Abdominal Wall Hernias: Emergency Ventral Hernia Repair
The number of patients presenting acutely due to complications from a ventral hernia is increasing. Complications may include incarceration, bowel obstruction, strangulation, acute worsening of pain, and skin rupture with associated ascites leak. Emergenc
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Julie L. Holihan and Mike K. Liang
Ventral hernia repair is one of the most common operations performed by general surgeons [1]. Approximately 10 % of ventral hernia repairs are performed emergently, and this rate is rising [2, 3]. The increasing prevalence of emergency ventral hernia repair may be partially related to the growing comorbid population (e.g., obesity, smoking, aging, sedentary lifestyle), improving understanding of the impact of comorbidities on outcomes, and evolving selection criteria among surgeons [4–6]. This has left a large population of comorbid patients with ventral hernias managed nonoperatively and at risk for presenting acutely and requiring emergent repair [7, 8]. Compared to elective ventral hernia repair, emergency repair is associated with increased complication rates including infections, mortalities, reoperations, and readmissions [2]. This may be partially attributed to the fact that patients presenting acutely more frequently have significant comorbidities (e.g., diabetes or obesity) and more advanced comorbidities (e.g., poorly controlled diabetes and morbid obesity) [3, 9]. Exacerbating these cases are an acute inflammatory process, metabolic and volume derangements, and off-hour presentation (i.e., potential systems issues). Contamination due to the presence of inflammation, organ ischemia, or organ necrosis is an additional and frequent challenge. These patients require a different treatment paradigm compared to elective ventral hernia repair. For example, using advanced techniques (such as component separation) in a sub-optimal setting may not only be less effective and complicate an inevitable future surgery, but also be associated with a higher wound infection and wound complication rate [10, 11]. In assessing the best option for a given clinical setting, clinicians must assess what the primary purpose of the current surgery is, consider future surgical plans, and balance the risks and benefits. J.L. Holihan • M.K. Liang (*) Department of Surgery, University of Texas Health Science Center at Houston, 6431 Fannin St., MSB 5.254, Houston, TX 77030, USA e-mail: [email protected]; [email protected]
Presentation and Preoperative Preparation Among patients with ventral hernias managed nonoperatively, the risk of acute presentation/year is reported to be 2.6 % (range 0–20 %) per year [12–19]. Acute presentation is more likely in two patient populations: (1) patients more likely to be managed non-operatively due to medical risk or poor access to healthcare and (2) patients with concerning mechanical hernia features (Table 37.1) [2, 3, 9, 20– 22]. Older, higher risk (i.e., greater and more severe comorbidities), and lower socioeconomic status (i.e., uninsured) individuals are less likely to undergo elective surgery, while younger, healthier patients, with health insurance are more likely to undergo repair [2, 3, 9, 20]. Often, elective surgery for patients with ventral hernias is delayed or deferred due to modifiable comorbidities such as obesity or smoking. The tradi
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