Factors Associated With Long-term Outcomes of Umbilical Hernia Repair
Authors: Divya A. Shankar, Kamal M. F. Itani, William J. O’Brien, Vivian M. Sanchez
Journal: JAMA Surgery (2017)

<h3>Importance</h3> Umbilical hernia repair is one of the most commonly performed general surgical procedures. However, there is little consensus about the factors that lead to umbilical hernia recurrence. <h3>Objective</h3> To better understand the factors associated with long-term umbilical hernia recurrence. <h3>Design, Setting, and Participants</h3> A retrospective cohort of 332 military veteran patients who underwent umbilical hernia repair was studied between January 1, 1998, and December 31, 2008, at the VA Boston Healthcare System. Recurrence and mortality outcomes were tracked from that period until June 1, 2014. Data were collected on patient characteristics, operative, and postoperative factors and univariate and multivariable analyses were used to assess which factors were significantly associated with umbilical hernia recurrence and mortality. All patients with primary umbilical hernia repair, with or without a concurrent unrelated procedure, were included in the study. Patients excluded were those who underwent umbilical hernia repair as a part of another major planned procedure with abdominal incisions. Data were collected from June 1, 2014, to November 1, 2015. Statistical analysis was performed from November 2, 2015, to April 1, 2016. <h3>Main Outcomes and Measures</h3> The primary study outcomes were umbilical hernia recurrence and death. <h3>Results</h3> Of the 332 patients in this study, 321 (96.7%) were male, mean age was 58.4 years, and mean (SD) time of follow-up was 8.5 (4.1) years. The hernia recurrence rate was 6.0% (n = 20) at a mean 3.1 years after index repair (median, 1.0-year; range, 0.33-13 years). The primary suture repair recurrence rate was 9.8% (16 of 163 patients), and the mesh repair recurrence rate was 2.4% (4 of 169 patients). On univariate analysis, ascites (<i>P</i> = .02), liver disease (<i>P</i> = .02), diabetes (<i>P</i> = .04), and primary suture (nonmesh) repairs (<i>P</i> = .04) were significantly associated with increased recurrence rates. Patients who had a history of hernias (125 [39%]) were less likely to have umbilical hernia recurrences (χ<sup>2</sup><sub>1</sub> = 4.65,<i>P</i> = .03). On multivariable regression analysis, obesity and ascites were associated with significantly increased odds ratios of recurrence of 3.3 (95% CI, 1.0-10.1) and 8.0 (95% CI, 1.8-34.4), respectively. Mesh repair was seen to decrease recurrence with odds of 0.28 (95% CI, 0.08-0.95). There was no significant difference in complication rates between mesh repair and primary suture repair. The survival rate was 73% (n = 242) at the end of the study. Factors associated with mortality were older age, smoking, liver disease, ascites, emergency or semiurgent repair, and need for intraoperative bowel resection. <h3>Conclusions and Relevance</h3> Ascites, liver disease, diabetes, obesity, and primary suture repair without mesh are associated with increased umbilical hernia recurrence rates. Elective umbilical hernia repair with mesh should be considered in patients with multiple comorbidities given that the use of mesh offers protection from recurrence without major morbidity.