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9 Patient Comorbidities Complicating aHernia Repair
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Enhanced Recovery inAbdominal
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Hernia Repair
AndrewS.Wright andRebeccaP.Petersen
“A surgeon can do more for the community by operating on
hernia cases and seeing that [their] recurrence rate is low than
[they] can by operating on cases of malignant disease.”
—Sir Cecil Wakely, 1948
While there is no question that operative technique is important in achieving good
patient outcomes, increasing evidence suggests that a coordinated and systematic
approach to pre-operative patient preparation, intra-operative management, and
post-operative care may be an even more critical contributor. Collectively, this
approach has come to be known as “Enhanced Recovery After Surgery,” or ERAS,
and represents a multidisciplinary approach to patient selection, pre-operative nutrition and optimization, intra-operative uid management, advanced pain control, and
early diet and mobilization. Originated and best studied in colorectal surgery, ERAS
protocols have been shown to reduce length of stay [1], reduce the rates of postoperative complications by up to 40% [2], and signicantly reduce costs [3]. In fact,
by one estimate, every dollar spent in implementation of ERAS protocols results in
a $3.8 savings [4]. ERAS protocols are now being adapted and extended to other
types of surgery including bariatric [5], hepatobiliary [6], gynecologic [7], and
recently to hernia surgery [8–10].
Although many of the principles of enhanced recovery come from the colorectal
literature, early results in extending these principles to hernia have been very
encouraging. Novitsky’s group at Case Comprehensive Hernia Center have recently
published their early results after implementation of an ERAS protocol in abdominal wall reconstruction [9] with a 1.8-day reduction in time to regular diet, a
10
A. S. Wright (*) · R. P. Petersen
University of Washington Medical Center, Seattle, WA, USA
e-mail: Awright2@uw.edu; rp9@uw.edu
© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2019
S. S. Davis Jr. et al. (eds.), The SAGES Manual of Hernia Surgery,
https://doi.org/10.1007/978-3-319-78411-3_10
125
126
A. S. Wright and R. P. Petersen
reduction in length of stay from 6.1 to 4.0 days, and signicantly reduced 90-day
readmission rate, from 16 to 4%.
At the UW Medicine Hernia Center, we have implemented a similar protocol,
but for all patients requiring inpatient admission following hernia repair—including
laparoscopic and open hernia repair as well as in more complex abdominal wall
reconstruction. Our current ERAS protocol is shown in Appendix 1, with key components as shown in Table 10.1. In our more heterogeneous population, we have
seen signicant improvements in length of stay and readmission (Table 10.2).
Importantly, this applies to both our laparoscopic and our open hernia population,
Table 10.1 Elements of a
typical hernia ERAS Pathway
Table 10.2 Results of ERAS implementation at the UW Hernia Center
# cases LOS ICU LOS Direct cost
All
Cases
Open
Cases
Lap
Cases
Pre-ERAS 138 5.21 0.52 $13,875 7.25
Post-ERAS 264 4.22 0.16 $11,917 5.30
%
Improvement
Pre-ERAS 116 5.31 0.57 $14,387 6.89
Post-ERAS 204 4.60 0.17 $12,372 6.86
%
Improvement
Pre-ERAS 22 4.75 0.22 $12,358 9.00
Post-ERAS 60 2.90 0.13 $10,729 0.00
%
Improvement
Pre-operative
Assessment of modiable risk factors
Patient optimization
Smoking cessation
Immunonutrition
Weight loss
Patient education
Peri-operative
Minimized pre-op fasting
Pre-op carbohydrate load
Restricted IV uid
Advanced pain control (epidural or TAP block)
Glycemic control
Antiemetic prophylaxis
Multimodal, opioid-sparing analgesia
Post-operative
Early nutrition
Early mobilization
Daily care maps
Dened discharge criteria
19.22% 14.11% 14.10% 26.90
13.20% 69.40% 14.00% 3.00
39.00% 41.30% 13.10% 100.00
30-day readmission (%)
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127
and was effective across two hospitals in our system with different cultures, administration, and IT infrastructure. Although the ERAS pathway was implemented with
a goal of improving patient outcomes, a benecial side effect has been signicant
cost savings, with over $500,000 saved annually after implementation.
This chapter is designed as a brief introduction to the concepts and principles of
ERAS programs, as well as an overview of implementation and application in the
realm of hernia surgery. SAGES and the ERAS Society have recently published a
Manual of Enhanced Recovery Programs in Gastrointestinal Surgery which explores
many of these topics in depth, and which is an excellent resource for surgeons or
others interested in starting or rening an ERAS program. Additionally, SAGES has
developed the SAGES SMART™ program to help disseminate information about
enhanced recovery programs, with further information available at https://www.
sages.org/smart-enhanced-recovery-program/ [11].
Pre-operative Phase
Success in hernia surgery starts at the rst clinic visit, with proper patient selection
and pre-operative optimization. Some risk factors (size and location of hernia, prior
operations, etc.) are not modiable but may affect decision-making about whether
to offer repair or may affect operative planning (surgical approach, use or type of
mesh). These considerations are out of the scope of this chapter, but are addressed
elsewhere in this textbook. ERAS pathways concentrate on identication of modiable risk factors that have been shown to affect patient outcomes.
Smoking has been demonstrated to affect post-operative complication rates
across almost all types of operations. In a recent analysis of the American College
of Surgeons National Surgical Quality Improvement Program (NSQIP), Schmid
etal. showed smokers have a higher risk of overall pulmonary, wound, and septic/
shock complications [12]. Although this paper did not specically look at hernia
operations, the effect of smoking on wound dehiscence and other wound complications is well described. Smoking increases the risk of hernia formation after abdominal surgery by 2×, the risk of wound dehiscence by almost 80%, and the risk of all
wound complications by 227% [13].
In the past, the impact of pre-operative smoking cessation has been controversial,
with some arguing that short-term cessation may not be sufcient to affect patient
outcomes [14]. A meta-analysis of 25 studies has shown that smoking cessation
signicantly reduces risks of both respiratory and wound complications although
the timing of cessation is important [15]. With respiratory complications, cessation
less than 4 weeks prior to surgery had no benet while cessation >4 weeks reduced
the relative risk (RR) of all complications to 0.77 and with even greater benet with
>8 weeks smoking cessation (RR 0.53). Based on this data, we recommend that no
elective hernia operations be performed in active smokers, and in our program we
require 8 weeks of abstinence prior to surgery. Compliance is checked with a urine
cotinine screening test the week prior to surgery.
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A. S. Wright and R. P. Petersen
Obesity is a risk factor for both wound complications [16] and recurrence [17,
18] after hernia repair. This is addressed more fully in the previous chapter. In the
context of ERAS protocols, the importance is recognition of patients with obesity as
a modiable risk factor. Rosen etal. have published their results with a medically
supervised program for pre-operative weight loss prior to surgery [19]. Out of 25
patients, 24 successfully lost weight with a mean weight loss of 24kg and a 9-point
reduction in BMI.Of these, 22 maintained weight loss for a median follow-up of 18
months. In our program, patients with a BMI >40 are referred to our weight loss
center, which offers both medical and surgical weight loss.
Poor pre-operative nutrition is clearly associated with poor surgical outcomes
[20]. There have been many proposed methods for assessing pre-operative nutrition
[21], many of which are impractical to use in clinical practice. In our center, we use
the Strong for Surgery checklist, available from the American College of Surgeons
(https://www.facs.org/quality-programs/strong-for-surgery) [22]. This consists of
four questions, with a “yes” answer to any questions resulting in referral to a nutritionist: Is BMI less than 19? Has the patient had unintentional weight loss of over
eight pounds in the last 3 months? Has the patient had a poor appetite—eating less
than half of meals or fewer than two meals per day? Is the patient unable to take
food orally (e.g., dysphagia, vomiting)? Although albumin is an imperfect marker of
nutritional status, all patients have a screening albumin checked, which is important
in risk stratication (albumin is a major contributor to the NSQIP algorithm) and in
identifying additional at-risk patients.
Pre-operative immunonutrition is a controversial topic, but is part of many
ERAS pathways. This consists of pre-operative nutritional supplementation using
a special formula including arginine and omega-3 fatty acids, theorized to support
wound healing and reduce infections complications [23]. A recent meta-analysis of
83 RCTs of immunonutrition in abdominal surgery showed a signicant benet
with reduced overall complications (odds ratio (OR) 0.79), infectious complications (OR 0.58), and 1.79 day reduced LOS [24]. Interestingly, the authors of this
meta- analysis found a strong likelihood of publication bias; when industry-funded
studies were removed from the analysis, the benets of immunonutrition disappeared. We currently use these supplements in our ERAS pathway although we
continue to have some concerns about compliance due to poor taste and expense
(average cost ~$55).
Glycemic control is very important prior to surgery, with uncontrolled blood
sugars being associated with signicant risk of post-operative complications [25]. It
is not uncommon for patients without the diagnosis of diabetes to have an elevated
hemoglobin A1C, essentially meaning that they were undiagnosed diabetics prior to
surgery. This elevated hemoglobin A1C in previously undiagnosed patients is associated with worse outcomes after surgery [26]. We therefore recommend testing
hemoglobin A1C in patients scheduled for hernia repair. Although there is no level
1 evidence that interventions to improve glycemic control in the pre-operative
period affect outcomes of surgery, we prefer to have patients attain a hemoglobin
A1C level below 8% prior to elective hernia repair.
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Other cardiopulmonary comorbidities should be assessed and optimized prior to
surgery. There are numerous clinical guidelines for whom should have pre-op testing for cardiac or other issues [27, 28]. In our practice, we have found assistance
from a dedicated medicine consultation hospitalist service to be invaluable. We liberally consult our medicine colleagues for assistance with pre-operative risk stratication and modication, as well as peri-operative management. Such services have
been shown to improve outcomes after vascular [29], orthopedic, and neurosurgical
procedures [30] although to our knowledge have not been studied in abdominal or
hernia surgery.
There is increasing interest in prehabilitation of patients prior to major elective
surgery. The group at McGill have initiated a 4-week program or pre-operative
moderate aerobic and resistance exercise, nutrition, and relaxation exercises [31].
They have shown this program to result in improved post-operative exercise capability 8 weeks following surgery, as measured with a 6-min walk test. It is unclear
which patients might most benet from such prehabilitation although it does appear
that patients with worse initial exercise tolerance may have a greater degree in
improvement than those with initially good exercise tolerance [32]. It is also unclear
if prehabilitation will affect other outcomes such as length of stay, complication
rates, or long-term physical function. While we have not incorporated prehabilitation into our formal hernia ERAS protocol, this is an interesting area for future
study and possible addition.
Peri-operative Phase
Long-standing tradition calls for nothing by mouth after midnight prior to surgery. In
fact, this tradition is contradicted by the evidence, which suggests that solid food can
be safely eaten up to 6h and clear liquids can be taken up to 2h prior to surgery [33].
A pre-operative carbohydrate-rich drink appears to actually improve post- operative
glycemic control, reduce insulin resistance, and decrease protein loss following surgery [34]. Most studies in this arena have used complex carbohydrate formulas,
whereas many hospitals that have adopted carbohydrate loading use sports drinks or
apple juice, which primarily contain simple sugars. It is unclear if such drinks will
have the same effect on post-operative glycemic control, or if they may in fact worsen
hyperglycemia due to differences in rapidity of absorption and metabolism.
There is great debate in the colorectal surgery literature regarding the utility of
bowel preparation, and bowel preparations of various sorts are typically included in
colorectal ERAS pathways [35]. Given that most hernia repairs do not require colon
resection, we have not included bowel preparations in our hernia ERAS protocol.
On the occasional setting of an enterocutaneous stula or expected concomitant
bowel resection, we often will move patients over to our colorectal, rather than hernia, ERAS pathway. For patients with a planned or likely bowel resection the pathway also includes alvimopan, a peripheral mu opioid-receptor blocker, which may
reduce ileus [36].
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A. S. Wright and R. P. Petersen
There are many anesthetic considerations which affect recovery following surgery [37]. Over or under resuscitation is common during surgery, and patients kept
close to uid balance (<2.5kg weight change) have signicantly less complications
and shorter LOS [38]. Prevention of post-operative nausea and vomiting improves
post-operative recovery [39], and there are numerous pharmacologic strategies to
deal with this. Normothermia reduces risk of surgical site infection (SSI) [40], and
this starts in the pre-operative holding area [41].
Hyperglycemia in the peri-operative period doubles the risk of SSI after major
abdominal surgery, and also increases the risk of both reintervention and death, as
seen in an analysis of a Washington state Surgical Care and Outcomes Assessment
Program database of more than 18,000 patients [42]. Interestingly, hyperglycemic
patients who received intra-operative insulin had no increased risk of complication,
reintervention, or death. This highlights the importance of early recognition and
management of hyperglycemia in the operating room. Despite this, more than 25%
of patients who were found to be hyperglycemic were never started on insulin.
Glucose monitoring should not be limited to diabetic patients, as hyperglycemia is
common in non-diabetic patients and outcomes of hyperglycemic non-diabetic
patients may actually be worse than outcomes of hyperglycemic diabetics, perhaps
due to underuse of insulin in this group [43]. In our practice all patients get pre-, intra-,
and post-operative glucose checks. Insulin drips are started for any glucose >140.
Avoidance of narcotics post-operatively has been a major goal of most ERAS
programs. Excellent pain control with minimal narcotics reduces post-operative
ileus, enhances post-operative mobility, and facilitates earlier recovery with reduced
LOS.Two main strategies exist for this: (1) use of blocks such as epidurals and (2)
multimodal analgesia. Together we call this “Advanced Pain Management,” which
crosses from the peri-operative to the post-operative period.
Epidurals have been frequently used in this effort [44]. As ERAS pathways and
use of laparoscopic surgery have driven LOS ever shorter, epidurals have become a
barrier to early discharge in some patients who may only need to be in the hospital
for 2–3 days but who are held up due to the logistics of the transition from epidural
to oral analgesia [45]. There is increasing experience with alternatives to epidurals
such as the Transversus Abdominus Plane (TAP) block [46].
The TAP block can be performed with standard local anesthetics injected into the
plane [47], with catheters threaded into the plane for continuous delivery of local
anesthetics [48], or more recently with slow-release liposomal bupivacaine [49].
Although literature is limited, use of liposomal bupivacaine may be more effective
than standard local anesthetics [50]; however, the costs of this new pharmacologic
agent are high and cost-effectiveness is still unclear. The relative efcacy of TAP
block in comparison to epidurals is also unknown, with limited evidence suggesting
that epidurals may be superior in some settings [48] and inferior in others [51].
Because of this uncertainty, our current ERAS pathway calls for epidural analgesia
in open cases but not in laparoscopic surgery. We have increasing experience with
TAP blocks using liposomal bupivacaine off pathway, and are in the midst of looking at our own outcomes to determine if our ERAS pathway should be modied to
include TAP blocks.
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By its nature, “multimodal analgesia” comprises many different adjunctive
treatments, and also spans the peri-operative and post-operative periods. A complete review of the entirety of options for multimodal analgesia is out of the scope
of this chapter, but there are a number of excellent reviews and guidelines available [52, 53]. Very briey, intravenous acetaminophen, nonsteroidal anti-inammatories, gabapentinoids (gabapentin or pregabalin), tramadol, intravenous
lidocaine, and glutamate receptor antagonists are all options that have been shown
to reduce post- operative narcotic use [52]. The relative efcacy of each of these
potential adjuncts is not clear, nor is cost-effectiveness. In our own pathway, we
have chosen to include pre- and post-operative gabapentin and oral acetaminophen and oral ibuprofen, with an option for intravenous ketorolac for patients
unable to tolerate a diet.
Post-operative Phase
Early feeding seems heretical to generations of surgeons trained to wait for return
of bowel function followed by a slow, stepwise introduction of rst clear liquids,
then full liquids, and nally a solid diet. There is a plethora of evidence that this
traditional approach actually delays return of bowel function and is ultimately counterproductive. In fact, early feeding reduces complication rates in gastrointestinal
surgery by 45% [54] and is safe in both colorectal and upper gastrointestinal surgery
[55]. The traditional clear liquid diet increases post-operative nausea and vomiting
in comparison to alternatives [56].
Multimodal pain management and close monitoring and control of hyperglycemia are continued in the post-operative period, as described above. Anecdotally,
many trainees are taught to advance to oral pain medicine at the same time as a diet
is ordered. This can be counterproductive in a setting with early feeding, as patients
may have a diet order written but may not actually be taking much by mouth. We
emphasize that the transition to an oral pain regimen begins when patients are actually tolerating an oral diet, typically on post-operative day 1–2 depending on clinical parameters. Similarly, intravenous uids are stopped as soon as patients take
greater than 500mL of oral intake, typically within 24h of surgery.
Early mobilization appears to signicantly ameliorate the functional and physical decline seen after abdominal surgery [57]. In a recent RCT, a structured program
of aerobic exercise along with resistance and exibility training resulted in a 22%
improvement in the percentage of patients able to walk unassisted 5 days following
abdominal surgery, with a number needed to treat of ve [58]. There is little evidence to date to specify what specic exercise or walking program is best. In our
practice, we have patients out of bed on day 0 and ambulating day 1, with specic
walking goals. Physical therapy is consulted on day 1 on all patients. Foley catheters
tend to impair mobility and prolonged catheterization promotes development of
catheter-associated urinary tract infections. We therefore recommend removal of
Foley catheters on day 1. There is no need to keep Foley catheters routinely in place
even in the presence of thoracic epidurals [59].
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