Abdominal wall hernias: risk factors for infection and resource utilization

doi:10.1016/S0022-4804(03)00077-5

Journal of Surgical Research

Volume 111, Issue 1, 1 May 2003, Pages 78-84

https://doi.org/10.1016/S0022-4804(03)00077-5 Get rights and content

Abstract

Background. Abdominal wall hernia repairs are common surgical procedures. Several recent reports have studied the outcomes of elderly patients undergoing inguinal hernia repair and documented a morbidity rate ranging from 5–57% and a mortality rate ranging from 1.6–14%. However, there has been limited data documenting the risk factors associated with postoperative morbidity and mortality from abdominal wall hernia repairs in general. Therefore, we sought to investigate the incidence of complications in patients undergoing abdominal wall hernia repair and to evaluate the risk factors for infection and resource utilization in these patients.

Methods. Prospective data (NSQIP) were collected on 6301 noncardiac surgical patients at the VA Maryland Healthcare System from 1995 to 2000. From this data set, 487 (7.7%) patients underwent abdominal wall hernia repairs and comprised the study cohort. Logistic and linear regression analyses were performed to identify risk factors for infection and hospital length of stay.

Results. The mean age of the study cohort was 60 ± 14 and the mean ASA class was 2.4 ± 0.7. Descriptive data revealed 99% were male, 43% used tobacco, 8.4% were diabetic, 7.4% used alcohol, 6.3% had chronic obstructive pulmonary disease (COPD), 2.1% were malnourished (defined as ≥ 10% weight loss over prior 6 months), 1.6% used steroids, 1.2% had ascites, and 0.2% had coronary artery disease (CAD). The mortality rate was low at 1% but the morbidity rate was higher with a 4.3% incidence of wound infections and a 15.1% incidence of recurrent hernias. The mean preoperative serum albumin level was 4.1 ± 0.6 g/dL, and the mean hospital length of stay was 1.4 ± 4.8 days. Multiple logistic and linear regression analyses documented that CAD, COPD, low preoperative serum albumin, and steroid use were independent risk factors for increased postoperative wound infections (P < 0.05) and increased hospital length of stay (P < 0.05).

Conclusions. Abdominal wall hernia repair is associated with significant morbidity in this predominantly elderly cohort but mortality rates were low. COPD and low preoperative serum albumin were independent predictors of wound infections and CAD, COPD, low preoperative serum albumin, and steroid use were independent predictors of increased hospital length of stay. Therefore, consideration should be given to optimizing patient’s cardiopulmonary and nutritional status before abdominal wall hernia repair.

Introduction

Abdominal wall hernia is defined as any protrusion of a peritoneal-lined sac through the musculoaponeurotic covering of the abdomen, including inguinal, incisional, umbilical, femoral, epigastric, spigelian, lumbar, and other more rare types of hernias [1]. Abdominal wall hernia repairs are the most common general surgical procedure performed in the United States. Hernia repairs, second only to cataracts, are one of the most common major surgical procedures performed in the United States each year with over 990,000 cases performed annually [2]. Inguinal hernia repairs (65.7%) comprise the majority of all abdominal wall hernia repairs performed in the United States followed by umbilical hernia repairs (15.7%), incisional hernia repairs (9.1%), femoral hernia repairs (2.4%), and other types of hernia repairs (7.1%) [3].

A 1999 report by the National Center for Health Statistics documented an increasing prevalence of abdominal wall hernias with age, from 16.9 per 1000 persons for all ages to 30.9 per 1000 for those ages 45 to 64 years of age and 48.4 per 1000 for those 65 years and older [4]. In addition, an increasing mortality rate with age was also documented in a 2000 report by the National Center for Health Statistics. This report documented a mortality rate from intestinal obstruction due to abdominal wall hernias of 2.5 per 100,000 population. The mortality rate increased to 3.2 per 100,000 for patient’s ages 65 to 69 with a maximum increase to 68.3 per 100,000 for patients 85 years and older [5]. These statistics documented the significant mortality associated with abdominal wall hernia repairs in the elderly.

Given the risk of increased morbidity and mortality in elderly patients, studies have sought to define risk factors for the morbidity and mortality associated with repair of groin hernias [6]. Lewis et al. studied 452 patients undergoing inguinal hernia repair, 116 (26%) of whom were greater than 65 years of age. The authors documented that emergency hernia repairs were significantly more common (16.4% versus 4.4%, P < 001), resulted in more complications (58% versus 22%, P < 0.001) and higher mortality (10% versus 0%) compared with elective repairs in the elderly. Similarly, Rorbaek-Madsen prospectively studied patients greater than 80 years of age to define factors that increased the risk associated with inguinal hernia repairs in these individuals. He documented a significant increase in complications (57% versus 5%, P < 0.001) and mortality (14% versus 0%) after emergency operations compared to elective operations. Both studies concluded that elective hernia repairs could be performed safely in the elderly and that emergency hernia repair in the elderly was associated with a high risk of morbidity and mortality 7, 8.

Despite these prior studies on inguinal hernia repairs, there is a paucity of data examining outcome after abdominal wall hernia repairs in general. Therefore, we sought to investigate the incidence of complications in veterans undergoing abdominal wall hernia repairs and to evaluate risk factors for infection and resource utilization in these patients.

Section snippets

Patient and methods

All patients undergoing noncardiac surgery (n = 6301) at the Veterans Affairs Maryland Healthcare System from 1995 to 2000 were selected from the National Surgical Quality Improvement Program (NSQIP) database for analysis. From this data set, 487 (7.7%) patients underwent abdominal wall hernia repairs and comprised the study cohort. Abdominal wall hernia repairs performed at the Veterans Affairs Maryland Healthcare System used only general or regional anesthesia and therefore were all included

Patient demographics

The overall study population included 6301 noncardiac surgical patients. The total population had a mean age of 61 ± 13, a mean ASA score of 2.6 ± 0.7, and a mean preoperative serum albumin level of 3.7 ± 0.9 g/dL; 95% were male, and 13.5% were classified as emergent cases. The hernia study cohort included 487 patients and was significantly different compared with the overall population. The hernia study cohort had a lower mean age of 60 ± 14, a lower mean ASA of 2.4 ± 0.7, and a higher mean

Discussion

Abdominal wall hernia repairs are one of the most common major surgical procedures performed in the United States each year with almost 1,000,000 cases performed annually and an incidence of mortality of 2.5 per 100,000 population 2, 5. Nilsson et al. prospectively studied 4879 patients undergoing inguinal hernia repairs. The authors documented a mortality rate of 0.07% for elective operations and 3.5% for emergent operations [11]. Similarly; incisional hernia repairs have a documented

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Cited by (153)

Microbiological epidemiology and antibiotic susceptibility of infected meshes after prosthetic abdominal wall repair
2023, Journal of Visceral Surgery
Infectious complications of parietal mesh after prosthetic abdominal wall repair are rare. Their management is complex. Furthermore, the emergence of bacterial resistance, the presence of a foreign material, the need to continue an extended antibiotic therapy, and the choice of an appropriate treatment are crucial. The objective of this study is to access the microbiological epidemiology of infected parietal meshes in order to optimize the empirical antibiotic therapy.
Between January 2016 and December 2021, a monocentric and retrospective study was performed in patients hospitalized for infected parietal meshes at Avicenne hospital, in Paris area. Clinical and microbiological data such as antibiotic susceptibility were collected.
Twenty-six patients with infected parietal meshes have been hospitalized during this period. Meshes were in preaponevrotic positions (n = 10; 38%), retromuscular (n = 6; 23%) and intraperitoneal (n = 10; 38%). Among the 22 (84.6%) documented cases of infections, 17 (77.3%) were polymicrobial. A total of 54 bacteria were isolated, 48 of which had an antibiogram available. The most frequently isolated bacteria were: Enterobacterales (n = 19), Enterococcus spp. (n = 11) and Staphylococcus aureus (n = 6), whereas anaerobes were poorly isolated (n = 3). Concerning these isolated bacteria, amoxicillin-clavulanic acid, metronidazole-associated cefotaxime, piperacillin-tazobactam and meropenem were susceptible in 45.5%, 68.2%, 63.6%, 77.2%, of cases, respectively.
This work highlights that infections of abdominal parietal meshes may be polymicrobial and the association amoxicillin-clavulanic acid cannot be used as a probabilist antibiotic therapy because of the high resistance rate in isolated bacteria. The association piperacillin-tazobactam appears to be a more adapted empirical treatment to preserve carbapenems, a broad-spectrum antibiotic class.
Preoperative computed tomography for acutely incarcerated ventral or inguinal hernia
2022, Surgery (United States)
The utility of preoperative computed tomography for urgent abdominal wall hernia repair is unclear. This study tests the hypothesis that there is no difference in patient outcomes for acutely incarcerated ventral or inguinal hernias diagnosed by preoperative computed tomography versus clinical assessment alone.
This retrospective cohort analysis included 270 adult patients undergoing urgent repair of ventral or inguinal hernia. Demographics, risk factors for complications, operative management strategies, and 1-year outcomes were compared between patients with (n = 179) versus without (n = 91) preoperative computed tomography.
Among 179 preoperative computed tomography scans, 15 (8.4%) were ordered by surgeons, and all others were ordered by referring providers. The computed tomography and no computed tomography groups had similar age (58 vs 58 years, P = .77), body mass index (30.7 vs 30.6 kg/m², P = .30), American Society of Anesthesiologists class (3.0 vs 3.0, P = .39), incidence of the systemic inflammatory response syndrome (19.0% vs 20.9%, P = .75), and incidence of recurrent hernia (16.8% vs 19.8%, P = .61). The interval between admission and incision was longer in the computed tomography group (11.2 hours vs 6.6 hours, P < .001). The computed tomography and no computed tomography groups had similar duration of surgery (125 minutes in both groups, P = .88), proportions of patients with biologic mesh (21.2% vs 17.6%, P = .52) and synthetic mesh (35.2% vs 46.2%, P = .09) placement, and 1-year outcomes including incidence of superficial (8.4% vs 6.6%, P = .81) and deep or organ/space surgical site infection (5.0% vs 6.6%, P = .59), mesh explant for infection (2.2% vs 3.3%, P = .69), reoperation for recurrent hernia (3.9% vs 1.1%, P = .27), and mortality (7.8% vs 4.4%, P = .44).
The performance of preoperative computed tomography was associated with a longer interval between admission and incision and no differences in mesh placement, mesh type, or 1-year patient outcomes. These results support the safety of performing urgent repair of acutely incarcerated ventral or inguinal hernias based on clinical assessment alone.
Systematic review and meta-analysis of risk factors for Mesh infection following Abdominal Wall Hernia Repair Surgery
2022, American Journal of Surgery
Surgical Mesh Infection (SMI) after Abdominal Wall Hernia Repair (AWHR) represents a catastrophic complication. We performed a systematic review and meta-analysis to analyze the risk factors for SMI in the context of AWHR.
PubMed, Embase, Scielo, and LILACS were searched without language or time restrictions from inception until June 2021. Articles evaluating the association between demographic, clinical, laboratory and surgical characteristics with SMI in AWHR were included.
23 studies were evaluated, comprising a total of 118,790 patients (98% males; mean age 56.5 years) with a mesh infection pooled prevalence of 4%. Significant risk factors for SMI were type 2 diabetes mellitus, obesity, smoking history, steroids use, ASA III/IV, laparotomy vs laparoscopy, emergency surgery, duration of surgery and onlay mesh position vs sublay. The quality of evidence was regarded as very low–moderate.
Several factors, highlighting sociodemographic characteristics, comorbidities, and the clinical scenario, may increase the risk of developing mesh infections in AWHR. The recognition and mitigation of these may significantly reduce mesh infection rates in this context.
Comparative study of biological versus synthetic prostheses in the treatment of ventral hernias classified as grade II/III by the Ventral Hernia Working Group
2022, Journal of Visceral Surgery
The implantation of biological prostheses in an at-risk environment has seen increasing use. Their markedly higher cost compared to synthetic prostheses makes it important to analyse their usefulness in terms of actual benefit and cost-effectiveness. This study aims to examine the relevance of bioprostheses during surgical repair of Grade II/III ventral hernias as classified by the Ventral hernia working group (VHWG).
This study analysed the data of 119 patients requiring non-emergency repair of VHWG II/III grade hernias between 2010 and 2017. The results of patients who were treated with a bioprosthesis (n = 59) were compared to those receiving a synthetic prosthesis (n = 60). The primary outcome was surgical site infection (SSI) at 90 days. The secondary endpoints were hernia recurrence rate, cost of the prosthesis, duration of hospital stay and re-hospitalisation rate.
The two groups were shown to be comparable by analysis of demographic, pre- and intraoperative data. The SSI rate was significantly higher in the bioprosthesis group (20% vs. 7%; P = 0.010), as was the recurrence rate (56% vs. 28%; P = 0.003) with a median follow-up of 40 months. The cost of the bioprosthesis was significantly higher than that of the synthetic prosthesis (€3363 vs. €249; P < 0.010).
In this retrospective study, the use of a bioprosthesis for repair of VHWG II/III ventral hernias was associated with a higher rate of both SSI and hernia recurrence at a cost 13 times greater than the use of a synthetic prosthesis.
Does immunosuppression increase perioperative wound morbidity in patients undergoing transversus abdominis release?
2022, Surgery (United States)
Citation Excerpt :
Alternatively, corticosteroids, which provide a more global anti-immune function (affecting both the inflammation and proliferation phase), affect wound healing immediately to impede wound contraction and to decrease tensile strength.25 The few studies that have evaluated steroid use as a potential risk factor for patient outcomes have more consistently shown a positive correlation between chronic steroid use and wound infections after hernia repair.26,27 To date, Lee et al is the only study that comments on this question: the authors found no difference in the risk of SSI or mesh infection in patients taking immunosuppression (all types) compared with those currently undergoing chemotherapy.
Transversus abdominis release is an effective procedure for complex ventral hernias. As wound complications contribute to hernia recurrences, mitigating risk factors is vitally important for hernia surgeons. Although immunosuppression can impair wound healing, it has inconsistently predicted wound occurrences, and its effect on wound morbidity after a transversus abdominis release is unknown.
Patients undergoing either an elective open or robotic bilateral transversus abdominis release with permanent synthetic mesh were retrospectively stratified by perioperative immunosuppression and secondarily by procedure type (open versus robotic) and immunosuppression.
A total of 321 patients were included for analysis. Overall, 63 (19.6%) patients were on chronic immunosuppression, with history of solid-organ transplant being the most common indication (43 patients). Patients stratified by perioperative immunosuppression were well-matched with similar defect size (P = .97), body mass index ≥30 (P = .32), diabetes (P = .09), history of surgical site infection (P = .53), surgical approach (P = .53), and tobacco use history (P = .33). No differences between cohorts were elicited for any wound event when stratified by immunosuppression use. Similarly, no differences were elicited when cohorts were further stratified also by procedure type.
Chronic immunosuppression is often viewed as a notable risk factor for wound occurrences after surgery. However, our data suggest immunosuppression may not significantly increase the risk of perioperative wound morbidity follow transversus abdominis release as previously predicted.
Loss of independence after emergency inguinal hernia repair in elderly patients: How aggressive should we be?
2022, American Journal of Surgery
Loss of independence (LOI) assesses patient quality of life after surgery and is associated with increased readmission and death. This paper compares LOI among the elderly who received elective versus emergent inguinal hernia repair.
The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant User Files from 2015 to 2017 were reviewed for inguinal hernia repairs in patients 70-years-old or older. Chi-square analysis, Student t-test, and backwards multivariate logistic analysis were performed appropriately.
Patients undergoing elective open or laparoscopic repair were less likely to experience LOI (OR 0.061, CI 0.035–0.106) and (OR 0.052 CI 0.024–0.113), respectively, and they were less likely to experience mortality (OR 0.07, CI 0.026–0.185) and (OR 0.059, CI 0.015–0.229), respectively.
Significant debility occurs following emergency inguinal hernia repair in elderly patients. Elective surgery may be indicated more often in order to reduce emergencies and LOI in elderly patients.

View all citing articles on Scopus

¹: Presented at the Association of VA Surgeons 2002 Annual Meeting April 27–30, 2002, Houston, Texas.

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Clinical ArticleAbdominal wall hernias: risk factors for infection and resource utilization1

Abstract

Introduction

Section snippets

Patient and methods

Patient demographics

Discussion

Surg Clin North Am

Surg Clin North Am

J Hosp Infect

Surg Clin North Am

Surg Clin North Am

Surgery

J Thorac Cardiovasc Surg

Am J Surg

Am J Surg

Hernias

Surgical operations in the United States. Then (1983) and now (1994)

Arch Surg

Prevalence Patterns-United States, 1996

Vital And Health Statistics Series

Mortality Patterns-United States, 1998

Vital And Health Statistics Series

Is elective hernia repair worthwhile in old patients?

Eur J Surg

Inguinal hernia repair in the elderly

J R Coll Surg Edinb

Herniorraphy in patients aged 80 years or more. A prospective analysis of morbidity and mortality

Eur J Surg

Clinical Article
Abdominal wall hernias: risk factors for infection and resource utilization¹