Association Between Midline Extraction Incision and Increased Risk of Incisional Hernia After Minimally Invasive Radical Nephrectomy: Results of an Observational Study From a High-Volume Center

Abstract

Purpose: Our goal was to determine whether specimen extraction incision and body morphometry analysis of skeletal muscle and fat mass are predictive of incisional hernia (IH) after minimally invasive nephrectomy (laparoscopic or robotic).

Materials and methods: We conducted an observational study of a prospectively maintained database of patients undergoing minimally invasive nephrectomy from 2005 to 2022. For inclusion, patients were required to have preoperative and 1-year and 2-year postoperative abdominal cross-sectional imaging. Skeletal muscle and fat mass indices were calculated based on measurements obtained from preoperative imaging. The location of the specimen extraction incision was determined from operative reports. IH was diagnosed on review of postoperative imaging. Logistic regression analysis was performed to identify predictors of IH.

Results: Four hundred ninety-four patients met inclusion criteria. The most commonly used extraction incisions were Gibson (250 patients, 51%), midline (98 patients, 20%), paramedian (58 patients, 12%), and Pfannenstiel (21 patients, 4.3%). At 2-year postoperative follow-up, 59 patients (12%) had developed IH. The incidence of IH was highest among patients receiving midline incision (23%), compared with all other incision types (≤10% each). Baseline fat mass index (odds ratio: 1.18, 95% CI: 1.06-1.32, P = .002) and midline extraction incision (odds ratio: 4.60, 95% CI: 2.23-9.48, P < .001) were independent predictors of IH.

Conclusions: A midline extraction incision is associated with a significantly higher risk of IH after minimally invasive nephrectomy. Body morphometry analysis did not improve predictive models compared with models using BMI. These data support a prospective trial to identify the optimal extraction incision for hernia-free survival and patient-reported quality of life.

Keywords: incisional hernia; minimally invasive surgical procedures; nephrectomy.