Preoperative Optimization and Enhanced Recovery Protocols in Ventral Hernia Repair
Large or complex ventral hernias remain a challenging endeavor with potential for high rates of morbidity. In an effort to maximize outcomes, pre- and perioperative management strategies have been developed to reduce wound and other patient complications,
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Sean B. Orenstein and Robert G. Martindale
27.1 Introduction Along with recurrence as an important indicator of success following ventral hernia repair (VHR), perioperative wound morbidity greatly influences short- and long-term outcomes in patients. It is well reported that perioperative surgical site occurrences (SSOs), defined as infection, seroma, wound ischemia, and dehiscence, increase the risk of recurrent hernia greatly [1]. Therefore, the surgeon should optimize any and all measures that will promote wound healing, reduce infection, and enhance early postoperative recovery. In the ventral hernia population, the most common complication in the immediate perioperative period is surgical site infection (SSI) [2]. This chapter briefly reviews several pre- and perioperative measures that have been reported to decrease SSOs and shorten length of hospital stay. Multiple patient factors such as obesity, smoking, uncontrolled diabetes mellitus, malnutrition, and surgical site contamination are all detrimental to wound healing and should be optimized prior to surgery. Wound healing as well as those with a propensity for postoperative infections are the primary targets, both of which increase the incidence of hernia recurrence. Obesity and smoking have been demonstrated to be independent risk factors for increased recurrence of abdominal wall hernias and SSO. Poor glycemic control in the remote preoperative period and perioperative and postoperative periods has repeatedly demonstrated increased risk for superficial and deep tissue infections. Similarly, patients with malnutrition have significant alterations in wound healing and immune function and will consequently have an increased incidence of postoperative SSI as well as hernia recurrence. Unfortunately, many of our patients have several of these detrimental factors at the time of hernia S.B. Orenstein, M.D. (*) • R.G. Martindale, M.D. Ph.D. Department of Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, L223A, Portland, OR 97239, USA e-mail: [email protected]; [email protected]
repair. While all these factors influence surgical outcomes and work congruently on morbidity, many can be evaluated and treated as separate entities. Herein, we aim to describe several interventions and evaluate their effectiveness in an effort to maximize outcomes for ventral hernia repair.
27.2 Preoperative Optimization 27.2.1 Obesity Perhaps the greatest threat for the development of incisional hernias as well as recurrence following ventral hernia repair is obesity. As BMI increases, so does the recurrence rate [3–5]. The propensity for obese patients to develop incisional hernias was noted early on by surgeons performing bariatric procedures [6]. The incidence of postoperative incisional hernia occurred in up to 40 % of patients following open gastric bypass [7]. In fact, the reduction of postoperative incisional hernias following laparoscopic gastric bypass was one of the major reasons for performing minimally invasive bariatric procedures. We have f
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