Patient Comorbidities Complicating a Hernia Repair: The Preoperative Workup and Postoperative Planning

  • Desmond T. K. Huynh
  • Omar M. Ghanem


Abdominal wall hernia is one of the most common surgical pathologies worldwide, and general surgeons must be able to address hernias on a daily basis. Despite the ubiquity, or perhaps because of it, approaches to hernia management vary widely. One facet of this management is the preoperative optimization of patients prior to surgery. New evidence has repeatedly highlighted the critical importance of preoperative optimization in obtaining the finest outcomes. This chapter reviews the available literature as it pertains to the management of patients prior to hernia repair and makes recommendations based on this evidence. We will address the specifics of hernia evaluation as well as describe how to safely address various comorbid conditions. Within each topic, we will review and recommend practices that have been shown in the literature to produce the best possible outcomes.


Patient comorbidities Preoperative workup Postoperative planning Hernia complications Inflammatory response Nutritional status NSQIP surgical risk calculator 


  1. 1.
    Sørensen LT. Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review. Ann Surg. 2012;255(6):1069–79.CrossRefGoogle Scholar
  2. 2.
    Sørensen LT, Toft BG, Rygaard J, Ladelund S, Paddon M, James T, et al. Effect of smoking, smoking cessation, and nicotine patch on wound dimension, vitamin C, and systemic markers of collagen metabolism. Surgery. 2010;148(5):982–90.CrossRefGoogle Scholar
  3. 3.
    Sorensen LT, Karlsmark T, Gottrup F. Abstinence from smoking reduces incisional wound infection: a randomized controlled trial. Ann Surg. 2003;238(1):1–5.PubMedPubMedCentralGoogle Scholar
  4. 4.
    Fischer JP, Wink JD, Nelson JA, Kovach SJ. Among 1,706 cases of abdominal wall reconstruction, what factors influence the occurrence of major operative complications? Surgery. 2014;155(2):311–9.CrossRefGoogle Scholar
  5. 5.
    Bluman LG, Mosca L, Newman N, Simon DG. Preoperative smoking habits and postoperative pulmonary complications. Chest. 1998;113(4):883–9.CrossRefGoogle Scholar
  6. 6.
    Landin M, Kubasiak JC, Schimpke S, Poirier J, Myers JA, Millikan KW, Luu MB. The effect of tobacco use on outcomes of laparoscopic and open inguinal hernia repairs: a review of the NSQIP dataset. Surg Endosc. 2017;31(2):917–21.CrossRefGoogle Scholar
  7. 7.
    Lovecchio F, Farmer R, Souza J, Khavanin N, Dumanian GA, Kim JY. Risk factors for 30-day readmission in patients undergoing ventral hernia repair. Surgery. 2014;155(4):702–10.CrossRefGoogle Scholar
  8. 8.
    Nelson JA, Fischer J, Chung CC, Wink J, Wes A, Serletti JM, Kovach S. Readmission following ventral hernia repair: a model derived from the ACS-NSQIP datasets. Hernia. 2015;19(1):125–33.CrossRefGoogle Scholar
  9. 9.
    Huerta S, Patel PM, Mokdad AA, Chang J. Predictors of inguinodynia, recurrence, and metachronous hernias after inguinal herniorrhaphy in veteran patients. Am J Surg. 2016;212(3):391–8.CrossRefGoogle Scholar
  10. 10.
    Sørensen LT, Hemmingsen UB, Kirkeby LT, Kallehave F, Jørgensen LN. Smoking is a risk factor for incisional hernia. Arch Surg. 2005;140(2):119–23.CrossRefGoogle Scholar
  11. 11.
    Lindström D, Azodi OS, Wladis A, Tønnesen H, Linder S, Nåsell H, et al. Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial. Ann Surg. 2008;248(5):739–45.CrossRefGoogle Scholar
  12. 12.
    Novitsky YW, Orenstein SB. Effect of patient and hospital characteristics on outcomes of elective ventral hernia repair in the United States. Hernia. 2013;17(5):639–45.CrossRefGoogle Scholar
  13. 13.
    Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic repair of ventral hernias: nine years’ experience with 850 consecutive hernias. Ann Surg. 2003;238(3):391–9.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Sauerland S, Korenkov M, Kleinen T, Arndt M, Paul A. Obesity is a risk factor for recurrence after incisional hernia repair. Hernia. 2004;8(1):42–6.CrossRefGoogle Scholar
  15. 15.
    Pernar LI, Pernar CH, Dieffenbach BV, Brooks DC, Smink DS, Tavakkoli A. What is the BMI threshold for open ventral hernia repair? Surg Endosc. 2017;31(3):1311–7.CrossRefGoogle Scholar
  16. 16.
    Froylich D, Segal M, Weinstein A, Hatib K, Shiloni E, Hazzan D. Laparoscopic versus open ventral hernia repair in obese patients: a long-term follow-up. Surg Endosc. 2016;30(2):670–5.CrossRefGoogle Scholar
  17. 17.
    Tsereteli Z, Pryor BA, Heniford BT, Park A, Voeller G, Ramshaw BJ. Laparoscopic ventral hernia repair (LVHR) in morbidly obese patients. Hernia. 2008;12(3):233–8.CrossRefGoogle Scholar
  18. 18.
    Rosen MJ, Aydogdu K, Grafmiller K, Petro CC, Faiman GH, Prabhu A. A multidisciplinary approach to medical weight loss prior to complex abdominal wall reconstruction: is it feasible? J Gastrointest Surg. 2015;19(8):1399–406.CrossRefGoogle Scholar
  19. 19.
    Hellspong G, Gunnarsson U, Dahlstrand U, Sandblom G. Diabetes as a risk factor in patients undergoing groin hernia surgery. Langenbecks Arch Surg. 2017;402(2):219–25.CrossRefGoogle Scholar
  20. 20.
    Won EJ, Lehman EB, Geletzke AK, Tangel MR, Matsushima K, Brunke-Reese D, et al. Association of postoperative hyperglycemia with outcomes among patients with complex ventral hernia repair. JAMA Surg. 2015;150(5):433–40.CrossRefGoogle Scholar
  21. 21.
    Petro CC, Posielski NM, Raigani S, Criss CN, Orenstein SB, Novitsky YW. Risk factors for wound morbidity after open retromuscular (sublay) hernia repair. Surgery. 2015;158(6):1658–68.CrossRefGoogle Scholar
  22. 22.
    Shankar DA, Itani KM, O’Brien WJ, Sanchez VM. Factors associated with long-term outcomes of umbilical hernia repair. JAMA Surg. 2017;152(5):461–6.CrossRefGoogle Scholar
  23. 23.
    Liang MK, Holihan JL, Itani K, Alawadi ZM, Gonzalez JRF, Askenasy EP, Ballecer C, et al. Ventral hernia management: expert consensus guided by systematic review. Ann Surg. 2017;265(1):80–9.CrossRefGoogle Scholar
  24. 24.
    Martindale RG, McClave SA, Vanek VW, McCarthy M, Roberts P, Taylor B, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition: executive summary. Crit Care Med. 2009;37(5):1757–61.CrossRefGoogle Scholar
  25. 25.
    Jie B, Jiang ZM, Nolan MT, Zhu SN, Yu K, Kondrup J. Impact of preoperative nutritional support on clinical outcome in abdominal surgical patients at nutritional risk. Nutrition. 2012;28(10):1022–7.CrossRefGoogle Scholar
  26. 26.
    Khuri SF, Daley J, Henderson W, Hur K, Gibbs JO, Barbour G, et al. Risk adjustment of the postoperative mortality rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study. J Am Coll Surg. 1997;185(4):315–27.PubMedGoogle Scholar
  27. 27.
    Kudsk KA, Tolley EA, DeWitt RC, Janu PG, Blackwell AP, Yeary S, King BK. Preoperative albumin and surgical site identify surgical risk for major postoperative complications. J Parenter Enteral Nutr. 2003;27(1):1–9.CrossRefGoogle Scholar
  28. 28.
    Prado CM, Heymsfield SB. Lean tissue imaging: a new era for nutritional assessment and intervention. J Parenter Enteral Nutr. 2014;38(8):940–53.CrossRefGoogle Scholar
  29. 29.
    Marik PE, Flemmer M. The immune response to surgery and trauma: implications for treatment. J Trauma Acute Care Surg. 2012;73(4):801–8.CrossRefGoogle Scholar
  30. 30.
    Rudolph FB, Van Buren CT. The metabolic effects of enterally administered ribonucleic acids. Curr Opin Clin Nutr Metab Care. 1998;1(6):527–30.CrossRefGoogle Scholar
  31. 31.
    Drover JW, Dhaliwal R, Weitzel L, Wischmeyer PE, Ochoa JB, Heyland DK. Perioperative use of arginine-supplemented diets: a systematic review of the evidence. J Am Coll Surg. 2011;212(3):385–99.CrossRefGoogle Scholar
  32. 32.
    Banerjee S, Garrison LP, Danel A, Gautier JBO, Flum DR. Effects of arginine-based immunonutrition on inpatient total costs and hospitalization outcomes for patients undergoing colorectal surgery. Nutrition. 2017;42:106–13.CrossRefGoogle Scholar
  33. 33.
    Braga M, Gianotti L, Nespoli L, Radaelli G, Di Carlo V. Nutritional approach in malnourished surgical patients: a prospective randomized study. Arch Surg. 2002;137(2):174–80.CrossRefGoogle Scholar
  34. 34.
    Braga M, Gianotti L, Vignali A, Schmid A, Nespoli L, Di Carlo V. Hospital resources consumed for surgical morbidity: effects of preoperative arginine and ω-3 fatty acid supplementation on costs. Nutrition. 2005;21(11):1078–86.CrossRefGoogle Scholar
  35. 35.
    Svanfeldt M, Thorell A, Hausel J, Soop M, Nygren J, Ljungqvist O. Effect of “preoperative” oral carbohydrate treatment on insulin action—a randomised cross-over unblinded study in healthy subjects. Clin Nutr. 2005;24(5):815–21.CrossRefGoogle Scholar
  36. 36.
    Bilimoria KY, Liu Y, Paruch JL, Zhou L, Kmiecik TE, Ko CY, Cohen ME. Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and surgeons. J Am Coll Surg. 2013;217(5):833–42.CrossRefGoogle Scholar
  37. 37.
    Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. Circulation. 2014;130(24):e278–333. Scholar
  38. 38.
    Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, Murray B, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977;297(16):845–50.CrossRefGoogle Scholar
  39. 39.
    Lara FP, Berges AF, Valdenebro MM, Fernández JD, Moreno ADR, Muñoz HO. The repair of large ventral hernias in patients with severe cardio-respiratory disease: volume transposition technique. Int J Surg. 2016;30:90–3.CrossRefGoogle Scholar
  40. 40.
    Bradley M, Morgan D, Pentlow B, Roe A. The groin hernia-an ultrasound diagnosis? Ann R Coll Surg Engl. 2003;85(3):178–80.CrossRefGoogle Scholar
  41. 41.
    Vasileff WK, Nekhline M, Kolowich PA, Talpos GB, Eyler WR, van Holsbeeck M. Inguinal hernia in athletes: role of dynamic ultrasound. Sports Health. 2017;9(5):414–21. Scholar
  42. 42.
    Robinson A, Light D, Kasim A, Nice C. A systematic review and meta-analysis of the role of radiology in the diagnosis of occult inguinal hernia. Surg Endosc. 2013;27(1):11–8.CrossRefGoogle Scholar
  43. 43.
    Rakic S, LeBlanc KA. The radiologic appearance of prosthetic materials used in hernia repair and a recommended classification. Am J Roentgenol. 2013;201(6):1180–3.CrossRefGoogle Scholar
  44. 44.
    Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, Samama CM. Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis: American College of Chest Physicians evidence-based clinical practice guidelines. Chest J. 2012;141(2_Suppl):e227S–77S.CrossRefGoogle Scholar
  45. 45.
    Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database Syst Rev. 2012;(9):CD004985.Google Scholar
  46. 46.
    Edmiston CE, Lee CJ, Krepel CJ, Spencer M, Leaper D, Brown KR, et al. Evidence for a standardized preadmission showering regimen to achieve maximal antiseptic skin surface concentrations of chlorhexidine gluconate, 4%, in surgical patients. JAMA Surg. 2015;150(11):1027–33.CrossRefGoogle Scholar
  47. 47.
    Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR, Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection, 1999. Am J Infect Control. 1999;27(2):97–134.CrossRefGoogle Scholar
  48. 48.
    Tanner J, Woodings D, Moncaster K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev. 2006;(3):CD004122.Google Scholar
  49. 49.
    Lefebvre A, Saliou P, Lucet JC, Mimoz O, Keita-Perse O, Grandbastien B, et al. Preoperative hair removal and surgical site infections: network meta-analysis of randomized controlled trials. J Hosp Infect. 2015;91(2):100–8.CrossRefGoogle Scholar
  50. 50.
    National Institute of Health and Clinical Excellence. Surgical site infection. Prevention and treatment of surgical site infection. NICE 2008. Accessed 4 Apr 2012; Clinical Guideline CG 74. Available from: URL:
  51. 51.
    Zhang D, Wang XC, Yang ZX, Gan JX, Pan JB, Yin LN. Preoperative chlorhexidine versus povidone-iodine antisepsis for preventing surgical site infection: a meta-analysis and trial sequential analysis of randomized controlled trials. Int J Surg. 2017;44:176–84.CrossRefGoogle Scholar
  52. 52.
    Swenson BR, Sawyer RG. Importance of alcohol in skin preparation protocols. Infect Control Hosp Epidemiol. 2010;31(9):977–8.CrossRefGoogle Scholar
  53. 53.
    Mazaki T, Mado K, Masuda H, Shiono M, Tochikura N, Kaburagi M. A randomized trial of antibiotic prophylaxis for the prevention of surgical site infection after open mesh-plug hernia repair. Am J Surg. 2014;207(4):476–84.CrossRefGoogle Scholar
  54. 54.
    Boonchan T, Wilasrusmee C, McEvoy M, Attia J, Thakkinstian A. Network meta-analysis of antibiotic prophylaxis for prevention of surgical-site infection after groin hernia surgery. Br J Surg. 2017;104(2):e106–17.CrossRefGoogle Scholar
  55. 55.
    Erdas E, Medas F, Pisano G, Nicolosi A, Calò PG. Antibiotic prophylaxis for open mesh repair of groin hernia: systematic review and meta-analysis. Hernia. 2016;20(6):765–76.CrossRefGoogle Scholar
  56. 56.
    Köckerling F, Bittner R, Jacob D, Schug-Pass C, Laurenz C, Adolf D, et al. Do we need antibiotic prophylaxis in endoscopic inguinal hernia repair? Results of the Herniamed registry. Surg Endosc. 2015;29(12):3741–9.CrossRefGoogle Scholar
  57. 57.
    Rios A, Rodriguez J, Munitiz V, Alcaraz P, Flores PD, Parrilla P. Antibiotic prophylaxis in incisional hernia repair using a prosthesis. Hernia. 2001;5(3):148–52.CrossRefGoogle Scholar
  58. 58.
    Ousley J, Baucom RB, Stewart MK, Phillips SE, Holzman MD, Ehrenfeld JM, et al. Previous methicillin-resistant Staphylococcus aureus infection independent of body site increases odds of surgical site infection after ventral hernia repair. J Am Coll Surg. 2015;221(2):470–7.CrossRefGoogle Scholar
  59. 59.
    Baucom RB, Ousley J, Oyefule OO, Stewart MK, Phillips SE, Browman KK, et al. Evaluation of long-term surgical site occurrences in ventral hernia repair: implications of preoperative site independent MRSA infection. Hernia. 2016;20(5):701–10.CrossRefGoogle Scholar
  60. 60.
    Bode LG, Kluytmans JA, Wertheim HF, Bogaers D, Vandenbroucke-Grauls CM, Roosendaal R, et al. Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. N Engl J Med. 2010;362(1):9–17.CrossRefGoogle Scholar
  61. 61.
    Chestovich PJ, Lin AY, Yoo J. Fast-track pathways in colorectal surgery. Surg Clin North Am. 2013;93(1):21–32.CrossRefGoogle Scholar
  62. 62.
    Fayezizadeh M, Petro CC, Rosen MJ, Novitsky YW. Enhanced recovery after surgery pathway for abdominal wall reconstruction: pilot study and preliminary outcomes. Plast Reconstr Surg. 2014;134(4S–2):151S–9S.CrossRefGoogle Scholar
  63. 63.
    Majumder A, Fayezizadeh M, Neupane R, Elliott HL, Novitsky YW. Benefits of multimodal enhanced recovery pathway in patients undergoing open ventral hernia repair. J Am Coll Surg. 2016;222(6):1106–15.CrossRefGoogle Scholar
  64. 64.
    Jensen KK, Brondum TL, Harling H, Kehlet H, Jorgensen LN. Enhanced recovery after giant ventral hernia repair. Hernia. 2016;20(2):249–56.CrossRefGoogle Scholar
  65. 65.
    Warren JA, Stoddard C, Hunter AL, Horton AJ, Atwood C, Ewing JA, et al. Effect of multimodal analgesia on opioid use after open ventral hernia repair. J Gastrointest Surg. 2017;21(10):1692–9.CrossRefGoogle Scholar

Copyright information

© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2019

Authors and Affiliations

  • Desmond T. K. Huynh
    • 1
  • Omar M. Ghanem
    • 2
  1. 1.Department of SurgeryCedars-Sinai Medical CenterLos AngelesUSA
  2. 2.Department of Surgery (Minimally Invasive and Bariatric Surgery Division)Mosaic Life CareSaint JosephUSA

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