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Society for Surgery of the Alimentary Tract

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Alexander Booth*, Kirkpatrick Gillen, Isabela Visintin, Wilson Ford, Mark Kovacs, Colston Edgerton, Virgilio V. George, Thomas Curran
Surgery, Medical University of South Carolina, Charleston, SC

Incisional hernia (IH) occurs in 10-15% of patients after abdominal surgery. Multiple patient and technical factors such as smoking, surgical site infection, and closure technique are associated with increased risk of IH. Compared to off-midline incisions, midline incisions have a higher incidence of IH. Diastasis recti (DR) is common but has not yet been studied as a risk factor for IH or included in hernia risk scores derived from large datasets. We examined the association between DR and IH development after midline incisions.
In this single-center case-control study, we identified all patients undergoing elective gastrointestinal surgery captured in a prospective surgical quality collaborative database between April 2016 – May 2020. Eligible patients were required to have axial imaging within six months prior to surgery and at least one scan no less than six months after surgery to ascertain whether DR and IH were present, respectively. Patients with open midline surgery or minimally invasive surgery with a vertical midline extraction site were included. Patients with previous midline incision or hernia >1 cm on preoperative imaging were excluded. Patients who developed IH hernia >1 cm on postoperative imaging were compared to those without IH using bivariate and multivariable logistic regression analyses. Covariates with p<0.1 on bivariate analysis were included in the multivariable model.
Of 1032 surgical patients, 156 were eligible for analysis. Forty-four (28.2%) developed radiographic IH >1 cm. Results of bivariate analyses are shown in Table 1. Median maximum distance between rectus muscles was 31 mm in the IH group and 22.5 mm in the control group (p=0.004). With DR as a categorical variable, 84.1% of IH patients had preoperative DR >20 mm compared to 62.5% of patients without IH (p=0.009). Mean BMI was higher in the IH group (p=0.01); patients with IH were more likely to have coronary artery disease (p=0.024). Other covariates including age, sex, surgical indication, procedure type, wound classification, and comorbid conditions (eg, diabetes, smoking) were not significantly associated with IH. Surgical site infections (SSI) differed between groups (13.6% IH vs 5.4% controls; p=0.081). SSI, DR >20 mm, BMI, and coronary disease were included in the multivariable model (Table 2). In the final iteration after backward stepwise elimination, DR >20 mm and coronary disease were independently associated with IH.
DR is significantly associated with development of IH after midline abdominal surgery. When DR is present on preoperative imaging, surgeons can include this information to discuss individual patient risk and consider an off-midline approach when feasible. Larger studies are needed to refine the effect size and incorporate DR into existing IH prediction models.

Table 1: Comparison of patients with and without incisional hernia

Table 2: Results of multivariable logistic regression for incisional hernia with backward stepwise elimination

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