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Page 2 of 14 Knapp et al. Plast Aesthet Res 2020;7:7 I http://dx.doi.org/10.20517/2347-9264.2019.69

Figure 1. The vicious hernia cycle [10]

recurrences or have other significant comorbidities affecting their surgical fitness. Optimizing surgical
outcomes and minimizing perioperative morbidity in this patient population requires careful preparation
and planning.

EPIDEMIOLOGY
The burden of VHR and abdominal wall reconstruction (AWR) is increasing not only with regards
[1,2]
to incidence but also in the case complexity, contributing to overall higher rates of complications .
While infection remains the most common postoperative complication, the issue of hernia recurrence
[3-6]
is arguably the most commonly discussed and used to monitor the success of an outcome . Following
[7]
each subsequent repair, the risk of recurrence is linear to and directly related to the number of repairs .
The financial burden for complications status post hernia surgery are significant: patients with recurrent
hernias constitute a minority (15%) of the AWR patient population, yet account for half of the total
[1]
spending for hernia surgery . Recurrent hernia patients tend to be older with more significant medical
comorbidities, and are associated with higher hospital and post-discharge health care costs such as
readmissions, emergency department visits, etc. The magnitude of increased financial burden is likely
under-reported as other expenses are more difficult to capture and quantify, including skilled nursing
facilities, long-term acute care, wound care, home health services, and hospital readmissions to hospitals
[8]
other than that of the primary procedure . Perioperative surgical site occurrence (infection, seroma,
[5]
and wound ischemia/dehiscence) increases the risk of hernia recurrence at least three-fold . Surgical
site infection (SSI) has been shown not only to be independently associated with an increased rate of SSI
at subsequent operation in an otherwise clean wound bed, but also to act as a marker of increased case
[9]
complexity . A vicious cycle often develops whereby a ventral herniorrhaphy can lead to an unfortunate
[10]
pattern of bacterial infection, hernia recurrence, reoperation, and hospital readmission [Figure 1] . With
an increasing emphasis placed on readmission to determine reimbursement, this cycle looms even larger
[11]
on the minds of hernia surgeons . Therefore, the surgeon should consider optimization of any and all
factors that can promote optimal patient recovery.

THE METABOLIC EFFECTS OF SURGERY
Large hernia repairs and AWR result in considerable surgical stress that induce a predictable sequence of
metabolic and physiologic changes in the patient. Further evaluation of these metabolic changes highlights
areas for intervention that may allow the patient to respond to the stress with a more favorable physiologic
state in the perioperative period. Immediately following surgical incision, the body initiates a response
on multiple levels, including the neuroendocrine system, the sympathetic system, and the hypothalamic-
pituitary axis. This concert of effects leads the body to tilt toward a catabolic state to provide a metabolic
substrate for mounting an acute phase response to the surgical trauma.