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Shih PK. Difficult abdominal wall closure: component separation versus partition technique. Hernia 2014; 19:301-5. [PMID: 24664165 DOI: 10.1007/s10029-014-1238-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Accepted: 03/10/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Partition technique and component separation techniques are natural methods of fascia-fascia closure. We present our experiences and research the differences between the two techniques. METHODS From January 2006 to August 2013, 41 patients with complex abdominal wall defects reconstructed with partition (N = 18) or component separation technique (N = 23) alone were enrolled into this study. The related data including gender, age, size of defect, operation time, hospital stay, duration of follow-up, comorbidities, body mass index (BMI) and complications were collected. Nonparametric Mann-Whitney test was used to evaluate the differences between the two groups in continuous data; Chi-square test was used to assess the categorical data. RESULTS The mean defect size of patients with partition technique (N = 18) was 12.55 cm (range 8.2-18.9 cm) with 148.63 min for average operation time, 8.66 days for hospital stay, and 28.8 months for mean follow-up. There were nine cases with postoperative complications (three cases with skin and soft tissue necrosis; two cases with fascia dehiscence; and three cases with wound infection). One case with fascia dehiscence suffered from pneumonia simultaneously. Four cases received secondary operation (fascia repair and split-thickness skin graft), and the other four cases healed spontaneously with mild wound debridement. The mean defect size of the patients with component separation (N = 23) technique was 9.45 cm (range 5.7-12.6 cm) with 143.27 min for average operation time, 7.43 days for hospital stay, and 34.33 months for mean follow-up. One case with skin and soft tissue necrosis underwent reconstruction with split-thickness skin graft and debridement. Two cases with wound infection healed spontaneously with mild wound debridement. There were no significant differences in gender, age, operation time, hospital stay, duration of follow-up, comorbidities, BMI and long-term postoperative complications between the two groups, except for size of defect and short-term postoperative complications. CONCLUSIONS The partition technique could close larger abdominal fascia defects than component separation technique, but simultaneously run the higher opportunities for short-term postoperative complications.
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Affiliation(s)
- P-K Shih
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, No. 2 Yuh-Der Road, Taichung, 404, Taiwan,
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102
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Complex ventral hernia repair using components separation with or without synthetic mesh: a cost-utility analysis. Plast Reconstr Surg 2014; 133:137-146. [PMID: 24374673 DOI: 10.1097/01.prs.0000436835.96194.79] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Components separation provides a useful option among closure choices for complex ventral hernia repairs. The use of synthetic mesh in addition to performing a components separation is controversial. The authors' goal was to perform the first cost-utility analysis on the use of synthetic mesh in addition to performing components separation when performing a complex ventral hernia repair in a noncontaminated field. METHODS A comprehensive literature review was conducted to identify published complication and recurrence rates for ventral hernia repairs (Ventral Hernia Workgroup I and II) requiring components separation with or without synthetic mesh. The probabilities of the most common complications were combined with Medicare Current Procedural Terminology reimbursement codes, Diagnosis-Related Group reimbursement codes, and expert utility estimates to fit into a decision model to evaluate the cost-effectiveness of components separation with and without synthetic mesh in reconstructing ventral hernias. RESULTS At average retail costs, the decision model revealed a cost increase of $541.69 and a 0.0357 increase in quality-adjusted life-years when using synthetic mesh, yielding a cost-effective incremental cost-utility ratio of $15,173.39 per quality-adjusted life-year. Univariate sensitivity analysis revealed that synthetic mesh is cost-effective when it costs less than $2049.97. CONCLUSIONS The addition of synthetic mesh when performing components separation in repairing complex ventral hernias is cost-effective when using average retail prices. Physicians and hospitals should use synthetic mesh in patients with noncontaminated wounds.
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Abstract
Hernia emergencies are commonly encountered by the acute care surgeon. Although the location and contents may vary, the basic principles are constant: address the life-threatening problem first, then perform the safest and most durable hernia repair possible. Mesh reinforcement provides the most durable long-term results. Underlay positioning is associated with the best outcomes. Components separation is a useful technique to achieve tension-free primary fascial reapproximation. The choice of mesh is dictated by the degree of contamination. Internal herniation is rare, and preoperative diagnosis remains difficult. In all hernia emergencies, morbidity is high, and postoperative wound complications should be anticipated.
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Affiliation(s)
- D Dante Yeh
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA 02114, USA.
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104
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Abdominal reoperation and mesh explantation following open ventral hernia repair with mesh. Am J Surg 2014; 208:670-6. [PMID: 25241955 DOI: 10.1016/j.amjsurg.2013.10.024] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 09/27/2013] [Accepted: 10/21/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND This study sought to identify the incidence, indications, and predictors of abdominal reoperation and mesh explantation following open ventral hernia repair with mesh (OVHR). METHODS A retrospective cohort study of all patients at a single institution who underwent an OVHR from 2000 to 2010 was performed. Patients who required subsequent abdominal reoperation or mesh explantation were compared with those who did not. Reasons for reoperation were recorded. The 2 groups were compared using univariate and multivariate analysis (MVA). RESULTS A total of 407 patients were followed for a median (range) of 57 (1 to 143) months. Subsequent abdominal reoperation was required in 69 (17%) patients. The most common reasons for reoperation were recurrence and surgical site infection. Only the number of prior abdominal surgeries was associated with abdominal reoperation on MVA. Twenty-eight patients (6.9%) underwent subsequent mesh explantation. Only the Ventral Hernia Working Group grade was associated with mesh explantation on MVA. CONCLUSIONS Abdominal reoperation and mesh explantation following OVHR are common. Overwhelmingly, surgical complications are themost common causes for reoperation and mesh explantation.
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105
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Abstract
Repair of huge ventral hernias is technically challenging for the surgeon and a major operation for the patient and should be performed by experienced surgeons in centers that are used to caring for patients who are commonly massively obese with significant comorbidities. Preoperative medical optimization of patients is an important part in the overall management of these large hernias. Conventional component separation with retromuscular mesh repair is the workhorse operation, which successfully deals with many giant ventral hernias, but multiple alternative strategies must be available to address situations in which myofascial elements are completely deficient or there is significant loss of domain The complexity of this surgery is reflected by recurrence rates ranging from 10% to 30% and wound complication rates as high as 40% to 50% in experienced centers.
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Affiliation(s)
- Jai Bikhchandani
- Department of General Surgery, Creighton University Medical Center, 601 N 30th Street, Omaha, NE 68131, USA.
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Skipworth JRA, Vyas S, Uppal L, Floyd D, Shankar A. Improved Outcomes in the Management of High-Risk Incisional Hernias Utilizing Biological Mesh and Soft-Tissue Reconstruction: A Single Center Experience. World J Surg 2014; 38:1026-34. [DOI: 10.1007/s00268-013-2442-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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107
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Component separation for complex congenital abdominal wall defects: not just for adults anymore. J Pediatr Surg 2013; 48:2525-9. [PMID: 24314197 DOI: 10.1016/j.jpedsurg.2013.05.067] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 05/13/2013] [Accepted: 05/14/2013] [Indexed: 11/23/2022]
Abstract
PURPOSE Operative repair of large abdominal wall defects in infants and children can be challenging. Component separation technique (CST) is utilized in adults to repair large abdominal wall defects but rarely used in children. The purpose of this report is to describe our experience with the CST in pediatric patients including the first description of CST use in newborns. METHODS After IRB approval, we reviewed all patients who underwent CST between June 1, 2010 and December 31, 2012 at a large children's hospital. CST included dissection of abdominal wall subcutaneous tissue from the muscle and fascia and an incision of the external oblique aponeurosis one centimeter lateral to the rectus sheath. Biologic mesh onlay or underlay was used to reinforce this closure. Patients were followed for complications. RESULTS Nine children, two patients with gastroschisis and seven with omphalocele, were repaired with CST at median (range) 1.1 years (5 days-10.1 years) of age. CST was the first surgical intervention for five children. There were minor wound complications and no recurrences after a median (range) follow up of 16 months (3-34 months). CONCLUSION CST can be a very useful technique to repair large abdominal wall defects in children with a loss of abdominal domain.
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109
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Sartelli M, Coccolini F, van Ramshorst GH, Campanelli G, Mandalà V, Ansaloni L, Moore EE, Peitzman A, Velmahos G, Moore FA, Leppaniemi A, Burlew CC, Biffl W, Koike K, Kluger Y, Fraga GP, Ordonez CA, Di Saverio S, Agresta F, Sakakushev B, Gerych I, Wani I, Kelly MD, Gomes CA, Faro MP, Taviloglu K, Demetrashvili Z, Lee JG, Vettoretto N, Guercioni G, Tranà C, Cui Y, Kok KY, Ghnnam WM, Abbas AES, Sato N, Marwah S, Rangarajan M, Ben-Ishay O, Adesunkanmi ARK, Segovia Lohse HA, Kenig J, Mandalà S, Patrizi A, Scibé R, Catena F. WSES guidelines for emergency repair of complicated abdominal wall hernias. World J Emerg Surg 2013; 8:50. [PMID: 24289453 PMCID: PMC4176144 DOI: 10.1186/1749-7922-8-50] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 11/25/2013] [Indexed: 02/08/2023] Open
Abstract
Emergency repair of complicated abdominal hernias is associated with poor prognosis and a high rate of post-operative complications.A World Society of Emergency Surgery (WSES) Consensus Conference was held in Bergamo in July 2013, during the 2nd Congress of the World Society of Emergency Surgery with the goal of defining recommendations for emergency repair of abdominal wall hernias in adults. This document represents the executive summary of the consensus conference approved by a WSES expert panel.
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Adekunle S, Pantelides NM, Hall NR, Praseedom R, Malata CM. Indications and outcomes of the components separation technique in the repair of complex abdominal wall hernias: experience from the cambridge plastic surgery department. EPLASTY 2013; 13:e47. [PMID: 24058718 PMCID: PMC3776569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The components separation technique (CST) is a widely described abdominal wall reconstructive technique. There have, however, been no UK reports of its use, prompting the present review. METHODS Between 2008 and 2012, 13 patients who underwent this procedure by a single plastic surgeon (C.M.M.) were retrospectively evaluated. The indications, operative details, and clinical outcomes were recorded. RESULTS There were 7 women and 6 men in the series with a mean age of 53 years (range: 30-80). Patients were referred from a variety of specialties, often as a last resort. The commonest indication for CST was herniation following abdominal surgery. All operations except 1 were jointly performed with general surgeons (for bowel resection, stoma reversal, and hernia dissection). The operations lasted a mean of 5 hours (range: 3-8 hours). There were no major intra- and postoperative problems, except in 1 patient who developed intra-abdominal compartment syndrome, secondary to massive hemorrhage. All patients were satisfied with the cosmetic improvement in their abdominal contours. None of the patients have developed a clinical recurrence after a mean follow-up of 16 months (range: 3-38 months). CONCLUSIONS The components separation technique is an effective method of treating large recalcitrant hernias but appears to be underutilized in the United Kingdom. The management of large abdominal wall defects requires a multidisciplinary approach, with input across a variety of specialities. Liaison with plastic surgery teams should be encouraged at an early stage and the CST should be more widely considered when presented with seemingly intractable abdominal wall defects.
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Affiliation(s)
- Shola Adekunle
- aDepartments of Plastic and Reconstructive surgery, Addenbrooke's University Hospital, Cambridge, UK
| | - Nicholas M. Pantelides
- aDepartments of Plastic and Reconstructive surgery, Addenbrooke's University Hospital, Cambridge, UK
| | - Nigel R. Hall
- bDepartments of General Surgery, Addenbrooke's University Hospital, Cambridge, UK
| | - Raaj Praseedom
- bDepartments of General Surgery, Addenbrooke's University Hospital, Cambridge, UK
| | - Charles M. Malata
- aDepartments of Plastic and Reconstructive surgery, Addenbrooke's University Hospital, Cambridge, UK,Correspondence:
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Multilayer myofascial-mesh repair for giant midline incisional hernias: a novel advantageous combination of old and new techniques. J Gastrointest Surg 2013; 17:1665-72. [PMID: 23868056 DOI: 10.1007/s11605-013-2285-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 07/03/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND The components separation technique has been proposed as the best solution when facing large abdominal wall defects. In counterpart, this sometimes comes at the price of high rates of wound complications and recurrence. Moreover, the components separation method alone seems insufficient for huge defects, in which it is impossible to reapproximate the rectus muscles without tension. For these cases, we illustrate a novel operation using a modified components separation technique. METHODS Twenty-eight patients with giant midline incisional hernias were treated with a combination of the components separation (bilateral sliding rectus abdominis advancement flaps), an autologous multilayer repair, and a retromuscular mesh reinforcement. RESULTS Twenty-four (85%) patients have been analyzed. Transverse defect size ranged from 15 to 25 cm (average, 18.8 cm). Wound complications occurred in nine (37%) cases; three of them required drainage of a subcutaneous abscess. After a mean follow-up of 22 (range, 12-48) months, one (4%) recurrence was identified. CONCLUSIONS Multilayer myofascial-mesh repair was associated with a low recurrence rate, and wound complications were managed without issues. This approach is a reliable technique for most surgeons and may constitute a new part of the armamentarium for the repair of challenging defects.
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112
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Abstract
The economic aspects of abdominal wall reconstruction are frequently overlooked, although understandings of the financial implications are essential in providing cost-efficient health care. Ventral hernia repairs are frequently performed surgical procedures with significant economic ramifications for employers, insurers, providers, and patients because of the volume of procedures, complication rates, the significant rate of recurrence, and escalating costs. Because biological mesh materials add significant expense to the costs of treating complex abdominal wall hernias, the role of such costly materials needs to be better defined to ensure the most cost-efficient and effective treatments for ventral abdominal wall hernias.
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Affiliation(s)
- Curtis Bower
- Section of Gastrointestinal & Minimally Invasive Surgery, Division of General Surgery, A. B. Chandler Medical Center, University of Kentucky, 800 Rose Street, UKMC - C224, Lexington, KY 40536-0298, USA
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113
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Abstract
In this article, the authors describe their current operative technique for open ventral hernia repair using component separation. Although methods of anterior component separation are described, in their current practice, the authors primarily use posterior component separation with transversus abdominis release to permit dissection beyond the retrorectus space. This method adheres to the literature-supported principles of a tension-free midline fascial closure with wide mesh overlap of mesh positioned in a sublay position. The authors' experience with this method supports a low recurrence rate and reduced wound morbidity.
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Affiliation(s)
- Eric M Pauli
- Department of Surgery, Penn State Hershey Medical Center, 500 University Drive, H149, Hershey, PA 17036, USA
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114
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Klima DA, Tsirline VB, Belyansky I, Dacey KT, Lincourt AE, Kercher KW, Heniford BT. Quality of Life Following Component Separation Versus Standard Open Ventral Hernia Repair for Large Hernias. Surg Innov 2013; 21:147-54. [DOI: 10.1177/1553350613495113] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction. Component separation (CS) has become a viable alternative to repair large ventral defects when the fascia cannot be reapproximated. However, the impact of transecting the external oblique to facilitate closure of the abdomen on quality of life (QOL) has yet to be investigated. The study goal was to investigate QOL and outcomes after standard open ventral hernia repair (OVHR) versus CS for large ventral hernias. Study design. Prospective data for all CSs were reviewed and compared with matched OVHR controls. All defects were 100 to 1000 cm2 in size and repaired with mesh. Comorbidities, complications, outcomes, and Carolinas Comfort Scale (CCS) scores, were reviewed. Results. Seventy-four CS patients were compared with 154 patients undergoing standard OVHR with similar defect sizes. Age (56.7±13.0 vs 54.7 ± 12.3 years, P = .26), defect sizes (299 ± 160 vs 304 ± 210cm2, P = .87), and BMI (32.7 ± 6.9 vs 34.2 ± 9.0 kg/m2, P = .26) were similar in both groups, respectively. There were no differences in major postoperative complications (P = .22), mesh infections (P = 1.00), wound infections (P = .07), or hernia recurrence (P = .09), but wound breakdown increased after CS (10% vs 1%, P < .001) as did seroma interventions (15% vs 4%, P = .005). Postoperative CCS scores were similar at 1 month (P = .82) and 1 year (P = .14). Conclusions. In the first comparative study of its kind, it is found that patient undergoing CS with mesh reinforcement had equal short- and long-term QOL outcomes compared with similar patients who underwent standard OVHR. Whereas wound breakdown and seroma formation are higher, the overall complication, mesh infection, and recurrence rates are similar.
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115
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Singh DP, Zahiri HR, Gastman B, Holton LH, Stromberg JA, Chopra K, Wang HD, Condé Green A, Silverman RP. A modified approach to component separation using biologic graft as a load-sharing onlay reinforcement for the repair of complex ventral hernia. Surg Innov 2013; 21:137-46. [PMID: 23804996 DOI: 10.1177/1553350613492585] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Components separation has been proposed as a means to close large ventral hernia without undue tension. We report a modification on open components separation that allows for the incorporation of onlaid noncrosslinked porcine acellular dermal matrix (Strattice, LifeCell Corp, Branchburg, NJ) as a load-sharing structure. METHODS This was a retrospective case series including all cases using Strattice from July 2008 through December 2009. Data evaluated included patient demographics, comorbidities associated with risk of recurrence, hernia grade, and postoperative complications. The primary outcomes were hernia recurrence and surgical site occurrences. RESULTS There were 58 patients; 60.8% presented with a recurrent incisional hernia. Average length of follow-up was 384 days. There were 4 hernia recurrences (7.9%). Complications included surgical site infection (20.7%), seroma (15.5%), and hematoma (5%) requiring intervention. Four deaths occurred in the series due to causes unrelated to the hernia repair, only 1 within 30 days of operation. CONCLUSIONS This series demonstrates that components separation reinforced with noncrosslinked porcine acellular dermal matrix onlay is an efficacious, single-stage repair with a low rate of recurrence and surgical site occurrences.
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116
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Abstract
PURPOSE Damage control laparotomy has become an accepted approach for patients with life-threatening abdominal conditions. This method compromises fascial integrity creating functionally and aesthetically debilitating hernias. The purpose of this study is to present our technique and outcomes with these complex abdominal wall reconstructions. METHODS A retrospective review was conducted on 56 patients with previous damage control laparotomies who underwent elective single-stage abdominal wall reconstruction between 1999 and 2006. Mean age was 42 years. Reconstruction consisted of a double-layer, subfascial Vicryl mesh buttress, combined with components separation and rectus muscle turnover flaps. Hernia recurrence and function were evaluated by clinical examinations and telephone surveys. RESULTS The major etiologies of abdominal hernias were gunshot wounds, motor vehicle accidents or blunt trauma, and sepsis or perforated bowel. The mean abdominal wall defect was 865 cm, and the average interval time to definitive repair was 17 months. The average length of follow-up was 29 months. Most patients (88%) had successful repair of their abdominal wall, with no hernia recurrence. There were 7 cases of hernia. Of these, 2 cases were from reopening of abdomen because of compartment syndrome that was not repaired, 3 were small asymptomatic hernias for which patients elected not to undergo further repair. Other complications include superficial skin dehiscence, all of which healed secondarily with daily wound care 12% (7 patients) and abdominal compartment syndrome 7.1% (4 patients), resulting in 2 postoperative mortalities in the initial part of the series. There were no mesh exposures, seromas, or fistulas. In all, 29% or 52% of patients were reached by telephone. Of those, 90% surveyed and who worked full-time prior to injury returned to their jobs, and 92% were functioning at premorbid activity levels. CONCLUSION Massive abdominal hernia following damage control laparotomy poses a great challenge to the reconstructive surgeon. This patient population is at significant risk for mortality and morbidity. We believe the use of a Vicryl mesh buttress is an important adjunctive tool in complex abdominal wall reconstruction. Functional results are excellent with most returning to work and preinjury activity levels.
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117
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The peritoneal flap hernioplasty for repair of large ventral and incisional hernias. Hernia 2013; 18:39-45. [DOI: 10.1007/s10029-013-1086-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Accepted: 03/23/2013] [Indexed: 11/27/2022]
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Brown RH, Subramanian A, Hwang CS, Chang S, Awad SS. Comparison of infectious complications with synthetic mesh in ventral hernia repair. Am J Surg 2013; 205:182-7. [PMID: 23331984 DOI: 10.1016/j.amjsurg.2012.02.023] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 02/26/2012] [Accepted: 02/26/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Infection can be a devastating complication associated with prosthetic incisional hernia repair. It is unclear whether the type of mesh used affects the risk of infection. METHODS A retrospective review was performed of all patients who underwent elective incisional hernia repair with permanent prosthetic mesh between January 1, 2000, and August 1, 2007. RESULTS A total of 176 patients underwent elective incisional hernia repair with mesh. The overall infection rate with the use of goretex (Flagstaff, AZ, USA) was 12 of 86 (14%) and 2 of 90 (2.2%) in cases in which nongoretex material was used (P = .016). In the goretex group, infection rates were significantly higher in open versus laparoscopic cases (26.5% vs 5.8%, P = .030). Methicillin-resistant Staphylococcus aureus was the most common organism recovered. CONCLUSIONS The risk of mesh infection with the use of goretex was found to be higher than with the use of nongoretex mesh. Laparoscopic placement of goretex reduces this risk of infection. No significant differences in recurrence rates were found.
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Affiliation(s)
- Rodger H Brown
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX 77030, USA
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Surgical treatment for giant incisional hernia: a qualitative systematic review. Hernia 2013; 18:31-8. [PMID: 23456151 DOI: 10.1007/s10029-013-1066-y] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 02/17/2013] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Repair for giant incisional hernias is a challenge due to unacceptable high morbidity and recurrence rates. Several surgical techniques are available, but all are poorly documented. This systematic review was undertaken to evaluate the existing literature on repair for giant incisional hernia. METHODS Literature was identified through a systematic search on PubMed, EMBASE, and CINAHL. We only included studies with clearly defined surgical techniques and defect size of at least 15 cm. The heterogeneity of the studies precluded a meta-analysis. The analysis was based on the premises of a systematic review of the literature. RESULTS We identified 14 studies (1,198 patients) including one randomised trial. Studies were mainly small and retrospective and highly heterogenic regarding design, outcome, inclusion, and exclusion criteria. The overall morbidity rate was median 32 % with a wide range between studies of 4-100 %. The mortality ranged from 0 to 5 % (median 0 %) and recurrence rate ranged from 0 to 53 % (median 5 %). Study follow-up ranged from 15 to 97 months (median 36 months). Mesh repair should always be used for patients undergoing repair for a giant hernia, and the sublay position may have advantages over onlay positioning. To avoid tension, it may be advisable to use a mesh in combination with a component separation technique. Inlay positioning of the mesh and repair without a mesh should be avoided. CONCLUSIONS Evidence to optimise repair for giant hernias is weak due to the heterogeneity and the poor quality of studies. However, sublay positioning of the mesh perhaps in combination with a component separation technique may be advantageous compared with other surgical techniques for giant hernia repair. Giant hernia repair is a challenging surgical procedure and severely lack evidence-based research from high-quality, large-scaled randomised studies.
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120
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Abstract
Complex abdominal wall defects refer to situations where simple ventral hernia repair is not feasible because the defect is very large, there is a concomitant infection or failed previous repair attempt, or if there is not enough original skin to cover the repair. Usually a complex abdominal wall repair is preceded by a period of temporary abdominal closure where the short-term aims include closure of the catabolic drain, protection of the viscera and preventing fistula formation, preventing bowel adherence to the abdominal wall, and enabling future fascial and skin closure. Currently the best way to achieve these goals is the vacuum- and mesh-mediated fascial traction method achieving close to 90% fascial closure rates. The long-term aims of an abdominal closure following a planned hernia strategy include intact skin cover, fascial closure at midline (if possible), good functional outcome with innervated abdominal musculature, no pain and good cosmetic result. The main methods of abdominal wall reconstruction include the use of prosthetic (mesh) or autologous material (tissue flaps). In patients with original skin cover over the fascial defect (simple ventral hernia), the most commonly used method is hernia repair with an artificial mesh. For more complex defects, our first choice of reconstruction is the component separation technique, sometimes combined with a mesh. In contaminated fields where component separation alone is not feasible, a combination with a biological mesh can be used. In large defects with grafted skin, a free TFL flap is the best option, sometimes reinforced with a mesh and enhanced with components separation.
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Affiliation(s)
- A. Leppäniemi
- Department of Abdominal Surgery, Helsinki University Hospital, Helsinki, Finland
| | - E. Tukiainen
- Department of Plastic Surgery, Helsinki University Hospital, Helsinki, Finland
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Outcomes of simultaneous large complex abdominal wall reconstruction and enterocutaneous fistula takedown. Am J Surg 2013; 205:354-8; discussion 358-9. [DOI: 10.1016/j.amjsurg.2012.10.013] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2012] [Revised: 09/22/2012] [Accepted: 10/13/2012] [Indexed: 11/23/2022]
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122
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Multi-staged repair of contaminated primary and recurrent giant incisional herniae in the same hospital admission: a proposal for a new approach. Hernia 2013; 18:57-63. [DOI: 10.1007/s10029-013-1051-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 01/19/2013] [Indexed: 11/27/2022]
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Deerenberg EB, Mulder IM, Grotenhuis N, Ditzel M, Jeekel J, Lange JF. Experimental study on synthetic and biological mesh implantation in a contaminated environment. Br J Surg 2013; 99:1734-41. [PMID: 23132422 DOI: 10.1002/bjs.8954] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Implantation of meshes in a contaminated environment can be complicated by mesh infection and adhesion formation. METHODS The caecal ligation and puncture model was used to induce peritonitis in 144 rats. Seven commercially available meshes were implanted intraperitoneally: six non-absorbable meshes, of which three had an absorbable coating, and one biological mesh. Mesh infection, intra-abdominal abscess formation, adhesion formation, incorporation and shrinkage were evaluated after 28 and 90 days. Histological examination with haematoxylin and eosin and picrosirius red staining was performed. RESULTS No mesh infections occurred in Sepramesh(®) , Omyramesh(®) and Strattice(®) . One mesh infection occurred in Parietene(®) and Parietene Composite(®) . Significantly more mesh infections were found in C-Qur(®) (15 of 16; P ≤ 0·006) and Dualmesh(®) (7 of 15; P ≤ 0·035). Sepramesh(®) showed a significant increase in adhesion coverage from 12·5 per cent at 28 days to 60·0 per cent at 90 days (P = 0·010). At 90 days there was no significant difference between median adhesion coverage of Parietene Composite(®) (35·0 per cent), Omyramesh(®) (42·5 per cent), Sepramesh(®) (60·0 per cent) and Parietene(®) (72·5 per cent). After 90 days the adhesion coverage of Strattice(®) was 5·0 per cent, and incorporation (13·4 per cent) was significantly poorer than for other non-infected meshes (P ≤ 0·009). Dualmesh(®) showed shrinkage of 63 per cent after 90 days. CONCLUSION Parietene Composite(®) and Omyramesh(®) performed well in a contaminated environment. Strattice(®) had little adhesion formation and no mesh infection, but poor incorporation. Some synthetic meshes can be as resistant to infection as biological meshes.
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Affiliation(s)
- E B Deerenberg
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands.
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124
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Abstract
Ventral hernias are a major surgical challenge with complications such as wound separations, infections, and recurrences contributing to patient morbidity. We describe a new adjunctive technique that may be helpful in repairing difficult ventral hernias: it involves using an appropriately chosen, redundant abdominal skin edge that is deepithelialized and used to reinforce the hernia repair. A series of 7 patients aged 23 to 84 years in whom the technique was used is presented. All patients had complete repair of their incisional ventral hernia defects without complications of infection, wound dehiscence, seroma formation, reoperation, or hernia recurrence. Furthermore, patients reported a subjective improvement in performing daily activities. Mean follow-up in this series was 19.2 months, with a range from 15.0 to 26.8 months. Advantages include the redistribution of mechanical tension, reinforcement of the midline site of greatest pressure, elimination of dead space, and staggering of suture lines to prevent direct external contamination of prosthetic material should wound dehiscence occur.
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125
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Godden AR, Daniels IR, Giordano P. The role of biologic meshes in abdominal wall reconstruction. Colorectal Dis 2012; 14 Suppl 3:7-11. [PMID: 23136818 DOI: 10.1111/codi.12043] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
There are unacceptably high rates of recurrence following surgery for incision hernia repair using suture repair techniques in isolation. As the reconstruction of abdominal walls has expanded with complex surgery, the materials used as adjuncts to support the repair have changed. In the article we review the current use of biologic meshes in abdominal wall reconstruction and the techniques used.
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Affiliation(s)
- A R Godden
- Exeter Health Services Research Unit, Royal Devon & Exeter Hospital, Barrack Road, Exeter, Devon, UK
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126
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Abstract
Enterocutaneous fistula and its variations are some of the most difficult problems encountered in the practice of general surgery. Reliable evidence that can be used to direct the care of patients afflicted with this malady is limited. There are controversies in several areas of care. This article addresses some of the gray areas of care for the patient with enterocutaneous fistula. There is particular attention directed toward the phenomenon of enteroatmospheric fistula, as well as prevention and abdominal wall reconstruction, which is often required in these individuals.
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Affiliation(s)
- Kurt G Davis
- Section of Colon and Rectal Surgery, Department of Surgery, William Beaumont Army Medical Center, Fort Bliss, TX 79920, USA
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127
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Prospective study of single-stage repair of contaminated hernias using a biologic porcine tissue matrix: The RICH Study. Surgery 2012; 152:498-505. [DOI: 10.1016/j.surg.2012.04.008] [Citation(s) in RCA: 212] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 04/27/2012] [Indexed: 12/29/2022]
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128
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Rulli F, Villa M, Tucci G. Endoscopic single-port "components separation technique" for postoperative abdominal reconstruction. J Minim Access Surg 2012; 8:62-4. [PMID: 22623830 PMCID: PMC3353617 DOI: 10.4103/0972-9941.95541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Accepted: 06/09/2011] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND: In 1990, Ramirez introduced a new procedure to close abdominal wall hernia (AWH), called “components separation technique (CST)”. Thanks to endoscopy, surgical repair possibilities have risen, reducing the operative trauma and preserving vascular and neuronal anatomical structures. This report aims to describe a single port endoscopic approach for CST to repair the abdominal wall of a patient undergoing surgery for abdominal aneurysm and already subject to placement of a mesh for AWH. METHODS: We performed endoscopic-assisted CST, using a single-port access with a gasless technique. CONCLUSION: CST is a useful procedure to close large abdominal wall incisional hernia avoiding the use of mesh, notably under contamination, when prosthetic material use is contraindicated. The endoscopic-assisted CST produces same results than the conventional open separation technique and also minimised tissue trauma that ensures blood supply and prevents postoperative wounds complications. The described single port method was found to be safe and effective to close large midline abdominal hernias when a primary open or laparoscopic closure is not feasible or when patients have been previously treated with abdominal meshes.
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Affiliation(s)
- Francesco Rulli
- Department of Surgery, University Hospital of Tor Vergata, Rome, Italy
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129
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130
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Components separation technique utilizing an intraperitoneal biologic and an onlay lightweight polypropylene mesh: “a sandwich technique”. Hernia 2012; 17:45-51. [DOI: 10.1007/s10029-012-0949-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Accepted: 06/22/2012] [Indexed: 10/28/2022]
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131
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Abstract
Planned ventral hernia is a management strategy in which the abdominal fascial layer has been left unclosed and the viscera are covered only with original or grafted skin. Leaving the fascia open can be deliberate or unavoidable and most commonly results from staged repair of the abdominal wall due to trauma, peritonitis, pancreatitis, abdominal vascular emergencies, or abdominal compartment syndrome. The abdominal wall defects can be categorized as type I or II defects depending on whether there is intact, stable skin coverage. In defects with intact skin coverage, the most commonly used methods are the components separation technique and a prosthetic repair, sometimes used in combination. The advantages of the components separation technique is the ability to close the linea alba at the midline, creating a better functional result than a repair with inert mesh. Although the reherniation risk seems higher after components separation, the risk of infection is considerably lower. With a type II defect, with absent or unstable skin coverage, fascial repair alone is inadequate. Of the more complex reconstruction techniques, the use of a free tensor fasciae latae (TFL) flap utilizing a saphenous vein arteriovenous loop is the most promising. The advantages of the TFL flap include constant anatomy of the pedicle, a strong fascial layer, large-caliber vessels matching the size of the AV loop, and the ability to use large flaps (up to 20 × 35 cm). Whatever technique is used, the repair of complex abdominal wall defects requires close collaboration with plastic and abdominal surgeons, which is best managed in specialized centers.
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132
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Kim W, Abdelshehid C, Lee HJ, Ahlering T. Robotic-assisted Laparoscopic Prostatectomy in Umbilical Hernia Patients: University of California, Irvine, Technique for Port Placement and Repair. Urology 2012; 79:1412.e1-3. [DOI: 10.1016/j.urology.2012.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Revised: 03/09/2012] [Accepted: 03/09/2012] [Indexed: 10/28/2022]
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133
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Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ. Transversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction. Am J Surg 2012; 204:709-16. [PMID: 22607741 DOI: 10.1016/j.amjsurg.2012.02.008] [Citation(s) in RCA: 387] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Revised: 02/27/2012] [Accepted: 02/27/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND Several modifications of the classic retromuscular Stoppa technique to facilitate dissection beyond the lateral border of the rectus sheath recently were reported. We describe a novel technique of transversus abdominis muscle release (TAR) for posterior component separation during major abdominal wall reconstructions. METHODS Retrospective review of consecutive patients undergoing TAR. Briefly, the retromuscular space is developed laterally to the edge of the rectus sheath. The posterior rectus sheath is incised 0.5-1 cm underlying medial to the linea semilunaris to expose the medial edge of the transversus abdominis muscle. The muscle then is divided, allowing entrance to the space anterior to the transversalis fascia. The posterior rectus fascia then is advanced medially. The mesh is placed as a sublay and the linea alba is restored ventral to the mesh. RESULTS Between December 2006 and December 2009, we have used this technique successfully in 42 patients with massive ventral defects. Thirty-two (76.2%) patients had recurrent hernias. The average mesh size used was 1,201 ± 820 cm(2) (range, 600-2,700). Ten (23.8%) patients developed various wound complications requiring reoperation/debridement in 3 patients. At a median follow-up period of 26.1 months, there have been 2 (4.7%) recurrences. CONCLUSIONS Our novel technique for posterior component separation was associated with a low perioperative morbidity and a low recurrence rate. Overall, transversus abdominis muscle release may be an important addition to the armamentarium of surgeons undertaking major abdominal wall reconstructions.
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Affiliation(s)
- Yuri W Novitsky
- Department of Surgery, University of Connecticut Health Center, Farmington, CT, USA.
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134
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Evaluation of surgical outcomes of retro-rectus versus intraperitoneal reinforcement with bio-prosthetic mesh in the repair of contaminated ventral hernias. Hernia 2012; 17:31-5. [PMID: 22415440 DOI: 10.1007/s10029-012-0909-2] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Accepted: 02/24/2012] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Hernia repairs in contaminated fields are often reinforced with a bioprosthetic mesh. When choosing which of the multiple musculofascial abdominal wall planes provides the most durable repair, there is little guidance. We hypothesized that the retro-rectus plane would reduce recurrence rates versus intraperitoneal placement due to greater surface area contact of mesh with well-vascularized tissue. METHODS Forty-nine of the 80 patients in an ongoing, prospective, multicenter study of contaminated ventral hernia repairs (RICH study, NCT00617357) achieved fascial closure after musculofascial centralization and reinforcement with non-crosslinked porcine acellular dermal matrix (Strattice™, LifeCell, Branchburg, NJ) and were retrospectively analyzed. The Strattice was placed in the retro-rectus position in 23 patients and in the intraperitoneal position in 26. RESULTS Subjects were comparable in age, obesity, prior wound infection, presence of a stoma, and infected mesh removal (p > 0.05). More smokers were present in the intraperitoneal group (p = 0.02). Retro-rectus defects were significantly wider and had larger area than the intraperitoneal repairs. At the 1-year follow-up, 44 (90%) of patients were available for review. There was no difference in wound infections, seromas, or hematomas. Recurrent hernias were identified in 10% of retro-rectus repairs and 30% of intraperitoneal repairs (p = 0.14). CONCLUSIONS In this retrospective analysis of a prospective multicenter study of large, contaminated ventral hernias, despite a larger hernia defect in the retro-rectus group, placement of the mesh in the retro-rectus compartment resulted in a similar recurrence rate to intraperitoneal mesh placement. Ongoing evaluation is important to establish longer-term outcomes and the validity of these findings.
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136
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Hillenbrand A, Henne-Bruns D, Wolf AM. Panniculus, giant hernias and surgical problems in patients with morbid obesity. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2012; 1:Doc05. [PMID: 26504689 PMCID: PMC4582477 DOI: 10.3205/iprs000005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Prevalence of morbid obesity is rising. Along with it, the adipose associated co-morbidities increase - included panniculus morbidus, the end stage of obesity of the abdominal wall. In the course of time panniculus often develop a herniation of bowel. An incarcerated hernia and acute exacerbation of a chronic inflammation of the panniculus must be treated immediately and presents a surgical challenge. The resection of such massive abdominal panniculus presents several technical problems to the surgeon. Preparation of long standing or fixed hernias may require demanding adhesiolysis. The wound created is huge and difficult to manage, and accompanied by considerable complications at the outset. We provide a comprehensive overview of a possible approach for panniculectomy and hernia repair and overlook of the existing literature.
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Affiliation(s)
- Andreas Hillenbrand
- Universitätsklinikum Ulm, Klinik für Allgemein-, Viszeral- u. Transplantationschirurgie, Ulm, Germany,*To whom correspondence should be addressed: Andreas Hillenbrand, Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Ulm, Steinhövelstr. 9, 89073 Ulm, Germany, E-mail:
| | - Doris Henne-Bruns
- Universitätsklinikum Ulm, Klinik für Allgemein-, Viszeral- u. Transplantationschirurgie, Ulm, Germany
| | - Anna M. Wolf
- Universitätsklinikum Ulm, Klinik für Allgemein-, Viszeral- u. Transplantationschirurgie, Ulm, Germany
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137
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Garvey PB, Bailey CM, Baumann DP, Liu J, Butler CE. Violation of the rectus complex is not a contraindication to component separation for abdominal wall reconstruction. J Am Coll Surg 2011; 214:131-9. [PMID: 22169002 DOI: 10.1016/j.jamcollsurg.2011.10.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Revised: 10/22/2011] [Accepted: 10/31/2011] [Indexed: 11/27/2022]
Abstract
BACKGROUND Component separation (CS) is an effective technique for reconstructing complex abdominal wall defects. Violation of the rectus abdominis complex is considered a contraindication for CS, but we hypothesized that patients have similar outcomes with or without rectus complex violation. STUDY DESIGN We retrospectively studied all consecutive patients who underwent CS for abdominal wall reconstruction during 8 years and compared outcomes of patients with and without rectus violation. Primary outcomes measures included complications and hernia recurrence. Logistic regression analysis identified potential associations between patient, defect, and reconstructive characteristics and surgical outcomes. RESULTS One hundred sixty-nine patients were included: 115 (68%) with and 54 (32%) without rectus violation. Mean follow-up was 21.3 ± 14.5 months. Patient and defect characteristics were similar, except for the rectus violation group having a higher body mass index. Overall complication rates were similar in the violation (24.3%) and nonviolation (24.0%) groups, as were the respective rates of recurrent hernia (7.8% vs 9.2%; p = 0.79), abdominal bulge (3.5% vs 5.6%; p = 0.71), skin dehiscence (20.0% vs 22.2%; p = 0.74), skin necrosis (6.1% vs 3.7%; p = 0.72), cellulitis (7.8% vs 9.2%; p = 0.75), and abscess (12.3% vs 9.2%; p = 0.58). Regression analysis demonstrated body mass index to be the only factor predictive of complications. CONCLUSIONS CS surgical outcomes were similar whether or not the rectus complex was violated. To our knowledge, this study is the first to evaluate the effects of rectus violation on surgical outcomes in CS patients. Surgeons should not routinely avoid CS when the rectus complex is violated.
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Affiliation(s)
- Patrick B Garvey
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, 1400 Pressler Blvd., Houston,TX 77030, USA
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138
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Johnson EK, Tushoski PL. Abdominal wall reconstruction in patients with digestive tract fistulas. Clin Colon Rectal Surg 2011; 23:195-208. [PMID: 21886470 DOI: 10.1055/s-0030-1262988] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Abdominal wall reconstruction in the digestive tract fistula patient is a complex issue. The authors review the available data and present information regarding the timing of surgery, techniques of abdominal wall reconstruction, hernia repair, and discuss pitfalls associated with the various options. A simple and basic approach to this problem is described.
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Affiliation(s)
- Eric K Johnson
- Colorectal Surgery and Surgical Endoscopy, Dwight David Eisenhower Army Medical Center, Ft. Gordon, Georgia
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139
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Abstract
Abdominal wall reconstruction is a complex and challenging surgical undertaking. While permanent prosthetic mesh is considered the gold standard for minimizing hernia recurrence, placement of synthetic mesh is sometimes imprudent due to contamination or risk of infection. Acellular dermal matrices (ADM) offer an exciting biologic alternative. This article provides a historical perspective on the evolution of complex ventral hernia repair leading up to and including the placement of ADM, an explanation of the biology of ADM as it relates to ventral hernia repair, and a description of the current indications, techniques, benefits, and shortcomings of its use in the abdominal wall.
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Affiliation(s)
- Ronald P Silverman
- Division of Plastic Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA.
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140
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Kanaan Z, Hicks N, Weller C, Bilchuk N, Galandiuk S, Vahrenhold C, Yuan X, Rai S. Abdominal wall component release is a sensible choice for patients requiring complicated closure of abdominal defects. Langenbecks Arch Surg 2011; 396:1263-70. [DOI: 10.1007/s00423-011-0841-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Accepted: 08/08/2011] [Indexed: 10/17/2022]
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141
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Giurgius M, Bendure L, Davenport DL, Roth JS. The endoscopic component separation technique for hernia repair results in reduced morbidity compared to the open component separation technique. Hernia 2011; 16:47-51. [PMID: 21833851 DOI: 10.1007/s10029-011-0866-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Accepted: 07/14/2011] [Indexed: 11/24/2022]
Abstract
PURPOSE The component separation technique for hernia repair results in significant wound morbidity due to the need for large undermining skin flaps. The endoscopic component separation technique allows for advancement of the abdominal wall while preserving the blood supply originating from the epigastric vessels. This study compares the outcomes following hernia repair utilizing these techniques. METHODS A retrospective review of patients undergoing component separation or endoscopic component separation hernia repair from 2008 to 2010. Patients underwent open component separation or endoscopic component separation with closure of the linea alba and reinforcement with mesh. RESULTS Thirty-five patients that underwent a component separation [14 open component separation (CST) and 21 that underwent endoscopic component separation (ECST)] were identified. There was no difference in hospital length of stay (CST 5.0 ± 3.0 days vs ECST 6.3 ± 3.6 days, P = 0.28) or operating room times (CST; 268 ± 62 min vs ECST; 229 ± 57 min, P = 0.07). Wound complications occurred in 57% of CST and 19% of ECST, P = 0.03. One recurrent hernia was identified in the ECST group with a mean follow up of 8 months (range 1-21 months). No recurrences were seen in the CST group. CONCLUSIONS ECST is associated with comparable hospital length of stay and operative times and reduced wound complications compared to CST.
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Affiliation(s)
- M Giurgius
- Department of Surgery, University of Kentucky College of Medicine, Lexington, KY 40536-0298, USA
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142
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Yegiyants S, Tam M, Lee DJ, Abbas MA. Outcome of components separation for contaminated complex abdominal wall defects. Hernia 2011; 16:41-5. [PMID: 21786148 DOI: 10.1007/s10029-011-0857-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Accepted: 07/01/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND Contaminated large abdominal wall defects can pose a formidable challenge to the surgeon. This study compared the outcome of components separation (CS) for complex ventral defects with or without contamination. METHODS A retrospective review was conducted of all patients who underwent CS over an 8-year period. Pre-operative factors such as the presence/absence of contamination were analyzed for their effect on length of hospitalization, readmission rate, post-operative complications, re-intervention rate, and long-term recurrence. RESULTS A total of 34 patients was analyzed. There were 18 males (53%) with a mean age of 57 years. Mean body mass index was 31 kg/m(2). Seventeen patients (50%) had prior repair (mean 2.1 repairs per patient, median 2). Mean size of abdominal defect was 255 cm(2). Out of the 34 patients, 13 had infected or contaminated defects, including 5 patients with infected mesh. Length of stay was longer in the contaminated group (11.1 vs 3.1 days, P < 0.01). A higher complication rate was noted in the setting of contamination (77 vs 38%, P = 0.03). During a mean follow-up of 47 months, no difference was noted in the re-intervention rate (38 vs 29%, P = 0.70) or long-term recurrence rate of the defect (8 vs 5%, P = 1.0) (contaminated vs non-contaminated group, respectively). CONCLUSIONS CS is a good option for closure of large contaminated complex abdominal wall defects. Despite an increased risk of postoperative complications and longer hospitalization length, long-term outcomes are favorable.
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Affiliation(s)
- S Yegiyants
- Department of Surgery, Kaiser Permanente, 4760 Sunset Boulevard, 3rd Floor, West Los Angeles, CA 90027, USA
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143
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Kakizoe S, Kakizoe Y, Matsuoka I, Kakizoe K. Flexible tack for ventral hernia repair. Surg Today 2011; 41:1024-5. [PMID: 21748627 DOI: 10.1007/s00595-010-4373-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2010] [Accepted: 05/21/2010] [Indexed: 11/29/2022]
Abstract
A mesh repair of a ventral hernia from the anterior approach is relatively difficult because it is necessary to fix the edge of the mesh from the hernial orifice. We developed a flexible tack for hernia repair, and used it for five lesions in four patients. The flexible tack allowed us to fix the edge of the mesh to the abdominal wall through the peritoneum without any complications. The durations of surgery were 123, 76, 124, and 89 min. We conclude that the flexible tack is useful device to perform hernia repair that provides an alternative to using mesh under the anterior approach.
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Affiliation(s)
- Saburo Kakizoe
- Department of Surgery, Kakizoe Hospital, 278 Kagamigawa, Hirado, Nagasaki, 859-5152, Japan
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144
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Albright E, Diaz D, Davenport D, Roth JS. The Component Separation Technique for Hernia Repair: A Comparison of Open and Endoscopic Techniques. Am Surg 2011. [DOI: 10.1177/000313481107700716] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The open components separation technique (CST) for hernia repair allows for autologous tissue repair with approximation of the midline fascia in patients with complex hernias. CST requires creation of large undermining skin flaps, whereas the endoscopic component separation technique (ECST) is performed without division of the epigastric perforating vessels and may minimize wound morbidity. A review of patient demographics and outcome measures of patients undergoing CST and ECST between November 2008 and February 2010 was performed. Twenty-five patients were identified who underwent either CST (14 patients) or ECST (11 patients). There were no differences in body mass index (CST 34.8 kg/m2, ECST 37.5 kg/m2, P = 0.45), operating room times (CST 268 minutes, ECST 252 minutes, P = 0.54), or hospital length of stay (CST 5 days, ECST 5.8 days, P = 0.78). Wound complications occurred less with ECST (9 vs 57%, P = 0.03). The time to resolution of wound complications in ECST was reduced * 1 vs 4 months). No recurrences were seen in either group with a mean follow-up of 4months (range, 1 to 12 months). ECST and CST require similar operative times and hospital lengths of stay. ECST is associated with reduced wound complications compared with CST. Short-term recurrence rates with CST and ECST are comparable.
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Affiliation(s)
- Emily Albright
- Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
- Division of General Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Dennis Diaz
- Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
- Division of General Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Daniel Davenport
- Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - John S. Roth
- Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
- Division of General Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
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145
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Kim Z, Kim YJ. Components separation technique for large abdominal wall defect. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2011; 80 Suppl 1:S63-6. [PMID: 22066088 PMCID: PMC3205369 DOI: 10.4174/jkss.2011.80.suppl1.s63] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Accepted: 08/09/2010] [Indexed: 11/30/2022]
Abstract
Repairing large incisional hernia with abdominal wall reconstruction is a technically challenging problem for surgeons. We report our experience of large midline incisional hernia which was repaired successfully with components separation technique. A patient with incisional hernia, 35 × 20 cm in size, underwent operation following standard components separation technique. The aponeurosis of the external abdominal oblique muscle was longitudinally transected from the rectus sheath, and the external abdominal oblique muscle was separated from the internal abdominal oblique muscle. With further separation of the posterior rectus sheath from the rectus abdominis muscle, closure of the abdominal wall was attained without tension. The post-operative course was uneventful with minor wound seroma. The patient discharged safely, and no further complication in terms of recurrence and wound problem has occurred. Components separation technique could be a possible and effective treatment option for repair of large abdominal wall defect.
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Affiliation(s)
- Zisun Kim
- Department of Surgery, Soonchunhyang University College of Medicine, Seoul, Korea
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146
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Open versus endoscopic component separation: a cost comparison. Surg Endosc 2011; 25:2865-70. [DOI: 10.1007/s00464-010-1526-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2010] [Accepted: 11/27/2010] [Indexed: 11/26/2022]
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Mazzocchi M, Dessy LA, Ranno R, Carlesimo B, Rubino C. “Component separation” technique and panniculectomy for repair of incisional hernia. Am J Surg 2011; 201:776-83. [DOI: 10.1016/j.amjsurg.2010.04.013] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2009] [Revised: 03/26/2010] [Accepted: 04/05/2010] [Indexed: 11/28/2022]
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148
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Comparison of Outcome After Mesh-Only Repair, Laparoscopic Component Separation, and Open Component Separation. Ann Plast Surg 2011; 66:551-6. [DOI: 10.1097/sap.0b013e31820b3c91] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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150
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