BACKGROUND/RATIONALE:
Abdominal wall hernias are one of the most common conditions treated by the general surgeon. Well over 100,000 repairs are performed annually. Despite this fact, there is no standard or uniformly accepted technical method to repair abdominal wall hernias. Hernias can be repaired with or without the use of a mesh prosthesis, the mesh can be placed in different locations within the abdominal wall, and the operation can be done via an open or laparoscopic approach. This study hypothesizes that variability in the method of repair, specifically the rate at which mesh is used for the repair, is directly related to surgical outcome. Consistent with this hypothesis, the overall hernia recurrence rates are as high as 24-40%. This rate would be unacceptable to any individual practicing surgeon. Without adequate data to support the superiority of one type of technical repair, surgeons will continue their current practice style.
OBJECTIVE(S):
1.To determine whether there are surgeon and/or hospital specific differences in mesh implantation rates, recurrence rates and complications rates. Specifically, we will examine whether there is variability across surgeons and facilities in the method and rate of mesh implantation for ventral hernia repair (VHR), which are unexplained by patient comorbidity or other clinical characteristics.
2.To identify key variables associated with recurrence and wound complications following ventral hernia repair.
3.To determine the impact of hernia recurrence and wound complications on patient quality of life.
METHODS:
The VA National Surgical Quality Improvement Program (NSQIP) was started in 1991. This program collects pre-operative and intra-operative risk factors and 30-day morbidity and mortality data. These data are feedback to individual sites and significant improvement in morbidity and mortality for surgical patients has been achieved. This is an observational study of the NSQIP dataset together with a subject survey on the outcomes of ventral hernia repair in the VA population. Patients who underwent ventral hernia repair at the 15 highest volume centers from 1999-2001 will be included in the study. Subjects will be mailed a survey to determine whether they have developed a recurrence or complication in the follow-up period. Health-related quality of life and pain will be assessed in the survey and linked to the 1999 Large Health Survey. The analysis will be an outcomes assessment. Risk-adjustment will be performed. We will apply multi-level statistical techniques to control for surgeon and hospital styles. Practice styles of individual physicians and VAMC sites will be studied to determine if certain practice styles are associated with optimal outcomes (i.e. low recurrence and low wound complication rates).
FINDINGS/RESULTS:
This study is in the data collection phase. Preliminary analyses on 13 sites show a mesh placement rate of 62.19% with an overall infection rate of 4.95%. Logistic regression analyses on these 13 sites indicate that absorbable mesh, prolonged operative time, smoking and steroid use for chronic conditions are predictors of post-operative wound infection. Examination of unplanned bowel resection and enterotomy (EBR) in 16 sites show an EBR rate of 5.5% for primary incisional hernias, 8.4% of recurrent incisional hernias and 21.0% for prior incisional mesh repairs. Multivariable analyses for any post-operative complication found that EBR, ASA class > 4 and incisional hernia repair to be significant predictors of post-operative complications. After adjusting for procedure type, age and ASA class, EBR was also associated with an increase in mean operative time and length of stay.
IMPACT:
Ventral hernia repairs are performed frequently, yet the outcomes remain poor. This study will determine best practice patterns for ventral hernia repair. This information is greatly needed by the surgical community. We will use the results from this study to develop an educational intervention targeting surgeon in the VA system to improve quality of care for veterans undergoing ventral hernia repair. The results of this study will also have broad implications for surgeons in the private sector.
PUBLICATIONS:
Journal Articles
- Gray SH, Hawn MT, Kilgore ML, Yun H, Christein JD. Does cholecystectomy prior to the diagnosis of pancreatic cancer affect outcome? American Surgeon. 2008; 74(7): 602-5; discussion 605-6.
- Gray SH, Vick CC, Graham LA, Finan KR, Neumayer LA, Hawn MT. Umbilical herniorrhapy in cirrhosis: improved outcomes with elective repair. Journal of Gastrointestinal Surgery : Official Journal of The Society For Surgery of The Alimentary Tract. 2008; 12(4): 675-81.
- Gray SH, Hawn MT, Itani KM. Surgical progress in inguinal and ventral incisional hernia repair. The Surgical Clinics of North America. 2008; 88(1): 17-26, vii.
- Itani KM, Hawn MT. Advances in abdominal wall hernia repair. Preface. The Surgical Clinics of North America. 2008; 88(1): xvii-xix.
- Finan KR, Vick CC, Kiefe CI, Neumayer L, Hawn MT. Predictors of wound infection in ventral hernia repair. American Journal of Surgery. 2005; 190(5): 676-81.
- Vick CC, Finan KR, Kiefe C, Neumayer L, Hawn MT. Variation in Institutional Review processes for a multisite observational study. American Journal of Surgery. 2005; 190(5): 805-9.
