RECONSTRUCTIVE

Enhanced Recovery Pathway for Complex

Abdominal Wall Reconstruction
Sean B. Orenstein, MD
Summary: Ventral hernia repair with abdominal wall reconstruction can be a
Robert G. Martindale, MD,
challenging endeavor, as patients commonly present not only with complex
PhD
and recurrent hernias but also often with comorbidities that increase the risk
Portland, Ore. of postoperative complications including wound morbidity and hernia recur-
rence, among other risks. By optimizing patient comorbidities in the preopera-
tive setting and managing postoperative care in a regimented fashion, enhanced
recovery after surgery pathways allow for a systematic approach to reduce
complications and speed up recovery following ventral hernia repair. (Plast.
Reconstr. Surg. 142: 133S, 2018.)

V
entral hernia repair (VHR) and abdominal infection, and enhance early postoperative recov-
wall reconstruction (AWR) have evolved ery, enhanced recovery pathways (ERPs) have
over the last few decades to encompass a set been developed for hernia repair (Table 1).3,4
of surgical repairs that address hernias of various Herein, we present our own ERP based on current
sizes and complexity. There are multiple factors literature and experience.
that go into a successful hernia repair, including
surgical technique, tissue plane dissection, and
PREOPERATIVE OPTIMIZATION
choice of mesh prosthetic implanted. In addi-
tion to these surgeon-entrusted factors, there are Postsurgical wound healing is a complicated
multiple elements of preoperative and postopera- process that not only is affected by the surgical
tive care that greatly affect outcomes. Of these procedure but also is greatly influenced by the
elements, many are patient-specific factors that patient’s own health and comorbidities. Modifi-
are modifiable. Thus, there is great potential to able factors including smoking, obesity, diabetes,
improve outcomes by ameliorating detrimental and poor nutritional status are all detrimental
patient factors before an elective hernia repair. to proper wound healing. Poor control of these
Although hernia recurrence is a major indica- comorbidities greatly increases the risk of SSI
tor of the success of the hernia repair, recurrence and hernia recurrence, among other postopera-
may not be seen for months or years following sur- tive complications. Therefore, time and effort
gery. Short-term success is commonly attributed should be spent optimizing the patient before
to outcomes regarding wound healing because embarking on a complex VHR. In fact, smoking
wound morbidity can greatly influence quality and obesity have been shown to be independent
of life. Wound complications such as surgical-site risk factors for hernia recurrence and surgical-
infections (SSIs) are the most common postoper- site occurrence.5,6 Although many patient-spe-
ative complication in patients undergoing VHR.1 cific factors can be evaluated and treated as
Such complications can lead to increased emer- separate entities, it is important to keep in mind
gency room visits, hospital readmissions, greater that patients commonly present with multiple
time in clinic, or reoperations to manage wound factors that require a comprehensive evalua-
complications. Additionally, perioperative surgi- tion by the surgeon and possibly by specialists to
cal-site occurrences, including SSI, seroma, wound achieve optimal results.
ischemia, and dehiscence, can greatly increase
the risk of hernia recurrence.2 In an effort to sup- Disclosure: Dr. Orenstein has received instructor,
port and promote optimal wound healing, reduce consulting, and/or speaking honoraria from Bard-
BD and LifeCell-Allergan. Dr. Martindale has re-
From the Oregon Health & Science University. ceived instructor, consulting, and/or speaking hono-
Received for publication February 24, 2018; accepted May raria from Bard-BD and LifeCell-Allergan. Neither
14, 2018. author has a financial interest in any of the prod-
Copyright © 2018 by the American Society of Plastic Surgeons ucts, devices, or drugs mentioned in this article.
DOI: 10.1097/PRS.0000000000004869

www.PRSJournal.com 133S
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 Plastic and Reconstructive Surgery • September Supplement 2018

Table 1. Enhanced Recovery Pathway Interventions for Ventral Hernia Repair

Solid Data to Support Intervention Awaiting Greater Confirmation of Data
Obesity and weight management Bowel preparation
• Sufficient weight loss necessary, however, no consensus on target BMI
Smoking cessation—30+ d preoperatively Patient warming
Diabetes management and perioperative glucose control Hyperoxygenation
• Preoperative HgbA1c <7.0
• Postoperative blood sugar 120–160 mg/dL
Nutrition and metabolic control Carbohydrate loading
• Preoperative and postoperative supplements
• Consider specific nutrients (arginine and omega-3 fatty acids)
Alcohol-containing skin preparation Prehabilitation
Antibiotic prophylaxis Antibiotic-impregnated sutures
• Choice of antibiotic—first generation cephalosporin for most
• Vancomycin in high-risk groups
• Duration—should stop when wound closed and all sutures placed
• Duration—for redosing, consider t1/2 of specific antibiotic; refer to ASHP and/
or hospital guidelines
ASHP, The American Society of Health-System Pharmacists.

Smoking require patients to cease all smoking activity for

The numerous detrimental effects of tobacco a minimum of 30 days preoperatively for those
use are well known and described in the litera- undergoing elective VHR.10 Although laparoscopic
ture. Because hernia repair relies intensely on and other minimally invasive techniques benefit
proper wound healing, any reduction of blood patients with reduced wound complications, active
and tissue oxygenation and impairment in colla- tobacco use still adds impairments to wound heal-
gen deposition within fresh wounds can greatly ing. We do, however, allow the use of nicotine sup-
affect the outcome of a hernia repair.7–9 Numer- plements (patches, gum, lozenges, etc.), as the data
ous experiments have shown detrimental effects are reasonably good indicating that nicotine is not
of smoking and have demonstrated significantly a strong impediment to proper wound healing.
increased risk of wound infections following VHR
in smokers.10–12 Smoking has also been shown to be Obesity
a risk factor for the development of primary inci- Among the various hazards affecting patient out-
sional hernias following abdominal operations.5 comes, obesity stands out as one of the most promi-
Additionally, because VHR frequently requires nent with regard to its incitement of both incisional
the use of a mesh prosthetic and various tissue hernia development and recurrence following VHR.
plane dissections, along with the possibility of a Regardless of the surgical technique employed for
concomitant gastrointestinal procedure, these VHR, hernia recurrence increases linearly as body
studies reinforce the need for smoking cessation mass index (BMI) increases.6,15,16 Because of the
before AWR. A landmark study by Sorensen et al13 challenges with treating ventral hernias in the set-
included 4 groups: smokers, nonsmokers, smok- ting of obesity, much clinic visit time is counseling
ers who quit for 30 days preoperatively, and those patients on methods to improve dietary habits and
who quit smoking plus nicotine patch. This study increase physical activity in an effort to lose weight.
demonstrates that smoking cessation for 30 days is If attempts at medical weight loss fail, it is our prac-
adequate to show alleviation of many deleterious tice to refer patients to a bariatric center for more
effects of cigarettes. However, detrimental effects intense medical or surgical weight loss discussions.
on cellular proliferation and remodeling still per- We have found that patients with BMI ≥50
sist despite smoking cessation.14 Interestingly, the have an unacceptably high hernia recurrence and
use of nicotine patches did not negate the benefi- wound morbidity rate. Therefore, we forego elec-
cial effects of smoking cessation. The unexpected tive VHR in these high-risk patients unless they
phenomenon is that nicotine patches do not pro- have signs or symptoms of bowel compromise (eg,
mote a deleterious effect on wound healing, sug- obstruction, ischemia, strangulation, etc.). For
gesting that it is not nicotine but something else these concerning patients, consideration is given
in the cigarette smoke that is harmful. for a laparoscopic or open repair with bowel reduc-
Given the high-quality literature demonstrat- tion and primary suture repair, or possibly with a
ing a clear correlation between active cigarette use bridged mesh. However, no formal AWR would
and impaired wound healing with its sequelae, we be done until the patient has achieved sufficient

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 Volume 142, Number 3S • Enhanced Recovery Pathway

weight loss. Likewise, if a patient chooses a bar- the concept that preoperative metabolic prepara-
iatric procedure before formal hernia repair, the tion can alter the systemic response to the surgi-
simplest hernia repair is performed at this time, cal insult.22–24 It has been shown that fish oils have
saving more complex repairs until after suffi- multiple mechanisms, including attenuating the
cient weight loss. Some surgeons have advocated metabolic response to stress, altering gene expres-
for concomitant VHR at the same time as sleeve sion to minimize the proinflammatory cytokines,
gastrectomy because sleeve gastrectomy does not beneficially modifying the Th1 to Th2 lymphocyte
result in the same degree of nutritional risks as gas- population to lower the inflammatory response,
tric bypass.17 However, until adequate weight loss and regulating bowel motility.26–31 Arginine has
has been achieved, the patient still remains high been reported to have a multitude of potential
risk for wound morbidity and hernia recurrence. benefits in the surgical populations, including
improved wound healing, optimizing lymphocyte
Diabetes proliferation and function, and enhancing blood
Although glucose management is important flow via the nitric oxide vasodilation.32,33
for all stages of patient care related to hernia Another area of metabolic manipulation is pre-
repair, preoperative glycemic control is essential operative carbohydrate loading.34 This metabolic
for optimal outcomes. This is routinely measured strategy uses an isotonic carbohydrate solution
in the preoperative setting with glycosylated hemo- given 3 hours preoperatively to alter stress metab-
globin (HgbA1c). Studies have demonstrated olism and decrease insulin resistance.35 In most
reduced wound healing and increased postop- Western surgical settings, the “routine” is for the
erative complications in diabetic patients under- patient to fast after midnight before surgery in the
going a variety of surgical procedures.18–20 We morning. Multiple authors have demonstrated the
postpone elective hernia repair in patients with beneficial effects of carbohydrate loading, report-
elevated HgbA1c (>8%), with attempts at achiev- ing primarily benefits in insulin resistance.36–39 Such
ing a HgbA1c goal closer to 6.5%. The patient is studies have consistently reported several meta-
referred to a diabetic educator or endocrinolo- bolic benefits including significantly reduced insu-
gist, and the VHR repair is rescheduled when gly- lin resistance, decreased postoperative nitrogen
cemic levels are controlled. Postoperative glucose loss, and better retention of muscle function.36,37
control is another important aspect for patients
with and without diabetes to reduce wound mor- PERIOPERATIVE AND POSTOPERATIVE
bidity; this is discussed later within the postopera- CARE
tive optimization section.
Surgical-Site Infection
Nutrition and Metabolic Control SSIs are the bane of many surgical procedures
Numerous randomized controlled trials because SSIs can have significant consequences
(RCTs), analyses, and reviews demonstrate the including severe illness, prolonged hospitaliza-
role that nutritional therapy plays in the ability tion, readmission(s), increased clinic time, and
of patients to heal and recover following surgery. reducing the success of the hernia repair itself.
Despite substantial evidence supporting the role Compared with other clean nonhernia surger-
that nutrition plays on perioperative outcomes ies, SSI rates are noted to be higher for VHRs.40
and healing, insufficient emphasis is placed on Another aspect of infections and hernia repair
optimizing the patient’s nutritional status in the revolves around the use of mesh, which are nec-
preoperative setting.21 essary for successful outcomes in the majority of
The concept of preoperative preparation VHRs. Traditionally used permanent meshes (eg,
with specific metabolic and immune active nutri- heavyweight microporous polypropylene) have
ents gained popularity after several landmark limited ability to eradicate contamination, lead-
RCTs by Gianotti et al.22–24 These investigations ing to additional surgery to explant the mesh and
demonstrated benefit in lowering perioperative clear infections. Salvage rates for synthetic meshes
complications by adding arginine, omega-3 fatty following mesh-related wound infections are
acids, and nucleotides for 5 days preoperatively. reported between 10% and 70%.2,41 Bacterial clear-
They reported reduction in morbidity in patients ance rates are dependent on the type and location
undergoing major foregut surgery. Similar ben- of mesh used, the extent of contamination, and
efit was noted in both the well-nourished and mal- the viability of the tissue and host defenses. In the
nourished patient populations.24,25 This supports setting of infection, polytetrafluoroethylene-based

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 Plastic and Reconstructive Surgery • September Supplement 2018

meshes are virtually impossible to clear, followed specific agents, redosing, and postoperative antibi-
by multifilament polyester, whereas macroporous otic use. According to guidelines developed jointly
(light/medium weight) polypropylene yields the by multiple societies, patients undergoing routine
best chance of salvage.41,42 In addition, infected ventral hernias repair should be given prophy-
mesh is associated with costly and serious mor- laxis using a first-generation cephalosporin.53 Dur-
bidity including prolonged wound management, ing the procedure, antibiotics should be redosed
enterocutaneous fistulae, and recurrent hernia. based on duration of surgery, antibiotic half-life,
These complications can be quite severe and blood loss, and use of cell saver. Cefazolin, being
expose the patient to significant morbidity, mor- the most commonly used cephalosporin, should
tality, and cost of care.42 be redosed every 4 hours. Importantly, because
of shorter half-lives, antibiotics such as cefoxitin,
Skin Preparation and Decolonization Protocols ampicillin-sulbactam, and piperacillin-tazobactam
Appropriate surgical field disinfection with are redosed every 2 hours when used for intraop-
various skin preparations has been well described. erative prophylaxis.53 One challenge with regard
Multiple publications have concluded that iodine- to antibiotic dosing is the obese population. In a
or chlorhexidine-based skin preparations are recent large survey, only 66% of patients received
equally effective, provided alcohol is a primary prophylactic dosing to reach adequate serum
ingredient within the preparation solution.43–46 levels when BMI was over 30.54 According to the
The data on skin sealants and surgical-site barriers American Society of Health-System Pharma-
are too inconsistent to make any formal recom- cists (ASHP) guidelines, it is recommended that
mendation. The use of preoperative showers with all patients under 120 kg receive 2 g cefazolin,
antiseptic soaps to decrease SSIs has also been whereas those ≥120 kg be given 3 g, then redosed
inconsistent.46–49 Showering with antiseptic agents every 4 hours for extended surgeries. Regarding
such as chlorhexidine or povidone-iodine, when the use of postoperative antibiotics, several RCTs
across multiple surgical disciplines have shown
compared with soap, has not shown significant
no benefit of dosing antibiotics after the skin has
benefit in lowering SSI, and it may alter the nor-
been closed in clean cases.46,53,55–58
mal protective skin flora (microbiome) and actu-
Commonly, vancomycin is given as a sole agent
ally increase the risk of SSI.50
in patients with a strong history of MRSA. How-
Much discussion on preoperative decoloniza-
ever, vancomycin is less effective against methicil-
tion revolves around the fact that the nares are
lin-sensitive S. aureus compared with cefazolin.53,59
the most common area of Staphylococcus aureus Given the need for mesh in many VHRs and
colonization. Bode et al51 helped popularize nasal potential for mesh infection, we routinely use
clearance of S. aureus in the preoperative setting, both cefazolin and vancomycin for prophylaxis
reporting a 42% decrease in S. aureus infections in patients who are high risk for MRSA infection.
in the treated group. In our practice, we selec- This ensures adequate coverage of both methicil-
tively treat high-risk patient populations instead lin-sensitive S. aureus and MRSA, especially in the
of random methicillin-resistant S. aureus (MRSA) setting of a mesh implant.53
nasal screening. High-risk patients include pre- For patients with active wound infections,
vious MRSA infection, cohabitant with MRSA, infected mesh, chronic draining sinuses, entero-
recently hospitalized within 6 months, living cutaneous fistulas, and so on, the primary initial
in a nursing facility or prison, currently on goal is removal of all sources of infection. Before
broad-spectrum antibiotics, and other high-risk definitive hernia repair, the goal is to remove all
patients. These patients are treated with mupi- infected mesh(es) and other foreign bodies (eg,
rocin ointment applied in each nostril twice suture material), debride all infected and poor
daily, along with chlorhexidine showers daily for integrity tissue, and perform any necessary gas-
5 days before surgery. More recently, an iodine- trointestinal resections with anastomoses, as indi-
based preparation for use in this setting has been cated. For many cases where the bioburden of
manufactured and may offer a single treatment bacteria is high, we stage the repair by closing the
option.52 abdomen with native tissue or absorbable mesh
and perform a subsequent hernia repair, likely
Perioperative Antibiotics with a biologic or biosynthetic resorbable mesh,
Although perioperative antibiotic prophy- at some point in the future depending on the
laxis has been routinely established for surgical patient’s condition, nutritional status, and degree
procedures, there still exists confusion regarding of contamination.60

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 Volume 142, Number 3S • Enhanced Recovery Pathway

Postoperative Blood Glucose Management degree of hernia repair because more complex
As already discussed, preoperative diabetes repairs will likely require greater breadth of anal-
management is an essential component to opti- gesics. Conversely, a straightforward umbilical
mizing the patient before elective VHR. Peri- and hernia repair may only require 1 or 2 analgesic
postoperative glucose control is another essential agents.
component to reduce wound complications in For our ERP, patients are routinely given
both diabetic and nondiabetic groups. Hypergly- some form of an opiate for immediate pain relief.
cemia has been shown to alter chemotaxis, phago- Patients undergoing same-day surgery can be dis-
cytosis, and oxidative burst, which can prevent the charged with oral oxycodone, hydromorphone,
early optimal killing of bacteria that entered the or hydrocodone. However, patients who are
wound during surgery.61 Therefore, appropriate admitted are routinely given a hydromorphone
glycemic control is vital within the first 24 hours of patient-controlled analgesia pump, which is tran-
the postoperative period to maximize neutrophil sitioned to oral opiates (eg, oxycodone or hydro-
activity and reduce wound complications. Mul- morphone) once tolerating a diet.
tiple, large randomized clinical trials have con- Acetaminophen is routinely given around the
firmed that the target blood glucose level in the clock because it carries a high-safety profile, includ-
immediate perioperative period appears optimal ing lack of sedation, ileus, bleeding, or impaired
in the 120–160 mg/dL range62–65 although some renal function. Because acetaminophen is primar-
guidelines recommend a range of 110–150 mg/ ily metabolized in the liver, however, its use should
dL.66 It is important to maintain glucose levels be cautioned in patients with hepatic dysfunction.
above 110 mg/dL because hypoglycemia can lead Despite its use for decades, the precise mechanism
to serious consequences.63,66 of acetaminophen remains unknown, although it
appears to have a central analgesic effect on mul-
tiple pathways.68 Because of its high-safety profile
Multimodal Pain Control
when dosed appropriately, patients will routinely
One of the biggest challenges following VHR be discharged with acetaminophen as a primary
is adequate pain control. Regardless of the repair analgesic. NSAIDs represent another class of non-
type, almost all hernia repairs require fascial reap- opiates but should be cautiously used with elderly
proximation and some degree of mesh fixation, patients given the risk of kidney injury. Therefore,
all of which incite pain. Many protocols focus NSAIDs are reserved for nonelderly patients for
on multimodal treatment of postoperative pain, only a short duration.
employing a combination of opiates and nonopi- Gabapentin remains another useful analge-
ates to mitigate the pain along multiple pathways.67 sic following hernia repair. Gabapentin acts at
Given the efficacy of pain relief with narcotics, the neuronal level, with mechanisms of action on
opiates are a common component of multimodal calcium channels and gamma-aminobutyric acid
pathways. However, the deleterious effects of opi- receptors.69–71 Multiple RCTs have demonstrated
ates including sedation, respiratory depression, the benefits of pain control and reduced opioid
constipation, addiction/dependence, and so on, use without the side-effect profile of opiates.71–75
make their use challenging. Multimodal strategies Although some patients experience sedative
help in reducing opiate consumption, thereby effects from gabapentin, this effect is less frequent
decreasing side effects and improve overall pain than with opiates. We routinely provide gabapen-
control. Although multiple ERP protocols exist, tin (300 mg thrice a day) immediately postopera-
the principal components of our postoperative tively until the day of discharge. Rarely, patients
multimodal pain regimen include an immediate- are prescribed gabapentin upon discharge, and
acting narcotic, acetaminophen, gabapentin, and this is typically reserved for patients with known
possibly nonsteroidal anti-inflammatory drugs chronic pain syndromes or if significant lateral
(NSAIDs). Other pharmaceuticals, including wall dissection was performed.
antispasmodics, may be added but are used less Because of the varying degrees of myofascial
routinely. Patients with sensitivities or allergies to dissection and transabdominal fixation, muscle
various components need to be taken into con- spasms can be common. Antispasmodic medica-
sideration (eg, avoidance of NSAIDs with renal tions can be a useful adjunct to aid in pain relief
insufficiency). Another benefit of multimodal by their muscle relaxant properties. Although
regimens is their ability to be scaled up or down typically thought of as an anxiolytic, diazepam
depending on repair type and complexity. The can be an effective muscle relaxant in the post-
multimodal approach should be tailored to the operative setting. There is limited literature

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 Plastic and Reconstructive Surgery • September Supplement 2018

regarding the use of diazepam for postoperative to the patient leads to multiple metabolic ben-
pain control in VHR; however, studies do sup- efits, as well as reducing postoperative ileus and
port diazepam in a multimodal regimen with decreasing length of hospitalization, without
narcotics.76,77 Diazepam is typically started on added risk. For our ERP, patients receive unlim-
postoperative day 1 or 2, allowing for evaluation ited clear liquids plus a clear liquid protein supple-
of sedation. Two to 5 mg of diazepam is sched- ment on postoperative day 1, followed by regular
uled every 6 hours around the clock for the diet on postoperative day 2. Antiemetics are pro-
first 48 postoperative hours, excluding elderly vided as needed. However, most patients tolerate
patients over 65 years old and all patients with this rapid progression without the need for diet
obstructive sleep apnea. Caution must be used cessation or nasogastric tube placement. The
with diazepam because an additive sedative exceptions are for patients who required signifi-
effect can be seen with other analgesics. Because cant adhesiolysis, bowel resection, or parastomal
of these sedative effects and greater addictive hernia repair. These groups are at higher risk for
profile of benzodiazepines, we routinely exclude ileus development; therefore, diets are adjusted
diazepam at discharge. according to the severity of abdominal distention,
Local and regional blocks are also useful nausea, and vomiting, which may prompt nasogas-
adjunct for analgesia.78 Transversus abdominis tric tube placement and withholding diet until the
plane (TAP) blocks have gained popularity given ileus has resolved.
its blockade of intercostal, subcostal, ilioinguinal,
and iliohypogastric nerves.79,80 TAP blocks use
local anesthetic infusion between the internal CONCLUSIONS
oblique and transversus abdominis muscles and Complex VHR is a challenging endeavor that
are performed either via ultrasound guidance, can result in high rates of wound complications
indirect visualization laparoscopically, or direct and hernia recurrence. There are multiple factors
visualization of the planes if performing a trans- that influence the outcome of the repair, many of
versus abdominis release. Studies have demon- which can be mitigated in the preoperative set-
strated a reduction in postoperative pain, overall ting. Preoperative optimization of modifiable fac-
narcotic usage, length of stay, and reduction of tors such as smoking cessation, weight loss, along
opioid-specific side effects with the use of TAP with diabetes and glycemic control can greatly
blocks.81–85 With regard to epidural anesthesia, influence the success of VHR. In the postopera-
we have found a lack of efficacy of adequate pain tive setting, close glucose control, adequate pain
relief in AWR patients. This lack of benefit, diffi- control, early enteral feeding, and other factors
culty with placement in obese patients, along with also impact the patient by reducing wound mor-
other side effects (eg, hypotension, urinary reten- bidity, increasing patient comfort, and allowing
tion, etc.), along with increased length of stay,86 for earlier hospital discharge. Although various
has led us to forgo epidural use in the majority of ERP protocols have been developed, ongoing
patients undergoing AWR. analysis of current pathways along with periodic
In summary, a multimodal pain regimen updates as we accrue more data will surely benefit
results in decreased postoperative pain while our patients following VHR and AWR.
significantly reducing opioid consumption. Sean B. Orenstein, MD
Although opiates are still an important aspect of Oregon Health & Science University
adequate pain relief at this time, a reduction in 3181 SW Sam Jackson Park Road, L223A
narcotic use is favored. Multimodal pain regimens Portland, OR 97239
will continue to evolve as we study the effects of orenstei@ohsu.edu
combining various analgesics, and patients should
be tailored for their own personal analgesic needs
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 Plastic and Reconstructive Surgery • September Supplement 2018

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