BACKGROUND:
Ventral hernias are a common, challenging, and expensive problem for both the general and reconstructive surgeon. Postoperative pulmonary complications have been reported in 1 in 5 patients undergoing this operation and can translate into significant morbidity and mortality (Blatnik et al., 2012). The aim of this study is to critically assess perioperative factors and cost utilization associated with PRM morbidity in AWR.
METHODS:
A retrospective review of AWR patients operated on between 2007 and 2012 by the senior surgeon (SJK) was performed. AWR was defined as a repair of an abdominal wall hernia with a significant loss of domain requiring a ventral hernia repair or a hernia repair requiring a component separation. Each patient record was reviewed for patient characteristics and comorbidities. Intraoperative variables including mesh type, intraoperative intra-abdominal pressures, and length of surgery were assessed. The main outcome of interest was PRM defined using hospital defined ICD-9 codes for acute respiratory complications. Multivariate logistic regression analyses were used to assess independent predictors of PRM and linear regression was used to determine the fiscal impact.
RESULTS:
One hundred thirty-four consecutive AWR performed by a single surgeon over a 5-year period at an academic teaching center were included. Patients were on average 50.2 ± 13.8 years of age with an average BMI of 32.4 ± 9.4 kg/m². Respiratory complications occurred in 15.7% (N=21) of patients and 33% required reintubation (N=7) (P<0.001). The most common co-morbid condition was hypertension (53.0%) and 67.2% of patients had at least one defined co-morbid condition. Of note, 21.6% of patients were active smokers. Hernias were frequently related to either trauma (33.6%)
or previously failed hernia repair (32.8%) and concurrent intra-abdominal procedures were commonly combined with AWR (39.6%). Component separation techniques were used in 80.1% of patients and fascial re-approximation was achieved in 72.4% of patients. ADM was used in 49.3% of patients. Procedures were on average 5.5 hours in duration.
Patients experiencing respiratory morbidity stayed on average 16.2 days long (P<0.0001) and represented the only 3 patients in the study experiencing mortality (P=0.003). Regression analysis demonstrated intraoperative blood transfusions (P=0.008), highest peak intraoperative airway pressure (P=0.017), fascial closure (P=0.013), and ASA (P=0.019) were all associated with morbidity. Linear regression analysis demonstrated that respiratory complications added cost of ,933 per patient (P<0.001). A post-hoc analysis of PRM demonstrated that patients experiencing complications stayed on average 16.2 days longer (10.4 ± 10.8 vs. 26.6 ± 17.7, P<0.0001) and represented the only 3 patients in the study experiencing mortality (0% vs. 14.3%, P=0.003). A total of 10 patients (47.5%) experiencing PRM required a tracheostomy.
CONCLUSIONS:
We present an assessment of PRM in AWR which demonstrates that preoperative surgical risk (ASA), intraoperative intra-abdominal pressures (highest peak pressure), blood transfusions, and fascial closure are factors linked to morbidity. PRM is associated with significant mortality and a tremendous cost burden underscoring the importance of preoperative risk stratification and patient selection to optimize outcome and contain cost.