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) - 23/03/15

Doi : 10.1016/j.jamcollsurg.2014.12.027

Christopher J. Goodenough, MD ^a, Tien C. Ko, MD, FACS ^a, Lillian S. Kao, MD, MS, FACS ^a, Mylan T. Nguyen, MPH ^a, Julie L. Holihan, MD ^a, Zeinab Alawadi, MD ^a, Duyen H. Nguyen, MPH ^a, Juan R. Flores, MD ^a, Nestor T. Arita, MD ^b, J. Scott Roth, MD, FACS ^c, Mike K. Liang, MD, FACS ^a,^⁎
^a Department of Surgery, University of Texas Health Science Center, Houston, TX
^b Department of Surgery, Baylor College of Medicine, Houston, TX
^c Department of Surgery, University of Kentucky, Lexington, KY

^∗Correspondence address: Mike K Liang, MD, FACS, Department of Surgery, University of Texas Health Science Center, 5656 Kelley St, Houston, TX 77023.

Abstract

Background

Ventral incisional hernias (VIH) develop in up to 20% of patients after abdominal surgery. No widely applicable preoperative risk-assessment tool exists. We aimed to develop and validate a risk-assessment tool to predict VIH after abdominal surgery.

Study Design

A prospective study of all patients undergoing abdominal surgery was conducted at a single institution from 2008 to 2010. Variables were defined in accordance with the National Surgical Quality Improvement Project, and VIH was determined through clinical and radiographic evaluation. A multivariate Cox proportional hazard model was built from a development cohort (2008 to 2009) to identify predictors of VIH. The HERNIAscore was created by converting the hazards ratios (HR) to points. The predictive accuracy was assessed on the validation cohort (2010) using a receiver operator characteristic curve and calculating the area under the curve (AUC).

Results

Of 625 patients followed for a median of 41 months (range 0.3 to 64 months), 93 (13.9%) developed a VIH. The training cohort (n = 428, VIH = 70, 16.4%) identified 4 independent predictors: laparotomy (HR 4.77, 95% CI 2.61 to 8.70) or hand-assisted laparoscopy (HAL, HR 4.00, 95% CI 2.08 to 7.70), COPD (HR 2.35; 95% CI 1.44 to 3.83), and BMI ≥ 25 kg/m² (HR1.74; 95% CI 1.04 to 2.91). Factors that were not predictive included age, sex, American Society of Anesthesioloigsts (ASA) score, albumin, immunosuppression, previous surgery, and suture material or technique. The predictive score had an AUC = 0.77 (95% CI 0.68 to 0.86) using the validation cohort (n = 197, VIH = 23, 11.6%). Using the HERNIAscore: HERNIAscore = 4∗Laparotomy+3∗HAL+1∗COPD+1∗ BMI ≥ 25, 3 classes stratified the risk of VIH: class I (0 to 3 points),5.2%; class II (4 to 5 points),19.6%; and class III (6 points), 55.0%.

Conclusions

The HERNIAscore accurately identifies patients at increased risk for VIH. Although external validation is needed, this provides a starting point to counsel patients and guide clinical decisions. Increasing the use of laparoscopy, weight-loss programs, community smoking prevention programs, and incisional reinforcement may help reduce rates of VIH.

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Abbreviations and Acronyms : AUC, HAL, HR, SSI, VIH

Plan

Disclosure Information: Nothing to disclose.

Support: Center for Clinical and Translational Sciences, which is funded by National Institutes of Health Clinical and Translational Award UL1 TR000371 and KL2 TR000370 from the National Center for Advancing Translational Sciences. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.