The quest to improve outcomes for abdominal wall incisional hernia repair in Pietermaritzburg: between Scylla and Charybdis

Background: The repair and outcomes of incisional abdominal wall hernias have not yet been benchmarked to allow comparison with recommended best practice in a South African context. This study aimed to address this deficit. Method: Patients who underwent an incisional hernia repair between December 2012 and December 2018 were analysed in respect to the following variables: demographics, comorbidities, indication for surgery, site, size, surgical approach, mesh usage, operating times, complications and 30-day mortality. Results: Of the cohort of 224 patients, 185 underwent elective repair. There were 152 open and 72 laparoscopic procedures, and 17 patients (8%) required a repeat operation with an overall in-hospital mortality rate of 6% (13). Eight patients developed an enteric leak. There were nine cardiovascular complications, 24 respiratory complications, 22 surgical site infections and 13 patients developed an acute kidney injury (AKI). There were 39 emergency operations. The emergency cohort were older than the elective with a higher rate of cardiovascular or surgical (CVS) complications and AKI. Eight patients developed an enteric leak. Mortality rates of were significantly higher in the emergency operation cohort compared to the elective group (18% vs 3%). The 13 in-hospital deaths were older, more likely to have undergone an emergency operation, to be diabetic (46% vs 10%), hypertensive (92% vs 33%), have a bowel anastomosis (39% vs 9%), experience an enteric leak (46% vs 1%) and require repeat operation than the patients who survived. Conclusion: Incisional abdominal wall hernias are difficult to manage as the patients often have several comorbidities which when coupled with an emergency operation leads to poor outcomes. Improving outcomes requires strategies that address comorbidities and shift the focus to elective rather than emergency repair.