Outcomes of Ventral Hernia Repair with Concomitant Cholecystectomy to Chole Or Not to Chole

Outcomes of Ventral Hernia Repair with Concomitant Cholecystectomy To chole or not to chole

Charlotte M. Horne, MD Fellow Cleveland Clinic Center for Abdominal Core Health 12.12.2019 Disclosures

• None Case Presentation

• 58 y/o F presenting with a painful recurrent incisional hernia • PMHx: Hypothyroidism • PSHx: TAH, VHR c/b mesh infection, recurrent hernia repair with Strattice underlay Case Presentation To chole or not to chole ? • Surgical history What factors • Operative approach • Size of hernia would guide • Gallstone size your decision? • Number of gallstones • Patient comorbidities Background

• Decision to remove gallbladder is complex • Many factors may guide operative decision making • Lack of data Background Complex AWR results in - Larger pieces of mesh being used - Increased technical difficulty of future cholecystectomy Background

Defer cholecystectomy ? Concomitant cholecystectomy

Pros Cons • Avoids re-operative • Upstage wound class cholecystectomy • ? Increase risk of • Avoids incisions in mesh infectious mesh • Decreased health care complication utilization • Patient may never need cholecystectomy • “Gallbladders can only make you look bad” Aim

To determine if concomitant cholecystectomy increases post-operative wound morbidity Methods: AHSQC 2013-2019

Excluded: Open Abdominal Wall • Concomitant cases • Intra-op complication Reconstruction +/- CCY

6440 Open AWR 130 Open AWR + CCY Clean Class 1 Methods: • Retrospective analysis

• Primary outcome: 30 day wound morbidity • SSI: superficial, deep or organ space infection • SSOPI: opening of wound, debridement, any mesh removal AWR AWR + CCY P-value N = 6440 N = 130

Results: ASA, n (%) 0.01 Demographics • 1 248 (4%) 2 (2%) • 2 2468 (38%) 24 (18%) • 3 3554 (55%) 99 (76%) • 4 165 (3%) 5 (4%) Gender, n (%) 0.357 • Male 3086 (48%) 57 (44%) • Female 3354 (52%) 73 (56%) BMI (Q1, median, Q3) 28 31 36 28 33 38 0.012 Immunosuppressants, n (%) 428 (7%) 7 (5%) 0.551 Smoking within 1 year, n (%) 750 (12%) 16 (12%) 0.844 Diabetes Mellitus, n (%) 1314 (21%) 37 (29%) 0.028 COPD, n (%) 456 (7%) 20 (15%) <0.001 History of Abd Wall SSI, n (%) 1150 (18%) 34 (26%) 0.017 Results: AWR AWR + P-value Hernia Characteristics N = CCY 6440 N = 130 Recurrent or Primary, n 0.018 (%) • Primary 3691 61 (47%) (57%) • Recurrent 2749 69 (53%) (43%) Hernia Width cm (Q1, 5 8 13 7 12 15 <0.001 median, Q3) Operative Details n (%) AWR AWR + CCY P-value N = 6440 N = 130

Operative Time (minutes) <0.001 0 – 59 703 (11%) 2 (2%) 60 – 119 1482 (23%) 8 (6%) 120 – 179 1803 (28%) 33 (25%) 180 – 239 1191 (18%) 32 (25%) 240+ 1261 (20%) 55 (42%) Fascial Closure, n (%) 6145 (95%) 123 (95%) 0.659 Myofascial Release, n (%) 4221 (66%) 105 (81%) <0.001 Mesh Location, n (%) 0.867 Intraperitoneal 706 (13%) 8 (7%) Preperitoneal 2272 (41%) 55 (48%) Retromuscular 3988 (71%) 99 (86%) >1 Location 1356 (24%) 47 (41%) AWR AWR + CCY P- Operative Details, n (%) N = 6440 N = 130 value Mesh Type Permanent Synthetic 6076 (94%) 106 (82%) <0.001

Resorbable Synthetic 196 (3%) 7 (5%)

Biologic 151 (2%) 16 (12%)

Wound Classification Clean (Class 1) 6440 (100%) 37 (29%) <0.001

Clean Contaminated (Class 2) Excluded 82 (63%)

Contaminated (Class 3) Excluded 8 (6%)

Dirty Infected (Class 4) Excluded 3 (2%) Results: 30 Day Outcomes

AWR AWR + CCY P-value N = 6440 N = 130

SSI, n (%) 219 (4%) 2 (2%) 0.250

SSOPI, n (%) 348 (6%) 7 (6%) 0.983

Re-operation, n (%) 101 (2%) 1 (1%) 0.473

Death n (%) 12 (<1%) 2 (2%) 0.020

PE, n (%) 44 (1%) 0 (0%) 0.347

DVT, n (%) 22 (<1%) 2 (2%) 0.024

Renal Insufficiency, n (%) 20 (<1%) 0 (0%) 0.527

Resp Failure with Intubation 46 (1%) 3 (3%) 0.035

Post-op Bleeding Transfusion 44 (1%) 0 (0%) 0.347 Factors associated with SSI • Female gender • Recurrent incisional hernia • Hx of ab wall SSI Factors associated with SSOPI • Diabetes • ASA Class • Hx of ab wall SSI • Subcutaneous flaps raised Conclusions

• Concomitant cholecystectomy in AWR was not shown to increase wound morbidity • Patient factors predictive or SSI/SSOPI - DM - ASA Class - Gender - Previous history of ab wall SSI Limitations

• Unclear indication for cholecystectomy • Database limitations • Groups were not similar - Larger, recurrent hernias - Increased comorbidities Summary

• Cholecystectomy can be offered at AWR

• Ideal candidates for concomitant cholecystectomy still undefined

• Consideration of patient factors & hernia complexity may help guide decision making hernia