Management of skin and subcutaneous tissue in complex open abdominal wall reconstruction

Modified Chevrel Technique: A Lifesaver for Surgeons

Background and Objectives: Ventral hernias (VH) pose significant challenges for surgeons due to the risk of recurrence, complexities in aligning abdominal muscles, and selecting the most suitable layer for mesh augmentation. This study aims to evaluate the effectiveness of utilizing the anterior rectus fascia as a turnover flap in conjunction with onlay mesh reinforcement, a procedure known as the modified Chevrel technique (MCT). Materials and Methods: We conducted a retrospective analysis of patients who were operated on using MCT for abdominal hernias between January 2013 and December 2019. Data were extracted from our hospital's electronic database. Recurrence rates, as well as the rates of surgical site occurrences (SSO), surgical site infections (SSI), and surgical site occurrences requiring procedural intervention (SSOPI), were analyzed based on patients' comorbidities and demographic characteristics. Results: The median follow-up period was 42.9 months (range: 14-96), and the recurrence rate was 4% (n = 3). Among the recurrent cases, three patients had chronic obstructive pulmonary disease, representing a statistically significant association (p = 0.02). Although all patients with recurrence were obese, this association did not reach statistical significance (p > 0.05). The mean hospitalization duration was 17.6 days (range: 6-29). SSO, SSI, and SSOPI rates were 39 (52%), 12 (16%), and 32 (42%), respectively. Conclusions: Managing VH remains a surgical challenge, emphasizing the importance of achieving effective abdominal closure for both functional and cosmetic outcomes. MCT presents a relatively simple approach compared to techniques like transversus abdominis release (TAR) and anterior component separation (ACS), with acceptable rates of SSO, SSOPI, SSI, and recurrence.

Predictive factors for complexity in abdominal wall hernias: a literature scope review

INTRODUCTION

Abdominal wall hernias encompass both ventral and incisional hernias, often poorly classified regarding complexity in general. This study aims to conduct a review on the primary topics related to defining the complexity of ventral hernias.

METHODS

this is a scope review conducted following the guidelines recommended by the PRISMA-ScR directive. Searches were carried out in electronic databases including PubMed, LILACS, and EMBASE, using the descriptors: Abdominal Hernia, Hernia, Ventral Hernia, Incisional Hernia, Complex, Classification, Classify, Grade, Scale, and Definition. Combinations of these terms were employed when appropriate. Inclusion criteria encompassed articles with definitions and classifications of complex hernias, as well as those utilizing these classifications to guide treatments and patient allocation. Synonyms and related topics were also considered. Articles outside the scope or lacking the themes in their title or abstract were excluded. The database search was conducted up to July 29, 2023.

RESULTS

several hernia classifications were identified as useful in predicting complexity. For this study, we considered six main criteria: size and location, loss of domain, use of abdominal wall relaxation techniques, characteristics of imaging exams, status of the subcutaneous cellular tissue, and likelihood of recurrence.

CONCLUSION

complex abdominal wall hernias can be defined by characteristics analyzed collectively, relating to the patients previous clinical status, size and location of the hernia defect, status of subcutaneous cellular tissue, myofascial release techniques, and other complicating factors.

Outcomes and Quality of Life After Resorbable Synthetic Ventral Hernia Repair in Contaminated Fields

INTRODUCTION

The ideal mesh type for hernia repair in a contaminated field remains controversial. Data regarding outcomes beyond 1 year and the impact on quality of life (QoL) are unknown. This study aims to evaluate the long-term surgical outcomes and patient-reported outcomes (PROs) after contaminated repair with poly-4-hydroxybutyrate (P4HB) mesh.

MATERIALS METHODS

Patients undergoing a contaminated hernia repair with P4HB between 2015 and 2020 were identified. Surgical site occurrences and hernia recurrences were recorded. Long-term PROs as defined by the Abdominal Hernia-Q and Hernia-Related Quality-of-Life Survey were assessed.

RESULTS

Fifty-five patients were included with a mean age of 54.5 years, a body mass index of 34 kg/m2, and a defect size of 356.9 ± 227.7 cm2. Median follow-up time was 49 months with a reoperation rate of 14.5% and a hernia recurrence rate of 7.3%. Of the 55 patients, 37 completed preoperative and postoperative PRO questionnaires. When comparing preoperative with postoperative Abdominal Hernia-Q, there was significant improvement in overall PROs (2.1 vs 3.5, P < 0.001). This improvement was maintained with no significant changes between postoperative scores over the course of 5 years. Patients with complications saw the same improvement in postoperative PRO scores as those without complications.

CONCLUSIONS

Our study found a low hernia recurrence and acceptable long-term reoperation rates in patients undergoing hernia repair with P4HB mesh in a contaminated setting. We demonstrate a sustained significant improvement in QoL scores after hernia repair. These data yield insight into the long-term outcomes and QoL improvement, providing physicians further knowledge to better counsel their patients.

Effect of stapled versus layered skin closure on surgical site occurrences after abdominal wall reconstruction

BACKGROUND

The effect of skin closure technique on surgical site occurrences (SSO) after open abdominal wall reconstruction (AWR) with retromuscular polypropylene mesh placement is largely unknown. We hypothesize that layered subcuticular skin closure with cyanoacrylate skin adhesive is protective of surgical site infection compared to standard stapled closure.

METHODS

A retrospective review utilizing the Abdominal Core Health Quality Collaborative (ACHQC) database of all patients at Prisma Health-Upstate. All patients with open abdominal wall reconstruction (AWR) of midline incisional hernia defects with retromuscular polypropylene mesh placement from January 2013 to February 2020 were included. Patient demographics, comorbidities, type of hernia repair with mesh location, method of skin closure, and SSOs were collected. Skin closure method was divided into two groups, reflecting a temporal change in practice: staples (historical control group) versus subcuticular suture with cyanoacrylate skin adhesive with/without polymer mesh tape (study group). Primary endpoint was SSI and SSO. Secondary endpoints were SSO or SSI requiring procedural intervention (SSOPI/SSIPI). Standard statistical methods were utilized.

RESULTS

A total of 834 patients were analyzed, with 263 treated with stapled skin closure and 571 with subcuticular and adhesive closure. On univariate analysis, the incidence of SSI was significantly lower in the study group (11.8 vs 6.8%; p = 0.002), as was the need for SSIPI (11.8 vs 6.7%; p = 0.015). Rate of SSO was not significantly different between groups (28.1 vs 27.2%), but the rate of SSO requiring intervention was lower in the study group (14.1 vs 9.3%; p = 0.045).

CONCLUSION

Layered skin closure technique, including subcuticular closure and adhesive, may reduce the risk of surgical site infection after open AWR. A prospective randomized trial is planned to confirm these findings.

Comparative Effectiveness Analysis of Resorbable Synthetic Onlay and Biologic Intraperitoneal Mesh for Abdominal Wall Reconstruction: A 2-Year Match-Paired Analysis

BACKGROUND

Abdominal wall reconstruction persists as a challenging surgical issue with a multitude of management strategies available. The aim of this study was to examine the efficacy of resorbable synthetic mesh onlay plane against biologic mesh in the intraperitoneal plane.

METHODS

A single-center, two-surgeon, 5-year retrospective review (2014 to 2019) was performed examining subjects who underwent abdominal wall reconstruction in the onlay plane with resorbable synthetic mesh or in the intraperitoneal plane with biologic mesh. A matched paired analysis was conducted. Data examining demographic characteristics, intraoperative variables, postoperative outcomes, and costs were analyzed.

RESULTS

Eighty-eight subjects (44 per group) were identified (median follow-up, 24.5 months). The mean age was 57.7 years, with a mean body mass index of 30.4 kg/m2. The average defect size was 292 ± 237 cm2, with most wounds being clean-contaminated (48.9 percent) and 55 percent having failed prior repair. Resorbable synthetic mesh onlay subjects were significantly less likely (4.5 percent) to experience recurrence compared to biologic intraperitoneal mesh subjects (22.7 percent; p < 0.026). In addition, mesh onlay suffered fewer postoperative surgical-site occurrences (18.2 percent versus 40.9 percent; p < 0.019) and required fewer procedural interventions (11.4 percent versus 36.4 percent; p < 0.011), and was also associated with significantly lower total costs ($16,658 ± $14,930) compared to biologic intraperitoneal mesh ($27,645 ± $16,864; p < 0.001).

CONCLUSIONS

Abdominal wall reconstruction remains an evolving field, with various techniques available for treatment. When faced with hernia repair, resorbable synthetic mesh in the onlay plane may be preferable to biologic mesh placed in the intraperitoneal plane because of lower long-term recurrence rates, surgical-site complications, and costs.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Reading a preoperative CT scan to guide complex abdominal wall reconstructive surgery

Computed tomography (CT) scanning is the imaging modality of choice when planning the overall management and operative approach to complex abdominal wall hernias. Despite its availability and well-recognised benefits there are no guidelines or recommendations regarding how best to read or report such scans for this application. In this paper we aim to outline an approach to interpreting preoperative CT scans in abdominal wall reconstruction (AWR). This approach breaks up the interpretive process into 4 steps-concentrating on the hernia or hernias, any complicating features of the hernia(s), the surrounding soft tissues and the abdominopelvic cavity as a whole-and was developed as a distillation of the authors' collective experience. We describe the key features that should be looked for at each of the four steps and the rationale for their inclusion.

Is simultaneous panniculectomy an ideal approach to repair a ventral hernia: a general surgeon's experience

BACKGROUND

The number of Australian patients undergoing ventral hernia repair has seen a significant increase in the last twenty years. With the obesity epidemic, the general surgeon is frequently seeing patients with hernias and significant abdominal aprons and is being asked to address this at the time of the hernia repair. This can be performed utilising a general surgery and plastic surgery team, but there may be some advantages to general surgeon being able incorporate this into their practice. We present our approach to patients undergoing ventral hernia repair and simultaneous panniculectomy (VHR + PAN) by a single general surgeon.

METHODS

Data were analysed from a single surgeon's experience performing VHR + PAN at the same operation. Data were collected prospectively from 2009 to 2020. 146 cases of patients undergoing VHR + PAN were identified and included in this study.

RESULTS

The mean age of patients undergoing VHR + PAN was 58 years. The mean BMI was 35, with 59% of patients losing weight loss prior to surgery. 66% of patients had a hernia repair with biosynthetic mesh and 91% of patients had retro-rectus or pre-peritoneal mesh approach to the repair. 42% of patients had a post-operative complication with 80.6% of these being related to surgical-site occurrences. Other complications included gastrointestinal (14%), respiratory (13%) and venous thromboembolism, such as a deep vein thrombus or pulmonary embolism (6%). There were 2 deaths in the series (1.3%). The hernia recurrence rate was 6%.

CONCLUSION

Simultaneous PAN is possible in patients with an abdominal apron who are undergoing VHR, with an acceptable risk of SSOs and other complications. This technique provides excellent exposure and with appropriate training is well within the remit of the general surgeon. This may save further operative management in the future and can offer patients improved self-esteem, mobility, and independence. Patient optimisation is key, paying careful attention to pre-operative weight loss, diabetic control, smoking cessation and respiratory function. VHR + PAN is an important technique that should be in the repertoire of all abdominal wall reconstruction units.

The effect of negative pressure wound therapy on surgical site occurrences in closed incision abdominal wall reconstructions: a retrospective single surgeon and institution study

PURPOSE

The use of closed incision negative pressure wound therapy (ciNPWT) in abdominal wall reconstruction is heavily debated. The current literature shows mixed results for its efficacy in preventing surgical site occurrences (SSOs), and many of the studies are limited by small sample size or a lack of generalizability. We sought to assess whether the use of prophylactic ciNPWT has an effect on reducing the rate of SSOs.

METHODS

Following institutional review board approval, a retrospective analysis of a prospectively collected abdominal wall reconstruction database of a single surgeon at a single institution was completed. Two hundred and seventy patients were reviewed. Univariate and multivariate logistic regressions were performed to assess the effect of each variable on the rate of SSOs.

RESULTS

Two hundred and fifty-eight patients (95.56%) met inclusion criteria. One hundred and fifty-nine (61.63%) of these patients received ciNPWT. The median duration of ciNPWT was 6 days. Multivariate logistic regression analysis showed no significant difference in the prevalence of SSOs between groups (OR = 0.843, 95% CI [0.445-1.594], p = 0.598). It did, however, show a significant decrease in the rates of seroma (7.07% vs. 0.63%, p = 0.004). Moreover, skin resection was associated with a decreased rate of SSO (OR = 0.295, 95% CI [0.096-0.911], p = 0.034).

CONCLUSIONS

ciNPWT was not associated with a decrease in SSOs following abdominal wall reconstruction but did show a statistically significant decrease in postoperative seromas. Future, large prospective analyses may help further discover the utility of ciNPWT in reducing SSOs.

Onlay Poly-4-Hydroxybutyrate (P4HB) Mesh for Complex Hernia: Early Clinical and Patient Reported Outcomes

BACKGROUND

While mesh re-enforcement and advanced surgical techniques are cornerstones of complex ventral hernia repair (CVHR), the risk of complications and recurrence is common. We aim to evaluate the efficacy, safety, and patient reported outcomes (PROs) of patients undergoing CVHR with onlay Poly-4-hydroxybutyrate (P4HB).

METHODS

Adult (>18 y old) patients undergoing VHR with P4HB (Phasix) in the onlay plane by a single surgeon from 01/2015 to 05/2020 were reviewed. VHR was considered complex if patients had significant co-morbidities, large abdominal wall defects, a history of extensive abdominal surgery, and/or concurrent intra-abdominal pathology. A composite of postoperative outcomes including surgical site occurrences (SSO), surgical site infection (SSI), and surgical site occurrences requiring procedural intervention (SSOpi), as well as PROs as defined by the Abdominal Hernia-Q (AHQ), were analyzed.

RESULTS

A total of 51 patients were included with average age and body mass index of 56.4 and 29.9 kg/m². Median follow up was 20 mo with a hernia recurrence rate of 5.9% (n = 3). 21 patients had an SSO (41.2%), 8 had an SSI (15.7%), and 6 had an SSOpi (11.8%). There was an association with Ventral Hernia Working Group ≥ 2 and development of SSO. There was a significant improvement in overall PROs (P < 0.0001) with no difference in those patients with and without complications (P > 0.05).

CONCLUSION

For hernia patients with large defects and complex intra-abdominal pathology, a safe and effective repair is difficult. The use of onlay P4HB was associated with acceptable postoperative outcomes and recurrence rate.

Resection and reconstruction of a giant primitive neuroectodermal tumour of the abdominal wall with an ultra-long lateral circumflex femoral artery musculocutaneous flap: a case report

Background

Primitive neuroectodermal tumours are clinically rare. Here, we report a case of a large peripheral primitive neuroectodermal tumour of the abdominal wall. The defect was reconstructed with the longest lateral circumflex femoral artery musculocutaneous flap reported to date.

Case presentation

A 15-year-old male suffered rupture and bleeding of an abdominal wall mass with a volume of approximately 23*18*10 cm³, involving the whole layer of the abdominal wall. Pathological examination revealed a peripheral primitive neuroectodermal tumour. The tumour was removed via oncologic resection, and the abdominal wall was reconstructed with a bilateral 44*8 cm² lateral circumflex femoral artery musculocutaneous flap combined with a titanium polypropylene patch. The patient had smooth recovery postoperative, and the functions of the donor and recipient areas of the flap were not significantly affected.

Conclusion

In this case report, we describe a rare primitive neuroectodermal tumour of the abdominal wall, which invaded almost the entire abdominal wall due to delay of treatment. After thoroughly removing the tumour, we immediately reconstructed the abdominal wall with an ultra-long lateral circumflex femoral artery musculocutaneous flap and achieved better appearance and function after the operation. This case suggests that we should adopt an integrated scheme of surgery combined with radiotherapy and chemotherapy in the treatment of peripheral primitive neuroectodermal tumours. Under the premise of determining the blood supply, the lateral circumflex femoral artery musculocutaneous flap can be cut to a sufficient length.

Chinese expert consensus on adult ventral abdominal wall defect repair and reconstruction

BACKGROUND

Surgical management of patients with ventral abdominal wall defects, especially complex abdominal wall defects, remains a challenging problem for abdominal wall reconstructive surgeons. Effective surgical treatment requires appropriate preoperative assessment, surgical planning, and correct operative procedure in order to improve postoperative clinical outcomes and minimize complications. Although substantial advances have been made in surgical techniques and prosthetic technologies, there is still insufficient high-level evidence favoring a specific technique. Broad variability in existing practice patterns, including clinical pre-operative evaluation, surgical techniques and surgical procedure selection, are still common.

DATA SOURCES

With the purpose of providing a best practice algorithm, a comprehensive search was conducted in Medline and PubMed. Sixty-four surgeons considered as experts on abdominal wall defect repair and reconstruction in China were solicited to develop a Chinese consensus and give recommendations to help surgeons standardize their techniques and improve clinical results.

CONCLUSIONS

This consensus serves as a starting point to provide recommendations for adult ventral abdominal wall repair and reconstruction in China and may help build opportunities for international cooperation to refine AWR practice.

Panniculectomy: Practical Pearls and Pitfalls

Panniculectomy is an increasingly common operation, given the current obesity epidemic and the increasing prevalence of bariatric surgery. At first glance, it could be considered a technically simple operation; however, this procedure can be fraught with complications, given the patient population and high demands placed on compromised abdominal tissue. Sufficient attention must be given to the nuances of patient optimization and surgical planning to maximize safe and ideal outcomes. We highlight our practical tips when performing standard or massive panniculectomy for preoperative optimization, intraoperative techniques, and postoperative management to reduce complication and maximize outcomes of this procedure from a surgeon's and a patient's perspective.

What Do We Know About the Chevrel Technique in Ventral Incisional Hernia Repair?

Introduction: In publications on ventral incisional hernia repair, the Chevrel technique and the onlay operation are often equated. This present review now aims to present the difference between these surgical techniques and analyze the findings available on the Chevrel technique.

Materials and Methods: A systematic search of the available literature was performed in January 2019 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library, as well as a search of relevant journals, books, and reference lists. Thirty-four publications were identified as relevant for this review. For assessment of the Chevrel-technique with other surgical procedures there are no randomized controlled trials, prospective or retrospective comparative studies available but only case series. In the majority of case series the follow-up procedure is not reported.

Results: In the onlay technique the defect is closed with direct suture or it is omitted altogether. Whereas, in the Chevrel technique this is done with sliding myofascial flaps harvested from the rectus sheaths. In the few case series available this appears to result in a lower recurrence rate for the Chevrel technique compared with the onlay technique. However, the rates of postoperative complications, surgical site occurrences (SSOs), surgical site infections (SSIs), seroma, and skin necrosis are as high as in the onlay technique. The reason for this is that both techniques require subcutaneous undermining with severance of perforator vessels.

Conclusion: If mesh placement in onlay position has been chosen for specific reasons, preference can be given to the Chevrel technique over the standard onlay technique, although the study quality is limited.

Complex Open Abdominal Wall Reconstruction: Management of the Skin and Subcutaneous Tissue

Optimal skin and soft tissue management in complex open abdominal wall reconstruction is an integral element of the operation to achieve optimal outcomes. Failure to provide stable, well-vascularized soft tissue coverage over the hernia repair can jeopardize the reconstruction through association with nonhealing wounds, mesh exposure, and even possible hernia recurrence. The literature has shown that careful attention to the skin and soft tissue, especially when part of a multidisciplinary approach to complex abdominal wall reconstruction, improves patient outcomes significantly.

The Value Proposition for Complex Abdominal Wall Reconstruction: How to Make It Work

BACKGROUND

The challenge for health care in the 21st century is to understand how to measure and improve value in the context of each patient care process for the entire cycle of care. For patients who undergo an abdominal wall reconstruction, there is a great opportunity to improve value because of the high cost and variability in outcomes for this complex operation.

METHODS

For almost a decade, our hernia team has been applying the principles of systems and data science to actual patient care. Tools from systems and data science applied to patient care include clinical quality improvement and nonlinear analytical methods such as factor analysis. The most important outcome to measure and improve is the value of care provided for the entire cycle of care.

RESULTS

Many measurement and improvement ideas have been applied to the abdominal wall reconstruction process in our hernia program, including the use of a less costly long-term resorbable mesh, multimodal pain management and enhanced recovery process improvement ideas, and surgical technique improvements that have led to decreased wound complications and the elimination of abdominal wall drains. More recently, the data analysis has shown an opportunity to improve outcomes through a robust prehabilitation program, including cognitive therapy to induce neural rewiring before surgery.

CONCLUSIONS

Improving value for patients who undergo abdominal wall reconstruction and for all patients in our global health care system should be a unifying goal. Understanding and applying systems and data science tools appropriately are necessary to achieve this goal.