The contribution of specific enhanced recovery after surgery (ERAS) protocol elements to reduced length of hospital stay after ventral hernia repair

  • Walker Ueland
  • Seth Walsh-Blackmore
  • Michael Nisiewicz
  • Daniel L. Davenport
  • Margaret A. Plymale
  • Mary Plymale
  • John S. RothEmail author
2019 SAGES Oral



Ventral hernia repair (VHR) is a commonly performed procedure that may be associated with prolonged hospitalization. Enhanced recovery after surgery (ERAS) protocols are intended to decrease hospital length of stay (LOS) and improve outcomes. This study evaluated the impact of compliance with individual VHR ERAS elements on LOS.


With IRB approval, a medical record review (perioperative characteristics, clinical outcomes, compliance with ERAS elements) was conducted of open VHR consecutive cases performed in August 2013–July 2017. The ERAS protocol was implemented in August 2015; elements in place prior to implementation were accounted for in compliance review. Clinical predictors of LOS were determined through forward regression of log-transformed LOS. The effects of specific ERAS elements on LOS were assessed by adding them to the model in the presence of the clinical predictors.


Two-hundred and thirty-four patients underwent VHR (109 ERAS, 125 pre-ERAS). Across all patients, the mean LOS was 5.4 days (SD = 3.3). Independent perioperative predictors (P’s < 0.05) of increased LOS were CDC Wound Class III/IV (38% increase above the mean), COPD (35%), prior infected mesh (21%), concomitant procedure (14%), mesh size (3% per 100 cm2), and age (8% increase per 10 years from mean age). Formal ERAS implementation was associated with a 15% or about 0.7 days (95% CI 6%–24%) reduction in mean LOS after adjustment. Compliance with acceleration of intestinal recovery was low (25.6%) as many patients were not eligible for alvimopan use due to preoperative opioids, yet when achieved, provided the greatest reduction in LOS (− 36%).


Implementation of an ERAS protocol for VHR results in decreased hospital LOS. Evaluation of the impact of specific ERAS element compliance to LOS is unique to this study. Compliance with acceleration of intestinal recovery, early postoperative mobilization, and multimodal pain management standards provided the greatest LOS reduction.


Ventral hernia repair Enhanced recovery after surgery Length of stay ERAS compliance 



Dr. Roth discloses he has Grant funding from Bard and Miromatrix; he is a consultant for Bard, Johnson & Johnson, and Allergan; and he owns stock in Miromatrix.

Compliance with ethical standards


Mr. Ueland, Mr. Walsh-Blackmore, Mr. Nisiewicz, Drs. Davenport and Plymale, and Ms. Plymale have no conflicts of interest or financial ties to disclose.


  1. 1.
    Mudge MHL (1985) Incisional hernia: a 10-year prospective study of incidence and attitudes. Br J Surg 72:70–71CrossRefGoogle Scholar
  2. 2.
    Cengiz YIL (1998) Incisional hernias in midline incisions: an eight-year follow up. Hernia 2:175–177CrossRefGoogle Scholar
  3. 3.
    Wechter MEPM, Hartmann KE (2005) Reclosure of the disrupted laparotomy wound; a systematic review. Obstet Gynecol 106:376–383CrossRefGoogle Scholar
  4. 4.
    Plymale MA, Ragulojan R, Davenport DL, Roth JS (2017) Ventral and incisional hernia: the cost of comorbidities and complications. Surg Endosc 31:341–351CrossRefGoogle Scholar
  5. 5.
    Reynolds D, Davenport DL, Korosec RL, Roth JS (2013) Financial implications of ventral hernia repair: a hospital cost analysis J Gastrointest Surg 17:159–166 (discussion 166–167) CrossRefGoogle Scholar
  6. 6.
    Adamina M, Kehlet H, Tomlinson GA, Senagore AJ, Delaney CP (2011) Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. Surgery 149:830–840CrossRefGoogle Scholar
  7. 7.
    Fayezizadeh M, Petro CC, Rosen MJ, Novitsky YW (2014) Enhanced recovery after surgery pathway for abdominal wall reconstruction: pilot study and preliminary outcomes. Plast Reconstr Surg 134(4 Suppl 2):151S–159SCrossRefGoogle Scholar
  8. 8.
    Jensen KK, Brondum TL, Harling H, Kehlet H, Jorgensen LN (2016) Enhanced recovery after giant ventral hernia repair. Hernia 20:249–256CrossRefGoogle Scholar
  9. 9.
    Majumder A, Fayezizadeh M, Neupane R, Elliott HL, Novitsky YW (2016) Benefits of multimodal enhanced recovery pathway in patients undergoing open ventral hernia repair. J Am Coll Surg 222:1106–1115CrossRefGoogle Scholar
  10. 10.
    Stearns E, Plymale MA, Davenport DL, Totten C, Carmichael SP, Tancula CS, Roth JS (2018) Early outcomes of an enhanced recovery protocol for open repair of ventral hernia. Surg Endosc 32:2914–2922CrossRefGoogle Scholar
  11. 11.
    Warren JA, Stoddard C, Hunter AL, Horton AJ, Atwood C, Ewing JA, Pusker S, Cancellaro VA, Walker KB, Cobb WS, Carbonell AM, Morgan RR (2017) Effect of multimodal analgesia on opioid use after open ventral hernia repair. J Gastrointest Surg 21:1692–1699CrossRefGoogle Scholar
  12. 12.
    Ahmed J, Khan S, Lim M, Chandrasekaran TV, MacFie J (2012) Enhanced recovery after surgery protocols—compliance and variations in practice during routine colorectal surgery. Colorectal Dis 14:1045–1051CrossRefGoogle Scholar
  13. 13.
    Doorly MG, Senagore AJ (2012) Pathogenesis and clinical and economic consequences of postoperative ileus. Surg Clin North Am 92:259–272CrossRefGoogle Scholar
  14. 14.
    Adam M, Lee L, Kim J, Shenoi M, Mallipeddi M, Aziz H, Stinnett S, Sun Z, Mantyh C, Thacker JK (2016) Alvimopan provides additional improvement in outcomes and cost savings in enhanced recovery colorectal surgery. Ann Surg 264:141–146CrossRefGoogle Scholar
  15. 15.
    Humes DJ, Abdul-Sultan A, Walker A, Ludvigsson JF, West J (2018) Duration and magnitude of postoperative risk of venous thromboembolism after planned inguinal hernia repair in men: a population-based cohort study. Hernia 2:447–453. CrossRefGoogle Scholar
  16. 16.
    Enoch S, Woon E, Blair SD (2003) Thromboprophylaxis can be omitted in selected patients undergoing varicose vein surgery and hernia repair. Br J Surg 90:818–820CrossRefGoogle Scholar
  17. 17.
    Kroese LF, Gillion JF, Jeekel J, Lange JF, Kleinrensink GJ, Members Hernia-Club (2018) Identification of risk factors for 30-day postoperative complications in patients undergoing primary ventral hernia repair: a prospective cohort study of 2374 patients. Surgery 163:1160–1164CrossRefGoogle Scholar
  18. 18.
    Liang MK, Bernardi K, Holihan JL, Cherla DV, Escamilla R, Lew D, Berger DH, Ko TC, Kao LS (2018) Modifying risks in ventral hernia patients with prehabilitation: a randomized controlled trial. Ann Surg 268:674–680CrossRefGoogle Scholar
  19. 19.
    DeLancey JO, Blay E Jr, Hewitt DB, Engelhardt K, Bilimoria KY, Holl JL, Odell DD, Yang AD, Stulberg JJ (2018) The effect of smoking on 30-day outcomes in elective hernia repair. Am J Surg 216:471–474CrossRefGoogle Scholar
  20. 20.
    Lindström D, Sadr Azodi O, Wladis A, Tønnesen H, Linder S, Nåsell H, Ponzer S, Adami J (2008) Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial. Ann Surg 248:739–745CrossRefGoogle Scholar

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© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.University of Kentucky College of MedicineLexingtonUSA
  2. 2.Department of SurgeryUniversity of KentuckyLexingtonUSA
  3. 3.Division of General SurgeryUniversity of KentuckyLexingtonUSA
  4. 4.Butler UniversityIndianapolisUSA
  5. 5.Division of General Surgery, Department of SurgeryUniversity of KentuckyLexingtonUSA

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