title: Clinical predictors of operative complexity in laparoscopic ventral hernia repair: a prospective study.
abstract: BACKGROUND
  Because of uncertainties about the complexity of laparoscopic ventral hernia repair for varying patient populations, surgeons may be reluctant to perform this procedure. This study aimed to delineate the risk factors that can be identified in the preoperative setting predictive of longer operative times and complexity in laparoscopic ventral hernia repair.
  
  
  METHODS
  Patient demographics including body mass index (BMI), comorbidities, previous laparoscopic and open surgical procedures, ventral hernia repairs, and hernia characteristics (defect size and location, adhesions, incarceration) were recorded prospectively. Data are given as mean +/- standard deviation. Times (min) required for abdominal access, adhesiolysis, and mesh placement as well as the total operative time were recorded during each case as outcome measures of operative difficulty. Univariate analyses were performed with the t-test or the Mann-Whitney U test as well as multivariate analyses using the stepwise analysis of covariance model to determine demographic and clinical variables influencing operative times.
  
  
  RESULTS
  The study enrolled 180 patients (78 men and 102 women) with a mean age of 54.8 +/- 12.2 years and a mean BMI of 33.3 +/- 13.0 kg/m(2). Multivariate analysis demonstrated significantly longer (p < 0.05) adhesiolysis and total operative times for patients with prior ventral hernia repairs, suprapubic hernia, bowel adhesion to the abdominal wall or hernia sac, and larger hernia defect. The total operative time also was increased (p < 0.05) with incarcerated hernia contents. Mesh placement time was increased (p < 0.05) with incarcerated hernia contents, suprapubic hernia location, hernias requiring larger mesh for repair, and decreased postgraduate year of the surgical assistant. The time required to obtain abdominal access was longer (p < 0.05) with a greater BMI and a higher American Society of Anesthesiology (ASA) classification. The operative times were not increased with a history of peritonitis, diabetes, immunosuppression, cancer, or with higher numbers of previous open or laparoscopic surgeries.
  
  
  CONCLUSIONS
  At least 10 preoperatively identifiable patient variables, either alone or in combination, are predictive of prolonged operative times during laparoscopic ventral hernia repair and may be used as surrogates to determine the complexity of a minimally invasive approach.
authors.affiliation: Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box #8109, St Louis, MO 63110, USA. jenkinse@wudosis.wustl.edu
authors.forename: Eric D
authors.initials: ED
authors.lastname: Jenkins
authors.forename: Victoria H
authors.initials: VH
authors.lastname: Yom
authors.forename: Lora
authors.initials: L
authors.lastname: Melman
authors.forename: Richard A
authors.initials: RA
authors.lastname: Pierce
authors.forename: Richard B
authors.initials: RB
authors.lastname: Schuessler
authors.forename: Margaret M
authors.initials: MM
authors.lastname: Frisella
authors.forename: J
authors.initials: J
authors.lastname: Christopher Eagon
authors.forename: L
authors.initials: L
authors.lastname: Michael Brunt
authors.forename: Brent D
authors.initials: BD
authors.lastname: Matthews
mesh_terms: D005260:Female; D006555:Hernia, Ventral / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology; D011300:Preoperative Care; D011446:Prospective Studies; D012307:Risk Factors; D013997:Time Factors