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Title: Hernia formation following bilateral subcostal incision for aortoiliac interventions
Objective: Studies suggest patients undergoing midline abdominal incision for aneurysmal disease (AAA) have a higher rate of subsequent incisional hernia formation than similar patients with aortoiliac occlusive disease (AIOD). We sought to evaluate the rates of perioperative incisional complications and of post-operative incisional hernia formation following bilateral subcostal incisions for both aortic pathologies and to identify risk factors for hernia development using this approach.
Methods: Patients undergoing procedures for AAA or AIOD via bilateral subcostal incision at a single institution between January 2003 and December 2010 were reviewed (n = 276). Demographics, intraoperative data, post-operative complications, imaging and follow-up was evaluated. All computed tomographic examinations (CT) performed after aortic surgery were evaluated, with CT available for review in 137/276 (50%) patients. Hernia occurrence was documented if present by clinical exam and symptoms or computed tomographic evaluation.
Results: Over this time period there were 218/276 (79%) patients treated for AAA and 58/276 (21%) treated for AIOD. Peri-operative wound complications occurred in 23/276 (8.3%) patients and included infection, hematoma, seroma or dehiscence. Post-operative hernias were identified clinically in 12 (4.3%) patients with an additional 14 identified by CT giving an overall postoperative hernia occurrence of 26/276 (9.4%). Patients treated for AAA had a hernia incidence of 9.6% (21/218) compared to 8.6% (5/58) in the AIOD group (p = NS). Univariate analysis identified higher BMI and perioperative wound complications as risk factors for development of hernia (p = .003 and .0004 respectively), with 31% of the patients in the hernia group having a perioperative wound complication compared to only 6% in the non-hernia group. Of the 12 patients with clinically evident hernias, 10/12 (83%) underwent hernia repair surgery by placement of mesh in all cases. None of the hernias identified incidentally by CT underwent repair.
Conclusions: Bilateral subcostal incision as an approach to the abdominal aorta has a low overall rate of clinically evident post-operative hernia formation. CT examination identifies an additional portion of patients with hernias, but the clinical relevance of this is not determined, as in our series, these patients were all asymptomatic. Patients with perioperative wound complications and increased BMI may be at increased risk of post-operative incisional hernia.