A. Y. Lee1, G. Sugiyama1, M. G. Sfakianos1, J. M. Nicastro1, G. F. Coppa1, P. Chung2,3 1Zucker School of Medicine, Hofstra Northwell,Department Of Surgery,Manhasset, NY, USA 2State University of New York Downstate Medical Center,Department Of Surgery,Brooklyn, NY, USA 3Coney Island Hospital,Department Of Surgery,Brooklyn, NY, USA
Introduction:
Laparoscopic ventral hernia repair is widely employed and associated with decreased postoperative pain and reduced length of stay (LOS). We sought to investigate factors that might influence LOS following laparoscopic ventral hernia repair, such as operative time.
Methods:
We used the 2010-2015 ACS NSQIP Participant Use Files (PUF) and identified cases with laparoscopic repair (CPT code 49652) for ventral hernia without mention of obstruction or gangrene (ICD9 codes 553.2, 553.20, 553.21, 553.29). We included only adult (≥18 years) patients that underwent elective surgery, admitted from home, performed by a General Surgeon. We excluded cases with small bowel resection (CPT code 44120), disseminated cancer, wound class III or IV, and missing data. Operative times <5 minutes and LOS >30 days were also excluded. Operative time was divided into quartiles (1st: <61 minutes; 2nd: 61-90 minutes; 3rd: 90-135 minutes; 4th: ≥135 minutes). Age was also divided into quartiles (1st: <47 years; 2nd: 47-58 years; 3rd: 58-67 years; 4th: >67 years). Risk variables included age, sex, race, morbid obesity status, history of diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), dyspnea, bleeding disorder, ascites, hypertension, renal failure, dialysis dependent, functional status, smoking status, steroid use, weight loss, preoperative transfusion within 72 hours of surgery, ASA class, and operative time. Primary outcome was LOS. Multivariable analysis was performed using negative binomial regression adjusting for all risk variables.
Results:
We found 1,791 patients with mean age 56.2 years. Majority were women (n=1,082, 60.4%), and White (n=1,534, 85.7%). Median LOS was 1.0 (SD 2.35) days. Negative binomial regression showed that ASA class IV vs I (IRR 2.90, p<0.0001), ASA class III vs I (IRR 2.92, p<0.0001), class II vs I (IRR 1.98, p=0.00013), partially dependent vs independent functional status (IRR 2.15, p=0.024), history of COPD (IRR 1.60, p=0.00047), insulin dependent diabetes (IRR 1.43, p=0.0037), and 4th vs 1st quartile of age (IRR 1.39, p=0.0011) were associated with increased LOS. Additionally, Black vs White race (IRR 1.32, p=0.0015), 4th vs 1st quartile (IRR 4.35, p<0.0001), 3rd vs 1st quartile (IRR 2.79, p<0.0001), 2nd vs 1st quartile (IRR 1.91, p<0.0001) operative times were highly associated with increased LOS. Dialysis dependent (IRR 0.59, p=0.040), male vs female sex (IRR 0.84, p=0.0035), and morbid obesity (IRR 0.87, p=0.036) were associated with decreased LOS.
Conclusion:
In this large observational study using a national clinical database, operative time in patients undergoing elective laparoscopic ventral hernia repair is independently associated with increased LOS in patients. Additionally, Black vs White race was also found to be independently associated with increased LOS. Prospective studies are warranted to determine ways to decrease disparities in care.