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.