Complex Hernia Repair Using Component Separation Technique Paired with Intraperitoneal Acellular Porcine Dermis and Synthetic Mesh Overlay:

The use of self-gripping mesh with anterior component separation technique in incisional hernia repair: A case series

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We present three cases of incisional hernia repair using onlay self-gripping mesh.

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The mesh was placed following the anterior component separation technique.

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Self-gripping mesh enhances tissue adhesion and requires minimal suture fixation.

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The advantages are more sufficient reinforcement and technical simplicity.

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The disadvantages are risk of decreased blood flow, infection, fistula, and pain.

Introduction

Incisional hernia (IH) is a common postoperative complication that affects 10% of the patients who undergo abdominal surgery. The component separation (CS) technique is suitable for large and/or complex hernias; however, CS alone may not eliminate recurrence and is associated with an increased incidence of wound complications. Self-gripping mesh enhances tissue adhesion and contributes to a reduced risk of migration, chronic pain, and other complications. Here, we present three cases of IH that were successfully repaired by anterior CS (ACS) using onlay self-gripping meshes.

Case presentation

All three patients underwent surgery using the following technique: Briefly, a skin flap was created with release of the external oblique muscle and preservation of the perforating vessels. The linea alba was closed with absorbable interrupted sutures. A self-gripping mesh was trimmed and placed with a 4–5 cm overlap bilaterally from the closed linea alba using an onlay technique. For all patients, the postoperative courses were uneventful and there were no complications at the 3-month follow-up.

Discussion

The advantages of our technique include more sufficient abdominal reinforcement, technical simplicity, and minimal time required for mesh placement. The disadvantages are the potential risk of decreased blood flow of the skin flaps, wound infection, intestinal fistula, persisting or chronic pain, and difficulty with subsequent abdominal surgery.

Conclusion

The use of self-gripping mesh with ACS can be performed without increasing the operative time or causing short-term surgical complications. This technique may be recommended for large IH because of its simplicity and secure abdominal reinforcement provided.

Treatment of Large Incisional Hernias in Sandwich Technique - A Review of the Literature

Introduction

In a systematic review of the surgical treatment of large incisional hernia sublay repair, the sandwich technique and aponeuroplasty with intraperitoneal mesh displayed the best results. In this systematic review only the sandwich technique, which used the hernia sac as an extension of the posterior and anterior rectus sheath and placement of a non-absorbable mesh in the sublay position, was included. Other modifications of the sandwich technique are published in the literature and were also analyzed in this literature review.

Methods

A systematic search of the available literature was performed in November 2017 using Medline, PubMed, and the Cochrane Library using the terms “sandwich technique”, “double prosthetic repair”, “double mesh intraperitoneal repair”, and “component separation technique with double mesh”. This review is based on 24 relevant publications. Unfortunately, the evidence of the available studies is not very high since only prospective and retrospective case series have been published. There are no comparative studies at all. Therefore, the findings of the published case series must be viewed in a critical light.

Results

The published studies report a remarkably low recurrence rate of 0-13% with a follow-up of 1–7 years. One limitation that must be mentioned here is that in around half of the studies the method of follow-up was not specified and in the remaining cases this was based on clinical examination by the surgical team. This puts into perspective the reported results, which appear to be too favorable given the complex nature of the hernias involved.

The major disadvantage of the sandwich technique is a very high rate of wound complications of up to 68%, mainly induced by creation of large skin and subcutaneous cellular tissue flaps.

Conclusion

It is difficult to evaluate the significance of the various modifications of the “sandwich technique” based on the available literature since it includes only case series and no comparative studies. The techniques used are associated with very high wound complication rates but with only relatively low recurrence rates despite the complexity of the cases involved. This must be verified in studies with a well-designed methodology.

What is the evidence for the use of biologic or biosynthetic meshes in abdominal wall reconstruction?

INTRODUCTION

Although many surgeons have adopted the use of biologic and biosynthetic meshes in complex abdominal wall hernia repair, others have questioned the use of these products. Criticism is addressed in several review articles on the poor standard of studies reporting on the use of biologic meshes for different abdominal wall repairs. The aim of this consensus review is to conduct an evidence-based analysis of the efficacy of biologic and biosynthetic meshes in predefined clinical situations.

METHODS

A European working group, "BioMesh Study Group", composed of invited surgeons with a special interest in surgical meshes, formulated key questions, and forwarded them for processing in subgroups. In January 2016, a workshop was held in Berlin where the findings were presented, discussed, and voted on for consensus. Findings were set out in writing by the subgroups followed by consensus being reached. For the review, 114 studies and background analyses were used.

RESULTS

The cumulative data regarding biologic mesh under contaminated conditions do not support the claim that it is better than synthetic mesh. Biologic mesh use should be avoided when bridging is needed. In inguinal hernia repair biologic and biosynthetic meshes do not have a clear advantage over the synthetic meshes. For prevention of incisional or parastomal hernias, there is no evidence to support the use of biologic/biosynthetic meshes. In complex abdominal wall hernia repairs (incarcerated hernia, parastomal hernia, infected mesh, open abdomen, enterocutaneous fistula, and component separation technique), biologic and biosynthetic meshes do not provide a superior alternative to synthetic meshes.

CONCLUSION

The routine use of biologic and biosynthetic meshes cannot be recommended.

Long-term outcomes of sandwich ventral hernia repair paired with hybrid vacuum-assisted closure

BACKGROUND

Sandwich ventral hernia repair (SVHR) may reduce ventral hernia recurrence rates, although with an increased risk of surgical site occurrences (SSOs) and surgical site infections (SSIs). Previously, we found that a modified negative pressure wound therapy (hybrid vacuum-assisted closure [HVAC]) system reduced SSOs and SSIs after ventral hernia repair. We aimed to describe our outcomes after SVHR paired with HVAC closure.

METHODS

We conducted a 4-y retrospective review of all complex SVHRs (biologic mesh underlay and synthetic mesh overlay) with HVAC closure performed at our institution by a single surgeon. All patients had fascial defects that could not be reapproximated primarily using anterior component separation. Descriptive statistics were used to report the incidence of postoperative complications and hernia recurrence.

RESULTS

A total of 60 patients (59.3 ± 11.4 y, 58.3% male, 75% American Society of Anesthesiologists class ≥3) with complex ventral hernias being underwent sandwich repair with HVAC closure. Major postoperative morbidity (Dindo-Clavien class ≥3) occurred in 14 (23.3%) patients, but incidence of SSO (n = 13, 21.7%) and SSI (n = 4, 6.7%) was low compared with historical reports. Median follow-up time for all patients was 12 mo (interquartile range 5.8-26.5 mo). Hernia recurrence occurred in eight patients (13.3%) after a median time of 20.6 months (interquartile range 16.4- 25.4 months).

CONCLUSIONS

Use of a dual layer sandwich repair for complex abdominal wall reconstruction is associated with low rates of hernia recurrence at 1 year postoperatively. The addition of the HVAC closure system may reduce the risk of SSOs and SSIs previously reported with this technique and deserves consideration in future prospective studies assessing optimization of ventral hernia repair approaches.

Tissue Expanders in Skin Deficient Ventral Hernias Utilizing Component Separation

Skin deficient complex ventral hernias are complicated surgical cases that have multimodal approaches. There is no current consensus on the management of those patients who also have concomitant stomas or enterocutaneous fistula. We present 2 cases in which the senior authors were able to apply tissue expanders above and between the abdominal wall in patients with an enterocutaneous fistula or stoma. After expansion and final closure, the patients did not experience recurrent hernias.

Negative-Pressure Wound Therapy in the Management of High-Grade Ventral Hernia Repairs

BACKGROUND

Despite improved operative techniques, open ventral hernia repair (VHR) surgery in high-risk, potentially contaminated patients remains challenging. As previously reported by our group, the use of a modified negative-pressure wound therapy system (hybrid-VAC or HVAC) in patients with grade 2 hernias is associated with lower surgical site occurrence (SSO) and surgical site infection (SSI) rates. Accordingly, the authors aim to evaluate whether the HVAC would similarly improve surgical site outcomes following VHR in patients with grade 3 hernias.

METHODS

A 4-year retrospective review (2011-2014) was conducted of all consecutive, modified ventral hernia working group (VHWG) grade 3 hernia repairs with HVAC closure performed by a single surgeon (FEE) at a single institution. Operative data and 90-day outcomes were evaluated. Overall outcomes (e.g., recurrence, reoperation, mortality) were reviewed for the study group.

RESULTS

A total of 117 patients with an average age of 56.7 ± 11.9 years were classified as grade 3 hernias and underwent open VHR with subsequent HVAC closure. Fifty patients were male (42.7 %), the mean BMI was 35.2 (±9.5), and 60.7 % had a history of prior hernia repair. The average fascial defect size was 201.5 (±167.3) cm(2) and the mean length of stay was 14.2 (±9.3) days. Ninety-day outcomes showed an SSO rate of 20.7 % and an SSI rate of 5.2 %. The overall hernia recurrence rate was 4.2 % (n=6) with a mean follow-up of 11 ± 7.3 months.

CONCLUSION

Modified VHWG grade 3 ventral hernias are associated with significant morbidity. In our series utilizing the HVAC system after VHR, the observed rate of SSO and SSI compared favorably to reported series. Further prospective cost-effective studies are warranted to validate these findings.

Outcomes following placement of non-cross-linked porcine-derived acellular dermal matrix in complex ventral hernia repair

Repair of complex ventral hernias frequently results in postoperative complications. This study assessed postoperative outcomes in a consecutive cohort of patients with ventral hernias who underwent herniorrhaphy using components separation techniques and reinforcement with non–cross-linked intact porcine-derived acellular dermal matrix (PADM) performed by a single surgeon between 2008 and 2012. Postoperative outcomes of interest included incidence of seroma, wound infection, deep-vein thrombosis, bleeding, and hernia recurrence determined via clinical examination. Of the 47 patients included in the study, 25% were classified as having Ventral Hernia Working Group grade 1 risk, 62% as grade 2, 2% as grade 3, and 11% as grade 4; 49% had undergone previous ventral hernia repair. During a mean follow-up of 31 months, 3 patients experienced hernia recurrence, and 9 experienced other postoperative complications: 4 (9%) experienced deep-vein thrombosis; 3 (6%), seroma; 2 (4%), wound infection; and 2 (4%), bleeding. The use of PADM reinforcement following components separation resulted in low rates of postoperative complications and hernia recurrence in this cohort of patients undergoing ventral hernia repair.

Complex ventral hernia repair with a human acellular dermal matrix and component separation: A case series

We present a case series of 19 patients requiring complex abdominal hernia repairs. Patients presented with challenging clinical histories with 95% having multiple significant comorbidities including overweight or obesity (84%), hypertension (53%), diabetes (42%), cancer (26%), and pulmonary disease (16%). The majority of patients (68%) had prior abdominal infections and 53% had at least one failed prior hernia repair. Upon examination, fascial defects averaged 282 cm². Anterior and posterior component separation was performed with placement of a human acellular dermal mesh. Midline abdominal closure under minimal tension was achieved primarily in all cases. Post-operative complications included 2 adverse events (11%) – one pulmonary embolism and one post-operative hemorrhage requiring transfusion; 6 wound-related complications (32%), 1 seroma (5%) and 1 patient with post-operative ileus (5%). Operative intervention was not required in any of the cases and most patients made an uneventful recovery. Increased patient age and longer OR time were independently predictive of early post-operative complications. At a median 2-year follow-up, three patients had a documented hernia recurrence (16%) and one patient was deceased due to unrelated causes.

Conclusion

Patients at high risk for post-operative events due to comorbidities, prior abdominal infection and failed mesh repairs do well following component separation reinforced with a human bioprosthetic mesh. Anticipated post-operative complications were managed conservatively and at a median 2-year follow-up, a low rate of hernia recurrence was observed with this approach.

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Intraperitoneal placement of acellular dermal matrix using component separation.

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Acceptable recurrence rates of 16% at 2 years of follow up.

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Correlation in age and complication chances.

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Retrorectus technique possibly the best surgical technique for hernia repair.

Critical analysis of Strattice performance in complex abdominal wall reconstruction: intermediate-risk patients and early complications

The purpose of this study was to analyze the performance of a porcine-derived acellular dermal matrix (Strattice Reconstructive Tissue Matrix) in patients at increased risk for perioperative complications. We reviewed medical records for patients with complex abdominal wall reconstruction (AWR) and Strattice underlay from 2007 to 2010. Intermediate-risk patients were defined as having multiple comorbidities without abdominal infection. Forty-one patients met the inclusion criteria (mean age, 60 years; mean body mass index, 35.5 kg/m(2)). Comorbidities included coronary artery disease (63.4%), diabetes mellitus (36.6%), and chronic obstructive pulmonary disease (17.1%). Fascial closure was achieved in 40 patients (97.6%). Average hospitalization was 6.4 days (range, 1-24 days). Complications included seroma (7.3%), wound dehiscence with Strattice exposure (4.9%), cellulitis (2.4%), and hematoma (2.4%). All patients achieved abdominal wall closure with no recurrent hernias or need for Strattice removal. Patients with multiple comorbidities at intermediate risk of postoperative complications can achieve successful, safe AWR with Strattice.

Regional variations in the histology of porcine skin

Porcine skin is commonly used as a model for human skin injury and as a source material for biologic scaffold materials. Although remarkable similarities between porcine and human skin exist, regional anatomic variations present in human skin are also present in porcine skin. The objective of this study was to evaluate the structure of porcine skin from 11 different anatomic regions in the American Yorkshire crossbreed. Both qualitative and quantitative methods were used, with emphasis on epidermal and dermal thickness, hair follicle density, and collagen and elastin composition and distribution. The results showed that significant regional differences in skin histology exist, particularly with regard to the thickness of the dermis and epidermis and the amount of collagen and elastin within each tissue. Differences were also seen in the distribution of type I and type III collagen within the dermis. Therefore, while porcine skin shares many similarities with human skin, distinct regional differences in composition and morphology exist. This study highlights the importance of appreciating these regional differences to avoid misinterpretation of experimental results when using porcine skin as a human analogue.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Does mesh location matter in abdominal wall reconstruction? A systematic review of the literature and a summary of recommendations

BACKGROUND

Mesh implantation during abdominal wall reconstruction decreases rates of ventral hernia recurrence and has become the dominant method of repair. The authors provide a comprehensive comparison of surgical outcomes and complications by location of mesh placement following ventral hernia repair with onlay, interposition, retrorectus, or underlay mesh.

METHODS

A systematic search of the English literature published from 1996 to 2012 in the PubMed, MEDLINE, and Cochrane library databases was conducted to identify patients who underwent abdominal wall reconstruction using either prosthetic or biological mesh for ventral hernia repair. Demographic information was obtained from each study.

RESULTS

Sixty-two relevant articles were included with 5824 patients treated with mesh repair of a ventral hernia between 1996 and 2012. Mesh position included onlay (19.6 percent), underlay (60.7 percent), interposition (6.4 percent), and retrorectus (12.4 percent). Prosthetic mesh was used in 80 percent of repairs and biological mesh in 20 percent. The weighted mean incidences of early events were as follows: wound complications, 19 percent; wound infections, 8 percent; seroma or hematoma formation, 11 percent; and reoperation, 10 percent. The weighted mean incidences of late complications included 8 percent for hernia recurrence and 2 percent for mesh explantation. Recurrence rates were highest for onlay (17 percent) or interposition (17 percent) reinforcement. The infection rate was also highest in the interposition cohort (25 percent). Seroma rates were lowest following a retrorectus repair (4 percent).

CONCLUSIONS

Mesh reinforcement of a ventral hernia repair is safe and efficacious, but the location of the reinforcement appears to influence outcomes. Underlay or retrorectus mesh placement is associated with lower recurrence rates.

Long-term IgG response to porcine Neu5Gc antigens without transmission of PERV in burn patients treated with porcine skin xenografts

Acellular materials of xenogenic origin are used worldwide as xenografts, and phase I trials of viable pig pancreatic islets are currently being performed. However, limited information is available on transmission of porcine endogenous retrovirus (PERV) after xenotransplantation and on the long-term immune response of recipients to xenoantigens. We analyzed the blood of burn patients who had received living pig-skin dressings for up to 8 wk for the presence of PERV as well as for the level and nature of their long term (maximum, 34 y) immune response against pig Ags. Although no evidence of PERV genomic material or anti-PERV Ab response was found, we observed a moderate increase in anti-αGal Abs and a high and sustained anti-non-αGal IgG response in those patients. Abs against the nonhuman sialic acid Neu5Gc constituted the anti-non-αGal response with the recognition pattern on a sialoglycan array differing from that of burn patients treated without pig skin. These data suggest that anti-Neu5Gc Abs represent a barrier for long-term acceptance of porcine xenografts. Because anti-Neu5Gc Abs can promote chronic inflammation, the long-term safety of living and acellular pig tissue implants in recipients warrants further evaluation.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Biological meshes: a review of their use in abdominal wall hernia repairs

PURPOSE

Biological meshes are mostly used in infected fields within complex abdominal wall hernia repairs. There is no consensus, however, on the most appropriate material to be used in a given situation.

METHODS

A literature review of published articles reporting the utilization of biological meshes in ventral/incisional hernia repair was conducted. Data were analyzed to compare the recurrence rates obtained with biological meshes.

MAIN FINDINGS

Only a few prospective comparative studies were identified. Most publications relate to AlloDerm®, Permacol™ and Surgisis™ with data from other meshes insufficient to draw conclusions. AlloDerm has a 0-100% recurrence rate among studies. It compares poorly with Surgisis and results in an unfavorable outcome when used as a 'bridge prosthesis'. Permacol has consistent recurrence rates of 0-15%, whatever the patients' profiles or the context of infected fields, when considering the most relevant studies. The Surgisis results are more conflicting: the mesh exhibits low recurrence rates in clean fields, but in infected fields the recurrence rate is up to 39%.

CONCLUSION

Taken together, these studies suggest that the cross-linked mesh, Permacol has the lowest failure rate and the longest time to failure, particularly in contaminated or infected fields. However, this data should be confirmed by large prospective randomized studies.