Jeffrey A. Blatnik

Abdominal hernia repair with bridging acellular dermal matrix--an expensive hernia sac.

BACKGROUND The ability of biologic mesh to remodel into native fascia and prevent hernia recurrence in complicated repairs is appealing. However, few long-term data exist evaluating these products in the setting of bridging fascial defects. These collagen-based mesh products are costly, and long-term evaluation of hernia recurrence rates are necessary to justify their expense. METHODS This was a retrospective review of patients undergoing repair of complex abdominal defects with acellular dermal matrix (ADM) at our institution was performed. RESULTS Between January 2004 and December 2005, 11 patients underwent complex ventral hernia repairs with bridging ADM. Indications for repair included resection of enterocutaneous fistula, infected mesh, and/or ventral hernia repair. A mean of 175 cm(2) (range 8 to 456) of ADM were used. Mean follow-up was 24 months (range 18 to 37). One patient died on postoperative day 20. Eight of the 10 (80%) remaining patients had recurrences, and 7 underwent further surgery for repair. One patient reported laxity but refused repair. The total cost of ADM alone for these 11 patients was

A 5-Year Clinical Experience With Single-Staged Repairs of Infected and Contaminated Abdominal Wall Defects Utilizing Biologic Mesh

61,926; the cost for the 8 patients having recurrences was

Posterior and open anterior components separations: a comparative analysis

40,776; and the total mean cost was

Design and initial implementation of HerQLes: A hernia-related quality-of-life survey to assess abdominal wall function

5,100/patient. CONCLUSIONS Although bridging fascial defects with ADM can be an appealing substitute in extremely complicated cases, our data demonstrate exceedingly high recurrence rates. The long-term outcome of bridging fascial defects with biologic prosthesis does not justify the expense of the product.

Optimum repair for massive ventral hernias in the morbidly obese patient—is panniculectomy helpful?

Objective:Our objective was to evaluate the safety and durability of biologic mesh for single-staged reconstruction of contaminated fields. Introduction:The presence of contamination during ventral hernia repair (VHR) poses a significant challenge. Some advocate for a multistaged reconstructive approach with delayed definitive repair, whereas others perform definitive repair at the initial operation. Methods:Patients undergoing single-staged VHR in a contaminated field with biologic mesh over a 5-year period were retrospectively reviewed from a prospectively maintained database. Outcome measures included wound complication and hernia recurrence. Results:A total of 128 patients (76 F, 52 M) were identified, with a mean age of 58.2 years, mean American Society of Anesthesiologist (ASA) score 3.1, and mean body mass index (BMI) 34.1 ± 9.7 kg/m2. Comorbidities included COPD (n = 29), diabetes (n = 65), smoking (n = 29), and immunosuppression (n = 8). Mean hernia defect size was 431 cm2 (range 40–2450 cm2). Reasons for contamination included the presence of infected mesh (n = 45), stoma (n = 24), concomitant gastrointestinal (GI) surgery (n = 17), enterocutaneous fistula (n = 25), open nonhealing wound(s) (n = 6), enterotomy/colotomy (n = 5), and chronic draining sinus (n = 6). Postoperative wound complications were identified in 61 (47.7%) patients. Predictors of wound complications included ASA score, diabetes, smoking, number of previous abdominal surgeries or hernia repairs, hernia defect size, and operative time. With a mean follow-up time of 21.7 months, hernia recurrence was identified in 40 (31.3%) patients. The majority of recurrent hernias were asymptomatic and 7 patients underwent repair. Conclusions:Despite the high rate of wound morbidity associated with single-staged reconstruction of contaminated fields, it can safely be performed with biologic mesh reinforcement. Although biologic mesh in these situations is safe, the long-term durability seems to be less favorable.

Effect of surgical wound classification on biologic graft performance in complex hernia repair: an experimental study.

BACKGROUND Anterior components separation (ACS) creates large lipocutaneous flaps to release the external oblique fascia often leading to major wound complications. Posterior components separation (PCS) involves the release of the posterior rectus sheath and transversus abdominis muscles. We hypothesized that PCS provides effective fascial advancement while reducing wound morbidity during abdominal wall reconstructions. METHODS A retrospective review of consecutive components separation performed by a single surgeon over 5 years. RESULTS One hundred eleven patients (56 ACS/55 PCS) were analyzed. The mean defect size was 472 and 531 cm(2), respectively (P = .28). Five patients in each group required a bridging repair. Wound complications occurred in significantly more ACS than PCS patients (48.2% vs 25.5%, P = .01). The recurrence rate was also higher in the ACS group (14.3% vs 3.6%, P = .09). CONCLUSIONS PCS provides equivalent myofascial advancement with significantly less wound morbidity when compared with ACS. Although further studies are needed, PCS has evolved as an important addition to the armamentarium of surgeons undertaking complex abdominal wall reconstructions.

Does a history of wound infection predict postoperative surgical site infection after ventral hernia repair

BACKGROUND Success of a surgical intervention is often measured by hard clinical outcomes. In ventral hernia repair (VHR) these include wound morbidity and hernia recurrence. These outcomes fail to account for a surgical interventions effect on a patients quality of life (QofL). Our objective was to design a hernia-specific QofL instrument with a focus on abdominal wall function, evaluate its measurement properties, and assess the impact of VHR on QofL using this new instrument. STUDY DESIGN A 16-question QofL survey tool, HerQLes, was constructed. Patients presenting for elective VHR completed the survey. Rasch modeling was used to evaluate the items; fit statistics, person-item mapping, separation index, and reliability were examined. Associations between baseline characteristics and QofL were assessed. RESULTS Eighty-eight patients completed the survey before assessment for VHR. Mean age was 57.2 years (±12.4 years), mean American Society of Anesthesiologists score was 2.8 (±0.5), and mean body mass index was 34.9 kg/m(2) (±9.3 kg/m(2)). Based on Rasch modeling, 12 of 16 items met model fit criteria. The 4 poorly fitting items were eliminated from further analysis. The 12 items retained have good internal consistency reliability (0.86). On a 0- to 100-point scale, mean QofL score was 47.2 (±15.6). Patients with higher grade hernias had lower HerQLes scores (p = 0.06). Patients showed significant improvement in abdominal wall function and QofL 6 months after VHR (p < 0.01). CONCLUSIONS Quality-of-life is an important component of surgical management of ventral hernias. The 12-question QofL survey, HerQLes, is reliable and valid. At baseline, patients with more complex hernias tended to have a decreased abdominal wall function and QofL. Six months after surgical repair, HerQLes scores change in the predicted direction. We believe HerQLes is potentially a valuable tool to assess patient-centered abdominal wall functional improvements after VHR.

Stitch versus scar--evaluation of laparoscopic pediatric inguinal hernia repair: a pilot study in a rabbit model.

BACKGROUND The appropriate surgical management of morbidly obese patients with symptomatic hernias is not well defined. The authors evaluated the role of simultaneous panniculectomy in complex abdominal wall reconstruction. METHODS A retrospective study (2007-2010) was conducted of morbidly obese (body mass index > 40 kg/m(2)) patients undergoing open complex abdominal wall reconstruction. RESULTS Thirty patients were identified. Twenty underwent simultaneous panniculectomy. The median pannus weight was 5.2 kg. Greater all-cause postoperative complications and wound-related morbidity occurred in the panniculectomy group (P < .05). Performing a panniculectomy increased the risk for a wound complication by 5-fold (P = .04). Following 7-month to 9-month follow-up, both groups had a recurrence rate of 10%. CONCLUSION Simultaneous panniculectomy in the setting of complex abdominal wall reconstruction is feasible but associated with significant postoperative morbidity. Its potential for benefit in reducing long-term hernia recurrence remains unclear.

Predicting severe postoperative respiratory complications following abdominal wall reconstruction.

BACKGROUND Despite relatively sparse data regarding their outcomes in the setting of infection, biologic grafts have gained rapid acceptance by the surgical community for complex hernia repair. These materials are heterogeneous in their procurement and processing techniques, which may ultimately have an impact in their ability to withstand infection. The objective of this study is to evaluate the impact of varying levels of contamination on biologic graft performance in a chronic ventral hernia animal model. METHODS Four commonly applied biologic grafts were used in the repair of a chronic ventral hernia rat model (n = 218). Each material was repaired in the setting of 1 of 4 surgical wound classifications (clean, clean contaminated, contaminated, dirty infected) with Staphylococcus aureus as our inoculum agent. After a 30-day survival, repairs underwent quantitative cultures, histological, and biomechanical testing. RESULTS Marked differences were observed in biologic graft bacterial burden, biomechanical and histological responses at 30 days. Persistent bacterial burden varied among the biologic grafts and increased with increasing wound contamination (P < .05). Delays in wound healing were observed in the contaminated and dirty infected setting (P < .05). Increasing infection weakened the biomechanical strength of repairs (P < .05). CONCLUSION The degree of bacterial contamination at the time of repair affected the rates of bacterial clearance, wound-healing ability, and subsequent repair strength. Material source and processing techniques might alter graft durability, biocompatibility, and ability to clear bacteria in a contaminated field. Clinical trials are warranted in contaminated settings.

Methodology of fibroblast and mesenchymal stem cell coating of surgical meshes: A pilot analysis

BACKGROUND Stratification of risks of postoperative wound/mesh infection after hernia repair remains a challenge. We aimed to determine the role of a previous wound infection on surgical site infection in patients undergoing open ventral hernia repair. METHODS All patients undergoing open ventral hernia repair in a clean setting were evaluated from a prospectively maintained database. The primary end point was the development of a postoperative surgical site infection. RESULTS A total of 146 patients were included in the analysis, and 22 patients had a history of previous wound infection. The rate of surgical site infection did not differ between those with or without a history of wound infection (14% vs 9%; P = .444). Patients with a history of chronic obstructive pulmonary disease or smoking were at an increased risk of developing a surgical site infection. CONCLUSIONS For patients undergoing open ventral hernia repair, a history of previous wound infection is not predictive of postoperative surgical site infection.