TABLE 4.
Preoperative patient assessment, risk factor recognition and options for patient prehabilitation to reduce the risk of postoperative complications following abdominal wall reconstruction.
| Preoperative patient assessment | |
|---|---|
| Comprehensive medical history | Including symptoms, drug use, and previous abdominal operations and AWR (request original surgical reports) |
| Physical examination | In standing and supine position: number of hernias, size, location, LOD (Valsalva maneuver), wounds, stomas, fistulas, amount and quality of skin |
| Radiological imaging | Contrast enhanced CT imaging, maximum 6 months old and performed after the last intra-abdominal operation or drainage a |
| Hernia classification systems | |
| EHS, mVHWG, and HPW classification | |
| Patient risk factors | Prehabilitation options |
| Smoking | Cessation at least 4 weeks prior to AWR |
| Consider nicotine replacement therapy | |
| Diabetes | Personal assessment by GP or diabetes specialist |
| Target HbA1c <7.0% (153 mg/dl) | |
| HbA1c > 8.0% (185 mg/dl): postpone elective reconstruction | |
| Obesity | BMI 30–40: personalized weight loss interventions |
| BMI >40: consider bariatric surgery first | |
| BMI >50: AWR is advised against; bariatric surgery may be an option | |
| Cardiopulmonary disease | Specialist referral with personalized assessment (CPET) and optimization |
| Malnutrition | Consider (temporary) enteral or parenteral feeding |
| Monitor the effect by weight gain, electrolyte and albumin level | |
| Anticoagulative and/or immunosuppressive drugs | Consider consultation of the prescribing physician to discuss the continuation/discontinuation, or bridging therapy |
| Hernia and Wound risk factors | Prehabilitation options |
| Large fascial defect (>10–15 cm) or large LOD (>15%–20%) | Consider preoperative botulinum toxin b , surgical tissue expanders, and/or PPP (only in highly selected cases) |
| Intestinal fistula(s) | Wound care: consider fistula adaptor/wound manager |
| AWR: ≥6–9 months after the last intra-abdominal procedure | |
| High-output reduction (reduced oral intake, medication (TPN if needed) | |
| Active contamination (e.g., active wound infection, acute mesh infection) | Bioburden reduction as the first step whenever possible (consider the use of V.A.C VeraFlo™) |
Abbreviations: LOD, loss of domain; EHS, European hernia society; mVHWG, modified Ventral Hernia Working Grade; HPW, hernia patient wound; GP, general practitioner; CPET, cardiopulmonary exercise testing; PPP, progressive pneumoperitoneum; TPN, total parenteral nutrition.
a
Except for small primary midline hernia.
b
There is currently no consensus on the indication of botulinum toxin prior to AWR.