Introduction
Emergent ventral hernia repair is associated with an up to 15-fold increase in the risk of postoperative mortality, reoperation, and readmission compared with repairs in the elective setting [1]. Although a component of increased risk is attributed to the emergent presentation [2], there is likely a component of operative management heterogeneity that contributes. Unlike in the elective repair setting, there is a paucity of data to guide decision making in the operative management of emergent ventral hernias. To begin to understand operative management in the repair of emergent recurrent and primary ventral hernia repair, we leveraged a population-level statewide hernia data registry to examine patient characteristics and current operative approaches in emergent ventral hernia repair stratified by recurrence to understand operative decision making in the emergent setting (Fig).
Figure.
Emergent recurrent hernia repair most likely to use mesh and component separation techniques.
Note: Mesh was placed in 55% of emergent primary ventral hernia repairs and 71% of emergent recurrent ventral hernia repair (P < .001). Component separation was used in 2% of emergent primary ventral hernia repairs and 7% of emergent recurrent ventral hernia repair (P < .001). MIS, minimally invasive surgery; MSQC-COHR, Michigan Surgical Quality Collaborative Core Optimization Hernia Registry.
Methods
The Michigan Surgical Quality Collaborative Core Optimization Hernia Registry (MSQC-COHR) is a population-level registry that abstracts data from encounters for emergent ventral hernia repair across approximately 90% of the hospitals in Michigan [3,4]. The MSQC-COHR was queried for adult patients who underwent emergent ventral hernia repair between January 2020 and November 2023. The registry uses professional abstracters to obtain patient characteristics, operative approach (such as open vs minimally invasive surgery [MIS] [including laparoscopic and robotic techniques], use of mesh, and use of component separation), and hernia-specific variables (hernia size and hernia-specific outcomes) from hospital encounter data.
The primary outcome of this analysis was the operative approach, open vs MIS. Secondary outcomes were mesh use and use of component separation. Descriptive statistics were used to compare patient characteristics, hernia characteristics, and operative approach across recurrence status. Two-sided P < .05 indicated statistical significance. Stata version MP18 (StataCorp LLC) was used for all statistical analyses.
Results
A total of 1200 emergent ventral hernia repairs were included; 963 of these repairs were performed in the context of an initial presentation (n = 237 for recurrent repairs). The cohort included 698 female patients (58.2%), and the mean age of the cohort was 58.4 years (SD = 15.6) with no differences across recurrence status (Table 1). There were significant differences in body mass index (BMI) by recurrence status (35.5 in primary vs 36.2 in recurrent; P < .001). Hernias classified as recurrent were measured as larger than those classified as primary (median size in cm, 5.5 vs 3.8; P < .001).
Table 1.
Characteristics of patients within MSQC-COHR undergoing emergency ventral hernia repair stratified by primary or recurrent presentation
| Patient characteristics | Emergent ventral hernia repair | |||
|---|---|---|---|---|
| Total | Primary | Recurrent | P value | |
| n = 1200 | n = 963 | n = 237 | ||
| Age, mean (SD) | 58.4 (15.6) | 58.3 (16.0) | 58.9 (14.0) | .63 |
| Female, % (n) | 58 (698) | 57 (551) | 62 (147) | .18 |
| BMI, median (IQR) | 34.5 (28.4–42.6) | 33.4 (28.1–41.6) | 39.4 (31.8–46.8) | < .001 |
| Patient comorbidities, % (n) | ||||
| Congestive heart failure | 2 (23) | 2 (21) | 1 (2) | .18 |
| COPD | 10 (124) | 9 (90) | 14 (34) | .02 |
| History of smoking within 1 y | 23 (275) | 22 (214) | 26 (61) | .25 |
| Diabetes mellitus | .11 | |||
| Noninsulin dependent | 16 (194) | 15 (146) | 20 (48) | |
| Insulin dependent | 7 (79) | 6 (61) | 8 (18) | |
| ASA class, % (n) | < .001 | |||
| 1 | 2 (18) | 2 (15) | 1 (3) | |
| 2 | 25 (300) | 27 (260) | 17 (40) | |
| 3 | 60 (724) | 58 (555) | 71 (169) | |
| 4 | 13 (152) | 13 (129) | 10 (23) | |
| 5 | 0 (5) | 0 (4) | 0 (1) | |
| Hernia characteristics | ||||
| Hernia width, mean in cm (SD) | 4.1 (3.4) | 3.8 (3.2) | 5.5 (3.8) | < .001 |
| Hernia location, % (n) | .002 | |||
| Epigastric | 15 (184) | 13 (130) | 23 (54) | |
| Umbilical | 62 (749) | 65 (625) | 52 (124) | |
| Infraumbilical | 10 (114) | 9 (89) | 11 (25) | |
| Suprapubic | 2 (24) | 2 (20) | 2 (4) | |
| Not midline | 8 (91) | 7 (66) | 11 (25) | |
| Unknown | 2 (27) | 2 (24) | 1 (3) | |
| Missing | 1 (11) | 1 (9) | 1 (2) | |
ASA, American Society of Anesthesiologists; BMI, body mass index; COPD, chronic obstructive pulmonary disease; MSQC-COHR, Michigan Surgical Quality Collaborative Core Optimization Hernia Registry.
Data source: MSQC-COHR, 2020–2023.
In the emergent setting, ventral hernias are most often repaired with an open approach with no differences across recurrence status (73% primary vs 71% recurrent; P =.576). Stratification by recurrence status demonstrated differences in the use of mesh; 71% of recurrent hernias were repaired with mesh (vs 55% of primary; P < .001). In addition, there were differences in the use of the component separation technique; 7% of recurrent hernias were repaired in this fashion (vs 2% of primary; P < .001). The component separation technique was primarily performed for hernias located in the epigastric (41.7%) and the umbilical regions (38.9%). Differences in operative approach by recurrent status remained significant after adjusting for the size of the hernia.
Conclusion
Our present study has 2 distinct findings. First, hernias classified as recurrent are present in patients with higher-risk profiles, higher BMI, and larger hernia size in the emergent setting. This suggests a potential selection bias in the elective setting against repairing higher-risk recurrent ventral hernias. A better understanding of the barriers to high-risk patients receiving optimization for elective surgery and the consequences of delays in optimization is necessary.
Second, after adjusting for hernia size, mesh is underutilized in emergency repairs, especially primary repairs. This may be caused by higher surgical wound classification in the emergent setting; however, recent evidence recommends mesh placement even in contaminated wounds [5]. This study is limited in its ability to explain this variation.
A limitation of this study is that MSQC-COHR represents single-state data; however, the granularity of data was necessary for the analysis.
Funding
Dr Picart receives funding from the University of Michigan Institute for Healthcare Policy and Innovation Clinician Scholars Program and the Agency for Healthcare Research and Quality Health Services Research Training Grant (5T32HS000053–33) as a post-doctoral fellow. Dr Schoel receives funding from the National Institute of Aging National Research Service Award (T32-AG062403). Dr Telem receives funding from the National Institute of Diabetes and Digestive and Kidney Disease (R01DK128179–01A1). Dr Telem receives consulting fees from Medtronic. Dr Ehlers receives funding from the National Institute of Diabetes and Digestive and Kidney Disease (K08DK135919).
Footnotes
Declaration of competing interest
The authors declare no competing interests.
References
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