Optimizing Hernia Care (It is more than patching a hole!)

Bulent Cetindag M.D. Associate Professor of Surgery

University of Iowa Carver College of Medicine

Goal of Optimizing

• Three hundred fifty thousand incisional/ventral hernias were done annually in U.S.

• This accounts for $3.2 Billion • Despite all the expense the recurrence rate is 10-63% • Additional 750,000 inguinal hernias have recurrence

rates 2-5%.

WHY!

Definition of Insanity

The definition of insanity is doing the same thing over and over again and expecting a different result. Albert Einstein

How to optimize ?

• Preoperative elimination of risk factors • Operative planning • Continuous Quality improvement Monitoring quality , benchmarking results Value care , achieve same or better results with less cost. VALUE=Quality/Cost Organizational improvement. Gathering everyone around the same goal of excellence.

Preoperative risk factors

• Smoking (Major) • Obesity (Major) • Diabetes (Major) • Immune suppression/ Chemotherapy • Colonization open wounds

Smoking

• Reduces Blood and tissue oxygen tension which causes healing problems.

• Causes collagen degradation (Native hernias are more common in smokers than non-smokers)

• Paralyses the enzymes of collagen synthesis (Recurrences)

Smoking

• Native hernias are more common in smokers • Incisional hernias more common in smokers

after abdominal surgery • Hernia recurrence and wound complications

can be increased 4 fold after smoking

Smoking 45 male 2 ppd smoker Diverticulitis, postop dehiscense X 3

Smoking/Colonization GOALS: Wound control Smoking cessation

Smoking Risk of Wound Complications is 25-40 %

Risk of wound complication or recurrence is up to 100-160%

Smoking

Smoking Cessation N=228 Smokers Nonsmokers 30 days of

smoking cessation

Nicotine patch

Surgical site occurences

12% 2% 2.3% 2.3%

Ann Surg. 2003 Jul;238(1):1-5. Abstinence from smoking reduces incisional wound infection: a randomized controlled trial. Sorensen LT1, Karlsmark T, Gottrup F.

• 53 y F with morbid obesity with history of multiple abdominal operations: – Cholecystectomy – Umbilical hernia repair – Small bowel resection – Multiple ventral hernia repair with mesh

implantation – Left oophorectomy

• Last VHR complicated by dehiscense • Plastics consulted for wound closure , Hb A1c

11

Diabetes

• Skin grafting, rhomboid flap • Continued problems with wound healing • Began draining yellow fluid in January 2014

– Enterocutaneous (EC) fistula

• Managed with NPO, TPN for months with out success of spontaneous closure of EC fistula

Diabetes

• HbA1c down to 7.9 • Taken to the OR on 4/7/14 • Takedown of enterocutaneous fistula with

small bowel resection and hernia repair with mesh

• Panniculectomy by Plastic surgery

Diabetes

Diabetes

DIABETES

• Hyperglycemia is associated with poor neutrophil function.

• HbA1c 7% or lower are associated with significantly reduced infection rate after elective non-cardiovascular surgery.

Chemotherapy/immunesupression

• 45 years old smoker male, perforated colon from chemo drugs , with stage-4 renal cancer

• Long recovery with wound issues. • Saw plastic surgery and demands for hernia

repair. • He receives biologic mesh repair • But, no stop of chemotherapy which was

consist of tyrosine kinase inhibitors.

Immune supression/Chemotherapy

Immune suppression/Chemotherapy

JR Merry Christmas!, Dr. Centindag, to the World Famous Doctor, that put me back together! God Bless you & your family Dec 25, 2016 · Sent from Messenger Bulent Cetindag Same to you, glad to hear from you! Hope all is well! Dec 25, 2016 JR Happy Birthday to the Specialist Doctor who put me back together. Have a Happy 51st! Is Dr. Hassan still Working with you at same Iowa Hospital? If so tell him I said hi! Oct 19, 2017 · Sent from Messenger Bulent Cetindag I will. It is great to hear from you anf know that you are doing well. I will let Imran know also Oct 19, 2017 JR Thank you, just had 2 wedge resection from right lung done at HSHS SpFld same kidney cancer diagnosis. Ct scan/chest/and/pelvis due 1/2/18 to see if Cancer free or not. Back to see Dr. Mocharnuk week after. Just had a colonoscopy done by Hassan’s replacement transfer Dr. Poola from Mayo Clinic =no polyps. Oct 19, 2017 · Sent from Messenger Bulent Cetindag Sounds like after all that scare things are looking up. Is abdominal wall holding up? Oct 20, 2017 JR Yes no problems abdomen anymore Oct 20, 2017 · Seen Oct 20 · Sent from Messenger

• 72 y F with morbid obesity, spinal stenosis • S/p gastric ileojejunal bypass over 3o yrs ago

– Over 200 lb wt loss – Still weighed nearly 300 lbs

• Previous hernia repair failed, once and sunsequent developed spontaneous ulceration on the pannus

• Initially seen by general surgery for chronic abdominal wall hernia, but decided against repair

• Also followed by wound center for chronic non-healing ulcer on abdominal wall for approximately 1 ½ yrs, lost another 60 lb

OBESITY

Obesity

Obesity

Obesity

• The ideal BMI is unknown. • But there is positive correlation between BMI

and recurrence rates • Obesity associated with higher complication

rates, such as SSO, SSI, and fat necrosis. • 10% increase in rate of recurrence per BMI

unit, in 24 month follow up. • BMI 50 is prohibitive risk for recurrence

Criteria for Mercy

• BMI < 35 • HbA1c < 7-7.5 • Smoking cessation at least 3 weeks, before

scheduling and 8 weeks following surgery. Nicotine test is done on case by case basis.

Other Preoperative Considerations

• Axial Imaging: With contrast and valsalva maneuver. Determine urgency of operation, evaluation of abdominal vasculature, anatomy of muscles, additional abdominal defects. Reveals rare intra-abdominal defect , that requires more immediate attention.

• Available ERAS protocols.

Setting goals with the patient

There are 2000 or more ways to fix a hernia, between mesh types, sutures, mesh location, repair techniques. • 4 main types of hernia mesh • 6 types of suture and fixation • 4 general main repair techniques • 4 different levels of mesh placement Only 384 combinations without getting into individual brands and techniques.

Mesh Types

• Synthetic • Biologic • Synthetic absorbable • Biologic absorbable

Surgical techniques

• Open • Laparoscopic • Robotic • Advancement flaps

Location of placement

Etiology of previous failures

Patient Health history

Material Chareacteristics

DECISION

Symptoms and size of hernia

Contamination

Intraoperative findings

Expectations

Patient culture

Cost

Previous surgical attempts

Factors influencing decision

Why Watchful Waiting is an Alternative

• Risk of incarceration in ventral incisional hernias 4% in 5 years.

• For inguinal hernias less 0.5% per patient year.

Quality Improvement

Monitoring quality , benchmarking results Value care , achieve same or better results with less cost. VALUE=Quality/Cost Organizational improvement. Gathering everyone around the same goal of excellence.

American Hernia Society Quality Collaborative (AHSQC)

• The Americas Hernia Society Quality Collaborative (AHSQC) was formed with the mission to provide health care professionals real-time information for maximizing value in hernia care. The initial disease areas selected for CQI were ventral hernias. Now includes inguinal hernias.

• A prospective registry was created with real-time analytic feedback to surgeons. A data assurance process was implemented to ensure maximal data quality and completeness. Four collaborative meetings per year were established to meet the goals of the AHSQC.

• Since 2014, over 27000 patients registered by 254 surgeons.

Patient Risk Factors Mercy vs AHSQC

Outcomes (Mercy vs AHSQC)

Value/Quality

• Epidurals are costly and associated with higher rate of DVT’s for Abdominal wall reconstruction

• Simple questionnaire 2 weeks of surgery reduces the complication rates

• Preoperative home skin decolonization maybe associated with increase SSO and SSI’s

• Laparoscopic ventral hernia repair has longer length of stay vs robotic and more SSO’s when mesh is placed in intra-peritoneal position.

Value/ Quality

• Robotic inguinal hernias are associated less chronic pain and better quality of life. (Unpublished Data)

AHSQC

AHSQC

Raw cost robotic vs laparoscopic

$ 38

$450 $461

Raw Cost

$145

$145

$54

Raw cost

$300

$300

$1 TAPP= $ 1492 R-TAPP= $ 791

What constitutes a high quality care

Institute of Medicine’s (IOM) report Crossing the Quality Chasm: A New Health System, for the 21st Century:

Safe Planned and managed to prevent harm to patients from medical or administrative errors.

Effective Based on scientific knowledge, and executed well to maximize their benefit.

Timely Patients receive needed transitions and consultative services without unnecessary delays.

Patient-centered

Responsive to patient and family needs and preferences.

Efficient Limited to necessary referrals, and avoids duplication of services.

Equitable The availability and quality of transitions and referrals should not vary by the personal characteristics of patients.