Predictors of mortality after elective ventral hernia repair: an analysis of national inpatient sample

Abstract

Purpose: Deciding between surgery and non-operative management of a non-obstructive ventral hernia (VH) in a high-risk patient often poses a clinical challenge. The aim of this study is to evaluate a national series of open and laparoscopic ventral hernia repair (VHR), and to assess predictors of mortality after elective VHR. Methods: A retrospective analysis of 2008–2014 data from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample was performed. All patients with a primary diagnosis of abdominal wall hernia were included. Inguinal, femoral, or diaphragmatic hernias were excluded. Patients were stratified by elective versus emergent repair. Factors associated with mortality after elective VHR were analyzed. Results: 103,635 patients were studied, including 14,787 (14.3%) umbilical, 63,685 (61.5%) incisional, and 25,163 (24.3%) other ventral hernias. Operative procedures included 59,993 (57.9%) elective and 43,642 (42.1%) emergent VHR. 21.3% elective VHRs were laparoscopic versus 13% in emergent cases (P < 0.001). Mesh was used in 52,642 (87.7%) elective versus 27,734 (63.5%) emergent VHR (P < 0.001). Median (interquartile range) length of stay was 2(3) days in laparoscopic and 3(3) days in open group (P < 0.001). Mortality was 0.2% (n = 135) in elective and 0.6% (n = 269) in emergent group (P < 0.001). In elective group, mortality rates were equal among laparoscopic and open VHR (0.2%), while in emergent group, it was lower in laparoscopic VHR (0.4% vs 0.6%, P = 0.028). Multivariate analysis of elective VHR showed that the following factors were associated with mortality during hospitalization: age > 50 years [Odds ratio (OR) = 1.96], male gender (OR = 2.37), congestive heart failure (OR = 2.15), pulmonary circulation disorders (OR = 5.26), coagulopathy (OR = 3.93), liver disease (OR = 1.89), fluid and electrolyte disturbances (OR = 8.66), metastatic cancer (OR = 4.66), neurological disorders (OR = 2.31), and paralysis (OR = 5.29). Conclusions: VHR has a low mortality, especially when performed laparoscopically. In patients undergoing elective VHR, higher age and some comorbidities are predictors of mortality. These include congestive heart failure, pulmonary circulation disorders, coagulopathy, liver disease, metastatic cancer, neurological disorders, and paralysis. Conservative management should be considered for these high-risk subgroups in context of the overall clinical presentation.