Hernia (2015) 19:113–123
DOI 10.1007/s10029-013-1155-y
ORIGINAL ARTICLE
Risk factors for postoperative wound infections and prolonged
hospitalization after ventral/incisional hernia repair
C. Kaoutzanis • S. W. Leichtle • N. J. Mouawad •
K. B. Welch • R. M. Lampman • W. L. Wahl •
R. K. Cleary
Received: 1 March 2013 / Accepted: 30 August 2013 / Published online: 13 September 2013
Ó Springer-Verlag France 2013
Abstract
Purpose The purpose of this study was to identify pre-
dictive factors for postoperative surgical site infections
(SSIs), and increased length of hospital stay (LOS) after
ventral/incisional hernia repair (VIHR) using multi-center,
prospectively collected data.
Study design Cases of VIHR from 2009 to 2010 were
identified in the American College of Surgeons National
Surgical Quality Improvement Program database. Using
logistic regression, a prediction model utilizing 41 vari-
ables was developed to identify risk factors for postoper-
ative SSIs, and increased LOS. Separate analyses were
carried out for reducible and incarcerated/strangulated
cases.
Results A total of 28,269 cases of VIHR were identified,
25,172 of which met inclusion criteria. 18,263 cases were
reducible hernias, and 6,909 cases were incarcerated/
strangulated hernias. Our prediction model demonstrated
that body mass index C30 kg/m2, smoking, American
This work was presented at:
Annual Conference, American College of Surgeons’ National
Surgical Quality Improvement Program National Conference, Salt
Lake City, Utah, United States; July 2012 and 58th Clinical Meeting
of the Frederick A. Coller Society, Annapolis, Maryland, United
States; September 2012.
C. Kaoutzanis (&)
S. W. Leichtle
N. J. Mouawad

R. M. Lampman
W. L. Wahl
R. K. Cleary
Department of Surgery, Saint Joseph Mercy Health System,
5333 McAuley Drive, Reichert Health Building, Suite R-2111,
Ann Arbor, MI 48106, USA
e-mail: ckaoutzanis@gmail.com
K. B. Welch
Center for Statistical Consultation and Research,
University of Michigan, Ann Arbor, MI, USA
Society of Anesthesiology (ASA) class 3, open surgical
approach, prolonged operative times, and inpatient admis-
sion following VIHR were significant predictors of post-
operative SSIs. In addition, risk factors associated with
prolonged LOS included older age, African American
ethnicity, history of alcohol abuse, ASA classes 3 and 4,
poor functional status, operation within the last 30 days of
the index operation, history of chronic obstructive pul-
monary disease, congestive heart failure, and bleeding
disorder, as well as open surgical approach, non-involve-
ment of residents, prolonged operative times, recurrent
hernia, emergency operation, and low preoperative serum
albumin level.
Conclusions Obesity and smoking are modifiable risk
factors for SSIs after VIHR, whereas a low serum albumin
level is a modifiable risk factor for prolonged LOS.
Addressing factors preoperatively might improve patient
outcome, and reduce health care expenditures associated
with VIHR. In addition, if feasible, the laparoscopic
approach should be strongly considered.
Keywords Ventral hernia
Incisional hernia

Ventral/incisional hernia repair
Postoperative
surgical site infection
Length of hospital stay

ACS-NSQIP
Introduction
It is estimated that over 400,000 patients undergo treatment
for ventral or incisional hernias (VIHs) in the USA each
year, a number that continues to increase by a small per-
centage annually [1]. Incisional hernias are a common
complication following abdominal surgery with a reported
incidence of 3–13 % [2]. A shift in patients’ characteristics
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over the last few decades, such as the increasing prevalence
of obesity and chronic obstructive pulmonary disease
(COPD), may be a major contributing factor. In addition,
improvements in health care have led to increased life
expectancy, and survival of critically ill and cancer patients
who have lived through major abdominal surgeries. The
clinical and economic burden of these hernias is profound,
and surgical intervention remains the only potentially
curative approach. However, despite the continuous
advancements in techniques and technologies, recurrence
rates remain unacceptably high [3, 4].
Wound infection and hernia recurrence are two closely
related adverse outcomes of any ventral/incisional hernia
repair (VIHR). Wound infections have been identified as a
major risk factor for recurrence after VIHR [5] and may
increase the incidence of incisional hernias up to 80 % for
those who develop wound infections [3, 5]. Therefore,
identifying factors associated with wound infections fol-
lowing VIHR has the potential to improve short-term and
long-term outcomes. Current literature regarding risk fac-
tors for the development of VIH is limited, and to our
knowledge, minimal or inconsistent data exist with regard
to which risk factors are most significant.
The postoperative length of hospital stay (LOS) is also
related to wound infections and can reflect the success of
VIHR. LOS affects the overall hospital cost and is a sur-
rogate for other important outcomes, such as postoperative
pain and return of bowel function. In a prospective cohort
study of 487 patients, it was found that COPD, coronary
artery disease, low preoperative serum albumin, and
chronic steroid use were independent risk factors for
increased LOS [6]. Further research is required to better
understand the risk factors that affect LOS following
VIHR, thereby decreasing health care expenditures.
This study queried the prospectively collected, multi-
center American College of Surgeons National Surgical
Quality Improvement Program (ACS-NSQIP) database to
delineate important risk factors for postoperative surgical
site infections (SSIs), and prolonged hospitalization after
VIHR. We hypothesized that modifiable risk factors play a
significant role in the development of postoperative SSIs
and prolonged hospitalization after VIHR.
Methods
The ACS-NSQIP database was queried for cases of VIHRs
from 2009 to 2010. The ACS-NSQIP is a large, rigorously
maintained database supported by the American College of
Surgeons. It employs a prospective, peer controlled, vali-
dated database to quantify 30-day risk-adjusted surgical
outcomes, which allows valid comparison of outcomes
among all hospitals in the program. Over 135 precisely
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Hernia (2015) 19:113–123
defined variables are collected on patients undergoing
major surgical procedures in both the inpatient and out-
patient settings, including demographic characteristics,
comorbidities, laboratory values, intraoperative events, and
30-day postoperative outcomes. During our study period,
more than 350 participating hospitals in the USA system-
atically collected these data prospectively. The data are
collected, validated, and submitted by a trained Surgical
Clinical Reviewer at each site. The high quality and
validity of the ACS-NSQIP database have been demon-
strated in several reports and studies [1–4] and inter-rater
reliability audits have demonstrated a disagreement rate on
variables in 2008 of \2 % [5, 7–11].
Cases were sampled by Current Procedural Technology
codes for reducible VIHRs (49560, 49565, 49655, 49657)
and incarcerated/strangulated VIHRs (49561, 49566,
49654, 49656). Separate analyses were performed for
reducible and incarcerated/strangulated hernias for all
wound types combined, for superficial SSIs, and for LOS.
All other analyses (i.e., occurrence of deep SSI, wound
disruption, and organ/space SSI) were combined with
respect to reducible and incarcerated/strangulated hernias.
And the type of hernia (reducible or incarcerated/strangu-
lated) was controlled for in the analysis. The Institutional
Review Board at the Saint Joseph Mercy Health System
approved this study.
Exclusion criteria included age under 18 years, current
pregnancy, involvement in trauma, American Society of
Anesthesiology (ASA) classes 5 and 6, presence of sys-
temic inflammatory response syndrome, severe sepsis or
septic shock within 48 h prior to the index operation, and
the presence of preoperative open wounds, with or without
infection. In addition, cases with operative times \20 min
or[240 min were excluded to analyze a more homogenous
case group, and avoid inclusion of potentially erroneous
data.
Outcomes of interest were all types of adverse postop-
erative wound complications including any occurrence of
superficial SSI, deep SSI, wound disruption, or organ/space
SSI. The definitions for these adverse outcomes were based
on Centers for Disease Control and Prevention and ACS-
NSQIP terminology. LOS, defined as the day of discharge
minus the day of operation, was also examined. Logistic
regression models were used for all SSI outcomes, while a
negative binomial model was employed for LOS, which
was highly skewed. Results of the analysis for this outcome
were presented as relative LOS, which was a multiplier
applied to the effect for a particular risk factor (for
example, a relative LOS of 1.2 would mean that patients in
the higher risk category had on average 20 % longer stay
after surgery).
Forty-one risk factors were included in our statistical
analysis, including demographic characteristics, general
Hernia (2015) 19:113–123
health factors, comorbidities, intraoperative factors, and
preoperative laboratory values. Comparisons of each risk
factor for reducible versus incarcerated/strangulated her-
nias were carried out using Pearson’s Chi-square test for all
categorical variables, age was compared using an inde-
pendent samples t test, and operative time was analyzed on
the natural log scale because it was found to be highly
skewed (Table 1). All the risk factors, except operative
time, were included in the discrete categories. Because the
relationship of age to adverse wound outcomes was not
linear, age was included in these models as a dummy
variable for each 10-year interval. The relationship
between age and LOS was linear, so age was included as a
continuous variable in the analysis for LOS. Since there
were many missing values for preoperative laboratory data,
missing values were included as a separate category in the
analysis.
Prediction models were developed to identify risk fac-
tors for all wound infection outcomes combined (any
occurrence of superficial SSI, deep SSI, wound disruption,
or organ/space SSI), for each of the four wound infection
outcomes separately, and for prolonged LOS. To develop
the prediction models, each of the risk factors was initially
used in an unadjusted analysis to predict wound infection
complication or prolonged LOS. The data were then divi-
ded into two random halves: the first half of the data being
used for model-building and the second half for model
validation. In the half used for model-building, all predic-
tors that had a p value B0.10 from the unadjusted analysis
were entered into a multiple regression model (logistic
regression for wound infection complications and negative
binomial regression for LOS), and backward selection was
used to derive the variables that were included in the val-
idation model. The variables identified as being potentially
important in the model-building half of the data (i.e., those
with p value B0.10 in the backward selection model) were
then used as the set of predictors in the validation model,
which was fitted using the other random half of the data.
Prediction models for any wound infection complication,
for superficial SSI, and for LOS were developed separately
for reducible and incarcerated/strangulated hernias, but for
the other individual wound infection complications (i.e.,
deep SSI, wound disruption, organ/space SSI), the predic-
tion model was developed for both of these subgroups
combined due to small numbers of adverse events, and the
type of case (reducible versus incarcerated/strangulated
VIH) was included as a predictor in the models.
Categorical risk factors were expressed as the number
and percent in each category. Age was expressed as
arithmetic mean ± standard deviation (SD). Because of its
skewed nature, LOS was expressed as geometric
mean ± 95 % confidence interval (CI). Statistical signifi-
cance for all analyses was indicated by a p value of 0.05 or
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less. Analyses were performed using SAS software for
Windows, release 9.3.
Results
For the years 2009 and 2010, a total of 28,269 cases of
VIHRs was listed in the ACS-NSQIP database, with 25,172
(89 %) cases meeting our inclusion criteria. Patient
demographics and other characteristics are shown in
Table 1. The mean age was 55 years in both types of hernia
patients, and more than half of the patients were females.
The body mass index (BMI) was [30 kg/m2 in 55 % of
patients with reducible hernias and in 65 % of patients with
incarcerated/strangulated hernias. The majority of VIHRs
were performed utilizing an open surgical technique. More
than 90 % of the study population was of ASA class 2 or 3,
and more than 95 % of the subjects had an independent
functional status. Tobacco use was documented in 21 % of
the reducible hernias and in 22 % of the incarcerated/
strangulated hernias. The most common comorbidities
amongst the subjects were hypertension requiring medi-
cation, diabetes mellitus, cardiovascular disease, COPD,
and cerebrovascular disease.
Prediction models
All wound occurrences
All wound occurrences were examined separately for the
reducible and incarcerated/strangulated VIHs. A total of
750 (4 %) adverse wound occurrences was reported among
the 18,263 reducible VIHRs. A total of 348 (5 %) adverse
wound occurrences was reported among the 6,909 incar-
cerated/strangulated VIHRs. Significant predictors of any
wound occurrence in patients who underwent VIHR for a
reducible hernia and an incarcerated/strangulated hernia
are shown in Tables 2 and 3, respectively.
Superficial surgical site infections
Superficial SSIs were also examined separately for reduc-
ible and incarcerated/strangulated VIHs. There were 436
(2 %) cases with a superficial SSI among the 18,263
reducible VIHRs. Among the reducible hernia subgroup,
open surgery was a significant risk factor for superficial SSI
after controlling for other covariates (OR 4.50,
CI 2.61–7.77, p \ 0.01). Other significant risk factors
included BMI C30 kg/m2 (OR 1.82, CI 1.35–2.45,
p \ 0.01), current smoking (OR 1.56, CI 1.16–2.10,
p \ 0.01), and inpatient status (OR 1.53, CI 1.10–2.12,
p = 0.01). Each 30-min longer operative time was associ-
ated with 1.2 times greater odds of having a superficial SSI,
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Table 1 Patient characteristics in reducible and incarcerated/strangulated VIHRs

Variable Reducible Incarcerated/Strangulated p value
Mean ± SD/N (%) Mean ± SD/N (%)
(n = 18,263) (n = 6,909)

Demographics
Age 56.6 ± 14.2 57.0 ± 14.4 0.081
Female gender 10,388 (56.9 %) 4,193 (60.7 %) \0.001
African American 1,668 (9.1 %) 899 (13.0 %) \0.001
BMI C30 10,040 (55.0 %) 4,460 (64.6 %) \0.001
General health factors
Tobacco use 3,775 (20.7 %) 1,509 (21.8 %) 0.042
Alcohol abuse 397 (2.2 %) 172 (2.5 %) 0.133
Dependent functional status 222 (1.2 %) 201 (2.9 %) \0.001
ASA class \0.001
ASA class 1 1,031 (5.6 %) 346 (5.0 %)
ASA class 2 9,524 (52.1 %) 3,248 (47.0 %)
ASA class 3 7,358 (40.3 %) 3,056 (44.2 %)
ASA class 4 350 (1.9 %) 259 (3.7 %)
Prior operation (within 30 days) 79 (0.4 %) 99 (1.4 %) \0.001
Comorbidities
Diabetes mellitus 2,774 (15.2 %) 1,281 (18.5 %) \0.001
COPD 909 (5.0 %) 407 (5.9 %) 0.004
Hypertension requiring medication(s) 9,122 (49.9 %) 3,701 (53.6 %) \0.001
Congestive heart failure (within 30 days) 31 (0.2 %) 38 (0.6 %) \0.001
Cardiovascular 1,783 (9.8 %) 612 (8.9 %) 0.029
Peripheral vascular disease 299 (1.6 %) 94 (1.4 %) 0.114
Renal failure 150 (0.8 %) 82 (1.2 %) 0.007
Ascites 65 (0.4 %) 60 (0.9 %) \0.001
Disseminated cancer 115 (0.6 %) 42 (0.6 %) 0.845
Chemoradiation (within 30 days) 93 (0.5 %) 35 (0.5 %) 0.979
Chronic steroid use 420 (2.3 %) 134 (1.9 %) 0.082
Weight loss [10 % (last 6 months) 78 (0.4 %) 40 (0.6 %) 0.116
Bleeding disorders 470 (2.6 %) 268 (3.9 %) \0.001
Cerebrovascular 940 (5.1 %) 358 (5.2 %) 0.912
Intraoperative factors
Open surgical approach 14,492 (79.3 %) 5,533 (80.0 %) 0.199
Use of mesh 9,135 (50.0 %) 3,335 (48.2 %) 0.013
Resident involvement 10,760 (58.9 %) 3,816 (55.4 %) \0.001
Operative time 87.0 ± 49.3 84.5 ± 48.7 \0.001
Other
Recurrent hernias 3,971 (21.7 %) 1,658 (24.0 %) \0.001
Emergency cases 285 (1.6 %) 935 (13.5 %) \0.001
Inpatient cases 8,999 (49.3 %) 3,927 (56.8 %) \0.001
Laboratory data
WBC \ 4.5 9 103/mcL 1,135 (6.2 %) 342 (5.0 %) \0.001
3
WBC [ 11 9 10 /mcL 901 (4.9 %) 693 (10.0 %) \0.001
Hematocrit \38 % 4247 (23.3 %) 1714 (24.8 %) 0.010
Hematocrit [45 % 1747 (9.6 %) 798 (11.6 %) \0.001
Platelet count \150 9 103/mcL 997 (5.5 %) 380 (5.5 %) 0.899
Platelet count [400 9 103/mcL 476 (2.6 %) 199 (2.9 %) 0.230
Blood urea nitrogen [40 mg/dL 233 (1.3 %) 126 (1.8 %) 0.001

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Table 1 continued
Variable Reducible Incarcerated/Strangulated p value
Mean ± SD/N (%) Mean ± SD/N (%)
(n = 18,263) (n = 6,909)

Creatinine [1.2 mg/dL 1,800 (9.9 %) 749 (10.8 %) 0.021

Serum albumin \3.2 gm/dL 353 (1.9 %) 256 (3.7 %) \0.001
Serum total bilirubin [1.0 mg/dL 694 (3.8 %) 449 (6.5 %) \0.001
Alkaline phosphatase [125 IU/L 724 (4.0 %) 355(5.1 %) \0.001
Aspartate aminotransferase [40 IU/L 853 (4.7 %) 400 (5.8 %) \0.001
INR [1.5 144 (0.8 %) 103 (1.5 %) \0.001
PTT [35 s 386 (2.1 %) 174 (2.5 %) 0.052
Tobacco abuse: smoking history within 1 year before the index operation. Alcohol abuse: more than two drinks per day within 2 weeks before
admission to the hospital for the index operation. Dependent functional status: partially or totally dependent. Diabetes mellitus: insulin and non-
insulin dependent. Cardiovascular: angina within the month prior to the index operation, myocardial infarction within 6 months prior to the index
operation, history of percutaneous coronary intervention, history of previous cardiac surgery. Peripheral vascular disease: rest pain or gangrene,
history of revascularization or amputation for peripheral vascular disease. Renal failure: acute renal failure, renal failure currently requiring or on
dialysis. Cerebrovascular: history of transient ischemic attacks, cerebrovascular accident with or without neurologic deficit, hemiplegia, para-
plegia, quadriplegia, impaired sensorium
BMI body mass index, ASA American Society of Anesthesiology, COPD chronic obstructive pulmonary disease, WBC white blood count, INR
International normalized ratio, PTT partial thromboplastin time

after controlling for other covariates (CI 1.12–1.31, Table 2 Risk factors for postoperative wound infection for reducible
p \ 0.01). hernias following VIHR
There were 206 (3 %) occurrences of superficial SSI Risk factor Odds ratio (95 % p value
among 6,909 incarcerated/strangulated VIHRs. Open confidence interval)
operative technique remained a significant risk factor for
Age category 0.243
superficial SSI, when controlling for other predictors in the
18–29 (ref) –
model (OR 2.44, CI 1.25–4.75, p \ 0.01). For each 30-min
30–39 0.74 (0.36–1.51) 0.403
increase in operative time, the odds of having a superficial
40–49 0.83 (0.43–1.62) 0.586
SSI increased by 22 %, after adjusting for other covariates
50–59 0.77 (0.40–1.49) 0.431
(OR 1.22, CI 1.09–1.37, p \ 0.01).
60–69 0.75 (0.38–1.46) 0.395
70–79 0.49 (0.24–1.02) 0.057
Deep surgical site infections
80? 0.55 (0.24–1.30) 0.173
BMI C30 1.49 (1.18–1.88) \0.001*
There were 231 (0.9 %) cases of deep wound infection
among the total of 25,172 patients. Patients undergoing Tobacco use 1.46 (1.13–1-84) 0.003*
VIHR with the open surgical technique had significantly ASA class 1 vs. 2 0.80 (0.41–1.56) 0.508
greater odds of deep wound SSI than those with the lapa- ASA class 3 vs. 2 1.33 (1.05–1.67) 0.016*
roscopic surgical technique (OR 10.15, CI 3.21–32.09, ASA class 4 vs. 2 1.59 (0.82–3.10) 0.167
p \ 0.01), after adjusting for other covariates. Additional Hypertension requiring 1.13 (0.90–1.43) 0.299
medication(s)
significant risk factors included BMI C 30 kg/m2
Open surgical approach 3.54 (2.41–5.21) \0.001*
(OR 2.87, CI 1.74–4.74, p \ 0.01), and inpatient status a
Operative time 1.25 (1.18–1.33) \0.001*
(OR 2.36, CI 1.35–4.12, p \ 0.01). Subjects with longer
Recurrent hernias 1.34 (1.07–1.69) 0.010*
operative times had a significantly higher risk of deep
wound infection; a 30-min increase in operative time was Inpatient status 1.98 (1.51–2.59) \0.001*
associated with a 34 % increase in the odds of a deep Blood urea nitrogen 0.61 (0.22–1.70) 0.343
[40 mg/dL
wound SSI (OR 1.34, CI 1.21–1.49, p \ 0.01).
Alkaline phosphatase 1.47 (0.95–2.28) 0.085
[125 IU/L
Wound disruption
BMI body mass index, ASA American Society of Anesthesiology
There were only 125 (0.5 %) cases of wound disruption * Statistically significant with p value \0.05
a
reported among the 25,172 patients. Patients operated upon Effect for every 30-min increase in operative time

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118 Hernia (2015) 19:113–123

Table 3 Risk factors for postoperative wound infection for incar- time was a significant predictor of organ/space SSI fol-
cerated/strangulated hernias following VIHR lowing VIHR, with a 30-min increase being associated
Risk factor Odds ratio (95 % confidence p value with a 67 % increase in the odds of organ/space SSI
interval) (OR 1.67, CI 1.49–1.86, p \ 0.01). In addition, patients
with renal failure were also found to have a significant
Age category 0.269
increase in the risk of organ/space SSI (OR 4.14,
18–29 (ref) –
CI 1.22–14.04, p = 0.02).
30–39 1.74 (0.49–6.11) 0.390
40–49 1.39 (0.41–4.75) 0.597
Length of hospital stay
50–59 1.15 (0.34–3.93) 0.820
60–69 1.17 (0.34–4.03) 0.799
The distribution of LOS was highly skewed. Seventy-five
70–79 0.72 (0.20–2.60) 0.615
percent of patients had a LOS of \3 days, while only 1 %
80? 0.92 (0.23–3.73) 0.910
of patients had a LOS [14 days, with the maximum being
BMI C30 1.52 (1.02–2.26) 0.041*
120 days. Significant risk factors for a prolonged LOS
ASA class 1 vs. 2 1.43 (0.58–3.52) 0.438 following reducible and incarcerated/strangulated VIHR
ASA class 3 vs. 2 2.05 (1.43–2.93) \ 0.001* are presented in Tables 4 and 5, respectively. For reducible
ASA class 4 vs. 2 0.92 (0.32–2.65) 0.128 hernias, the geometric mean of LOS was 2.3 days (95 %
Open surgical 4.91 (2.55–9.44) \ 0.001* CI 2.27–2.34 days), whereas for the incarcerated/strangu-
approach
lated cases the geometric mean LOS was 2.59 days (95 %
Resident 1.06 (0.76–1.49) 0.716
involvement
CI 2.53–2.65 days).
Operative timea 1.27 (1.16–1.40) \ 0.001*
Recurrent hernias 1.06 (0.74–1.51) 0.760
Discussion
Inpatient status 1.68 (1.10–2.56) 0.016*
Hematocrit \38 % 1.11 (0.76–1.62) 0.596
This analysis of more than 25,000 cases of VIHRs in ACS-
Hematocrit [45 % 1.18 (0.72–1.92) 0.522
NSQIP hospitals throughout the USA revealed a relatively
BMI body mass index, ASA American Society of Anesthesiology low incidence of postoperative SSIs for reducible and
* Statistically significant with p value \0.05 incarcerated/strangulated VIHRs at 4.1 and 5.0 %,
a
Effect for every 30-min increase in operative time respectively. These results compare favorably with the
previously reported results ranging from 0 to 33 % [12].
This study, to our knowledge the largest to examine risk
using an open surgical approach had significantly greater factors associated with wound infection and prolonged
odds of wound disruption than those with a laparoscopic LOS following VIHR, demonstrated that a multitude of
surgical approach (OR 7.16, CI 1.74–29.49, p \ 0.01), perioperative factors can impact outcomes. Furthermore,
after adjusting for other covariates. Additional risk factors our study examines risk factors for wound infection and
for wound disruption included current smoking (OR 1.85, LOS separately for reducible and incarcerated/strangulated
CI 1.04–3.31, p = 0.04), BMI C30 kg/m2 (OR 4.50, VIHs. This is important, because repairs of incarcerated/
CI 2.02–10.05, p \ 0.01), and inpatient status (OR 2.41, strangulated hernias are performed in a potentially con-
CI 1.16–5.02, p = 0.02). Operative time was also a sig- taminated environment, a setting that may be associated
nificant predictor of wound disruption following VIHR, with higher rates of wound infections, particularly with the
with a 30-min increase being associated with a 17 % use of mesh. Incarcerated/strangulated VIHRs may also be
increase in the odds of wound disruption (OR 1.17, associated with intestinal ischemia requiring bowel resec-
CI 1.003–1.36, p = 0.05). Having a hematocrit\35 % was tion. Previous studies reported that bowel resection did not
also associated with greater odds of having a wound dis- affect mortality. However, it increased postoperative
ruption (OR 1.89, CI 1.04–3.43, p = 0.04). complications such as wound infections as well as LOS
[13, 14]. In addition, this ACS-NSQIP data analysis dem-
Organ/space surgical site infections onstrated that the incidence of postoperative wound
infections for incarcerated/strangulated hernias was 0.9 %
Organ/space SSIs were reported for 168 (0.7 %) of the higher than that for reducible hernias. Although the dif-
25,172 cases. Cases using an open surgical approach were ference is small, it is statistically significant and indicates
found to have greater odds of organ/space SSI than lapa- that patients who undergo operative intervention for an
roscopic surgical approach (OR 2.42, CI 1.20–4.85, incarcerated/strangulated hernia are more likely to develop
p = 0.01), after adjusting for other covariates. Operative a postoperative SSI, regardless of the surgical approach.

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Table 4 Risk factors for prolonged LOS for reducible hernias fol- Table 5 Risk factors for prolonged LOS for incarcerated/strangu-
lowing VIHR lated hernias following VIHR
Risk factors Relative LOS (95 % p value Risk factor Relative LOS (95 % p value
confidence limits) confidence limits)

Older agea 1.07 (1.06–1.09) \0.001* Older agea 1.08 (1.06–1.11) \0.001*
African American 1.11 (1.03–1.20) 0.005* Dependent functional 1.46 (1.26–1.70) \0.001*
Alcohol abuse 1.26 (1.11–1.44) \0.001* status
Dependent functional 1.31 (1.12–1.53) \0.001* ASA class 1 vs. 2 0.61 (0.48–0.78) \0.001*
status ASA class 3 vs. 2 1.21 (1.12–1.29) \0.001*
ASA class 1 vs. 2 0.69 (0.60–0.79) \0.001* ASA class 4 vs. 2 1.77 (1.53–2.05) \0.001*
ASA class 3 vs. 2 1.17 (1.12–1.23) \0.001* Prior operation (within 1.57 (1.29–1.90) \0.001*
ASA class 4 vs. 2 1.32 (1.16–1.51) \0.001* 30 days)
Prior operation (within 1.53 (1.19–1.97) \0.001* History of congestive 1.41 (1.01–1.95) 0.040*
30 days) heart failure
History of COPD 1.29 (1.19–1.40) \0.001* Open surgical approach 1.14 (1.04–1.24) 0.003*
Ascites 1.63 (1.22–2.17) \0.001* Involvement of resident 0.91 (0.86–0.98) \0.001*
Bleeding disorder 1.27 (1.14–1.41) \0.001* Operative timeb 1.27 (1.24–1.29) \0.001*
Open surgical approach 1.13 (1.07–1.20) \0.001* Emergency case 1.33 (1.22–1.45) \0.001*
Non-involvement of 1.05 (1.01–1.10) 0.018 * Dependent functional status: partially or totally dependent
resident ASA American society of anesthesiology
Operative timeb 1.22 (1.21–1.24) \0.001* * Statistically significant with p value \0.05
Recurrent hernias 1.07 (1.02–1.13) 0.005 * a
Effect for every 10-year increase in age
Emergency case 1.30 (1.14–1.49) \0.001* b
Effect for every 30-min increase in operative time
Low serum albumin 1.28 (1.22–1.45) \0.001*
(\3.2 gm/dL)
Alcohol abuse: more than two drinks per day within 2 weeks before
admission to the hospital for the index operation. Dependent func- strangulated group including high ASA class (3 or 4), open
tional status: partially or totally dependent surgical approach, prolonged operative times, and inpatient
ASA American Society of Anesthesiology. COPD chronic obstructive status. Smoking was identified to be a risk factor for wound
pulmonary disease disruption.
* Statistically significant with p value \0.05 The open surgical approach was found to be the stron-
a
Effect for every 10-year increase in age gest independent predictor for postoperative SSIs following
b
Effect for every 30-min increase in operative time VIHRs. It was associated with a [3-fold increase in the
odds of postoperative wound infection for reducible, and an
almost 5-fold increase in the odds of postoperative wound
The ACS-NSQIP database provided a sufficient number infection for incarcerated/strangulated hernias when com-
of cases to allow an analysis of the risk factors for all pared with laparoscopic surgical approach. This finding is
wounds types combined and for superficial SSI separately not surprising as the open technique involves a more
for the reducible and incarcerated/strangulated hernia extensive dissection of the subcutaneous tissues with
subgroups. This is a substantial advantage over clinical resultant tissue trauma, whereas the laparoscopic technique
trials on this topic, which would require a prohibitively involves only limited dissection of subcutaneous tissue and
large number of participants to detect these differences. small skin incisions making migration of bacteria into the
Despite using this large database, we did not have a large subcutaneous space less likely. On the other hand, it has
enough sample to examine risk factors for the other three been postulated that the laparoscopic approach is associ-
types of wound infections, i.e., deep SSI, wound disruption, ated with more severe intra-abdominal complications such
and organ/space SSI, for the reducible and incarcerated/ as intraoperative hemorrhage or bowel injury, given the
strangulated hernia subgroups separately. need for extensive lysis of adhesions in the area of the
For patients with reducible VIHs, several risk factors abdominal wall in which the mesh will be positioned [15].
were found to impact postoperative wound infections Our study, however, demonstrated that it is the open sur-
including BMI [30 kg/m2, high ASA class (3 or 4), open gical approach that represents a risk factor for postopera-
surgical approach, prolonged operative times, recurrent tive organ/space SSIs. This may be attributed to the
hernias, and inpatient status. A variety of risk factors for superior visualization with laparoscopy, enabling easier
postoperative SSIs were also identified for the incarcerated/ identification and dissection of tissue planes.

123
120
Previous studies have shown that the risk of postoper-
ative SSI is related to longer operative times [16, 17].
Medina et al. [17] prospectively evaluated 497 patients
undergoing various types of abdominal wall hernia repairs
and sought to determine the predictors of wound infections
in these patients. Duration of operation was found to be a
risk factor for wound infection. Specifically, they showed a
2-fold increase in the risk of wound infection with each
additional hour of operative time (OR 2.11, CI 1.12–4.00,
p \ 0.05). In a previous ACS-NSQIP study, Dimick et al.
[18] demonstrated that hospitals that were high outliers for
SSIs had substantially longer operative times. In our study,
we have also established an association between postop-
erative SSIs and longer operative times. We demonstrated
that for every 30-min increase in operative time, the odds
of having postoperative SSI were increased by 12–67 %,
depending on the subtype of SSI. It is yet to be determined
if the increased risk of SSI is a result of the complexity of
the operation or a biologic process such as prolonged tissue
hypoxia.
Most importantly, our study was able to identify two
modifiable risk factors, namely obesity and tobacco use.
These factors were also recognized as significant inde-
pendent predictors of wound infection in other, smaller
series [6, 16]. In obese individuals, the relative hypoper-
fusion and ischemia that occur in the excess subcutaneous
adipose tissue can make the wound more susceptible to
postoperative SSIs. This susceptibility to infection may be
even more pronounced in this patient population because
the suboptimal tissue perfusion does not allow appropriate
delivery of perioperative antibiotics. In fact, this phenom-
enon was evident in patients undergoing elective colorectal
surgery, where the incidence of SSI was higher in patients
with a BMI C30 kg/m2, regardless of the prophylactic
antibiotic [19]. In addition to the local conditions, several
systemic factors have also been proposed to negatively
impact wound healing and increase wound complications.
For instance, obesity can be associated with conditions that
impair the immune response such as stress, anxiety, and
depression [20].
In the last few decades, there has been a growing
amount of literature indicating that smoking has an enor-
mous impact on all phases of wound healing and the
microenvironment of the tissue. This has been established
through the higher rates of postoperative wound infections
observed across multiple surgical specialties such as car-
diovascular, gastrointestinal and plastic surgery [21].
Within the first hour after a cigarette is put out, blood flow,
tissue oxygen, and metabolism return to normal [22]. The
improvement of inflammatory cell function and host
defense by smoking cessation provides a potential mech-
anism for the clinical observations of reduced infectious
complications, such as SSI, after at least 4 weeks of
123
Hernia (2015) 19:113–123
abstinence from smoking in randomized controlled trials
[21, 23]. In a systematic review analyzing the pathophys-
iological impact of smoking and smoking cessation on
wound infection in surgery, it was concluded that smoking
cessation only reverses some of the pathologic processes
induced by smoking because many of these mechanisms
appear to be prolonged or even irreversible [21].
ASA class is a well-established risk factor for SSIs in a
variety of surgical procedures [24, 25]. In the present study,
ASA classes 3 and 4 were found to be associated with an
increased risk of wound infections following VIHR. This is
not surprising, as one would expect to encounter more
wound healing problems in patients with several comor-
bidities. The reason for the increased risk of wound
infection in hospitalized patients detected in our study is
unknown. We speculate that it may be due to the frequent
exposure of the wound to more virulent organisms while in
the hospital, and perhaps the fact that patients requiring
admission postoperatively comprise a morbid population
that is inherently more prone to infections. Based on this
observation, it is important that physicians have a lower
threshold in reviewing the wounds of these patients if there
is concern after the patient is discharged from the hospital.
The contemporary need to decrease health care expen-
ditures makes the postoperative LOS a critical and salient
factor. Identifying modifiable risk factors that can decrease
LOS following VIHR may not only result in substantial
health cost savings, but might also improve patient out-
come and quality of care. For example, complications
associated with prolonged hospitalizations, such as hospital
acquired infections and pressure ulcers, can be minimized.
Also, physicians may be able to better inform their patients
about postoperative recovery, and set more realistic
expectations.
To our knowledge, this is the largest study analyzing
risk factors associated with prolonged LOS following
VIHR. Numerous risk factors that impact LOS were
identified for reducible hernias, including older age, Afri-
can American ethnicity, history of alcohol abuse, poor
functional status, higher ASA class, prior operation within
the last 30 days of the index operation, history of COPD,
ascites, bleeding disorders, open surgical approach, non-
involvement of resident, prolonged operative time, recur-
rent hernia repair, emergency cases, and low preoperative
serum albumin level. For the incarcerated/strangulated
hernias, predictors of longer LOS included older age, poor
functional status, higher ASA class, prior operation within
the last 30 days of the index operation, history of conges-
tive heart failure, open surgical technique, non-involve-
ment of resident, prolonged operative time, and emergency
cases.
Several studies have advocated that laparoscopic VIHR
can improve outcomes with regard to LOS [26, 27].
Hernia (2015) 19:113–123
Multiple series compared duration of hospitalization
between the open and laparoscopic techniques with
inconsistent results. Although some randomized controlled
trials reported shorter LOS in the laparoscopic group,
others failed to demonstrate a significant difference in LOS
between the open and laparoscopic techniques [28, 29].
Using the ACS-NSQIP database, we recently demonstrated
a significantly shorter LOS for the laparoscopic approach
to VIHR, for both reducible and incarcerated/strangulated
hernias [30]. To further support our recent findings, this
study identified the open surgical approach as a predictor of
longer LOS in patients undergoing VIHR.
Comorbidities and ASA class are important factors in
defining risks related to surgery and anesthesia. Alvarez
and colleagues, in a review of 147 patients who underwent
emergency surgery for incarcerated groin hernias, found
that LOS was significantly increased in patients with con-
comitant diseases and high ASA class [14]. Similarly,
Kulah et al. [31] studied 189 elderly patients who under-
went emergency hernia repair, and identified an association
between high ASA class and increased LOS. They also
concluded that patients with comorbidities had signifi-
cantly increased LOS compared to those without these
comorbidities. Comorbid diseases were also found to be
associated with prolonged LOS in patients undergoing
emergent repairs for incarcerated abdominal wall hernias
[32]. Using the ACS-NSQIP database, Dunne and col-
leagues investigated 487 patients who underwent abdomi-
nal wall hernia repairs to identify risk factors for LOS [6].
They found that coronary artery disease, COPD, and
chronic steroid use were independent predictors of
increased LOS. Our study supports the above findings and
expands the knowledge of comorbidities that can poten-
tially prolong hospitalization. High ASA class and
numerous comorbid factors including COPD, congestive
heart failure, ascites, bleeding disorders, and poor func-
tional status were identified to be significant predictors of
increased LOS.
Preoperative hypoalbuminemia has been described as a
predictor of prolonged LOS among different surgical
populations. For instance, serum albumin level lower than
2.5 g/dL was independently associated with increased total
LOS after cardiac operations [33]. Similarly, hypoalbumi-
nemia was associated with longer LOS in patients with
gynecological malignancies [34]. In a previous small study
cohort, low preoperative serum albumin level was shown to
be an independent risk factor of prolonged LOS in patients
undergoing abdominal wall hernia repairs [6]. In this ACS-
NSQIP analysis, we have also demonstrated that low pre-
operative serum albumin, specifically lower than 3.2 g/dL,
is a predictor of longer LOS. Measurement of the preop-
erative serum albumin in patients undergoing VIHR, and
optimization of the serum levels if feasible, for example
121
with nutritional support, should be considered by the
treating physician.
In our study, we also examined the relationship between
operative time and LOS. Previously, Akinci et al. [35]
analyzed 1,170 abdominal wall hernia repairs to identify
predictors for duration of hospital stay. They showed that
longer operative times were associated with longer LOS. In
this study, we have similarly noted an association between
longer operative times and prolonged LOS. Specifically,
we observed approximately a 25 % increase in the relative
LOS for every 30-min increase in the duration of surgery. It
may be that the increase in operative time is a marker of a
more severe disease process. Moreover, longer exposure to
anesthesia or arrival of the patient to the floor later in the
day due to a prolonged operation may delay execution of
standardized patient care pathways, which can potentially
affect patient’s postoperative course and delay hospital
discharge.
There are several limitations associated with the use of
the ACS-NSQIP database, which have to be taken into
consideration when interpreting the results of this study.
The ACS-NSQIP database lacks procedure specific details
and long-term outcomes. Hence our analysis was limited to
the variables and outcomes that are available in the data-
base. This did not allow us to evaluate and account for all
potential confounders. For instance, we have shown that
LOS was significantly longer for patients with poor func-
tional status, but we were not able to account for patient’s
discharge status due to database limitations. Patients with
poor functional status may occasionally require placement
in a rehabilitation facility following VIHR, which can
potentially affect LOS outcomes. Also, some important
patient-specific characteristics that can affect the intraop-
erative course and resultant outcomes, such as anatomic
variations, hernia defect size and number of previous
recurrences, were not examined. In addition, this analysis
has a limited ability in controlling for some confounding
system-specific factors, such as standardized meticulous
skin preparation or efficiency of operating room staff.
Likewise, there is little doubt that surgeon-specific factors
can confound our results and are difficult to control with
the current ACS-NSQIP dataset. For example, technical
expertise as well as information related to the surgical
technique and judgement, such as position and type of the
mesh is not available. Moreover, ACS-NSQIP database
does not provide information regarding laparoscopic con-
version to open operation. A word of caution seems
appropriate here regarding the generalizability of our
results. Although the ACS-NSQIP database is limited to
ACS-NSQIP participating hospitals, it includes more than
450 hospitals across the USA, making it a representative
sample. On the other hand, even in ACS-NSQIP partici-
pating hospital, it is conceivable that LOS is influenced in
123
122
many ways by medico-cultural factors, and it is sometimes
based on local or national traditions rather than patho-
physiologic reasons.
In conclusion, this large multi-institutional analysis
examined predictive factors for postoperative SSIs and
LOS after VIHR, to identify modifiable actions that could
improve these two important outcomes, and thus optimize
the overall care of patients undergoing VIHR. Our results
demonstrate that obesity with BMI C30 kg/m2 and current
tobacco use were significant predictors for postoperative
wound infection in VIHR. Poor nutritional or overall
clinical status, as evidenced by a low preoperative serum
albumin level, was a significant predictor of increased LOS
following VIHR. In contrast to the several other risk factors
identified, these three findings represent modifiable risk
factors, and their recognition and treatment if feasible,
might improve patient outcomes, optimize hospital
resource utilization, and reduce health care expenditures.
Furthermore, the open surgical approach was found to be
the strongest predictive factor for postoperative SSIs, and
was also associated with prolonged LOS. Therefore, in
eligible cases, laparoscopy should be strongly considered
for VIHRs.
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