J. M. Weissler1, M. G. Tecce1, M. N. Basta2, V. Shubinets1, M. A. Lanni1, M. N. Mirzabeigi1, M. J. Carney1, L. Cooney1, S. Senapati1, A. F. Haggerty1, J. P. Fischer1 1University Of Pennsylvania,Plastic Surgery,Philadelphia, PA, USA 2Brown University School Of Medicine,Plastic Surgery,Providence, RI, USA
Introduction: Incisional hernia (IH) is a pervasive complication across surgical specialties and presents a significant burden to both the patient and healthcare system. Morbidity associated with IH permeates all surgical specialties, including gynecologic surgery. Approximately 600,000 women undergo hysterectomy annually in the US and IH is estimated to complicate 8-16.9% of all abdominal hysterectomies. An open approach to abdominal hysterectomy portends increased risk for IH development, however there is a substantial knowledge gap regarding which procedure-specific factors govern risk. The purpose of this study is to assess the incidence and health care cost of surgically repaired IH after open abdominal hysterectomy, identify actionable, perioperative risk factors, and create a predictive risk mode to identify at-risk patients who could benefit from prevention strategies.
Methods: We conduct a retrospective review of patients who underwent hysterectomy through an open abdominal approach between 1/2005 and 6/2013 at the University of Pennsylvania. The primary outcome of interest was post-hysterectomy IH. Univariate and multivariate cox proportional hazard analyses were performed to identify perioperative risk factors. Patients with prior hernia, less than 1 year follow-up, or emergency surgeries were excluded. Cox hazard regression modeling with bootstrapped validation, risk factor stratification, and assessment of model performance were performed.
Results: Overall, 2,145 patients underwent open abdominal hysterectomy during the study period. 76 patients developed IH, all of whom underwent hernia repair. 31.3% underwent further reoperation, generating significantly higher costs of care ($71,559 vs. $23,313, p<0.001). 8 risk factors were identified and included in the final adjusted risk model, the strongest of which were presence of a vertical incision (HR=3.73 [2.01-6.92]) and ascites (HR=2.39 [1.40-4.08]). Extreme risk patients experienced the highest incidence of IH after hysterectomy (22%), followed by the high-risk group (9.7%), moderate-risk group (2.7%), and low-risk group (0.8%) (C-statistic=0.82) (Figure 1).
Conclusion: This study presents an internally validated risk model of IH in patients undergoing open hysterectomy after a review of 2,145 cases. The model can serve to accurately stratify patients, facilitate pre-operative counseling, and potentially imply risk reductive techniques.
