Drain versus no drain in elective open incisional hernia repair: a propensity score matching analysis using the ACHQC database.

Introduction: The benefits of prophylactic drain placement are controversial during elective open incisional hernia repair. The aim of this study was to evaluate drain impact on surgical site occurrences (SSO) and infection (SSI) after open elective incisional hernia repair with mesh.

Methods: A retrospective review of prospectively collected data from the Abdominal Core Health Quality Collaborative (ACHQC) was performed to include all adult patients who underwent elective open incisional hernia repair with permanent synthetic or resorbable synthetic mesh. A 1: 1 propensity score match (PSM) was conducted for balanced groups. Univariate analysis was performed to compare two groups (drain versus no-drain) across preoperative, intraoperative, and postoperative timeframes.

Results: The ACHQC database identified 10,821 patients with incisional ventral hernias who underwent open VHR. A PSM analysis stratified 1,337 patients to each group with a 2,674 patients. Most patients had M3 and M2 hernias (according to the EHS classification) in both groups. Median defect width was 6.0 cm (IQR 4-8) in the drain group versus 5.0 (IQR 3.0- 7.0) in the no-drain group, with no significant difference. Median hernia length was 8.0 cm (IQR 6.0-11.0) in the drain group versus 6.0 (4.0-10.0) in the no-drain group. After matching, the standard mean difference (SMD) is 0.061, indicating a good balance between groups. Recurrent hernia was higher in the drain group (607; 45% vs. 437; 33%; p < 0.001). Transversus abdominis release (TAR) was higher in the drain group (198; 15% vs. 138; 10%; p < 0.001). Moreover, the drain group had a higher number of cases with two meshes when compared with the no-drain group (30; 2.2% vs. 16; 1.2%; p 0.037). Sublay repair was more common in both groups, followed by Onlay repair. The retromuscular repair is the most common type of sublay repair in both groups. Moreover, median mesh width was higher in the drain group (15 cm; IQR 12-20 vs. 12 (IQR 8-15); p < 0.001. The drain group had more cases with more than 180 min than to the no-drain group (419; 31% vs. 164; 12.2%; p < 0.001). The Median Length of Stay (LOS) was 3 days (IQR 1-4) in the drain group and 1 day (IQR 0-3) in the no-drain group (p < 0.001). (Table 4) Thirty-day readmission was higher in the drain group compared to the no-drain group (65; 4.9% versus 42; 3.1%; p = 0.002). There was no difference in reoperation and recurrence at 30 days. (Table 4) In the univariate analysis, SSI was higher in the drain group (55; 4.1% versus 35; 2.6%; p = 0.032) with no difference in SSO between the groups. When evaluating only seroma, the no-drain group had more seroma when compared with the drain group (116; 8.7% versus 73; 5.5%; p = 0.001). There was no difference in SSOPI between the groups. Regarding LOS, logistic regression demonstrated drain use (OR 2.7, CI 2.2-3.5; p < 0.001), hernia length (OR 1.1, CI 1.05-1.1; p < 0.001), hernia width (OR 1.06 95% CI 1.03-1.1; p < 0.001)and TAR (OR 1.6, CI 1.2-2.2; p < 0.001) were strongly associated with longer LOS. Drain use was independently associated with readmissions in 30 days after surgery (OR 1.5; 95% CI 1.03-2.3; p = 0.037). Drain use was not associated with increased SSI (OR 1.5, CI 1.0-2.4 ; p = 0.055) or SSO ( OR 0.8, CI 0.64-1.03, p = 0.082). Logistic regression showed that drain use prevented seroma formation at 30 days (OR 0.6; 95% CI 0.44- 0.81; P < 0.001).

Conclusion: Drain use in elective open incisional hernia repair with mesh was linked to reduced seroma risk but increased length of stay and 30-day readmission, without higher SSI or SSOPI rates. These findings are not generalizable and prospective studies are needed in the future.