Parag Bhanot

Does mesh location matter in abdominal wall reconstruction? A systematic review of the literature and a summary of recommendations.

Background: Mesh implantation during abdominal wall reconstruction decreases rates of ventral hernia recurrence and has become the dominant method of repair. The authors provide a comprehensive comparison of surgical outcomes and complications by location of mesh placement following ventral hernia repair with onlay, interposition, retrorectus, or underlay mesh. Methods: A systematic search of the English literature published from 1996 to 2012 in the PubMed, MEDLINE, and Cochrane library databases was conducted to identify patients who underwent abdominal wall reconstruction using either prosthetic or biological mesh for ventral hernia repair. Demographic information was obtained from each study. Results: Sixty-two relevant articles were included with 5824 patients treated with mesh repair of a ventral hernia between 1996 and 2012. Mesh position included onlay (19.6 percent), underlay (60.7 percent), interposition (6.4 percent), and retrorectus (12.4 percent). Prosthetic mesh was used in 80 percent of repairs and biological mesh in 20 percent. The weighted mean incidences of early events were as follows: wound complications, 19 percent; wound infections, 8 percent; seroma or hematoma formation, 11 percent; and reoperation, 10 percent. The weighted mean incidences of late complications included 8 percent for hernia recurrence and 2 percent for mesh explantation. Recurrence rates were highest for onlay (17 percent) or interposition (17 percent) reinforcement. The infection rate was also highest in the interposition cohort (25 percent). Seroma rates were lowest following a retrorectus repair (4 percent). Conclusions: Mesh reinforcement of a ventral hernia repair is safe and efficacious, but the location of the reinforcement appears to influence outcomes. Underlay or retrorectus mesh placement is associated with lower recurrence rates.

Indications and outcomes following complex abdominal reconstruction with component separation combined with porcine acellular dermal matrix reinforcement.

PurposeComponent separation (CS) is an effective technique for complex abdominal wall reconstruction (AWR). Reinforcement of the repair with mesh can add durability. The purpose of this study was to evaluate the indications and outcomes following CS combined with a porcine acellular dermal matrix (PADM) for reinforcement. MethodsA retrospective review of all patients who underwent complex AWR at the authors’ institution was completed between 2007 and 2010. Patients with complex hernias who underwent CS in conjunction with PADM as an underlay were included. The PADM used in this cohort was Strattice (LifeCell Corporation, Branchburg, NJ). Patient demographics, indications, perioperative details, postoperative care, and long-term outcomes were reviewed. ResultsA total of 78 patients were identified as having PADM implanted for AWR. Of this cohort, 41 patients met the criteria as having a CS to achieve midline closure, with the PADM placed as reinforcement in an underlay manner. These patients were classified as grade II (33; 80.5%), grade III (4; 9.8%), and grade IV (4; 9.8%). Average patient age was 57.6 years (range, 33–80), and average body mass index (BMI) was 35.8 kg/m2 (range, 21.6–52.1). Patient comorbidities included coronary artery disease (19; 46.3%), diabetes mellitus (14; 34.2%), chronic obstructive pulmonary disease (COPD) (6; 14.6%), and chronic steroid use (2; 4.9%). Previous mesh infection occurred in 9 (28.1%). The mean defect diameter was found to be 14.3 cm. Perforator preservation of the subcutaneous flaps was performed in 34 (82.9%) patients. A concomitant panniculectomy was performed in 9 (22%) patients. A staged approach was used in 3 (7.3%) patients. The overall complication rate was 24.4%. Strattice exposure occurred in 5 (12.2%) patients. All patients went on to heal wounds without explantation.No hernia recurrences or symptomatic bulges were observed in the follow-up period of 474 days (range, 194–1017 days). No significant predictors of complications were identified. ConclusionsStrattice is an effective adjunct to AWR when used as reinforcement during CS for a wide variety of indications. Complication rates remain low in complex patients. In addition, Strattice appears to add durability to midline reconstructions with no recurrences during the follow-up period.

Complications of acellular dermal matrices in abdominal wall reconstruction.

Background: Acellular dermal matrices have been increasingly used in abdominal wall reconstruction. Unique characteristics of these grafts have allowed surgeons to reconstruct increasingly complex abdominal wall defects. This has resulted in a myriad of complications related to the acellular dermal matrix with unique management strategies as compared with synthetic mesh. Methods: A review of the literature was performed to identify studies evaluating the use and efficacy of acellular dermal matrices in abdominal wall reconstruction. Complication profiles were identified and are compared. Differences between porcine and human derivatives were identified. Results: Hernia recurrence, infection, skin necrosis, and fluid collections were among the most common complications following abdominal wall reconstruction identified in the literature. Differences among various acellular dermal matrix products make certain types more suitable for abdominal wall reconstruction. Conclusions: Complications are frequent in abdominal wall reconstruction. Many acellular dermal matrices have properties that allow for conservative management and maintenance of reconstruction when complications occur. With traditional synthetic mesh reconstruction, complications likely result in mesh explantation and prolonged morbidity. With acellular dermal matrix reconstruction, however, more conservative treatment strategies will allow for mesh salvage.

A Patient-centered Appraisal of Outcomes following Abdominal Wall Reconstruction: A Systematic Review of the Current Literature

Background: Published assessment tools have attempted to investigate patient-centered outcomes after abdominal wall defect repairs, including quality-of-life measures, functional outcomes, pain assessment, and overall satisfaction scores; however, health-related quality of life following hernia repair remains unclear. Methods: The MEDLINE, PubMed, and Cochrane databases were queried and 880 articles were identified. Of these, 22 met inclusion/exclusion criteria. Analysis included health-related quality-of-life metrics focusing on quality of life, pain, physical function, overall satisfaction with surgery, impact of component separation, use of synthetic or biologic mesh, and emotional sequelae of an abdominal wall defect and repair. Results: Twenty-two studies were reviewed; the mean study size was 117.7 patients (range, 14 to 402 patients). Mean and median ventral hernia defect sizes were 104.5 cm2 and 71.5 cm2, respectively. All studies reported open repairs using synthetic mesh. The Short Form-36 was used most often (11 of 22) in comparison to other assessment methods. Patients had global improvement in quality of life, functionality, impact on social function, and patient satisfaction. Hernia recurrence was found to have a major negative impact on quality of life. Midline repair improved overall pain and abdominal wall functionality in both presurgical patients and those with hernia recurrence. Component separation techniques appear to have a positive impact on global health-related quality of life. Conclusions: Adopting an abdominal wall procedure–specific quality-of-life assessment tool as the standard is strongly recommended to gain a comprehensive understanding of abdominal wall defects and repairs. The available literature in open abdominal wall repair suggests an improved quality of life. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Use of intraoperative indocyanin-green angiography to minimize wound healing complications in abdominal wall reconstruction

Abstract Complication rates following abdominal wall reconstruction (AWR) remain high. Early complications are related to skin necrosis and delayed healing, whereas late complications are related to recurrence. When concomitant body contouring procedures are performed, complication rates can be further increased. It is hypothesised that fluorescent angiography using indocyanin green (ICG) can identify poorly perfused tissues and thus reduce the incidence of delayed healing. A retrospective review was conducted of all patients who underwent AWR with concomitant panniculectomy from 2007–2012. Intraoperative ICG angiography with the SPY system (LifeCell Corp.) was used to determine the amount of resection for body contouring in patients who underwent reconstruction in a cohort of patients. SPY-Q was used to assess relative perfusion of analysed areas. Preoperative, postoperative, and operative details were analyzed. Seventeen patients met inclusion criteria, 12 patients were included in the non-ICG cohort, while five patients were included in the ICG cohorts. Wound-healing complications occurred in 5/12 (42%) patients in the non-ICG cohort vs 1/5 (20%) of the ICG cohorts. A description of the sole patient with complications in the ICG cohort is illustrated. Operative debridement and wound infection development occurred more frequently in the non-ICG cohort compared with the ICG cohort (17%, 17% vs 0%, 0%, respectively). Average time to wound healing was 41.1 days. Intraoperative ICG angiography can accurately detect perfusion abnormalities and can decrease wound healing related complications in complex hernia repair with concomitant panniculectomy. Assessing and ensuring skin viability can decrease the need for operative debridement.

The use of porcine acellular dermal matrix in a bridge technique for complex abdominal wall reconstruction: an outcome analysis

BACKGROUND Outcomes using the porcine acellular dermal matrix (PADM) in abdominal wall reconstruction (AWR) have been reported when used for midline reinforcement; however, there have been no reports focused on outcomes when used as a bridging mesh. METHODS A retrospective review was conducted of all patients who underwent AWR with a non-cross-linked PADM as a bridged repair without midline fascial approximation. RESULTS Nine patients were identified with an average follow-up of 546 days. The average preoperative hernia defect diameter was 22.4 cm. After PADM placement, the average defect diameter was 9.8 cm. Complications occurred in 55.6% of patients, with PADM exposure occurring in all of these patients. No PADM was explanted, and all patients eventually healed. Abdominal wall eventration and/or recurrence occurred in 8 of 9 (88.9%) patients. CONCLUSIONS When fascial approximation cannot be achieved, PADM bridging may be the best option to avoid complications associated with synthetic mesh. However, there is a high potential for abdominal wall eventration and/or recurrence.

Immediate, multistaged approach to infected synthetic mesh outcomes after abdominal wall reconstruction with porcine acellular dermal matrix

BackgroundInfection of synthetic mesh after abdominal wall hernia repair is a complex problem. The purpose of this study was to determine whether a staged approach to abdominal wall reconstruction (AWR) using a porcine acellular dermal matrix (PADM) is beneficial in the setting of infected synthetic mesh. MethodsThe authors performed a retrospective review of 27 patients who underwent immediate, staged complex AWR using PADM from 2007 to 2012. ResultsAfter a component separation, primary fascial closure was achieved in 21/27 (78%) patients, whereas 6/22 (22%) received a bridged hernia repair with PADM. Wound-related complications developed in 7/27 (26%) patients including wound dehiscence 6/27 (22%), surgical site infection 5/27 (19%), and hematoma 1/27 (4%). The hernia recurrence rate observed by 32 months was 19%. A bridged hernia repair and the development of a postoperative infection were associated with hernia recurrence, P < 0.05. ConclusionsA 2-stage approach to AWR with PADM can provide a safe and effective solution for patients with infected synthetic mesh.

Predicting Abdominal Closure After Component Separation for Complex Ventral Hernias Maximizing the Use of Preoperative Computed Tomography

BackgroundComponent separation techniques (CSTs) have allowed for midline fascial reapproximation in large midline ventral hernias. In certain cases, however, fascial apposition is not feasible, resulting in a bridged repair that is suboptimal. Previous estimates on myofascial advancement are based on hernia location and do not take into account variability between patients. Examination of preoperative computed tomography (CT) may provide insight into these variabilities and may allow for prediction of abdominal closure with CST. Study DesignA retrospective review was conducted of patients who underwent abdominal wall reconstruction from 2007 to 2012 with CST. Preoperative CT was obtained, and specific parameters were analyzed using image analysis software. Logistic regression was used to predict ideal operative closure. Multivariate analyses were adjusted for age and sex. An a priori value was set at P < 0.05. ResultsFifty-four patients met the criteria and had preoperative CT available for analysis. Forty-eight patients had fascial reapproximation achieved, whereas 6 patients had a bridged repair. Age, sex, weight, and body mass index were similar between groups (P > 0.05). Significant differences were seen between groups in 3 variables: transverse defect size (19.8 vs 10 cm, P < 0.05), defect area (420 vs 184.2 cm2, P < 0.05), and percent abdominal wall defect (18.9% vs 10.6%, P < 0.05). ConclusionsPreoperative determination of abdominal wall defect ratios and hernia defect areas may represent a more accurate method to predict abdominal wall closure after CST. Predicting midline approximation after CST is critical because outcomes after bridged repair can result in higher recurrence rates.

Proceed™ Mesh for Laparoscopic Ventral Hernia Repair

A laparoscopic approach to ventral hernia repair using Proceed mesh was associated with low conversion rate and no major complications in this study of single surgeons experience.

Critical Analysis of Strattice Performance in Complex Abdominal Wall Reconstruction: Intermediate-Risk Patients and Early Complications

The purpose of this study was to analyze the performance of a porcine-derived acellular dermal matrix (Strattice Reconstructive Tissue Matrix) in patients at increased risk for perioperative complications. We reviewed medical records for patients with complex abdominal wall reconstruction (AWR) and Strattice underlay from 2007 to 2010. Intermediate-risk patients were defined as having multiple comorbidities without abdominal infection. Forty-one patients met the inclusion criteria (mean age, 60 years; mean body mass index, 35.5 kg/m(2)). Comorbidities included coronary artery disease (63.4%), diabetes mellitus (36.6%), and chronic obstructive pulmonary disease (17.1%). Fascial closure was achieved in 40 patients (97.6%). Average hospitalization was 6.4 days (range, 1-24 days). Complications included seroma (7.3%), wound dehiscence with Strattice exposure (4.9%), cellulitis (2.4%), and hematoma (2.4%). All patients achieved abdominal wall closure with no recurrent hernias or need for Strattice removal. Patients with multiple comorbidities at intermediate risk of postoperative complications can achieve successful, safe AWR with Strattice.