Gala Zachary, Lemdani Mehdi S, Crystal Dustin, Ewing Jane N, Broach Robyn B, Fischer John P, Kovach Stephen J
Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Pennsylvania, 3400 Civic Center Blvd. - Perelman Center for Advanced Medicine, 14 thFloor, South Building, Philadelphia, PA, 19104, USA.
Hernia. 2025 Jun 18;29(1):210. doi: 10.1007/s10029-025-03350-7.
Complications from ventral hernia repair (VHR) pose a significant healthcare burden. Risk assessment and stratification models are thus incentivized to improve cost-effectiveness and patient outcomes. The Ventral Hernia Risk Score (VHRS) and Ventral Hernia Work Group Classification (VHWG) are metrics that attempt to stratify and predict surgical site infection (SSI) and surgical site occurrence (SSO) risk based on patient characteristics. Our study aims to evaluate these models and assess external validity.
A retrospective review of all VHR procedures between October 2013 - August 2022 performed by the senior authors was conducted. Demographic, comorbidity, perioperative and outcome-related information was collected. Non-SSI and non-SSO cohorts were compared to SSI and SSO cohorts respectively to assess possible significant differences in patient demographics and operative characteristics. The VHRS and VHWG models were applied to each patient to predict risk. The Youden index of the respective Receiver Operating Characteristic (ROC) curves defined optimal score cutoffs for both models. Area under curve (AUC) was reported to assess model prediction quality.
A total of 1,414 patients who underwent VHR was identified, of which 175 (12.4%) experienced SSI and 367 (26.0%) SSO. Mean follow-up was 1.72 years [30 days, 13.65 years]. Patient demographics were similar between both non-SSI and SSI as well as non-SSO and SSO cohorts. However, comorbidities including prior non-VHR abdominal surgery (SSI: p < 0.001; SSO: p < 0.001), prior-VHR (SSI: p = 0.001; SSO: p-0.012), and prior mesh infection (p = 0.004) were significant between non-SSI and SSI cohorts as well as non-SSO and SSO cohorts. Operative characteristics including mesh plane (SSI: p = 0.008; SSO: p < 0.001) and adhesiolysis (SSI: p < 0.001; SSO: p < 0.001) were also significant in similar manner. Youden index of VHRS suggested a score of 7 as the optimal cutoff for increased SSI risk and 6 for SSO risk. The AUC was 0.609 for the VHRS-SSI model and 0.5882 for the VHRS-SSO model. VHWG grade of 3 was the optimal cutoff for both SSI and SSO. Model AUC was 0.616 for VHWG-SSI and 0.614 for VHWG-SSO.
Our study presents the largest external validation cohort for assessing the VHRS model. The VHRS was not superior toc the VHWG for SSI or SSO prediction. While the VHRS was designed for simplicity and basis in obvious patient or operative characteristics, it fails to appropriately weight pre-operative measures and more holistically evaluate clinical factors. Both models have limited predictability and generalizability in patients undergoing ventral hernia repair.
腹疝修补术（VHR）的并发症带来了巨大的医疗负担。因此，风险评估和分层模型有助于提高成本效益和患者预后。腹疝风险评分（VHRS）和腹疝工作组分类（VHWG）是基于患者特征对手术部位感染（SSI）和手术部位事件（SSO）风险进行分层和预测的指标。我们的研究旨在评估这些模型并评估其外部有效性。
对2013年10月至2022年8月期间由资深作者进行的所有VHR手术进行回顾性研究。收集人口统计学、合并症、围手术期和结局相关信息。将非SSI和非SSO队列分别与SSI和SSO队列进行比较，以评估患者人口统计学和手术特征中可能存在的显著差异。将VHRS和VHWG模型应用于每位患者以预测风险。通过各自的受试者工作特征（ROC）曲线的约登指数确定两个模型的最佳评分临界值。报告曲线下面积（AUC）以评估模型预测质量。
共确定了1414例接受VHR的患者，其中175例（12.4%）发生SSI，367例（26.0%）发生SSO。平均随访时间为1.72年[30天，13.65年]。非SSI与SSI队列以及非SSO与SSO队列之间的患者人口统计学特征相似。然而，包括既往非VHR腹部手术（SSI：p<0.001；SSO：p<0.001）、既往VHR（SSI：p = 0.001；SSO：p = 0.012）和既往补片感染（p = 0.004）在内的合并症在非SSI与SSI队列以及非SSO与SSO队列之间存在显著差异。包括补片平面（SSI：p = 0.008；SSO：p<0.001）和粘连松解（SSI：p<0.001；SSO：p<0.001）在内的手术特征也以类似方式存在显著差异。VHRS的约登指数表明，SSI风险增加的最佳临界评分为7分，SSO风险为6分。VHRS-SSI模型的AUC为0.609，VHRS-SSO模型的AUC为0.5882。VHWG 3级是SSI和SSO的最佳临界值。VHWG-SSI模型的AUC为0.616，VHWG-SSO模型的AUC为0.614。
我们的研究展示了用于评估VHRS模型的最大外部验证队列。对于SSI或SSO预测，VHRS并不优于VHWG。虽然VHRS设计得简单，基于明显的患者或手术特征，但它未能适当权衡术前指标，也未能更全面地评估临床因素。这两个模型在接受腹疝修补术的患者中预测能力和通用性都有限。
