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9 Patient Comorbidities Complicating aHernia Repair
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showing a signicant increase in postoperative wound infection in smokers compared to nonsmokers. In addition to the above operative complications, multiple
studies have demonstrated smoking to be a signicant predictor of perioperative
respiratory complications in the setting of all surgery [5] as well as hernia repair
surgery specically [6]. Smoking has also been shown to increase the risk for
readmission following hernia repair in numerous studies [7, 8]. Finally, in addition to the increased risk of surgical site occurrence and perioperative complications, smoking has been shown to be a direct predictor of recurrence following
hernia repair [9, 10].
As previously noted, smoking presents as a unique preoperative risk factor that
is readily intervened upon before surgery. These interventions may include both
counseling and nicotine replacement therapy, which has been shown to be effective
in patients undergoing hernia repair. While some of the detrimental physiologic
activity of smoking may be attributable to nicotine, smoking cessation strategies
that utilize nicotine patches have been shown in prospective randomized controlled
trials to have an overall benet in the reduction of postoperative complications
including wound infection, dehiscence, and readmission [11].
With this evidence in mind, our recommendation in elective hernia repair is for
the mandatory cessation of smoking preoperatively for at least 4 weeks [10].
Compliance toward smoking cessation can be evaluated using the cotinine assay,
which has a high diagnostic performance in determining whether patients are currently smoking and are expected to have a high risk of perioperative complications. While we recommend both counseling and nicotine replacement therapy as
strategies to achieve smoking cessation, it should be noted that nicotine replacement will yield a positive cotinine test; thus, this test should be ruled out in determining compliance. Thus, if the surgeon suspects noncompliance, obtaining
anabasine or nornicotine levels (indicates tobacco use irrespective of nicotine
replacement therapy) may be warranted. To decrease morbidity, we recommend
that any patient found to be non-compliant should be rescheduled for surgery
particularly in the setting of complex hernia repair and abdominal wall reconstruction. When dealing with smaller noncomplex hernias, smoking might not
necessarily result in signicant wound morbidity; however, uniform smoking cessation is our rule.
Obesity
Obesity represents a signicant risk factor in hernia repair during both the perioperative and longitudinal periods. The relationship between obesity, metabolic syndrome, and cardiopulmonary comorbidities predisposes patients to complications
during the physiologic demands of surgery. This relationship was demonstrated in
a retrospective analysis of 78,348 patients who underwent ventral hernia repair in
the United States between 2004 and 2008.This analysis showed an increased risk
of serious pulmonary complications, including pneumonia, respiratory distress,
and pulmonary embolism, as well as signicantly longer hospital admissions in
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D. T. K. Huynh and O. M. Ghanem
patients with obesity [12]. This evidence has been correlated in multiple studies
that also identify the relationship between obesity and complications in the immediate postoperative period as well as the role of obesity as a risk factor for recurrence [13, 14].
In the setting of open ventral hernia repair, patients with a BMI≥40 have been
shown to be signicantly more likely to undergo a subsequent operation to repair a
recurrence [15]. One of the primary reasons for this increased risk for recurrence
lies in the predisposition of obese patients toward surgical site occurrences [16]. As
such, minimally invasive approaches have been postulated to decrease this risk of
surgical site occurrence and thereby decrease the chance of recurrence. However,
obesity presents a unique challenge in minimally invasive approaches as thick
abdominal walls and large amounts of visceral fat increase the technical difculty
of these repairs. Ultimately, the evidence shows similar ndings between laparoscopic approaches and open ventral hernia repair. A retrospective study of 901
patients who underwent laparoscopic ventral hernia repair also showed that patients
with a BMI≥40 are at an increased risk for recurrence following hernia repair [17].
Following this evidence, we currently recommend that patients whose BMI falls
into this range should not undergo open or laparoscopic elective hernia repair until
their weight has been optimized.
Rapid developments in the eld of hernia repair and bariatrics create an everchanging landscape in managing these patients. Guidelines for optimal management will change as more ventral hernia repairs and abdominal wall reconstructions
employ minimally invasive approaches with mesh in the retrorectus and preperitoneal positions. Guidelines will also change with new bariatric solutions, such as
balloon occlusion and endoscopic gastric sleeve. In light of this, our current recommendations for managing hernia in obese patients are as follows.
Preoperative weight loss begins with medical weight loss. A well-established
protocol for patients with ventral hernias and associated obesity was described by
Rosen etal. [18] The protocol utilizes a protein-sparing modied fast in collaboration with a medical weight loss specialist. Using this technique, the authors were
able to reduce the BMI of a group of 25 patients from an average of 49 to 40 kg/m
over an average period of 17months prior to undergoing complex abdominal wall
reconstruction. In addition, 88% of the patients were able to maintain this reduction in weight for up to 18 months postoperatively. If this initial medical and
behavioral therapy fails, we recommend bariatric surgical intervention. In patients
with concomitant morbid obesity and ventral hernia who have failed medical management, we recommend a minimally invasive weight loss operation followed by
repair of the hernia. Repair of the hernia should be timed to occur during the plateau in the weight loss curve after bariatric surgery, typically at approximately
12–18months postoperatively. Patients for whom a minimally invasive bariatric
procedure is not an option present a more complicated clinical decision. In cases
that necessitate an open weight loss operation, the surgeon must evaluate the risks
and benets of simultaneously repairing the hernia in order to close the abdominal
fascia without tension.
2
9 Patient Comorbidities Complicating aHernia Repair
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Diabetes
Hyperglycemia has profound effects on wound healing through both immunomodulatory and vasculopathic mechanisms. Due to a blunted inammatory response,
patients with diabetes are at risk for delayed wound healing. Additionally, damage
to the microvasculature can lead to relative ischemia, further decreasing the patient’s
capacity to recover following surgery. For patients undergoing inguinal hernia
repair, diabetes has been shown to increase the risk of complications in the intraoperative and immediate postoperative period (<30days). This increased risk of complications included infections, bleeding complications, and supercial wound
dehiscence [19]. Regarding complex hernia repairs, insulin-dependent patients and
patients with a blood glucose of >140mg/dL were found to have a lengthened time
to their rst meal following surgery as well as an increased length of stay and
increased cost of hospitalization [20].
As described in the studies above, a patient’s current glycemic status plays a
critical role in their ability to heal and ght infection. A study conducted between
2000 and 2003 showed a signicant reduction in surgical site infection in patients
with a hemoglobin A1c of less than 7% in the setting of all non-cardiac surgery. This
generalized nding has been corroborated in hernia repair as well; Petro et al.
showed that a diagnosis of diabetes is a signicant predictor of surgical site occurrence including surgical site infection [21]. Following from this association in
regard to surgical site occurrence, diabetes has also been linked to an increased risk
of recurrence in umbilical hernia repair [22].
Considering this evidence, our recommendations align with the expert consensus
on ventral hernia management [23]. Patients with a hemoglobin A1c of greater than
8% should not undergo elective hernia repair. Patients with a hemoglobin A1c
between 6.5 and 8% must rst be optimized through either medical or surgical
means. Once long-term glycemic control has been achieved, we recommend a perioperative blood glucose level of approximately 140 mg/dL, which prevents the
aforementioned consequences of hyperglycemia while also preventing the risks
associated with hypoglycemia in the operative setting.
Nutritional Assessment andSupplements
Nutritional status is of critical importance when considering a patient for surgery.
Failing to optimize a patient’s nutritional status preoperatively increases the risks of
morbidity, mortality, and poor outcomes [24, 25]. A well-studied method of assessing nutritional status in the surgical literature uses serum chemistries, such as albumin, with low levels of albumin predicting poor postoperative outcomes [26, 27].
However, recent evidence offers imaging techniques as an alternate modality for
assessing a patient’s preoperative nutritional status. Using cross-sectional imaging,
a patient’s sarcopenia, and thereby their nutritional status, can be evaluated by comparing the ratio of lean body mass to lipid content [28].
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Several nutrients have been evaluated in the literature and have been demonstrated to have a signicant clinical impact when given prior to surgery. Arginine is
one such nutrient and has been shown to improve wound healing, augment the tissue inammatory response, and prevent ischemia by promoting vasodilation through
local increases in NO [29–31]. While the specic benets of preoperative arginine
administration have not been shown in hernia surgery specically, they have been
described in the colorectal literature and showed a decrease in the number of readmissions and hospital days [32].
In addition to individual agents, the repletion of certain combinations of nutrients has been shown to decrease the rate of perioperative complications. One
well-studied regimen is the “metabolic modulating formula” described by Braga
etal. [33], which included omega-3 fatty acids, docosahexaenoic acid, and eicosapentaenoic acid. When preoperatively optimized using these nutrients, patients
were demonstrated to have reductions in infection, length of stay, and hospital
cost [34]. In addition to optimizing patients with these nutrients, the patients can
also be preoperatively loaded with carbohydrates to maximize glycogen stores
during surgery [35].
We nd that while nutrition is of critical importance, it is often overlooked during the preoperative planning period. There remains a signicant lack of evidencebased recommendations on the subject, especially as it pertains to specic areas of
surgery such as hernia. To date, there is a marked absence of evidence guiding
nutritional management in abdominal wall reconstruction. In this setting, we apply
the generalized data discussed above and administer the Impact© Nutritional
Supplement three times daily for the 5days leading up to surgery to replete the validated nutrients in the metabolic modulating formula.
Other Comorbid Conditions
The NSQIP surgical risk calculator is the premier resource for a comprehensive
assessment of perioperative risk [36]. The calculator represents a global assessment
of a patient’s risk for all complications in the perioperative period and sub-straties
by risk for specic complications.
Due to the stress of surgery, patients with outstanding medical conditions should
be evaluated before planning surgery and optimized prior to operating. Conditions
of the heart, lungs, and liver as well as all concurrent medical issues should be
investigated and considered when weighing the risks and benets of proceeding
with a repair.
When assessing a patient’s cardiac readiness for surgery, we recommend assessment using the American College of Cardiology/American Heart Association guidelines on perioperative cardiovascular evaluation [37] as well as the multifactorial
index of cardiac risk [38]. Patients with pulmonary comorbidities who require small
abdominal wall or groin hernia repair should be managed using monitored anesthetic care if possible to avoid the respiratory strain of general anesthesia and ventilation. Larger hernias in this population also warrant attention to the effects of
9 Patient Comorbidities Complicating aHernia Repair
restoration following the loss of domain because the reduction of hernia content into
the abdominal cavity will create signicant pulmonary changes in peak airway pressures and oxygenation. To successfully manage these patients, new studies have
described and demonstrated the efcacy of a volume transposition technique [39] in
which hernia repair is achieved with mesh that has been sized according to the calculated hernia volume. This avoids any increases in the intraabdominal pressure and
may reduce the risk of recurrence.
Finally, all pathologies that predispose patients to increased intraabdominal pressure should be optimized preoperatively because these pathologies put patients at
risk for increased herniagenicity as well as postoperative recurrence. Such conditions include chronic constipation, chronic cough, and obstructive uropathies.
115
Preoperative Workup
Laboratory Studies
The laboratory studies that will be useful when planning for a hernia repair are
dened by the specics of the patient in question. Based on comorbidities, the type
of anesthesia, and the type of repair, different studies must be obtained to optimize
and clear the patient for surgery. To this end, the studies we recommend have been
discussed alongside the condition that they are aimed to assess. In general, we recommend obtaining a complete blood count, basic metabolic panel, coagulation
panel, serum albumin, hemoglobin A1c, and cotinine if the patient is a smoker. In
addition to laboratory studies, we wish to emphasize evaluation through imaging
studies.
Imaging
While simple hernia may be diagnosed and managed based on physical examination
alone, imaging can be an invaluable if not mandatory part of preoperative planning
in complex hernias.
Ultrasound can be a helpful adjunct in the detection and management of hernias,
particularly those in the groin [40]. Ultrasound had the benet of being inexpensive,
noninvasive, and easily performed in the clinic. Ultrasound has achieved particular
utility in the detection of occult inguinal hernia as a cause of groin pain. Due to the
real-time nature of ultrasound, physicians can image as part of the physical exam
and are able to correlate exam ndings and maneuvers, such as Valsalva, with ultrasound imaging [41].
With more complicated hernias, both inguinal and otherwise, CT is an invaluable imaging modality for herniography [42], being both relatively inexpensive
and nonoperator dependent. CT not only yields information regarding the abdominal wall but also provides insight into a patient’s intraabdominal condition. CT
scan can be used to assess hernia contents, for example, in the acute setting of
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D. T. K. Huynh and O. M. Ghanem
small bowel obstruction when attempting to determine if the nidus of obstruction
is within the hernia sac or due to intraabdominal adhesions. Certain considerations should be made when interpreting a CT before hernia repair. First and
foremost, the imaging should be assessed in its entirety to identify all defects and
their locations so that the most efcient operation can be planned with regard to
approach and technique. This identication is best guided by comparison with the
physical exam, which should always guide the assessment of hernia. Once the
defects have been identied, they should be characterized by answering the following questions: What is the size of the defect? Can the defect be primarily
closed? What planes have been violated and does this corroborate with data from
previous operations? What is the optimal location for mesh placement? How
robust is the abdominal wall, and is component separation necessary or even possible? When considering recurrent hernias, one must also assess the position of
any old mesh and formulate a strategy for safe explant if needed. Old mesh should
be assessed for long-term mesh-related complications, such as shrinkage and
adhesions, and these imaging ndings should be compared with the history and
physical exam [43].
Perioperative Considerations
Anticoagulation
Anticoagulants are a powerful class of medication that when used appropriately in
the surgical setting provide signicant benets to morbidity and mortality but
which by denition increase the risk of uncontrolled bleeding: the classic surgical
complication. When deciding on whether and when to continue anticoagulation, it
is vital to understand what the medication is treating. Ultimately, there is no hard
and fast rule to dictate when to maintain and when to discontinue anticoagulation.
When in the elective setting, these decisions should be discussed with the cardiology, medicine, and vascular specialists who are responsible for prescribing these
medications, and there should be consensus on whether to stop or bridge these
medications. In the emergent setting, we recommend reversal of the agent if possible while ensuring that considerations are made to restart the medication at the
appropriate time postoperatively.
Venous Thromboembolism Prophylaxis
Venous thromboembolism is a common perioperative complication in hernia repair.
As the complexity and size of the hernia repair increase, so does the period of intraand postoperative immobility and thus the risk of a venous thromboembolic event.
Thus, we recommend adherence to the CHEST guidelines [44] for antithrombotic
therapy. These include either low-molecular-weight heparin or low-dose unfractionated heparin in addition to mechanical prophylaxis.
9 Patient Comorbidities Complicating aHernia Repair
117
Infection Prophylaxis andControl
A signicant part of hernia repair optimization does involve infection prophylaxis
and control. This segment will discuss the different aspects in this regard including
antiseptic rinsing, hair removal, skin preparation, antibiotic prophylaxis, as well as
MRSA testing.
Preoperative rinses or showering is a controversial subject that has shown varying benet in previous studies. A Cochrane review evaluated the effectiveness of
preoperative rinses with antiseptic agents such as chlorhexidine or betadine versus
the use of normal soap and found no benet in reducing surgical site infection [45].
However, many of the existing studies available for review have been underpowered
and retrospective in a heterogeneous population. Additionally, this evaluation places
all antiseptic use in one arm with no consistent protocol with which to compare.
With this in mind, we recommend the protocol described in a 2015 study by
Edmiston et al. This protocol involves a preoperative minimum of at least two
sequential showers using 118 mL of aqueous chlorhexidine gluconate 4% per
shower with a 1-min pause after application and before rinsing [46]. This optimizes
the antiseptic concentration to best eliminate gram-positive and gram-negative ora
prior to surgical intervention.
Hair removal is another intervention in which the evidence has shifted over time.
In 1999, the CDC strongly recommended against the removal of hair prior to surgery
[47]. However, a 2011 Cochrane review involving 14 randomized trials found no dif-
ference in the rate of surgical site infection in patients who had hair preoperatively
removed versus those who did not. Moreover, the review concluded that electric clippers used to remove hair were associated with a lower rate of surgical site infection
than razors [48], a nding that has been recapitulated in other meta-analyses [49]. On
the other hand, the National Institute for Health and Clinical Excellence recommendations suggested that hair may serve as a nidus for infection and thus recommend
that the mode of hair removal should minimize skin trauma [50]. In keeping with
these ndings, we recommend the use of either clippers or depilatory cream prior to
surgery when it is necessary to gain adequate vision or access to the operative site.
When selecting surgical prep solutions, we recommend chlorhexidine versus
povidone-iodine in the clean and clean-contaminated setting of hernia repair surgery
[51]. Further, and because alcohol appears to be the operative agent in these solu-
tions, alcohol-based preps such as DuraPrep
comparable outcomes [52].
The discussion on preoperative antibiotics can rst be divided into the settings of
inguinal versus ventral hernias. In inguinal hernias, the discussion can be further
delineated by approach. In a double-blinded comparison of antibiotics versus placebo in open inguinal hernias repaired with a mesh plug, antibiotics signicantly
reduced the rate of surgical site infection [53] with β-lactam/β-lactamase antibiotics
as the most effective agent followed by rst-generation cephalosporins [54].
Conversely, in open groin hernia not restricted to the mesh plug technique, a recent
meta-analysis showed no difference in outcomes when preoperative antibiotics were
utilized [55]. When considering a laparoscopic approach, studies have similarly
®
and ChloraPrep® can be used with
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D. T. K. Huynh and O. M. Ghanem
shown no benet for antibiotics preoperatively [56]. Nevertheless, our practice still
uses prophylactic antibiotics prior to both open and laparoscopic inguinal hernia
repair.
The evidence for antibiotics in ventral hernia repair paints a different picture,
particularly in incisional hernia. The evidence currently suggests that the rate of
wound infection is higher in incisional hernia repair than in other cases similarly
classied as clean. As such, the evidence shows a clear benet for the use of systemic
antibiotics when performing incisional hernia repair [57]. In keeping with the evidence, we recommend following Surgical Care Improvement Project measures, with
the administration of preoperative antibiotics within 60min of the surgical start time.
The prophylaxis of methicillin-resistant Staphylococcus aureus (MRSA) is a controversial topic. A 2015 study in the Journal of the American College of Surgeons
showed that a history of MRSA infection, even those isolated away from the abdominal wall, increases the risk of MRSA surgical site infection in ventral hernia repair
within the rst 30days postoperatively [58]. However, a similar study published in
Hernia Journal in 2016 contradicted these ndings, showing that a history of MRSA
infection had no impact on surgical site infection [59]. Both studies were limited as
they were retrospective single institution studies; however, when taken together,
they appeared to suggest that it was more effective to identify and treat higher risk
patients and move away from long-term suppressive antibiotics.
A 2017 discussion post on the International Hernia Collaboration© Facebook
group page showed three main strategies for managing MRSA among hernia surgeons. The rst, in accordance with the 2015 Journal of the American College of
Surgeons study, does not test for MRSA at all. The second selectively tests high-risk
patients preoperatively using nasal swabs to determine if treatment is necessary,
with a high risk being dened as having a personal history of MRSA infection,
health care workers, or a history of SSI.The third protocol tested for MRSA with
nasal swabs in all patients and treated them accordingly, a strategy that we
recommend.
If MRSA testing is positive, we recommend the treatment protocol described by
Bode etal., which is comprised of nasal mupirocin twice per day for 5days preoperatively and daily chlorhexidine showers for 5days [
60]. This protocol was shown
to signicantly decrease the rate of surgical site infection. In addition to this protocol, we administer cefazolin and vancomycin in the immediate preoperative period
to treat both methicillin-sensitive Staphylococcus aureus and MRSA.However, a
positive MRSA culture from the wound in proximity or overlying a hernia (stula,
infected mesh, etc.) mandates, in addition to the above measures, prolonged (up to
a year) suppressive postoperative doxycycline therapy.
Postoperative Considerations
The postoperative optimization is achieved through the enhanced recovery after surgery pathway protocol aims to reduce the metabolic, neuroendocrine, and inammatory impact of surgery to minimize morbidity and length of stay postoperatively
9 Patient Comorbidities Complicating aHernia Repair
119
[61]. This pathway relies on several key principles to accomplish this goal: the
maintenance of physiologic function, the reduction of intraoperative stress, the minimization of postoperative pain, the optimization of mobilization after surgery, and
early postoperative enteral nutrition. In application, this involves a preoperative discussion of the hospital course and planned interventions for recovery with the
patient to maintain expectations and maximize their participation in their care. In
the immediate preoperative period, pain medication and alvimopan should be
started to reduce surgical stress and promote postoperative motility, respectively.
This leads into the postoperative protocol, which emphasizes an early transition to
enteral feeding, early ambulation, incentive spirometry, and the minimal use of
narcotics.
Compared to other areas of gastrointestinal surgery, such as colorectal surgery,
hernia surgery has lagged behind in implementing enhanced recovery pathways.
The rst group to report a protocolized pathway was Novitsky etal. [62], who
described an enhanced recovery pathway that we currently follow. These pathways
have been validated through numerous metrics and have demonstrated a more rapid
advancement of diet and decreased time to return of gastrointestinal function with a
signicant cumulative reduction in the length of stay and decreased rate of readmission [63]. These ndings have been recapitulated by many labs, all demonstrating
similar benets as well as reductions in reported pain [64] and opiate usage [65].
Conclusion
To best prepare for a hernia, the surgeon must orchestrate a host of interventions
that come together to give the patient the best chance of a good outcome. This
begins with a proper history and physical and the proper use of laboratory studies
and imaging. These tools enable the surgeon to determine the specic preopera-
tive interventions that will benet these patients. Interventions such as optimiz-
ing nutritional status, encouraging smoking cessation, and promoting good
glycemic control provide the patient with a benet that is greater than the sum of
each individual intervention. When combined, this preoperative optimization
enables the surgeon to perform a superior operation and allows the patient to
achieve a superior recovery, thereby decreasing the risks of complications, mor-
bidity, and mortality following hernia repair. The literature guiding these inter-
ventions is constantly in ux; however, we have offered recommendations that
we employ in our own practices and that we believe best embody currently avail-
able evidence.
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