Laparoscopy Today

Bariatric Centers of Excellence as Another Pay-for-Performance Program

PAY-FOR-PERFORMANCE

ALEX GANDSAS, MD, MICHAEL SCHWEITZER, MD

INTRODUCTION

Historically, employees in the corporate world have been financially rewarded for outstanding performance and for their contribution to the organization. This reward usually comes in quarterly or yearly bonuses, stocks, or both of these. In the current healthcare system, financial incentives are based solely on productivity measured by volume only, irrespective of the quality of care or outcomes. Doctors and hospitals are equally financially compensated regardless of the quality of care delivered to patients. In the current healthcare reimbursement system, a fee-for-service approach rewards volume productivity without concern for quality, the capitation model incentivizes efficiency while penalizing utilization with again the risk of compromising quality, and a salary system awards constancy without nurturing innovation or productivity. The current models leave the provider with few incentives to strive for or compete for high-quality medicine. A new paradigm of how patient care will be assessed, known as pay-for-performance (P4P), promises to motivate healthcare providers and health organizations by providing higher reimbursements as long as high “quality” evidence-based-medicine is delivered. Moreover, performance measures will be published to give the consumer a selection tool that will ultimately have an impact on provider image, market share, and income. For a program to be deemed successful, the financial rewards to physician groups should be the result of collaborative work between health plans, medical directors, academia, and industry experts. Furthermore, payments should vary depending on the type of incentive program chosen.

HISTORY

Following the report Crossing the Quality Chasm in 2001 [1], in which more than 98,000 preventable deaths were attributed to medical errors [2], a growing consensus was reported that the new approach to health care should include fair payments to providers as a reward for good clinical management and outcome.

The concept of pay-for-performance is not new. Programs that compensated clinicians for being compliant with quality assurance programs were attempted in the past but failed due to the lack of physician support. These programs focused mainly on cost and utilization, rather than on clinical outcomes. With the incorporation of information technology as a means to better track patient data, most programs in charge of developing quality measures are likely to request reports of clinical outcomes. In the year 2000, the Integrated Healthcare Association, a California leadership group of health plans, physician groups, health systems, pharmaceutical industry, and consumer representatives, developed the concept of rewarding physician groups for good documented performance. Basically, this plan was based on (a) patient satisfaction (40%), (b) prevention (25%), (c) chronic care management (25%), and (d) use of information technology (10%) [2].

In general, most pay-for-performance programs establish clinical goals, either as direct implementation of a therapy (eg, give patient aspirin after being diagnosed with myocardial infarction) or as an outcome measurement (eg, morbidity and mortality). Nonclinical goals usually refer to the use of information technology applied to electronic medical records and patient satisfaction. Electronic medical records and computerized follow-up are the main ingredients of the P4P proposition. Practices will need to establish an electronic health infrastructure to provide the payer with performance data.

MEDICARE JOINS THE GAME

Medicare has studied more than 270 hospitals enrolled in its program, looking specifically at the treatment of pneumonia, heart attacks, coronary artery bypass graft operations, and hip arthroplasties. After the first 9 months of implementing the program, an increase was noted in the median score of 6% for all conditions. In this test, hospitals scoring in the top 10% in quality ratings received an extra 2% financial compensation per case, while those scoring in the next 10% received payment increments of 1% per case. On the other hand, a reduction of 2% in payments was made to hospitals that failed to increase their baseline scores [3].

PAY-FOR-PERFORMANCE
STILL IN THE WORKS

Proponents of pay-for-performance promise a new way of improving quality and reducing cost by offering financial incentives to those health-care organizations, physicians, or both, who implement evidence-based medicine to improve clinical outcomes and who adopt a robust information technology infrastructure capable of handling electronic medical records. However, because it seems to be a new way of getting reimbursed for high-quality outcome data, risk adjustment parameters should be implemented to prevent physicians from drawing back from the high-risk patient.

In addition, a close collaboration should exist between providers and payers in setting up feasible goals and defining quality measures and bonus payment parameters, including payment timelines. This new relationship may impact new contract negotiations and caution should be exercised in order not to infringe on antitrust laws. 

On another note, some practitioners may be concerned because this type of program may tend to lower the threshold, resulting in lower payments for those not participating or not achieving quality goals. Furthermore, a successful practice may capture a greater market share once it is identified as being “quality approved” by the payer. Concomitantly, data should be cautiously analyzed because outliers may skew small-volume practices.

In an ideal world, the participation in P4P programs should be completely voluntary, without punishing low-volume practices. Actually, the American Medical Association is concerned that these P4P models are simply “old-fashioned” withholding programs, in which payments from a withheld pool are returned to the practice once medical groups or hospitals meet specific performance criteria.

The fact that so many private payers and Centers for Medicare & Medicaid Services are experimenting with P4P programs indicates that this new paradigm in health care will continue to expand. Currently, more than 400 hospitals have enrolled in P4P programs, and it is thought that by the end of 2006 more than 100 programs will be available. Pay-for-performance has the potential to modify the current approach of health care by rewarding acute preventive care and promoting better use of medical resources.

CENTERS OF EXCELLENCE FOR BARIATRIC SURGERY
RATIONALE

Obesity in America has reached epidemic proportions. It is estimated that more than 97 million Americans are overweight or obese. Furthermore, approximately 7 million are considered morbidly obese with a body mass index of 40 or higher and at least 100 pounds over their ideal body weight.

Studies have shown that a surgical option is the most effective way to achieve and maintain weight loss, significantly reducing major comorbidities, such as hypertension, type II diabetes, sleep apnea, and dyslipidemias [4].

Over the last 10 years, a significant increment has been noted in weight loss procedures performed in the United States per year, reaching more than 175,000 cases in 2005. Furthermore, last year, the Centers of Medicare and Medicaid Services have defined obesity as a disease instead of a condition. It has been estimated that the cost of treating obesity in the United States was approximately $117 billion, of which $61 billion is related to direct medical costs [5].

To maintain a level of efficacy, efficiency, and safety, the American Society of Bariatric Surgery (ASBS) and the American College of Surgeons (ACS) have launched the Centers of Excellence Programs, aimed at identifying practices, surgeons, and institutions able to deliver care to bariatric patients in the safest possible way. Both programs have set 125 as the minimum number of cases per year performed by surgeons to obtain full approval status (Table 1).

In many ways, the Bariatric Centers of Excellence Programs share similar principles with a pay-for-performance program.

1.    Improve Clinical Outcomes:  Bariatric surgery is known to be a challenging field because it has to deal with a high-risk population suffering from multiple comorbid conditions. Insurance companies and malpractice premiums are closely linked to physician performance. Good outcome data with a low morbidity and mortality rate may help contain or decrease premiums and the overall cost per patient.

2.    Information Technology: Although not specifically required by Bariatric Centers of Excellence Programs, as seen in traditional pay-for-performance programs, information technology is a “must have” tool for data submission and subsequent analysis to qualify as a participating program.

3.    Indirectly assess patient satisfaction by ensuring that the following resources are available:
    a.    Access to healthcare providers
    b.    Gowns
    c.    Sensitive in-services
    d.    Nutritional counseling
    e.    Support groups
    f.    Well-equipped facilities (furniture, bathrooms)

4.    Financial reward is not rendered monetarily but instead with assumed growth of market share and fast precertification processing.

Several third-party payers have already launched their own Centers of Excellence criteria to identify centers that have a comprehensive bariatric surgery program, including preoperative medical, psychological, and surgical assessment and long-term postoperative follow-ups. The program must also meet volume thresholds and surgeons should demonstrate a commitment to reporting outcome data.

Most of these criteria focus on outcomes, because these parameters are linked to hospital utilization. It is expected that while those practices with higher complication rates will drive costs up by utilizing several hospital resources, practices with good outcomes, mainly low morbidity, mortality, or both, will result in lower hospital readmissions, specifically those that fall outside the global period.

Centers of Excellence programs, like P4P, will lead to an ultimately less expensive approach to weight-loss surgery, financially rewarding surgeons who perform procedures with documented lower complication rates. Hospital administrations will be in a stronger position to capture a larger market share, negotiate a better case rate with insurance companies, and have better leverage to negotiate with malpractice insurance companies. Recently, Blue Cross and Blue Shield of North Carolina increased the average reimbursement rates by 30% to 50% to surgeons and bariatric surgery practices that have been endorsed as Centers of Excellence [6].

Proponents of the Center of Excellence concept believe that this will help patients decide which surgeon or practice has an excellent track record and comparable outcome data with benchmark standards.

CONCLUSION

Centers of Excellence programs are in many ways a preamble to pay-for-performance programs, where the patient and payers are empowered to choose a surgeon or practice with an excellent track record and comparable outcome data against benchmark standards.

Address reprint requests to: Alex Gandsas, MD, Hoffberger Professional Building, 2435 W. Belvedere Ave, Ste 41, Baltimore, MD 21215, USA. Telephone: 410 601 4838, E-mail: webmaster@laparoscopy.com

 Alex Gandsas, MD, is Associate Professor of Surgery at The Johns Hopkins University School of Medicine and Head, Division Bariatric and Minimally Invasive Surgery at the Sinai Hospital of Baltimore. Dr Gandsas sits on the Society of Laparoendoscopic Surgeons Board of Directors and is active in several other societies including the American Society for Bariatric Surgery. He has authored numerous scientific articles and is founder of the popular Laparoscopy.com Internet site for laparoscopic surgery. 

Michael Schweitzer, MD, is Assistant Professor of Surgery at the The Johns Hopkins University School of Medicine and Director of Minimally Invasive Bariatric Surgery at the Johns Hopkins Bayview Medical Center. Dr Schweitzer has published his scientific findings in several journals and has presented his work throughout the United States. He is a member of several societies including the American Society for Bariatric Surgery and sits on the editorial board of three journals.

References

1.  Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.

2.  Achieving high performance in health care: Pay-for-performance. Moving the bar on quality reporting and accountability. Available at: http://www.accenture.com/NR/rdonlyres/ACE1C0B8-6130-4A65-A73B-853751BADD2F/0/pay_performance.pdf. Accessed February 2006.

3.  Kahn III CN, Ault T, Isenstein H, et al. Snapshot reporting and pay-for-performance under medicare of hospital quality. Health Affairs. 2006;25(1):148-162.

4.  Schauer PR, Ikramuddin S, Gourash W, et al. Outcomes after laparoscopic roux-en-y gastric bypass for morbid obesity. Ann Surg. 2000;232(4):515-529.

5.  Kelly J, Tarnoff M, Shikora S, et al. Best practice recommendations for surgical care in weight loss surgery. Obes Res. 2005;13:227-233.

6.  The AIS Report on Blue Cross and Blue Shield Plans, November 2004. Available at: http://www.aishealth.com/ManagedCare/BluesNews/BLUObesityRelatedBluesBulge.html. Accessed November 17, 2005.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

"BETTER SCRUB UP...AND PLAY SOME VIDEO GAMES

Video Game Warm Up May Reduce Surgical Error

A study of surgeons and video gaming conducted by James “Butch” Rosser, Jr. and his team at Beth Israel Medical Center in New York in conjunction with The National Institute on Media and the Family revealed that 20 minutes of warming up by playing video games before operating may reduce surgical error. The study also confirmed earlier research showing a significant correlation between past experience with video games and proficiency at laparoscopic surgical drills.

The study pool contained over 300 surgeons. Highlighted findings included:

• That demonstrated skill on video games is a compellingly strong predictor of advanced laparoscopic surgical drill skills, when compared with clinical training, number of laparoscopic surgeries performed, knowledge of laparoscopic surgical techniques, and demonstrated laparoscopic suturing skill.

• There is likely to be a great deal of transfer of learning from certain types of video games to surgical skill.  However, the mechanisms of learning and transfer have yet to be discovered.

• Surgeons who played video games immediately prior to a Cobra Rope drill (the drill uses laparoscopic tools to move along a piece of string, clamping it at marked intervals) were significantly faster on their first attempt at the Cobra Rope, and were significantly faster overall across all 10 trials. 

• In general, the surgeons who had played the video games prior to the drill started better and stayed better than the surgeons who had not played video games immediately prior to the drill.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: JSLS NOTES

Natural Orifice Translumenal Endoscopic Surgery: “NOTES.” Kavic MS. 2006;10(2):133-134. • This editorial provides an overview of NOTES, one of the latest ideas in minimally invasive surgery, and the issues surrounding the use of this technique. Kavic also discusses a NOTES White Paper developed in October 2005 by a working group of ASGE and SAGES. The paper outlines several potential barriers to the adoption of NOTES including prevention of infection and management of intraperitoneal complications.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: J Am Coll Surg LAGB

Laparoscopic Adjustable Gastric Banding: 1,014 Consecutive Cases. Ponce J et al. 2005;201:529-535 • Ponce, et al. examined the LAGB procedures that were performed at their center from October 2000 to December 2004. The authors were able to follow up with over 85% of the patients for 48 months. Women comprised 81.8% of the patients. Nine slippages occurred in the 44 patients who had perigastric dissection, while 14 occurred in the 970 patients with the pars flaccida technique. Ponce et al concluded that LAGB can achieve effective and safe weight loss, and that the pars flaccida technique reduced slippage when compared to the perigastric technique.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

ACS ACCREDITED EDUCATION INSTITUTES

The following institutions have successfully met the program requirements of the American College of Surgeons (ACS) Program for Accreditation of Education Institutes, and as a result are accredited as Level I ACS Accredited Education Institutes. Program requirements include standards for learners, curriculum, and technical support and resources including a demonstration of program effectiveness, specific personnel requirements, and accreditation by the LCME, ACGME, ACCME or their international equivalents.

Simulation and Skills Center, Beth Israel Deaconess Medical Center, Boston, Massachusetts

Institute for Clinical Simulation and Patient Safety, Temple University School of Medicine, Philadelphia, Pennsylvania

Centre of Excellence for Surgical Education and Innovation, University of British Columbia, Vancouver, British Columbia

Minimally Invasive Surgery Education Center, University of California Irvine School of Medicine, Orange, California

The University of New Mexico Health Science Center, BATCAVE Medical Simulation Program, Albuquerque, New Mexico

Southwestern Center for Minimally Invasive Surgery, UT Southwestern Medical Center, Dallas, Texas

Institute for Surgical and Interventional Simulation (ISIS), University of Washington, Seattle, Washington

One of the goals of this ACS program is to build a community of institutions interested in furthering surgical education. Therefore, for those institutions willing to share information about their program, contact information is available at http://www.facs.org/education/accreditationprogram/list.html.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

CONFERENCE REPORT: Scoping Out New Options in Pelvic Reconstruction

FROM THE 15TH INTERNATIONAL CONGRESS AND ENDO EXPO
LAPAROSCOPY UPDATE: ABDOMINAL/PELVIC PAIN/ADHESIONS

CONRAD DUNCAN, MD

Members of SLS support both the application of minimally invasive innovations as well as the application of evidenced-based medicine in our surgical practices.

In the past 10 years, urologists and gynecologists have witnessed the introduction and widespread adoption of the use of synthetic mesh in the management of patients with stress urinary incontinence (SUI). The introduction of the Tension Free Vaginal Tape‚ essentially revolutionized the treatment of SUI. “Long term” (10 yr) data has shown the tension-free mid-urethral sling to be a relatively safe and efficacious minimally invasive treatment option for SUI.

We are now witnessing the propagation of the use of synthetic mesh in the correction of a wide range of vaginal vault defects including total uterine prolapse. Surgical application of mesh for the repair of pelvic organ prolapse has been based on theoretical principles, extrapolation from the general surgery literature, industry sponsorship and surgeon preference, as we do not yet have evidence-based data to support their widespread use. Yet, many pelvic reconstructive surgeons have embraced their application as an even more minimally invasive alternative than laparoscopic pelvic reconstruction.

We will review the anatomical and surgical principles involved in the placement of a total vaginal mesh, review the surgical technique in video and review some of the preliminary surgical outcomes data.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

Conversion From Open to Robotic-Assisted Radical Prostatectomy Is Associated With a Reduction in Positive Surgical Margins Among Private Practice-Based Urologists

FROM THE 15TH INTERNATIONAL CONGRESS AND ENDO EXPO 2006, SLS ANNUAL MEETING, BOSTON, MASS, SEPTEMBER 6–9, 2006

RALPH MADEB, DRAGAN GOLIJANIN, CRAIG NICHOLSON, JOY KNOPF, KELLY PICONE, FREDERICK TONETTI, JOHN R. VALVO, LOUIS EICHEL

INTRODUCTION: Several recent studies have suggested that leaders in robotic surgery have decreased their own positive margin rates by switching from open to robot-assisted radical prostatectomy. Theoretically, this improvement is largely attributed to enhanced visualization of the deep pelvis and precision of dissection afforded by the instrumentation. To date, it has not been determined whether this phenomenon exists among nonfellowship-trained urologists in private practice. Herein, we describe the positive margin rates of 2 nonfellowship-trained private practice urologists who converted from open radical retropubic prostatectomy to robot-assisted laparoscopic radical prostatectomy.

METHODS: The margin positivity data from 2 nonfellowship-trained, private practice urologists (surgeon 1 and surgeon 2) were reviewed retrospectively. The last 50 cases of open radical retropubic prostatectomy from each surgeon were compared with the first 50 and 43 robotic prostatectomy cases of surgeons 1 and 2, respectively. A positive surgical margin was defined as a tumor present at the inked margin of the prostate.

RESULTS: A significant decrease occurred in the overall and pT2 positive margin rates for both surgeons. The overall positive margin rate and pT2 positive margin rate for surgeon 1 dropped from 44% to 20% and from 37% to 5.7%, respectively, after changing from open to robotic prostatectomy. For surgeon 2, the overall positive margin rate changed from 26% to 16% and the pT2 positive margin rate changed from 27.5% to 8% after converting.

CONCLUSION: Changing from open to robotic-assisted radical prostatectomy may improve the ability of urologists to obtain negative surgical margins. This phenomenon does seem to apply to nonfellowship-trained urologists in private practice and can be realized within the first 50 cases performed.

For additional information about SLS programs for residents, including the Outstanding Laparoendoscopic Resident Award, scholarships to SLS conferences, and special membership rates, visit www.Laparoscopy.org. 

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: J Minim Invasive Gynecol Intestinal Endometriosis

Laparoscopic Resection of Intestinal Endometriosis: A 5-Year Experience. Ribeiro PAA et al. 2006;13(5):442-446 • The authors set out to describe the clinical manifestations, surgical techniques, and observed complications in patients undergoing laparoscopic resection of intestinal deeply infiltrating endometriosis. Ribeiro PAA et al describe their evaluation of and 7-step surgical technique for treating 125 patients who underwent laparoscopic radical excision followed by resection of the rectosigmoid colon for treatment of intestinal endometriosis. The authors concluded that symptoms of intestinal endometriosis are not specific; laparoscopy is a safe and effective treatment; and special attention must be given to intestinal anastomosis and nerve preservation.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: PROTO Down the Hatch

Down the Hatch. Slack C. Spring 2006:14-19 • NOTES or natural orifice translumenal endoscopic surgery could be the next big thing in surgery, and this article explains the procedure, its brief history, its potential, and its potential drawbacks. The author provides thoughts on the topic from several gastroenterologists and laparoscopic surgeons who point out possible advantages, such as a reduction in the need for general anesthesia, as well as new equipment needs to correct for issues with spatial orientation.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

Infections in Laparoscopic Surgery

EXCERPT FROM NEW TEXTBOOK
Prevention and Management of Laparoendoscopic Surgical Complications, 2nd Edition

MICHAEL S. KAVIC, MD, GAYETTE F. GRIMM, MD, JOHN THOMAS, MD

INTRODUCTION

A common complication of surgery is infection, which can range from minor wound infections to large, complex intraabdominal catastrophes, as well as infections distant to the site of surgery. The purpose of this chapter is to synthesize current clinical and basic science knowledge of laparoscopic infections and collate that knowledge into a set of coherent principles. This will be done by using laparoscopic hernioplasty as a conceptual framework of a sound approach to management of prosthetic infections.

GRAFT INFECTION

Most cases of surgical infection are due to deficiencies in surgical technique (including breaks in sterile technique) or failure to control the bacterial milieu of a surgical wound. For instance, delicate handling of tissues, gentle dissection, and meticulous homeostasis are time-honored surgical principles that diminish the potential for infection [10]. Thus, any surgical technique that minimizes the amount of contamination and decreases the amount of devitalized tissue at the operative site will decrease the incidence of surgical-site infection by decreasing the quantity of nutrients available to potential pathogens.

Distinct differences exist between laparoscopic procedures in gaining access to the operative site. In general, laparoscopic surgery has smaller skin incisions, less dissection (especially in the subcutaneous tissues), and incisions that are often distant from the operative field. This causes less traumatized tissues overall and provides fewer nutrients for pathogens as discussed above. In addition, it is thought that the smaller incisions grant fewer opportunities for introduction of bacteria into an operative site and thereby reduce the chance of infection.

Sutures or tacking materials also make a great difference in the incidence of surgical infection. As previously noted, the presence of suture material in a wound decreases the minimum bacterial concentration needed to produce clinical infection [1]. Braided sutures compound this problem due to the presence of very small interstices between the braided strands that provide a “safe harbor” for bacteria. But even monofilament suture can have interstices, such as between the throws of a knot, that can harbor bacteria [13, 11, 12]. Thus, the use of any suture can increase the risk of infection. In some laparoscopic procedures, especially laparoscopic hernia repairs, inert, metal-anchoring tacks or clips are used. These devices are minimally reactive and have no interstices, thus providing little place for bacteria to hide and cause infection.

Finally, the presence of mesh in a surgical site also increases the chance of infections by reducing the threshold numbers of bacteria required for infection and increasing the virulence factor of bacteria [6]. In the presence of a synthetic graft, bacteria bind to the prosthesis via microbial surface components recognizing adhesive matrix molecules (MSCRAMMs) that are elaborated by the bacteria themselves [11]. These adhesion molecules recognize and bind to elements of the host’s interstitial matrix. The binding process then leads to an elaboration of a glycoprotein layer that impedes the entrance of host bactericidal elements. In addition, traumatized tissues have surfaces devoid of a protective cellular layer, competent protective extracellular polysaccharide (glycocalyx), and a basement membrane, all of which promote bacterial growth [11,13].

The type of mesh chosen for hernia repair can also affect the chance of infection because macrophages and neutrophils require larger pores for admission than bacteria do. Synthetic mesh can be classified by pore size into 4 groups:

Type I—Prostheses with pores greater than 75 microns. Examples: Marlex, monofilament polypropylene meshes [8,14,15];

Type II—Prostheses with pore sizes less than 10 microns in at least 1 of their 3 dimensions. Examples: ePTFE, Dual Mesh, surgical membrane;

Type III—Macroporous prosthesis with multifilamentous or microporous components. Examples: braided Dacron, braided polypropylene;

Type IV—Biomaterial with submicron pore size. Example: silastic.

The completely macroporous materials (all pores >10 microns) will allow for admission of macrophages, fibroblasts, blood vessels, and collage fibers into the mesh, thus providing a lesser chance of infection.

In summary, current techniques of laparoscopic hernia surgery have optimized conditions to make bacterial infection of the prosthetic materials less likely. Reducing the potential inoculum with small incisions remote from the operative site minimizes bacterial contamination overall and especially to the operative site. Laparoscopic dissection is typically more meticulous than open methods due to the magnification of laparoscopic imaging, thus the amount of devitalized tissue available for bacteria to bind and utilize as nutrition is reduced. Common use of Type I biomaterials and fixation with staples or other inert tacking devices eliminates interstices less than 10 microns. The result of using the laparoscopic method and these materials is a hernia repair that is quite resistant to infection with infection rates reported as 0% to 0.1% [10,16,22,23].

DIAGNOSIS AND TREATMENT OF MESH INFECTIONS

Complications of laparoscopic hernioplasty can occur, and any deviation from normal postoperative recovery should raise suspicion of a problem. In general, the complications are similar to those of open hernioplasty, and the differential diagnosis should include hernia recurrence, hematoma, seroma, orchitis, neuralgia, “mesh inguinodynia,” and mesh infection.

Two distinct types of prosthetic infection have been described. The first type is an uncomplicated infection caused by contamination of the prosthetic material at the time of operation. This contamination may be from endogenous or exogenous sources. In uncomplicated infections, the source of sepsis is localized and not ongoing. The second type of prosthetic infection, a complicated prosthetic infection, usually results from mesh migration and erosion into adjacent viscera. In these instances, an ongoing source of sepsis is present from the eroded organ [10,16-21].

Uncomplicated infection can frequently be treated by local measures without removal of the prosthesis (particularly if a Type I mesh with large pores constructed of monofilament material has been utilized) [12]. Graft migration, however, requires surgical intervention for removal of the mesh and management of the enteric source of sepsis [11,16,18-20]. Distinguishing between these 2 types of compilations is essential for successful management. Their clinical signs and symptoms, however, are not necessarily specific to mesh infection and may be indistinguishable from each other as well as from other postherniorrhaphy complications.

For example, hernia recurrence after laparoscopic inguinal hernia repair can present with swelling at the operative site, pain, obstructive symptoms, and skin discoloration. The presentation of recurrence may be early or delayed. Differentiating recurrence from other types of complications is important because successful treatment of mesh infections depends on the results of bacteriologic studies of fluid aspirated or drained from the operative site. Aspiration or incision and drainage of the visceral content of a recurrent hernia, however, could prove disastrous. Ultrasound and computed tomography are useful to rule out early hernia recurrence as a cause for prolonged groin swelling or pain. Radiographic evidence of recurrence does not rule out infection, but does mandate reoperation.

Once recurrence is eliminated, the differential includes infection, seroma, hematoma, and orchitis along with neuralgia. A diagnosis of postoperative neuropathy is established if the patient describes pain in the distribution of the ilioinguinal, iliohypogastric, genitofemoral, or lateral femoral cutaneous nerve that has arisen since surgery. In addition, there must be no systemic signs or symptoms of sepsis (ie, fever, leukocytosis, elevated erythrocyte sedimentation rate) and radiographic imaging is normal. Delayed presentations of postoperative neuropathy have been reported. Confirmation of neuralgia is aided when infiltration of the involved nerve with local anesthetic relieves pain. Treatment may require medication such as amitriptyline, local injection with steroid, or mesh removal with or without neurectomy of the iliohypogastric, ilioinguinal, and genitofemoral nerves.

Swelling from hematoma, seroma, and orchitis must be differentiated from swelling caused by mesh infection, as the treatment of these conditions is quite different. Seroma and hematoma can be managed expectantly with resolution expected within 6 weeks to 12 weeks. Orchitis is usually painless and associated with an indurated testicle that slowly subsides with or without antibiotics and can result in an atrophic testicle, usually within a year. Mesh infections often have the universal signs of infection: pain, redness, swelling, warmth, and possibly fever and leukocytosis.

Occasionally, persistent draining sinus tracts have been described with complicated and uncomplicated mesh infections and may herald a stitch abscess or a more severe infection [8,11,16,19,20]. Once infection is suspected and recurrence is ruled out, aspiration of fluid with appropriate bacteriologic studies should be done. Additionally, cultures of any drainage from chronic sinus tracts should be performed. Aspirations of purulent fluid should prompt open drainage and administration of broad-spectrum antibiotics [11]. Polymicrobial infections or growth of enteric organisms should raise the suspicion of a visceral injury and prompt radiographic investigation with computed tomography or fistulography [11,18-20].

Infections that are not the result of an enteric source and involve Type I mesh are generally treatable by exposure of the prosthesis and removal of suture and unincorporated mesh, along with local wound care. Good results usually follow [11,12]. Vacuum system dressings have been used for infected wounds to reduce the effect of wound secretions and encourage tissue ingrowth. Early experience with these systems suggests that they may have utility in conservative management of open infected abdominal wall grafts (Figures 1 and 2).

Figure 1. Graft. 

Figure 2. Vacuum System Dressing.

Type II prostheses typically need to be removed, as tissue incorporation is impaired in the presence of infection. A trial of conservative management with antibiotic, exposure, and local wound care, however, is warranted before removal. On the other hand, enteric fistulas will not respond well to local care and require removal of the mesh as well as repair of the fistula independent of the type of mesh used [18-20]. The operative approach for mesh removal and fistula repair may require open incision and drainage of the groin followed by laparotomy. Alternatively, a laparoscopic intervention may be attempted if the operator has sufficient skill and experience. With infection, mesh usually becomes unincorporated from the operative site and is not difficult to remove. The operator’s experience and judgment guide the choice or approach (open or laparoscopic).

SUBSEQUENT REPAIR

As described above, it is rare for mesh to be removed because of an infectious complication. In addition, when mesh is removed after hernioplasty, recurrence seems to be infrequent [12]. However, when mesh must be replaced because of infection, care must be taken to avoid recurrent infection. Deysine [11] has outlined an approach to this problem based on orthopedic experience with implantable prostheses. Essentially, this investigator advocates aspiration of any infected material to test for residual bacteria. If percutaneous microbiological wound sampling is positive, remove the prosthesis and treat the infection. Once cultures are negative, repair with a new prosthesis is possible; otherwise perform wound exploration with secondary closure (Figure 3).

Figure 3. Algorithm for Treatment of Postherniorrhaphy Infection.

CONCLUSION

In summary, infection related to laparoscopic surgery is not much different from that of conventional surgery, and all the same principles of good surgical practice hold true. The major difference is that infection seems to be much reduced with laparoscopy when compared with conventional surgery. This is likely due to a multitude of reasons, such as smaller incisions, less trauma to tissues, and use of inert foreign bodies. But, some studies suggest that physiological reasons, such as less immune system depression, may exist that account for the lower infection rates. In general, infections that do occur after a laparoscopic procedure can be treated in a similar fashion to conventional surgical infections. 

Michael S. Kavic, MD, is Director of Education, General Surgery for the St. Elizabeth Health Center; Professor of Surgery and Vice Chair, Department of Surgery for the Northeastern Ohio Universities College of Medicine; and an Adjunct Professor of Surgery, Department of Surgery at the University of Pittsburgh School of Medicine. He is a founding member of the SLS and is Editor-in-Chief of JSLS, Journal of the Society of Laparoendoscopic Surgeons. Dr Kavic has written and published numerous book chapters, journal articles, and editorials and has lectured nationally and internationally on laparoscopic surgery. He is a past president of both SLS and the American Hernia Society.

Gayette F. Grimm, MD, is a general surgeon at Gundersen Lutheran Clinic in Prairie du Chien, Wisconsin. She completed her general surgery internship and residency at St. Elizabeth’s Health Center in Youngstown, Ohio. Dr Grimm is an active member of the Society of Laparoendoscopic Surgeons.

John Thomas, MD, is with the Department of General Surgery at Stonewall Jackson Memorial Hospital in Westin, West Virginia. He completed his residency at Mount Carmel Health. Dr Thomas is an active member of the Society of Laparoendoscopic Surgeons.

References

1.     Wangensteen OH, Wangensteen SD, Klinger CF. Surgical infection and history. In: Simmons RL, Howard RJ, eds. Surgical Infectious Diseases. New York, NY: Appleton-Century-Crofts; 1982:1-10.

2.     Koch R. Die aetiologie der tuberculose. Berl Klin Wschr. 1882;9:221-230.

3.     Dorland’s Illustrated Medical Dictionary. 28th ed. Philadelphia, PA: WB Saunders Co; 1994:1341.

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