Ventral Hernia Repair in Contaminated Fields: A Survey to Identify Current Surgical Practices.

Shuddhadeb Ray, MD¹, Kyle C Ward, DO¹, Sara Baalman, MA¹, Brent Matthews, MD, FACS², Corey R Deeken, PhD¹. ¹Washington University School of Medicine, ²Carolinas Medical Center

INTRODUCTION: Treatment of ventral hernias in contaminated settings is currently an area of active discussion. Recent data suggests synthetic mesh can safely be used in clean-contaminated and contaminated fields. However, to date, there exists no consensus guiding surgeons how to treat ventral hernias in contaminated fields. The objective of this study is to evaluate how surgeons experienced in treatment of hernia currently treat ventral incisional hernias in the setting of contaminated fields, assess how their management aligns with currently available data, identify what types of mesh if any surgeons prefer, and describe how surgeons currently prefer to treat mesh infections.

METHODS: An anonymous electronic scenario-based survey was sent to the members of a surgical society based in North America. The survey response period started in January 2013 and is still open. Questions in the survey focus on respondent characteristics, years in practice, volume of hernia surgery performed, and also preferences in the treatment of ventral hernias in contaminated fields including type of repair, selection of mesh used for repair, identification of classification of contamination, and also how they prefer to treat mesh infections. Responses were tabulated and differences in proportion data were tested using either the Chi-square or Fischer Exact Test with p<0.05 considered statistically significant.

RESULTS: 1,850 surveys were sent out to members of a surgical society focused on the treatment of hernia. 317 (17.1%) have sent responses thus far. Interim analysis reveals that the majority of respondents were male (289, 92.0%), aged 46-55 (111, 35.2%), and have been in practice over 20 years (157, 49.8%). The majority of respondents (230, 75.1%) completed greater than 25 ventral hernia repairs in a given year, and 249 (79.0%) performed laparoscopic hernia repair as part of their practice. There is significant variation in the technique used to treat ventral hernia in contaminated fields: biologic mesh (144, 45.9%), permanent synthetic mesh (100, 31.8%), primary repair (44, 14.0%), and absorbable synthetic mesh (26, 8.3%). When presented with patient scenarios, respondents identified the correct 10-year recurrence rate after underlay mesh repair 31.0% of the time, and 76.1% were able to correctly identify a clean-contaminated field. In the setting of infected mesh in the post-operative period, while most (204, 66.7%) chose a CT-guided percutaneous drain as a part of their management strategy, a wide distribution of respondents chose observation or open exploration with varying levels of mesh removal.

CONCLUSIONS: Preliminary data show there is significant variation in how ventral hernias are treated in the setting of contaminated fields. This may be due to the lack of convincing evidence to definitively recommend a particular treatment pathway. However, not only does the treatment vary from patient to patient, but some practice patterns do not take currently existing data, guidelines, and classification schemes into account when treating ventral hernias in contaminated settings. The creation of consensus best practice guidelines to treat ventral hernias in contaminated fields, incorporating the most current literature coupled with practices suggested by expert surgeons can help standardize and improve patient care.