The American Journal of Surgery 226 (2023) 360–364

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The American Journal of Surgery

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Original Research Article

Ventral hernia repair with concurrent intra-abdominal surgery: Results from

an eleven-year population-based cohort in Sweden
€wenmark, Karin Strigård, Ulf Gunnarsson
Mikael Lindmark *, Thyra Lo
Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Sweden

A R T I C L E I N F O A B S T R A C T

Keywords: Background: One remaining question in ventral hernia repair is whether to perform concurrent abdominal surgery
Ventral hernia or plan two-stage procedures. The aim was to explore the risk for reoperation and mortality due to surgical
Concurrent surgery complication during index admission.
National register
Method: Eleven-year data were retrieved from the National Patient Register and 68,058 primary surgical ad-
Reoperation
Mortality
missions were included, divided into minor and major hernia surgery and concurrent abdominal surgery. Results
were evaluated by logistic regression analysis.
Results: The risk for reoperation during index admission was higher for patients with concurrent surgery. Major
hernia surgery and major concurrent surgery had an OR 37.9 compared to major hernia surgery only. Mortality
rate within 30 days increased, OR 9.32. The combined risk for serious adverse event was accumulative.
Conclusion: These results stress the importance of critically evaluating needs for and planning of concurrent
abdominal surgery during ventral hernia repair. Reoperation rate was a valid and useful outcome variable.

1. Introduction showed a marked increase in risk for complications. Interpretation of

Ventral hernia repair is one of the most common surgical procedures
performed worldwide.1 Despite the large volume performed, there is no
consensus as to the best surgical technique, indications for repair, and
best choice of prosthetic material.2 A considerable proportion of ventral
hernia patients also need some other form of abdominal surgery. The
decision whether to perform a concurrent procedure or to follow a
two-stage strategy remains a challenge in the absence of more solid ev-
idence, as described in a recent review article.3
Results from the literature do not enable consensus and are mainly
based on small case series. Neither inguinal nor ventral hernia repair
with concurrent cholecystectomy have been shown to increase the risk
for surgical complication.4,5 Outcome after bariatric surgery with con-
current ventral hernia repair has varied, but a comprehensive review
article6 confirmed by a recent study7 speaks in favour of combining the
procedures. An evaluation of risk factors for surgical complications in
ventral hernia repair at two tertiary units found hernia aperture size to be
the most important risk factor, while concurrent intestinal surgery did
not manifest as an independent risk factor.8 On the other hand, evalua-
tion of specific high-risk procedures such as concurrent ventral hernia
repair and Hartman reversal9 as well as closure of a mix of stoma types10
results from risk scoring systems such as the Ventral Hernia Working
Group classification and its modifications, is complicated since those
systems also include unavoidable factors such as contamination from a
permanent stoma. However, concurrent procedures have also been
quoted as an independent risk factor in this respect.11,12
Data from the Danish Hernia Database show that the risk for reop-
eration for recurrence is increased after incisional hernia repair with
concurrent stoma closure compared to incisional hernia repair only.13
For more than a decade the Hernia Society has published interna-
tional guidelines, collected current evidence, and highlighted gaps in our
knowledge.14,15 The huge variation among hernia patients is a major
challenge when performing RCTs. This leads to low generalisability to
cohorts with other confounding factors than those investigated in the
specific study. When scrutinising the literature for studies on concurrent
abdominal surgery during ventral hernia repair or staging these pro-
cedures, it becomes evident that most are based on small, often retro-
spective patient materials. Register-based data, preferably
population-based, mirroring outcome of routine surgery, thus consti-
tute a valuable compliment to RCTs.
Population-based hernia surgery quality registers have been intro-
duced to improve quality of care and gain a better overview of results at

* Corresponding author. Department of Surgical and Perioperative Sciences, Surgery, Umeå University, 901 87, Umeå, Sweden.
E-mail address: mikael.e.lindmark@umu.se (M. Lindmark).

https://doi.org/10.1016/j.amjsurg.2023.06.006
Received 18 January 2023; Received in revised form 29 May 2023; Accepted 1 June 2023
0002-9610/© 2023 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
M. Lindmark et al.
the national level. The Swedish National Inguinal Hernia Register and the
Danish Hernia Database are two examples of registers that over the years
have reached a high coverage and delivered unique data.16 The Swedish
ventral hernia register to date has a coverage of only 20% and therefore a
thorough investigation of results from a national register seemed
worthwhile. The main advantage of dedicated, procedure- or
diagnosis-specific registers is their ability to tailor variables and sample
data relevant to making detailed adjustments in a healthcare process. On
the other hand, these registers usually lack direct relationships with other
events such as concurrent abdominal procedures.Large population-based
healthcare registers, often run by the authorities, provide an almost
complete coverage of surgical procedures, hospital admissions, and di-
agnoses. Such registers, unfortunately, lack follow-up variables, and
outcome registration is limited to complications, reoperations, and death.
Furthermore, these registers do not include procedure-specific variables
and thus have limited value when optimising a specific procedure. Un-
fortunately, the validity of secondary diagnosis registration, indicating
relevant intercurrent disease, is low in most register-based materials.
Missing and incorrect data lead to false conclusions, suboptimal design of
treatment algorithms, and ultimately misleads the surgical community.17
In view of our current knowledge, a relevant question is whether it is
ever beneficial for the patient to electively undergo a concurrent surgical
procedure during hernia repair?8,17 And in cases where combined bowel
and hernia surgery seems inevitable, what is the proper setting and
work-up prior to the procedure?
The aim of this study was to assess the risk of concurrent intra-
abdominal surgery during ventral hernia repair in terms of surgical
reintervention or death due to a surgical complication, in a large
nationwide population-based cohort.
2. Methods
2.1. Patients and method
From the National Board of Health and Welfare's patient register, data
on patients who had a ventral hernia procedure between 2004 and 2014
were retrieved. The National Patient Register began in 1964 and full
coverage of in-patient procedures was reached in 1989. Since 2001
procedures performed in outpatient practice are also included in this
register and mandatory registration of all procedures was introduced in
2007. A validation study was performed in 2011 showing that less than
1% of all procedures performed were missing, and that the positive
predictive value was high, reaching well over 90% for most surgical
procedures.18
This register provides the opportunity to analyse the risk for occur-
rence of adverse events during ventral hernia repair in routine clinical
practice. Patients with an ICD-code indicating ventral hernia repair were
gathered and codes for cardiovascular complication, reoperation, and
death within 30 days after index operation were included in the final
dataset. The inclusion of all codes for ventral hernia repair enabled us to
compare open and laparoscopic ventral hernia repair.
With these specifications, the dataset included 58,887 visits. Pro-
cedures were divided between minor and major hernia surgery and be-
tween minor and major concurrent surgery. Open repairs of epigastric
and umbilical hernias with onlay or inlay mesh and open and laparo-
scopic sutured repairs were classified as minor hernia procedures. All
others were classified as major hernia surgery. Examples of minor con-
current surgery include appendectomy and cholecystectomy, as well as
minor gynaecological and urological procedures. Major surgery includes
procedures such as low anterior resection, cystectomy, and liver
resection.
Patients below 18 years were not included in this material. A list of
variables is given in the supplementary material (S1).
The study was approved by the Regional Ethics Review Board in
Umeå (2017-205/32).
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The American Journal of Surgery 226 (2023) 360–364
2.2. Statistical methods
Statistical significance for dichotomic variables was tested by Fisch-
er's exact test and analysis where a p value < 0,05 was regarded as sig-
nificant. Patient data were acquired from the National Board Of health
and Welfare as an Excel® file (Microsoft Corp.). Database processing was
performed by an accredited statistician at Umeå University in R®. Final
statistical analysis of the data was performed using Statistica version 12
(Statsoft, Tulsa, OK, USA).
Uni- and multivariable logistic regression analyses were used to
determine the odds ratio (OR) for independent variables suspected to be
determinative for the dependent main outcome variable.
Logistic regression was used for uni- and multivariable analyses.
Variables not significant in the univariable analyses were excluded from
the multivariable analysis.
3. Results
Patient admissions were grouped into six groups based on major or
minor hernia surgery and major or minor concurrent surgery. Groups 3
and 4 comprised patients with no concurrent surgery. ICD codes used for
the groupings are given in the supplementary material (S1). The number
of admissions included in each group are listed in Table 1 together with
descriptive data of the groups. In all, 58,887 admissions were included
and 53% were male. The age range was 18–101 years. Repair for an
incisional hernia was performed in 22,029 (37.4%) cases, and 1451 pa-
tients (2.5%) were operated laparoscopically. Reoperation due to surgi-
cal complication was performed in 2143 (3.6%) during the index
admission. In all, 185 (0.3%) patients suffered a complication with
deadly outcome during the 30 days after surgery.
The risk of reoperation and death is increased in incisional hernia
repair compared to primary hernia repair, and is shown in Table 2.
There was a significantly increased risk for reoperation and death due
to surgical complication among patients with incisional hernia repair
compared with primary repair, which was confirmed in the multivariable
analyses shown in Tables 3 and 4.
The risk for reoperation during the index admission was higher for
patients with concurrent surgery. For patients undergoing major hernia
surgery with major concurrent surgery, the OR for reoperation was 37.9
(30.4–47.2) compared to those with major hernia surgery alone. These
patients also had a higher mortality rate due to a complication within 30
days after surgery with an OR of 9.32 (5.73–15.19).
The OR for reoperation of patients undergoing major hernia surgery
and minor concurrent surgery was 22.4 (17.3–29.0) compared to major
hernia surgery alone. OR for reoperation was also increased for patients
undergoing minor hernia repair with minor and major concurrent sur-
gery with an OR of 16.0 (12.6–20.3) for minor concurrent surgery and
OR 31.4 (25.2–39.0) for major concurrent surgery.
Males had a slightly higher OR 1.33 (1.22–1.45) for reoperation.
Multivariable analysis of risk for reoperation during index admission
is shown in Table 3.
Multivariable analysis of risk of death due to a complication within 30
days is shown in Table 4.
4. Discussion
Our study adds important data to the existing literature on concurrent
intra abdominal surgery during ventral hernia repair. We identified that
the need for reoperation was directly influenced by the extent of the
surgeries in this large population-based study. In addition, we also
discovered that the risk seems to accumulate the larger the surgeries are
(Table 3). These finds can be used to guide when there is a choice be-
tween a staged or a concurrent procedure. The entire treatment chain
must be considered, including the perioperative risk of performing two
procedures and increased morbidity due to delay of the second
procedure.
M. Lindmark et al. The American Journal of Surgery 226 (2023) 360–364

Table 1
Patient data for index surgical admission.
Group Admissions (%) Male (%) Median age (%) laparoscopic surgery (%) Incisional hernias (%) Reoperation (%)

Major hernia surgery and minor concurrent surgery 1161 (1.7) 511(44.0) 61.2 (22-95) 90 (7.8) 919 (79.2) 155 (13.4)
Major hernia surgery and major concurrent surgery 2362 (3.4) 1104(46.7) 66.6 (23-100) 130 (5.5) 2077 (87.9) 498 (21.1)
Major hernia surgery and no other concurrent surgery 14278 (20.7) 6571(46.0) 60.7 (18-98) 1231 (8.6) 12045 (84.4) 100 (0.7)
Minor hernia surgery and no other concurrent surgery 31398 (45.5) 1794(57.2) 51.1 (18-101) 0 4625 (14.7) 183 (0.6)
Minor hernia surgery and minor other concurrent surgery 4526 (6.6) 2536(56.0) 55.8 (18-95) 0 680 (15.0) 360 (8.0)
Minor hernia surgery and major other concurrent surgery 5162 (7.5) 2545(49.3) 65.7 (19-97) 0 1683 (32.6) 847 (16.4)
Total 58887 31231 (53.0) 56.2 (18-101) 1451 (2.5) 22029 (37.4) 2143 (3.6)

wound. Thus, the subgroup of patients with concurrent intra-abdominal

Table 2
surgery constitutes a minority in such studies, resulting in lack of power.
Incisional hernia versus primary ventral hernia.
An interesting study19 based on a British public healthcare register
Incisional hernia Primary hernia P-value (English Hospital Episode Statistics) attempted to classify 214,082 inci-
(%) (%)
sional hernia operations according to the Ventral Hernia Working Group
Reoperation, index admission 1106 (5.0) 1037 (2.8) <0.001 classification. This included the effect of concurrent abdominal surgery
Surgical complication 106 (0.5) 82 (0.2) <0.001
but did not specifically account for such cases. In that study, a clear
Medical complication 98 (0.4) 85 (0.2) <0.001
Reoperation, readmission 119 (0.5) 142 (0.4) 0.007 relationship between contaminated field and long-term risk for a further
Complication causing death within 103 (0.5) 82 (0.2) <0.001 hernia procedure was seen. Unfortunately, they did not include reoper-
30 d ation during index admission in their study. It might be that the risk for
Total 22029 36858 recurrent hernia is most pronounced among those operated with a con-
current minor or major abdominal procedure. Furthermore, that study
Our results are congruent with the results of dedicated studies on also showed an increase in postoperative mortality among cases judged
high-risk procedures.9,10 In this study, such procedures were assigned to to be contaminated, which is congruent with the increase in mortality
Groups 2 and 6 (major or minor hernia surgery with major concurrent amongst cases with concurrent major abdominal surgery in this study.
procedure). In a previous but smaller study based on a hernia procedure-specific
From our results (Table 3) it seems that concurrent surgery is the most register by our group, concurrent bowel surgery was not found to be an
important risk factor for reoperation. The present study focuses on the independent risk factor.8 That analysis was based on material from two
increase in risk caused by a concurrent procedure. tertiary referral centres, and the level of complexity was generally high.
Several publications from more limited but hernia-specific registers Most surgeons specialised in hernia surgery in that study were also
point out the relationship between a contaminated surgical field and colorectal surgeons. One explanation why concurrent surgery did not
surgical site complication according to the Ventral Hernia Working manifest as a risk factor may be selection bias due to data from speci-
Group classifications (or modifications of it).11,12 The main weakness of alised centres as opposed to large population-based materials. Another
such studies based on a limited number of cases, is that contamination possible explanation, as noted in most studies in this field, is that in our
includes not only a concurrent intestinal procedure but also unavoidable previous study,8 increased risk of concurrent bowel surgery did not reach
factors such as the presence of a permanent stoma or a contaminated statistical significance due to low power when analysed together with

Table 3
Uni- and multivariable analyses for reoperation during index admission.
Univariable OR (95% CI) Multivariable OR (95% CI)

Male 1.33 (1.22-1.45) 1.18 (1.07-1.29)

Age 1.03 (1.03-1.04) 1.01 (1.01-1.01)
Laparoscopy 0.73 (0.53-1.00)
Incisional hernia 0.55 (0.50-0.60) 0.74 (0.66-0.83)
Major hernia surgery and minor other concurrent surgery 21.8 (16.9-28.3) 22.4 (17.3-29.0)
Major hernia surgery and major other concurrent surgery 37.9 (30.4-47.2) 36.0 (28.9-44.9)
Major hernia surgery and no other concurrent surgery 1 1
Minor hernia surgery and no other concurrent surgery 0.83 (0.65-1.06) 1.12 (0.87-1.45)
Minor hernia surgery and minor other concurrent surgery 12.3 (9.79-15.3) 16.0 (12.6-20.3)
Minor hernia surgery and major other concurrent surgery 27.8 (22.6-34.3) 31.4 (25.2-39.0)

Table 4
Uni- and multivariable analysis for death within 30d due to complication.
Univariable OR (95% CI) Multivariable OR (95% CI)

Male 1.45 (1.09-1.94) 1.11 (0.83-1.50)

Age 1.11 (1.10-1-13) 1.08 (1.07-1.10)
Laparoscopy 0.87 (0.32-2.36)
Incisional hernia 0.48 (0.36-0.64) 0.87 (0.61-1.25)
Major hernia surgery and minor other concurrent surgery 1.37 (0.41-4.51) 1.39 (0.42-4.58)
Major hernia surgery and major other concurrent surgery 9.32 (5.73-15.19) 6.38 (3.90-10.4)
Major hernia surgery and no other concurrent surgery 1 1
Minor hernia surgery and no other concurrent surgery 0.27 (0.15-0.50) 0.46 (0.24-0.89)
Minor hernia surgery and minor other concurrent surgery 0.58 (0.23-1.52) 0.85 (0.32-2.81)
Minor hernia surgery and major other concurrent surgery 9.69 (6.30-14.9) 7.03 (4.37-11.3)

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other complex cases.
As seen in Table 1, patients undergoing ventral hernia repair and
concurrent abdominal surgery were older than those undergoing hernia
repair only. This is probably due to accumulation of disease requiring
surgical correction as patients grow older. Since age also manifested as an
independent risk factor for both reoperation and death during the index
admission, this stresses the need for careful assessment of old patients
when considering a concurrent surgical procedure. Male gender was also
an independent risk factor for reoperation but not for death; a factor that
must also be included in this critical decision. As seen in Table 2 and in
the multivariable analyses of risk for reoperation and death (Tables 3 and
4), incisional hernia manifested as an independent risk factor, further
emphasising the need for tailored decision-making based on the indi-
vidual patient's characteristics and nature of the hernia.
Major surgery inevitably puts a higher strain on the patient, and
frailty is thus an important factor to consider before planning major
surgery.20,21 One can argue that staging procedures leads to two peri-
operative events where complications can occur. Nevertheless, the con-
sequences of anastomotic leakage, fistula, and deep infection are more
hazardous in the presence of prosthetic material. There are, however,
situations where it is advisable to perform both bowel surgery and
ventral hernia repair as a combined procedure, but we stress the need for
rigorous planning and optimisation of the patient before surgery. Com-
plex cases should be managed by a specialised team and should be dis-
cussed in a multidisciplinary conference prior to repair.22,23
Reoperation and mortality were chosen as outcome variables for this
study, while surgical complication was not used as an outcome mea-
surement. The reason for this was prior experience and validation of the
register used together with the Swedish quality registers for colorectal
cancer surgery24: as with many other registers, the registration of surgical
complications is often incomplete whereas outcome variables such as
reoperation and mortality have high validity and completeness. This is
also seen in Table 3 in the present study where the number of registered
complications is strikingly low in relation to the number of reoperations.
The main strength of the present study is the large population-based
study cohort sampled with almost 100% completeness. The structure of
the data-source also guarantees accuracy of our allocation of patients to
the study groups (Table 1).
The Limitation is the use of a general healthcare register and not a
procedure-specific quality register, implying lack of data on hernia-
specific variables such as aperture diameter and positioning of the
mesh (not coded in the ICD system during the study period). Another
weakness is the lack of data on comorbidity possibly influencing the
magnitude of differences between the treatment groups (Table 1).
However, there is no reason why systematic effects arising from the
magnitude of the surgical procedure should be explained by differences
in comorbidity. Unfortunately, ICD coding of secondary diagnoses is
often insufficient and incomplete, while coding of the main diagnosis has
a high degree of accuracy. Another limitation is that national healthcare
registers do not contain data making it possible to judge whether a
combined procedure was mandatory for medical reasons or if there was
also the choice of a staged procedure.
5. Conclusions
There was an accumulative increase in risk for complication neces-
sitating reoperation when performing ventral hernia repair plus con-
current intra-abdominal surgery. Age and male gender were further
independent risk factors. Decisions whether to perform a staged pro-
cedure or concurrent surgery should be preceded by careful assessment
and evaluation of risk factors in each case.
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The American Journal of Surgery 226 (2023) 360–364
Sources of funding
Financial support was provided through a regional agreement be-
tween Umeå University and V€asterbotten County Council (ALF).
Declaration of competing interest
None of the authors have any conflict of interest to declare.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.amjsurg.2023.06.006.
References
1. Sauerland S, Walgenbach M, Habermalz B, et al. Laparoscopic versus open surgical
techniques for ventral or incisional hernia repair. Cochrane Database Syst Rev. 2011;
(3):Cd007781. https://doi.org/10.1002/14651858.CD007781.pub2.
2. Al Chalabi H, Larkin J, Mehigan B, McCormick P. A systematic review of laparoscopic
versus open abdominal incisional hernia repair, with meta-analysis of randomized
controlled trials. Int J Surg. 2015;20:65–74. https://doi.org/10.1016/
j.ijsu.2015.05.050.
3. Petro CC, Rosen MJ. Fight or flight: the role of staged approaches to complex
abdominal wall reconstruction. Plast Reconstr Surg. 2018 Sep;142(3 Suppl):38S–44S.
https://doi.org/10.1097/PRS.0000000000004847.
4. Claus CMP, Ruggeri JRB, Ramos EB, et al. Simultaneous laparoscopic inguinal hernia
repair and cholecystectomy: does it cause mesh infection? Arq Bras Cir Dig. 2021 Oct
15;34(2):e1600. https://doi.org/10.1590/0102-672020210002e1600.
5. AlMarzooqi R, Tish S, Tastaldi L, et al. Is concurrent cholecystectomy safe during
abdominal wall reconstruction? An AHSQC analysis. Hernia. 2021 Apr;25(2):
295–303. https://doi.org/10.1007/s10029-020-02208-4.
6. Vilallonga R, Beisani M, Sanchez-Cordero S, et al. Abdominal wall hernia and
metabolic bariatric surgery. J Laparoendosc Adv Surg Tech. 2020 Aug;30(8):891–895.
https://doi.org/10.1089/lap.2020.0257.
7. Moszkowicz D, Jacota M, Nkam L, et al. Ventral hernia repair and obesity: results
from a nationwide register study in France according to the timeframes of hernia
repair and bariatric surgery. Obes Surg. 2021 Dec;31(12):5251–5259. https://
doi.org/10.1007/s11695-021-05720-3.
8. Lindmark M, Strigard K, Lowenmark T, et al. Risk factors for surgical complications
in ventral hernia repair. World J Surg. 2018;42(11):3528–3536. https://doi.org/
10.1007/s00268-018-4642-6.
9. Rudnicki Y, Horesh N, Lessing Y, et al. Synchronous Hartmann reversal and
incisional hernia repair is associated with higher complication rate compared to a
staged procedure. Sci Rep. 2021 Jan 14;11(1):1390. https://doi.org/10.1038/
s41598-021-81064-3.
10. Baastrup NN, Hartwig MFS, Krarup PM, et al. Anastomotic leakage after stoma
reversal combined with incisional hernia repair. World J Surg. 2019 Apr;43(4):
988–997. https://doi.org/10.1007/s00268-018-4866-5.
11. Kanters AE, Krpata DM, Blatnik JA, et al. Modified hernia grading scale to stratify
surgical site occurrence after open ventral hernia repairs. J Am Coll Surg. 2012 Dec;
215(6):787–793. https://doi.org/10.1016/j.jamcollsurg.2012.08.012.
12. Ashuvanth S, Anandhi A, Sureshkumar S. Validation of ventral hernia risk score in
predicting surgical site infections. Hernia. 2022 Jun;26(3):911–917. https://doi.org/
10.1007/s10029-021-02537-y.
13. Oma E, Baastrup NN, Jensen KK. Should simultaneous stoma closure and incisional
hernia repair be avoided? Hernia: the journal of hernias and abdominal wall surgery.
2021;25(3):649–654. https://doi.org/10.1007/s10029-020-02312-5.
14. Bittner R, Bain K, Bansal VK, et al. Update of Guidelines for Laparoscopic Treatment of
Ventral and Incisional Abdominal Wall Hernias (International Endohernia Society
(IEHS)): Part B. Surgical Endoscopy. 2019. https://doi.org/10.1007/s00464-019-
06908-6.
15. Bittner R, Bain K, Bansal VK, et al. Update of Guidelines for laparoscopic treatment of
ventral and incisional abdominal wall hernias (International Endohernia Society
(IEHS))-Part A. Surg Endosc. 2019;33(10):3069–3139. https://doi.org/10.1007/
s00464-019-06907-7.
16. Helgstrand F. National results after ventral hernia repair. Danish Med J. 2016;63(7).
17. Nolan TW. Understanding medical systems. Ann Intern Med. 1998;128(4):293–298.
https://doi.org/10.7326/0003-4819-128-4-199802150-00009.
18. Ludvigsson JF, Andersson E, Ekbom A, et al. External review and validation of the
Swedish national inpatient register. BMC Publ Health. 2011;11:450. https://doi.org/
10.1186/1471-2458-11-450.
19. Bueno-Lled o J, Bonafe-Diana S, Carbonell-Tatay F, et al. Component separation and
large incisional hernia: predictive factors of recurrence. Hernia. 2021 Dec;25(6):
1593–1600. https://doi.org/10.1007/s10029-021-02489-3.
M. Lindmark et al.
20. Sandini M, Pinotti E, Persico I, et al. Systematic review and meta-analysis of frailty as
a predictor of morbidity and mortality after major abdominal surgery. BJS open.
2017;1(5):128–137. https://doi.org/10.1002/bjs5.22.
21. Seib CD, Rochefort H, Chomsky-Higgins K, et al. Association of patient frailty with
increased morbidity after common ambulatory general surgery operations. JAMA
Surgery. 2018;153(2):160–168. https://doi.org/10.1001/jamasurg.2017.4007.
22. Muirhead LJ, Shaw AV, Kontovounisios C, Warren OJ. Establishing a robust
multidisciplinary team process in complex abdominal wall reconstruction within a
364
The American Journal of Surgery 226 (2023) 360–364
colorectal surgical unit. Tech Coloproctol. 2019 Apr;23(4):379–383. https://doi.org/
10.1007/s10151-019-01965-4.
23. Grove TN, Kontovounisios C, Montgomery A, et al. AWR Europe Collaborative.
Perioperative optimization in complex abdominal wall hernias: delphi consensus
statement. BJS Open. 2021 Sep 6;5(5):zrab082. https://doi.org/10.1093/bjsopen/
zrab082.
24. Gunnarsson U, Seligsohn E, Jestin P, Påhlman L. Registration and validity of surgical
complications in colorectal cancer surgery. Br J Surg. 2003 Apr;90(4):454–459.
https://doi.org/10.1002/bjs.4058.