J. Fernandez-Moure1, A. M. Wes2, L. Kaplan1, J. Fischer2 1Hospital Of The University Of Pennsylvania,Traumatology, Surgical Critical Care, And Emergency Surgery,Philadelphia, PA, USA 2Hospital Of The University Of Pennsylvania,Plastic Surgery,Philadelphia, PA, USA
Introduction: Emergency surgery (ES) has been associated with increased rates of ventral incisional hernia (VIH). In high-risk patients, prophylactic mesh (PM) placement and small bite fascial sutures (SBS) have been shown to be safe and effective in preventing VIH. A preoperative risk stratification model for VIH following ES may identify patients who could benefit from PM. This study aims to quantify the incidence of surgically treated VIH in ES patients and develop a clinically actionable risk stratification scheme.
Methods: We retrospectively reviewed all patients who underwent abdominal operations requiring fascial incision within an urban academic hospital system from 2005-2013. Comorbidities and operative characteristics were assessed. The primary outcome was surgically treated VIH. We excluded patients having less than 1-year follow-up and patients undergoing elective surgery, planned hernia surgery, or a urologic procedure. Hernia risk was calculated with logistic regression modeling and validated using bootstrapping techniques. Beta (β ) coefficients were calculated to correlate risk. A simplified clinical risk assessment tool was derived by assigning point values to the rounded b coefficients.
Results: 4,400 patients with a 14.5% incidence of surgically treated VIH were identified. The strongest risk factors associated with VIH included hypertension, BMI >30, tobacco use, age >30 yr, prior GI surgery, and peritoneal contamination. Each risk factor was assigned a rounded risk score of 1 based on β coefficients and 3 risk tiers were stratified. VIH incidence in high risk patients was 10.9% compared with 4% and 1% of medium and low risk patients, respectively (C-statistic=0.68) (Figure 1). Patients with all six risk factors evidenced the highest VIH risk (20%).
Conclusion: Preoperative identification of ES patients at risk for VIH may help guide a preventative strategy to reduce its incidence and aid in pre-operative patient counseling. Given the primary outcome was surgically corrected VIH within the same system the incidence of hernia in this poplulation may be underestimated. At-risk patient identification may be aided by using a clinically relevant 6-factor risk stratification model. Model use may inform the decision to engage in specific VIH reduction strategies that could include prophylactic mesh placement.
