Staged repair of massive incisional hernias with loss of abdominal domain: a novel approach

Bilateral rectus muscle turning-over for complicated and eventrated abdominal wall hernias: results of a novel method

PURPOSE

We present a technique for covering large midline loss of abdominal wall using a novel method by autologous tissues.

METHODS

Twenty-two patients (body mass index = 35,6 ± 6,9 kg/m2) were involved in the prospective cohort study. Acute and elective cases were included. The gap area was 450.1 ± 54 cm2. The average width of the midline gap was 16,3 ± 3,2 cm. The rectus muscles were mobilized from its posterior sheath. Both muscles were turned by180º medially, so that the complete abdominal wall gap could be covered without considerable tension. Changes in intra-abdominal pressure, quality of life and hernia recurrency were determined.

RESULTS

There was no significant increase in the intra-abdominal pressure. Wound infection and seroma occurred in four cases. Bleeding occurred in one case. Pre- and post-operative quality of life index significantly improved (23 ± 13 vs. 47 ± 6; p = 0,0013). One recurrent hernia was registered. The procedure could be performed safely and yielded excellent results. The method was applied in acute cases. The intact anatomical structure of rectus muscles was essential.

CONCLUSIONS

The midline reconstruction with bilateral turned-over rectus muscles provided low tension abdominal wall status, and it did not require synthetic mesh implantation.

Staged abdominal wall reconstruction in the setting of complex gastrointestinal reconstruction

PURPOSE

Literature on one- versus two-staged abdominal wall reconstruction (AWR) with complex gastrointestinal reconstruction (GIR) is limited to single-arm case series with a focus on patients who complete all planned stages. Herein, we describe our experience with both one- and two-staged approaches to AWR/GIR, with attention to those who did not complete both intended stages.

METHODS

A retrospective review of prospectively collected data was conducted to identify patients who underwent a one- or two-stage approach to GIR/AWR from 2013 to 2020. The one-stage approach included GIR and definitive sublay mesh herniorrhaphy. The two-stage approach included Stage 1 (S1)-GIR and non-definitive herniorrhaphy and Stage 2 (S2)-definitive sublay mesh herniorrhaphy.

RESULTS

Fifty-four patients underwent GIR/AWR: 20 (37.0%) underwent a planned 1-stage operation while 34 (63.0%) underwent S1 of a planned 2-stage approach. Patients assigned to the 2-stage approach were more likely to be smokers, have a history of mesh infection, have an enterocutaneous fistula, and a contaminated wound class (p<0.05). Of the 34 patients who underwent S1, 12 (35.3%) completed S2 during the mean follow-up period of 44 months while 22 (64.7%) did not complete S2. Of these, 10 (45.5%) developed hernia recurrence but did not undergo S2 secondary to elective nonoperative management (40%), pending preoperative optimization (30%), additional complex GIR (10%), hernia-related incarceration requiring emergent surgery (10%), or unrelated death (10%). No differences in outcome including SSI, SSO, readmission, and recurrence were noted between the 12 patients who completed the two-stage approach and the 20 patients who completed a one-stage approach, despite increased risk factors for complications in the 2-stage group (p>0.05).

CONCLUSION

Planned two-stage operations for GIR/AWR may distribute operative complexity and post-operative morbidity into separate surgical interventions. However, many patients may never undergo the intended definitive S2 herniorrhaphy. Future evaluation of 1- versus 2-stage GIR/AWR is needed to clarify indications for each approach. This work must also consider the frequent deviations from intended clinical course demonstrated in this study.

The increased angiogenic capacity and decreased inflammatory response when a mesh is used in combination with an omental flap. A prospective experimental study

BACKGROUND

The use of a surgical mesh for abdominal wall reconstruction is well established and has been used for long with minor complications, whereas the omental flap has been used for decades in reconstructive surgery.

AIM

To demonstrate the increased angiogenic capacity and the reduced inflammatory markers of a synthetic mesh when used in combination with an omental flap. Furthermore, we compare two independent meshes when used alone or in combination with the omental flap.

MATERIALS AND METHODS

Twenty-eight rats were included in the study. To determine the effect of using an omental flap under two different meshes, the animals were separated into four groups, i.e., group A (flap + mesh 1), group B (flap + mesh 1 + silicone), group C (flap + mesh 2), and group D (flap + mesh 2 + silicone). A silicone sheet was placed as a barrier between the mesh and the flap. All groups were sacrificed 8 weeks post-operatively.

RESULTS

The use of a silicone sheet barrier between any of the two synthetic meshes and the omental flap in an abdominal wall defect is accompanied by a markedly reduced angiogenesis in terms of a cluster of differentiation (CD)-34 (p < 0.001) and factor VIII (p = 0.0012) and by increased inflammatory response CD-68 (p = 0.0024) and visual scoring (p < 0.001).

CONCLUSIONS

Τhe increased angiogenic capacity and the reduced inflammatory markers of a synthetic surgical mesh when used in combination with an omental flap make it a useful option in the reconstruction of an abdominal wall defect on a large or contaminated wound.

Outcomes of biologic versus synthetic mesh in CDC class 3 and 4 open abdominal wall reconstruction

INTRODUCTION

Abdominal wall reconstruction (AWR) in a contaminated field is associated with an increased risk of wound complications, infection, and reoperation. The best method of repair and mesh choice in these operations have generated marked controversy. Our aim was to compare outcomes of patients who underwent AWR with biologic versus synthetic mesh in CDC class 3 and 4 wounds.

METHODS

A prospective, single-institution database was queried for AWR using biologic or synthetic mesh in CDC Class 3 and 4 wounds. Hernia recurrence and complications were measured. Multivariable logistic regression was performed to identify factors predicting both.

RESULTS

In total, 386 patients with contaminated wounds underwent AWR, 335 with biologic and 51 with synthetic mesh. Groups were similar in age, sex, BMI, and rate of diabetes. Biologic mesh patients had larger hernia defects (298 ± 233cm² vs. 208 ± 155cm²; p = 0.004) and a higher rate of recurrent hernias (72.2% vs 47.1%; p < 0.001), comorbidities(5.8 ± 2.7 vs. 4.2 ± 2.4, p < 0.01), and a nearly fivefold increase in Class 4 wounds (47.8% vs. 9.8%, p < 0.001), while fascial closure trended to being less common (90.7% vs 96.1%; p = 0.078). Hernia recurrence was comparable between biologic and synthetic mesh (10.4% vs. 17.6%, p = 0.132). Wound complication rates were similar (36.1% vs. 33.3%, p = 0.699), but synthetic mesh had higher rates of mesh infection (1.2% vs 11.8%; p < 0.001) and infection-related resection (0% vs 7.8%, p < 0.001), with 66% of those synthetic mesh infections requiring excision. On logistic regression, wound complications (OR 5.96 [CI 1.60-22.17]; p = 0.008) and bridging mesh (OR 13.10 [CI 2.71-63.42];p = 0.030) predicted of hernia recurrence (p < 0.05), while synthetic mesh (OR 18.6 [CI 2.35-260.4] p = 0.012) and wound complications (OR 20.6 [CI 3.15-417.7] p = 0.008) predicted mesh infection.

CONCLUSIONS

Wound complications in AWR with CDC class 3 and 4 wounds significantly increased mesh infection and hernia recurrence; failure to achieve fascial closure also increased hernia recurrence. Use of synthetic versus biologic mesh increased the mesh infection rate by 18.6 times.

A simplified method to evaluate the loss of domain

PURPOSE

The treatment of giant incisional hernia (IH) with loss of domain (LOD, IHLD) is considerably challenging due to technical difficulties and subsequent post-operative complications. These post-operative risks may be anticipated by calculating the abdominal cavity (AC) volume (ACV) and the IH volume (IHV) on the preoperative CT-scans, using the AC and IH dimensions (Tanaka's method) or using tridimensional volumetry (Sabbagh's method). These techniques are often time-consuming and require specific softwares. The aim of the present study was to develop a simple method to rapidly obtain the LOD-ratio on the preoperative CT-Scan.

METHODS

The CT-scans (n = 89) of patients with IHLD were retrospectively studied. Several ratios were calculated using different parameters of the AC and the IH, including width, height and depth, the areas (axial and sagittal ellipse, as well as freehand sagittal surface areas) and these were compared with the reference methods of Sabbagh et al. and Tanaka et al. RESULTS: The LOD ratios calculated from the two reference methods gave similar results (ICC = 0.82, p < 0.0001). The new "R-ratios" (Reims-ratios) obtained from the IH and AC surface areas measured using the "freehand ROI" tool on sagittal view or roughly evaluated by an ellipse on axial view showed excellent correlation with both reference ratios (all ICC ≥ 0.71, p < 0.0001).

CONCLUSION

The LOD ratio may be quickly obtained by drawing two circles on the pre-operative CT scan ("R ratios") and available on the webpage https://romeo.univ-reims.fr/Rratio/ . This will certainly help surgeons to routinely anticipate the post-operative complications before IHLD repair.

Adjunct botox to preoperative progressive pneumoperitoneum for incisional hernia with loss of domain: no additional effect but may improve outcomes

INTRODUCTION

Incisional hernia with loss of domain (IHLD) remains a surgical challenge. Its management requires complex approaches including specific preoperative and intra-operative techniques. This study focuses on the interest of adding preoperative botulinum toxin A (BTA) injection to preoperative progressive pneumoperitoneum (PPP), compared to PPP alone.

MATERIAL

Patients between January 2015 and March 2020 with IHLD who underwent pre-operative preparation were included. Their baseline characteristics were retrospectively analyzed, along with the characteristics of their incisional hernia before and after preparation including CT-scan volumetry. Intra-operative data, early post-operative outcomes, surgical site occurrences (SSOs) including surgical site infection (SSI) were recorded.

RESULTS

Four hundred and fifty (450) patients with incisional hernia were operated, including 41 patients (9.1%) with IHLD, 13 of which had both BTA and PPP, while 28 had PPP only. Both groups were comparable in term of patients and IHLD characteristics. Median increase in the volume of the abdominal cavity (VAbC) was + 55% for the entire population (+ 58.3% for the BTA-PPP group, p < 0.0001 and + 52.8% for the PPP-alone group, p < 0.0001) although the increase in volume was not different between the two groups (p = 0.99). Complete fascial closure was achieved in all patients. SSOs were more frequent in the PPP-alone group than in the BTA-PPP group (17 (60.7%) versus 3 (23.1%) patients, respectively, p = 0.043).

CONCLUSION

BTA and PPP are both useful in pre-operative preparation for IHLD. Combining both significantly increases the volume of abdominal cavity but associating BTA to PPP does not add any volumetric benefit but may decrease the post-operative SSO rate.

Combining anterior and posterior component separation for extreme cases of abdominal wall reconstruction

PURPOSE

The closure of midline in abdominal wall incisional hernias is an essential principle. In some exceptional circumstances, despite adequate component separation techniques, this midline closure cannot be achieved. This study aims to review the results of using both anterior and component separation in these exceptional cases.

METHODS

We reviewed our experience using the combination of both anterior and posterior component separation in the attempt to close the midline. Our first step was to perform a TAR and a complete extensive dissection of the retromuscular preperitoneal plane developed laterally as far as the posterior axillary line. When the closure of midline was not possible, an external oblique release was made. A retromuscular preperitoneal reinforcement was made with the combination of an absorbable mesh and a 50 × 50 polypropylene mesh.

RESULTS

Twelve patients underwent anterior and posterior component separation. The mean hernia width was 23.5 ± 5. The majority were classified as severe complex incisional hernia and had previous attempts of repair. After a mean follow-up of 27 months (range 8-45), no case of recurrence was registered. Only one patient (8.33%) presented with an asymptomatic bulging in the follow-up. European Hernia Society's quality of life scores showed a significant improvement at 2 years postoperatively in the three domains: pain (p = 0.01), restrictions (p = 0.04) and cosmetic (p = 0.01).

CONCLUSIONS

The combination of posterior and anterior component separation can effectively treat massive and challenging cases of abdominal wall reconstruction in which the primary midline closure is impossible to achieve despite appropriate optimization of surgery.

A novel tool to evaluate bias in literature on use of biologic mesh in abdominal wall hernia repair

PURPOSE

Biologic meshes are being increasingly used for abdominal hernia repair in high-risk patients or patients with a previous history of wound infection, due to their infection-resistant properties. Several studies have been carried out to assess whether biologic mesh is superior to synthetic mesh, as well as to establish guidelines for their use. Unfortunately, most of these studies were not rigorously designed and were vulnerable to different types of bias. The systematic reviews that have been published so far on this topic contain the same biases and limitations of the primary articles that are analyzed. The lack of a literature review on the bias on the use of biological mesh prompted us to conduct the literature search, assessment and plan this article.

METHODS

We performed a literature search in PubMed, Embase and Cochrane databases of systematic reviews on biologic mesh for ventral hernia repair. The literature review was conducted using the Population, Intervention, Comparisons, Outcomes and Design approach. We identified 40 studies that matched the stringent criteria we had set. We then created a 13-point instrument to assess for bias and applied it on the primary studies that we intended to analyze.

RESULTS

Most primary studies are case series or case reports of patients undergoing abdominal hernia repair with biologic mesh, without any comparison group, and the inclusion of cases was only specified to be consecutive in 6 out of 40 cases. In terms of assessing outcomes, in none of the 40 articles were the outcome assessors blinded to the intervention or exposure status of participants.

CONCLUSION

The instrument that we created could allow to assess the risk of bias in different kind of studies. Our assessment of the studies based on the criteria that we had set up in the instrument clearly identified that further research needs to be done due to the lack of unbiased studies regarding the use of biologic meshes for abdominal hernia repair.

A Meta-analysis of Outcomes Using Acellular Dermal Matrix in Breast and Abdominal Wall Reconstructions: Event Rates and Risk Factors Predictive of Complications

BACKGROUND

The use of acellular dermal matrix (ADM) has gained acceptance in breast and abdominal wall reconstructions. Despite its extensive use, there is currently a wide variation of reported outcomes in the literature. This study definitively elucidates the outcome rates associated with ADM use in breast and abdominal wall surgeries and identifies risk factors predisposing to the development of complications.

METHODS

A literature search was conducted using the Medline database (PubMed, US National Library of Medicine) and the Cochrane Library. A total of 464 articles were identified, of which 53 were eligible for meta-analysis. The endpoints of interest were the incidences of seroma, cellulitis, infection, wound dehiscence, implant failure, and hernia. The effects of various risk factors such as smoking, radiation, chemotherapy, and diabetes on the development of complications were also evaluated.

RESULTS

A majority of the studies were retrospective (68.6%) with a mean follow-up of 16.8 months (SD ± 10.1 months) in the breast group and 14.2 months (SD ± 7.8 months) in the abdominal wall reconstructive group. The overall risks and complications were as follows: cellulitis, 5.1%; implant failure, 5.9%; seroma formation, 8%; wound dehiscence, 8.1%; wound infection, 16.1%; hernia, 27.6%; and abdominal bulging, 28.1%. Complication rates were further stratified separately for the breast and abdominal cohorts, and the data were reported. This provides additional information on the associated abdominal wall morbidity in patients undergoing autologous breast reconstruction in which mesh reinforcement was considered as closure of the abdominal wall donor site. Radiation resulted in a significant increase in the rates of cellulitis (P = 0.021), and chemotherapy was associated with a higher incidence of seroma (P = 0.014).

CONCLUSION

This study evaluates the overall complication rates associated with ADM use by conducting a meta-analysis of published data. This will offer physicians a single comprehensive source of information during informed consent discussions as well as an awareness of the risk factors predictive of complications.

Comparison of Synthetic and Biologic Mesh in Ventral Hernia Repair Using Components Separation Technique

Ventral hernia repair (VHR) for large abdominal wall defects is challenging. Prior research established that the use of mesh is superior to suture closure alone and that component separation is an effective technique to combat loss of abdominal domain. Studies comparing component separation technique (CST) outcomes utilizing synthetic versus biologic mesh are limited. A retrospective review was conducted of 72 consecutive patients who underwent VHR with CST between 2006 and 2010 at our institution. Surgeon preference and the presence of contamination guided whether synthetic mesh (27 patients) or biologic mesh (45 patients) was used. Mean follow-up interval for all comers was 13.9 months and similar in both groups (P > 0.05). Degree of contamination and severity of premorbid medical conditions were significantly higher in the biologic mesh group, as reflected in the higher Ventral Hernia Working Group (VHWG) score (2.04 versus 2.86). Clinical outcomes, as measured by both minor and major complication rates and recurrence rates, were not significantly different. Minor complication rates were 26% in the synthetic group and 37% in the biologic group and major complication rates 15% in the synthetic group and 22% in the biologic group. There was 1 recurrence (4%) in the synthetic mesh group versus 5 (11%) in the biologic mesh group. Multivariable analysis for major complications revealed no significant difference for either synthetic or biologic mesh while controlling for other variables. Subset analysis of uncontaminated cases revealed recurrence rates of 4% in the synthetic mesh group and 6% in the biologic mesh group. VHR using CST and either synthetic mesh or biologic mesh resulted in low recurrence rates with similar overall complication profiles, despite the higher average VHWG grading score in the biologic mesh group. Our results support the VHWG recommendation for biologic mesh utilization in higher VHWG grade patients. In VHWG grade 2 patients, our clinical outcomes were similar, supporting the use of either type of mesh.

Incarcerated and eventrated abdominal wall hernia reconstruction with autologous double-layer dermal graft in the field of purulent peritonitis-A case report

•

This is the first applied autologous dermal graft for eventrated hernia in an emergency case.

•

Terminal ileum and ascending colon were perforated into the hernia sac causing dirty operating field.

•

It was impossible to close the 223 cm² gap with sutures, biological mesh was not available.

•

Specially prepared grafts were applied to reconstruct the gap in a double- layer tension free fashion.

•

No hernia recurrency was observed 8 months after the surgery.

Introduction

Double-layer dermal grafts are used for the management of complicated abdominal wall hernias in obese, high risk patients. The method has not yet been used in case of emergency in septic/dirty environment.

Case report

A 76-year old female patient (BMI 36.7 kg/m²) was admitted with mechanical bowel obstruction and sepsis caused by a third time recurred, incarcerated and eventrated abdominal wall hernia. During the emergency surgery perforation of the terminal ileum and the ascending colon was detected, along with a feculent peritonitis and extended abdominal wall necrosis. Extended right hemicolectomy and necrectomy of the abdominal wall were performed. The surgery resulted in an abdominal wall defect measuring 223 cm², for the management of which direct closure was not possible. Using a specific method, an autologous dermal graft was prepared from the redundant skin. The first dermal graft was placed under the abdominal wall with 5 cm overlap, and the second layer was placed onto the first layer with 3 cm overlap in a perforated fashion. The operating time was 250 min. No significant intra-abdominal pressure elevation was measured. No reoperation was performed. On the fifth postoperative day, the patient was mobilised. She was discharged in satisfactory general condition on the 18th postoperative day. There is no recurrent hernia 8 months after the surgery.

Discussion

Abdominal wall reconstruction was possible in a necrotic, purulent environment by using a de-epithelised autologous double layer dermal graft, without synthetic or biological graft implantation. The advantage of the procedure was cost-effectivity, and the disadvantage was that only in an obese patient is the sufficient quantity of dermal graft available.

Conclusion

A homogeneous internal and perforated outer dermal graft was suitable for bridging the abdominal gap in the case of an obese, high risk patient. Autologous dermal grafts can be a safe and feasible alternative to biological meshes in emergency abdominal wall surgeries. Evaluation of a case series can be the next cornerstone of the method described above.

Immediate, Multistaged Approach to Infected Synthetic Mesh: Outcomes After Abdominal Wall Reconstruction With Porcine Acellular Dermal Matrix

BACKGROUND

Infection of synthetic mesh after abdominal wall hernia repair is a complex problem. The purpose of this study was to determine whether a staged approach to abdominal wall reconstruction (AWR) using a porcine acellular dermal matrix (PADM) is beneficial in the setting of infected synthetic mesh.

METHODS

The authors performed a retrospective review of 27 patients who underwent immediate, staged complex AWR using PADM from 2007 to 2012.

RESULTS

After a component separation, primary fascial closure was achieved in 21/27 (78%) patients, whereas 6/22 (22%) received a bridged hernia repair with PADM. Wound-related complications developed in 7/27 (26%) patients including wound dehiscence 6/27 (22%), surgical site infection 5/27 (19%), and hematoma 1/27 (4%). The hernia recurrence rate observed by 32 months was 19%. A bridged hernia repair and the development of a postoperative infection were associated with hernia recurrence, P<0.05.

CONCLUSIONS

A 2-stage approach to AWR with PADM can provide a safe and effective solution for patients with infected synthetic mesh.

The repair of large ventral hernias in patients with severe cardio-respiratory disease: Volume transposition technique

Massive hernias of the abdominal wall present a major challenge to the general surgeon. In some extreme cases of patients with severe cardio-respiratory disease, the repair of such hernias may be impracticable. In these cases, we believe the volume transposition technique is appropriate. In this approach, the hernia volume is calculated and the wall repaired with mesh to accommodate the estimated volume of the hernia sac, thus avoiding any increase in intra-abdominal pressure. We believe this technique is simple, reproducible and useful in cases that are inoperable due to cardio-respiratory problems that make any loss of lung volume unacceptable.

A randomized controlled experimental study comparing chitosan coated polypropylene mesh and Proceed™ mesh for abdominal wall defect closure

BACKGROUND

Abdominal wall defects and hernias are commonly repaired with synthetic or biological materials. Adhesions and recurrences are a common problem. A study was conducted to compare Chitosan coated polypropylene mesh and a polypropylene-polydioxanone composite with oxidized cellulose coating mesh (Proceed™) in repair of abdominal wall defect in a Rabbit hernia model.

METHODS

A randomized controlled experimental study was done on twelve New Zealand white rabbits. A ventral abdominal defect was created in each of the rabbits. The rabbits were divided into two groups. In one group the defect was repaired with Chitosan coated polypropylene mesh and Proceed mesh™ in the other. The rabbits were operated in two phases. They were followed up at four weeks and twelve weeks respectively after which the rabbits were sacrificed. They were evaluated by open exploration and histopathological examination. Their efficacy in reducing adhesion and ability of remodeling and tissue integration were studied.

RESULTS

There was no statistical significance in the area of adhesion, the force required to remove the adhesions, tissue integration and remodeling between Chitosan and Proceed™ group. Histological analysis revealed that the inflammatory response, fibrosis, material degradation and remodeling were similar in both the groups. There were no hernias, wound infection or dehiscence in any of the studied animals.

CONCLUSION

Chitosan coated polypropylene mesh was found to have similar efficacy to Proceed™ mesh. Chitosan coated polypropylene mesh, can act as an anti adhesive barrier when used in the repair of incisional hernias and abdominal wall defects.

Endoscopic versus open component separation: systematic review and meta-analysis

BACKGROUND

The component separation technique (CST) was developed to improve the integrity of abdominal wall reconstruction for large, complex hernias. Open CST necessitates large subcutaneous skin flaps and, therefore, is associated with significant ischemic wound complications. The minimally invasive or endoscopic component separation technique (MICST) has been suggested in preliminary studies to reduce wound complication rates post-operatively. In this study, we systematically reviewed the literature comparing open versus endoscopic component separation and performed a meta-analysis of controlled studies.

METHODS

A comprehensive search of electronic databases was completed. All English, randomized controlled trials, non-randomized comparison study, and case series were included. All comparison studies included in the meta-analysis were assessed independently by two reviewers for methodological quality using the Cochrane Risk of Bias tools.

RESULTS

63 primary studies (3,055 patients) were identified; 7 controlled studies and 56 case series. The total wound complication rate was lower for MICST (20.6 %) compared to Open CST (34.6 %). MICST compared to open CST was shown to have lower rates of superficial infections (3.5 vs 8.9 %), skin dehiscence (5.3 vs 8.2 %), necrosis (2.1 vs 6.8 %), hematoma/seroma formation (4.6 vs 7.4 %), fistula tract formation (0.4 vs 1.0 %), fascial dehiscence (0.0 vs 0.4 %), and mortality (0.4 vs 0.6 %.) The open component CST did have lower rates of intra-abdominal abscess formation (3.8 vs 4.6 %) and recurrence rates (11.1 vs 15.1 %). The meta-analysis included 7 non-randomized controlled studies (387 patients). A similar suggestive overall trend was found favoring MICST, although most types of wound complications did not show to significance. MICST was associated with a significantly decreased rate of fascial dehiscence and was shown to be significantly shorter procedure.

CONCLUSION

This systematic review and meta-analysis comparing MICST to open CST suggests MICST is associated with decreased overall post-operative wound complication rates. Further prospective studies are needed to verify these findings.

Repair of giant ventral hernias

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Early repair of open abdomen with a tailored two-component mesh and conditioning vacuum packing: a safe alternative to the planned giant ventral hernia

Purpose

Once open abdomen therapy has succeeded, the problem of closing the abdominal wall must be addressed. We present a new four-stage procedure involving the application of a two-component mesh and vacuum conditioning for abdominal wall closure of even large defects. The aim is to prevent the development of a giant ventral hernia and the eventual need for the repair of the abdominal wall.

Methods

Nineteen of 62 patients treated by open abdomen over a two-year period could not receive primary abdominal wall closure. To achieve closure in these patients, we applied the following four-stage procedure: stage 1: abdominal damage control and conditioning of the abdominal wall; stage 2: attachment of a tailored two-component mesh of polyglycolic acid (PGA) and large pore polypropylene (PP) in intraperitoneal position (IPOM) plus placement of a vacuum bandage; stage 3: vacuum therapy for 3–4 weeks to allow granulation of the mesh and optimization of dermatotraction; stage 4: final skin suture. During stage 3, eligible patients were weaned from respirator and mobilized.

Results

The abdominal wall gap in the 19 patients ranged in size from 240 cm² to more than 900 cm². An average of 3.44 vacuum dressing changes over 19 days were required to achieve 60–100 % granulation of the surface area, so final skin suture could be made. Already in stage 3, 14 patients (73.68 %) could be weaned from respirator an average of 6.78 days after placement of the two-component mesh; 6 patients (31.57 %) could be mobilized on the edge of the bed and/or to a bedside chair after an average of 13 days. No mesh-related hematomas, seromas, or intestinal fistulas were observed.

Conclusion

The four-stage procedure presented here is a viable option for achieving abdominal wall closure in patients treated with open abdomen, enabling us to avoid the development of planned giant ventral hernias. It has few complications and has the special advantage of allowing mobilization of the patients before final skin closure. Long-term course in a large number of patients must still confirm this result.

Peritoneal volume is predictive of tension-free fascia closure of large incisional hernias with loss of domain: a prospective study

INTRODUCTION

The surgical treatment of large incisional hernias with loss of domain (LIHLD) carries the risk of fascia closure under tension and, thus, abdominal compartment syndrome. We investigated volume measurements as a predictive factor for tension-free fascia closure.

PATIENTS AND METHODS

From September 2004 to July 2008, we prospectively included 17 patients with LIHLD. The operation was prepared by a progressive preoperative pneumoperitoneum (PPP) technique known as the Goni Moreno procedure. The patient's age and body mass index (BMI), the incisional hernia's width, length and surface area, and the incisional hernia volume (IHV)/peritoneal volume (PV) ratio <20% were evaluated as predictive factors for tension-free fascia closure. A tension-free closure was defined as a closure in which the use of a surgical device for avoiding postoperative compartment syndrome was not required.

RESULTS

The mean PPP volume introduced was 12.7 ± 4.4 l (range 4.5-19.2) over a period of 11 ± 6 days (range 4-24). The mean width, height and surface area of the incisional hernia after PPP were 11.3 ± 4.7 cm (range 4.5-19), 13.4 ± 7.8 cm (range 4.4-30) and 165 ± 101 cm(2) (range 19-304), respectively. The mean IHV after PPP was 2,374 ± 1,356 cc (range 517-4,802) and the mean abdominal cavity volume was 9,558 ± 4,106 cc (range 4,785-21,782). The mean IHV/PV ratio was 16.3 ± 10.4% (range 4.4-34). In a univariate analysis, the BMI and the IHV/PV ratio were predictive of tension-free fascia closure. In a multivariate analysis, only an IHV/PV ratio <20% was a significant predictive factor.

CONCLUSIONS

The IHV/PV ratio is predictive of tension-free fascia closure for hernias or incisional hernias with loss of domain. Simplification of the volumetry method is necessary.

Grandes hérnias incisionais

INTRODUÇÃO: A correção de hérnias incisionais abdominais permanece como um dos procedimentos cirúrgicos mais comuns uma vez que ela ocorre em cerca de 11% das laparotomias. Vários são os fatores de risco. Surgem, em geral, nos primeiros cinco anos após a operação e seu manuseio ainda é controverso. OBJETIVO: Atualizar os meios e métodos empregados para a correção cirúrgica das hérnias abdominais gigantes. MÉTODO: Revisão da literatura com base no Pubmed, Scielo e Lilacs com cruzamento dos descritores "hérnia abdominal, próteses, complicações e técnicas cirúrgicas", e adicionando contribuição própria baseada na experiência dos autores no manuseio desta afecção. CONCLUSÃO: Mesmo as correções bem sucedidas, com a utilização ou não de grandes próteses, não são os procedimentos isentos de inconvenientes, pois a parede abdominal não retoma a sua elasticidade e complacência normais. Por este motivo, é importante que o paciente seja alertado da possibilidade da sua expectativa em relação ao resultado, tanto estético quanto funcional, não ser alcançada.

Comparison of three separate antiadhesive barriers for intraperitoneal onlay mesh hernia repair in an experimental model

Background

Adhesion formation is a common adverse effect in intraperitoneal onlay mesh (IPOM) surgery. Different methods of adhesion prevention have been developed, including coated meshes and separate antiadhesive barriers (SABs). In this study one type of mesh was tested with different SABs, which were fixed to the sutured mesh using fibrin sealant. The primary aim was to compare adhesion prevention between different SABs. Secondary aims were the assessment of tissue integration and evaluation of SAB fixation with fibrin sealant.

Methods

Thirty-two rats were randomized to one of three treatment groups (SurgiWrap®, Prevadh® and Seprafilm®) or a control group (no SAB). Animals were operated on with an open IPOM technique (8 per group). One macroporous polypropylene mesh per animal (2 × 2 cm) was fixed with four non-absorbable sutures. An antiadhesive barrier of 2·5 × 2·5 cm was fixed with fibrin sealant. After 30 days, adhesion formation, tissue integration, seroma formation, inflammation and vascularization were evaluated macroscopically and by histology.

Results

Prevadh® and Seprafilm® groups showed a significant reduction in adhesion formation compared with the control group. Tissue integration of the mesh was reduced in these groups. Fibrin sealant fixed the SAB to the mesh securely in all groups.

Conclusion

Prevadh® and Seprafilm® are potent materials for the reduction of adhesion formation. A potential relationship between effective adhesion prevention and impaired tissue integration of the implant was observed. Fibrin sealant proved an excellent agent for SAB fixation.

[Abdominal wall closure by incisional hernia and herniation after laparostoma]

As hernias and abdominal wall defects have a variety of etiologies each with its own complications and comorbidities in various constellations, efficient treatment requires patient-oriented management. There is no recommended standard treatment and the very different clinical pictures demand an individualized interdisciplinary approach. Particularly in the case of complicated hernias, the planning of the operation should focus on the problems posed by the individual patient. Treatment mainly depends on the etiology of the hernia, immediate or long-term complications and the efficiency of individual repair techniques. Abdominal wall repair for recurrent herniation requires direct closure of the fascia generally using the sublay technique with a lightweight mesh. It is still unclear whether persistent inflammation, mesh dislocation, fistula formation or other long-term complications are due to certain materials or to the surgical technique. With mesh infections it has been shown to be advantageous to remove a polytetrafluoroethylene (PTFE) mesh, while the combination of systemic and local treatment appears to suffice for a polypropylene or polyester mesh. Heavier meshes in the sublay position or plastic reconstruction with autologous tissue are indicated as substitutes for the abdominal wall for giant hernias, repeated recurrences and large abdominal wall defects. A laparostoma is increasingly more often created to treat septic intra-abdominal processes but is very often responsible for a complicated hernia. If primary repair of the abdominal wall is not an option, resorbable material or split skin is used for coverage under the auspices of a planned hernia repair.

Morphological and mechanical characteristics of the reconstructed rat abdominal wall following use of a wet electrospun biodegradable polyurethane elastomer scaffold

Although a variety of materials are currently used for abdominal wall repair, general complications encountered include herniation, infection, and mechanical mismatch with native tissue. An approach wherein a degradable synthetic material is ultimately replaced by tissue mechanically approximating the native state could obviate these complications. We report here on the generation of biodegradable scaffolds for abdominal wall replacement using a wet electrospinning technique in which fibers of a biodegradable elastomer, poly(ester urethane)urea (PEUU), were concurrently deposited with electrosprayed serum-based culture medium. Wet electrospun PEUU (wet ePEUU) was found to exhibit markedly different mechanical behavior and to possess an altered microstructure relative to dry processed ePEUU. In a rat model for abdominal wall replacement, wet ePEUU scaffolds (1x2.5 cm) provided a healing result that developed toward approximating physiologic mechanical behavior at 8 weeks. An extensive cellular infiltrate possessing contractile smooth muscle markers was observed together with extensive extracellular matrix (collagens, elastin) elaboration. Control implants of dry ePEUU and expanded polytetrafluoroethylene did not experience substantial cellular infiltration and did not take on the native mechanical anisotropy of the rat abdominal wall. These results illustrate the markedly different in vivo behavior observed with this newly reported wet electrospinning process, offering a potentially useful refinement of an increasingly common biomaterial processing technique.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Management of Complex Abdominal Wall Defects Using Acellular Porcine Dermal Collagen

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

Inactivation of bacterial spores and viruses in biological material using supercritical carbon dioxide with sterilant

The purpose of this study was to validate supercritical carbon dioxide (SC-CO(2)) as a terminal sterilization method for biological materials, specifically acellular dermal matrix. In this study, bacterial spores, Bacillus atrophaeus, were inoculated onto porcine acellular dermal matrix to serve as a "worst case" challenge device. The inactivation of the spores by SC-CO(2) with peracetic acid (PAA) sterilant was analyzed as a function of exposure times ranging from 1 to 30 min. A linear inactivation profile for the Bacillus atrophaeus spores was observed, and a SC-CO(2) exposure time of 27 min was determined to achieve a sterility assurance level of 10(-6). The inactivation of viruses was also studied using Encephalomyocarditis (EMC) viruses. After 15 min of exposure to SC-CO(2) with PAA sterilant, more than a 6 log(10) reduction was observed for EMC viruses. Biochemical and biomechanical evaluations showed that the SC-CO(2) treatment with PAA sterilant did not cause significant changes in porcine acellular matrix's susceptibility to collagenase digestion, tensile or tear strength, indicating limited alteration of the tissue structure following SC-CO(2) sterilization.

A review of tissue-engineered skin bioconstructs available for skin reconstruction

Situations where normal autografts cannot be used to replace damaged skin often lead to a greater risk of mortality, prolonged hospital stay and increased expenditure for the National Health Service. There is a substantial need for tissue-engineered skin bioconstructs and research is active in this field. Significant progress has been made over the years in the development and clinical use of bioengineered components of the various skin layers. Off-the-shelf availability of such constructs, or production of sufficient quantities of biological materials to aid rapid wound closure, are often the only means to help patients with major skin loss. The aim of this review is to describe those materials already commercially available for clinical use as well as to give a short insight to those under development. It seeks to provide skin scientists/tissue engineers with the information required to not only develop in vitro models of skin, but to move closer to achieving the ultimate goal of an off-the-shelf, complete full-thickness skin replacement.

Management of giant ventral hernia by polypropylene mesh and host tissue barrier: trial of simplification

BACKGROUND

Surgical management of giant ventral hernias is a surgical challenge due to limited abdominal cavity. This study evaluates management of giant ventral hernias using polypropylene mesh and host tissue barrier after suitable preoperative preparation.

METHODS

In the period from January 2005 and January 2007, 35 patients with giant ventral hernias underwent hernia repair. After careful preoperative preparation, repair was done using polypropylene mesh. The mesh was separated from the viscera by a small part of the hernia sac and the greater omentum.

RESULTS

The average age of the patients was 52. Twenty patients had post-operative incisional and 15 had para-umbilical hernias. The mean hernia defect size was 16.8 cm. Mean body mass index was 33. Follow up ranged from 18-36 months. No patient required ventilation after operation. Recurrent seroma, which responded to repeated aspiration, was experienced in 4 patients. Minor wound infection was observed in 5 patients. Small hernia recurrence occurred in one patient.

CONCLUSION

The use of polypropylene and host tissue barrier after suitable preoperative preparation is relatively simple, safe, and reliable surgical solution to the problem of giant ventral hernia.

KEYWORDS

Hernia repair; Giant ventral hernia; Polypropylene mesh.

Prosthetic abdominal wall hernia repair in emergency surgery: from polypropylene to biological meshes

The use of nonabsorbable prosthetic materials such as polypropylene, polyester, and ePTFE, have expanded and are now widely used in reparative surgery for abdominal wall hernias.There are still difficulties to find correct indication for prosthetic implant in emergency hernia surgery: as a matter of fact there is still a great debate if to use non-absorbable prostheses in potentially or truly infected operating fields [e.g. after intestinal resections].All these problems can be avoided with the use of absorbable prosthetic materials such as those composed of lactic acid polymers or lactic and glycolic acid copolymers: however, the use of these absorbable prosthesis exposes the patient to a rapid and inevitable hernia recurrence.It is important to remember that prosthetic repair has been proven to have a significant less risk of recurrence than repair with direct sutures.Recently, new "biologic" prosthetic materials have been developed and proposed for the clinical use in infected fields. These materials can be called "remodeling" for the way by which they are replaced after their placement within the patient. The "remodeling" process is made possible through a process of incorporation, where a reproduction of a site-specific tissue similar to the original host tissue is created.

New "biological" meshes: the need for a register. The EHS Registry for Biological Prostheses: call for participating European surgeons

Non-absorbable prosthetic materials in hernia surgery can cause relatively rare complications, which include chronic pain, a feeling of stiffness with reduced compliance of the abdominal wall, prosthetic erosion/fistulisation and an increased risk of persistent deep infection. Recently, to avoid these problems, new "biological" prosthetic materials have been developed and proposed for clinical use. These materials are all essentially composed of an extracellular matrix stripped of its cellular components, and differ substantially only in their source (porcine small intestine submucosa, porcine dermis or cadaveric human dermis). Because of the numerous variables involved, it is very difficult to conduct a randomised controlled trial. Therefore, the European Hernia Society (EHS) has decided to start the EHS Registry for Biological Prostheses (ERBP). This is a prospective registry in Europe on the use of collagen meshes in (potentially) contaminated circumstances or clean surgical fields. The registry intends to collect some preoperative data on the patient and indication, intraoperative data and outcome data.