University of Mississippi, Jackson, MS, USA.
Purpose: Identification of risk factors for recurrence in repair of complex abdominal hernias
Methods: 46 patients were operated upon and followed by a single surgeon over a three year period as they underwent repair of complex abdominal hernias. Concurrent records were examined and all patients are currently followed in clinic.
Results: 46 patients over a three year period were operated upon by a single surgeon for large abdominal wall hernias. 21 (47%) had had at least one prior attempt at hernia repair. All patients were symptomatic with back or abdominal pain, inability to perform activities, and dissatisfaction with their appearance. Repair techniques included components separation in 40 (89%), with rectus fascia 33 (73%), external oblique 33 (73%), or both 26 (58%) releases employed. Six (13%) repairs included mesh primarily. Three of 25 patients undergoing their first hernia repair had recurrences (12%). These three have undergone secondary procedures and have intact repairs. Twenty one patients had a history of one or more prior repairs by other surgeons. In this group there were 12 (57%) recurrences, 9 occurring in patients with at least 2 prior repairs. All defects were significantly smaller after repair. Of these 12 recurrences, 7 required one additional operation, 4 required 2 operations, and 1 required 3 operations. One patient has a persistent hernia but is asymptomatic and does not wish further surgery. Secondary procedures included prosthetic mesh in 7 patients, local flaps in 2, and primary closure in 3. We evaluated each potential risk factor for recurrence independently of the other factors and found 69.2%, 37.5%, and 12.0% recurrence, respectively, among patients who had 2+, 1, and 0 prior operations. The odds ratio was significantly greater than 1.0 for patients who had 2+ prior operations relative to patients who had no prior operations (OR=16.5, 95% CI=2.2-43.1, p=0.007). For 1 prior operation, the ratio was not statistically significant (OR=4.4, CI=0.7-28.6, p=0.92). We found borderline significance for wound infection (recurrence=53.8% vs 24.2%, OR=3.6, CI=0.9-14.1, p=0.054) and obesity (recurrence=44.0% vs 19.0%, OR=3.3, CI=0.9-12.8, p=0.072). We performed a logistic regression analysis to evaluate the effect of each factor in turn adjusted for the other factors and found the best explanatory model for predicting recurrence included two significant risk factors: 2+ prior operations (adjusted OR=17.2, CI=2.3-128.8, p=0.011) and obesity (adjusted OR=7.8, CI=1.2-49.5, p=0.029). Our findings indicate that a history of 2+ prior operations and obesity increases the risk of recurrence in patients who undergo hernia surgery.
Conclusions: Successful repair of complicated abdominal hernias appears to be compromised by previous unsuccessful repairs. Essential components of a dynamic repair may be damaged by techniques involving direct suture or prosthetic repairs. A strategy of primary use of component separation techniques appears in this study to lead to successful outcomes.