Do smokers deserve "No"? Management and outcomes of smokers undergoing elective ventral hernia repair

Smoking has long been regarded as a contraindication to elective ventral hernia repair, however some have begun to question whether this practice is unnecessarily restrictive. In order to better understand the implications of more liberal patient selection for commonly encountered hernias, we evaluated outcomes among smokers and nonsmokers undergoing elective ventral hernia repair.

We retrospectively reviewed a population-level registry to identify adults who underwent elective ventral hernia repair between 2021 and 2023. The primary explanatory variable was active smoking, which was defined as smoking within the month prior to surgery. Outcomes included 30-day complications, emergency department utilization (including reason for utilization), readmission, and reoperation. Multivariable logistic regression was used to assess the association of smoking with all outcomes while controlling for patient, hernia, and operative characteristics.

12,233 patients underwent elective ventral hernia repair during the study period. Mean age was 54.3 (14.3) years, 5151 (42.1%) patients were female, and mean hernia width was 3.3 (3.2) cm. 2059 (16.8%) patients smoked prior to surgery. Smokers were younger, had higher ASA classifications, and more pulmonary disease. Regarding management, smokers were less likely to have myofascial release, but there was no difference in surgical approach or mesh use. Smoking was not associated with increased odds of 30-day complications, readmission, or reoperation. Smoking was associated with increased odds of 30-day ED utilization (6.83% [95% CI 5.76-7.90%] vs. 4.87% [95% CI 4.45-5.30%], P < 001), however this was due to pain-related issues (43.3% vs. 32.9%, P = 0.017) and not infectious or wound-related issues.

In this cohort of patients undergoing elective ventral hernia repair, management of smokers and nonsmokers was similar, and smokers did not have significantly worse short-term outcomes than nonsmokers. These findings may help inform patient selection and expectations, however long-term outcomes including recurrence require evaluation as well.