By Monica J. Smith

CHARLOTTE, N.C.—Following laparotomy, incisional hernias occur in 5% to 20% of all patients and in up to 30% of high-risk individuals, and their impact on those who acquire them range from nuisance to catastrophic. Numerous factors drive the occurrence of incisional hernias, but surgeons and institutions can follow measures to reduce their numbers.

At the 2022 meeting of the American Hernia Society, experts discussed optimal techniques for abdominal wall closure, explored the possibility of dedicated closing teams and took a deep dive into the financial implications of incisional hernias and their prevention.

Optimizing Abdominal Wall Closure

Given that the etiology of an incisional hernia is multifactorial, it is impossible to make exact recommendations for preventive approaches that will work for every patient. However, closure of the abdomen is the most crucial step for surgeons, said Manuel López Cano, MD, PhD, the coordinator of the Abdominal Wall Surgery Unit at University Hospital Vall d’Hebron, in Barcelona, Spain.

“Closure of the midline incision is a technical factor, and it’s 100% under the surgeon’s control, not like diabetes or other types of risk factors,” he said.

The pursuit of optimal closure is nothing new. Use of the 4:1 suture-to-wound length ratio to prevent wound disruption was first described in 1976; 25 years later, research showed that small bites result in greater wound strength (Br J Surg 1976;63[11]:873-876; Arch Surg 2001;136[3]:272-275). Since then, two randomized trials concluded that small bites should be the standardized closure (Arch Surg 2009;144[11]:1056-1059; Lancet 2015;386[10000]:1254-1260).

“These ideas were then ratified by appearing in the European Hernia Society guidelines for the closure of abdominal wall incisions in 2015. So, to me, the idea of standardization is well established and very well known,” Dr. López Cano said.

So, why is it that only 35% of surgeons follow these guidelines, or that most only follow them to a degree? According to a survey of surgeons on their approach to abdominal wall closure, 72% use small bites and 79% use a 4:1 suture-to-wound length ratio. But it would seem most who adhere to the ideal ratio are eyeballing it, because only 16% indicated they measure the suture and wound lengths (Hernia 2019;23[2]:329-334).

“We also know there is a high level of variation in abdominal closure. We trained surgeons from different specialties and followed them for a year to see if they implemented the small bites technique. We found that although the learning was good, the implementation was poor. From this, we conclude there is still a long way to go,” Dr. López Cano said (Surgery 2021;170[1]:140-145).

What will it take to get surgeons to adhere to a standardized abdominal closure? The first step would be mandatory teaching and training of general surgeons “in all countries with residency programs,” Dr. López Cano said. 

A registry specifically for abdominal wall closure also would be helpful, with input from all specialties involved in opening and closing the abdominal wall, he said: urologic, gynecologic, vascular, bariatric and hepatobiliary surgery.

“And we probably need closure teams, although that approach needs more research in a variety of settings— different hospitals, the availability of resources, what happens in emergency surgeries compared with elective surgeries,” Dr. López Cano said.

“We also need total collaboration with nurses, who should check all the steps the surgeons are doing in closing the abdomen.”

Finally, abdominal wall closure should be considered by policymakers as a benchmark of surgical quality, he said. “This is important, because we see figures as high as 35% or even higher of incisional hernias in some series. Maybe those figures can decrease if abdominal wall closure is a quality benchmark,” Dr. López Cano said.

“Standardizing this process probably will move the wheel of improvement, and we have a lot of room for improvement.”

Is It Time for Closure Teams?

Although most of the discussions related to hernia prevention and management are conducted by hernia surgeons, they usually aren’t the ones performing the laparotomies that result in these defects.

“Most hernia surgeons are fixing hernias and not doing a lot of other general surgery,” said William Hope, MD, the general surgery residency program director at Novant Health in Wilmington, N.C. Patients come to hernia surgeons after they’ve undergone colorectal, trauma/acute care, gynecologic or urologic surgery that led to an incisional hernia.

“This raises the question of whether those surgeons are comfortable using prophylactic mesh. Some of them are, but many subspecialists do not know much about the different meshes and are not comfortable doing hernia repair or using mesh,” Dr. Hope said.

In a talk that he described as more of a philosophical discussion, Dr. Hope presented two different approaches to minimizing the risk for incisional hernia: training all surgeons in the basics of prophylactic mesh, or leaving the last stages of abdominal surgery to specialized closing teams familiar with optimal closing techniques.

The first option assumes that with education and thought, any surgeon should be able to mitigate an incisional hernia by judicious use of prophylactic mesh. “For various reasons, we’ve tried to make this as easy as possible. That’s why some of the older literature showing an onlay procedure, which is a little easier to do and a little more straightforward, is as effective as a retrorectus or major hernia repair,” Dr. Hope said.

The other side of the coin is that, given the already high rate of incisional hernia occurrence, it’s time to enlist a group of surgeons who know a lot about mesh and the technical aspects of placing it, and are also adept at the optimal suturing technique for closing the abdomen (i.e., hernia surgeons).

“The hernia surgeon is deeply invested in how that closure goes, because they’re the ones who are going to have to deal with a hernia if it happens. While subspecialists and other surgeons will just refer a patient out if a hernia develops, hernia surgeons have a lot of skin in the game. No one in healthcare cares more about patients developing a hernia than the hernia surgeons,” Dr. Hope said.

He acknowledged there is room for both these strategies. It may be practical and efficient to have an available closing team in some hospitals, while others will lack the resources to do so and first need to train their surgeons in basic mesh techniques.

“This is not the forefront of prophylactic mesh discussions, but it’s a logistics issue that many centers will need to deal with, so it’s good to be thinking about it. We need to educate people on this topic, and we need to make prophylactic mesh as easy as possible,” Dr. Hope said.

The Financial Implications of Hernia Prevention

What is the cost of a hernia compared with doing what it takes to avoid one? Multiple patient and provider variables are at play, so it’s difficult to determine the answer. Sean O’Neill, MD, PhD, a clinical assistant professor of surgery at the University of Michigan, in Ann Arbor, shed some light on the tricky topic, delving into the literature to unearth the state of current evidence.

“This is not a formal cost–benefit analysis, but a structured overview of the existing data,” Dr. O’Neill said.

First, the prevalence of incisional hernias and the cost of repairing them vary considerably depending on the patient population and era within which the data were collected. 

A 2016 cost analysis established a hernia rate of 3.5% in 12,000 patients who underwent surgery between 2005 and 2013. The cost of care was around $41,000 for patients who did not develop a hernia and $80,000 for those who did, for an excess cost of $17.5 million over nine years (Ann Surg 2016;263[5]:1010-1017).

Of note, some of their data came from an era when open bariatric surgery was still the norm, Dr. O’Neill said. “That inflates the hernia rate a bit.”

A review of claims data examining the impact of incisional hernias on total healthcare costs found an incidence rate of 9%, adding a cost of $21,000 to $29,000 per patient. The investigators also established that incisional hernias that occur within one year of the initial surgery tend to be more severe, associated with more complications and can double the cost (Surg Endosc 2018;32[5]:2381-2386).

“They make an important point about the costs we are not able to measure, such as loss of productivity and loss of earnings, which are not included in any of these estimates,” Dr. O’Neill said.

An analysis of incisional hernias in patients undergoing trauma laparotomy found a 10-year cumulative incidence of 11%, with an additional cost of $16,000 to repair the hernia (JAMA Surg 2021;156[9]:e213104).

“In this population, at least 30% of the hernias were managed nonoperatively, which is probably an underestimate; it is very common for people to just live with their incisional hernias,” Dr. O’Neill said.

Then there’s a proportion of patients who experience a recurrence after the first incisional hernia is repaired. Among Medicare recipients, 16% undergo a second repair of the same hernia (JAMA 2022;327[9]:872-874).

“Once you go back in the second, third, fourth time, the success rate just gets lower and lower,” Dr. O’Neill said.

As for the cost of prevention, while it’s hard to put a number on strategies like patient optimization, prophylactic mesh has a price tag. A comparison of the cost of primary suture closure, with a 20% risk for hernia, and prophylactic mesh augmentation, with a 5.5% risk for hernia, in which mesh cost $268, concluded that even if the mesh cost $3,700, it would remain a dominant strategy (Surgery 2015;158[3]:700-711). Again, this was a study of open bariatric surgery patients.

“These numbers give us something to think about,” Dr. O’Neill said.

So, considering the probability of a hernia multiplied by the cost of repairing one, what’s the expected cost of an unprevented incisional hernia? Again, it varies a bit: $1,400 in the paper with a hernia rate of 3.5%, $1,800 in the paper that cited a rate of 11% and $1,900 in the paper with a 9% hernia rate.

“If we know that the expected future cost of hernia is $1,400 to $1,900, and if we can prevent a hernia in a way that costs less than that range, it may make economic sense to do so, and the cost–benefit ratio will be greatest in highest risk patients,” Dr. O’Neill said.

The next part of the equation comes down to who or what entity pays these costs. “Is it the insurer and the payor at the first operation? The hospital at the second? And who pays the cost of a prevention strategy? None of this has been clearly determined,” Dr. O’Neill said.

There are hints in the data that a strong case could be made for payors to fund preventive strategies, given the significant cost associated with incisional hernias, “but it’s incumbent upon our field to clearly define the high-risk criteria for which we would advise pursuing these prevention strategies.” 

Dr. Hope reported financial relationships with BD, Gore, Intuitive and Medtronic. Dr. López Cano reported financial relationships with BD, Gore and Medtronic. Dr. O’Neill reported no relevant financial disclosures.