Here’s what you need to know before your next complex hernia repair.
You know the odds: Many of your complex ventral hernia patients will experience a reoccurrence, and their success is often predetermined even before they set foot in your operating room. That’s why more and more surgeons are now focused on establishing an Enhanced Recovery After Surgery (ERAS) protocol, that is optimizing patient-related factors like body mass index (BMI), smoking and diabetes control, before open hernia repair surgery.
That’s quite a challenge. Nearly half of adults in the U.S. are classified as obese, and it’s no wonder that patients are presenting with ever-larger complex ventral hernias with loss of domain so severe as to upset their center of gravity.
“My usual patient has a pretty big hernia,” says Dr. Eric Pauli, chief of the Division of Minimally Invasive and Bariatric Surgery at the Milton S. Hershey Medical Center in Hershey, PA. “They say, ‘I’ll bet you’ve never seen anything like this before,’ and I usually tell them, ‘You’re not the biggest hernia I’m going to see in clinic today.’ They’ve been referred to me because the doctor who first saw them said, ‘That’s too big. I can’t fix it.’”
Complex Hernias and Complex Health Factors
A large complex ventral hernia is typically defined as larger than 10 cm or having a loss of domain greater than 30% of abdominal contents, but complexity also depends on a myriad of factors including location, size, depth and condition of the surrounding tissue. The involved nature of these complex hernias means that they are often repaired in open hernia repair surgery.
Recurrence rates following primary repair range as high as 25% to 49%, and breakdown following conventional treatment of recurrent hernias can exceed 50%. Hernias that recur are associated with an even higher risk of wound infection (42% vs. 12% for initial surgery) and future recurrence. Patient-related factors such as obesity, smoking and uncontrolled diabetes have been linked with higher recurrence and complication rates.
While hernias can come from a variety of sources, incisional hernias— the most common complication after a laparotomy—are a driving cause of complex ventral hernias. There are an estimated 4 million laparotomies performed each year in the U.S. alone, and that number is rising.
Despite surgical innovations in complex ventral hernia repair, namely the separation of components technique and advanced suture techniques such as the short stitch, recurrence rates remain high. There is also no single, definitive surgical approach.
In response, surgeons have moved towards optimizing patient-related factors before surgery to improve outcomes, reduce complications and minimize recurrence. “The best opportunity to fix your hernia is the first time,” says Dr. J. Scott Roth, division chief, General, Endocrine and Metabolic Surgery at the University of Kentucky College of Medicine. “Every subsequent operation has a higher failure rate than the one prior.
The ERAS Protocol
In 1997, a group of general surgeons in Northern Europe introduced the Enhanced Recovery After Surgery (ERAS) protocol for preoperative patient management associated with improved clinical outcomes.
ERAS protocol recommendations include:
- Smoking cessation at least four weeks prior to surgery
- Glucose level below 110 mg/dL
- Hemoglobin A1C concentration less than 7.0%
- BMI as follows:
- BMI > 30 kg/ m2 (weight loss and diet counseling)
- BMI > 45 kg/m2 (consider bariatric surgery referral)
- BMI > 50 kg/m2 (not recommended for elective repair).
In addition to improved clinical outcomes, the ERAS protocol for all surgeries are associated with shorter hospital stays, a faster return to bowel function, a 50% reduction in surgical site infections and a 75% reduction in superficial surgical site infections.
“We set goals and maintain standards because we can point to good patient outcomes when we meet those criteria in our Hernia Center,” says Dr. Pauli. “It’s a challenge to say to what degree one particular factor makes compared to another. That’s why we try to treat all of these factors and take them all seriously.
Learn how other hernia surgeons approach obesity, smoking, nutrition and uncontrolled diabetes in our special report, How to Optimize Patient-Related Factors in Complex Ventral Hernia Repair.