Managing acute postoperative pain in patients on chronic opioid therapy is challenging. There is little data regarding optimal perioperative chronic opioid management. We hypothesized that continuing ...the home dose of opioid while inpatient following ventral hernia repair (VHR) would reduce total opioid consumption postoperatively.
Chronic opioid users were ordered their home opioid scheduled and our standard multimodal analgesia regimen. At time of discharge, we reviewed inpatient opioid use and prescribed opioids based on morphine milligram equivalent (MME) consumed per our established protocol.
VHR was performed in 658 patients with 117 utilizing chronic opioid medications from June 2017 through March 2022; 43 patients were managed on protocol and 74 were not. Inpatient daily MME consumption was similar between groups (34 vs 36 MME; p = 0.285). Patients treated according to protocol received significantly lower MME prescriptions at discharge (80 vs 225 MME; p < 0.001) with similar refills (21.4 vs 25.4 %; p = 0.820).
Continuing home opioids for chronic opioid users following VHR resulted in less opioid prescribing with no increase in refills.
•Minimal guidelines exist for perioperative opioid management in chronic opioid users.•Maintaining a home opioid regimen inpatient decreases opioid prescribing and refills.•Management of acute perioperative pain in chronic opioid users can be difficult due to multiple factors leading to widely variable management strategies.
A common surgical procedure, ventral hernia repair has long been a vexing problem, with no clear standard for repair and significant postoperative morbidity. Laparoscopic repair has the clear ...advantage of lower postoperative morbidity. However, application of laparoscopic ventral hernia repair is often limited by patient factors and hernia morphology. Long-term complications of intraperitoneal mesh and recurrence are concerning. Robotic-assisted surgery is the latest advance in minimally invasive hernia repair, combining the advantages of open repair with complete abdominal wall reconstruction and restoration of functional anatomy with the wound morbidity and decreased recovery time of laparoscopy.
Background Mesh repair of incisional hernias has been consistently shown to diminish recurrence rates after repair, with an increased risk of infectious complications. We present a consecutive series ...of elective, retrorectus mesh repairs of the abdominal wall and attempt to determine predictors of wound events and recurrence. Study Design A retrospective review was performed to include elective, retromuscular mesh repairs of complex incisional hernias from August 2006 to August 2013. Demographics, operative details, and postoperative events including wound events, surgical site infections (SSI), and recurrences were recorded. Results Over the 7-year period, 255 retromuscular mesh repairs of midline incisional defects were performed. Median age of the patients was 58 years, with an average BMI of 32.2 kg/m2 . Average size of the fascial defect was 181.4 cm2 , with recurrent defects making up 48% of repairs. Wound events occurred in 37.7% of cases; SSIs occurred in 19.6% of cases. Recurrence rate was 16.9%, with mean time to recurrence of 19.2 months. With respect to mesh type, recurrences were 16.2% with synthetic, 17.1% for bioabsorbable, and 25% for biologic mesh. When evaluating polypropylene meshes, recurrence was more likely with lightweight mesh (22.9%) vs midweight mesh (10.6%) (p = 0.045). Predictors of SSI included history of mesh infection (odds ratio OR 4.8, 95% CI 1.9 to 12.1; p < 0.001) and recurrent repairs (OR 2.5, 95% CI 1.1 to 5.8; p < 0.05). The only predictor of recurrence was the presence of an SSI (OR 3.1, 95% CI 1.5 to 6.3; p < 0.01). Conclusions Wound events are common after open mesh repairs of complex incisional hernias. Previous mesh infections and recurrent repairs increase the likelihood of an SSI, which significantly increases the risk of recurrence. Recurrences after retrorectus mesh repairs are significantly higher with lightweight compared with mid-weight meshes.
Background
Laparoscopic ventral hernia repair (LVHR) demonstrates comparable recurrence rates, but lower incidence of surgical site infection (SSI) than open repair. Delayed complications can occur ...with intraperitoneal mesh, particularly if a subsequent abdominal operation is required, potentially resulting in bowel injury. Robotic retromuscular ventral hernia repair (RRVHR) allows abdominal wall reconstruction (AWR) and extraperitoneal mesh placement previously only possible with open repair, with the wound morbidity of LVHR.
Methods
All LVHR and RRVHR performed in our institution between June 2013 and May 2015 contained in the Americas Hernia Society Quality Collaborative database were analyzed. Continuous bivariate analysis was performed with Student’s
t
test. Continuous nonparametric data were compared with Chi-squared test, or Fisher’s exact for small sample sizes.
p
values <0.05 were considered significant.
Results
We compared 103 LVHR with 53 RRVHR. LVHR patients were older (60.2 vs. 52.9 years;
p
= 0.001), but demographics were otherwise similar between groups. Hernia width was similar (6.9 vs. 6.5 cm,
p
= 0.508). Fascial closure was achieved more often with RRVHR (96.2 vs. 50.5 %;
p
< 0.001) and aided by myofascial release in 43.4 %. Mesh was placed in an intraperitoneal position in 90.3 % of LVHR and extraperitoneal in 96.2 % of RRVHR. RRVHR operative time was longer (245 vs. 122 min,
p
< 0.001). Narcotic requirement was similar between LVHR and RRVHR (1.8 vs. 1.4 morphine equivalents/h;
p
= 0.176). Seroma was more common after RRVHR (47.2 vs. 16.5 %,
p
< 0.001), but SSI was similar (3.8 vs. 1 %,
p
= 0.592). Median length of stay was shorter after RRVHR (1 vs. 2 days,
p
= 0.004). Direct hospital cost was similar (LVHR $13,943 vs. RRVHR $19,532;
p
= 0.07).
Conclusion
RRVHR enables true AWR, with myofascial release to offset tension for midline fascial closure, and obviates the need for intraperitoneal mesh. Perioperative morbidity of RRVHR is comparable to LVHR, with shorter length of stay despite a longer operative time and extensive tissue dissection.
The immunoglobulin heavy-chain locus (IGH) encodes variable (IGHV), diversity (IGHD), joining (IGHJ), and constant (IGHC) genes and is responsible for antibody heavy-chain biosynthesis, which is ...vital to the adaptive immune response. Programmed V-(D)-J somatic rearrangement and the complex duplicated nature of the locus have impeded attempts to reconcile its genomic organization based on traditional B-lymphocyte derived genetic material. As a result, sequence descriptions of germline variation within IGHV are lacking, haplotype inference using traditional linkage disequilibrium methods has been difficult, and the human genome reference assembly is missing several expressed IGHV genes. By using a hydatidiform mole BAC clone resource, we present the most complete haplotype of IGHV, IGHD, and IGHJ gene regions derived from a single chromosome, representing an alternate assembly of ∼1 Mbp of high-quality finished sequence. From this we add 101 kbp of previously uncharacterized sequence, including functional IGHV genes, and characterize four large germline copy-number variants (CNVs). In addition to this germline reference, we identify and characterize eight CNV-containing haplotypes from a panel of nine diploid genomes of diverse ethnic origin, discovering previously unmapped IGHV genes and an additional 121 kbp of insertion sequence. We genotype four of these CNVs by using PCR in 425 individuals from nine human populations. We find that all four are highly polymorphic and show considerable evidence of stratification (Fst = 0.3–0.5), with the greatest differences observed between African and Asian populations. These CNVs exhibit weak linkage disequilibrium with SNPs from two commercial arrays in most of the populations tested.
The aim of this study was to compare length of stay (LOS) after robotic-assisted and open retromuscular ventral hernia repair (RVHR).
RVHR has traditionally been performed by open techniques. ...Robotic-assisted surgery enables surgeons to perform minimally invasive RVHR, but with unknown benefit. Using real-world evidence, this study compared LOS after open (o-RVHR) and robotic-assisted (r-RVHR) approach.
Multi-institutional data from patients undergoing elective RVHR in the Americas Hernia Society Quality Collaborative between 2013 and 2016 were analyzed. Propensity score matching was used to compare median LOS between o-RVHR and r-RVHR groups. This work was supported by an unrestricted grant from Intuitive Surgical, and all clinical authors have declared direct or indirect relationships with Intuitive Surgical.
In all, 333 patients met inclusion criteria for a 2:1 match performed on 111 r-RVHR patients using propensity scores, with 222 o-RVHR patients having similar characteristics as the robotic-assisted group. Median LOS interquartile range (IQR) was significantly decreased for r-RVHR patients 2 days (IQR 2) compared with o-RVHR patients 3 days (IQR 3), P < 0.001. No differences in 30-day readmissions or surgical site infections were observed. Higher surgical site occurrences were noted with r-RVHR, consisting mostly of seromas not requiring intervention.
Using real-world evidence, a robotic-assisted approach to RVHR offers the clinical benefit of reduced postoperative LOS. Ongoing monitoring of this technique should be employed through continuous quality improvement to determine the long-term effect on hernia recurrence, complications, patient satisfaction, and overall cost.
Ventral and incisional hernias in obese patients are particularly challenging. Suboptimal outcomes are reported for elective repair in this population. Preoperative weight loss is ideal but is not ...achievable in all patients for a variety of reasons, including access to bariatric surgery, poor quality of life, and risk of incarceration. Surgeons must carefully weigh the risk of complications from ventral hernia repair with patient symptoms, the ability to achieve adequate weight loss, and the risks of emergency hernia repair in obese patients.
Introduction
Laparoscopic ventral hernia repair (LVHR) with intraperitoneal mesh placement is well established; however, the fate of patients requiring future abdominal operations is not well ...understood. This study identifies the characteristics of LVHR patients undergoing reoperation and the sequelae of reoperation.
Methods
A retrospective review of a prospectively maintained database at a hernia referral center identified patients who underwent LVHR between 2005 and 2014 and then underwent a subsequent abdominal operation. The outcomes of those reoperations were collected. Data are presented as a mean with ranges.
Results
A total of 733 patients underwent LVHR. The average age was 56.5 years, BMI 33.9 kg/m
2
, hernia size 115 cm
2
(range 1–660 cm
2
), and mesh size 411 cm
2
(range 17.7–1360 cm
2
). After a mean follow-up of 19.4 months, the overall hernia recurrence rate was 8.4 %. Subsequent abdominal operations were performed in 17 % (125 patients) at a mean 2.2 years. The most common indication for reoperation was recurrent hernia (33 patients, 26.4 %), followed by bowel obstruction (18 patients, 14.4 %), hepatopancreaticobiliary (17 patients, 13.6 %) and infected mesh removal (15 patients, 12 %), gynecologic (10 patients, 8 %), colorectal (8 patients, 6.4 %), bariatric (4 patients, 3 %), trauma (1 patient, 0.8 %), and other (19 patients, 15 %). The overall incidence of enterotomy or unplanned bowel resection (EBR) at reoperation was 4 %. This occurred exclusively in those reoperated for complete bowel obstruction, and the reason for EBR was mesh–bowel adhesions. No other indication for reoperation resulted in EBR. The incidence of secondary mesh infection after subsequent operation was 2.4 %.
Conclusion
In a large consecutive series of LVHR, the rate of abdominal reoperation was 17 %. Generally, these reoperations can be performed safely. A reoperation for bowel obstruction, however, may carry an increased risk of EBR as a direct result of mesh–bowel adhesions. Secondary mesh infection after reoperation, although rare, may also occur. Surgeons should discuss with their patients the potential long-term implications of having an intraperitoneal mesh and how it may impact future abdominal surgery.
We investigate the effect of antiplatelet and anticoagulant medications on bleeding complications in patients undergoing ventral hernia repair.
The Abdominal Core Health Quality Collaborative ...registry was queried from 2013 to 2022 for patients who underwent ventral hernia repair, evaluating the association between antiplatelet or anticoagulant use and bleeding complications.
37,973 patients underwent ventral hernia repair: 11.5 % on antiplatelet therapy alone and 5.8 % on anticoagulation alone. Despite being held, an adjusted regression analysis showed that anticoagulation was associated with an increased risk for postoperative bleeding requiring transfusion (OR 2.4 1.7–3.4, p < 0.0001), reoperation for postoperative bleeding (OR 6.3 3.9–10.0, p < 0.0001), and readmission for bleeding complications (OR 4.9 2.9–8.2, p < 0.0001). Antiplatelet use was not a risk factor for any postoperative bleeding complication.
Despite being held preoperatively, patients on anticoagulants are at an increased risk for postoperative hemorrhagic complications. Antiplatelet therapy does not pose the same risk.
•Patients on anticoagulants were at a higher risk of bleeding complications than those not on anticoagulants.•This was not true for patients on antiplatelet agents.•Surgeons may consider holding anticoagulants for a longer perioperative period in patients undergoing hernia repair.
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