Designing a ventral hernia staging system

The absence of a standardized classification scheme for ventral hernias hinders comparisons within the literature, indirectly delaying meaningful discussions regarding technique. We aimed to generate a comprehensive staging system that stratifies patients by risk of developing wound morbidity and hernia recurrence.

Our prospective database of all ventral hernia repairs (2006-2013) was reviewed with no exclusion based on technique or prosthetic. The presence of patient comorbidities, contamination and hernia dimensions-width/location on computed topography-was evaluated to identify variables most closely associated with surgical site occurrence (SSO) and recurrence. Predicted odds ratios and relative hazards, for SSO and recurrence, respectively, were used to partition patients into stages corresponding with increasing levels of risk.

Hernia width (OR 2.24, HR 1.73) and the presence of contamination (OR 1.81, HR 2.04) were most significantly associated with increased risk of SSO and recurrence, while hernia location and the presence of comorbidities were not. Stage I hernias are <10 cm/clean and associated with low SSO and recurrence risk. Stage II hernias are 10-20 cm/clean or <10 cm contaminated and carry an intermediate risk of SSO and recurrence. Stage III hernias are either ≥10/contaminated or any hernia ≥20 cm, and these are associated with high SSO and recurrence risk. Stages I-III carry a concordance index of 0.67 for SSO and 0.61 for recurrence.

Hernia width and wound class can be used to stratify patients into stages (I-III) with increasing risk of wound morbidity and recurrence. This can be the foundation for future inclusion and exclusion criteria.