49.02 Emergent Laparoscopic Ventral Hernia Repairs (LVHR)

A. M. Kao1, C. R. Huntington1, J. Otero1, T. Prasad1, V. Augenstein1, A. E. Lincourt1, P. D. Colavita1, B. T. Heniford1  1Carolinas Medical Center,Gastrointestinal And Minimally Invasive Surgery,Charlotte, NC, USA

Introduction:
Despite its popularity in the elective operative setting, few studies have examined the feasibility of laparoscopy in emergent VHR and, much less, its potential benefits. The aim for this study was to examine a national quality improvement program data for LVHR in the emergent setting.

Methods:
Patients who underwent an emergent VHR from 2005-2014 were queried from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Descriptive and univariate analysis were used to compare demographics, comorbidities and 30-day outcomes based on surgical approach. Multivariate linear and logistic regression models were utilized to adjust for differences in baseline patient characteristics. Multivariate models were created using statistically significant (p<0.05) variables on univariate analysis, including age, preoperative sepsis and comorbidities.

Results:
A total of 8,826 patients underwent emergency VHR; 953 (10.8%) were performed laparoscopically and 7,873 (89.2%) underwent open repair. Laparoscopic (L) VHR in the emergent setting increased over time, from 10.5% in 2009 to 14.0% in 2014. Additionally, LVHR was performed more often by an attending and resident compared to an attending alone (43.5%vs37.0%,p<0.0001). Patients who underwent open (O)VHR were older (59.7±14.8 vs 55.5±15.2,p<0.0001) and more likely to be female (65.6%vs60.7%,p<0.002), smokers (20.7%vs17.7%,p<0.03),and have ASA >3 (69.8%vs54%,p<0.0001) with increased comorbidities including diabetes, COPD, and chronic steroid use. There was no difference between BMI or functional status. Preoperative sepsis was higher in OVHR (28.5%vs16.6%,p<0.0001) and was associated with 40% increase in postoperative wound complications(95%CI 1.02-1.65). 30-day mortality rate after emergent VHR was 2.7% overall, with 2.9% after OVHR and 1.0% after LVHR. Patients who underwent LVHR had readmission rate of 6.9% and reoperation rate of 2.7% compared to OVHR with readmission of 10.1%(p<0.0007) and reoperation 5.1%(p<0.0005).  After multivariate regression to control for confounding factors, LVHR was independently associated with 63% fewer surgical site infections (95% CI 0.35-0.93) and 56% decrease in wound complications(95%CI 0.24-0.81) compared to OVHR. Patients who underwent OVHR were 1.8 times more likely to have a minor complication(95%CI 1.08-2.86), however there were no statistical differences in 30-day mortality, major complication, septic shock or reoperation between LVHR and OVHR. Total hospital length of stay was 1.6 days longer(standard error 0.79, p<0.04) in patients who underwent OVHR.

Conclusion:
Emergent LVHR is more often utilized in younger, less comorbid patients.  When controlling for these issues LVHR offers a decrease in wound complications.  OVHR otherwise appears to be an appropriate option in the emergent setting.  Long term data concerning recurrence, mesh complications, and other issues are needed.