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

The Role of Indocyanine Green Fluorescence Angiography in Complex Abdominal Wall Reconstruction: A Scoping Review of the Literature

BACKGROUND

Indocyanine green fluorescence angiography (ICGFA) is a technique for assessing vascularity and perfusion which has multiple proven applications across a variety of surgical procedures. Studies have been performed assessing its potential role in evaluating skin flap viability in complex abdominal wall reconstruction (CAWR) in order to avoid postoperative surgical site occurrences (SSO).

OBJECTIVES

This scoping review was intended to summarise the literature concerning ICGFA in CAWR in order to facilitate future evidence-based guidelines for its use.

ELIGIBILITY CRITERIA

Inclusion - cohort studies, randomised controlled trials, case series, case reports and ventral midline hernias only. Exclusion - patients aged under 18 years and non-human test subjects.

SOURCES OF EVIDENCE

PubMed, MEDLINE®, Cochrane, Embase and OpenGrey RESULTS: A total of 3416 unique titles were yielded from our search of which 9 met our inclusion criteria: 3 case reports, 1 retrospective case series, 1 prospective case series, 3 non-blinded, non-randomised retrospective case-controlled studies and 1 prospective, double-blinded randomised controlled study. The included studies varied considerably in size and method however the consensus appeared to support ICGFA as being a safe and feasible means of assessing tissue flap vascularity in CAWR. The studies returned contrasting results regarding the impact of ICGFA in predicting and avoiding SSOs however there were insufficient numbers of studies for a meta-analysis.

CONCLUSIONS

We identify three case reports and four lower quality studies suggesting a possible application for ICGFA in CAWR and two higher quality studies showing no overall benefit. Evidence-based guidelines on the role of ICGFA in CAWR will require the assessment of further studies.

Nationwide increase in component separation without concomitant rise in readmissions: A nationwide readmissions database analysis

BACKGROUND

The use of component separation technique (CST) in complex abdominal wall reconstruction (AWR) increases the rate of primary musculofascial closure but can be associated with increased wound complications, which may require readmission. This study examines 3-year trends in readmissions for patients undergoing AWR with or without CST.

METHODS

The Nationwide Readmissions Database was queried for patients undergoing elective AWR from 2016-2018. CST, demographic characteristics, and 90-day complications and readmissions were determined. CST versus non-CST readmissions were compared, including matched subgroups. Standard statistics and logistic regression were used.

RESULTS

Over the 3-year period, 94,784 patients underwent AWR. There was an annual increase in the prevalence of CST: 4.0% in 2016; 6.1% in 2017; 6.7% in 2018 (P < .01), which is a 67.5% upsurge during that time. Most cases (82.3%) occurred at urban teaching hospitals, which had more comorbid patients (P < .01). The yearly 90-day readmission rate did not change: 16.0%, 18.2%, and 16.9% (P = .26). Readmissions were higher for CST patients than non-CST patients (17.1% vs 15.7%), but not in the matched subgroup (17.0% vs 16.4%; P = .41). Most commonly, readmissions were for infection (28.3%); 14.3% of readmitted patients underwent reoperation. Smoking, morbid obesity, diabetes, chronic lung disease, urban-teaching hospital status, and increased length of stay increased the chance of readmission (all P < .05).

CONCLUSION

From 2016 to 2018, the use of CST increased 67.5% nationwide without an increase in readmissions. As we look toward clinical targets to reduce risk of readmission, modifiable health conditions, such as smoking, morbid obesity, and diabetes should be targeted during the prehabilitation process.

Hinge Flap of Rectus Abdominis Muscle Combined with Component Separation Technique: Clinical Cases

Some techniques to reconstruct the abdominal wall have been published, including the component separation procedure. The contribution of the rectus abdominis flap in the reconstruction of a giant incisional hernia is reported. The authors report three clinical cases in which the component separation technique was insufficient to reconstruct a giant midline incisional hernia. As a salvage technique, the rectus abdominis flap was dissected in the form of a hinge. The postoperative period was successful in all patients, combining both techniques. The rectus abdominis hinge flap could be used as a complementary technique to component separation to reconstruct a giant midline incisional hernia. There are several options to reconstruct the abdominal wall, such as anterior transposition of the posterior rectus sheath,¹ or rotation of the anterior sheath toward the midline. This strategy is known as open book.² The rectus turnover flap is also used.³ The anterior component separation technique closes defects less than 20 cm width.⁴ If it is wider, the reconstruction is more difficult. When the operative plan fails in the operating room, an additional technique should be considered. We report on the cases in which we use the rectus abdominis hinge flap.

Strategies for Mesh Fixation in Abdominal Wall Reconstruction: Concepts and Techniques

SUMMARY

Ventral hernias have numerous causes, ranging from sequelae of surgical procedures to congenital deformities. Patients suffering from these hernias experience a reduced quality of life through pain, associated complications, and physical disfigurement. Therefore, it is important to provide these patients with a steadfast repair that restores functionality and native anatomy. To do this, techniques and materials for abdominal wall reconstruction have advanced throughout the decades, leading to durable surgical repairs. At the cornerstone of this lies the use of mesh. When providing abdominal wall reconstruction, a surgeon must make many decisions with regard to mesh use. Along with the type of mesh and plane of placement of mesh, a surgeon must decide on the method of mesh fixation. Fixation of mesh provides an equal distribution of tension and a more robust tissue-mesh interface, which promotes integration. There exist numerous modalities for mesh fixation, each with its own benefits and drawbacks. This Special Topic article aims to compare and contrast methods of mesh fixation in terms of strength of fixation, clinical outcomes, and cost-effectiveness. Methods included in this review are suture, tack, fibrin glue, mesh strip, and self-adhering modes of fixation.

How-we-do-it: the repair of postoperative ventral hernias after a Mercedes abdominal incision

PURPOSE

To describe the abdominal wall reconstruction technique with an Ultrapro mesh and outcome for the repair of postoperative ventral hernias after the use of a Mercedes incision during the initial abdominal operation.

METHOD

A retrospective review of all the patients undergoing elective postoperative ventral hernia repair between 2013 and 2019. The cohort of these patients that had an initial Mercedes incision was used for this study.

RESULTS

Fourteen patients met the criteria for this study. Thirteen of the patients were transplant patients (10 liver transplant and 3 combined pancreas and kidney transplant), and one patient was after a hepatectomy. Fifty-seven percent of these hernias were multiple defects. All the patients underwent the same repair of a modified Rives-Stoppa, transversus abdominis release, and a bilateral transverse plication. A partially absorbable Ultrapro mesh was used for all the patients, with two of the patients needing an additional Symbotex mesh in order to bridge a portion of the posterior fascia. There were 6 minor early postoperative complications (hematoma, superficial wound infection, and seroma) that did not require reoperation. Two patients were readmitted for observation of a wound hematoma, and two patients (14.2%) had recurrence during the follow-up period. The average length of hospitalization was 5.6 days.

CONCLUSION

This technique, with the use of an Ultrapro mesh, was found to be safe and effective for the repair of a postoperative ventral hernia due to an initial Mercedes incision.

Beyond the Hernia Repair: A Review of the Insurance Coverage of Critical Adjuncts in Abdominal Wall Reconstruction

The prevalence of complex abdominal wall defects continues to rise, which necessitates increasingly sophisticated medical and surgical management. Insurance coverage for reconstructive surgery varies due to differing interpretations of medical necessity. The authors sought to characterize the current insurance landscape for a subset of key adjunctive procedures in abdominal wall reconstruction, including component separation and simultaneous ventral hernia repair with panniculectomy (SVHR-P) or abdominoplasty (SVHR-A), and synthesize a set of reporting recommendations based on insurer criteria.

Methods

Insurance companies were selected based on their national and state market share. Preauthorization criteria, preauthorization lists, and medical/clinical policies by each company for component separation, SVRH-P, and SVRH-A were examined. Coverage criteria were abstracted and analyzed.

Results

Fifty insurance companies were included in the study. Only 1 company had clear approval criteria for component separation, while 38 cover it on a case-by-case basis. Four companies had clear approval policies for SVHR-P, 4 cover them on an individual case basis, and 28 flatly do not cover SVHR-P. Similarly, 3 companies had clear approval policies for SVHR-A, 6 cover them case by case, and 33 do not cover SVHR-A.

Conclusions

Component separation and soft tissue contouring are important adjunctive AWR procedures with efficacy supported by peer-reviewed literature. The variability in SVHR-P and SVHR-A coverage likely decreases access to these procedures even when there are established medical indications. The authors recommend standardization of coverage criteria for component separation, given that differing interpretations of medical necessity increase the likelihood of insurance denials.

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

BACKGROUND

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

DATA SOURCES

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

CONCLUSIONS

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

Prevention of intestinal adhesion and regeneration of abdominal wall tissue with meshes containing an electrostatically spun acellular dermal matrix (ADM)/silk fibroin (SF) fiber composite polypropylene mesh

The repair of abdominal wall defects often requires the use of polypropylene (PP) as the main material. After a PP mesh is implanted in the body, contact with the intestine can cause adhesions between the intestine and the mesh, leading to serious complications such as intestinal fistula. In this study, we used electrostatic spinning technology to coat one side of PP meshes with an electrostatically spun isolating layer of acellular dermal matrix (ADM)/silk fibroin (SF) hybrid material. These meshes were used to repair abdominal wall defects in model rats and were compared with polycaprolactone (PCL) composite polypropylene meshes and PP meshes. The results showed that the adhesion score and area of ADM/SF-PP meshes were smaller than those of PCL-PP and PP meshes. Immunohistochemical assessment revealed that the ADM/SF meshes could effectively reduce the inflammatory response at the contact surface between the meshes and abdominal organs. The tissues regenerated on the abdominal side were rich in new blood vessels. Furthermore, the ADM/SF meshes could effectively reduce the expression levels of the inflammation-related factors IL-6 and TNF-α. The expression levels of tissue regeneration-related factors, such as VEGF and PAX-7, were also higher after ADM/SF-PP mesh-mediated repair than after PCL-PP mesh and PP mesh repair. Thus, ADM/SF-PP meshes can effectively reduce the inflammatory response at the contact surface between the meshes and abdominal organs and quickly promote regeneration of abdominal surface tissue to prevent and reduce abdominal adhesion and support restoration of the abdominal wall.

Panniculectomy: Practical Pearls and Pitfalls

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

Subcuticular sutures in laparoscopic colorectal surgery: a comparative study to evaluate wound infection rates and cosmetic results

Laparoscopic colorectal surgery is categorized as clean-contaminated surgery. It is important to prevent incisional surgical site infections (SSIs), because SSIs can prolong hospital stays, increase medical costs and produce negative cosmetic outcomes for patients. The aim of this study is to evaluate the efficacy of subcuticular skin sutures following colorectal laparoscopic surgery in terms of wound infection rates and aesthetic results. A retrospective analysis on a database of a consecutive series of unselected patients was conducted. Patients underwent elective colorectal laparoscopic surgery in a single center between October 1st of 2016 and October 30th of 2017. Data on patients' demographics, operative details, short-term and long-term outcomes and aesthetic satisfaction were prospectively recorded. A total of 100 patients were selected and divided in 2 groups: 43 patients who had received subcuticular sutures, 57 patients who had received separate stitch sutures. Wound infection rates were lower, with no statistical significance in the subcuticular suture group (6.9% versus 15.8%, p = 0.182), but the patient-reported cosmetic results were superior in the subcuticular suture group (1.9 versus 2.9, p < 0.001). Multivariate analyses identified high BMI and low preoperative hemoglobin level as possible risk factors associated with wound infection after colorectal laparoscopic surgery. Subcuticular sutures could improve cosmetic results in patients undergoing elective laparoscopic surgery for colorectal cancer with comparable risks of wound infection. In this population, high BMI and low preoperative hemoglobin levels appear to be risk factors associated with wound infections.

Hernio-abdominoplasty with or without Scarpa's Fascia Preservation for Ventral Hernia and Abdominal Wall Deformity

Scarpa’s fascia preservation plays a great role in decreasing the volume of wound drainage and reducing seroma after abdominoplasty. This study aimed to assess the role of Scarpa’s fascia preservation in patients with ventral hernias associated with abdominal wall deformity who underwent concomitant hernio-abdominoplasty in terms of early and late postoperative outcome and quality of life.

The 4 Principles of Complex Abdominal Wall Reconstruction

Abdominal wall defects are some of the most common and challenging problems encountered by plastic surgeons. A high proportion of patients with abdominal wall defects have significant comorbidities and/or contamination, putting them at high risk for complications. In addition to advanced surgical skills and precise anatomical knowledge, the plastic surgeon needs strict discipline and medical acumen, to optimize patients before and after surgery. In this paper, we discuss the goals of abdominal wall reconstruction, and the 4 steps to successful surgery: preoperative patient selection/optimization, durable and dynamic reconstruction of the musculofascial layer, careful attention to the skin and subcutaneous tissue, and meticulous postoperative management.