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Winaikosol K, Punchai S. Composite Anterolateral Thigh-Tensor Fascia Lata-Vastus Lateralis Flap with Synthetic Mesh Reconstruction for Giant Ventral Hernia Repair. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5994. [PMID: 39027888 PMCID: PMC11257660 DOI: 10.1097/gox.0000000000005994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 05/31/2024] [Indexed: 07/20/2024]
Abstract
Dealing with a giant ventral hernia can be a complex situation because it involves a considerable loss of space within the body. Although various surgical techniques are available for treating this condition, the recurrence rate remains high, making it challenging. This article presents a surgical treatment for a giant ventral hernia using synthetic mesh and a composite anterolateral thigh-tensor fasciae latae-vastus lateralis free flap. The average size of the hernia ring was 375.83 cm2, and all procedures were successful with minimal complications. After a follow-up period of 28 months, there have been no reports of recurrence. The technique is an effective option for treating patients with giant ventral hernias, particularly in cases where the component separation technique is not feasible.
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Affiliation(s)
- Kengkart Winaikosol
- From the Plastic and Reconstructive Unit, Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Suriya Punchai
- Minimally Invasive Surgery Unit, Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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2
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Pizza F, Maida P, Bertoglio C, Antinori A, Mongardini FM, Cerbara L, Sordelli I, Alampi BD, Marte G, Morini L, Grimaldi S, Gili S, Docimo L, Gambardella C. Two-meshes approach in posterior component separation with transversus abdominis release: the IMPACT study (Italian Multicentric Posterior-separation Abdominal Complex hernia Transversus-release). Hernia 2024; 28:871-881. [PMID: 38568350 DOI: 10.1007/s10029-024-03001-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/20/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND Surgical management of large ventral hernias (VH) has remained a challenge. Various techniques like anterior component separation and posterior component separation (PCS) with transversus abdominis release (TAR) have been employed. Despite the initial success, the long-term efficacy of TAR is not yet comprehensively studied. Authors aimed to investigate the early-, medium-, and long-term outcomes and health-related quality of life (QoL) in patients treated with PCS and TAR. METHODS This multicenter retrospective study analyzed data of 308 patients who underwent open PCS with TAR for primary or recurrent complex abdominal hernias between 2015 and 2020. The primary endpoint was the rate of hernia recurrence (HR) and mesh bulging (MB) at 3, 6, 12, 24, and 36 months. Secondary outcomes included surgical site events and QoL, assessed using EuraHS-QoL score. RESULTS The average follow-up was 38.3 ± 12.7 months. The overall HR rate was 3.5% and the MB rate was 4.7%. Most of the recurrences were detected by clinical and ultrasound examination. QoL metrics showed improvement post-surgery. CONCLUSIONS This study supports the long-term efficacy of PCS with TAR in the treatment of large and complex VH, with a low recurrence rate and an improvement in QoL. Further research is needed for a more in-depth understanding of these outcomes and the factors affecting them.
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Affiliation(s)
- F Pizza
- Asl Napoli2 Nord Department of Surgery, Hospital 'Rizzoli', Naples, Italy.
| | - P Maida
- Casa Di Cura Privata Malzoni, Surgery Avellino, Campania, Italy
| | - C Bertoglio
- Division of General Surgery, ASST Ovest Milanese, Hospital of Magenta, 20013, Magenta, Italy
| | - A Antinori
- U.O.C. Di Chirurgia Generale 1 Fondazione Policlinico Universitario Agostino Gemelli IRCCS Università Cattolica del Sacro Cuore, Rome, Italy
| | - F M Mongardini
- Division of General, Mininvasive and Bariatric Surgery, Campania 'Luigi Vanvitelli', Naples, Italy
| | - L Cerbara
- Institute for Research On Population and Social Policies, National Research Council of Italy, Rome, Italy
| | - I Sordelli
- Casa Di Cura Privata Malzoni, Surgery Avellino, Campania, Italy
| | - B D Alampi
- ASST GOM NIGUARDA, Chirurgia Generale Oncologica e Mininvasiva, Milan, Italy
| | - G Marte
- Ospedale del Mare Aslnapoli1, Naples, Italy
| | - L Morini
- ASST GOM NIGUARDA, Chirurgia Generale Oncologica e Mininvasiva, Milan, Italy
| | - S Grimaldi
- ASST GOM NIGUARDA, Chirurgia Generale Oncologica e Mininvasiva, Milan, Italy
| | - S Gili
- Asl Napoli3 Sud Department of Surgery, Hospital 'San Leonardo', Castellammare, Italy
| | - L Docimo
- Division of General, Mininvasive and Bariatric Surgery, Campania 'Luigi Vanvitelli', Naples, Italy
| | - C Gambardella
- Division of General, Mininvasive and Bariatric Surgery, Campania 'Luigi Vanvitelli', Naples, Italy
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Haidar MGM, Sharaf NAH, Haidar FM, Sukaina M. Impact of combined component separation technique and shoelace repair on big medline abdominal wall defect. Asian J Surg 2023; 46:4363-4370. [PMID: 36641271 DOI: 10.1016/j.asjsur.2022.12.157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 11/27/2022] [Accepted: 12/29/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Closure of large anterior abdominal wall defects, regardless of their etiology, is challenging. There is no standardized information describing definitive management. Therefore, we conducted this study to illustrate our experience on large midline abdominal wall defect repair using an effective modified reconstructive technique. METHODS This retrospective study was conducted at Al Naqib Hospital in Aden/Yemen between 2012 and 2019. Twenty-six patients with large midline abdominal wall defects of various etiologies underwent surgical repair using a combination of shoelace repair and the component separation technique. The procedure involved bilateral longitudinal division of the anterior rectus sheet and creation of a posterior layer by approximation of the medial edges of the divided rectus sheet (shoelace abdominoplasty) and anterior external oblique muscle aponeurosis separation (component separation technique) to approximate the lateral edges of the divided rectus sheet and move the rectus muscles toward the midline for constructing the anterior abdominal wall layer. The posterior and anterior layers and bilateral separated sheets were covered with a polypropylene mesh in all patients, except in those who underwent emergency damage control surgery. RESULTS Four, one, and two patients developed seroma, skin necrosis and chronic pain, and post-surgical wound infection, respectively. No recurrent herniation was recorded during the median follow-up of 5 years. CONCLUSION This technique is effective in restoring the integrity of the abdominal wall in large midline abdominal wall defects and has an acceptable aesthetic appearance. In our study, minimal complications were reported, and no cases of recurrent hernias were diagnosed during follow-up.
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Affiliation(s)
- Muad Gamil M Haidar
- University of Aden, Faculty of Medicine and Health Science, Aden, Yemen; Al Gamhoria Modern Hospital, Department of General Surgery and Endoscopy, Aden, Yemen; Al-Naqeeb Hospital, Department of General Surgery, Aden, Yemen.
| | - Nuha Ahmed H Sharaf
- University of Aden, Faculty of Medicine and Health Science, Aden, Yemen; Al-Naqeeb Hospital, Department of General Surgery, Aden, Yemen
| | - Fatima M Haidar
- University of Aden, Faculty of Medicine and Health Science, Aden, Yemen
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Zuvela M, Galun D, Bogdanovic A, Loncar Z, Zivanovic M, Zuvela M, Zuvela M. The combination of the three modifications of the component separation technique in the management of complex subcostal abdominal wall hernia. Hernia 2022; 26:1369-1379. [PMID: 35575863 DOI: 10.1007/s10029-022-02622-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 04/21/2022] [Indexed: 11/04/2022]
Abstract
PURPOSE The purpose of this study is to present a concept combining three modifications of the component separation technique (CST) in one procedure as an original solution for the management of complex subcostal abdominal wall hernia. METHODS Between January 2010 and January 2020, seven patients presenting at the high-volume academic center with complex subcostal hernia underwent surgery in which three modifications of CST were combined into one procedure. Major complex subcostal hernia was defined by either width or length of the defect being greater than 10 cm. The following were the stages of the operative technique: (a) the "method of wide myofascial release" at the side of the hernia defect; (b) "open-book variation" of the component separation technique at the opposite side of the hernia defect; (c) a modified component separation technique for closure of midline abdominal wall hernias in the presence of enterostomies; (d) suturing of the myofascial flaps to each other to cover the defect; and (e) repair augmentation with an absorbable mesh in the onlay position. RESULTS The median length and width of the complex subcostal hernias were 15 cm (10-19) and 15 cm (8-24), respectively. The overall morbidity rate was 57.1% (wound infection occurred in three patients, seroma in two patients, and skin necrosis in one patient). There was no hernia recurrence during the median follow-up period of 19 months. CONCLUSION The operative technique integrating three modifications of CST in one procedure with onlay absorbable mesh reinforcement is a feasible solution for the management of complex subcostal abdominal wall hernia.
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Affiliation(s)
- M Zuvela
- Clinic for Digestive Surgery, University Clinical Center of Serbia, Koste Todorovica 6, 11 000, Belgrade, Serbia.,School of Medicine, University of Belgrade, 11 000, Belgrade, Serbia
| | - D Galun
- Clinic for Digestive Surgery, University Clinical Center of Serbia, Koste Todorovica 6, 11 000, Belgrade, Serbia.,School of Medicine, University of Belgrade, 11 000, Belgrade, Serbia
| | - A Bogdanovic
- Clinic for Digestive Surgery, University Clinical Center of Serbia, Koste Todorovica 6, 11 000, Belgrade, Serbia. .,School of Medicine, University of Belgrade, 11 000, Belgrade, Serbia.
| | - Z Loncar
- Emergency Center, University Clinical Center of Serbia, 11 000, Belgrade, Serbia.,School of Medicine, University of Belgrade, 11 000, Belgrade, Serbia
| | - M Zivanovic
- Clinic for Digestive Surgery, University Clinical Center of Serbia, Koste Todorovica 6, 11 000, Belgrade, Serbia
| | - M Zuvela
- Clinic for Digestive Surgery, University Clinical Center of Serbia, Koste Todorovica 6, 11 000, Belgrade, Serbia
| | - M Zuvela
- Clinic for Digestive Surgery, University Clinical Center of Serbia, Koste Todorovica 6, 11 000, Belgrade, Serbia
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Christopher AN, Morris MP, Barrette LX, Patel V, Broach RB, Fischer JP. Longitudinal Clinical and Patient-Reported Outcomes After Transversus Abdominis Release for Complex Hernia Repair With a Review of the Literature. Am Surg 2021:31348211038580. [PMID: 34406098 DOI: 10.1177/00031348211038580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE Posterior component separation with transversus abdominis release (TAR) enables medial myofascial flap advancement in complex abdominal wall reconstruction. Here, we add to a growing body of literature on TAR by assessing longitudinal clinical and patient-reported outcomes (PROs) after complex ventral hernia repair (VHR) with TAR. METHODS Adult patients undergoing VHR with TAR between 10/15/2015 and 1/15/2020 were retrospectively identified. Patients with parastomal hernias and <12 months of follow-up were excluded. Clinical outcomes and PROs were assessed. RESULTS Fifty-six patients were included with a median age and body mass index of 60 and 30.8 kg/m2, respectively. The average hernia defect was 384 cm2 [IQR 205-471], and all patients had retromuscular mesh placed. The most common complications were delayed healing (19.6%) and seroma (14.3%). There were no cases of mesh infection or explantation. Previous hernia repair and concurrent panniculectomy were risk factors for developing complications (P < .05). One patient (1.8%) recurred at a median follow-up of 25.2 months [IQR 18.2-42.4]. Significant improvement in disease-specific PROs was maintained throughout the follow-up period (before to after P < .05). CONCLUSION Transversus abdominis release is a safe and efficacious technique to achieve fascial closure and retromuscular mesh in the repair of complex hernia defects.
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Affiliation(s)
- Adrienne N Christopher
- Division of Plastic Surgery, Department of Surgery, 6572University of Pennsylvania, Philadelphia, PA, USA.,Department of Surgery. Thomas Jefferson University, Philadelphia, PA, USA
| | - Martin P Morris
- Division of Plastic Surgery, Department of Surgery, 6572University of Pennsylvania, Philadelphia, PA, USA
| | | | - Viren Patel
- Perelman School of Medicine, 6572University of Pennsylvania, Philadelphia, PA, USA
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, 6572University of Pennsylvania, Philadelphia, PA, USA
| | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, 6572University of Pennsylvania, Philadelphia, PA, USA
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Faustino LD, Ferreira LM, Ramirez OM, Nahas FX. Components separation technique of the abdominal wall: Which muscle release produces the greatest reduction in tension on the mideline? J Plast Reconstr Aesthet Surg 2021; 74:3361-3370. [PMID: 34229956 DOI: 10.1016/j.bjps.2021.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 03/24/2021] [Accepted: 05/24/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The components separation technique (CS) is used for the reconstruction of complex abdominal wall defects. Release and undermining of the rectus abdominis muscle (RAM) and external oblique muscle (EOM) decrease tension on the abdominal midline, reducing recurrence of ventral hernia, but causes major changes in the physiology of abdominal wall. The purpose of the study was to determine which muscle release and undermining produces the lowest tension on the midline. METHODS Twenty fresh cadavers were dissected and the anterior and posterior layers of the rectus sheath were isolated in the midline. The forces necessary to advance the layers of the rectus sheath to the mid abdomen were measured bilaterally at two points located 3 cm above and 2 cm below the umbilicus, and at 3 different stages: before any muscle release; after release and undermining of the right RAM and left EOM; and after release and undermining of the left RAM and right EOM. Comparisons of tensile forces were conducted separately for the different muscles involved, layers of the rectus sheath, measurement points, and stages of separation. RESULTS Tension on the abdominal midline after the release and undermining of both the RAM and EOM was reduced by 56% (p <0.05), 42% after the release and undermining of the EOM alone (p <0.05), and 35% after release and undermining of the RAM alone (p <0.05). CONCLUSION Release and undermining of the EOM by CS led to lower tension on the abdominal midline compared to that associated with the release of the RAM alone.
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Affiliation(s)
- Leandro Dario Faustino
- Division of Plastic Surgery, Department of Surgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Lydia Masako Ferreira
- Division of Plastic Surgery, Department of Surgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Oscar M Ramirez
- Division of Plastic Surgery, Cleveland Clinic, Fort Lauderdale, FL, United States
| | - Fábio Xerfan Nahas
- Division of Plastic Surgery, Department of Surgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
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7
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Long-term outcomes and quality of life assessment after posterior component separation with transversus abdominis muscle release (TAR). Surg Endosc 2021; 36:1278-1283. [PMID: 33661379 DOI: 10.1007/s00464-021-08402-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 02/15/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Although transversus abdominis release (TAR) to treat large incisional hernias has shown favorable postoperative outcomes, devastating complications may occur when it is used in suboptimal conditions. We aimed to evaluate postoperative outcomes and long-term follow-up after TAR for large incisional hernias. METHODS A consecutive series of patients undergoing TAR for complex incisional hernias between 2014 and 2019 with a minimum of 6 month follow-up was included. Demographics, operative and postoperative variables were analyzed. Postoperative imaging (CT-scan) was also evaluated to detect occult recurrences. The HerQLes survey for quality of life (QoL) assessment was performed preoperatively and 6 months after the surgery. RESULTS A total of 50 TAR repairs were performed. Mean age was 65 (35-83) years, BMI was 28.5 ± 3.4 kg/m2, and 8 (16%) patients had diabetes. Mean Tanaka index was 14.2 ± 8.5. Mean defect area was 420 (100-720) cm2, average defect width was 19 ± 6.2 cm, and mesh area was 900 (500-1050) cm2; 78% were clean procedures, and in 60% a panniculectomy was associated. Operative time was 252 (162-438) minutes, and hospital stay was 4.5 (2-16) days. Thirty-day morbidity was 24% (12 patients), and 16% (8 patients) had surgical site infections. Overall recurrence rate was 4% (2 patients) after 28.2 ± 20.1 months of follow-up. QoL showed a significant improvement after surgery (p = 0.001). CONCLUSIONS The TAR technique is an effective treatment modality for large incisional hernias, showing an acceptable postoperative morbidity, a significant improvement in QoL, and low recurrence rates at long-term follow-up.
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Niebuhr H, Aufenberg T, Dag H, Reinpold W, Peiper C, Schardey HM, Renter MA, Aly M, Eucker D, Köckerling F, Eichelter J. Intraoperative Fascia Tension as an Alternative to Component Separation. A Prospective Observational Study. Front Surg 2021; 7:616669. [PMID: 33708790 PMCID: PMC7940755 DOI: 10.3389/fsurg.2020.616669] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/14/2020] [Indexed: 11/13/2022] Open
Abstract
Incisional hernias are common late complications of abdominal surgery, with a 1-year post-laparotomy incidence of about 20%. A giant hernia is often preceded by severe peritonitis of various causes. The Fasciotens® Abdomen device is used to stretch the fascia in a measurably controlled manner during surgery to achieve primary tension-free abdominal closure. This prospective observational study aims to clarify the extent to which this traction method can function as an alternative to component separation (CS) methods. Methods: We included data of 21 patients treated with intraoperative fascia stretching in seven specialized hernia centers between November 2019 and August 2020. Results: Intraoperatively-measured fascial distance averaged 17.3 cm (range 8.5-44 cm). After application of diagonal-anterior traction >10 kg for an average duration of 32.3 min (range 30-40 min), the fascial distance decreased by 9.8 cm (1-26 cm) to an average 7.5 cm (range 2-19 cm), which is a large effect (r = 0.62). The fascial length increase (average 9.8 cm) after applied traction was highly significant. All hernias were closed under moderate tension after the traction phase. In 19 patients, this closure was reinforced with mesh using a sublay technique. Conclusion: This method allows primary closure of complex (LOD) hernias and is potentially less prone to complications than component separation (CS) methods.
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Affiliation(s)
| | | | - Halil Dag
- Hanse Hernia Centre, Hamburg, Germany
| | | | - Christian Peiper
- Clinic for General, Visceral and Thoracic Surgery, Protestant Hospital, Hamm, Germany
| | - Hans Martin Schardey
- Clinic for General, Visceral, Vascular and Endocrine Surgery, Agatharied Hospital, Hausham, Germany
| | | | - Mohamed Aly
- Clinic for General, Visceral and Thoracic Surgery, Landshut-Achdorf Hospital, Landshut, Germany
| | - Dietmar Eucker
- Clinic for General, Visceral, Thoracic and Vascular Surgery, Canton Hospital Basel-Land, Liestal, Switzerland
| | - Ferdinand Köckerling
- Clinic for General, Visceral and Vascular Surgery, Vivantes Klinikum Spandau, Berlin, Germany
| | - Jakob Eichelter
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Vienna, Austria
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Non-coated versus coated mesh for retrorectus ventral hernia repair: a propensity score-matched analysis of the Americas Hernia Society Quality Collaborative (AHSQC). Hernia 2020; 25:665-672. [PMID: 32495048 DOI: 10.1007/s10029-020-02229-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 05/25/2020] [Indexed: 01/09/2023]
Abstract
PURPOSE The outcomes of utilizing anti-adhesive barrier-coated mesh in the retrorectus position during open ventral hernia repair are unknown. We compared the wound-related outcomes between non-coated (NCM) and coated mesh (CM) placed in the retrorectus space. METHODS Patients undergoing elective, open, clean ventral hernia repair with retrorectus mesh were retrospectively identified in the Americas Hernia Society Quality Collaborative. Propensity score matching was performed based on clinically relevant demographic and operative covariates. The primary outcome was wound morbidity, defined as surgical site infection (SSI), surgical site occurrence (SSO), and SSO requiring procedural intervention (SSOPI). RESULTS 3609 patients were included (3281 NCM, 328 CM). Following 2:1 propensity score matching, rates of myofascial release remained the only statistically different matching parameter; external oblique releases were performed more frequently in the CM group (8% vs. 15%; p = 0.03). Rates of SSI (3% vs. 4%; p = 0.16) were similar between groups. Increased rates of SSO (13% vs. 18%; p = 0.045) and SSOPI (4% vs. 8%; p = 0.038) were observed in the CM group. The CM group had a higher rate of postoperative seroma (3% vs. 7%; p = 0.027) compared to the NCM group. CONCLUSION Barrier-coated mesh in the retrorectus position was associated with increased wound morbidity requiring procedural intervention. Due to a lack of clinical benefit, the use of more costly barrier-coated mesh in the retrorectus position is not justified for routine, open ventral hernia repairs at this time.
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Burns FA, Heywood EG, Challand CP, Lee MJ. Is there a role for prophylactic mesh in abdominal wall closure after emergency laparotomy? A systematic review and meta-analysis. Hernia 2020; 24:441-447. [PMID: 31641872 PMCID: PMC7210219 DOI: 10.1007/s10029-019-02060-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 09/27/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Incisional hernias are a common complication of emergency laparotomy and are associated with significant morbidity. Recent studies have found a reduction in incisional hernias when mesh is placed prophylactically during abdominal closure in elective laparotomies. This systematic review will assess the safety and efficacy of prophylactic mesh placement in emergency laparotomy. METHODS A systematic review was performed according to the PROSPERO registered protocol (CRD42018109283). Papers were dual screened for eligibility, and included when a comparison was made between closure with prophylactic mesh and closure with a standard technique, reported using a comparative design (i.e. case-control, cohort or randomised trial), where the primary outcome was incisional hernia. Bias was assessed using the Cochrane risk of bias in non-randomised studies tool. A meta-analysis of incisional hernia rate was performed to estimate risk ratio using a random effects model (Mantel-Haenszel approach). RESULTS 332 studies were screened for eligibility, 29 full texts were reviewed and 2 non-randomised studies were included. Both studies were biased due to confounding factors, as closure technique was based on patient risk factors for incisional hernia. Both studies found significantly fewer incisional hernias in the mesh groups [3.2% vs 28.6% (p < 0.001) and 5.9% vs 33.3% (p = 0.0001)]. A meta-analysis of incisional hernia risk favoured prophylactic mesh closure [risk ratio 0.15 (95% CI 0.6-0.35, p < 0.001)]. Neither study found an association between mesh and infection or enterocutaneous fistula. CONCLUSION This review found that there are limited data to assess the effect or safety profile of prophylactic mesh in the emergency laparotomy setting. The current data cannot reliably assess the use of mesh due to confounding factors, and a randomised controlled trial is required to address this important clinical question.
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Affiliation(s)
- F A Burns
- Academic Department of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S5 7AU, UK
| | - E G Heywood
- Academic Department of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S5 7AU, UK
| | - C P Challand
- Academic Department of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S5 7AU, UK
| | - Matthew J Lee
- Academic Department of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S5 7AU, UK.
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, S10 2RX, UK.
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Abdominal Wall Reconstruction (AWR): Initial Experience from an Indian Centre. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02123-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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12
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Nielsen MF, de Beaux A, Tulloh B. Peritoneal Flap Hernioplasty for Reconstruction of Large Ventral Hernias: Long-Term Outcome in 251 Patients. World J Surg 2019; 43:2157-2163. [DOI: 10.1007/s00268-019-05011-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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13
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Sneiders D, Yurtkap Y, Kroese LF, Jeekel J, Muysoms FE, Kleinrensink GJ, Lange JF. Anatomical study comparing medialization after Rives-Stoppa, anterior component separation, and posterior component separation. Surgery 2019; 165:996-1002. [DOI: 10.1016/j.surg.2018.11.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/12/2018] [Accepted: 11/19/2018] [Indexed: 02/07/2023]
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Abstract
In the field of hernia surgery, there have been many advances in techniques that have provided the surgeon with a variety of options to repair the difficult abdominal wall hernia. Regardless of the technique, the ultimate goal was to provide a tension-free repair, which attempts to approximate the midline while returning abdominal wall musculature to its normal anatomic position, thus providing the patient with both a cosmetic and durable result with or without the use of a prosthetic reinforcement. Component separation techniques have been widely popularized as techniques to repair complex hernias and are frequently categorized based upon the anatomic location of the myofascial release. CSTs are generally categorized as either an anterior component separation or posterior component separation based upon the surgical approach to the abdominal wall musculature. This report objectively outlines the various techniques of component separation and specifically compares the outcomes among techniques to facilitate decision making in abdominal wall reconstruction.
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Moores N, Conway H, Donato D, Gociman B, Pannucci CJ, Agarwal J. Is release of the posterior lamella enough? A cadaveric exploration of posterior component separation techniques. Am J Surg 2018; 218:533-536. [PMID: 30591182 DOI: 10.1016/j.amjsurg.2018.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 12/05/2018] [Accepted: 12/10/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND As posterior component separation techniques continue to gain popularity there is uncertainty regarding the degree of fascial advancement afforded by the various techniques. Our study seeks to compare the degree anterior rectus sheath translation seen in full transversus abdominus release compared to simple release of the posterior lamella of the rectus sheath. METHODS Ten hemi-abdomens in five fresh cadavers were dissected. One hemi-abdomen underwent external oblique release. The contralateral hemi-abdomen underwent retrorectus dissection and initial release of the internal lamella of the internal oblique, followed by full transversus abdominus release. A 4 kg weight was suspended from the fascia and excursion was measured after 1) external oblique separation, 2) posterior lamella of the internal oblique separation, and 3) transversus abdominis separation. RESULTS Average unilateral hemifascial translation after release of the external oblique provided an average unilateral hemi-fascial translation of 3.38 cm (+/- 0.69). Release of the posterior lamella of the internal oblique provided 3.98 cm (+/- 0.94). After transversus release the average translation increased to 4.31 cm (+/- 0.89). CONCLUSIONS In this cadaveric study, the majority (92%) of fascial advancement afforded by posterior component separation was achieved by an intermediate step in the transversus abdominus release operation: division of the posterior lamella of the internal oblique.
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Affiliation(s)
- N Moores
- University of Utah, Division of Plastic Surgery, 30N 1900 E, #3B400, Salt Lake City, UT, 84132, USA.
| | - H Conway
- Huntsman Cancer Institute, 2000 Circle of Hope dr, Rm 5524.12, Salt Lake City, UT, 84123, USA.
| | - D Donato
- University of Utah, Division of Plastic Surgery, 30N 1900 E, #3B400, Salt Lake City, UT, 84132, USA.
| | - B Gociman
- University of Utah, Division of Plastic Surgery, 30N 1900 E, #3B400, Salt Lake City, UT, 84132, USA.
| | - C J Pannucci
- University of Utah, Division of Plastic Surgery, 30N 1900 E, #3B400, Salt Lake City, UT, 84132, USA.
| | - J Agarwal
- University of Utah, Division of Plastic Surgery, 30N 1900 E, #3B400, Salt Lake City, UT, 84132, USA.
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Trujillo CN, Fowler A, Al-Temimi MH, Ali A, Johna S, Tessier D. Complex Ventral Hernias: A Review of Past to Present. Perm J 2018; 22:17-015. [PMID: 29272245 DOI: 10.7812/tpp/17-015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
With the incidence of ventral hernias increasing, surgeons are faced with greater complexity in dealing with these conditions. Proper knowledge of the history and the advancements made in managing complex ventral hernias will enhance surgical results. This review article highlights the literature regarding complex ventral hernias, including a shift from a focus that stressed surgical technique toward a multimodal approach, which involves optimization and identification of suboptimal characteristics.
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Affiliation(s)
- Charles N Trujillo
- General Surgery Resident at the Kaiser-Fontana/Arrowhead Regional Medical Center in CA.
| | - Aaron Fowler
- General Surgery Resident at the Kaiser-Fontana/Arrowhead Regional Medical Center in CA.
| | - Mohammed H Al-Temimi
- General Surgery Resident at the Kaiser-Fontana/Arrowhead Regional Medical Center in CA.
| | - Aamna Ali
- General Surgery Resident at the Kaiser-Fontana/Arrowhead Regional Medical Center in CA.
| | - Samir Johna
- Attending Surgeon and the Program Director for the General Surgery Residency Program at the Kaiser-Fontana/Arrowhead Regional Medical Center in CA.
| | - Deron Tessier
- Attending Surgeon and the Associate Program Director for the General Surgery Residency Program at Kaiser-Fontana/Arrowhead Regional Medical Center in CA.
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Components Separation for Abdominal Wall Reconstruction in the Recalcitrant, High-Comorbidity Patient: A Review of 311 Single-Surgeon Cases. Ann Plast Surg 2018; 80:262-267. [PMID: 29309326 DOI: 10.1097/sap.0000000000001275] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Components separation of the abdominal musculature remains a mainstay for closure of complicated midline and paramedian abdominal wall defects. The authors critically analyzed their experience with this technique to identify prognosticators affecting long-term clinical outcomes. METHODS A retrospective review was performed of patients undergoing components separation by a single senior surgeon (J.M.R.) between 2000 and 2010. Numerous perioperative patient characteristics were collected and analyzed to determine their effects on long-term clinical outcomes. Multivariable logistic regression was used to predict hernia recurrence and other adverse clinical outcomes. RESULTS A total of 311 patients were identified (male, 51.1%). Mean age was 53.1 ± 14.0 years, preoperative body mass index was 33.1 ± 8.2 kg/m, and defect width was 11.4 ± 7.5 cm. Patients who had prior hernia repair were 97.4%, with 38.3% having prior mesh placement. Average follow-up was 2.9 ± 2.4 years. Overall hernia recurrence rate was 18.3%. Postoperative complications included seroma (9.3%), superficial wound infection (9.0%), skin dehiscence (4.82%), hematoma (3.2%), deep vein thrombos or pulmonary emolbus (3.2%), and skin flap ischemia (1.0%). Respiratory comorbidity (odds ratio, [OR], 2.02; P < 0.029), prior failed mesh repair (OR, 1.86; P < 0.045), and occurrence of any postoperative complication (OR, 2.02; P < 0.034) significantly increased the risk of eventual hernia recurrence. Preoperative body mass index was not associated with hernia recurrence (P < 0.351) or increased incidence of any aforementioned postoperative complications. CONCLUSIONS This study provides a comprehensive review of one of the largest single-surgeon experiences using components separation to date. Patients with respiratory comorbidities, prior failed mesh repair, and the occurrence of any postoperative complication are at significantly increased risk for hernia recurrence.
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Clay L, Stark B, Gunnarsson U, Strigård K. Full-thickness skin graft vs. synthetic mesh in the repair of giant incisional hernia: a randomized controlled multicenter study. Hernia 2017; 22:325-332. [PMID: 29247365 PMCID: PMC5937886 DOI: 10.1007/s10029-017-1712-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 12/09/2017] [Indexed: 12/15/2022]
Abstract
PURPOSE Repair of large incisional hernias includes the implantation of a synthetic mesh, but this may lead to pain, stiffness, infection and enterocutaneous fistulae. Autologous full-thickness skin graft as on-lay reinforcement has been tested in eight high-risk patients in a proof-of-concept study, with satisfactory results. In this multicenter randomized study, the use of skin graft was compared to synthetic mesh in giant ventral hernia repair. METHODS Non-smoking patients with a ventral hernia > 10 cm wide were randomized to repair using an on-lay autologous full-thickness skin graft or a synthetic mesh. The primary endpoint was surgical site complications during the first 3 months. A secondary endpoint was patient comfort. Fifty-three patients were included. Clinical evaluation was performed at a 3-month follow-up appointment. RESULTS There were fewer patients in the skin graft group reporting discomfort: 3 (13%) vs. 12 (43%) (p = 0.016). Skin graft patients had less pain and a better general improvement. No difference was seen regarding seroma; 13 (54%) vs. 13 (46%), or subcutaneous wound infection; 5 (20%) vs. 7 (25%). One recurrence appeared in each group. Three patients in the skin graft group and two in the synthetic mesh group were admitted to the intensive care unit. CONCLUSION No difference was seen for the primary endpoint short-term surgical complication. Full-thickness skin graft appears to be a reliable material for ventral hernia repair producing no more complications than when using synthetic mesh. Patients repaired with a skin graft have less subjective abdominal wall symptoms.
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Affiliation(s)
- L Clay
- Department of Clinical Science, Intervention and Technology (CLINTEC), H9, Karolinska Institutet, 171 64, Stockholm, Sweden
| | - B Stark
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 64, Stockholm, Sweden
| | - U Gunnarsson
- Department of Surgical and Perioperative Sciences, Umeå University, 907 85, Umeå, Sweden
| | - K Strigård
- Department of Surgical and Perioperative Sciences, Umeå University, 907 85, Umeå, Sweden.
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Outcomes of Posterior Component Separation With Transversus Abdominis Muscle Release and Synthetic Mesh Sublay Reinforcement. Ann Surg 2017; 264:226-32. [PMID: 26910200 DOI: 10.1097/sla.0000000000001673] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To evaluate the safety and efficacy of transversus abdominis muscle release (TAR) with retrorectus synthetic mesh reinforcement in a large series of complex hernia patients. BACKGROUND Posterior component separation via TAR during abdominal wall reconstruction (AWR) continues to gain popularity. Although our early experience with TAR has been promising, long-term outcomes have not been reported. METHODS From December 2006 to December 2014, consecutive patients undergoing open AWR utilizing TAR were identified in our prospectively maintained database and reviewed retrospectively. Main outcome measures included demographics, perioperative details, wound complications, and recurrences. RESULTS During the study period, 428 consecutive TAR procedures were analyzed. Mean age was 58, with mean body mass index 34.4 kg/m (range 20-65). Major comorbidities included diabetes (21%), chronic obstructive pulmonary disease (12%), and immunosuppression (3%). Mean hernia defect area was 606 cm (range 180-1280) and average mesh size was 1220 cm (range 600-4500). The majority of cases (66%) were clean, 26% were clean-contaminated, and 8% were contaminated. Eighty (18.7%) surgical-site events occurred, of which 39 (9.1%) were surgical-site infections. Three patients required mesh debridement; however, no instances of mesh explantation occurred. Of the 347 (81%) patients with at least 1-year follow-up (mean 31.5 mo), there were 13 (3.7%) recurrences. CONCLUSIONS Complex AWR represents a formidable surgical challenge. In this large series, we demonstrated that posterior component separation via TAR with wide synthetic mesh sublay provides a very durable repair with low morbidity, even in comorbid patients with large defects. We strongly advocate TAR as a robust addition to the armamentarium of reconstructive surgeons.
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Denney B, De Latorre JI. Multipoint Suture Fixation Technique for Abdominal Wall Reconstruction with Component Separation and Onlay Biological Mesh Placement. Am Surg 2017. [DOI: 10.1177/000313481708300529] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Component separation with mesh reinforcement has become the primary modality for complex abdominal wall reconstruction. However, many fundamental questions remain unanswered, such as whether underlay versus overlay mesh placement is superior, and what is the best means of suture fixation technique for mesh placement? This study presents the senior author's technique for onlay biologic mesh placement with multipoint suture fixation in combination with component separation and its subsequent low recurrence rates. This is a retrospective review of the senior author's cases of component separation with onlay biologic mesh placement during his tenure at the home institution of the University of Alabama at Birmingham. A total of 75 patients were included, all of whom underwent complex abdominal wall reconstruction from September 2002 to April 2012. Patients were excluded from the dataset if their surgery occurred less than two years before date of data collection to give a minimum 2-year follow-up. Patients were identified by Current Procedural Terminology codes for component separation and their charts reviewed by the home institution's electronic medical record. Data point entries included patient demographics and comorbidities, concomitant procedures such as bowel resection or panniculectomy, and characteristics of the reconstruction such as type of mesh used. Primary data endpoints were complications following surgery, particularly recurrence and laxity. A total of 75 patients were included in the study from September 2002 to April 2012 with a minimum 2-year follow-up period. The recurrence rate was 13 per cent and the rate of laxity 2.7 per cent. There was one death (1.35%). The most frequent complication was seromas at a rate of 17 per cent. Multipoint fixation suture technique for abdominal wall reconstruction with component separation and onlay biologic mesh is a reproducible technique with reliably low recurrence rates.
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Affiliation(s)
- Brad Denney
- Division of Plastic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jorge I. De Latorre
- Division of Plastic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
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Haskins IN, Voeller GR, Stoikes NF, Webb DL, Chandler RG, Phillips S, Poulose BK, Rosen MJ. Onlay with Adhesive Use Compared with Sublay Mesh Placement in Ventral Hernia Repair: Was Chevrel Right? An Americas Hernia Society Quality Collaborative Analysis. J Am Coll Surg 2017; 224:962-970. [DOI: 10.1016/j.jamcollsurg.2017.01.048] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 01/11/2017] [Accepted: 01/17/2017] [Indexed: 11/24/2022]
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Majumder A, Miller HJ, Patel P, Wu YV, Elliott HL, Novitsky YW. Evaluation of antibiotic pressurized pulse lavage for contaminated retromuscular abdominal wall reconstruction. Surg Endosc 2016; 31:2763-2770. [PMID: 27800587 DOI: 10.1007/s00464-016-5283-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 10/04/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite patient risk factors such as diabetes and obesity, contamination during surgery remains a significant cause of infections and subsequent wound morbidity. Pressurized pulse lavage (PPL) has been utilized as a method to reduce bacterial bioburden with promising results in many fields. Although existing methods of lavage have been utilized during abdominal operations, no studies have examined the use of PPL during complex hernia repair. METHODS Patients undergoing abdominal wall reconstruction (AWR) in clean-contaminated or contaminated fields with antibiotic PPL, from January 2012 to May 2013, were prospectively evaluated. Primary outcome measures studied were conversion of retrorectus space culture from positive to negative after PPL and 30-day surgical site infection (SSI) rate. RESULTS A total of 56 patients underwent AWR, with 44 patients (78.6 %) having clean-contaminated fields and 12 patients (21.4 %) having contaminated ones. Twenty-two patients (39.3 %) had positive pre-PPL cultures, 18 of which (81.8 %) converted to negative cultures after PPL. Eleven patients (19.6 %) developed SSIs. Those with persistently positive cultures after PPL had the highest rate of SSI, where two out of four patients (50.0 %) developed an SSI. Contrastingly, only 5 of 18 patients (27.8 %) who converted from a positive to negative culture after PPL developed an SSI. CONCLUSION Our findings demonstrate that antibiotic PPL is an effective method to reduce bacterial bioburden during AWR in clean-contaminated and contaminated fields. While complete conversion and eradication of SSI were not achieved, we believe that PPL may be a useful adjunct to standard operative asepsis in preventing prosthetic contamination during contaminated AWR.
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Affiliation(s)
- Arnab Majumder
- Department of Surgery, UH Comprehensive Hernia Center, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Heidi J Miller
- Department of Surgery, UH Comprehensive Hernia Center, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Parita Patel
- Department of Surgery, UH Comprehensive Hernia Center, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Yuhsin V Wu
- Department of Surgery, UH Comprehensive Hernia Center, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Heidi L Elliott
- Department of Surgery, UH Comprehensive Hernia Center, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Yuri W Novitsky
- Department of Surgery, UH Comprehensive Hernia Center, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
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Joels CS, Vanderveer AS, Newcomb WL, Lincourt AE, Polhill JL, Jacobs DG, Sing RF, Heniford BT. Abdominal Wall Reconstruction After Temporary Abdominal Closure: A Ten-Year Review. Surg Innov 2016; 13:223-30. [PMID: 17227920 DOI: 10.1177/1553350606296922] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abdominal wall reconstruction (AWR) is often required for hernias created after temporary abdominal closure (TAC). Demographic and clinical data from patients undergoing TAC and AWR between January 1, 1992, and December 31, 2002, were collected and univariate analysis performed. Temporary abdominal closure and AWR were performed in 21 patients. Complications developed in 12 patients (57.1%) after TAC; associated risk factors were mesh placement ( P = .04) and skin grafting ( P = .04). Successful AWR included mesh (n = 6), component separation (n = 6), primary repair (n = 4), and 3 combination techniques. Six patients (28.6%) developed intraoperative complications, and 14 (66.7%) developed postoperative complications. Intraoperative complications were increased in patients with tissue expanders ( P = .01). Postoperative complications ( P = .04) were less likely with component separation. The complication rate with TAC and AWR is high. Tissue expanders are associated with an increased risk of intraoperative complications with AWR, whereas component separation is associated with a reduction in postoperative complications.
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Affiliation(s)
- Charles S Joels
- Carolinas Hernia Center, Division of Gastrointestinal and Minimally Invasive Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina 28203, USA
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Differences in midline fascial forces exist following laparoscopic and open transversus abdominis release in a porcine model. Surg Endosc 2016; 31:829-836. [PMID: 27352787 DOI: 10.1007/s00464-016-5040-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 06/11/2016] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Posterior component separation herniorrhaphy via transversus abdominis release (TAR) permits midline reapproximation of large fascial defects. To date, no report delineates the reduction in tensile force to reapproximate midline fascia following TAR. We hypothesized that open and laparoscopic TAR would provide similar reductions in midline reapproximation forces in a porcine model. METHODS Under general anesthesia, a 20-cm midline laparotomy was created and bilateral lipocutaneous flaps were raised to expose the anterior rectus sheath. Five stainless steel hooks were placed at 1-cm intervals lateral to the midline at three locations: 5 cm above, at, and 5 cm below the umbilicus bilaterally. Baseline force measurements were taken by pulling each lateral point to midline. Laparoscopic TAR was performed unilaterally by incising the parietal peritoneum and transversus muscle lateral to the linea semilunaris. Open TAR was performed contralaterally, and force measurements were repeated. Comparisons were made to baseline and between the groups. RESULTS Following laparoscopic TAR, 87 % (13/15) of points showed significant reduction compared to baseline forces, whereas only 20 % (3/15) of open TAR points had significant force reductions. Compared to open TAR, three locations favored the laparoscopic approach [1 cm lateral to midline, 5 cm above the umbilicus (p = 0.04; 95 % CI 0.78-1.00), 2 cm lateral to midline at the umbilicus (p = 0.04; 95 % CI 0.80-1.00), and 1 cm lateral to midline 5 cm below the umbilicus (p = 0.05; 95 % CI 0.79-1.00)]. The mean length of TAR was longer for laparoscopic than open at 27.29 versus 19.55 cm (p < 0.0001; 95 % CI 6.46-9.02). CONCLUSIONS Open TAR reduced midline tensile force at few locations, suggesting that the mechanism by which TAR facilitates herniorraphy may not solely be through reductions in linea alba tensile forces. At specific locations, laparoscopic TAR provides superior reduction in midline closure force compared to open TAR, likely as a result of a longer muscle release.
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Desai NK, Leitman IM, Mills C, Lavarias V, Lucido DL, Karpeh MS. Open repair of large abdominal wall hernias with and without components separation; an analysis from the ACS-NSQIP database. Ann Med Surg (Lond) 2016; 7:14-9. [PMID: 27158489 PMCID: PMC4843100 DOI: 10.1016/j.amsu.2016.02.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 02/27/2016] [Accepted: 02/28/2016] [Indexed: 11/29/2022] Open
Abstract
Background Components separation technique emerged several years ago as a novel procedure to improve durability of repair for ventral abdominal hernias. Almost twenty-five years since its initial description, little comprehensive risk adjusted data exists on the morbidity of this procedure. This study is the largest analysis to date of short-term outcomes for these cases. Methods The ACS-NSQIP database identified open ventral or incisional hernia repairs with components separation from 2005 to 2012. A data set of cohorts without this technique, matched for preoperative risk factors and operative characteristics, was developed for comparison. A comprehensive risk-adjusted analysis of outcomes and morbidity was performed. Results A total of 68,439 patients underwent open ventral hernia repair during the study period (2245 with components separation performed (3.3%) and 66,194 without). In comparison with risk-adjusted controls, use of components separation increased operative duration (additional 83 min), length of stay (6.4 days vs. 3.8 days, p < 0.001), return to the OR rate (5.9% vs. 3.6%, p < 0.001), and 30-day morbidity (10.1% vs. 7.6%, p < 0.001) with no increase in mortality (0.0% in each group). Conclusions Components separation technique for large incisional hernias significantly increases length of stay and postoperative morbidity. Novel strategies to improve short-term outcomes are needed with continued use of this technique. The repair of large abdominal wall hernias is more frequently performed using components separation. While this technique appears to reduce recurrence, morbidity has not been previously studied. When compared to a large cohort, components separation has a higher complication rate than traditional open hernia repair.
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Affiliation(s)
- Nirav K Desai
- Department of Surgery, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - I Michael Leitman
- Department of Surgery, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher Mills
- Department of Surgery, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Valentina Lavarias
- Department of Surgery, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David L Lucido
- Department of Surgery, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Martin S Karpeh
- Department of Surgery, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Techniques for Abdominal Wall Closure after Damage Control Laparotomy: From Temporary Abdominal Closure to Early/Delayed Fascial Closure-A Review. Gastroenterol Res Pract 2015; 2016:2073260. [PMID: 26819597 PMCID: PMC4706912 DOI: 10.1155/2016/2073260] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 09/27/2015] [Indexed: 12/11/2022] Open
Abstract
Open abdomen (OA) has been an effective treatment for abdominal catastrophes in traumatic and general surgery. However, management of patients with OA remains a formidable task for surgeons. The central goal of OA is closure of fascial defect as early as is clinically feasible without precipitating abdominal compartment syndrome. Historically, techniques such as packing, mesh, and vacuum-assisted closure have been developed to assist temporary abdominal closure, and techniques such as components separation, mesh-mediated traction, bridging fascial defect with permanent synthetic mesh, or biologic mesh have also been attempted to achieve early primary fascial closure, either alone or in combined use. The objective of this review is to present the challenges of these techniques for OA with a goal of early primary fascial closure, when the patient's physiological condition allows.
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Abdominal compartment syndrome as a rare complication following component separation repair: case report and review of the literature. Hernia 2015; 19:293-9. [DOI: 10.1007/s10029-015-1362-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 02/20/2015] [Indexed: 10/23/2022]
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Abstract
Hernia formation after surgical procedures continues to be an important cause of surgical morbidity. Incisional reinforcement at the time of the initial operation has been used in some patient populations to reduce the risk of subsequent hernia formation. In this article, reinforcement techniques in different surgical wounds are examined to identify situations in which hernia formation may be prevented. Mesh use for midline closure, pelvic floor reconstruction, and stoma site reinforcement is discussed. Additionally, the use of retention sutures, closure of the open abdomen, and reinforcement after component separation are examined using current literature. Although existing studies do not support the routine use of mesh reinforcement for all surgical incisions, certain patient populations appear to benefit from reinforcement with lower rates of subsequent hernia formation. The identification and characterization of these groups will guide the future use of mesh reinforcement in surgical incisions.
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Affiliation(s)
- Timothy F Feldmann
- Department of Surgery, University of California Irvine, Orange County, California
| | - Monica T Young
- Department of Surgery, University of California Irvine, Orange County, California
| | - Alessio Pigazzi
- Department of Surgery, University of California Irvine, Orange County, California
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Zhang R, Wang C, Chen Y, Zheng B, Shi Y. The use of unilateral or bilateral external oblique myocutaneous flap in the reconstruction of lower abdominal wall or groin defects after malignant tumor resection. J Surg Oncol 2014; 110:930-4. [PMID: 25154885 DOI: 10.1002/jso.23763] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Accepted: 07/28/2014] [Indexed: 01/09/2023]
Abstract
BACKGROUND External oblique myocutaneous flap (EOMF) has been used successfully for many years in reconstructive plastic surgery, its function is mainly concentrated in the restoration of chest wall defects following breast cancer resection. However, for the lower abdominal wall or groin defects after malignant tumor resection, reconstruction with EOMF is little reported. In this study, we report our experience with EOMF downward transposition to repair the defects. METHODS 12 patients with malignant diseases in the lower abdominal wall or groin underwent aggressive tumor resection, the defects were reconstructed immediately with EOMF. Patient characteristics, details of operation and postoperative complications were described. RESULTS 12 patients received radical resection, the defect size ranged from 140 to 588 cm(2) . Ipsilateral or bilateral EOMF was utilized to repair the defects. The EOMF had good quality skin and soft tissue to cover the defects, postoperatively, four patients developed seroma, two patients had distal tip necrosis, but no serious complications occurred, the wound of donor site healed well, no abdominal hernia was found. CONCLUSION Our study provides a new and alternative approach to reconstruct large defects with EOMF downward transposition after malignant tumor resection in the lower abdominal wall or groin.
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Affiliation(s)
- Ruming Zhang
- Department of Gastric Cancer and Soft Tissue Sarcomas, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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Ibarra-Hurtado TR, Nuño-Guzmán CM, Miranda-Díaz AG, Troyo-Sanromán R, Navarro-Ibarra R, Bravo-Cuéllar L. Effect of botulinum toxin type A in lateral abdominal wall muscles thickness and length of patients with midline incisional hernia secondary to open abdomen management. Hernia 2014; 18:647-52. [PMID: 25033942 DOI: 10.1007/s10029-014-1280-2] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 06/27/2014] [Indexed: 01/17/2023]
Abstract
PURPOSE Abdominal wall hernia secondary to open abdomen management represents a surgical challenge. The hernia worsens due to lateral muscle retraction. Our objective was to evaluate if Botulinum Toxin Type A (BTA) application in lateral abdominal wall muscles modifies its thickness and length. METHODS A clinical trial of male trauma patients with hernia secondary to open abdomen management was performed from January 2009 to July 2011. Thickness and length of lateral abdominal muscles were measured by a basal Computed Tomography and 1 month after BTA application. A dosage of 250 units of BTA was applied at five points at each side between the external and internal oblique muscles under ultrasonographic guidance. Statistical analysis for differences between basal and after BTA application measures was performed by a paired Student's t test (significance: p < 0.05). RESULTS Seventeen male patients with a mean age of 35 years were included. There were muscle measure modifications in all the patients. Left muscle thickness: mean reduction of 1 ± 0.55 cm (p < 0.001). Right muscle thickness: mean reduction of 1.00 ± 0.49 cm (p < 0.001). Left muscle length: mean increase of 2.44 ± 1.22 cm (p < 0.001). Right muscle length: mean increase of 2.59 ± 1.38 cm (p < 0.001). No complications secondary to BTA or recurrences at mean follow-up of 49 months were observed. CONCLUSIONS BTA application in lateral abdominal muscles decreases its thickness and increases its length in abdominal wall hernia patients secondary to open abdomen management.
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Affiliation(s)
- T R Ibarra-Hurtado
- Department of Trauma Surgery, Antiguo Hospital Civil de Guadalajara "Fray Antonio Alcalde", Calle Hospital 278, Col. El Retiro, 44280, Guadalajara, Jalisco, Mexico,
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Libberecht K, Colpaert SDM, Van Hee R, Jadoul JL, De Clercq S, Sonneville T. New developments in abdominal wall reconstruction after abdominal compartment syndrome decompression. Acta Clin Belg 2014; 62 Suppl 1:220-4. [PMID: 24881723 DOI: 10.1179/acb.2007.62.s1.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
The acute abdominal compartment syndrome (ACS) is most often treated with surgical abdominal decompression. After the acute phase, primary closure of the abdominal wall may not be possible, due to tissue loss and retraction of the abdominal wall and its musculofascial components. This article gives an update of the reconstructive ladder for abdominal wall defects. Because of improved intensive care treatment and wound dressing, reconstruction can usually be delayed until infection and oedema have settled. Recent developments in bioprosthetics and new surgical techniques like component separation make better results with less donor site morbidity possible. However, there is still a place for local and distant flaps.
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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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Fox M, Cannon RM, Egger M, Spate K, Kehdy FJ. Laparoscopic component separation reduces postoperative wound complications but does not alter recurrence rates in complex hernia repairs. Am J Surg 2013; 206:869-74; discussion 874-5. [PMID: 24112668 DOI: 10.1016/j.amjsurg.2013.08.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 08/06/2013] [Accepted: 08/07/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate and compare the incidence of wound complications after laparoscopic component separation (LCS) vs open component separation (OCS) in patients with complex abdominal wall hernias. METHODS A retrospective review was performed of all patients who underwent LCS or OCS for repair of a complex abdominal wall hernia at a single institution between 2009 and 2011. Charts were reviewed to identify postoperative wound complications. A computed tomographic scan or physical examination was used for the determination of hernia recurrence. Categoric variables were compared using the Fisher exact test. Univariate and multivariate analyses were performed using linear and Cox regression. Recurrence rates were compared using log-rank tests (Kaplan-Meier method). RESULTS A total of 44 patients underwent LCS (n = 18) or OCS (n = 26). There was no statistically significant difference between categoric variables. Multivariate analysis using wound complications as the dependent variable showed a statistically significantly lower rate of wound complications in the LCS group. CONCLUSIONS LCS is associated with a lower rate of wound complications when compared with OCS but yields comparable recurrence rates.
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Affiliation(s)
- Mathew Fox
- Department of Surgery, University of Louisville, 550 S Jackson Street, 2nd Floor ACB, Louisville, KY 40202, USA
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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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Moazzez A, Mason RJ, Darehzereshki A, Katkhouda N. Totally laparoscopic abdominal wall reconstruction: lessons learned and results of a short-term follow-up. Hernia 2013; 17:633-8. [PMID: 23929497 DOI: 10.1007/s10029-013-1145-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2012] [Accepted: 07/28/2013] [Indexed: 02/05/2023]
Abstract
PURPOSE Totally Laparoscopic Abdominal Wall Reconstruction (TLAWR) combines the laparoscopic component separation and the laparoscopic ventral hernia repair, with the purpose of further increasing the benefits of a minimally invasive procedure. However, neither the patient selection criteria nor the long-term results of this technique have been reported. Our objective is to discuss our experience with five patients who received a TLAWR. METHODS All patients with a midline incisional hernia who underwent a TLAWR from September 2008 to October 2009 were retrospectively reviewed for early and late postoperative complications. RESULTS A total of five patients underwent the procedure, with a mean age of 48.6 ± 7.9 years. The mean length of stay was 9.2 ± 5.4 days, and follow-up was 12.3 ± 6.8 months. The mean defect size was 175.8 ± 56.2 cm(2). There were no early or late wound complications. Two patients had an early respiratory complication, and one patient developed a port site hernia and small bowel obstruction early after procedure, which required a re-operation. Three patients (60 %) experienced a recurrence. Possible risk factors for recurrence include previous failed hernia repair, loss of domain, large hernias and close proximity to bony structures. CONCLUSIONS Although TLAWR is feasible and improves wound complications, it may be associated with higher recurrence. Appropriate patient selection is imperative in order for the patient to benefit from this technique.
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Affiliation(s)
- A Moazzez
- Harbor-UCLA Medical Center, Torrance, CA, USA,
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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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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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Heller L, Chike-Obi C, Xue AS. Abdominal wall reconstruction with mesh and components separation. Semin Plast Surg 2013; 26:29-35. [PMID: 23372456 DOI: 10.1055/s-0032-1302463] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Incisional hernias in the abdominal wall are a by-product of multiple previous laparotomies. Unfortunately, the incidence of incisional hernias has risen, as we have progressed with new surgical techniques in the treatment of abdominal pathologies. Many methods have been attempted in the past to achieve a better and more durable repair, namely using components separation to bring the fascia into the midline, and reinforce incisional hernias with different mesh materials. The authors review the recent literature regarding the efficacy of these synthetic materials and biomaterials in incisional hernia repair, as well as share their experience in treating complex abdominal wall defects using components separation and biologic mesh.
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Affiliation(s)
- Lior Heller
- Division of Plastic Surgery, Baylor College of Medicine, TCH Clinical Care Center, Houston, Texas
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Abdominal wall reconstruction: a case series of ventral hernia repair using the component separation technique with biologic mesh. Am J Surg 2013; 205:322-7; discussion 327-8. [PMID: 23351508 DOI: 10.1016/j.amjsurg.2012.10.024] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Revised: 10/22/2012] [Accepted: 10/28/2012] [Indexed: 11/24/2022]
Abstract
BACKGROUND Sixty-eight consecutive patients from October 2008 until February 2012 were selected for this retrospective review. METHODS A midline fascial closure with component separation was completed using biologic mesh onlay in all cases. Recurrence rates of the hernias, complication rates, patient satisfaction, and time to return to work/normal activities were investigated. RESULTS The recurrence rate was 1.5% (n = 65) with ongoing follow-ups (mean = 20 months). The average age was 57 years, and the average body mass index was 36 kg/m(2) (range 22 to 60). The average hernia defect was 20 cm (range 12 to 26) transversely. Wound infection and/or breakdown occurred in 32%, and seroma formation occurred in 9% of patients. Patient satisfaction was 3.63 of 4. The average time to return to work/normal activities was 16 weeks (range 1 to 76 weeks). CONCLUSIONS Large complex ventral hernias can be reliably repaired using the component separation technique. The short-term recurrence rate is significantly reduced in this case series using a biologic mesh onlay.
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Espinosa-de-los-Monteros A, Domínguez I, Zamora-Valdés D, Castillo T, Fernández-Díaz OF, Luna-Torres HA. Closure of midline contaminated and recurrent incisional hernias with components separation technique reinforced with plication of the rectus muscles. Hernia 2012. [PMID: 23180145 DOI: 10.1007/s10029-012-1012-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE Midline incisional hernia reconstruction by defect closure and reinforcement with either prosthetic or biologic materials has shown to significantly decrease recurrence rates even for complex cases. The purpose of this study is to evaluate outcomes regarding large incisional hernia reconstruction with components separation technique using rectus muscle plication as a reinforcement method. METHODS Thirteen patients having large midline incisional hernias and either history of abdominal wall contamination or recurrence in the presence of mesh were treated between January 2007 and December 2011 with closure using components separation technique reinforced by rectus muscle plication. RESULTS Average hernia square was 222 cm(2), and mean follow-up was 24 months. Complications occurred in 6 patients with a mean time to resolution of 59 days. One recurrence was present. CONCLUSIONS When use of mesh or biologic materials is not desired, rectus muscle plication is a feasible tool as a reinforcement method after large hernia closure with components separation.
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Affiliation(s)
- A Espinosa-de-los-Monteros
- Plastic Surgery Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Col. Sección XVI, Tlalpan, CP 14000, Mexico City, Mexico.
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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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D'Ambra L, Berti S, Feleppa C, Magistrelli P, Bonfante P, Falco E. Use of bovine pericardium graft for abdominal wall reconstruction in contaminated fields. World J Gastrointest Surg 2012; 4:171-6. [PMID: 22905285 PMCID: PMC3420984 DOI: 10.4240/wjgs.v4.i7.171] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 06/22/2012] [Accepted: 06/29/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To employ, in such conditions, a biological graft such as bovine pericardium that offers resistance to infection.
METHODS: In our surgical department, from January 2006 to June 2010, 48 patients underwent abdominal wall reconstruction using acellular bovine pericardium; of these 34 patients had a contaminated wound due to diffuse peritonitis (complicated diverticulitis, bowel perforation, intestinal infarction, strangled hernia, etc.) and 14 patients had hernia relapse on infected synthetic mesh.
RESULTS: In our series, one patient died of multi-organ failure 3 d after surgery. After placement of the pericardium mesh four cases of hernia relapse occurred.
CONCLUSION: Recurrence rate is similar to that of prosthetic mesh repair and the application of acellular bovine pericardium (Tutomesh®, Tutogen Medical Gmbh Germany) is moreover a safe and feasible option that can be employed to manage complicated abdominal wall defects where prosthetic mesh is unsuitable.
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Affiliation(s)
- Luigi D'Ambra
- Luigi D'Ambra, Stefano Berti, Cosimo Feleppa, Prospero Magistrelli, Pierfrancesco Bonfante, Emilio Falco, Department of Surgery, S. Andrea Hospital, 19100 La Spezia, Italy
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Krpata DM, Blatnik JA, Novitsky YW, Rosen MJ. Posterior and open anterior components separations: a comparative analysis. Am J Surg 2012; 203:318-22; discussion 322. [DOI: 10.1016/j.amjsurg.2011.10.009] [Citation(s) in RCA: 102] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Revised: 10/16/2011] [Accepted: 10/16/2011] [Indexed: 10/14/2022]
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Satterwhite TS, Miri S, Chung C, Spain DA, Lorenz HP, Lee GK. Abdominal wall reconstruction with dual layer cross-linked porcine dermal xenograft: The “Pork Sandwich” herniorraphy. J Plast Reconstr Aesthet Surg 2012; 65:333-41. [DOI: 10.1016/j.bjps.2011.09.044] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Revised: 09/10/2011] [Accepted: 09/27/2011] [Indexed: 11/25/2022]
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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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Initial experience of double-layer tension free reconstruction of abdominal wall defects with porcine acellular dermal collagen implant and polypropylene mesh. Ir J Med Sci 2011; 181:205-9. [DOI: 10.1007/s11845-011-0776-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Accepted: 10/13/2011] [Indexed: 01/15/2023]
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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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Abdominal ventral hernia repair with current biological prostheses: an experimental large animal model. Ann Plast Surg 2011; 66:403-9. [PMID: 21042180 DOI: 10.1097/sap.0b013e3181e051ed] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Biologic prostheses have emerged to address the limitations of synthetic materials for ventral hernia repairs; however, they lack experimental comparative data. Fifteen swine were randomly assigned to 1 of 3 bioprosthetic groups (DermaMatrix, AlloDerm, and Permacol) after creation of a full thickness ventral fascial defect. At 15 weeks, host incorporation, hernia recurrence, adhesion formation, neovascularization, inflammation, and biomechanical properties were assessed. No animals had hernia recurrence or eventration. DermaMatrix and Alloderm implants demonstrated more adhesions, greater inflammatory infiltration, and more longitudinal laxity, but near identical neovascularization and tensile strength to Permacol. We found that porcine acellular dermal products (Permacol) contain following essential properties of an ideal ventral hernia repair material: low inflammation, less elastin and stretch, lower adhesion rates and cost, and more contracture. The addition of lower cost xenogeneic acellular dermal products to the repertoire of available acellular dermal products demonstrates promise, but requires long-term clinical studies to verify advantages and efficacy.
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