being an octogenarian was not independently predictive of mortality (odds ratio (OR) 1.373[95% confidence interval 0.962-1.959], p = 0.081), but a non-elective operation was (OR 3.180[2.492-4.057], p < 0.001). Being an octogenarian was a risk factor for readmission within 30 days (OR 1.512[1.348-1.697], p < 0.001)., Conclusions: Octogenarians represented a substantial proportion of patients undergoing PEHR and were more likely to undergo a non-elective operation. Being an octogenarian was not an independent predictor of perioperative mortality, but a non-elective operation was. Octogenarians' morbidity and mortality was reduced in elective procedures but was still higher than non-octogenarians. Elective PEHR in octogenarians is reasonable but should involve a thorough risk-benefit analysis., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: The use of component separation results in myofascial release and increased rates of fascial closure in abdominal wall reconstruction(AWR). These complex dissections have been associated with increased rates of wound complications with anterior component separation having the greatest wound morbidity. The aim of this paper was to compare the wound complication rate between perforator sparing anterior component separation(PS-ACST) and transversus abdominus release(TAR)., Methods: Patients were identified from a prospective, single institution hernia center database who underwent PS-ACST and TAR from 2015 to 2021. The primary outcome was wound complication rate. Standard statistical methods were used, univariate analysis and multivariable logistic regression were performed., Results: A total of 172 patients met criteria, 39 had PS-ACST and 133 had TAR performed. The PS-ACST and TAR groups were similar in terms of diabetes (15.4% vs 28.6%, p = 0.097), but the PS-ACST group had a greater percentage of smokers (46.2% vs 14.3%, p < 0.001). The PS-ACST group had a larger hernia defect size (375.2 ± 156.7 vs 234.4 ± 126.9cm 2 , p < 0.001) and more patients who underwent preoperative Botulinum toxin A (BTA) injections (43.6% vs 6.0%, p < 0.001). The overall wound complication rate was not significantly different (23.1% vs 36.1%, p = 0.129) nor was the mesh infection rate (0% vs 1.6%, p = 0.438). Using logistic regression, none of the factors that were significantly different in the univariate analysis were associated with wound complication rate (all p > 0.05)., Conclusion: PS-ACST and TAR are comparable in terms of wound complication rates. PS-ACST can be used for large hernia defects and promote fascial closure with low overall wound morbidity and perioperative complications., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Introduction: Our aim was to define the national incidence of enterotomy (ENT) during minimally invasive ventral hernia repair (MIS-VHR) and evaluate impact on short-term outcomes., Methods: The 2016-2018 Nationwide Readmissions Database was queried using ICD-10 codes for MIS-VHR and enterotomy. All patients had 3-months follow-up. Patients were stratified by elective status; patients without ENT (No-ENT) were compared against ENT patients., Results: In total, 30,025 patients underwent LVHR and ENT occurred in 388 (1.3%) patients; 19,188 (63.9%) cases were elective including 244 elective-ENT patients. Incidence was similar between elective versus non-elective cohorts (1.27% vs 1.33%; p = 0.674). Compared to laparoscopy, ENT was more common during robotic procedures (1.2% vs 1.7%; p = 0.004). Comparison of elective-No-ENT vs elective-ENT showed that elective-ENT patients had a longer median LOS (2 vs 5 days; p < 0.001), higher mean hospital cost ($51,656 vs $76,466; p < 0.001), increased rates of mortality (0.3% vs 2.9%; p < 0.001), and higher 3-month readmission (10.1% vs 13.9%; p = 0.048). Non-elective cohort comparison demonstrated non-elective-ENT patients had a longer median LOS (4 vs 7 days; p < 0.001), higher mean hospital cost ($58,379 vs $87,850; p < 0.001), increased rates of mortality (0.7% vs 2.1%;p < 0.001), and higher 3-month readmission (13.6% vs 22.2%; p < 0.001). In multivariable analysis (odds ratio, 95% CI), higher odds of enterotomy were associated with robotic-assisted procedures (1.386, 1.095-1.754; p = 0.007) and older age (1.014, 1.004-1.024; p = 0.006). Lower odds of ENT were associated with BMI > 25 kg/m 2 (0.784, 0.624-0.984; p = 0.036) and metropolitan teaching vs metropolitan non-teaching (0.784, 0.622-0.987; p = 0.044). ENT patients (n = 388) were more likely to be readmitted with post-operative infection (1.9% vs 4.1%; p = 0.002) or bowel obstruction (1.0% vs 5.2%;p < 0.001) and more likely to undergo reoperation for intestinal adhesions (0.3% vs 1.0%; p = 0.036)., Conclusion: Inadvertent ENT occurred in 1.3% of MIS-VHRs, had similar rates between elective and urgent cases, but was more common for robotic procedures. ENT patients had a longer LOS, and increased cost and infection, readmission, re-operation and mortality rates., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Enhanced recovery after surgery (ERAS) programs have become increasingly popular in general surgery, yet no guidelines exist for an abdominal wall reconstruction (AWR)-specific program. We aimed to evaluate predictors of increased length of stay (LOS) in the AWR population to aid in creating an AWR-specific ERAS protocol., Methods: A prospective, single institution hernia center database was queried for all patients undergoing open AWR (1999-2019). Standard statistical methods and linear and logistic regression were used to evaluate for predictors of increased LOS. Groups were compared based on LOS below or above the median LOS of 6 days (IQR = 4-8)., Results: Inclusion criteria were met by 2,505 patients. On average, the high LOS group was older, with higher rates of CAD, COPD, diabetes, obesity, and pre-operative narcotic use (all P < .05). Longer LOS patients had more complex hernias with larger defects, higher rates of mesh infection/fistula, and more often required a component separation (all P < .05). Multivariate analysis identified age (β0.04,SE0.02), BMI (β0.06,SE0.03), hernia defect size (β0.003,SE0.001), active mesh infection or mesh fistula (β1.8,SE0.72), operative time (β0.02,SE0.002), and ASA score >4 (β3.6,SE1.7) as independently associated factors for increased LOS (all P < .05). Logistic regression showed that an increased length of stay trended toward an increased risk of hernia recurrence ( P = .06)., Conclusions: Multiple patient and hernia characteristics are shown to significantly affect LOS, which, in turn, increases the odds of AWR failure. Weight loss, peri-operative geriatric optimization, prehabilitation of comorbidities, and operating room efficiency can enhance recovery and shorten LOS following AWR.

Introduction: Abdominal wall reconstruction (AWR) in a contaminated field is associated with an increased risk of wound complications, infection, and reoperation. The best method of repair and mesh choice in these operations have generated marked controversy. Our aim was to compare outcomes of patients who underwent AWR with biologic versus synthetic mesh in CDC class 3 and 4 wounds., Methods: A prospective, single-institution database was queried for AWR using biologic or synthetic mesh in CDC Class 3 and 4 wounds. Hernia recurrence and complications were measured. Multivariable logistic regression was performed to identify factors predicting both., Results: In total, 386 patients with contaminated wounds underwent AWR, 335 with biologic and 51 with synthetic mesh. Groups were similar in age, sex, BMI, and rate of diabetes. Biologic mesh patients had larger hernia defects (298 ± 233cm 2 vs. 208 ± 155cm 2 ; p = 0.004) and a higher rate of recurrent hernias (72.2% vs 47.1%; p < 0.001), comorbidities(5.8 ± 2.7 vs. 4.2 ± 2.4, p < 0.01), and a nearly fivefold increase in Class 4 wounds (47.8% vs. 9.8%, p < 0.001), while fascial closure trended to being less common (90.7% vs 96.1%; p = 0.078). Hernia recurrence was comparable between biologic and synthetic mesh (10.4% vs. 17.6%, p = 0.132). Wound complication rates were similar (36.1% vs. 33.3%, p = 0.699), but synthetic mesh had higher rates of mesh infection (1.2% vs 11.8%; p < 0.001) and infection-related resection (0% vs 7.8%, p < 0.001), with 66% of those synthetic mesh infections requiring excision. On logistic regression, wound complications (OR 5.96 [CI 1.60-22.17]; p = 0.008) and bridging mesh (OR 13.10 [CI 2.71-63.42];p = 0.030) predicted of hernia recurrence (p < 0.05), while synthetic mesh (OR 18.6 [CI 2.35-260.4] p = 0.012) and wound complications (OR 20.6 [CI 3.15-417.7] p = 0.008) predicted mesh infection., Conclusions: Wound complications in AWR with CDC class 3 and 4 wounds significantly increased mesh infection and hernia recurrence; failure to achieve fascial closure also increased hernia recurrence. Use of synthetic versus biologic mesh increased the mesh infection rate by 18.6 times., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Deep learning models with imbalanced data sets are a challenge in the fields of artificial intelligence and surgery. The aim of this study was to develop and compare deep learning models that predict rare but devastating postoperative complications after abdominal wall reconstruction., Methods: A prospectively maintained institutional database was used to identify abdominal wall reconstruction patients with preoperative computed tomography scans. Conventional deep learning models were developed using an 8-layer convolutional neural network and a 2-class training system (ie, learns negative and positive outcomes). Conventional deep learning models were compared to deep learning models that were developed using a generative adversarial network anomaly framework, which uses image augmentation and anomaly detection. The primary outcomes were receiver operating characteristic values for predicting mesh infection and pulmonary failure., Results: Computed tomography scans from 510 patients were used with a total of 10,004 images. Mesh infection and pulmonary failure occurred in 3.7% and 5.6% of patients, respectively. The conventional deep learning models were less effective than generative adversarial network anomaly for predicting mesh infection (receiver operating characteristic 0.61 vs 0.73, P < .01) and pulmonary failure (receiver operating characteristic 0.59 vs 0.70, P < .01). Although the conventional deep learning models had higher accuracies/specificities for predicting mesh infection (0.93 vs 0.78, P < .01/.96 vs .78, P < .01) and pulmonary failure (0.88 vs 0.68, P < .01/.92 vs .67, P < .01), they were substantially compromised by decreased model sensitivity (0.25 vs 0.68, P < .01/.27 vs .73, P < .01)., Conclusion: Compared to conventional deep learning models, generative adversarial network anomaly deep learning models showed improved performance on imbalanced data sets, predominantly by increasing model sensitivity. Understanding patients who are at risk for rare but devastating postoperative complications can improve risk stratification, resource utilization, and the consent process., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Complete fascial closure significantly reduces recurrence rates and wound complications in abdominal wall reconstruction. While component separation techniques have clear effectiveness in closing large abdominal wall defects, preoperative botulinum toxin A has emerged as an adjunct to aid in fascial closure. Few data exist comparing preoperative botulinum toxin A to component separation techniques, and the aim was to do so in a matched study., Methods: A prospective, single-center, hernia-specific database was queried, and a 3:1 propensity-matched study of patients undergoing open abdominal wall reconstruction from 2016 to 2021 with botulinum toxin A versus component separation techniques was performed based on body mass index, defect width, hernia volume, and Centers for Disease Control and Prevention wound classification. Demographics, operative characteristics, and outcomes were evaluated., Results: Matched patients included 105 component separation techniques and 35 botulinum toxin A. There was no difference in tobacco use, diabetes, or body mass index (all P > .5). Hernia defects and volume were large for both the component separation techniques and botulinum toxin A groups (mean size: component separation techniques 286.2 ± 179.9 cm 2 vs botulinum toxin A 289.7 ± 162.4 cm 2 ; P = .73) (mean volume: 1,498.3 + 2,043.4 cm 3 vs 2,914.7 + 6,539.4 cm 3 ; P = .35). Centers for Disease Control and Prevention wound classifications were equivalent (CDC3 and 4%-39.1% vs 40.0%; P = .97). Component separation techniques were more frequently performed in European Hernia Society M1 hernias (21% vs 2.9%; P = .01). The botulinum toxin A group had fewer surgical site occurrences (32.4% vs 11.4%; P = .02) and surgical site infections (11.7% vs 0%; P = .04). In multivariate analysis, botulinum toxin A was associated with lower rates of surgical site occurrences (odds ratio = 5.3; 95% confidence interval [1.4-34.4]). There was no difference in fascial closure (90.5% vs 100%; P = .11) or recurrence (12.4% vs 2.9%; P = .10) with follow-up (22.8 + 29.7 vs 9.8 + 12.7 months; P = .13)., Conclusion: In a matched study comparing patients with botulinum toxin A versus component separation techniques, there was no difference in fascial closure rates or in hernia recurrence between the 2 groups. Preoperative botulinum toxin A can achieve similar outcomes as component separation techniques, while decreasing the frequency of surgical site occurrences., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Our center has adopted many evidence-based practices to improve outcomes for complex abdominal wall reconstruction with porcine dermal matrix. This study analyzed outcomes over time using porcine dermal matrix in complex abdominal wall reconstruction., Methods: Prospective, tertiary hernia center data was examined for patients undergoing complex abdominal wall reconstruction with porcine dermal matrix. Early (2008-2014) and Recent (2015-2021) cohorts were defined by dividing the study interval in half. Multivariable analyses of wound complications and recurrence were performed., Results: Comparing 117 Early vs 245 Recent patients, both groups had high rates of previously repaired hernias (76.1% vs 67.4%; P = .110), Centers for Disease Control and Prevention class 3 or 4 wounds (76.0% vs 66.6%; P = .002), and very large hernia defects (320 ± 317 vs 282 ± 164 cm 2 ; P = .640). Recent patients had higher rates of preoperative botulinum injection (0% vs 21.2%; P < .001), posterior component separation (15.4% vs 35.5%; P < .001), and delayed primary closure (23.1% vs 38.8%; P < .001), but lower rates of concurrent panniculectomy (32.3% vs 27.8%; P = .027) and similar anterior component separation (29.1% vs 18.2%; P = .060). Most mesh was placed preperitoneal (74.4% vs 93.3%; P < .001). Recent patients had less inlay (9.4% vs 2.1%; P < .01) and other mesh locations as fascial closure rate increased (88.0% vs 95.5%; P < .001). Over time, there was a decrease in wound complications (42.1% vs 14.3%; P < .001), length of stay (median [interquartile range]:8 [6-13] vs 7 [6-9]; P = .003), and 30-day readmissions (32.7% vs 10.3%; P < .001). Hernia recurrence decreased (10.3% vs 3.7%; P = .016) with mean follow-up of 2.8 ± 3.2 and 1.7 ± 1.7 years, respectively. Respective multivariable models(odds ratio, 95% confidence interval) demonstrated an increased risk of wound complications with diabetes (2.65, 1.16-5.98; P = .020), panniculectomy (2.63, 1.21-5.73; P = .014), and anterior component separation (5.1, 1.98-12.9; P < .001), with recurrence risk increased by wound complication (3.8, 1.4-2-7.62; P = .032)., Conclusion: Porcine dermal matrix in complex abdominal wall reconstruction performs well with low recurrence rates. Internal assessment and implementation of evidence-based practices improved outcomes such as length of stay, wound complications, and recurrence rate., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: This study aimed to describe progressive evidence-based changes in perioperative management of open preperitoneal ventral hernia repair and subsequent surgical outcomes and to analyze factors that affect recurrence and wound complications., Methods: Prospective, tertiary hernia center data (2004-2021) were examined for patients undergoing midline open preperitoneal ventral hernia repair with mesh. "Early" (2004-2012) and "Recent" (2013-2021) groups were based on surgery date., Results: Comparison of Early (n = 675) versus Recent (n = 1,167) groups showed that Recent patients were, on average, older (56.9 ± 12.6 vs 58.7 ± 12.1 years; P < .001) with a lower body mass index (33.5 ± 8.3 vs 32.0 ± 6.8 kg/m 2 ; P = .003) and a higher number of comorbidities (3.6 ± 2.2 vs 5.2 ± 2.6; P < .001). Recent patients had higher proportions of prior failed ventral hernia repair (46.5% vs 60.8%; P < .001), larger hernia defects (199.7 ± 232.8 vs 214.4 ± 170.5 cm 2 ; P < .001), more Center for Disease Control class 3 or 4 wounds (11.3% vs 18.6%; P < .001), and more component separations (22.5% vs 45.7%; P < .001). Hernia recurrence decreased over time (7.1% vs 2.4%; P < .001), as did wound complication rates (26.7% vs 13.2%; P < .001). Comparing respective multivariable analyses (Early versus Recent), wound complications were associated with panniculectomy (odds ratio [95% confidence interval]: 2.9 [1.9-4.5], P < .001 vs 2.1 [1.4-3.3], P < .01), contaminated wounds (2.1 [1.1-3.7], P = .02 vs 1.8 [1.1-3.1], P = .02), anterior component separation technique (1.8 [1.1-2.9], P = .02 vs 3.2[1.9-5.3], P < .01), and operative time (per minute: 1.01 [1.008-1.015], P < .01 vs 1.004 [1.001-1.007], P < .01). Diabetes (2.6 [1.7-4.0], P < .01) and tobacco (1.8 [1.1-2.9], P = .02) were only significant in the early group. In both groups, recurrence was associated with wound complication (8.9 [4.1-20.1], P < .01 vs 3.4 [1.3-8.2]. P < .01) and recurrent hernias (4.9 [2.3-11.5], P < .01 vs 2.1 [1.1-4.2], P = .036)., Conclusion: Despite significant increased patient complexity over time, detecting and implementing best practices as determined by recurring data analysis of a center's outcomes has significantly improved patient care results., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: Robotic inguinal hernia repair (RIHR) is becoming increasingly common and is the minimally invasive alternative to laparoscopic inguinal hernia repair (LIHR). Thus far, there is little data directly comparing LIHR and RIHR. The purpose of this study will be to compare outcomes for LIHR and RIHR at a single center., Methods: A prospective institutional hernia database was queried for patients who underwent transabdominal LIHR or RIHR from 2012 to 2020. The patients were then matched based on the surgeon performing the operation (single, expert hernia surgeon) and laterality of repair. Standard descriptive statistics were used., Results: There were 282 patients who met criteria for the study, 141 LIHR and 141 RIHR; 32.6% of patients in each group had a bilateral repair (p = 1.00). LIHR patients were slightly younger (54.4 ± 15.6 vs 58.6 ± 13.8; p = 0.03) but similar in terms of BMI (27.1 ± 5.1 vs 29.1 ± 2.1; p = 0.70) and number of comorbidities (2.9 ± 2.5 vs 2.6 ± 2.2; p = 0.59). Operative time was found to be longer in the RIHR group, but when evaluating RIHR at the beginning of the study versus the end of the study, there was a 50-min decrease in operative time (p < 0.01). Recurrence rates were low for both groups (0.7% vs 1.4%; p = 0.38) with mean follow-up time 13.0 ± 13.3 months. There was only one wound infection, which was in the robotic group. No patients required return to the operating room for complications relating to their surgery. There were no 30-day readmissions in the LIHR group and three 30-day readmissions in the RIHR group (p = 0.28)., Conclusion: LIHR and RIHR are both performed with low morbidity and have comparable overall outcomes. The total charges were increased in the RIHR group. Either LIHR or RIHR may be considered when performing inguinal hernia repair and should depend on surgeon and patient preference; continued evaluation of the outcomes is warranted., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

The surgical treatment of parastomal hernias is considered complex and is known to be prone to complications. Traditionally, this condition was treated using relocation techniques or local suture repairs. Since then, several mesh-based techniques have been proposed and are nowadays used in minimally invasive surgery. Since the introduction of robot-assisted surgery to the field of abdominal wall surgery, several adaptations to these techniques have been made, which may significantly improve patient outcomes. In this contribution, we provide an overview of available techniques in robot-assisted parastomal hernia repair. Technical considerations and preliminary results of robot-assisted modified Sugarbaker repair, robot-assisted Pauli technique, and minimally invasive use of a funnel-shaped mesh in the treatment of parastomal hernias are presented. Furthermore, challenges in robot-assisted ileal conduit parastomal hernia repair are discussed. These techniques are illustrated by photographic and video material. Besides providing a comprehensive overview of robot-assisted parastomal hernia repair, this article focuses on the specific advantages of robot-assisted techniques in the treatment of this condition., (© 2022. The Author(s).)

Background: An evidence-based approach to the repair of umbilical hernias (UH)<1 cm has yet to be defined., Methods: A prospectively maintained, institutional hernia database was queried for patients undergoing primary suture repair of UH ≤ 1 cm. The primary outcome was recurrence and secondary outcomes were wound complications., Results: Of 332 patients included (226-primary, 106-incisional), recurrence was identified in 4 (1.8%) primary versus 8 (7.5%) incisional-UH (p = 0.022), with follow-up of 4.7 ± 4.4 years. There were 10 (3.0%) wound complications: 4 (1.2%) superficial wound infections, 1 (0.3%) superficial wound dehiscence, and 5 (1.5%) seromas. On multivariable analysis of recurrence, incisional-UH had an odds ratio of 4.2 compared to primary. Suture choice, diabetes, BMI, tobacco-use history, and wound complications were not significant., Conclusions: With long term follow-up, recurrence after primary suture repair of UH ≤ 1 cm occurred in 1.8% of primary and 7.5% of incisional UH. On multivariable analysis, incisional-UH increased recurrence odds by 4.2 times compared to primary., Competing Interests: Declaration of competing interest Dr. Colavita has an investigator sponsored agreement with Medtronic. Dr. Augenstein receives speaking honoraria from Medtronic, Allergan, Intuitive, Acelity, and Bard. Dr. Heniford receives surgical research/education grants as well as honoraria for speaking from Allergan and W.L. Gore. Dr. Katzen, Dr. Sacco, Mr. Ku, and Mr. Scarola have no conflicts of interest or financial ties to disclosures. No external funding was received to support this study., (Copyright © 2022. Published by Elsevier Inc.)

The surgical treatment of parastomal hernias is considered complex and is known to be prone to complications. Traditionally, this condition was treated using relocation techniques or local suture repairs. Since then, several mesh-based techniques have been proposed and are nowadays used in minimally invasive surgery. Since the introduction of robot-assisted surgery to the field of abdominal wall surgery, several adaptations to these techniques have been made, which may significantly improve patient outcomes. In this contribution, we provide an overview of available techniques in robot-assisted parastomal hernia repair. Technical considerations and preliminary results of robot-assisted modified Sugarbaker repair, robot-assisted Pauli technique, and minimally invasive use of a funnel-shaped mesh in the treatment of parastomal hernias are presented. Furthermore, challenges in robot-assisted ileal conduit parastomal hernia repair are discussed. These techniques are illustrated by photographic and video material. Besides providing a comprehensive overview of robot-assisted parastomal hernia repair, this article focuses on the specific advantages of robot-assisted techniques in the treatment of this condition., (© 2022. The Author(s).)

Introduction: Umbilical hernia repair (UHR) is a common operation with varying surgical approaches. Laparoscopic (LUHR) and open (OUHR) operations are routinely performed, but their impact on quality of life (QoL) is not well described. Our aim was to evaluate perioperative outcomes and QoL of LUHR versus OUHR., Methods: The prospectively collected International Hernia Mesh Registry was queried for patients undergoing UHR with mesh placement. QoL was measured using the Carolinas Comfort Scale preoperatively and 1, 6, 12, and 24 months postoperatively. Propensity match was performed controlling for hernia defect size (HDS), recurrent hernias, and BMI., Results: 585 patients underwent 178 (30.4%) LUHR and 407 (69.6%) OUHR. LUHR patients had higher BMI, larger HDS, and more recurrent hernias (p < 0.05). Rates of other comorbidities were similar (p > 0.05). Tacks were used more frequently in LUHR (91.6% vs 1.7%, p < 0.001), and suture was used more often in OUHR (97.1% vs 47.8%, p < 0.001). Postoperative outcomes were similar (p > 0.05) except LUHR had higher rates of seroma (13.9% vs 4.3%, p < 0.001). Overall recurrence rates trended to favor OUHR, but not significantly (4.7% vs 8.4%, p = 0.07). The propensity match yielded 138 matched pairs. LUHR had more seromas and OUHR had higher infection rates (p < 0.05). Hernia recurrence was higher following LUHR (9.4% vs 2.9%, p = 0.02). QoL data were available for an average of 457 patients at each time period. QoL was superior in the OUHR group for pain and overall QoL at each time point and activity limitations at 6 and 12 months (p < 0.05). When examining patients who were asymptomatic preoperatively, OUHR had improved one-month overall QoL, but both groups had over 90% of patients report being asymptomatic postoperatively., Conclusions: OUHR is associated with higher rates of surgical site infections, but significantly lower rates of seroma formation and hernia recurrence compared to LUHR, while having superior QoL in both short- and long-term follow-up. Asymptomatic patients tend to have excellent QoL outcomes., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Barrier-coated meshes were designed to reduce adhesion formation between mesh and the surrounding viscera. There have been questions raised but little data to determine if rapidly absorbable coatings pose an increased risk of infection. The objective of this study was to determine if a difference exists in wound and mesh infection rates between coated and uncoated polypropylene mesh in patients undergoing open ventral hernia repair., Methods: A prospective, institutional database at a tertiary hernia center identified patients undergoing open preperitoneal ventral hernia repair (OPPVHR) with polypropylene mesh in CDC class 1 and 2 wounds. Using propensity score matching, an absorbable, coated and uncoated group were matched based on age, comorbidities, wound class, defect size, and mesh size., Results: There were 265 patients each in the matched coated and uncoated mesh groups for a total of 530 patients. Postoperative wound infections (10.9% versus 4.6%, P = 0.01) and need for IV antibiotics (10.5% versus 4.3%, P = 0.01) were significantly higher in the coated group. There was an increase in mesh infection for the coated group (3.4% versus 0.4%, P = 0.02), and of those developing a mesh infection, 60.0% eventually required mesh excision., Conclusions: Coated mesh was associated with increased postoperative wound and mesh infection following OPPVHR. An uncoated mesh should be strongly considered when placed in an extraperitoneal location., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: The degree to which Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is aerosolized has yet to be determined. The aim of this study is to prove methods of detection of aerosolization of SARS-CoV-2 in hospitalized patients in anticipation of testing for aerosolization in procedural and operative settings., Methods: In this prospective study, inpatients with SARS-CoV-2 were identified. Demographic information was obtained, and a symptom questionnaire was completed. Polytetrafluoroethylene (PTFE) filters, which were attached to an air pump, were used to detect viral aerosolization and placed in four locations in each patient's room. The filters were left in the rooms for a three-hour period., Results: There were 10 patients who enrolled in the study, none of whom were vaccinated. Only two patients were more than a week from the onset of symptoms, and half of the patients received treatment for COVID with antivirals and steroids. Among ten RT-PCR positive and hospitalized patients, and four filters per patient, there was only one positive SARS-CoV-2 aerosol sample, and it was directly attached to one of the patients. Overall, there was no correlation between symptoms or symptom onset and aerosolized test result., Conclusions: The results of this suggest that there is limited aerosolization of SARS-CoV-2 and provided proof of concept for this filter sampling technique. Further studies with increased sample size should be performed in a procedural and operative setting to provide more information about SARS-CoV-2 aerosolization., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: Patients undergoing abdominal wall reconstruction (AWR) with concomitant panniculectomy (CP) may be at higher risk for wound complications due to the need for large incisions and tissue undermining. The aim of this study was to evaluate whether the use of closed-incision negative pressure therapy (ciNPT) decreases wound complications in AWR patients undergoing CP., Methods: Beginning in February 2018, all patients at this institution who underwent AWR with CP received ciNPT. These patients were identified from a prospectively maintained institutional database. A standard dressing (non-NPT) group was then created in a 1:1 fashion by identifying patients who had AWR with CP immediately before the beginning of ciNPT use (2016-2018). A univariate comparison was made between the ciNPT and non-NPT groups. The primary outcome was wound complication rate; however, other perioperative outcomes, such as requirement for reoperation, were also tracked. Standard statistical methods and logistic regression were used., Results: In total, 134 patients met criteria, with 67 patients each in the ciNPT and non-NPT groups. When comparing patients in the ciNPT and non-NPT groups, they were demographically similar, including body mass index, smoking, and diabetes (P < 0.05). Hernias was large on average (289.5 ± 158.2 vs 315.3 ± 197.3 cm2, P = 0.92) and predominantly recurrent (58.5% vs 72.6%, P = 0.14). Wound complications were much lower in the ciNPT group (15.6% vs 35.5%, P = 0.01), which was mainly driven by a decrease in superficial wound breakdown (3.1% vs 19.7%, P < 0.01). Patients in the ciNPT group were less likely to require a return trip to the operating room for wound complications (0.0% vs 13.3%, P < 0.01). In logistic regression, the use of ciNPT continued to correlate with reduced wound complication rates (P = 0.02)., Conclusions: In AWR with CP, the use of ciNPT significantly decreased the risk of postoperative wound complications, particularly superficial wound breakdown, and lessened the need for wound-related reoperation., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Minimally invasive ventral hernia repair (MISVHR) has been performed for almost 30 years; recently, there has been an accelerated adoption of the robotic platform leading to renewed comparisons to open ventral hernia repair (OVHR). The present study evaluates patterns and outcomes of readmissions for MISVHR and OVHR patients., Methods: The Nationwide Readmissions Database (NRD) was queried for patients undergoing OVHR and MISVHR from 2016 to 2018. Demographic characteristics, complications, and 90-day readmissions were determined. A subgroup analysis was performed to compare robotic ventral hernia repair (RVHR) vs laparoscopic hernia repair (LVHR). Standard statistical methods and logistic regression were used., Results: Over the 3-year period, there were 25 795 MISVHR and 180 635 OVHR admissions. Minimally invasive ventral hernia repair was associated with a lower rate of 90-day readmission (11.3% vs 17.3%, P < .01), length of stay (LOS) (4.0 vs 7.9 days, P < .01), and hospital charges ($68,240 ± 75 680 vs $87,701 ± 73 165, P < .01), which remained true when elective and non-elective repairs were evaluated independently. Postoperative infection was the most common reason for readmission but was less common in the MISVHR group (8.4% vs 16.8%, P < .01). Robotic ventral hernia repair increased over the 3-year period and was associated with decreased LOS (3.7 vs 4.1 days, P < .01) and comparable readmissions (11.3% vs 11.2%, P = .74) to LVHR, but was nearly $20,000 more expensive. In logistic regression, OVHR, non-elective operation, urban-teaching hospital, increased LOS, comorbidities, and payer type were predictive of readmission., Conclusions: Open ventral hernia repair was associated with increased LOS and increased readmissions compared to MISVHR. Robotic ventral hernia repair had comparable readmissions and decreased LOS to LVHR, but it was more expensive.

Background: Wound complications following abdominal wall reconstruction (AWR) in a contaminated setting are common and significantly increase the risk of hernia recurrence. The purpose of this study was to examine the effect of short-term negative pressure wound therapy (NPWT) followed by operative delayed primary closure (DPC) of the skin and subcutaneous tissue after AWR in a contaminated setting., Methods: A prospective institutional hernia database was queried for patients who underwent NPWT-assisted DPC after contaminated AWR between 2008 and 2020. Primary outcomes included wound complication rate and reopening of the incision. A non-DPC group was created using propensity-matching. Standard descriptive statistics were used, and a univariate analysis was performed between the DPC and non-DPC groups., Results: In total, 110 patients underwent DPC following AWR. The hernias were on average large (188 ± 133.6 cm 2 ), often recurrent (81.5%), and 60.5% required a components separation. All patients had CDC Class 3 (14.5%) or 4 (85.5%) wounds and biologic mesh placed. Using CeDAR, the wound complication rate was estimated to be 66.3%. Postoperatively, 26.4% patients developed a wound complication, but only 5.5% patients required reopening of the wound. The rate of recurrence was 5.5% with mean follow-up of 22.6 ± 27.1 months. After propensity-matching, there were 73 patients each in the DPC and non-DPC groups. DPC patients had fewer overall wound complications (23.0% vs 43.9%, p = 0.02). While 4.1% of the DPC group required reopening of the incision, 20.5% of patients in the non-DPC required reopening of the incision (p = 0.005) with an average time to healing of 150 days. Hernia recurrence remained low overall (2.7% vs 5.4%, p = 0.17)., Conclusions: DPC can be performed with a high rate of success in complex, contaminated AWR patients by reducing the rate of wound complications and avoiding prolonged healing times. In patients undergoing AWR in a contaminated setting, a NPWT-assisted DPC should be considered., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The use of component separation technique (CST) in complex abdominal wall reconstruction (AWR) increases the rate of primary musculofascial closure but can be associated with increased wound complications, which may require readmission. This study examines 3-year trends in readmissions for patients undergoing AWR with or without CST., Methods: The Nationwide Readmissions Database was queried for patients undergoing elective AWR from 2016-2018. CST, demographic characteristics, and 90-day complications and readmissions were determined. CST versus non-CST readmissions were compared, including matched subgroups. Standard statistics and logistic regression were used., Results: Over the 3-year period, 94,784 patients underwent AWR. There was an annual increase in the prevalence of CST: 4.0% in 2016; 6.1% in 2017; 6.7% in 2018 (P < .01), which is a 67.5% upsurge during that time. Most cases (82.3%) occurred at urban teaching hospitals, which had more comorbid patients (P < .01). The yearly 90-day readmission rate did not change: 16.0%, 18.2%, and 16.9% (P = .26). Readmissions were higher for CST patients than non-CST patients (17.1% vs 15.7%), but not in the matched subgroup (17.0% vs 16.4%; P = .41). Most commonly, readmissions were for infection (28.3%); 14.3% of readmitted patients underwent reoperation. Smoking, morbid obesity, diabetes, chronic lung disease, urban-teaching hospital status, and increased length of stay increased the chance of readmission (all P < .05)., Conclusion: From 2016 to 2018, the use of CST increased 67.5% nationwide without an increase in readmissions. As we look toward clinical targets to reduce risk of readmission, modifiable health conditions, such as smoking, morbid obesity, and diabetes should be targeted during the prehabilitation process., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: Elective repair versus watchful waiting remains controversial in paraesophageal hernia (PEH) patients. Generation of predictive factors to determine patients at greatest risk for emergent repair may prove helpful. The aim of this study was to evaluate patients undergoing elective versus emergent PEH repair and supplement this comparison with 3D volumetric analysis of hiatal defect area (HDA) and intrathoracic hernia sac volume (HSV) to determine risk factors for increased likelihood of emergent repair., Methods: A retrospective review of a prospectively enrolled, single-center hernia database was performed on all patients undergoing elective and emergent PEH repairs. Patients with adequate preoperative computed tomography (CT) imaging were analyzed using volumetric analysis software., Results: Of the 376 PEH patients, 32 (8.5%) were emergent. Emergent patients had lower rates of preoperative heartburn (68.8%vs85.1%, p = 0.016) and regurgitation (21.9%vs40.2%, p = 0.04), with similar rates of other symptoms. Emergent patients more frequently had type IV PEHs (43.8%vs13.5%, p < 0.001). Volumetric analysis was performed on 201 patients, and emergent patients had a larger HSV (805.6 ± 483.5vs398.0 ± 353.1cm 3 , p < 0.001) and HDA (41.7 ± 19.5vs26.5 ± 14.7 cm 2 , p < 0.001). In multivariate analysis, HSV increase of 100cm 3 (OR 1.17 CI 1.02-1.35, p = 0.022) was independently associated with greater likelihood of emergent repair. Post-operatively, emergent patients had increased length of stay, major complication rates, ICU utilization, reoperation, and mortality (all p < 0.05). Emergent group recurrence rates were higher and occurred faster secondary to increased use of gastropexy alone as treatment (p > 0.05). With a formal PEH repair, there was no difference in rate or timing of recurrence., Conclusions: Emergent patients are more likely to suffer complications, require ICU care, have a higher mortality, and an increased likelihood of reoperation. A graduated increase in HSV increasingly predicts the need for an emergent operation. Those patients presenting electively with a large PEH may benefit from early elective surgery., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Biologic mesh has historically been used in contaminated abdominal wall reconstructions (AWRs). No study has compared outcomes of biologic and synthetic in clean and clean-contaminated hernia ventral hernia repair., Methods: A prospective AWR database identified patients undergoing open, preperitoneal AWR with biologic mesh in CDC class 1 and 2 wounds. Using propensity score matching, a matched cohort of patients with synthetic mesh was created. The objective was to assess recurrence rates and postoperative complications., Results: Fifty-eight patients were matched in each group. Patient in the biologic group had higher rates of immunosuppression, history of transplantation, and inflammatory bowel disease (p ≤ 0.05). Operative variables were comparable for biologic vs synthetic, including defect size (230.5 ± 135.4 vs 268.7 ± 194.5 cm 2 , p = 0.62), but the synthetic mesh group had larger meshes placed (575.6 ± 247.0 vs 898.8 ± 246.0 cm 2 p < 0.0001). Wound infections (15.5% vs 8.9%, p = 0.28) were equivalent, and recurrence rates (1.7% vs 3.4%, p = 1.00) were similar on follow up (19.3 ± 23.3 vs 23.3 ± 29.7 months, p = 0.56)., Conclusions: In matched, lower risk, complex AWR patients with large hernia defects, biologic and synthetic meshes have equal outcomes., (Copyright © 2021 Elsevier Inc. All rights reserved.)