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Laparoscopy linked to lower surgical infections for hernia surgery



– A large retrospective study found that laparoscopic repair of umbilical hernias in patients with obesity resulted in lower rates of wound complications than open repair even though the laparoscopic group had higher body mass index and rates of other key comorbidities, according to results reported at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

“In patients with obesity, even though our laparoscopic umbilical hernia repair [UHR] group had an overall higher BMI; higher rates of diabetes, hypertension, and current smoking status; and longer operative times, they experienced decreased postoperative wound complications, compared to the open-repair group,” said Kristen Williams, MD, of TriHealth in Cincinnati.

The retrospective cohort study evaluated 12,026 adult patients with a BMI of more than 30 kg/m2 in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who had UHR in 2016. Almost four times as many patients had open rather than laparoscopic surgery (9,695 vs. 2,331, respectively)

Dr. Williams noted that two previous studies reported lower wound infection rates after laparoscopic hernia repair in patients with obesity: an analysis of ventral, not just umbilical, hernia repair based on the NSQIP database from 2009-2012 (Am J Surg. 2015;210:1029-30) and a single-institution retrospective chart review from 2003-2009 of patients who had umbilical hernia repair (Am J Surg. 2013;205:231-6). “In our study we wanted to compare the rate of postoperative complications after laparoscopic vs. open umbilical hernia repairs in patients with obesity based on NSQIP review,” she said.

The rate of composite surgical-site infections in the open group was 1.9% vs. 1.1% in the laparoscopic group (P less than .01), Dr. Williams noted. “SSI was statistically significantly higher in the open-repair group, and there was a trend toward higher deep SSI in the open group [0.3% vs. 0.1%; P = .147],” she said. Laparoscopic patients had significantly higher rates of postoperative pneumonia (0.4% vs 0.1%; P = .012), but Dr. Williams noted this was only significant in the non–elective surgery group. Operative times were significantly longer in the laparoscopic repair group (70 vs. 44 minutes). “The literature shows that longer operative times are associated with higher rates of SSI,” Dr. Williams added. “However our laparoscopic group still had lower rates of composite SSI.”

“Logistic regression was utilized and found that morbidity, defined as superficial, deep, and organ-space SSIs, was significantly increased in the open-repair group,” Dr. Williams said.

A higher percentage of patients in the laparoscopic group were women than in the open group (29.4% vs. 24.4%; P less than .001). The laparoscopic group had statistically significant higher average BMI (37.5 vs. 36.1; P less than .001) and higher rates of smoking (18.6% vs. 16.5%; P = .018), diabetes (18.4% vs. 15.8%; P = .002), and hypertension (47.5% vs. 43.8%; P = .001) than the open group.

The study also analyzed outcomes by BMI class. “As BMI class increased, superficial SSI, deep SSI, return-to-OR rates, postoperative pneumonia rates, and composite SSI increased in the open-repair group, indicating that higher BMI is associated with higher rates of complications in the open-repair group,” Dr. Williams said. Likewise, as obesity class increased, so did operative times in both the open and laparoscopic groups, she added.

She also noted that this study reported a significant increase in the proportion of laparoscopic UHRs than did a retrospective cohort study of 2009 and 2010 NSQIP files of UHR (Surg Endosc. 2014;28:741-6), 19.4% in this study versus 10.5% in that one.

Dr. Williams had no financial relationships to disclose.

SOURCE: Williams K et al. SAGES 2019, Abstract S099.

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