Abstract
Purpose
The modified Ventral Hernia Working Group (mVHWG) classification stratifies patients by risk for complications; however, real-world evidence quantifying complication burden across mVHWG grades remains limited. This study developed and applied a claims-based algorithm to approximate the mVHWG classification and assess variations in postoperative complication burden by mVHWG grade.
Methods
A retrospective cohort study was conducted using MarketScan®. Adults undergoing VHR between January 2021 and December 2024 were included if they had continuous enrollment for at least 12 months pre-procedure and 6 months post-procedure. Patients were classified into mVHWG Grades 1–3 using diagnosis and procedure codes. Postoperative complications within 6 months were identified using claims data. Incidence and number of complications per patient were assessed.
Results
29,845 patients were included, classified as Grade 1 (44.4%), Grade 2 (44%), and Grade 3 (11.6%). Within 6 months, 17.2% experienced postoperative complications, with a significant stepwise increase in incidence by mVHWG grade (10.6%, 15.7% and 48.5% for Grades 1–3 respectively). The number of recorded complications per patient was higher with increased mVHWG grade.
Conclusion
This study operationalizes mVHWG classification in claims data and demonstrates an increase in complication burden across mVHWG grades following VHR, including higher incidence and greater number of complications per patient. Grade 2 patients represented a large proportion of the cohort and experience greater complication burden than Grade 1 patients, underscoring the importance of this risk group. Further research is warranted to validate the algorithm against clinically assigned mVHWG grades as well as to examine long-term outcomes and costs associated with early complications across mVHWG grades.
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1007/s10029-026-03867-5.
Keywords: Ventral hernia working grade, ventral hernia repair, MarketScan
Introduction
Over 600,000 ventral hernia repairs (VHR) are performed each year, almost doubling from 2006 to 2019 [1, 2]. VHR are complex with a 30-day complication rate of approximately 20% [3, 4] and clinical hernia recurrence rates of 40% to 70% depending on mesh usage [5]. The management of VHR, including complications, can result in significant cost to the US healthcare system, estimated to be approximately $10 billion per year in the US in 2019 [2].
There are multiple risk factors for postoperative complications following VHR [3, 5]. Ventral Hernia Work Group (VHWG) classification system was developed to provide a standardized approach to assess an individual patient’s risk for wound infection and other instances of surgical-site occurrence (SSO) following a VHR [6]. The ventral hernia grade, ranging from grade 1 (low risk of SSO) to grade 4 (high risk of SSO), was intended to guide surgeons in their decision-making process regarding surgical technique and the optimal type of mesh to use for the repair1. A modified grading scale, aimed at strengthening the ability to predict SSO, was introduced in 2013 and reduced the scale from 4 levels to 3 levels. The modified scale (mVHWG) combines Grade 3 and Grade 4 groupings into one and further stratifies patients according to the Centers for Disease Control and Prevention (CDC) wound classification system [7]. The modified scale not only predicts short-term outcomes [7], but also long-term hernia recurrence [8].
Grade 2 and 3 patients are at higher risk of complications due to contamination and comorbidities [7]. Prior studies outline the resource utilization and cost for the most complex cases (VHWG Grade 3 and 4) based on mesh type using administrative claims data [9], but there is limited evidence on the burden in Grade 2 patients who have comorbidities that put them at higher risk of complications. Further, despite the widespread clinical adoption of the modified Ventral Hernia Working Group (mVHWG) classification system, outcomes research using administrative claims data has been limited by the absence of a standardized, reproducible approach to operationalizing mVHWG grades using this data source.
Claims databases do not capture mVHWG classification. Therefore, an algorithm to define the individual components of the scale is necessary to systematically evaluate postoperative outcomes across mVHWG. The objective of the study was to develop and apply a claims-based algorithm to approximate the mVHWG classification using diagnosis and procedures codes and to assess how the burden of postoperative complications varies by mVHWG. Defining a claims-based approach to approximate mVHWG categories could support future robust population-level analyses of postoperative complications.
Materials and methods
A retrospective, cohort study comparing the incidence rates for postoperative complications up to 6-months following a VHR for adult patients (aged 18 years and older) classified as mVHWG Grade 1, 2, or 3 was conducted using data derived from the Merative™ MarketScan® Commercial Databases between January 1, 2021 and December 31, 2024. Together, these fully integrated databases provide one of the largest collections of de-identified patient data available for healthcare research in the United States, featuring approximately 293 million covered individuals [10].
Patients were identified based on an index VHR, using the procedure codes listed in Supplemental Information (SI-1). Inclusion criteria were patients 18 + years at index VHR, 12 months of continuous insurance enrollment pre-index VHR, and 6 months of continuous insurance enrollment post-index VHR. Patients were excluded if they had a history of transplant at any point in time or VHR during the 12 months of continuous enrollment pre-index [Supplemental Information (SI-2)].
Ventral hernias were graded using the mVHWG classification system [7]. In this analysis, ventral hernias were grouped by grade using the 10th revision of International Classification of Diseases (ICD) diagnosis (ICD-10-CM) and procedure codes (ICD-PCS), in addition to Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes to approximate the criteria specified by the mVHWG [Supplemental Information (SI-3)]. mVHWG categories (Grade 1–3) were assigned using a hierarchical, rule-based algorithm that combined clinical history, comorbidities, and procedure-based contamination signals derived from claims data (Table 1). Grade 3 (highest risk of SSO) was assigned if the patient had evidence of any high-risk or contamination-related factors. Grade 2 (Comorbid Conditions) was assigned if no Grade 3 criteria were met but the patient had one or more comorbidities, including COPD, smoking, diabetes, or obesity. Grade 1 (low risk of SSO) was assigned if the patient had no Grade 2 or Grade 3 indicators. All component indicators were constructed at the patient level, deduplicated, and missing values were recoded to zero prior to category assignment.
Table 1.
Modified Ventral Hernia Working Grade (mVHWG) classification. Patients were grouped into mutually exclusive categories using a hierarchical approach
| mVHWG Classification | Sub-Category | Timing relative to index VHR |
|---|---|---|
| Grade 3 | Infected mesh | Relevant if identified within ≤ 1 year prior to index VHR |
| Previous wound infection | Depending on codes outlined in Supplemental Information (SI-3) the following relative timing applies: Relevant if identified within ≤ 1 year prior to index VHR OR Relevant if diagnosed from 1 week before to 1 month after abdominal surgery within the year preceding index VHR. | |
| Septic dehiscence | ||
| Stoma present | ≤ 3 months prior to index VHR | |
| Violation of GI tract | Same day as index VHR | |
| Grade 2 | Active smoker | ≤ 1 month prior to index VHR |
| COPD | ≤ 1 year prior to index VHR | |
| Diabetes | ||
| Obesity | ||
| Grade 1 | All patients not classified in Grades 2 or 3 | ≤ 1 year prior to index VHR |
Abbreviations: VHR ventral hernia repair, GI gastrointestinal, COPD chronic obstructive pulmonary disease
Post-index outcomes or complications were identified from diagnosis and procedure codes occurring after the index date (day 1) and within 6 months of follow-up, excluding events on the index day itself. Complications of interest included infected mesh removal, infection, graft/mesh/wound complications without mesh removal, seroma, bowel obstruction/other GI complications, enteritis/colitis, fistula, hematoma, peritonitis, procedural complications, skin/connective tissue complications, and excision of abdominal wall lesion/reopening of recent laparotomy site. Complication assignment was not a mutually exclusive process; therefore, there was no limit to the number or type of complications a patient could have. Infected mesh removal was defined by the presence of a specific CPT code for infected mesh removal, and/or a hernia repair procedure code paired with an infection diagnosis or infection-related procedure on the same day as done in DeNoto et al 2013 [9]. Infection was identified using a broad set of infection-related diagnosis codes and infection-related procedures. Graft/mesh/wound complications (without mesh removal) were identified using diagnosis codes indicative of wound, graft, or mesh complications. Patients with at least one of the aforementioned complications were grouped into the ‘Patients with at least 1 complication’ category.
See Supplemental Information (SI-4) for the list of relevant diagnosis and procedure codes for each complication.
Statistical analysis
Categorical variables were summarized by counts and percentages. Continuous variables were summarized using means and standard deviations. Outcomes were summarized both as incidence of postoperative complications and the proportion of patients experiencing at least one complication to capture differences in both incidence and multiplicity of recorded complications across mVHWG grades. The analysis was conducted in SAS 9.4 (Cary, North Carolina). Event proportions for each outcome across mVHWG grades were compared using Pearson chi‑square tests, with a Bonferroni correction applied to p‑values to control for multiple comparisons. Data was collected and managed by Merative™ MarketScan® Commercial Databases.
Ethics and compliance statement
This study used de-identified administrative claims data from the Merative™ MarketScan® Commercial Database. As the data are fully de-identified this study was determined to be exempt from Institutional Review Board (IRB) review by WCG IRB under 45 CFR § 46.104(d)(4), study #20261854.
Results
The analytic cohort included 29,845 adults undergoing VHR with 44.4% classified as Grade 1 (n = 13,253), 44.0% as Grade 2 (n = 13,145), and 11.6% as Grade 3 (n = 3,447; Fig. 1). The overall cohort was predominantly male (58.8%) with a mean age of 49.6 years (Table 2).
Fig. 1.
Construction of analytic cohort for sample of patients in MarketScan aged 18+ years with their first ventral hernia procedure performed in 2021 - 2024
Table 2.
Distribution of patient characteristics for sample with continuous enrollment, grouped by mVHWG category (N = 29,845)
| Variable | Analytic cohort | mVHWG category n(%) | ||
|---|---|---|---|---|
| Grade 1 | Grade 2 | Grade 3 | ||
| Group size | 29,845 | 13,253 (44.4) | 13,145 (44.0) | 3,447 (11.6) |
| Year of index VHR, N (%) | ||||
| 2022 | 2,274 (7.6) | 541 (4.1) | 697 (5.3) | 1,036 (30.1) |
| 2023 | 18,531 (62.1) | 8,562 (64.6) | 8,308 (63.2) | 1,661 (48.2) |
| 2024 | 9,040 (30.3) | 4,150 (31.3) | 4,140 (31.5) | 750 (21.8) |
| Patient sex, N (%) | ||||
| Male | 17,550 (58.8) | 8,096 (61.1) | 7,891 (60.0) | 1,563 (45.3) |
| Age at index VHR (years) | ||||
| Mean (Std Dev) | 49.6 (9.9) | 48.5 (10.4) | 50.6 (9.2) | 50.2 (9.9) |
| Median (IQR) | 51.0 (15.0) | 50.0 (16.0) | 52.0 (14.0) | 52.0 (14.0) |
| Age grouping (years), N (%) | ||||
| 18–34 | 2,494 (8.4) | 1,423 (10.7) | 795 (6.1) | 276 (8.0) |
| 35–44 | 6,364 (21.3) | 3,158 (23.8) | 2,571 (19.6) | 635 (18.4) |
| 45–54 | 9,768 (32.7) | 4,098 (30.9) | 4,494 (34.2) | 1,176 (34.1) |
| 55–64 | 11,219 (37.6) | 4,574 (34.5) | 5,285 (40.2) | 1,360 (39.5) |
| Site of service for index VHR, N (%) | ||||
| Inpatient hospital | 2,450 (8.2) | 433 (3.3) | 650 (4.9) | 1,367 (39.7) |
| Outpatient hospital | 17,320 (58.0) | 8,444 (63.7) | 8,427 (64.1) | 449 (13.0) |
| Ambulatory Surgical Center (ASC) | 2,139 (7.2) | 1,461 (11.0) | 648 (4.9) | 30 (0.9) |
| Other sites of servicea | 7,936 (26.5) | 2,915 (22) | 3,420 (26) | 1,601 (46.4) |
| Employment status, N (%) | ||||
| Active - Full time | 22,144 (74.2) | 10,070 (76.0) | 9,617 (73.2) | 2,457 (71.3) |
| Active - Part time or seasonal | 289 (1.0) | 143 (1.1) | 109 (0.8) | 37 (1.1) |
| Early retiree | 1,203 (4.0) | 489 (3.7) | 568 (4.3) | 146 (4.2) |
| Medicare-eligible retiree | 117 (0.4) | 35 (0.3) | 67 (0.5) | 15 (0.4) |
| Long term disability | 258 (0.9) | 91 (0.7) | 123 (0.9) | 44 (1.3) |
| Unknown/otherb | 5,834 (19.5) | 2,425 (18.3) | 2,661 (20.2) | 748 (21.7) |
| Region, N (%) | ||||
| Northeast | 4,372 (14.7) | 2,018 (15.2) | 1,871 (14.2) | 483 (14.0) |
| North Central | 7,020 (23.5) | 3,053 (23.0) | 3,197 (24.3) | 770 (22.3) |
| South | 14,141 (47.4) | 5,911 (44.6) | 6,455 (49.1) | 1,775 (51.5) |
| West | 4,262 (14.3) | 2,245 (16.9) | 1,602 (12.2) | 415 (12.0) |
| Unknown | 50 (0.2) | 26 (0.2) | 20 (0.2) | 4 (0.1) |
aThe ‘Other sites of service’ category includes both standalone sites (e.g. provider’s office, urgent care, inpatient/outpatient not elsewhere classified, etc.) and combinations of sites (e.g. outpatient hospital + emergency room + inpatient hospital, provider’s office + outpatient hospital, etc.) based on the CMS place of service code(s) present on the professional claim(s) for a patient’s index VHR procedure
bPatients included in the ‘Unknown/other’ group for employment status were originally categorized in the Merative data as one of the following: Retiree (status unknown), COBRA continuee, surviving spouse/dependent, or unknown/unavailable employment status
Baseline characteristics varied by mVHWG grade (Table 2). Grade 3 patients were more likely to undergo repair in an inpatient setting (Grade 1: 3.3%; Grade 2: 4.9%; Grade 39.7%). Demographic characteristics by age, employment status, region, and benefit plan type were broadly similar across groups (Table 2). The mVHWG Grade 3 group had a smaller percentage of males compared to mVHWG Grade 1 and 2.
During the 6 month follow up, 17.2% of patients experienced at least one postoperative complication. Complication rates were significantly higher with mVHWG grade: 10.6% of Grade 1 patients, 15.7% of Grade 2 patients, and 48.5% of Grade 3 patients (Table 3, Fig. 2). A similar stepwise higher incidence with mVHWG grade was observed for individual complication categories and differed significantly across groups for infected mesh removal (χ² = 668.67, df = 2, p < 0.001), infection (χ² = 1437.97, df = 2, p < 0.001), and graft/mesh/wound complications without mesh removal (χ² = 822.75, df = 2, p < 0.001; Fig 2). Post‑hoc pairwise comparisons demonstrated statistically significant differences between all mVHWG grades (Grade 2 vs Grade 1, Grade 3 vs Grade 1, and Grade 3 vs Grade 2; all adjusted p < 0.001).
Table 3.
Number of complications per patient in the 6-month period after index VHR, grouped by mVHWG category
| Complication type | Analytic cohort | mVHWG category | P-value | ||
|---|---|---|---|---|---|
| Grade 1 | Grade 2 | Grade 3 | |||
| Group size | 29,845 | 13,253 (44.4) | 13,145 (44.0) | 3,447 (11.6) | |
| Patients with at least 1 complication, N (%) | 5,138 (17.2) | 1,402 (10.6) | 2,066 (15.7) | 1,670 (48.5) | < 0.0001 |
| Infected mesh removal | 1,094 (3.7) | 267 (2.0) | 439 (3.3) | 388 (11.3) | < 0.0001 |
| Infection | 1,146 (3.8) | 219 (1.7) | 397 (3.0) | 530 (15.4) | < 0.0001 |
| Graft/mesh/wound complications without mesh removal | 763 (2.6) | 149 (1.1) | 280 (2.1) | 334 (9.7) | < 0.0001 |
| Seroma | 102 (0.3) | 20 (0.2) | 48 (0.4) | 34 (1.0) | < 0.0001 |
| Bowel obstruction/other GI complications | 2,852 (9.6) | 637 (4.8) | 1,096 (8.3) | 1,119 (32.5) | < 0.0001 |
| Other complications*, N (%) | 2,450 (8.2) | 664 (5.0) | 881 (6.7) | 905 (26.3) | < 0.0001 |
| Enteritis/colitis | 470 (1.6) | 131 (1.0) | 120 (0.9) | 219 (6.4) | < 0.0001 |
| Fistula | 165 (0.6) | 17 (0.1) | 13 (0.1) | 135 (3.9) | < 0.0001 |
| Hematoma | 64 (0.2) | 12 (0.1) | 30 (0.2) | 22 (0.6) | < 0.0001 |
| Peritonitis | 996 (3.3) | 194 (1.5) | 335 (2.6) | 467 (13.6) | < 0.0001 |
| Procedural complication | 470 (1.6) | 76 (0.6) | 174 (1.3) | 220 (6.4) | < 0.0001 |
| Skin/connective tissue complication | 1,226 (4.1) | 358 (2.7) | 490 (3.7) | 378 (11.0) | < 0.0001 |
| Excision of abdominal wall lesion or reopening of recent laparotomy | 10 (0.03) | 1 (0.01) | 3 (0.02) | 6 (0.2) | < 0.0001 |
*Patients with ‘Other complications’ were defined as those with enteritis/colitis, fistula, hematoma, peritonitis, procedural complications, skin/connective tissue complications, or excision of abdominal wall lesion or reopening of recent laparotomy within 6-months of their index VHR. The ‘Other complications’ count represents unique patients; patients may have experienced more than one complication, and individual complication categories are not mutually exclusive
Fig. 2.
Distribution of complications in the 6-month period after index VHR, grouped by mVHWG category. *P<0.001. “Patients with at least 1 complication” category is inclusive of all the complications listed in Table 3
Among the 5,138 patients who experienced at least one complication, the median number of complications per patient was 1.0. Grade 3 patients had a higher median number of complications (2.0 ) compared with Grade 1 (1.0) and Grade 2 (1.0) patients (Table 4).
Table 4.
Number of complications experienced by patients with at least 1 complication
| Analytic cohort | mVHWG category | |||
|---|---|---|---|---|
| Grade 1 | Grade 2 | Grade 3 | ||
| Patients with at least 1 complication identified during post-index follow-up (N) | 5,138 | 1,402 | 2,066 | 1,670 |
| Median number of complications per patient (IQR) | 1.0 (1.0) | 1.0 (1.0) | 1.0 (1.0) | 2.0 (2.0) |
Discussion
This study operationalizes the mVHWG classification within administrative claims data using a hierarchical, rule-based algorithm using diagnosis and procedure codes. By translating the widely used clinical risk stratification framework into a reproducible approach using real-world claims data that does not capture mVHWG classification directly, this work addresses a key methodological barrier that has limited the use of mVHWG in large-scale outcomes research. Application of this algorithm to a national administrative claims cohort revealed a stepwise higher risk in postoperative complication burden across mVHWG within 6 months following VHR. In addition to a higher incidence of complications, the number of complications per patient was higher as mVHWG increased. This highlights the utility of mVHWG classification for characterizing postoperative complication burden in real-world practice.
While the mVHWG classification system has been widely adopted in clinical practice and validated in registry-based and institutional cohorts, its use in population-level outcomes research has been limited by the absence of a standardized, reproducible approach to assigning mVHWG grade in administrative claims data [6, 7]. The postoperative complication burden with mVHWG Grade 3 patients is recognized and has been examined in prior studies, including analyses stratified by mesh type [9]. The current study confirms that patients classified with mVHWG Grade 3 have the highest complication burden and further demonstrates that patients classified with mVHWG Grade 2 experience higher postoperative complication rates compared to Grade 1 patients. The observed stepwise higher complication burden across mVHWG grades in the current study (mVHWG 1 = 11%, mVHWG 2 16%, mVHWG 3 = 49%) is consistent with prior findings (mVHWG 1 = 14%, mVHWG 2 = 27%, mVHWG 3 = 46%) [7]. This suggests that the key elements of hernia complexity and patient risk are captured by the claims-based algorithm despite the absence of a direct assessment by the surgeon. This alignment across data sources reinforces the utility of the algorithm for large-scale claims research when clinical grading is unavailable. However, this study does not assess criterion validity and individual-level classification accuracy. Future work should validate the claims data with surgeon assigned grades.
Notably, Grade 2 patients represent a large proportion of the analytic cohort highlighting that this intermediate-risk group contributes meaningfully to the overall burden of postoperative complications following VHR. This intermediate-risk group has received less attention in studies despite representing a meaningful proportion of patients undergoing VHR. The higher complication burden observed among Grade 2 patients relative to Grade 1 patients supports the risk stratification among the three groups. Interestingly, the proportion of male patients was lower in the mVHWG Grade 3 cohort than in Grades 1 and 2. This finding is consistent with recent work by Head et al. 2026, who reported a higher proportion of female patients among higher-risk ventral hernia populations [11]. Although the reasons for this association cannot be determined from claims data, it highlights an area for future research.
Within 6 months after surgery, over 17% of patients experienced postoperative complications as listed in Table 3. This overall complication burden was primarily driven by non–mesh-specific events, particularly gastrointestinal and other systemic complications in Grade 3 patients.Further, infection and other wound complications were higher in a stepwise function based on mVHWG classification. Although less common than gastrointestinal complications, these events may have important downstream consequences. Patients with early (within 30 days) wound complications are significantly more likely to undergo a later mesh removal [12]. In addition, patients with a preceding surgical site infection had double the chance of a hernia recurrence and quadruple the chance of a reoperation creating a vicious cycle of VHR [13]. According to Holihab et al. 2015, previous VHR increases the complication profile of repair, creating a vicious cycle of repair, complications, reoperation, and re-repair [13]. This suggests that early postoperative complications may contribute to a cascade of adverse outcomes underscoring the importance of understanding the early complications that can drive later complication burden.
In addition to clinical implications, the early complication burden (within 6 months) following VHR is associated with substantial healthcare costs. Prior population-based analyses have demonstrated that any complication identified within 90 days can increase the spending per episode by over $9000, while a serious complication identified within 90 days can increase the spending per episode by $26,000 [14]. Mesh removal represents one of the most economically burdensome complications requiring additional operations and prolonged hospital care, and can potentially double hospital costs [15]. The overall rate of infected mesh removal was 3.7%, increasing from 2.0% in Grade 1 patients to 11.3% in Grade 3 patients which is consistent with the increasing risk profile represented by the mVHWG classification. Prior studies report approximately 2% mesh removal in elective repairs [12, 16] and 9% infected mesh removal in high-risk and contaminated patients treated with synthetic mesh consistent with the mVHWG Grade 3 group in the current study [17]. The results of the current study should be interpreted within the context of the study definition for mesh removal, which incorporated both specific infected mesh removal procedure codes and hernia repair procedures accompanied by infection-related diagnoses or procedures in the same day. Consequently, this approach may have captured mesh-related infections requiring intervention that are not identified by explantation codes alone. In addition, other complications observed in this study, including infection and wound complications, occur frequently after VHR especially in patients with higher mVHWG, and collectively contribute to increases in healthcare utilization. By demonstrating a stepwise higher complication burden across mVHWG grades, the current study provides important context for how patient risk may translate into differences in healthcare resource utilization and costs. Future research should understand the costs associated with the higher complication burden as patients progress from Grade 1 to Grade 3.
The administrative claims data in the current study allows for investigation of a large, geographically diverse US population with longitudinal follow-up representative of real-world practice, including capture of postoperative care received outside the index surgical institution, which is often not available in single-center or surgeon-reported datasets. There are limitations associated with claims-based data. The analytic cohort is a small subset of the initially identified patient population because of the necessary inclusion criteria related to continuous insurance enrollment to ensure baseline risk characteristics and postoperative outcomes were reliably assessed. While necessary, this may limit the generalizability of the findings. Because mVHWG classification could not be determined for excluded patients, it is unknown whether the distribution of mVHWG grades among excluded patients differed from that of the analytic cohort. Modified VHWG classification in this study was approximated using diagnosis and procedure codes available in administrative claims data rather than intraoperative clinical assessment. Claims-based algorithms may under-ascertain clinical conditions when relevant diagnoses are not coded, potentially resulting in misclassification of some patients into lower-risk categories. However, the consistent stepwise gradient observed across mVHWG grades suggests that the classification approach could provide clinically meaningful discrimination, and future work should formally validate the algorithm against clinically assigned mVHWG grades. Postoperative complications were identified using claims-based diagnosis and procedure codes and therefore reflect events that resulted in healthcare encounters or reimbursement. Subclinical complications or events managed without formal claims submission may not have been captured, potentially leading to underreporting of certain outcomes. Further, follow-up was limited to 6 months after the index repair, capturing early postoperative morbidity but not long-term outcomes such as late recurrence or delayed mesh-related events.
In conclusion, this study operationalizes mVHWG classification in claims data and demonstrates a stepwise higher risk in postoperative complication burden across mVHWG grades following VHR, including higher incidence and greater number of complications among higher risk patients. This increased complication burden can be associated with higher healthcare resource utilization and cost. Patients classified as mVHWG Grade 2 represented a large proportion of the cohort and experienced greater complication burden than Grade 1 patients, underscoring the importance of this risk group. These findings support the relevance of risk stratification frameworks for contextualizing the burden of VHR in real-world practice and demonstrate the feasibility of applying mVHWG classification in administrative claims data to support population-level outcomes research and post market surveillance. Further research is warranted to validate the algorithm against clinically assigned mVHWG grades as well as to examine long-term outcomes and costs associated with early postoperative complications across mVHWG grades.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgments
Figure 2 was created in https://BioRender.com.
Author contributions
Conceptualization: [BKP, CG, MW, MJ, HG]; Methodology: [BKP, CG, MW, MJ, HG]; Formal analysis and investigation: [CG, MJ]; Writing - original draft preparation: [CCS]; Writing - review and editing: [BKP, CG, MW, MJ, HG, CA]; Supervision: [MW, HG]
Declarations
BKP receives salary support from the ACHQC, received research support from BD, Tissium, Sealonix, and Advanced Medical Solutions, serves as a consultant for Abbvie Allergan, and holds equity in EndoEvolve.
CG, CCS, and CA report employment by Becton, Dickinson and Company during the conduct of this study. MJ, MW, HG are employed and had stock ownership at Becton, Dickinson and Company during the conduct of this study.
Footnotes
No mesh is currently indicated in the U.S. for use in contaminated or infected fields.
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Poulose B, Shelton J, Phillips S et al (2012) Epidemiology and cost of ventral hernia repair: making the case for hernia research. Hernia 16:179–183. 10.1007/s10029-011-0879-9 [DOI] [PubMed] [Google Scholar]
- 2.Schlosser KA, Renshaw SM, Tamer RM et al (2023) Ventral hernia repair: an increasing burden affecting abdominal core health. Hernia 27:415–421. 10.1007/s10029-022-02707-6 [DOI] [PubMed] [Google Scholar]
- 3.Al-Mansour MR, Ding DD, Yergin CG et al (2024) The association of hernia-specific and procedural risk factors with early complications in ventral hernia repair: ACHQC analysis. Am J Surg The 233:100–107. 10.1016/j.amjsurg.2024.02.028 [DOI] [PubMed] [Google Scholar]
- 4.Helgstrand F (2016) National results after ventral hernia repair. Dan Med J 63:B5258–B5258 [PubMed]
- 5.Bhardwaj P, Huayllani MT, Olson MA, Janis JE (2024) Year-Over-Year Ventral Hernia Recurrence Rates and Risk Factors. JAMA Surg 159:651–658. 10.1001/jamasurg.2024.0233 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.The Ventral Hernia Working Group, Breuing K, Butler CE et al (2010) Incisional ventral hernias: Review of the literature and recommendations regarding the grading and technique of repair. Surgery 148:544–558. 10.1016/j.surg.2010.01.008 [DOI] [PubMed] [Google Scholar]
- 7.Kanters AE, Krpata DM, Blatnik JA et al (2012) Modified hernia grading scale to stratify surgical site occurrence after open ventral hernia repairs. J Am Coll Surg 215:787–793. 10.1016/j.jamcollsurg.2012.08.012 [DOI] [PubMed] [Google Scholar]
- 8.Hodgkinson JD, Worley G, Warusavitarne J et al (2020) Evaluation of the ventral hernia working group classification for long-term outcome using english hospital episode statistics: a population study. Hernia 25:977–984. 10.1007/s10029-021-02379-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.DeNoto GIII, Reaven N, Funk S (2013) Ventral hernia: retrospective cost analysis of primary repair, repair with synthetic mesh, and repair with acellular xenograft implant. Open Access Surg 2013:23–32. 10.2147/OAS.S44647 [DOI] [Google Scholar]
- 10.Merative (2023) Merative MarketScan Research Databases. https://www.merative.com/documents/merative-marketscan-research-databases
- 11.Head W, Collins CM, Aldridge A et al (2026) From preoperative to postoperative: gender differences in elective ventral hernia repair. Hernia 30. 10.1007/s10029-026-03678-8 [DOI] [PMC free article] [PubMed]
- 12.Ehlers AP, Sinamo JK, Howard R et al (2025) Long-term risk of mesh infection requiring removal after elective ventral hernia repair. JAMA Surg 160:1318–1325. 10.1001/jamasurg.2025.3915 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Holihan, Alawadi M et al (2015) Adverse events after ventral hernia repair: The vicious cycle of complications. J Am Coll Surg 221:478–485. 10.1016/j.jamcollsurg.2015.04.026 [DOI] [PubMed] [Google Scholar]
- 14.Howard RMD, Thompson M, PhDMPH, Fan ZMDMPH et al (2019) Costs Associated With Modifiable Risk Factors in Ventral and Incisional Hernia Repair. JAMA Netw Open 2:E1916330. 10.1001/jamanetworkopen.2019.16330 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Plymale MA, Davenport DL, Walsh-Blackmore S et al (2020) Costs and Complications Associated with Infected Mesh for Ventral Hernia Repair. Surg Infect (Larchmt) 21:344–349. 10.1089/sur.2019.183 [DOI] [PubMed] [Google Scholar]
- 16.Kokotovic D, Bisgaard T, Helgstrand F (2016) Long-term Recurrence and Complications Associated With Elective Incisional Hernia Repair. JAMA 316:1575–1582. 10.1001/jama.2016.15217 [DOI] [PubMed] [Google Scholar]
- 17.Morales-Conde S, Hernández-Granados P, Tallón-Aguilar L et al (2022) Ventral hernia repair in high-risk patients and contaminated fields using a single mesh: proportional meta-analysis. Hernia 26:1459–1471. 10.1007/s10029-022-02668-w [DOI] [PMC free article] [PubMed] [Google Scholar]
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