National results after ventral hernia repair

Frederik Helgstrand
Danish Medical Journal 2016, 63 (7)
Ventral hernia repairs are among the most frequently performed surgical procedures. The variations of repair techniques are multiple and outcome has been unacceptable. Despite the high volume, it has been difficult to obtain sufficient data to provide evidence for best practice. In order to monitor national surgical quality and provide the warranted high volume data, the first national ventral hernia register (The Danish Ventral Hernia Database) was established in 2007 in Denmark. The present study series show that data from a well-established database supported by clinical examinations, patient files, questionnaires, and administrative data makes it possible to obtain nationwide high volume data and to achieve evidence for better outcome in a complex surgical condition as ventral hernia. Due to the high volume and included variables on surgical technique, it is now possible to make analyses adjusting for a variety of surgical techniques and different hernia specifications. We documented high 30-day complications and recurrence rates for both primary and secondary ventral hernias in a nationwide cohort. Furthermore, recurrence found by clinical examination was shown to exceed the number of patients undergoing reoperation for recurrence by a factor 4-5. The nationwide adjusted analyses proved that open mesh and laparoscopic repair for umbilical and epigastric hernias does not differ in 30-day outcome or in risk of recurrence. There is a minor risk reduction in early complications after open sutured repairs. However, the risk for a later recurrence repair is significantly higher after sutured repairs compared with mesh repairs. The study series showed that large hernia defects and open re-pairs were independent predictors for 30-day complications after an incisional hernia repair. Open procedures and large hernia defects were independent risk factors for a later recurrence re-pair. However, patients with large defects (> 15 cm) seemed to benefit from an open mesh repair compared with laparoscopic repairs. Additionally, the open sublay mesh position independently decreased the risk of recurrence repair compared with other open mesh positions. Emergency repair for a ventral hernia is dangerous and our studies revealed up to 15 times higher risk for post operative complications than after elective repairs. Especially females, older patients, and patients with small to medium sized hernias were at risk for an emergency repair compared with elective repairs. However, the many patients with untreated ventral hernias not included in the analysis, makes conclusions on risk factors for emergency repairs problematic. Because of the general lower morbidity and more advanced technology the proportion of laparoscopic procedures continues to increase at the expense of open surgery. The low incisional hernia rate is one of the major benefits of laparoscopic surgery. After 12 years follow-up, we demonstrated a low risk for a trocar site hernia repair, but the percentage of emergency repairs was relatively high. Parastomal hernias are relatively common. Nevertheless, few parastomal hernia repairs are performed annually. We documented that outcome in terms of early morbidity and recurrence is unacceptable. No difference in outcome is shown between open or laparoscopic repairs, or between the laparoscopic Keyhole and Sugerbaker technique. However, the 25% risk for 30-day mortality after an emergency parastomal hernia underlines the importance of special attention on these patients by centralisation to relative few dedicated centres and by more research to provide better surgical solutions. Based predominantly on nationwide data, the present thesis has accomplished pioneering results on outcome from ventral hernia repairs. The results have inspired to increased research and the development of other ventral hernia databases, as well as pointed out a number of risk factors for poor outcome and future challenges in ventral hernia surgery. DVHD and similar registers have a huge potential and can serve as an essential and important platform for further improvement of ventral hernia surgery in the future.

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