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Open Preperitoneal Ventral Hernia Repair (OPPVHR): Outcomes Over 18 Years And 1842 Patients
*Michael Katzen, *Jana Sacco, *Dau Ku, *Greg Scarola, Bradley Davis, Kent Kercher, Paul Colavita, Vedra Augenstein, B Todd Heniford
Atrium Health, Charlotte, NC

OBJECTIVE(S):
Since our first description of OPPVHR in 2006, frequent data analysis has demonstrated areas for quality improvement in patient care leading to adoption of many evidence-based changes(figure 1). The aim of this study was to describe progressive changes in perioperative management and subsequent surgical outcomes and to analyze factors that impact wound complications and recurrence.
METHODS:
Prospective, tertiary hernia center data(2004-2021) was examined for patients undergoing midline OPPVHR with mesh. Umbilical and parastomal hernias were excluded. “Early”(2004-2012) and “recent”(2013-2021) groups were based on surgery date. Standard statistical methods were used, including multivariate analysis of wound complications and hernia recurrence.
RESULTS:
Comparing early(n=675) and recent(n=1167) groups, there was no difference in gender(54.5%femalevs54.1%;p=0.85) or rate of diabetes(23.7%vs24.8%;p=0.59). The recent group had increased mean age(56.9vs58.7;p<0.01), history of tobacco-use(16.4%vs26.5%;p<0.01), prior failed VHR(46.5%vs60.8%;p<0.01), hernia-defect(200cm2 vs214cm2;p<0.01), and mesh-size(790vs846cm2;p<0.01), with lower pre-op BMI(33.5vs32.0;p<0.01), operative-time(191minvs175;p<0.01), and panniculectomy rate(31.3%vs25.6%;p=0.03). Recent patients were more likely to have contaminated wounds(CDC-class 3/4:11.3%vs18.6%; p<0.01). Rate of CST increased(22.5%vs45.7%;p<0.01): external-oblique release(EOR) remained common, but less so (17.6%vs13.0%;p=0.04), and posterior-CST increased(4.9%vs32.7%;p<0.01).The recent group had a higher rate of pre-op Botox(0%vs12.3%;p<0.01), delayed-primary closure(0.7%vs9.4%;p<0.01), and biologic mesh(10.1%vs24.8%;p<0.01). Length-of-stay(LOS) was similar(6.7vs6.3days;p=0.43), though a separate comparison of patients pre vs post 2018 shows decreased LOS(6.7 vs 5.5 days p<0.01). Recent patients had lower wound complications(26.7%vs13.2%;p<0.01), specifically cellulitis(13.4%vs4.3%;p<0.01), wound infection(14.2%vs6.4%), wound breakdown(14.5%vs6.0%;p<0.01), and mesh infection(3.1%vs0.9%;p<0.01). Hernia recurrence rate decreased(7.1%vs2.4%;p<0.01). Early patients had longer mean follow-up(4.2vs2.2years;p<0.01).Comparing respective multivariate analyses for early vs recent groups, wound complications were independently associated with panniculectomy(OR:2.9,CI:1.9-4.5,p<0.01vs2.1[1.4-3.3],p<0.01), as were contaminated wounds(2.1[1.1-3.7],p=0.02vs1.8[1.1-3.1],p=0.02), EOR(1.8[1.1-2.9],p=0.02vs3.2[1.9-5.3],p<0.01), and operative time(per minute:1.01[1.008-1.015],p<0.01vs1.004[1.001-1.007],p<0.01). Diabetes(2.6[1.7-4.0],p<0.01) and tobacco(1.8[1.1-2.9],p=0.02) were only significant in the early group; recent group requirements included preop smoking cessation and HgbA1C<7.2. In both groups, recurrence was independently associated with wound complication(8.9[4.1-20.1],p<0.01vs3.4[1.3-8.2],p<0.01) and previously failed VHR(4.9[2.3-11.5],p<0.01vs6.8[1.9-43.5]p=0.01). BMI, posterior-CST, Botox, and biologic mesh did not impact outcomes. CONCLUSIONS:
Despite an increase in patient complexity over time, detecting and implementing best practices as determined by recurring data analysis of a center’s outcomes has significantly improved patient care results.


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