Ventral herniorrhaphy: experience with two different biosynthetic mesh materials, Surgisis and Alloderm

Abdominal wall defect repair with biological prosthesis in transplanted patients: single center retrospective analysis and review of the literature

The risk of fascial dehiscence, wound infection and incisional hernias in organ recipients is higher. Retrospective analysis of our departments database, checking the last 12 years (2000-2012), and of the literature (1966-2012) were conducted. In our database we found seven patients: five liver (71.4 %), one kidney (14.3 %), one multivisceral (14.3 %); five males (71.4 %), two females (28.6 %). Five (71.4 %) were operated in urgency setting and two in ordinary setting (28.6 %). The mean/median number of laparotomies before the incisional hernia is of 2.1/1 (range 1-5). In five patients swine intestinal submucosa (71.4 %) have been used and in two porcine dermal collagen (28.6 %). The mean/median age was 48.3/52 years (range 18-61). The mean/median body mass index was 26.7/27 (range 19-34). The mean/median for follow-up after intervention was 40.1/33 months (range 50-21). Recurrence rate was 14.3 %. Complication rate was 28.6 %. Adding the present report, the literature reports 70 cases. 20 % of prosthesis have been implanted inlay, 25.7 % underlay, in 5.7 % intraperitoneal and in 48.6 % were not specified. The mean age ranges from 0.7 to 48.3 years. Kidney, liver, pancreas, bowel and multivisceral transplant are reported. Porcine dermal collagen has been implanted in 24.3 %, human dermal collagen in 51.4 % and swine intestinal submucosa in 24.3 %. The immunosuppression regimens comprehend variable associations of tacrolimus, steroids, mycophenolate mofetil, sirolimus, thymoglobulin, azathioprine/basiliximab and daclizumab. The mean follow-up is 16.2 months. The mean complication rate is 9.4 %. Biological prosthesis seems to be useful and safe in abdominal wall repair surgery in transplanted patients.

Management of the perineal wound after abdominoperineal resection

Although many options are available for the management of perineal wounds after abdominoperineal resection, ranging from direct closure to flap reconstruction, treatment remains challenging. A better understanding of the aims, drawbacks and progress in perineal wound management after abdominoperineal rectal resection can help the surgeon make better choices for each patient, but it is very difficult to propose a single, optimal, evidence-based procedure for the management of pelvic exenteration. Recent progress provided by the extralevator abdominoperineal resection technique and perforator flap concepts have changed our conception of reconstruction leading to the different technical options highlighted in this review.

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.

Acellular dermal matrices in abdominal wall reconstruction: a systematic review of the current evidence

BACKGROUND

Reconstruction of the anterior abdominal wall is a complex procedure that can be complicated by contamination, loss of domain, previous scarring or radiotherapy, and reduced availability of local tissues. With the introduction of acellular dermal matrices to clinical use, it was hoped that many of the problems associated with previous synthetic materials could be overcome. With their enhanced biocompatibility, acellular dermal matrices are believed to integrate with surrounding tissues while demonstrating resistance to infection, extrusion, erosion, and adhesion formation.

METHODS

The MEDLINE database was reviewed, including all publications as of December 31, 2011, using the search terms "dermal matrix" or "human dermis" or "porcine dermis" or "bovine dermis," applying the limits "human" and "English language." Prospective and retrospective clinical articles were identified.

RESULTS

A total of 40 eligible articles were identified and included in this review. Thirty-five of the studies were level IV; the remaining studies were level III. Acellular dermal matrix was used to reconstruct the abdominal wall in a wide range of clinical settings, including trauma, tumor resection, sepsis, and hernia repairs. The operative methods varied widely among clinical studies. While the heterogeneity of the patient populations and techniques limited interpretation of the data, concerns were identified regarding high rates of hernia recurrence with acellular dermal matrix use.

CONCLUSION

High-quality data derived from level I, II, and III studies are necessary to determine the indications for acellular dermal matrix use and the optimal surgical techniques to maximize outcomes in abdominal wall reconstruction.

A decade of ventral incisional hernia repairs with biologic acellular dermal matrix: what have we learned?

BACKGROUND

Innovative types of biologic mesh have provided new alternatives to ventral incisional hernia repair, especially in the face of contamination. The authors studied the experience and outcomes of patients who underwent repair of a ventral incisional hernia with biologic mesh.

METHODS

Online database and detailed reference searches were conducted. Studies chosen for review had a sample size of at least 40 patients, level IV evidence at most, and a Methodological Index for Nonrandomized Studies index of at least 10. Indications for use of biologic mesh, type of mesh, patient comorbidities, and surgical techniques were also noted.

RESULTS

Eight studies fulfilled the search criteria and included 635 patients using AlloDerm, Surgisis, and Strattice biologic tissue matrices. In one study, indications and surgical techniques were standardized, and follow-up was prospective. In the other seven studies, indications, surgical techniques, and follow-up were assessed retrospectively. The mean patient age, when reported, was 55.7 years. Body mass index ranged from 30 to 35 kg/m2 in 44 percent of the reported patients. In seven of the eight studies [565 patients (89 percent)], the mean follow-up was 25.8 months and the mean hernia recurrence rate was 21 percent. Complication rate exceeded 20 percent in most studies.

CONCLUSIONS

Biologic tissue matrices are mostly used in contaminated fields, which has allowed for a one-stage repair with no or little subsequent mesh removal. Ventral incisional hernia repair with these matrices continues to be plagued by a high recurrence rate and complications. Prospective randomized trials are needed to properly direct practice in the use of these meshes and evaluate their ultimate value.

A critical review of biologic mesh use in ventral hernia repairs under contaminated conditions

PURPOSE

We used an evidence-based approach to determine whether the promotions and claims of superiority of biologic mesh over synthetic mesh use in ventral hernia repairs (VHRs) under contaminated conditions were sound and valid.

METHODS

We searched the Medline database to specifically identify review articles relating to biologic mesh and VHR and critically reviewed these studies using an evidence-based approach.

RESULTS

For the past 45 years, four clinical reviews and one systematic review have included biologic meshes as part of a larger discussion on available prosthetics for VHR. All reviews supported biologic mesh use, especially in the setting of contaminated fields. Yet, the primary literature included in these reviews and served as the basis for these conclusions consisted entirely of case series and case reports, which have the lowest level of evidence in determining scientific validity. Furthermore, the FDA has neither cleared nor approved this particular use.

CONCLUSIONS

The cumulative data regarding biologic mesh use in VHRs under contaminated conditions does not support the claim that it is better than synthetic mesh used under the same conditions. The highly promoted and at least moderately utilized practice of placing biologic mesh in contamination is being done outside of the original intended use, and a re-evaluation of or possible moratorium on biologic mesh use in hernia surgery is seriously warranted. Alternatively, an industry-sponsored national registry of patients in whom ventral hernia repairs involved biologic mesh would substantively add to our understanding regarding how these intriguing biomaterials are being used and their overall clinical efficacy.

Repair of abdominal wall defects with biodegradable laminar prostheses: polymeric or biological?

Introduction

Biological and synthetic laminar absorbable prostheses are available for the repair of hernia defects in the abdominal wall. They share the important feature of being gradually degraded in the host, resulting in place the formation of a neotissue. This study was designed to assess the host tissue’s incorporation of collagen bioprostheses and a synthetic absorbable prosthesis.

Methods

Partial defects were created in the abdominal walls of 72 New Zealand rabbits and repaired using collagen bioprostheses Tutomesh® and Strattice® or a synthetic prosthesis Bio-A®. Specimens were collected for light microscopy, collagens gene and protein expression, macrophage response and biomechanical resistance at 14, 30, 90 and 180 days post-implantation.

Results

Tutomesh® and Bio-A® were gradually infiltrated by the host tissue and almost completely degraded by 180 days post-implantation. In contrast, Strattice® exhibited material encapsulation, no prosthetic degradation and low cell infiltration at earlier timepoints, whereas at later study time, collagen deposition could be observed within the mesh. In the short term, Bio-A® exhibited higher level of collagen 1 and 3 mRNA expression compared with the two other biological prostheses, which exhibited two peaks of higher expression at 14 and 90 days. The expression of collagen III was homogeneous throughout the study and collagen I deposition was more evident in Strattice®. Macrophage response decreased over time in biomeshes. However, in the synthetic mesh remained high and homogeneous until 90 days. The biomechanical analysis demonstrated the progressively increasing tensile strength of all biomaterials.

Conclusions

The tissue infiltration of laminar absorbable prostheses is affected by the structure and composition of the mesh. The synthetic prosthesis exhibited a distinct pattern of tissue incorporation and a greater macrophage response than did the biological prostheses. Of all of the laminar, absorbable biomaterials that were tested in this study, Strattice® demonstrated the optimal levels of integration and degradation.

The role of biologic mesh in abdominal wall reconstruction: a systematic review of the current literature

BACKGROUND

Biologic mesh in the form of allograft or xenograft products have been used in complicated abdominal hernia repair, but few comparative studies exist.

METHODS

A systematic review of original incisional hernia studies was conducted to include 2 primary end points: hernia recurrence and surgical site occurrence. Analysis of variance and a Satterthwaite t test compared the devices.

RESULTS

Twenty-nine studies were included in this analysis, which included 1,257 patients. The total number of studies and the total subjects for each device include the following: Permacol (Tissue Science Laboratories, Hampshire, UK) (4/64), Surgisis (Cook Medical, Bloomington, IN) (3/87), and Alloderm (LifeCell, Corp, Branchburg, NJ) (23/1,106). Device-specific recurrence rates and surgical site occurrence rates, respectively, were as follows: Alloderm (20.8%, 31.4%), Permacol (10.9%, 25%), and Surgisis (8.0%, 40.2%). A Satterthwaite t test comparison revealed significantly higher numbers of hernia recurrence (P = .006) and surgical site occurrence (P = .04) when comparing Alloderm with Permacol.

CONCLUSIONS

Biologic mesh does play a beneficial role in abdominal wall reconstruction although allograft acellular dermal matrix does have a higher recurrence rate as compared with xenograft products, which limits its current role in hernia repair.

Biologic grafts for ventral hernia repair: a systematic review

BACKGROUND

Biologic grafts hold promise of a durable repair for ventral hernias with the potential for fewer complications than synthetic mesh. This systematic review was performed to evaluate the effectiveness and safety of biologic grafts for ventral hernia repair.

METHODS

MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched for studies on biologic grafts for the repair of ventral hernias. Outcomes are presented as weighted pooled proportions.

RESULTS

Twenty-five retrospective studies were included. Recurrence depended on wound class, with an overall rate of 13.8% (95% confidence interval [CI], 7.6-21.3). The recurrence rate in contaminated/dirty repairs was 23.1% (95% CI, 11.3-37.6). Abdominal wall laxity occurred in 10.5% (95% CI, 3.7-20.3) of patients. The surgical morbidity rate was 46.3% (95% CI, 33.3-59.6). Infection occurred in 15.9% (95% CI, 9.8-23.2) of patients but only led to graft removal in 4.9% of cases.

CONCLUSIONS

No randomized trials are available to properly evaluate biologic grafts for ventral hernia repair. The current evidence suggests that biologic grafts perform similarly to other surgical options. Biologic grafts are associated with a high salvage rate when faced with infection.

Repair of incisional hernias with biological prosthesis: a systematic review of current evidence

BACKGROUND

No consensus has been reached on the use of bioprosthetics to repair abdominal wall defects. The purpose of this systematic review was to summarize the outcomes from studies describing this use of various bioprosthetics for incisional hernia repair.

METHODS

Studies published by October 2011 were identified through literature searches using EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials.

RESULTS

A total of 491 articles were scanned, 60 met eligibility criteria. Most studies were retrospective case studies. The studies ranged considerably in methodologic quality, with a modified Methodological Index of Nonrandomized Studies score from 5 to 12. Many repairs were performed in contaminated surgical sites (47.9%). At least one complication was seen in 87% of repairs. Major complications noted were wound infections (16.9%) and seroma (12.0%). With a mean follow-up period of 13.6 months the hernia recurrence rate was 15.2%.

CONCLUSIONS

There is an insufficient level of high-quality evidence in the literature on the value of bioprosthetics for incisional hernia repair. Randomized controlled trials that use standardized reporting comparing bioprosthetics with synthetic mesh for incisional hernia repair are needed.

Use of bovine pericardium graft for abdominal wall reconstruction in contaminated fields

AIM: To employ, in such conditions, a biological graft such as bovine pericardium that offers resistance to infection.

METHODS: In our surgical department, from January 2006 to June 2010, 48 patients underwent abdominal wall reconstruction using acellular bovine pericardium; of these 34 patients had a contaminated wound due to diffuse peritonitis (complicated diverticulitis, bowel perforation, intestinal infarction, strangled hernia, etc.) and 14 patients had hernia relapse on infected synthetic mesh.

RESULTS: In our series, one patient died of multi-organ failure 3 d after surgery. After placement of the pericardium mesh four cases of hernia relapse occurred.

CONCLUSION: Recurrence rate is similar to that of prosthetic mesh repair and the application of acellular bovine pericardium (Tutomesh^®, Tutogen Medical Gmbh Germany) is moreover a safe and feasible option that can be employed to manage complicated abdominal wall defects where prosthetic mesh is unsuitable.

Concomitant laparoscopic ventral hernia mesh repair and bariatric surgery: a retrospective study from a tertiary care center

OBJECTIVE

To analyze the safety in combing laparoscopic ventral hernia repair with a mesh and bariatric surgery.

BACKGROUND

Obesity is one of the important precipitating factors for primary and recurrent ventral hernias (incisional and umbilical) and it is not uncommon to find these hernias in patients opting for obesity surgery. But, with no consensus or recommendation and concern of mesh infection, surgeons fear in combining these procedures, especially Roux en Y gastric bypass and sleeve gastrectomy.

METHODS

In this study, we have retrospectively analyzed all patients who underwent concomitant bariatric procedure and mesh repair for ventral hernia at our institute.

RESULTS

A total of 36 out of 765 patients operated at our institute between 2003 and 2011 had concomitant procedures. Eleven patients had Roux en Y gastric bypass (group I) and remaining 25 had sleeve gastrectomy (group II) performed on them. The operating times were 149 min(120-210 min) in group I and 122 min (90-220min) in group II. No immediate complications or any incidence of mesh infection or recurrence in either of the groups.

CONCLUSION

Concomitant mesh repair for ventral hernias can be safely combined with bariatric procedures like Roux en Y gastric bypass and sleeve gastrectomy. But, for beginners, these should be done only in selected cases after fully informed consent from the patients.

Radical tumor excision and immediate abdominal wall reconstruction in patients with aggressive neoplasm compromised full-thickness lower abdominal wall

BACKGROUND

Radical tumor resection and immediate lower abdominal wall reconstruction in patients with aggressive neoplasm invading full-thickness abdominal wall are challenging because of their close proximity and possible invasion to bone and great vessels, as well as consequent giant defect.

METHODS

Data on 16 patients were reviewed retrospectively. Radical neoplasm resection and immediate abdominal wall reconstruction using the combined technique of intraperitoneal mesh placement, sublay technique, pedicled great omentum flap, and rotation skin graft were performed.

RESULTS

Sixteen patients underwent radical abdominal wall neoplasm resection, achieving clear margin of >3 cm. The mean size of consequent giant defect was 226.5 ± 65.5 cm(2), with a mean polypropylene mesh size of 160.7 ± 40.5 cm(2) and a mean compound mesh size of 330.8 ± 100.2 cm(2). Sixteen patients had a mean follow-up duration of 32.5 ± 12.5 months. Four patients developed incisional infections, and 1 patient died of several metastatic lesions 24 months postoperatively. No ventral hernia and abdominal wall recurrence were observed.

CONCLUSIONS

Radical neoplasm resection and immediate abdominal wall reconstruction are appropriate for patients with aggressive neoplasm in the lower abdominal wall.

Evaluation of Surgisis for patch repair of abdominal wall defects in children

BACKGROUND

Abdominal wall defects in children are not always amenable to primary repair and may require a patch. The ideal material has yet to be established. We sought to evaluate our experience using the bioabsorbable material Surgisis (Cook Surgical, Bloomington, IN) for abdominal closure.

METHODS

A retrospective chart review of abdominal wall defects repaired with Surgisis in our institution from 2000 to 2010 was performed. Data extracted included cause of defect, age at operation, possibility of skin coverage, recurrence, length of follow-up, and rate of wound infection.

RESULTS

Thirteen patients were identified. Cause of defect was gastroschisis (n = 2), ventral hernia after diaphragmatic hernia repair (n = 2), and omphalocele (n = 9). At median follow-up of 60 months (range, 10-90), 5 (38%) of 13 patients recurred, and 1 patient recurred twice. All recurrences required subsequent patch closure. Six instances of wound infection required antibiotics. None required patch removal. There was a trend toward more frequent recurrence among infants undergoing patch repair (3/4 recurrences in this group) than neonates (1/4 recurrences) or children older than 18 months (1/5 recurrences).

CONCLUSION

Our data suggest that Surgisis is moderately successful in the repair of pediatric abdominal wall defects. We noted a trend toward a higher recurrence rate in infants. Further studies investigating timing of repair and alternative biosynthetic materials are warranted.

Biological meshes: a review of their use in abdominal wall hernia repairs

PURPOSE

Biological meshes are mostly used in infected fields within complex abdominal wall hernia repairs. There is no consensus, however, on the most appropriate material to be used in a given situation.

METHODS

A literature review of published articles reporting the utilization of biological meshes in ventral/incisional hernia repair was conducted. Data were analyzed to compare the recurrence rates obtained with biological meshes.

MAIN FINDINGS

Only a few prospective comparative studies were identified. Most publications relate to AlloDerm®, Permacol™ and Surgisis™ with data from other meshes insufficient to draw conclusions. AlloDerm has a 0-100% recurrence rate among studies. It compares poorly with Surgisis and results in an unfavorable outcome when used as a 'bridge prosthesis'. Permacol has consistent recurrence rates of 0-15%, whatever the patients' profiles or the context of infected fields, when considering the most relevant studies. The Surgisis results are more conflicting: the mesh exhibits low recurrence rates in clean fields, but in infected fields the recurrence rate is up to 39%.

CONCLUSION

Taken together, these studies suggest that the cross-linked mesh, Permacol has the lowest failure rate and the longest time to failure, particularly in contaminated or infected fields. However, this data should be confirmed by large prospective randomized studies.

Transthoracic repair of an incarcerated diaphragmatic hernia using hexamethylene diisocyanate cross-linked porcine dermal collagen (Permacol)

It is the general surgeon who commonly repairs paraesophageal hernias nowadays, and they are repaired laparoscopically, making the performance of thoracotomy relatively rare. Whether to use prosthetic materials to repair the hiatus is still under debate, as is the question of which material to use, if any. We report a case of a 38-year-old man who had a large, incarcerated paraesophageal hernia. He had a past history of extensive abdominal surgery for exomphalos, which rendered any abdominal surgical approach a high-risk procedure. We therefore decided to proceed with thoracotomy and repair of the hiatus with hexamethylene diisocyanate (HMDI) cross-linked porcine dermal collagen. He made a good recovery with no complications.

Pelvic reconstruction after abdominoperineal resection: a pilot study using an absorbable synthetic prosthesis

BACKGROUND

Abdominoperineal resection (APR) is not free of complications, in particular complications due to the occupation of the pelvis by the small bowel after surgery. A number of surgical techniques have been described to prevent the small bowel from entering and adhering to the pelvis (pelvic partition), but there is no agreement concerning their use. The aim of this study was to evaluate the feasibility, effectiveness and safety of using an absorbable synthetic prosthetic material for pelvic partitioning after APR.

METHODS

A prospective non-randomised longitudinal pilot study was carried out on a series of 10 patients who underwent APR due to lower-third rectal cancer, in order to evaluate the feasibility, safety and efficacy of pelvic partitioning with an absorbable synthetic prosthetic material.

RESULTS

In all the patients, it was possible to perform a radical resection and to install the prosthesis. After a mean follow-up of 9 months (range: 4-18 months), no abdominal or perineal complications were detected. One patient (10%) suffered chronic pelvic pain.

CONCLUSIONS

Pelvic partition after APR of the rectum with an absorbable synthetic prosthesis is feasible, effective and safe.

Acellular dermal matrix: general principles for the plastic surgeon

Acellular dermal matrix (ADM) is a recently-developed, biologically-derived product with many useful applications in plastic surgery, in both cosmetic and reconstructive procedures. While the use of ADM initially outpaced quality literature, within the past 10 years the literature on ADM has rapidly expanded. Some of these data show promising results in treating historically-challenging problems within our field; thus, an effort to clarify and summarize existing work with ADM is indicated. While subsequent articles in this supplement focus on specific applications, this article provides a general overview of the biology of, applications for, and existing literature on ADM.

Evaluation of crosslinked and non-crosslinked biologic prostheses for abdominal hernia repair

Introduction

Abdominal wall defects and incisional hernias represent a challenging problem. Currently, several commercially available biologic prostheses are used clinically for hernia repair. We compared the performance and efficacy of two non-crosslinked meshes in ventral hernia repair to two crosslinked prostheses in a rodent model.

Methods

Animals were divided into 12 groups (4 matrix types and 3 termination time-points per matrix). A ventral defect was carefully created and overlapped with the biologic prosthesis.

Results

Major complications were seroma induction (3 mesh types), implant extrusion (1 mesh type), severe inflammatory and immune responses (non-crosslinked mesh), fibrosis and mineralisation (3 mesh types). After inflammation resolution, 3 of the matrices tested supported hernia healing but with marked tissue and temporal differences. AlloDerm^®* and Surgisis Gold™ showed tissue reactivity with the host and a rapid rate of matrix remodelling. Bard CollaMend™^* Implant proved to be inept for hernia repair under the conditions tested. Permacol™ biological implant integration with host tissue increased over time, supporting hernia healing with strength of tissue, and appears to be a safe prosthetic material for ventral hernia repair based on the results of this rodent study.

Elastin-like protein matrix reinforced with collagen microfibers for soft tissue repair

Artificial composites designed to mimic the structure and properties of native extracellular matrix may lead to acellular materials for soft tissue repair and replacement, which display mechanical strength, stiffness, and resilience resembling native tissue. We describe the fabrication of thin lamellae consisting of continuous collagen microfiber embedded at controlled orientations and densities in a recombinant elastin-like protein polymer matrix. Multilamellar stacking affords flexible, protein-based composite sheets whose properties are dependent upon both the elastomeric matrix and collagen content and organization. Sheets are produced with properties that range over 13-fold in elongation to break (23-314%), six-fold in Young's modulus (5.3-33.1 MPa), and more than two-fold in tensile strength (1.85-4.08 MPa), exceeding that of a number of native human tissues, including urinary bladder, pulmonary artery, and aorta. A sheet approximating the mechanical response of human abdominal wall fascia is investigated as a fascial substitute for ventral hernia repair. Protein-based composite patches prevent hernia recurrence in Wistar rats over an 8-week period with new tissue formation and sustained structural integrity.

Biological mesh for abdominal wall hernia synthetic mesh multidrug-resistant Pseudomonas aeruginosa infection: report of a case

The use of biological mesh for the treatment of synthetic mesh-related infections in patients who undergo ventral hernia repair has been considered over the past few years. Removal of the infected synthetic mesh, which may be required in such cases, can result in recurring herniation. Biological implants have thus been recently used for the reconstruction of the existing defect. We herein present the case of a patient who developed multidrug-resistant Pseudomonas aeruginosa synthetic mesh infection following hernia repair, which was managed by the removal of the material and the application of a biological mesh in the contaminated area.

A review of available prosthetics for ventral hernia repair

OBJECTIVE

To review mesh products currently available for ventral hernia repair and to evaluate their efficacy in complex repair, including contaminated and reoperative fields.

BACKGROUND

Although commonly referenced, the concept of the ideal prosthetic has never been fully realized. With the development of newer prosthetics and approaches to the ventral hernia repair, many surgeons do not fully understand the properties of the available prosthetics or the circumstances that warrant the use of a specific mesh.

METHODS

A systematic review of published literature from 1951 to June of 2009 was conducted to identify articles relating to ventral hernia repairs and the use of prosthetics in herniorrhaphy.

RESULTS

Important differences exist between the synthetics, composites, and biologic prosthetics used for ventral hernia repair in terms of mechanics, cost, and the ideal situation in which each should be used.

CONCLUSIONS

The use of synthetic mesh remains an appropriate solution for most ventral hernia repairs. Laparoscopic ventral hernia repair has created a niche for both expanded polytetrafluoroethylene and composite mesh, as they are suited to intraperitoneal placement. Preliminary studies have demonstrated that the newer biologic prosthetics are reasonable options for hernia repair in contaminated fields and for large abdominal wall defects; however, more studies need to be done before advocating the use of these biologics in other settings.

Biological Mesh in Hernia Repair, Abdominal Wall Defects, and Reconstruction and Treatment of Pelvic Organ Prolapse: A Review of the Clinical Evidence

The use of biological meshes seems to be an innovation that influences all surgical fields. The existing evidence indicates that biological meshes cannot only be applied on the area of hernia repair, but also on cases of abdominal reconstruction and pelvic organ prolapse treatment, especially in the presence of contaminated or potentially contaminated surgical fields. Low risks of graft rejection, complications, and infection seem to be the main advantages of biological meshes in comparison with the synthetic nonabsorbable ones. Nevertheless, the elevated costs suggest that biological mesh implantation should be evaluated in correlation to the needs of each clinical case.

Umbilical Herniorrhaphy Reinforced with Biologic Mesh

The true recurrence rate after umbilical hernia repair in not known. After simple closure, the reported rate of recurrence in the literature is as high as 54 per cent. With synthetic mesh repair, the recurrence rates are lowered to less than 10 per cent. However, synthetic mesh is associated with complications such as enterocutaneous fistula and mesh infections. This preliminary study looks at the safety and effectiveness of biologic extracellular matrix mesh reinforcement in the repair of umbilical hernias. We retrospectively reviewed all patients who underwent repair of an umbilical hernia defect (2-3 cm) with primary approximation of the margins and reinforced using a biologic mesh placed beneath the umbilical fascia from 2007 to 2009. Demographic data were collected. Patients were followed prospectively at 2 weeks, 8 weeks, 6 months, and 1 year. Data were reviewed for postoperative complications, hernia recurrence, and patient satisfaction. During the study period, 16 patients completed the 1 year follow-up. There were 10 men and six women. Ages ranged from 28 to 75 years with a mean age of 47.6 years. The hernias were 2 to 3 cm in size. Complications were minimal. Overall patient satisfaction with the procedure was high. There were no mesh infections. During a mean follow-up of 12 months, only one patient had recurrent hernia (6%). This preliminary evaluation shows promise for an alternative treatment of umbilical hernias using biologic extracellular matrix mesh added as an underlay to reinforce a primary closure. The biologic mesh has a low incidence of infection and complications and results in high patient satisfaction. This preliminary study begs for a randomized, prospective evaluation with long-term follow-up.

Surgisis® in the management of the complex abdominal wall in trauma: a case series and review of the literature

Managing complex abdominal wall injuries acutely or at the time of reconstruction is challenging. Contaminated surgical fields, devitalized tissue, intestinal fistula and tissues under tension contribute to clinical scenarios where closure is not possible or morbidity is unacceptable. The introduction of an absorbable extracellular matrix derived from porcine small intestinal submucosa (Surgisis) adds a potentially useful tool to the surgeon's armamentarium. A retrospective case series of the initial experience in 5 patients with complex abdominal wall injury following trauma managed with Surgisis is described. A review of the literature describing the use of Surgisis in contaminated fields is also performed.

Early results on the use of biomaterials as adjuvant to abdominal wall closure following cytoreduction and hyperthermic intraperitoneal chemotherapy

Background

Hyperthermic chemotherapy applies thermal energy to both abdominal wall as well as the intra-abdominal viscera. The combination of the hyperthemia, chemotherapy and cytoreductive surgery (CRS) is associated with a defined risk of abdominal wall and intestinal morbidity reported to be as high as 15%, respectively to date, no studies have evaluated the use of biomaterial mesh as adjuvant to abdominal wall closure in this group of patients. In the present report, we hypothesized that post HIPEC closure with a biomaterial can reduce abdominal wall morbidity after CRS and hyperthermic intraperitoneal chemotherapy.

Materials and methods

All patients treated with HIPEC in a tertiary care center over 12 months (2008-2009) period were included. Eight patients received cytoreductive surgery followed by HIPEC for 90 minutes using Mitomycin C (15 mg q 45 minutes × 2). Abdominal wall closure was performed using Surgisis (Cook Biotech.) mesh in an underlay position with 3 cm fascial overlap-closure. Operative time, hospital length of stay (LOS) as well as postoperative outcome with special attention to abdominal wall and bowel morbidity were assessed.

Results

Eight patients, mean age 59.7 ys (36-80) were treated according to the above protocol. The primary pathology was appendiceal mucinous adenocarcinoma (n = 3) colorectal cancer (n = 3), and ovarian cancer (n = 2). Four patients (50%) presented initially with abdominal wall morbidity including incisional ventral hernia (n = 3) and excessive abdominal wall metastatic implants (n = 1). The mean peritoneal cancer index (PCI) was 8.75. Twenty eight CRS were performed (3.5 CRS/patient). The mean operating time was 6 hours. Seven patients had no abdominal wall or bowel morbidity, the mean LOS for these patients was 8 days. During the follow up period (mean 6.3 months), one patient required exploratory laparotomy 2 weeks after surgery and subsequently developed an incisional hernia and enterocutaneous fistula.

Conclusion

The use of biomaterial mesh in concert with HIPEC enables the repair of concomitant abdominal wall hernia and facilitates abdominal wall closure following the liberal resection of abdominal wall tumors. Biomaterial mesh prevents evisceration on repeat laparotomy and resists infection in immunocompromised patients even when associated with bowel resection.

Use of biological meshes for abdominal wall reconstruction in highly contaminated fields

Abdominal wall defects and incisional hernias represent a challenging problem. In particular, when a synthetic mesh is applied to contaminated wounds, its removal is required in 50%-90% of cases. Biosynthetic meshes are the newest tool available to surgeons and they could have a role in ventral hernia repair in a potentially contaminated field. We describe the use of a sheet of bovine pericardium graft in the reconstruction of abdominal wall defect in two patients. Bovine pericardium graft was placed in the retrorectus space and secured to the anterior abdominal wall using polypropylene sutures in a tension-free manner. We experienced no evidence of recurrence at 4 and 5 years follow-up.

Incisional ventral hernias: review of the literature and recommendations regarding the grading and technique of repair

Despite advances in surgical technique and prosthetic technologies, the risks for recurrence and infection are high following the repair of incisional ventral hernias. High-quality data suggest that all ventral hernia repairs should be reinforced with prosthetic repair materials. The current standard for reinforced hernia repair is synthetic mesh, which can reduce the risk for recurrence in many patients. However, permanent synthetic mesh can pose a serious clinical problem in the setting of infection. Assessing patients' risk for wound infection and other surgical-site occurrences, therefore, is an outstanding need. To our knowledge, there currently exists no consensus in the literature regarding the accurate assessment of risk of surgical-site occurrences in association with or the appropriate techniques for the repair of incisional ventral hernias. This article proposes a novel hernia grading system based on risk factor characteristics of the patient and the wound. Using this system, surgeons may better assess each patient's risk for surgical-site occurrences and thereby select the appropriate surgical technique, repair material, and overall clinical approach for the patient. A generalized approach and technical considerations for the repair of incisional ventral hernias are outlined, including the appropriate use of component separation and the growing role of biologic repair materials.

Short-term outcomes with the use of bioprosthetics for the management of parastomal hernias

PURPOSE

This study was undertaken to determine the safety and short-term outcomes using bioprosthetics for the management of parastomal hernias.

METHODS

A retrospective review of prospectively collected data for all of the patients who underwent repair of a parastomal hernia was conducted.

RESULTS

Between April 2004 and September 2007, 20 consecutive patients had 22 parastomal hernias repaired through a midline incision using a bioprosthetic with the stoma entering the abdomen lateral to the graft. A colostomy was present in 17 patients; an ileostomy was present in 3 patients. All of the patients had parastomal hernia-related complications. Postoperatively there were no infections of the midline wound or the prosthetic, and none of the grafts were removed. There were 4 seromas (40%) that required aspiration in the 10 procedures performed before the routine placement of a drain. No incisional hernias have developed in the midline wound. There have been 2 (9%) recurrent parastomal hernias on physical examination at a median follow-up of 18 months (range, 12-54).

CONCLUSIONS

These data suggest that bioprosthetics are safe and are effective in the short term for the repair of parastomal hernias.

Pelvic floor reconstruction using human acellular dermal matrix after cylindrical abdominoperineal resection

PURPOSE

Patients who undergo cylindrical abdominoperineal resection can have significant complications, especially those who require pelvic reconstruction using myocutaneous flaps. Reconstruction using a biomaterial may be a novel alternative. The purpose of this study is to report the initial results of pelvic reconstruction using human acellular dermal matrix after cylindrical abdominoperineal resection.

METHODS

Between January 2008 and February 2009, pelvic floor reconstruction was performed in 12 consecutive patients who underwent cylindrical abdominoperineal resection for advanced ultralow rectal cancer.

RESULTS

Two weeks after the operation, primary complete healing of the perineal wound was seen in 11 patients. At a median follow-up of 8 months, there was no perineal wound breakdown, bulge, or herniation. One patient had an asymptomatic seroma, one patient had a perineal wound infection, and 4 patients had perineal pain that resolved.

CONCLUSIONS

Human acellular dermal matrix provided a safe alternative for the reconstruction of large pelvic defect in the patients after cylindrical abdominoperineal resection.

Outcomes after the repair of rectoceles with transperineal insertion of a bioprosthetic graft

PURPOSE

This study was performed to determine the early outcomes with the use of bioprosthetic grafts for the management of rectoceles and to compare them to those achieved with transanal techniques.

METHODS

A retrospective analysis of prospectively collected data was performed for patients treated for a rectocele. Data collected included age, technique of repair, complications, and functional outcomes. Defecatory function was determined using the Birmingham Bowel and Urinary Symptoms Questionnaire, a validated instrument for the measurement of bowel symptoms. The questionnaire was administered preoperatively and at 12 weeks and 12 months postoperatively.

RESULTS

In this series, 88 women underwent a transanal repair, compared to 32 women who had their rectocele managed with a bioprosthetic graft. After 1 year of follow-up, patients whose rectocele was repaired using a bioprosthetic had significantly fewer complications with comparable functional results between the 2 techniques.

CONCLUSIONS

These data suggest that transperineal, bioprosthetic repair of rectoceles is associated with similar functional results but fewer complications when compared to transanal techniques during the early postoperative period. Randomized studies with longer-term follow-up will be required before the role of bioprosthetic repair of rectoceles can be determined.

Abdominal wall repair using human acellular dermal matrix: a follow-up study

BACKGROUND

The role of acellular dermal matrix (ADM) in abdominal wall reconstruction (AWR) is unclear. The aim of this study was to review the management, complications, and long-term outcomes of AWR using ADM in a large surgical cohort.

METHODS

Retrospective chart review of patients undergoing AWR using ADM from 2004 to 2007 was performed. Demographic data, comorbidities, complications, and long-term outcomes were collected.

RESULTS

There were 77 cases in 68 patients with mean age of 61.1 +/- 1.4 years. The most common indication was infected fascia (n = 19 [25%]). Wound closure was achieved in 75% of the cases via primary (n = 26 [45%]), secondary intention (n = 17 [29%]), or skin graft (n = 15 [26%]). Nonprimary closure was achieved in 5.7 +/- .7 months. There were 32 perioperative (39%) and 33 long-term (43%) complications. Over a mean follow-up period of 13.2 +/- 1.5 months, the hernia recurrence rate was 27% (n = 21).

CONCLUSION

Although ADM is a viable option in AWR, the high hernia recurrence rate warrants a continued search for alternative biologic materials to improve outcomes.

Management of Complex Abdominal Wall Defects Using Acellular Porcine Dermal Collagen

Multiple techniques have been used for the repair of complex abdominal wall defects after recurrent incisional hernias with varying rates of success. Primary repair has been associated with high recurrence rates, and prosthetic mesh placement is contraindicated in contaminated surgical fields. The development of biologic prostheses has changed the approach to these difficult problems. This study evaluates the management of complex abdominal wall defects using acellular porcine dermal collagen. Between August 2006 and May 2007, 18 patients underwent abdominal wall reconstruction for complex defects with acellular porcine dermal collagen (CollaMend™; Bard Inc., Warwick, RI). Patient demographics, preoperative risk factors, previous herniorrhaphy attempts, postoperative complications, recurrences, and long-term results were retrospectively reviewed. Records were reviewed at a mean follow up of 7.3 months; the recurrence rate was 44.4 per cent. A total of 38.9 per cent (seven of 18) developed a postoperative wound complications, including infection in 22.2 per cent (four of 18). All of the patients with infection required prosthesis removal as a result of encapsulation rather than incorporation of the biologic prosthesis. Acellular porcine dermal collagen has the potential for reconstruction of abdominal wall defects with postoperative wound occurrences comparable with other biologic materials. Encapsulation of the material was a major problem in cases with wound infection that required graft removal rather than local wound measures. Hernia recurrence and dehiscence of the graft were problems in noncompromised surgical fields.

Long-term surgical outcomes in congenital diaphragmatic hernia: observations from a single institution

BACKGROUND/PURPOSE

Surgical complications are common in survivors of congenital diaphragmatic hernia (CDH), but little is known about long-term incidence patterns and associated predictors.

METHODS

A cohort of 99 CDH survivors was prospectively followed at a single-institution multidisciplinary clinic. Data were gathered regarding the adverse surgical outcomes of hernia recurrence, chest and spinal deformity, and operative small bowel obstruction (SBO), and then were retrospectively analyzed in relation to perinatal and perioperative markers of disease severity to determine significant predictors. Statistical methods used included univariate and multivariate regression analysis, hazard modeling, and Kaplan-Meier analysis.

RESULTS

At a median cohort age of 4.7 (range, 0.2-10.6) years, 46% of patients with patch repairs and 10% of those with primary repairs had a hernia recurrence at a median time of 0.9 (range, 0.1-7.3) years after repair. Chest deformity was detected in 47%. Small bowel obstruction and scoliosis occurred in 13%. Recurrence and chest deformity were significantly more common with patch repair, liver herniation, age at neonatal extubation greater than 16 days, oxygen requirement at discharge, and prematurity. The strongest predictor of SBO was patch repair. Multivariate analysis showed that patch repair was independently predictive of recurrence and early chest deformity (odds ratios of 5.0 and 4.8, confidence intervals of 1-24 and 1-21, P < .05). Use of an absorbable patch was associated with the highest risk of surgical complications.

CONCLUSIONS

For long-term survivors of CDH, specific perinatal and operative variables, particularly patch repair, are associated with subsequent adverse surgical outcomes.

Major Complications Associated With Xenograft Biologic Mesh Implantation in Abdominal Wall Reconstruction

Background. There is limited research for xenograft biologic mesh performance in the setting of infection despite widespread use and significant associated costs. Design. The authors retrospectively reviewed an FDA database for reported xenograft adverse events (AEs). All meshes were used in the setting of abdominal wall reconstruction from 1997 to 2008. Results. The authors identified 150 AEs. Permacol and Collamend comprised 75% (n = 112) of reported cases. Main AEs included acute mechanical failure (42%; n = 63), mesh disintegration (32%; n = 48), and poor mesh integration (13%; n = 20); 80% of cases were described as infected, and nearly 90% of AEs required reoperation. Conclusions . Major complications are reported to the FDA for xenograft biologic meshes. Cross-linked meshes had the most AE reports to the FDA. The intrinsic properties of meshes and how they relate to infection-related outcomes are poorly understood. The findings from this FDA database review point toward a need to carefully evaluate these products.

Repair of abdominal wall defects with bovine pericardium

BACKGROUND

Ventral hernia repair with prosthetic mesh has recurrence rates up to 54% and is contraindicated in the setting of infection. The aim of this study was to provide our experience with acellular bovine pericardium (Veritas collagen matrix; Synovis Life Technologies, Inc., St. Paul, MN) in complex abdominal wall reconstruction where prosthetic mesh had failed or was contraindicated. Between 2005 and 2008, a retrospective review of a single general surgeon's practice identified patients reconstructed with acellular bovine pericardium. Thirty primary or recurrent ventral hernias were treated in 26 patients. All patients presented with either contaminated wounds or failure of a prosthetic mesh material.

RESULTS

Hernia size ranged from 20 cm(2) to 600 cm(2) (mean 111 cm(2)). Seven patients had previous hernia repair with prosthetic mesh, and 16 patients had ongoing infection or gross contamination at the time of repair. The mean follow-up was 22 months. The hernia recurrence rate in our series was 19% with no fistula development.

CONCLUSIONS

Acellular bovine pericardium's high strength, minimal infection rate, and low cost allow its use in the reconstruction of complex abdominal wall defects.

Reconstruction of complex abdominal wall hernias using acellular human dermal matrix: a single institution experience

BACKGROUND

Acellular human dermal matrix (AHDM) has mechanical properties suitable for complex abdominal wall reconstructions and physiologic properties that allow more resistance to infection in contaminated fields. The purpose of this study was to determine which patient and technical factors lead to optimal surgical outcomes.

METHODS

A retrospective review was conducted of 144 abdominal wall reconstructions using AHDM over a 33-month period. Data were recorded and analyzed.

RESULTS

Fifty-three percent were women. The average age was 55 years, with an average body mass index of 35 kg/m(2). Thirty percent were smokers at the time of repair, and 24% had diabetes. Forty-three percent of the operative fields had some degree of contamination. The indication for operation in half the patients was to reconstruct a previously failed hernia repair. The recurrence rate was 27.1%. The significant factors that affected the recurrence rate were female gender (P = .02), reconstructing a failed prior repair (P = .025), and high body mass index (P = .004). An underlay mesh placement trended to a lower recurrence rate (P = .053). Average follow-up time was 23 weeks (range, 0-100 weeks).

CONCLUSIONS

Three patient factors contributed significantly to the recurrence rate in this study: gender, above-normal body mass index, and repairing a recurrent hernia. Placing the matrix as an underlay appears to decrease recurrence rates. Long-term follow-up is needed to further determine the durability of hernia repairs with AHDM. AHDM offers a viable option with acceptable morbidity in complex abdominal wall reconstructions in high-risk patient populations.

Definitive abdominal wall closure using a porcine intestinal submucosa biodegradable membrane in pediatric transplantation

Abdominal closure in children less than 10 kg following liver or kidney transplantation can be challenging. Excessive pressure attained from a tight closure can result in abdominal compartment syndrome, graft compromise and loss. Concerns over using prosthetic patches are that of infection and dehiscence. We report a series of definitive abdominal wall closure using a biodegradable membrane from porcine intestinal submucosa (Surgisis; Cook Biotech Incorporated, West Lafayette, IN, USA). A prospective collection and follow up of liver and kidney transplant patients weighing less than 10 kg who required abdominal wall augmentation with Surgisis in order to achieve satisfactory closure. There were 10 liver and two renal transplant patients. The average weight of the liver transplant patients was 6.6 kg (5.4-8.5 kg) and the renal 9.8 kg. The average area of Surgisis used was 71.2 cm(2) (25-160 cm(2)) and length of follow up was 15.3 months (1-27 months). Concomitant measures to aid abdominal closure included bilateral recipient nephrectomy for the renal patients and reduction by 33% of the lateral segmental grafts in two liver transplant patients. Delayed closure occurred in all patients except one and the average days to closure from the first surgery was 3.75 days (0-6 days). Following liver transplantation one patient died from multiple organ failure at one month secondary to hemophagocytosis from underlying combined immune deficiency syndrome and one patient with hepatic artery thrombosis was salvaged at re-exploration. There were two wound complications, one patient developed two small sinuses and some skin dehiscence which healed over four months and the second developed a skin sinus following trans-patch liver biopsy which healed in three wk. Both had positive microbial cultures but neither necessitated removal of the graft. There were no incisional hernias. Surgisis is a safe method for facilitating abdominal closure in pediatric transplant patients. It appears to have long-term durability with no incisional hernias on short- and medium-term follow up, and is fairly resistant to infection.