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Original Investigation
August 3, 2022

Reoperation Through a Prosthetic-Reinforced Abdominal Wall and Its Association With Postoperative Outcomes and Longitudinal Health Care Utilization

Author Affiliations
  • 1Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
  • 2Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
  • 3Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia
  • 4Division of Gastrointestinal Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
JAMA Surg. Published online August 3, 2022. doi:10.1001/jamasurg.2022.3320
Key Points

Question  Is the risk of adverse postoperative outcomes and health care utilization after an abdominal operation increased by a history of incisional hernia repair with mesh (IHRWM)?

Findings  In this multistate, population-based cohort study, prior IHRWM was associated with a 43%-increased risk of postoperative complications, 1-day increased length of hospital stay, and increased charges of $11 896 after common abdominal procedures compared with propensity score–matched controls without a history of abdominal surgical procedures. The observed treatment outcome persisted when prior IHRWM was compared with a history of previous abdominal operation.

Meaning  Reoperation through a prosthetic-reinforced abdominal wall is associated with increased adverse postoperative outcomes and health care utilization.

Abstract

Importance  Prosthetic reinforcement of critically sized incisional hernias is necessary to decrease hernia recurrence, but long-term prosthetic-mesh footprint may increase complication risk during subsequent abdominal operations.

Objective  To investigate the association of prior incisional hernia repair with mesh (IHRWM) with postoperative outcomes and health care utilization after common abdominal operations.

Design, Setting, and Participants  This was a population-based, retrospective cohort study of patients undergoing inpatient abdominal surgical procedures during the period of January 2009 to December 2016, with at least 1 year of follow-up within 5 geographically diverse statewide inpatient/ambulatory databases (Florida, Iowa, Nebraska, New York, Utah). History of an abdominal operation was ascertained within the 3-year period preceding the index operation. Patients admitted to the hospital with a history of an abdominal operation (ie, bariatric, cholecystectomy, small- or large-bowel resection, prostatectomy, gynecologic) were identified using the International Classification of Diseases, Ninth Revision and Tenth Revision, Clinical Modification procedure codes. Patients with prior IHRWM were propensity score matched (1:1) to controls both with and without a history of an abdominal surgical procedure based on clinical and operative characteristics. Data analysis was conducted from March 1 to November 27, 2021.

Main Outcomes and Measures  The primary outcome was a composite of adverse postoperative outcomes (surgical and nonsurgical). Secondary outcomes included health care utilization determined by length of hospital stay, hospital charges, and 1-year readmissions. Logistic and Cox regression determined the association of prior IHRWM with the outcomes of interest. Additional subanalyses matched and compared patients with prior IHR without mesh (IHRWOM) to those with a history of an abdominal operation.

Results  Of the 914 105 patients undergoing common abdominal surgical procedures (81 123 bariatric [8.9%], 284 450 small- or large-bowel resection [31.1%], 223 768 cholecystectomy [24.5%], 33 183 prostatectomy [3.6%], and 291 581 gynecologic [31.9%]), all 3517 patients (age group: 46-55 years, 1547 [44.0%]; 2396 majority sex [68.1%]) with prior IHRWM were matched to patients without a history of abdominal surgical procedures. After matching, prior IHRWM was associated with increased overall complications (odds ratio [OR], 1.43; 95% CI, 1.27-1.60), surgical complications (OR, 1.51; 95% CI, 1.34-1.70), length of hospital stay (mean increase of 1.03 days; 95% CI, 0.56-1.49 days; P < .001), index admission charges (predicted mean difference of $11 896.10; 95% CI, $6096.80-$17 695.40; P < .001), and 1-year unplanned readmissions (hazard ratio, 1.14; 95% CI, 1.05-1.25; P = .002). This trend persisted even when comparing matched patients with prior IHRWM to patients with a history of abdominal surgical procedures, and the treatment outcome disappeared when comparing patients with prior IHRWOM to those without a previous abdominal operation.

Conclusions and Relevance  Reoperation through a previously prosthetic-reinforced abdominal wall was associated with increased surgical complications and health care utilization. This risk appeared to be independent of a history of abdominal surgical procedures and was magnified by the presence of a prosthetic-mesh footprint in the abdominal wall.

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