Patient selection, Pre-operative optimization, and Peri-Operative care for Incisional Hernia Repair and Abdominal Wall Reconstruction

1. Complex Ventral & AWR
Patient Selection
Pre-op Optimization and Planning
Peri-operative Management
Andrew S. Wright MD
University of Washington
Twitter: @andrewswright
Email: awright2@uw.edu

2. “A surgeon can do more for the community by operating
on hernia cases and seeing that his recurrence rate is low
than he can by operating on cases of malignant disease ”
Sir Cecil Wakely 1948

3. Spectrum of Disease

5. Patient Selection

6. Initial Evaluation
 Symptoms
 Beware pre-op pain
 Increases risk of chronic post-op pain 2x
 Of pts w/ severe pain 1/3 resolve, 1/3 improve, 1/3 persist

7. Initial Evaluation
 Physical Exam
 All Prior Op Notes
 ? Imaging

8. Patient Selection
 Is it a recurrence?
 How was the initial repair done?
 If mesh used,
 Size and Type
 Where placed?
 Was there an early complication?

9. Patient Selection
 Is it a recurrence?
 How was the initial repair done?
 If mesh used,
 Size and Type
 Where placed?
 Was there an early complication?
How can I do it better or differently this time?

10. Factors Leading to Recurrence

11. Pre-op Optimization

12. ACS Risk Calculator

13. Pre-op Optimization and Counseling
 Smoking Cessation
 Morbid Obesity
 Nutrition
 Glucose Control
 Risk Stratification and Management

14. Tobacco
 2X risk of SSI
 30% higher risk of 30 day re-admission

15. Obesity
SSI Risk

16. Obesity
BMI 33 2.6X risk
BMI 38 4.2X risk

17. Pre-op Weight Loss
 Referral to medical weight loss
 Protein-sparing fast
 PT/exercise
 Avoid specific weight loss target
 Goal BMI<40
 3 month recheck with surgeon

19. Diabetes

20. CeDAR

21. Immunonutrition
 Arginine-based supplement 5-7 days pre-op
 Reduces SSI 2X (colorectal literature)

22. Value of Medicine Consult Service

23. Liver Disease

24. UW Pre-op Risk Modification Strategy
 No elective hernia repair in smokers
 Urine Cotinine
 BMI>40 referral to Bariatrics and/or Medical Weight Loss
 Immunonutrition
 MRSA Screening
 HgbA1C, CMP (albumin)
 Medicine Consultation

25. Pre-op Planning and
Decision-Making

26. Pre-op planning
 Who gets which approach?
 “Traditional” Open
 “Traditional” Lap
 Abdominal Wall Reconstruction
 Open or MIS

28. Innovative approaches: Abdominal Wall Reconstruction
Lap/Robotic AWR

34. “Difficult Hernias”
 Stomas
 Loss of Domain
 Infection/EC Fistula
 Prior Component Separation

35. Difficult Hernia - Stoma
 Sugarbaker
 Lap vs Open

36. Difficult Hernia - Stoma
 External Oblique release (lateral to stoma)
 Avoids stoma (through rectus)
 Avoids retrorectus Space
 Underlay vs Onlay Mesh

37. Difficult Hernia - Stoma
 STORM (retrorectus keyhole)
Photos courtesy Conrad Ballecer

38. Difficult Hernia - Stoma
 Pauli technique (Sugarbaker/retrorectus hybrid)

39. Difficult Hernia: Loss of Domain

41. Difficult Hernia: Loss of Domain
 Progressive pneumoperitoneum
 Pre-op Botox?
Hernia (2016) 20:191–199

42. Difficult Hernia - Recurrence after prior
“component”
 Anatomy is key!

43. Difficult Hernia –
Infected Mesh/EC Fistula
 Source Control
 Role of definitive repair?
 47% wound complication rate
 Hernia recurrence 31% (majority asymptomatic)

44. The Difficult Hernia
 Open Abdomen
 Damage Control
 Serial Washouts/Serial
Closure
 Fascial closure if possible,
bridge if not

45. “End Stage Hernia”
 No Repair!
 Consider Palliative Care or Rehab Medicine

46. Calling for Help

49. Peri-op Management

52. ERAS Protocol
 Pre-op optimization
 Patient Education
 Anesthesia and pain control
 Limit fluid resuscitation
 Epidural vs TAP blocks
 Gabapentin
 Glucose control
 Early feeding and mobilization

53. Prior to
DOS
Implement
Strong for
Surgery pre-
hospital clinical
interventions
Clinic Staff Discuss
Care Map with
Patients & Set
Expectations
MRSA/
MSSA
screen
If MRSA positive,
Intranasal
Mupirocin for 5
days prior
Impact
drink, 6 days
prior
(optional)
Patient drinks 8 oz
of apple juice b/f
midnight, 1 day
prior
No food after
midnight; Clear
liquids as
instructed
Day 0:
Pre-Op
8oz of apple
juice 2 hours
b/f surgery
Check Glucose: If > 100, recheck
30-60 min after incision. If > 140,
start insulin GTT
For patients needing Vancomycin,
should be administered 60 min
prior to operation
For Bowel Resection ONLY (5% of cases):
Minimum of 30 min prior: Alvimopan 12
mg po q12h until first B.M. or discharge*
Portable
SCDs in Pre-
Op
Fluids: If IV in
place, LR at
50 ml/hr
Pain: 1000 mg
Acetaminophen po (then po
or IV q6h until discharge)
Pain: Gabapentin 300 mg
po (continue tid once
tolerating pills again)
Pain: Thoracic Epidural for ALL pathway
patients: aimed at upper level of incision (tested
with 3 ml 1.5% Lidocaine w/ Epi 1:200K)
Heparin
5000 units
subcu
Day 0:
Intra-Op
in OR
Fluid: Induction
period: 7 ml/kg of
LR over 30 min
Fluid: During surgery: 5 ml/kg/hr
of LR . Target a urine output of
0.3-0.5 ml/kg/hr
Blood Loss – Replace
with colloid (5%
Albumin) ml for ml
Pain: 1/16% Bupivicaine plus Fentanyl 2 micrograms/ml
infused at 10 ml/hr started ASAP after anesthesia induction.
Avoid systemic opiates (especially Morphine and Dilaudid)
Day 0:
Intra-Op
in OR
For patients not
receiving Vancomycin,
initiate IV Abx in OR
Glucose
management
Place
Foley
No nasogastric tubes (remove
at end of case if placed for
gastric decompression)
Abdominal binder for
comfort per surgeon
discretion
Day 0:
PACU
Continue
Glucose
Management
Fluid: LR
at 1
ml/kg/hr
Target urine
output of 0.3-
0.5 ml/kg/hr
Pain: Changed to
PCEA with 6 ml/hr
infusion
Breakthrough Pain: Epidural Fentanyl (25-50 micrograms) (followed
by 3 cc NS) and infusion increased, by 2ml/hr - followed by increased
Bupivicaine concentration (1/10% then 1/8%) if BP okay. **
Hernia~ Clinical Care Pathway At Surgeon
Discretion

54. Target LOS = 3 to 4 days
Day
0
Mobility: Edge of bed after last set
of post-op VS (usually 6 hours) with
orthostatic VS
Diet: Ice
chips & sips
of clears
Incentive Spirometer
10x/hr while awake
until discharge
Sequential Compression
Device on, unless ambulating,
until discharge
Heparin
5000units
SQ Q8h
Glucose
Mngmt
Day
1
PT visit
on Day 1,
latest
Mobility: OOB for all meals.
Walk 3-4 times in the hall –
Goal 9 laps. OOB 6hr/day
Diet: Advance diet as tolerated. General
Diet, if patient has no nausea, no
distention, no belching/hiccups
DC Foley
(just pull)
Labs Days 1-4, as
clinically
indicated
Da
y 1
Fluids: LR at 1 ml/kg/hr. Cease IV fluids asap.
Saline lock IV fluids when oral intake greater
than 500 or adequate urine output. Aim for
early oral fluid intake
Pain, PCEA and acetaminophen PO continued. After
clear liquid lunch, start Ibuprofen 600 mg po q6h
(consider ketorolac 15 mg q6h if opiate side effects
and NPO).
Day
2
Mobility: OOB for all meals. Walk
3-4 times in the hall – Goal 18
laps. OOB 6hrs/day until discharge
Pain: Epidural stopped and oxycodone
started after breakfast tolerated
(epidural pulled 4 hours later).
JP Drain
Teaching
Day 3, 4
Stool Softener
docusate 100mg PO
BID (NOT Senna)
DC Alvimopan
(if bowel
movement)
Med Rec on Day
before
Discharge
Pain: Gabapentin
discontinued on Day 3.
Pain: Acetaminophen
and ibuprofen continued
at discharge.*
Hernia Clinical Care Pathway At Surgeon
Discretion

57. Impact of AWR ERAS Pathway

58. Impact of UW Hernia ERAS Pathway