Conference Coverage

Algorithm helps assess surgical trade-offs of hernia repair



– Choosing an operative approach for ventral hernia can be a matter of weighing the trade-offs between infection risk, postop quality of life, and patient and defect characteristics. A predictive algorithm has been developed to help with this decision, according to a study presented at the annual clinical congress of the American College of Surgeons.

A surgeon operates on a patient jacoblund/Thinkstock

Body mass index (BMI) and defect size are important factors to consider when choosing laparoscopic versus open operative approach for ventral hernia repair. Predictive modeling indicates that open repair might be considered, for example, in low BMI patients with large defects because of potentially fewer anticipated complications and improved quality of life, according to authors of the study. Conversely, laparoscopic repair might be considered in high BMI patients with recurrent hernias to decrease the associated risk of infection, the authors noted in a published abstract of the study.

The retrospective study was based on data on ventral hernia repairs in the International Hernia Mesh Registry that were performed between 2007 and 2017. Investigators used that data to build a predictive algorithm that took into account the impact on outcomes of BMI, hernia size, and operative approach, as well as age, sex, and diabetes status.

They identified 1,906 repairs, of which about 60% were open procedures. The mean patient age was 54.9 years, while mean BMI was 31.2 kg/m2 and the mean defect area was 44.8 cm2. Patients undergoing open procedures were significantly more likely to have infections, at 3.1% versus 0.3% for the laparoscopic approach (P less than .0001), investigators found.

A multivariate regression analysis controlling for confounding variables found that patients undergoing laparoscopic repair had an increased risk of seroma (odds ratio 1.78, confidence interval 1.05-3.03) but a decreased risk of infection (OR 0.05, CI 0.01-0.42). In addition, those undergoing laparoscopic procedures were more likely to have non-ideal quality of life at 1, 6, 12, and 24 months postoperatively, said the study’s lead author, Kathryn A. Schlosser, MD, a resident in the division of gastrointestinal and minimally invasive surgery, department of surgery, Carolinas Medical Center, Charlotte, N.C.

“These are both important factors — infection and non-ideal quality of life — and need to be part of our preoperative discussion with our patients when we start managing their expectations around the time of surgery,” Dr. Schlosser said in a podium presentation.

She and her colleagues calculated probability of infection based on the ratio of BMI to defect area. They found that, for example, the probability of postoperative infection was 21% for a diabetic 69-year-old female with a recurrent hernia who had a BMI of 39 and a defect area of 20 cm2. By contrast, infection probability was 3% in a 66-year-old female with a BMI of 37, a defect area of 1 cm2, and no diabetes, Dr. Schlosser said at the meeting.

Laparoscopic versus open procedures represented a trade-off between infection risk and quality of life in this algorithm. For patients at medium risk for infection based on BMI, defect size, and other variables, switching to a laparoscopic approach dropped the infection probability from 3%-8% down to 0.1%-0.5%, Dr. Schlosser told attendees. On the other hand, switching to a laparoscopic approach increased the risk of non-ideal quality of life, she said.

One sample patient Dr. Schlosser described had an infection risk of 7.2% with the open procedure that dropped to just 0.4% for the laparoscopic procedure; however, that switch would mean that her likelihood of non-ideal quality of life 12 months after surgery increased from 24% with the open repair to 44% with the laparoscopic repair.

Dr. Schlosser had no disclosures related to the study. Co-authors provided disclosures related to Acelity, Allergan, Intuitive, Stryker, and W.L. Gore.

SOURCE: Schlosser KA, et al. abstract SF215 presented at the American College of Surgeons Clinical Congress 2018.

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