Preoperative Hernia Optimization

Educational Objectives

The goal of this program is to improve optimization of patients for hernia repair. After hearing and assimilating this program, the clinician will be better able to:

1. Explain the risks of smoking on surgical outcomes in hernia repair.
2. Cite evidence associating increased risk for complications with diabetes.

Summary

Surgical outcome: nonmodifiable preoperative factors influencing surgical outcome include patient selection, size and location of hernia, surgical history, and comorbidities (eg, cardiac, pulmonary); modifiable preoperative factors include smoking, obesity, nutrition, and diabetes

Preoperative optimization: patients presenting to the emergency department with perforation or unrelenting obstruction require emergent surgery, with no scope for preoperative optimization; patients with escalating symptoms and pending skin issues may require urgent surgery in the next 1 to 4 wk; elective hernia surgery presents more opportunity to modify risk factors and optimize the likelihood of success

History taking: prior operative notes for ventral hernia repair are critical (eg, prior mesh, prior releases); with a prior anterior compartment release, a posterior compartment release carries a higher risk of destabilizing the abdominal wall; a history of prior infections (eg, methicillin-resistant Staphylococcus aureus [MRSA], Pseudomonas aeruginosa) may warrant planning for preoperative antibiotics

Effect of smoking: smoking increases the risk for hernia formation (2-fold); wound dehiscence increases by 80% and wound complications overall increase 2.5-fold in smokers; a study (Borad et al [2017]) found that smokers undergoing hernia repair have an increased likelihood of mortality (odds ratio [OR], 1.4), morbidity (OR, 1.40), wound complications (OR, 1.4), respiratory complications, and cardiac complications (OR, 1.9)

Timing of cessation: cessation of smoking <4 wk before surgery offers no benefits; a period of 8 wk after cessation is required to realize risk reduction of all complications; patients may be followed up after 2 to 3 wk to confirm cessation (a negative urine nicotine test); another visit to review and schedule the surgery after 4 wk may help realize the benefits of smoking cessation

Diabetes and hyperglycemia: a study from Emory University found a 31% increase in sternal wound infections in patients undergoing coronary artery bypass graft if hemoglobin A_1c (HbA_1c) is >7%; in another study, the wound morbidity was 9-fold higher in patients undergoing joint surgery if HbA_1c was >6.7%; other evidence (Hikata et al [2014]) found that after spinal surgery, the rate of surgical site infections (SSIs) was 0% vs 35% with HbA_1c <7% vs >7%, respectively; another study found that the rate of noncardiac postoperative infections was 12% vs 20% with HbA_1c <7% vs >7%, respectively; good preoperative glycemic control is important to prevent postoperative infections, especially in hernia surgeries involving mesh repair

Infection control: MRSA carriers and patients at risk for MRSA infection (eg, patients undergoing dialysis) should have preoperative vancomycin; a study (Bode et al [2010]) randomized nasal carriers of S aureus to decolonization drugs or placebo; in the decolonized group, the relative risk (RR) for S aureus infection was 0.4 and the RR for deep SSI was 0.2; MRSA carriers can be decolonized with mupirocin nasal ointment for 5 days after a positive nasal swab

Universal decolonization: may be implemented for major open surgeries

Chlorhexidine gluconate scrub: data from Americas Hernia Society Quality Collaborative (Prabhu et al [2017]) found that preoperative chlorhexidine gluconate scrub in patients undergoing hernia repair increased the risk for surgical site occurrence (OR, 1.34) and SSI (OR, 1.4); other studies reported similar results; chlorhexidine scrub may be harmful (may alter the local biome)

MRSA screening: routine for complex open hernia surgeries; if positive, mupirocin twice a day for 5 days may be administered; preoperative vancomycin may be planned for MRSA carriers and patients who had prior wound cultures positive for MRSA; patients with positive wound culture may receive postoperative doxycycline for 3 to 6 mo to suppress MRSA

Immunonutrition: arginine and omega-3 fatty acids may support wound healing and reduce infections; meta-analysis (Probst et al [2017]) evaluated the potential benefits of immunonutrition; although immunonutrition reduced overall complications, infectious complications, and the length of hospital stay, the benefits disappeared when the industry-funded studies were removed; standard oral nutritional supplementation may provide similar benefits; immunonutrition is controversial

Predicting the risk for complications: the CeDAR mobile application from Carolinas HealthCare System calculates the risk for complications from risk factors including height, weight, diabetes, smoking status, active infection, and concurrent gastrointestinal surgery; it also displays the increase in cost of hospital and follow-up care; the app helps in optimizing preoperative conditions by encouraging patients to better manage their risk factors

Patient education: the Emory University Hospital uses a book that aims to educate patients on how to decrease the risk for SSIs in ventral hernia surgery; different sections of the book describe appropriate steps to be followed on the day of surgery, during hospital stay, and during follow-up care; patients, with the help of a nurse practitioner, go over the book and are encouraged to carry the book at all times during their care; the nurse practitioner educates patients on drain care, explains the surgery, obtains consent, and shares nutrition advice preoperatively

Weight loss: setting unrealistic goals for patients is often detrimental; patient-set goals may deliver better results over 6 to 8 wk, with good surgical outcomes; an effective strategy of weight loss involves a mean time to surgery of 17 mo, although some patients do develop urgent symptoms

Prehabilitation: intended to optimize various factors including renal disease, obesity, nutrition, physical debilitation, diabetes, and smoking; a physical exercise program after evaluation by a physical therapist improves frailty; improving at least some risk factors before surgery may increase the likelihood of a good surgical outcome; a study (Delaney et al [2021]) evaluated the feasibility of a preoperative optimization program; only 9% of patients achieved optimization and 14% patients stopped smoking; urgent hernia surgery was required in 3% of patients

Obesity: a risk factor for hernia recurrence; a study (Pernar et al [2017]) showed that hernia repair is better not performed in patients with a body mass index (BMI) >40; the risk of developing a recurrence was 28% in patients with a BMI >40 compared with 14% in those with a BMI <40

Bariatric surgery: patients with escalating symptoms need urgent surgery; in elective surgery, bariatric surgery (eg, sleeve gastrectomy) may be considered in patients with complex hernias as an adjunct if adequate time is available (≈1 yr); optimization before hernia repair, if possible, can be beneficial

Readings

Bode LGM, Kluytmans JAJW, Wertheim HFL, et al. Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. N Engl J Med. 2010;362(1):9-17. doi:10.1056/NEJMoa0808939; Borad NP, Merchant AM. The effect of smoking on surgical outcomes in ventral hernia repair: a propensity score matched analysis of the National Surgical Quality Improvement Program data. Hernia. 2017;21(6):855-867. doi:10.1007/s10029-017-1664-1; Delaney LD, Howard R, Palazzolo K, et al. Outcomes of a presurgical optimization program for elective hernia repairs among high-risk patients. JAMA Netw Open. 2021;4(11):e2130016. doi:10.1001/jamanetworkopen.2021.30016; Eid GM, Wikiel KJ, Entabi F, et al. Ventral hernias in morbidly obese patients: a suggested algorithm for operative repair. Obes Surg. 2013;23(5):703-709. doi:10.1007/s11695-013-0883-5; Hikata T, Iwanami A, Hosogane N, et al. High preoperative hemoglobin A1c is a risk factor for surgical site infection after posterior thoracic and lumbar spinal instrumentation surgery. J Orthop Sci. 2014;19(2):223-228. doi:10.1007/s00776-013-0518-7; Pernar LIM, Pernar CH, Dieffenbach BV, et al. What is the BMI threshold for open ventral hernia repair? Surg Endosc. 2017;31(3):1311-1317. doi:10.1007/s00464-016-5113-5; Prabhu AS, Krpata DM, Phillips S, et al. Preoperative chlorhexidine gluconate use can increase risk for surgical site infections after ventral hernia repair. J Am Coll Surg. 2017;224(3):334-340. doi:10.1016/j.jamcollsurg.2016.12.013; Probst P, Ohmann S, Klaiber U, et al. Meta-analysis of immunonutrition in major abdominal surgery. Br J Surg. 2017;104(12):1594-1608. doi:10.1002/bjs.10659; Sørensen LT. Wound healing and infection in surgery. The clinical impact of smoking and smoking cessation: a systematic review and meta-analysis. Arch Surg. 2012;147(4):373-383. doi:10.1001/archsurg.2012.5; Wong J, Lam DP, Abrishami A, et al. Short-term preoperative smoking cessation and postoperative complications: a systematic review and meta-analysis. Can J Anaesth. 2012;59(3):268-279. doi:10.1007/s12630-011-9652-x.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Davis reported nothing relevant to disclose. Members of the planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Davis was recorded at the 51st Phoenix Surgical Symposium, held February 2-4, 2023, in Scottsdale, AZ, and presented by Phoenix Surgical Society. For more information about upcoming CME activities from this presenter, please visit http://www.phoenixsurgicalsociety.com. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

ABS Continuous Certification

Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit/s toward the CME [and Self-Assessment] requirements of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider’s responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

GS701001

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.