Incidence, Burden on the Health Care System, and Factors Associated With Incisional Hernia After Trauma Laparotomy | Gastrointestinal Surgery | JN Learning | AMA Ed Hub [Skip to Content]
[Skip to Content Landing]

Incidence, Burden on the Health Care System, and Factors Associated With Incisional Hernia After Trauma Laparotomy

Educational Objective
To identify the incidence, factors associated with incisional hernia, and burden on the health care system following trauma laparotomy.
1 Credit CME
Key Points

Question  What are the incidence, burden on the health care system, and factors associated with incisional hernia (IH) following trauma laparotomy (TL)?

Findings  This cohort study found a 10-year IH rate of 11.1% following TL that resulted in an additional 39.9% in aggregate costs relative to TL. Obesity, intestinal procedures, and repeated disruptions of the abdominal wall are among the strongest factors associated with IH.

Meaning  In this study, IHs were prevalent complications after TL with a similar patient profile to nontrauma populations; they resulted in considerable health care utilization and burdens to the health care system.

Abstract

Importance  The evidence provided supports routine and systematic capture of long-term outcomes after trauma, lengthening the follow-up for patients at risk for incisional hernia (IH) after trauma laparotomy (TL), counseling on the risk of IH during the postdischarge period, and consideration of preventive strategies before future abdominal operations to lessen IH prevalence as well as the patient and health care burden.

Objective  To determine burden of and factors associated with IH formation following TL at a population-based level across health care settings.

Design, Setting, and Participants  This population-based cohort study included adult patients who were admitted with traumatic injuries and underwent laparotomy with follow-up of 2 or more years. The study used 18 statewide databases containing data collected from January 2006 through December 2016 and corresponding to 6 states in diverse regions of the US. Longitudinal outcomes were identified within the Statewide Inpatient, Ambulatory, and Emergency Department Databases. Patients admitted with International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for traumatic injuries with 1 or more concurrent open abdominal operations were included. Data analysis was conducted from March 2020 through June 2020.

Main Outcomes and Measures  The primary outcome was IH after TL. Risk-adjusted Cox regression allowed identification of patient-level, operative, and postoperative factors associated with IH.

Results  Of 35 666 patients undergoing TL, 3127 (8.8%) developed IH (median [interquartile range] follow-up, 5.6 [3.4-8.6] years). Patients had a median age of 49 (interquartile range, 31-67) years, and most were male (21 014 [58.9%]), White (21 584 [60.5%]), and admitted for nonpenetrating trauma (28 909 [81.1%]). The 10-year IH rate and annual incidence were 11.1% (95% CI, 10.7%-11.5%) and 15.6 (95% CI, 15.1-16.2) cases per 1000 people, respectively. Within risk-adjusted analyses, reoperation (adjusted hazard ratio [aHR], 1.28 [95% CI, 1.2-1.37]) and subsequent abdominal surgeries (aHR, 1.71 [95% CI, 1.56-1.88]), as well as obesity (aHR, 1.88 [95% CI, 1.69-2.10]), intestinal procedures (aHR, 1.47 [95% CI, 1.36-1.59]), and public insurance (aHRs: Medicare, 1.38 [95% CI, 1.20-1.57]; Medicaid, 1.35 [95% CI, 1.21-1.51]) were among the variables most strongly associated with IH. Every additional reoperation at the index admission and subsequently resulted in a 28% (95% CI, 20%-37%) and 71% (95% CI, 56%-88%) increased risk for IH, respectively. Repair of IH represented an additional $36.1 million in aggregate costs (39.9%) relative to all index TL admissions.

Conclusions and Relevance  Incisional hernia after TL mirrors the epidemiology and patient profile characteristics seen in the elective setting. We identified patient-level, perioperative, and novel postoperative factors associated with IH, with obesity, intestinal procedures, and repeated disruption of the abdominal wall among the factors most strongly associated with this outcome. These data support preemptive strategies at the time of reoperation to lessen IH incidence. Longer follow-up may be considered after TL for patients at high risk for IH.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Article Information

Accepted for Publication: April 21, 2021.

Published Online: July 14, 2021. doi:10.1001/jamasurg.2021.3104

Corresponding Author: John P. Fischer, MD, MPH, Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, 51 N 39th St, Wright Saunders Building, Philadelphia, PA 19104 (john.fischer2@pennmedicine.upenn.edu).

Author Contributions: Dr Rios-Diaz had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Rios-Diaz, Hsu, Reilly, Broach, Fischer.

Acquisition, analysis, or interpretation of data: Rios-Diaz, Cunning, Elfanagely, Marks, Grenda, Broach, Fischer.

Drafting of the manuscript: Rios-Diaz, Cunning, Grenda, Fischer.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Rios-Diaz, Cunning, Hsu, Elfanagely, Grenda.

Administrative, technical, or material support: Rios-Diaz, Reilly, Broach.

Supervision: Rios-Diaz, Marks, Broach, Fischer.

Conflict of Interest Disclosures: Dr Fischer has received funding from Becton Dickinson, Integra, Gore and Allergan for speaking and teaching, honoraria, and consulting fees. No other disclosures were reported.

References
1.
Berrevoet  F .  Prevention of incisional hernias after open abdomen treatment.   Front Surg. 2018;5:11. doi:10.3389/fsurg.2018.00011 PubMedGoogle ScholarCrossref
2.
Bosanquet  DC , Ansell  J , Abdelrahman  T ,  et al.  Systematic review and meta-regression of factors affecting midline incisional hernia rates: analysis of 14,618 patients.   PLoS One. 2015;10(9):e0138745. doi:10.1371/journal.pone.0138745 PubMedGoogle Scholar
3.
Brolin  RE .  Prospective, randomized evaluation of midline fascial closure in gastric bariatric operations.   Am J Surg. 1996;172(4):328-331. doi:10.1016/S0002-9610(96)00194-8 PubMedGoogle ScholarCrossref
4.
Brosi  P , Glauser  PM , Speich  B , Käser  SA , Maurer  CA .  Prophylactic intraperitoneal onlay mesh reinforcement reduces the risk of incisional hernia, two-year results of a randomized clinical trial.   World J Surg. 2018;42(6):1687-1694. doi:10.1007/s00268-017-4363-2 PubMedGoogle ScholarCrossref
5.
Davila  DG , Parikh  N , Frelich  MJ , Goldblatt  MI .  The increased cost of ventral hernia recurrence: a cost analysis.   Hernia. 2016;20(6):811-817. doi:10.1007/s10029-016-1515-5 PubMedGoogle ScholarCrossref
6.
Bevis  PM , Windhaber  RAJ , Lear  PA , Poskitt  KR , Earnshaw  JJ , Mitchell  DC .  Randomized clinical trial of mesh versus sutured wound closure after open abdominal aortic aneurysm surgery.   Br J Surg. 2010;97(10):1497-1502. doi:10.1002/bjs.7137 PubMedGoogle ScholarCrossref
7.
Bloemen  A , van Dooren  P , Huizinga  BF , Hoofwijk  AGM .  Randomized clinical trial comparing polypropylene or polydioxanone for midline abdominal wall closure.   Br J Surg. 2011;98(5):633-639. doi:10.1002/bjs.7398 PubMedGoogle ScholarCrossref
8.
Fink  C , Baumann  P , Wente  MN ,  et al.  Incisional hernia rate 3 years after midline laparotomy.   Br J Surg. 2014;101(2):51-54. doi:10.1002/bjs.9364 PubMedGoogle ScholarCrossref
9.
Diener  MK , Voss  S , Jensen  K , Büchler  MW , Seiler  CM .  Elective midline laparotomy closure: the INLINE systematic review and meta-analysis.   Ann Surg. 2010;251(5):843-856. doi:10.1097/SLA.0b013e3181d973e4 PubMedGoogle ScholarCrossref
10.
Singhal  V , Szeto  P , VanderMeer  TJ , Cagir  B .  Ventral hernia repair: outcomes change with long-term follow-up.   JSLS. 2012;16(3):373-379. doi:10.4293/108680812X13427982377067PubMedGoogle ScholarCrossref
11.
Lewis  RT , Wiegand  FM .  Natural history of vertical abdominal parietal closure: Prolene versus Dexon.   Can J Surg. 1989;32(3):196-200.PubMedGoogle Scholar
12.
Rhemtulla  IA , Hsu  JY , Broach  RB ,  et al.  The incisional hernia epidemic: evaluation of outcomes, recurrence, and expenses using the Healthcare Cost and Utilization Project (HCUP) datasets.   Hernia. 2021. doi:10.1007/s10029-021-02405-9PubMedGoogle Scholar
13.
van Ramshorst  GH , Eker  HH , Hop  WCJ , Jeekel  J , Lange  JF .  Impact of incisional hernia on health-related quality of life and body image: a prospective cohort study.   Am J Surg. 2012;204(2):144-150. doi:10.1016/j.amjsurg.2012.01.012 PubMedGoogle ScholarCrossref
14.
Snyder  CW , Graham  LA , Vick  CC , Gray  SH , Finan  KR , Hawn  MT .  Patient satisfaction, chronic pain, and quality of life after elective incisional hernia repair: effects of recurrence and repair technique.   Hernia. 2011;15(2):123-129. doi:10.1007/s10029-010-0750-4 PubMedGoogle ScholarCrossref
15.
Liang  MK , Berger  RL , Li  LT , Davila  JA , Hicks  SC , Kao  LS .  Outcomes of laparoscopic vs open repair of primary ventral hernias.   JAMA Surg. 2013;148(11):1043-1048. doi:10.1001/jamasurg.2013.3587 PubMedGoogle ScholarCrossref
16.
Shubinets  V , Fox  JP , Lanni  MA ,  et al.  Incisional hernia in the United States: trends in hospital encounters and corresponding healthcare charges.   Am Surg. 2018;84(1):118-125. Accessed July 24, 2019. doi:10.1177/000313481808400132 PubMedGoogle ScholarCrossref
17.
Rios-Diaz  AJ , Lam  J , Zogg  CK .  The need for postdischarge, patient-centered data in trauma.   JAMA Surg. 2016;151(12):1101-1102. Accessed July 23, 2019. doi:10.1001/jamasurg.2016.2343 PubMedGoogle ScholarCrossref
18.
Zelle  BA , Buttacavoli  FA , Shroff  JB , Stirton  JB .  Loss of follow-up in orthopaedic trauma: who is getting lost to follow-up?   J Orthop Trauma. 2015;29(11):510-515. doi:10.1097/BOT.0000000000000346 PubMedGoogle ScholarCrossref
19.
Li  T , Robertson-More  C , Maclean  AR ,  et al.  Bowel obstructions and incisional hernias following trauma laparotomy and the nonoperative therapy of solid organ injuries: a retrospective population-based analysis.   J Trauma Acute Care Surg. 2015;79(3):386-392. doi:10.1097/TA.0000000000000765 PubMedGoogle ScholarCrossref
20.
Bowie  JM , Badiee  J , Calvo  RY ,  et al.  Outcomes after single-look trauma laparotomy: a large population-based study.   J Trauma Acute Care Surg. 2019;86(4):565-572. doi:10.1097/TA.0000000000002167 PubMedGoogle ScholarCrossref
21.
Borab  ZM , Shakir  S , Lanni  MA ,  et al.  Does prophylactic mesh placement in elective, midline laparotomy reduce the incidence of incisional hernia? a systematic review and meta-analysis.   Surgery. 2017;161(4):1149-1163. doi:10.1016/j.surg.2016.09.036 PubMedGoogle ScholarCrossref
22.
Itatsu  K , Yokoyama  Y , Sugawara  G ,  et al.  Incidence of and risk factors for incisional hernia after abdominal surgery.   Br J Surg. 2014;101(11):1439-1447. doi:10.1002/bjs.9600 PubMedGoogle ScholarCrossref
23.
Fischer  JP , Basta  MN , Mirzabeigi  MN ,  et al.  A risk model and cost analysis of incisional hernia after elective abdominal surgery based on 12,373 cases: the case for targeted prophylactic intervention.   Ann Surg. 2016;263(5):1010-1017. doi:10.1097/SLA.0000000000001394 PubMedGoogle ScholarCrossref
24.
Basta  MN , Mirzabeigi  MN , Shubinets  V , Kelz  RR , Williams  NN , Fischer  JP .  Predicting incisional hernia after bariatric surgery: a risk stratification model based upon 2161 operations.   Surg Obes Relat Dis. 2016;12(8):1466-1473. doi:10.1016/j.soard.2016.03.022PubMedGoogle ScholarCrossref
25.
Goodenough  CJ , Ko  TC , Kao  LS ,  et al.  Development and validation of a risk stratification score for ventral incisional hernia after abdominal surgery: hernia expectation rates in intra-abdominal surgery (the HERNIA Project).   J Am Coll Surg. 2015;220(4):405-413. doi:10.1016/j.jamcollsurg.2014.12.027PubMedGoogle ScholarCrossref
26.
Basta  MN , Kozak  GM , Broach  RB ,  et al.  Can we predict incisional hernia?: development of a surgery-specific decision-support interface.   Ann Surg. 2019;270(3):544-553. doi:10.1097/SLA.0000000000003472PubMedGoogle ScholarCrossref
27.
Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project. SID database documentation. Published 2017. Accessed June 7, 2021. https://www.hcup-us.ahrq.gov/db/state/siddbdocumentation.jsp
28.
Healthcare Cost and Utilization Project. SEDD database documentation. Published 2019. Accessed January 10, 2019.https://www.hcup-us.ahrq.gov/db/state/sedddbdocumentation.jsp
29.
Healthcare Cost and Utilization Project. SASD database documentation. Published 2019. Accessed June 7, 2021. https://www.hcup-us.ahrq.gov/db/state/sasddbdocumentation.jsp
30.
Clark  DE , Osler  TM , Hahn  DR .  ICDPIC: Stata module to provide methods for translating International Classification of Diseases (Ninth Revision) diagnosis codes into standard injury categories and/or scores.   Statistical Software Components. 2009;S457028.Google Scholar
31.
Rios-Diaz  AJ , Cunning  JR , Broach  RB ,  et al.  One-year health care utilization and recurrence after incisional hernia repair in the United States: a population-based study using the Nationwide Readmission Database.   J Surg Res. 2020;255:267-276. doi:10.1016/j.jss.2020.03.070 PubMedGoogle ScholarCrossref
32.
Hietbrink  F , Smeeing  D , Karhof  S ,  et al.  Outcome of trauma-related emergency laparotomies, in an era of far-reaching specialization.   World J Emerg Surg. 2019;14(1):40. doi:10.1186/s13017-019-0257-y PubMedGoogle ScholarCrossref
33.
Moas  V , Eskridge  S , Clouser  M , Kurapaty  S , Dyke  C , Souza  J .  Incisional hernia incidence following laparotomy for combat trauma: investigating 15 years of US war surgery.   J Trauma Acute Care Surg. 2020;89(2S)(suppl 2):S200-S206. doi:10.1097/TA.0000000000002769 PubMedGoogle ScholarCrossref
34.
Höer  J , Lawong  G , Klinge  U , Schumpelick  V .  Einflussfaktoren der Narbenhernienentstehung: retrospektive Untersuchung an 2.983 laparotomierten Patienten über einen Zeitraum von 10 Jahren.   Chirurg. 2002;73(5):474-480. doi:10.1007/s00104-002-0425-5PubMedGoogle ScholarCrossref
35.
Sharrock  AE , Barker  T , Yuen  HM , Rickard  R , Tai  N .  Management and closure of the open abdomen after damage control laparotomy for trauma: a systematic review and meta-analysis.   Injury. 2016;47(2):296-306. doi:10.1016/j.injury.2015.09.008 PubMedGoogle ScholarCrossref
36.
DiMaggio  CJ , Avraham  JB , Lee  DC , Frangos  SG , Wall  SP .  The epidemiology of emergency department trauma discharges in the United States.   Acad Emerg Med. 2017;24(10):1244-1256. doi:10.1111/acem.13223 PubMedGoogle ScholarCrossref
37.
Lamont  PM , Ellis  H .  Incisional hernia in re-opened abdominal incisions: an overlooked risk factor.   Br J Surg. 1988;75(4):374-376. doi:10.1002/bjs.1800750426 PubMedGoogle ScholarCrossref
38.
Basta  MN , Kozak  GM , Broach  RB ,  et al.  Can we predict incisional hernia?: development of a surgery-specific decision-support interface.   Ann Surg. 2019;270(3):544-553. doi:10.1097/SLA.0000000000003472 PubMedGoogle ScholarCrossref
39.
Kohler  A , Lavanchy  JL , Lenoir  U , Kurmann  A , Candinas  D , Beldi  G .  Effectiveness of prophylactic intraperitoneal mesh implantation for prevention of incisional hernia in patients undergoing open abdominal surgery: a randomized clinical trial.   JAMA Surg. 2019;154(2):109-115. doi:10.1001/jamasurg.2018.4221 PubMedGoogle ScholarCrossref
40.
Deerenberg  EB , Harlaar  JJ , Steyerberg  EW ,  et al.  Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial.   Lancet. 2015;386(10000):1254-1260. doi:10.1016/S0140-6736(15)60459-7 PubMedGoogle ScholarCrossref
41.
Nguyen  D , Szomstein  S , Ordonez  A ,  et al.  Unidirectional barbed sutures as a novel technique for laparoscopic ventral hernia repair.   Surg Endosc. 2016;30(2):764-769. doi:10.1007/s00464-015-4275-x PubMedGoogle ScholarCrossref
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Close
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close