Quality of life and abdominal wall functionality after abdominal wall reconstruction: A prospective single center follow-up study

Abstract

Background: Fascial breakdown with the occurrence of an incisional hernia (IH) is an important and challenging complication of any laparotomy. For a long time, the success of the abdominal wall reconstruction (AWR) was measured only from the surgeon's perspective by defining outcome measures such as wound morbidity and recurrence. The understanding that complete recovery is difficult to assess without considering patients has shifted the paradigm of optimal outcomes to Patient Reported Outcome Measures (PROMS) and Quality of Life (QoL), which are pivotal to evaluate the success and efficacy of AWR.

Methods: We conducted a prospective follow-up study of 91 patients undergoing mesh-augmented abdominal wall reconstruction for primary or recurrent incisional hernia between January 2021 and December 2023. Demographic data, comorbidities, and hernia characteristics were recorded. All patients were evaluated preoperatively by a native abdomino-pelvic CT scan to assess the characteristics of hernia (length, width, surface, and volume of the incisional hernia sac and of peritoneal cavity), the presence of mesh (if previously inserted), and abdominal wall muscles status. All intervention were performed by the same surgical team according to the techniques described by Rives - Stoppa (RS), Ramirez (ACS), and Novitsky (PCS). Abdominal wall function was assessed using trunk raising (TR) and double leg lowering (DLL) measurements performed preoperatively, 1 month, 6 months, and 1 year postoperatively. At the same time, pre- and post-operative quality of life was analysed using the EQ-5D score.

Results: Mean age of 59.42 ± 12.28 years and a male/female ratio of 35/56 were recorded, most of them being obese. There were 36 (42%) patients with defects larger than 10 cm. The distribution of the type of surgical intervention was: RS 35 patients, ACS 13 patients, and PCS 43 patients. The mean value of combined score for the preoperative abdominal wall functionality was 4.41 ± 1.67 (2-8) while the mean value of preoperative EQ-5D index was 0.652 ± 0.026 (-0.32-1.00). QoL was poor and very poor for 48% (44) of the patients who recorded index values less than 0.56 (50% percentile). Preoperative EQ-5D index was highly correlated with Combined AWF score (r = 0.620; p < 0.0001) and the correlation was specific (AUC = 0.799; p < 0.0001; asymptotic 95%CI = 0.711-0.923). At 12 months, the AWF score increased to 8.13 ± 2.58 (1-10) and the QoL total score to 0.979 ± 0.007 (0.71-1). Good and very good total scores for QoL were recorded for 47 patients (84%) compared to 33 (36%) in the preoperative evaluation (χ² with Yates continuity correction for two degrees of liberty = 46.04; p < 0.00001).

Conclusion: Our results suggest that patients can expect to see a significant overall improvement in all five components of QoL measured with the help of Eq. 5D questionnaire. This improvement is dependent by hernia size, and some individual patient's factors (diabetes, cardiovascular diseases, and age over 60 years).

Keywords: ACS; EQ-5D score; Incisional hernia; PCS; Quality of life; Rives-Stoppa; Truncal function.

Fig. 1

EQ-5D-5 L descriptive system. Source: EuroQol Research Foundation. EQ-5D-5 L User Guide, 2019. Latest version available from: https://euroqol.org/publications/user-guides

Fig. 2

The flow chart of patient’s distribution according to inclusion and exclusion criteria

Fig. 3

The evolution of abdominal wall functionality in relation to the EQ-5D QoL index. The difference with the 1-month score was significant (p < 0.0001; 95% CI of difference = 2.51–3.51). Data expressed as mean ± SD for AWF and as mean ± SEM for QoL index

Fig. 4

EQ-5D QoL index in relation to type of surgery; Preop – preoperatively; Index 1–1-month index value; Index 6–6 months index value; Index 12–12 months index value. Preoperatively scores for the QoL were lower for the patients with Rives – Stoppa repair comparing with ACS (p = 0.007) and TAR (p = 0.00023). Quality of life was insignificantly different in patients with ACS compared to TAR patients (p = 0.528). Data expressed as mean ± SEM