A Prospective, International, Multi-institution Study Evaluating Type of Fixation and Number of Tacks Affecting Quality of Life (QOL) after Ventral Hernia Repair(VHR)

Tiffany C Cox, MD, Laurel J Blair, MD, Ciara R Huntington, MD, Tanushree Prasad, MA, Vedra A Augenstein, MD, FACS, B. Todd Heniford, MD, FACS. Carolinas Medical Center

Background: QOL becomes a major aspect of discussion with patients to determine when to perform VHR and one of the major indices defining successful outcome.   Herein, we identify if fixation method, tack type, or number of tacks used impact QOL after VHR.

Methods: A prospective study of VHR patients was performed via the International Hernia Mesh Registry.  Anonymous, self-reported, quality of life(QOL) data utilizing the Carolinas Comfort Scale(CCS) was recorded preoperatively, and 1,6, and 12-months postoperatively.  Pain was identified as a score of ≥2(mild but bothersome to severe).  Univariate and logistic regression analyses were performed individually for LVHR and OVHR including patient demographics, mesh used, suture fixation, type of tacks, number of tacks, glue, combinations of fixation, and no fixation.   Predictors were included in multivariable models using backwards elimination with retention criterion of  p<0.15. Goodness-of-fit of the model was tested using Hosmer-Lemeshow test. A value of ≥70% for the area under the curve(AUC) was considered most accurate diagnostically after internal validation.

Results: A total of 950 patients underwent VHR between 2007-2015:443 laparoscopic(LVHR) and 507 open(OVHR).  The patients had an average age of 57.2 ± 12.8 years, 52.6% were female, 17.1% were active smokers, and 12.9% used pain medications preoperatively. Preoperative pain(CCS score ≥2) were reported by 54.9% of patients. 

For OVHR, in cases with suture fixation alone, this was protective against postoperative pain at 6-months(odds ratio(OR):0.5, 95%confidence interval(CI): 0.2-1.1,p=0.08); no other fixation factors affected QOL for OVHR at any other time-points. 

For LVHR, independent protective fixation factors against pain at 1-month included fixation with less than 40 tacks(OR:0.4, CI:0.1-0.8,p=0.01) even if combined with suture fixation(OR:0.6,CI:0.4-1.0,p=0.05). The final logistic regression model had an AUC of 0.70 and after internal validation corrected to 0.66.  When we further analyzed number of tacks impacting pain at 1-month, there was further significant difference if ≥60 tacks were used(OR:2.8,CI:1.3-6.2,p=0.01).  Comparison of absorbable versus non-absorbable, if <20 tacks were used, there was an increase in postoperative pain at 1-month for absorbable tacks(OR:3.9,CI:1.3-11.9,p=0.02), but otherwise no difference existed among tack type.

Despite method of fixation, no difference existed in rates of postoperative complications such as seroma, hematoma, abdominal wall complications, or recurrence(p>0.05).

Conclusions: Reducing the number of tacks to <40 for LVHR lessens the rate of short term pain at 1-month.  While suture fixation alone is a protective factor for pain at 6-months in OVHR, no method of fixation increases rates of chronic pain at 1-year after surgery.

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