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Liu Y, Huang J, Li S, Li Z, Chen C, Qu G, Chen K, Teng Y, Ma R, Ren J, Wu X. Recent Advances in Functional Hydrogel for Repair of Abdominal Wall Defects: A Review. Biomater Res 2024; 28:0031. [PMID: 38845842 PMCID: PMC11156463 DOI: 10.34133/bmr.0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/18/2024] [Indexed: 06/09/2024] Open
Abstract
The abdominal wall plays a crucial role in safeguarding the internal organs of the body, serving as an essential protective barrier. Defects in the abdominal wall are common due to surgery, infection, or trauma. Complex defects have limited self-healing capacity and require external intervention. Traditional treatments have drawbacks, and biomaterials have not fully achieved the desired outcomes. Hydrogel has emerged as a promising strategy that is extensively studied and applied in promoting tissue regeneration by filling or repairing damaged tissue due to its unique properties. This review summarizes the five prominent properties and advances in using hydrogels to enhance the healing and repair of abdominal wall defects: (a) good biocompatibility with host tissues that reduces adverse reactions and immune responses while supporting cell adhesion migration proliferation; (b) tunable mechanical properties matching those of the abdominal wall that adapt to normal movement deformations while reducing tissue stress, thereby influencing regulating cell behavior tissue regeneration; (c) drug carriers continuously delivering drugs and bioactive molecules to sites optimizing healing processes enhancing tissue regeneration; (d) promotion of cell interactions by simulating hydrated extracellular matrix environments, providing physical support, space, and cues for cell migration, adhesion, and proliferation; (e) easy manipulation and application in surgical procedures, allowing precise placement and close adhesion to the defective abdominal wall, providing mechanical support. Additionally, the advances of hydrogels for repairing defects in the abdominal wall are also mentioned. Finally, an overview is provided on the current obstacles and constraints faced by hydrogels, along with potential prospects in the repair of abdominal wall defects.
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Affiliation(s)
- Ye Liu
- School of Medicine,
Southeast University, Nanjing 210009, China
- Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School,
Nanjing University, Nanjing 210002, China
| | - Jinjian Huang
- Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School,
Nanjing University, Nanjing 210002, China
| | - Sicheng Li
- Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School,
Nanjing University, Nanjing 210002, China
| | - Ze Li
- Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School,
Nanjing University, Nanjing 210002, China
| | - Canwen Chen
- Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School,
Nanjing University, Nanjing 210002, China
| | - Guiwen Qu
- School of Medicine,
Southeast University, Nanjing 210009, China
- Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School,
Nanjing University, Nanjing 210002, China
| | - Kang Chen
- Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School,
Nanjing University, Nanjing 210002, China
| | - Yitian Teng
- Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School,
Nanjing University, Nanjing 210002, China
| | - Rui Ma
- School of Medicine,
Southeast University, Nanjing 210009, China
- Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School,
Nanjing University, Nanjing 210002, China
| | - Jianan Ren
- School of Medicine,
Southeast University, Nanjing 210009, China
- Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School,
Nanjing University, Nanjing 210002, China
| | - Xiuwen Wu
- School of Medicine,
Southeast University, Nanjing 210009, China
- Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School,
Nanjing University, Nanjing 210002, China
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Tang F, Miao D, Huang R, Zheng B, Yu Y, Ma P, Peng B, Li Y, Wang H, Wu D. Double-Layer Asymmetric Porous Mesh with Dynamic Mechanical Support Properties Enables Efficient Single-Stage Repair of Contaminated Abdominal Wall Defect. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2024; 36:e2307845. [PMID: 38408735 DOI: 10.1002/adma.202307845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 02/08/2024] [Indexed: 02/28/2024]
Abstract
Contamination tolerance and long-term mechanical support are the two critical properties of meshes for contaminated abdominal wall defect repair. However, biological meshes with excellent pollution tolerance fail to provide bio-adaptive long-term mechanical support due to their rapid degradation. Here, a novel double-layer asymmetric porous mesh (SIS/PVA-EXO) is designed by simple and efficient in situ freeze-thaw of sticky polyvinyl alcohol (PVA) solution on the loosely porous surface of small intestinal submucosal decellularized matrix (SIS), which can successfully repair the contaminated abdominal wall defect with bio-adaptive dynamic mechanical support through only single-stage surgery. The exosome-loaded degradable loosely porous SIS layer accelerates the tissue healing; meanwhile, the exosome-loaded densely porous PVA layer can maintain long-term mechanical support without any abdominal adhesion. In addition, the tensile strength and strain at break of SIS/PVA-EXO mesh change gradually from 0.37 MPa and 210% to 0.10 MPa and 385% with the degradation of SIS layer. This unique performance can dynamically adapt to the variable mechanical demands during different periods of contaminated abdominal wall reconstruction. As a result, this SIS/PVA-EXO mesh shows an attractive prospect in the treatment of contaminated abdominal wall defect without recurrence by integrating local immune regulation, tissue remodeling, and dynamic mechanical supporting.
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Affiliation(s)
- Fuxin Tang
- Department of General Surgery (Colorectal Surgery), Guangdong Institute of Gastroenterology, Biomedical Innovation Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, P. R. China
| | - Dongtian Miao
- PCFM Lab, School of Chemistry, Sun Yat-sen University, Guangzhou, 510006, P. R. China
| | - Rongkang Huang
- Department of General Surgery (Colorectal Surgery), Guangdong Institute of Gastroenterology, Biomedical Innovation Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, P. R. China
| | - Bingna Zheng
- The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518000, P.R. China
| | - Yang Yu
- Department of General Surgery (Colorectal Surgery), Guangdong Institute of Gastroenterology, Biomedical Innovation Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, P. R. China
| | - Pengwei Ma
- PCFM Lab, School of Chemistry, Sun Yat-sen University, Guangzhou, 510006, P. R. China
| | - Binying Peng
- Department of General Surgery (Colorectal Surgery), Guangdong Institute of Gastroenterology, Biomedical Innovation Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, P. R. China
| | - Yong Li
- Department of General Surgery (Gastrointestinal Surgery), Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, P. R. China
| | - Hui Wang
- Department of General Surgery (Colorectal Surgery), Guangdong Institute of Gastroenterology, Biomedical Innovation Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, P. R. China
| | - Dingcai Wu
- PCFM Lab, School of Chemistry, Sun Yat-sen University, Guangzhou, 510006, P. R. China
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Huang EY, Broderick RC, Spurzem GJ, Li JZ, Blitzer RR, Cheverie JN, Sandler BJ, Horgan S, Jacobsen GR. Long-term outcomes of PGA-TMC absorbable synthetic scaffold in both clean and contaminated ventral hernia repairs. Surg Endosc 2024; 38:2231-2239. [PMID: 38498213 DOI: 10.1007/s00464-024-10777-z] [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: 03/31/2023] [Accepted: 03/04/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Biosynthetic meshes afford the cost advantages of being made from fully synthetic material, but are also biodegradable, making them a versatile option that can be used in both clean and contaminated cases. The aim of this study is to evaluate the safety profile and long-term outcomes of using GORE BIO-A (BIO-A) as an adjunct to abdominal wall reconstruction in all wound classes. METHODS A retrospective review identified patients undergoing abdominal hernia repair using BIO-A from October 2008 to June 2018. The primary outcome was hernia recurrence rate. Only patients with at least 6-month follow-up were included when looking at recurrence rates. Secondary outcomes included 30-day morbidity categorized according to CDC Surgical Site Infection Criteria, return to operating/procedure room (RTOR), 30-day readmission, length of stay (LOS), and mortality. RESULTS A total of 207 patients were identified, CDC Wound Classification breakdown was 127 (61.4%), 41 (19.8%), 14 (6.8%), and 25 (12.1%) for wound classes I, II, III, and IV, respectively. Median follow-up was 55.4 months (range 0.2-162.4). Overall recurrence rate was 17.4%. Contaminated cases experienced higher recurrence rates (28.8% versus 10.4%, p = 0.002) at a mean follow up of 46.9 and 60.8 months for contaminated and clean patients, respectively. Recurrent patients had higher BMI (32.4 versus 28.4 kg/m2, p = 0.0011), larger hernias (162.2 versus 106.7 cm2, p = 0.10), higher LOS (11.1 versus 5.6 days, p = 0.0051), and higher RTOR rates (16.7% versus 5.6%, p = 0.053). 51 (24.5%) patients experienced some morbidity, including 19 (9.2%) surgical site occurences, 7 (3.4%) superficial surgical site infections, 16 (7.7%) deep surgical site infections, and 1 (0.5%) organ space infection. CONCLUSION This study affirms the use of biosynthetic mesh as a cost-effective alternative in all wound classifications, yielding good outcomes, limited long-term complications, and low recurrence. rates.
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Affiliation(s)
- Estella Y Huang
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, CA, 92093-0740, USA
| | - Ryan C Broderick
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, CA, 92093-0740, USA
| | - Graham J Spurzem
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, CA, 92093-0740, USA.
| | - Jonathan Z Li
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, CA, 92093-0740, USA
| | - Rachel R Blitzer
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, CA, 92093-0740, USA
| | - Joslin N Cheverie
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, CA, 92093-0740, USA
| | - Bryan J Sandler
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, CA, 92093-0740, USA
| | - Santiago Horgan
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, CA, 92093-0740, USA
| | - Garth R Jacobsen
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, CA, 92093-0740, USA
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Lemdani MS, Niu EF, Amro C, Gala Z, Ewing JN, Honig SE, Broach RB, Fischer JP. Outcomes and Quality of Life After Resorbable Synthetic Ventral Hernia Repair in Contaminated Fields. Ann Plast Surg 2024; 92:S156-S160. [PMID: 38556666 DOI: 10.1097/sap.0000000000003860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
INTRODUCTION The ideal mesh type for hernia repair in a contaminated field remains controversial. Data regarding outcomes beyond 1 year and the impact on quality of life (QoL) are unknown. This study aims to evaluate the long-term surgical outcomes and patient-reported outcomes (PROs) after contaminated repair with poly-4-hydroxybutyrate (P4HB) mesh. MATERIALS METHODS Patients undergoing a contaminated hernia repair with P4HB between 2015 and 2020 were identified. Surgical site occurrences and hernia recurrences were recorded. Long-term PROs as defined by the Abdominal Hernia-Q and Hernia-Related Quality-of-Life Survey were assessed. RESULTS Fifty-five patients were included with a mean age of 54.5 years, a body mass index of 34 kg/m2, and a defect size of 356.9 ± 227.7 cm2. Median follow-up time was 49 months with a reoperation rate of 14.5% and a hernia recurrence rate of 7.3%. Of the 55 patients, 37 completed preoperative and postoperative PRO questionnaires. When comparing preoperative with postoperative Abdominal Hernia-Q, there was significant improvement in overall PROs (2.1 vs 3.5, P < 0.001). This improvement was maintained with no significant changes between postoperative scores over the course of 5 years. Patients with complications saw the same improvement in postoperative PRO scores as those without complications. CONCLUSIONS Our study found a low hernia recurrence and acceptable long-term reoperation rates in patients undergoing hernia repair with P4HB mesh in a contaminated setting. We demonstrate a sustained significant improvement in QoL scores after hernia repair. These data yield insight into the long-term outcomes and QoL improvement, providing physicians further knowledge to better counsel their patients.
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Affiliation(s)
- Mehdi S Lemdani
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
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Sweitzer K, O'Shea A, Tawil C, Weissberg J, Tomtschik J, Butterfield J, Fowler C, Langstein H, Bell D. Hernia Recurrence and Complications After Abdominal Reconstruction With Reinforced Versus Nonreinforced Biologic Mesh. Ann Plast Surg 2024; 92:S196-S199. [PMID: 38556672 DOI: 10.1097/sap.0000000000003875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
INTRODUCTION Both biologic and permanent (synthetic) meshes are used for abdominal wall reconstruction. Biologic mesh has the advantage of eventual incorporation, which makes it generally preferred in contaminated patients compared with synthetic mesh (Ann Surg. 2013;257:991-996). However, synthetic mesh has been shown to have decreased long-term hernia recurrence despite increased complications (JAMA Surg. 2022;157:293-301). Ovitex (TelaBio, Ltd, Auckland, New Zealand) is a combined reinforced biologic mesh with a permanent Prolene suture weave that theoretically combines incorporation with a long-term strength component. We hypothesize that a reinforced biologic will have a similar complication profile but decreased long-term hernia recurrence. METHODS A single-center retrospective review was performed from January 2013 to January 2022. Baseline patient characteristics and outcomes including 90-day complications and recurrence were compared. Categorical and continuous variables were analyzed with χ2 and Wilcoxon rank sum tests, respectively. Predictors of postoperative complications and hernia recurrence were analyzed via univariate logistic regression and multivariate logistic regression with backward stepwise selection with a threshold of P < 0.2. RESULTS Two hundred fifty-four patients underwent abdominal wall reconstruction biologic mesh (Strattice, Allergan; FlexHD, MTF Biologics; Alloderm, Allergan; Surgisis Gold, Cook Biotech; Ovitex, Telabio) with retrorectus (66.5%) or intraperitoneal (33.5%) mesh placement. Sixty-six of these used reinforced biologic mesh (Ovitex, TelaBio). Baseline characteristics were comparable including preoperative hernia size measured on CT. The mean follow-up time was 343 days. The majority of patients underwent component separation (80.3% bilateral, 11.4% unilateral, 8.3% none). On univariate analysis, reinforced biologic mesh did not impact 90-day complication rates (P = 0.391) or hernia recurrence rates (P = 0.349). On multivariate analysis, reinforced mesh had no impact on complication or recurrence rates (P > 0.2). A previous history of infected mesh was an independent risk factor for hernia recurrence (P = 0.019). Nonreinforced biologics were more likely to be used in instances of previous mesh infection (P = 0.025), bowel resection (P = 0.026), and concomitantly at the time of stoma takedown (P = 0.04). Reinforced biologics were more likely to be used with a history of previous hernia repair with recurrence not due to infection (P = 0.001). Body mass index >35 was an independent risk factor across both groups for 90-day complications (P = 0.028). CONCLUSIONS Reinforced versus nonreinforced biologics have similar risk profile and recurrence rate when placed primary fascial repair achieved. In abdominal walls with history of infection, or abdominal wall reconstruction performed concomitantly at the time of stoma takedown or bowel resection/anastomosis, nonreinforced biologics were used more commonly with no difference in negative outcomes. This implies that they may have a role for use in contaminated surgical cases. Reinforced biologics were more commonly used as a mesh choice in the setting of previous hernia repair with recurrence with no difference in outcomes. This implies that the reinforced nature may be useful in situations where extra reinforcement of already traumatized abdominal wall tissue is needed. Retrorectus or intraperitoneal placement of any biologic mesh is acceptable and should be chosen based off surgeon comfort and anticipated cost saving of individual mesh brands. There may be a role for reinforced mesh in the setting of previous failed hernia repair with weakened fascia, as well as nonreinforced in contaminated cases.
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Affiliation(s)
- Keith Sweitzer
- From the Division of Plastic Surgery, Department of Surgery, University of Rochester, Rochester, NY
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Li Q, Wang L, Yu L, Li C, Xie X, Yan H, Zhou W, Wang C, Liu Z, Hou G, Zhao YQ. Polysaccharide-Based Coating with Excellent Antibiofilm and Repeatable Antifouling-Bactericidal Properties for Treating Infected Hernia. Biomacromolecules 2024; 25:1180-1190. [PMID: 38240673 DOI: 10.1021/acs.biomac.3c01175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2024]
Abstract
In recent years, the utilization of medical devices has gradually increased and implantation procedures have become common treatments. However, patients are susceptible to the risk of implant infections. This study utilized chemical grafting to immobilize polyethylenimine (QPEI) and hyaluronic acid (HA) on the surface of the mesh to improve biocompatibility while being able to achieve antifouling antimicrobial effects. From the in vitro testing, PP-PDA-Q-HA exhibited a high antibacterial ratio of 93% against S. aureus, 93% against E. coli, and 85% against C. albicans. In addition, after five rounds of antimicrobial testing, the coating continued to exhibit excellent antimicrobial properties; PP-PDA-Q-HA also inhibits the formation of bacterial biofilms. In addition, PP-PDA-Q-HA has good hemocompatibility and cytocompatibility. In vivo studies in animal implantation infection models also demonstrated the excellent antimicrobial properties of PP-PDA-Q-HA. Our study provides a promising strategy for the development of antimicrobial surface medical materials with excellent biocompatibility.
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Affiliation(s)
- Qifen Li
- School of Pharmacy, Key Laboratory of Medical Antibacterial Materials of Shandong Province, Binzhou Medical University, Yantai 264003, PR China
| | - Leixiang Wang
- School of Pharmacy, Key Laboratory of Medical Antibacterial Materials of Shandong Province, Binzhou Medical University, Yantai 264003, PR China
| | - Lu Yu
- School of Pharmacy, Key Laboratory of Medical Antibacterial Materials of Shandong Province, Binzhou Medical University, Yantai 264003, PR China
| | - Chengbo Li
- School of Pharmacy, Key Laboratory of Medical Antibacterial Materials of Shandong Province, Binzhou Medical University, Yantai 264003, PR China
| | - Xianrui Xie
- School of Pharmacy, Key Laboratory of Medical Antibacterial Materials of Shandong Province, Binzhou Medical University, Yantai 264003, PR China
| | - Huanhuan Yan
- School of Pharmacy, Key Laboratory of Medical Antibacterial Materials of Shandong Province, Binzhou Medical University, Yantai 264003, PR China
| | - Wenjuan Zhou
- The Affiliated Yantai Stomatological Hospital, Binzhou Medical University, Yantai 264003, PR China
| | - Chunhua Wang
- School of Pharmacy, Key Laboratory of Medical Antibacterial Materials of Shandong Province, Binzhou Medical University, Yantai 264003, PR China
| | - Zhonghao Liu
- The Affiliated Yantai Stomatological Hospital, Binzhou Medical University, Yantai 264003, PR China
| | - Guige Hou
- School of Pharmacy, Key Laboratory of Medical Antibacterial Materials of Shandong Province, Binzhou Medical University, Yantai 264003, PR China
| | - Yu-Qing Zhao
- School of Pharmacy, Key Laboratory of Medical Antibacterial Materials of Shandong Province, Binzhou Medical University, Yantai 264003, PR China
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DeLong CG, Crowell KT, Liu AT, Deutsch MJ, Scow JS, Pauli EM, Horne CM. Staged abdominal wall reconstruction in the setting of complex gastrointestinal reconstruction. Hernia 2024; 28:97-107. [PMID: 37648895 DOI: 10.1007/s10029-023-02856-2] [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: 03/12/2023] [Accepted: 07/27/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE Literature on one- versus two-staged abdominal wall reconstruction (AWR) with complex gastrointestinal reconstruction (GIR) is limited to single-arm case series with a focus on patients who complete all planned stages. Herein, we describe our experience with both one- and two-staged approaches to AWR/GIR, with attention to those who did not complete both intended stages. METHODS A retrospective review of prospectively collected data was conducted to identify patients who underwent a one- or two-stage approach to GIR/AWR from 2013 to 2020. The one-stage approach included GIR and definitive sublay mesh herniorrhaphy. The two-stage approach included Stage 1 (S1)-GIR and non-definitive herniorrhaphy and Stage 2 (S2)-definitive sublay mesh herniorrhaphy. RESULTS Fifty-four patients underwent GIR/AWR: 20 (37.0%) underwent a planned 1-stage operation while 34 (63.0%) underwent S1 of a planned 2-stage approach. Patients assigned to the 2-stage approach were more likely to be smokers, have a history of mesh infection, have an enterocutaneous fistula, and a contaminated wound class (p<0.05). Of the 34 patients who underwent S1, 12 (35.3%) completed S2 during the mean follow-up period of 44 months while 22 (64.7%) did not complete S2. Of these, 10 (45.5%) developed hernia recurrence but did not undergo S2 secondary to elective nonoperative management (40%), pending preoperative optimization (30%), additional complex GIR (10%), hernia-related incarceration requiring emergent surgery (10%), or unrelated death (10%). No differences in outcome including SSI, SSO, readmission, and recurrence were noted between the 12 patients who completed the two-stage approach and the 20 patients who completed a one-stage approach, despite increased risk factors for complications in the 2-stage group (p>0.05). CONCLUSION Planned two-stage operations for GIR/AWR may distribute operative complexity and post-operative morbidity into separate surgical interventions. However, many patients may never undergo the intended definitive S2 herniorrhaphy. Future evaluation of 1- versus 2-stage GIR/AWR is needed to clarify indications for each approach. This work must also consider the frequent deviations from intended clinical course demonstrated in this study.
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Affiliation(s)
- C G DeLong
- Department of Surgery, Penn State University College of Medicine, 500 University Drive, Hershey, PA, 17033-0850, USA
| | - K T Crowell
- Division of Colon and Rectal Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - A T Liu
- Department of Surgery, Penn State University College of Medicine, 500 University Drive, Hershey, PA, 17033-0850, USA
| | - M J Deutsch
- Division of Colon and Rectal Surgery, Penn State University College of Medicine, Hershey, PA, USA
| | - J S Scow
- Division of Colon and Rectal Surgery, Penn State University College of Medicine, Hershey, PA, USA
| | - E M Pauli
- Division of Minimally Invasive and Bariatric Surgery, Penn State University College of Medicine, Hershey, PA, USA
| | - C M Horne
- Division of Minimally Invasive and Bariatric Surgery, Penn State University College of Medicine, Hershey, PA, USA.
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Siddiqui A, Lyons NB, Anwoju O, Cohen BL, Ramsey WA, O'Neil CF, Ali Z, Liang MK. Mesh Type With Ventral Hernia Repair: A Systematic Review and Meta-analysis of Randomized Trials. J Surg Res 2023; 291:603-610. [PMID: 37542774 DOI: 10.1016/j.jss.2023.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 06/28/2023] [Accepted: 07/05/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION Synthetic mesh is widely utilized for clean ventral hernia repair; however, it is unclear if synthetic mesh provides the same benefits with high-risk patients or during contaminated cases. Many surgeons use biologic mesh in these settings, but there is little evidence to support this practice. Our objective was to compare the clinical outcomes of utilizing biologic mesh versus synthetic mesh during ventral hernia repair. METHODS Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a review of the literature was conducted using Cochrane library, EMBASE, Clinicaltrials.gov, and PubMed for randomized controlled trials published that compared biologic versus synthetic mesh during ventral hernia repair. The primary outcome was major complications defined as deep or organ space surgical site infection, reoperations, and hernia recurrences. RESULTS Of 1889 manuscripts screened, four publications were included. The four studies included a total of 758 patients, with 381 receiving biologic mesh and 377 receiving synthetic mesh. Compared to biologic mesh, synthetic mesh had lower rates of major complications (38.6% versus 23.4, risk ratio = 0.55, 95% confidence interval = 0.35 to 0.86, P = 0.009) and hernia recurrence (24.5 % versus 10.3%, risk ratio = 0.44, 95% confidence interval = 0.28 to 0.69, P = 0.004). In addition, there was a lower percentage of surgical site infection and reoperation in the synthetic mesh group. CONCLUSIONS Contrary to current surgical teaching, placement of permanent synthetic mesh into a contaminated field yielded rates of complications that were comparable or reduced compared to biologic mesh.
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Affiliation(s)
- Ali Siddiqui
- Department of Surgery, HCA Healthcare Kingwood, University of Houston, Kingwood, Texas
| | - Nicole B Lyons
- Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida.
| | - Oluwatunmininu Anwoju
- Department of Surgery, HCA Healthcare Kingwood, University of Houston, Kingwood, Texas
| | - Brianna L Cohen
- Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Walter A Ramsey
- Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Christopher F O'Neil
- Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Zuhair Ali
- Department of Surgery, HCA Healthcare Kingwood, University of Houston, Kingwood, Texas
| | - Mike K Liang
- Department of Surgery, HCA Healthcare Kingwood, University of Houston, Kingwood, Texas
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Plitzko GA, Stüben BO, Giannou A, Reeh M, Izbicki JR, Melling N, Tachezy M. Robotic-assisted repair of incisional hernia-early experiences of a university robotic hernia program and comparison with open and minimally invasive sublay technique (eMILOS). Langenbecks Arch Surg 2023; 408:396. [PMID: 37821644 PMCID: PMC10567888 DOI: 10.1007/s00423-023-03129-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 09/29/2023] [Indexed: 10/13/2023]
Abstract
PURPOSE With robotic surgical devices, an innovative tool has stepped into the arena of minimally invasive hernia surgery. It combines the advantages of open (low recurrence rates and ability to perform complex procedure such as transverse abdominis release) and laparoscopic surgery (low rate of wound and mesh infections, less pain). However, a superiority to standard minimally invasive procedures has not yet been proven. We present our first experiences of robotic mesh repair of incisional hernias and a comparison of our results with open and minimally invasive sublay techniques. METHODS A retrospective analysis of all patients who underwent robotic-assisted mesh repair (RAHR) for incisional hernia between April and November 2022 (RAHR group) and patients who underwent open sublay (Sublay group) or eMILOS hernia repair (eMILOS group) between January 2018 and November 2022 was carried out. Patients in the RAHR group were matched 1:2 to patients in the Sublay group by propensity score matching. Patient demographics, preoperative hernia characteristics and cause of hernia, intraoperative variables, and postoperative outcomes were evaluated. Furthermore, a subgroup analysis of only midline hernia was performed. RESULTS A total of 21 patients received robotic-assisted incisional hernia repair. Procedures performed included robotic retro-muscular hernia repair (r-RMHR, 76%), with transverse abdominis release in 56% of the cases. In one patient, r-RHMR was combined with robotic inguinal hernia repair. Two patients (10%) were operated with total extraperitoneal technique (eTEP). Robotic-assisted transabdominal preperitoneal hernia repair (r-TAPP) was performed in three patients (14%). Median (range) operating time in the RAHR group was significantly longer than in the sublay and eMILOS group (291 (122-311) vs. 109.5 (48-270) min vs. 123 (100-192) min, respectively, p < 0.001). The meshes applied in the RAHR group were significantly compared to the sublay (mean (SD) 529 ± 311 cm2 vs. 356 ± 231, p = 0.037), but without a difference compared to the eMILOS group (mean (SD) 596 ± 266 cm2). Median (range) length of hospital stay in the RAHR group was significantly shorter compared to the Sublay group (3 (2-7) vs. 5 (1-9) days, p = 0.032), but not significantly different to the eMILOS group. In short term follow-up, no hernia recurrence was observed in the RAHR and eMILOS group, with 9% in the Sublay group. The subgroup analysis of midline hernia revealed very similar results. CONCLUSION Our data show a promising outcome after robotic-assisted incisional hernia repair, but no superiority compared to the eMILOS technique. However, RAHR is a promising technique especially for complex hernia in patients with relevant risk factors, especially immunosuppression. Longer follow-up times are needed to accurately assess recurrence rates, and large prospective trials are needed to show superiority of robotic compared to standard open and minimally invasive hernia repair.
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Affiliation(s)
- Gabriel A Plitzko
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martini Str. 52, 20246, Hamburg, Germany
| | - Björn-Ole Stüben
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martini Str. 52, 20246, Hamburg, Germany
| | - Anastasios Giannou
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martini Str. 52, 20246, Hamburg, Germany
| | - Matthias Reeh
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martini Str. 52, 20246, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martini Str. 52, 20246, Hamburg, Germany
| | - Nathaniel Melling
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martini Str. 52, 20246, Hamburg, Germany
| | - Michael Tachezy
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martini Str. 52, 20246, Hamburg, Germany.
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10
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Shi H, Wang R, Dong W, Yang D, Song H, Gu Y. Synthetic Versus Biological Mesh in Ventral Hernia Repair and Abdominal Wall Reconstruction: A Systematic Review and Recommendations from Evidence-Based Medicine. World J Surg 2023; 47:2416-2424. [PMID: 37268782 DOI: 10.1007/s00268-023-07067-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2023] [Indexed: 06/04/2023]
Abstract
AIM To compare the efficacy and safety of synthetic and biological meshes in ventral hernia repair (VHR) and abdominal wall reconstruction (AWR). METHODS We screened all clinical trials that reported the application of synthetic and biological meshes in VHR and AWR using Medline, Web of Science, and Embase (Ovid). Only comparative studies with similar baselines such as age, sex, body mass index, degree of wound contamination, and hernia defects between the intervention and control groups were included. Effect sizes with 95% confidence were pooled using a random- or fixed-effects model based on the size of heterogeneity. A sensitivity analysis was performed to test the stability of the results. RESULTS Ten studies with 1305 participants were included. Biological meshes were associated with significantly higher recurrence rate (OR, 2.09; 95% CI 1.42-3.08; I2 = 50%), surgical site infection (OR, 1.47; 95% CI 1.10-1.97; I2 = 30%), higher re-admission rate (OR, 1.51; 95% CI 1.05-2.17; I2 = 50%), and longer length of hospital stay (SMD, 0.37; 95% CI 0.10-0.65; I2 = 72%). Similar surgical site occurrence, re-operation rate, and mesh explantation rate were observed among biological and synthetic meshes. Biological meshes have no difference in recurrence rate as compared to synthetic meshes, between the clean-contaminated, and contamination-infected fields (OR, 1.41; 95% CI 0.41-4.87 vs 3.00; 95% CI 1.07-8.46; P = 0.36). CONCLUSION Synthetic meshes are a safe alternative to biological meshes for VHR and AWR. Considering the high cost of biological meshes, synthetic meshes are more appropriate for the VHR and AWR.
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Affiliation(s)
- Hekai Shi
- Department of General Surgery, Fudan University Affiliated Huadong Hospital, No. 221, West Yan'an Road, Jing'an District, Shanghai, 200040, People's Republic of China
| | - Rui Wang
- Department of General Surgery, Fudan University Affiliated Huadong Hospital, No. 221, West Yan'an Road, Jing'an District, Shanghai, 200040, People's Republic of China
| | - Wenpei Dong
- Department of General Surgery, Fudan University Affiliated Huadong Hospital, No. 221, West Yan'an Road, Jing'an District, Shanghai, 200040, People's Republic of China
| | - Dongchao Yang
- Department of General Surgery, Fudan University Affiliated Huadong Hospital, No. 221, West Yan'an Road, Jing'an District, Shanghai, 200040, People's Republic of China
| | - Heng Song
- Department of General Surgery, Fudan University Affiliated Huadong Hospital, No. 221, West Yan'an Road, Jing'an District, Shanghai, 200040, People's Republic of China
| | - Yan Gu
- Department of General Surgery, Fudan University Affiliated Huadong Hospital, No. 221, West Yan'an Road, Jing'an District, Shanghai, 200040, People's Republic of China.
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11
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Alimi Y, Deldar R, Sosin M, Lofthus A, Nijhar K, Bartholomew AJ, Fan KL, Bhanot P. Outcomes of Immediate Multistaged Abdominal Wall Reconstruction of Infected Mesh: Predictors of Surgical Site Complications and Hernia Recurrence. Ann Plast Surg 2023; 91:473-478. [PMID: 37713152 DOI: 10.1097/sap.0000000000003641] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
BACKGROUND Mesh infection is one of the most devastating complications after ventral hernia repair. To date, no clear consensus exists on the optimal timing of definitive abdominal wall reconstruction (AWR) after excision of infected mesh. We evaluated outcomes of immediate multistaged AWR in patients with mesh infection. METHODS We performed a retrospective review of patients with mesh infection who underwent immediate, multistaged AWR, which consisted of exploratory laparotomy with debridement and mesh explantation, followed by definitive AWR during the same admission. Primary outcomes included hernia recurrence and surgical site occurrences, defined as wound dehiscence, surgical site infection, hematoma, and seroma. RESULTS Forty-seven patients with infected mesh were identified. At mean follow-up of 9.5 months, 5 patients (10.6%) experienced hernia recurrence. Higher body mass index (P = 0.006), bridge repair (P = 0.035), and postoperative surgical site infection (P = 0.005) were associated with hernia recurrence. CONCLUSION Immediate multistaged AWR is an effective surgical approach in patients with infected mesh.
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Affiliation(s)
| | | | - Michael Sosin
- Plastic Surgery Arts of New Jersey, New Brunswick, NJ
| | | | | | | | - Kenneth L Fan
- Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
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12
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Schlosser KA, Warren JA. Hernia Mesh Complications: Management of Mesh Infections and Enteroprosthetic Fistula. Surg Clin North Am 2023; 103:1029-1042. [PMID: 37709388 DOI: 10.1016/j.suc.2023.04.011] [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] [Indexed: 09/16/2023]
Abstract
The potential consequences of mesh infection mandate careful consideration of surgical approach, mesh selection, and preoperative patient optimization when planning for ventral hernia repair. Intraperitoneal mesh, microporous or laminar mesh, and multifilament mesh typically require explantation, whereas macroporous, monofilament mesh in an extraperitoneal position is often salvageable. Delayed presentation of mesh infection should raise the suspicion for enteroprosthetic fistula when intraperitoneal mesh is present. When mesh excision is necessary, the surgeon must carefully consider both the risk of recurrent infection as well as hernia recurrence when deciding on single-stage definitive reconstruction versus primary closure with delayed reconstruction.
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Affiliation(s)
- Kathryn A Schlosser
- Department of Surgery, Prisma Health, 701 Grove Road, Support Tower 3, Greenville, SC 29605, USA. https://twitter.com/KT_Schlosser
| | - Jeremy A Warren
- Department of Surgery, Division of Minimal Access Surgery, University of South Carolina School of Medicine Greenville, Prisma Health, 701 Grove Road, Support Tower 3, Greenville, SC 29605, USA.
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13
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Ricker AB, Marturano MN, Matthews BD. What Mesh Should be Used in Hernia Repair? Adv Surg 2023; 57:225-231. [PMID: 37536855 DOI: 10.1016/j.yasu.2023.04.004] [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] [Indexed: 08/05/2023]
Abstract
Ventral hernia repair is one of the most frequently performed general surgery operations in the world, yet the treatment of clean-contaminated and contaminated cases remains controversial. Biologic mesh has been thought to resist infection, decrease chronic wound complications, and reduce the need for reoperation. Their use continues to be predominant in contaminated and dirty cases. This article is a comprehensive review of what mesh to choose in both clean and contaminated single-staged, open ventral hernia repair with further considerations of tissue incorporation characteristics, cost, safety profiles, complications, recurrence, and long-term outcomes.
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Affiliation(s)
- Ansley Beth Ricker
- Department of Surgery at Atrium Health Carolinas Medical Center, 1000 Blythe Boulevard, Medical Education Building Ste 6A, Charlotte, NC 28203, USA. https://twitter.com/ansleybeth_14
| | - Matthew N Marturano
- Department of Surgery at Atrium Health Carolinas Medical Center, 1000 Blythe Boulevard, Medical Education Building Ste 6A, Charlotte, NC 28203, USA. https://twitter.com/MarturanoMd
| | - Brent D Matthews
- Department of Surgery at Atrium Health Carolinas Medical Center, 1000 Blythe Boulevard, Medical Education Building Ste 6A, Charlotte, NC 28203, USA.
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14
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Morrison BG, Gledhill K, Plymale MA, Davenport DL, Roth JS. Comparative long-term effectiveness between ventral hernia repairs with biosynthetic and synthetic mesh. Surg Endosc 2023:10.1007/s00464-023-10082-1. [PMID: 37118030 DOI: 10.1007/s00464-023-10082-1] [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: 09/08/2022] [Accepted: 04/17/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Debate exists regarding the most appropriate type of mesh to use in ventral hernia repair (VHR). Meshes are broadly categorized as synthetic or biologic, each mesh with individual advantages and disadvantages. More recently developed biosynthetic mesh has characteristics of both mesh types. The current study aims to examine long-term follow-up data and directly compare outcomes-specifically hernia recurrence-of VHR with biosynthetic versus synthetic mesh. METHODS With IRB approval, consecutive cases of VHR (CPT codes 49,560, 49,561, 49,565, and 49,566 with 49,568) performed between 2013 and 2018 at a single institution were reviewed. Local NSQIP data was utilized for patient demographics, perioperative characteristics, CDC Wound Class, comorbidities, and mesh type. A review of electronic medical records provided additional variables including hernia defect size, postoperative wound events to six months, duration of follow-up, and incidence of hernia recurrence. Longevity of repair was measured using Kaplan-Meier method and adjusted Cox proportional hazards regression. RESULTS Biosynthetic mesh was used in 101 patients (23%) and synthetic mesh in 338 (77%). On average, patients repaired using biosynthetic mesh were older than those with synthetic mesh (57 vs. 52 years; p = .008). Also, ASA Class ≥ III was more common in biosynthetic mesh cases (70.3% vs. 55.1%; p = .016). Patients repaired with biosynthetic mesh were more likely than patients with synthetic mesh to have had a prior abdominal infection (30.7% vs. 19.8%; p = .029). Using a Kaplan-Meier analysis, there was not a significant difference in hernia recurrence between the two mesh types, with both types having Kaplan Meir 5-year recurrence-free survival rates of about 72%. CONCLUSION Using Kaplan-Meier analysis, synthetic mesh and biosynthetic mesh result in comparable hernia recurrence rates and surgical site infection rates in abdominal wall reconstruction patients with follow-up to as long as five years.
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Affiliation(s)
| | - Kiah Gledhill
- College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Margaret A Plymale
- Division of General, Endocrine & Metabolic Surgery, Department of Surgery, University of Kentucky, C 240, Chandler Medical Center, 800 Rose Street, Lexington, KY, 40536, USA
| | - Daniel L Davenport
- Division of Health Outcomes and Optimal Patient Services, Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - John S Roth
- Division of General, Endocrine & Metabolic Surgery, Department of Surgery, University of Kentucky, C 240, Chandler Medical Center, 800 Rose Street, Lexington, KY, 40536, USA.
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15
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Perrone G, Giuffrida M, Bonati E, Petracca GL, Catena F. Biosynthetic meshes in contaminated fields: where are we now? A systematic review and meta-analysis in humans. Hernia 2023:10.1007/s10029-023-02763-6. [PMID: 36943520 DOI: 10.1007/s10029-023-02763-6] [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: 06/19/2022] [Accepted: 03/09/2023] [Indexed: 03/23/2023]
Abstract
PURPOSE Selection of an appropriate mesh reinforcement for hernia repair in contaminated fields is a significant problem for surgeons. To date the proper mesh for contaminated fields has not been found. Biosynthetic meshes have emerged as new treatment option in contaminated fields. This study aims to evaluate the postoperative outcomes of biosynthetic meshes in contaminated fields. METHODS Systematic electronic search (PubMed, Medline, Embase, Scopus), according to PRISMA criteria, was performed. A literature search of scientific papers was performed by two reviewers until April 2021. Articles were chosen based on reference to biosynthetic meshes, their use in infected fields, and in human subjects. GRADE methodology and the modified Newcastle-Ottawa scale were used to assess the quality of studies. According to CDC-Centers for Disease Control classes patients were divided into two subgroups, group 1 (CDC class 2) and group 2 (CDC classes 3-4). RESULTS The research included 21 articles and 1619 patients were analyzed. Long-term follow-up showed a significant higher recurrence rate than short-term follow-up. P < 0.001. Meta-analysis of these studies showed that the SSI were significantly higher in CDC classes 3-4 than CDC class 2 (P < 0.01). No differences were found in SSO (P = 0.06) and recurrence (P = 0.37) rate among the two groups. Phasix™ was the most common mesh in 15 studies. The mean follow-up was 23.0 months. The surgical site infection (SSI) rate was 17.3%. The surgical site occurrence (SSO) rate was 32.4%. Recurrence rate was 11.5%. CONCLUSION This is the first systematic review and meta-analysis on the clinical outcomes of abdominal wall repair using biosynthetic mesh in contaminated-infected settings. The results show good results in patients at high risk of postoperative wound complications. The aim of this study is to add to the growing literature on biosynthetic mesh a picture of current literature evidence to help future researchers performing further studies on this topic.
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Affiliation(s)
- G Perrone
- Department of Emergency Surgery, Parma University Hospital, Parma, Italy
| | - M Giuffrida
- General Surgery Unit, Department of Medicine and Surgery, Parma University Hospital, Via A. Gramsci 14, 43126, Parma, Italy.
| | - E Bonati
- General Surgery Unit, Department of Medicine and Surgery, Parma University Hospital, Via A. Gramsci 14, 43126, Parma, Italy
| | - G L Petracca
- Department of Emergency Surgery, Parma University Hospital, Parma, Italy
| | - F Catena
- Department of Emergency and Trauma Surgey, Bufalini Trauma Center, Cesena, Italy
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16
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Katzen MM, Kercher KW, Sacco JM, Ku D, Scarola GT, Davis BR, Colavita PD, Augenstein VA, Heniford BT. Open preperitoneal ventral hernia repair: Prospective observational study of quality improvement outcomes over 18 years and 1,842 patients. Surgery 2023; 173:739-747. [PMID: 36280505 DOI: 10.1016/j.surg.2022.07.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND This study aimed to describe progressive evidence-based changes in perioperative management of open preperitoneal ventral hernia repair and subsequent surgical outcomes and to analyze factors that affect recurrence and wound complications. METHODS Prospective, tertiary hernia center data (2004-2021) were examined for patients undergoing midline open preperitoneal ventral hernia repair with mesh. "Early" (2004-2012) and "Recent" (2013-2021) groups were based on surgery date. RESULTS Comparison of Early (n = 675) versus Recent (n = 1,167) groups showed that Recent patients were, on average, older (56.9 ± 12.6 vs 58.7 ± 12.1 years; P < .001) with a lower body mass index (33.5 ± 8.3 vs 32.0 ± 6.8 kg/m2; P = .003) and a higher number of comorbidities (3.6 ± 2.2 vs 5.2 ± 2.6; P < .001). Recent patients had higher proportions of prior failed ventral hernia repair (46.5% vs 60.8%; P < .001), larger hernia defects (199.7 ± 232.8 vs 214.4 ± 170.5 cm2; P < .001), more Center for Disease Control class 3 or 4 wounds (11.3% vs 18.6%; P < .001), and more component separations (22.5% vs 45.7%; P < .001). Hernia recurrence decreased over time (7.1% vs 2.4%; P < .001), as did wound complication rates (26.7% vs 13.2%; P < .001). Comparing respective multivariable analyses (Early versus Recent), wound complications were associated with panniculectomy (odds ratio [95% confidence interval]: 2.9 [1.9-4.5], P < .001 vs 2.1 [1.4-3.3], P < .01), contaminated wounds (2.1 [1.1-3.7], P = .02 vs 1.8 [1.1-3.1], P = .02), anterior component separation technique (1.8 [1.1-2.9], P = .02 vs 3.2[1.9-5.3], P < .01), and operative time (per minute: 1.01 [1.008-1.015], P < .01 vs 1.004 [1.001-1.007], P < .01). Diabetes (2.6 [1.7-4.0], P < .01) and tobacco (1.8 [1.1-2.9], P = .02) were only significant in the early group. In both groups, recurrence was associated with wound complication (8.9 [4.1-20.1], P < .01 vs 3.4 [1.3-8.2]. P < .01) and recurrent hernias (4.9 [2.3-11.5], P < .01 vs 2.1 [1.1-4.2], P = .036). CONCLUSION Despite significant increased patient complexity over time, detecting and implementing best practices as determined by recurring data analysis of a center's outcomes has significantly improved patient care results.
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Affiliation(s)
- Michael M Katzen
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Kent W Kercher
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Jana M Sacco
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Dau Ku
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Gregory T Scarola
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Bradley R Davis
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Paul D Colavita
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Vedra A Augenstein
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - B Todd Heniford
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC.
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17
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Hu A, Pauli EM. Management of Parastomal Hernias. SEMINARS IN COLON AND RECTAL SURGERY 2023. [DOI: 10.1016/j.scrs.2023.100956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
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18
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Predicting rare outcomes in abdominal wall reconstruction using image-based deep learning models. Surgery 2023; 173:748-755. [PMID: 36229252 DOI: 10.1016/j.surg.2022.06.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/04/2022] [Accepted: 06/27/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Deep learning models with imbalanced data sets are a challenge in the fields of artificial intelligence and surgery. The aim of this study was to develop and compare deep learning models that predict rare but devastating postoperative complications after abdominal wall reconstruction. METHODS A prospectively maintained institutional database was used to identify abdominal wall reconstruction patients with preoperative computed tomography scans. Conventional deep learning models were developed using an 8-layer convolutional neural network and a 2-class training system (ie, learns negative and positive outcomes). Conventional deep learning models were compared to deep learning models that were developed using a generative adversarial network anomaly framework, which uses image augmentation and anomaly detection. The primary outcomes were receiver operating characteristic values for predicting mesh infection and pulmonary failure. RESULTS Computed tomography scans from 510 patients were used with a total of 10,004 images. Mesh infection and pulmonary failure occurred in 3.7% and 5.6% of patients, respectively. The conventional deep learning models were less effective than generative adversarial network anomaly for predicting mesh infection (receiver operating characteristic 0.61 vs 0.73, P < .01) and pulmonary failure (receiver operating characteristic 0.59 vs 0.70, P < .01). Although the conventional deep learning models had higher accuracies/specificities for predicting mesh infection (0.93 vs 0.78, P < .01/.96 vs .78, P < .01) and pulmonary failure (0.88 vs 0.68, P < .01/.92 vs .67, P < .01), they were substantially compromised by decreased model sensitivity (0.25 vs 0.68, P < .01/.27 vs .73, P < .01). CONCLUSION Compared to conventional deep learning models, generative adversarial network anomaly deep learning models showed improved performance on imbalanced data sets, predominantly by increasing model sensitivity. Understanding patients who are at risk for rare but devastating postoperative complications can improve risk stratification, resource utilization, and the consent process.
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Marturano MN, Ayuso SA, Ku D, Raible R, Lopez R, Scarola GT, Gersin K, Colavita PD, Augenstein VA, Heniford BT. Preoperative botulinum toxin A (BTA) injection versus component separation techniques (CST) in complex abdominal wall reconstruction (AWR): A propensity-scored matched study. Surgery 2023; 173:756-764. [PMID: 36229258 DOI: 10.1016/j.surg.2022.07.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/14/2022] [Accepted: 07/05/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Complete fascial closure significantly reduces recurrence rates and wound complications in abdominal wall reconstruction. While component separation techniques have clear effectiveness in closing large abdominal wall defects, preoperative botulinum toxin A has emerged as an adjunct to aid in fascial closure. Few data exist comparing preoperative botulinum toxin A to component separation techniques, and the aim was to do so in a matched study. METHODS A prospective, single-center, hernia-specific database was queried, and a 3:1 propensity-matched study of patients undergoing open abdominal wall reconstruction from 2016 to 2021 with botulinum toxin A versus component separation techniques was performed based on body mass index, defect width, hernia volume, and Centers for Disease Control and Prevention wound classification. Demographics, operative characteristics, and outcomes were evaluated. RESULTS Matched patients included 105 component separation techniques and 35 botulinum toxin A. There was no difference in tobacco use, diabetes, or body mass index (all P > .5). Hernia defects and volume were large for both the component separation techniques and botulinum toxin A groups (mean size: component separation techniques 286.2 ± 179.9 cm2 vs botulinum toxin A 289.7 ± 162.4 cm2; P = .73) (mean volume: 1,498.3 + 2,043.4 cm3 vs 2,914.7 + 6,539.4 cm3; P = .35). Centers for Disease Control and Prevention wound classifications were equivalent (CDC3 and 4%-39.1% vs 40.0%; P = .97). Component separation techniques were more frequently performed in European Hernia Society M1 hernias (21% vs 2.9%; P = .01). The botulinum toxin A group had fewer surgical site occurrences (32.4% vs 11.4%; P = .02) and surgical site infections (11.7% vs 0%; P = .04). In multivariate analysis, botulinum toxin A was associated with lower rates of surgical site occurrences (odds ratio = 5.3; 95% confidence interval [1.4-34.4]). There was no difference in fascial closure (90.5% vs 100%; P = .11) or recurrence (12.4% vs 2.9%; P = .10) with follow-up (22.8 + 29.7 vs 9.8 + 12.7 months; P = .13). CONCLUSION In a matched study comparing patients with botulinum toxin A versus component separation techniques, there was no difference in fascial closure rates or in hernia recurrence between the 2 groups. Preoperative botulinum toxin A can achieve similar outcomes as component separation techniques, while decreasing the frequency of surgical site occurrences.
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Affiliation(s)
- Matthew N Marturano
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC. https://twitter.com/MarturanoMd
| | - Sullivan A Ayuso
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC. https://twitter.com/SAyusoMD
| | - David Ku
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | | | | | - Gregory T Scarola
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Keith Gersin
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Paul D Colavita
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC. https://twitter.com/PDColavita
| | - Vedra A Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC. https://twitter.com/VedraAugenstein
| | - B Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC.
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Lampridis S, Billè A. A paradigm shift for diaphragmatic and chest wall reconstruction using a bovine acellular dermal matrix: an analysis versus synthetic meshes. Gen Thorac Cardiovasc Surg 2023; 71:121-128. [PMID: 35960481 DOI: 10.1007/s11748-022-01862-y] [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: 04/17/2022] [Accepted: 07/31/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Recently, biologic meshes have gained increasing popularity in soft tissue reconstruction. The aim of this study was to investigate the use of a bovine acellular dermal matrix (SurgiMend, Integra LifeSciences, Princeton, NJ, USA) in diaphragmatic and chest wall reconstruction by comparing it with synthetic meshes. METHODS Consecutive patients who underwent diaphragmatic and/or chest wall reconstruction at a single center from 2016 to 2021 were retrospectively reviewed. Outcome measures included surgical site complications, readmission, and reoperation. RESULTS Sixty-six patients underwent diaphragmatic and/or chest wall reconstruction for a malignant (74.2%) or benign (25.8%) disease. SurgiMend was used in 26 (39.4%) patients and a synthetic mesh in 40 (60.6%) patients. There were no significant differences in baseline characteristics between the groups. Surgical site complications included prolonged air leak (12.1%), pleural effusion (9.1%), pneumothorax (3%), empyema (1.5%), and wound infection (1.5%). The patients in the synthetic mesh group developed a significantly higher rate of surgical site complications compared to those in the SurgiMend group (37.5% vs. 11.5%; p = 0.025). Similarly, the readmission rate was significantly higher in the synthetic mesh group (17.5% vs. 0%; p = 0.037), with causes including pleural effusion (n = 3), pneumothorax (n = 2), empyema (n = 1), and pneumonia (n = 1). Among the study cohort, only 1 patient with a synthetic mesh underwent reoperation (p > 0.99). CONCLUSIONS The use of surgiMend in diaphragmatic and chest wall reconstruction is associated with fewer surgical site complications and readmissions compared to synthetic meshes.
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Affiliation(s)
- Savvas Lampridis
- Department of Thoracic Surgery, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, SE1 9RT, UK.
| | - Andrea Billè
- Department of Thoracic Surgery, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, SE1 9RT, UK
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21
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Passot G, Margier J, Kefleyesus A, Rousset P, Ortega-Deballon P, Renard Y, Bin S, Villeneuve L. Slowly absorbable mesh versus standard care in the management of contaminated midline incisional hernia (COMpACT-BIO): a multicentre randomised controlled phase III trial including a health economic evaluation. BMJ Open 2022; 12:e061184. [PMID: 36008058 PMCID: PMC9422840 DOI: 10.1136/bmjopen-2022-061184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Incisional hernia (IH) is the most frequent mid-term and long-term complication after midline laparotomy. The current standard treatment includes repair using a mesh. In a contaminated field, the use of a non-absorbable mesh increases the risk of surgical site infection and the costs. Slowly absorbable meshes are safe in contaminated fields, but no data have been reported regarding their long-term recurrence rate. COMpACT-BIO is a multicentre prospective randomised controlled phase III trial designed to compare the 3-year recurrence rate in patients undergoing contaminated IH repair with either a slowly absorbable mesh or standard care. METHODS In patients undergoing midline IH repair in a contaminated surgical field (grade III of the modified Ventral Hernia Working Group classification), the COMpACT-BIO study compares the use of a slowly absorbable mesh with that of conventional care according to standardised surgical procedures (primary closure, non-absorbable synthetic mesh or biologic mesh, at the discretion of the surgeon). Randomisation is done during surgery before closure the fascia with an allocation ratio of 1:1. The choice of the slowly absorbable mesh is left to the criteria of each centre. The primary endpoint is the proportion of patients with scan-confirmed IH recurrence within 3 years after repair. ETHICS/DISSEMINATION This trial is conducted in compliance with international standards for research practice and reporting. Written informed consent will be obtained from patients prior to inclusion. All data were identified and anonymised prior to analysis. The protocol has been approved by an Institutional Review Board (2020-A0823-36/SI:20.07.03.66831), and will be conducted in compliance with the CONSORT (Consolidated Standards of Reporting Trials) statement. Results will be submitted for publication in peer-reviewed medical journals and presented to patients and healthcare professionals. PROTOCOL VERSION Version 2-13 October 2020. TRIAL REGISTRATION NUMBER NCT04597840.
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Affiliation(s)
- Guillaume Passot
- Department of Surgical Oncology, Hopital Lyon Sud, Hospices Civils de Lyon, Pierre Bénite, France
- Centre Hospitalier Universitaire de Lyon, Lyon, France
| | | | - Amaniel Kefleyesus
- Department of Surgical Oncology, Hopital Lyon Sud, Hospices Civils de Lyon, Pierre Bénite, France
| | - Pascal Rousset
- Department of Radiology, Centre Hospitalier Lyon-Sud, Pierre-Benite, France
| | - Pablo Ortega-Deballon
- Departement of General Surgery, Centre Hospitalier Universitaire du Bocage, Dijon, France
| | - Yohann Renard
- Departement of General Surgery, Reims Champagne-Ardenne University, Reims, France
| | - Sylvie Bin
- Department of Surgical Oncology, Hopital Lyon Sud, Hospices Civils de Lyon, Pierre Bénite, France
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22
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Zhou H, Shen Y, Zhang Z, Liu X, Zhang J, Chen J. Comparison of outcomes of ventral hernia repair using different meshes: a systematic review and network meta-analysis. Hernia 2022; 26:1561-1571. [PMID: 35925502 DOI: 10.1007/s10029-022-02652-4] [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: 04/22/2022] [Accepted: 07/14/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE We conducted a network meta-analysis to evaluate potential differences in patient outcomes when different meshes, especially biological meshes, were used for ventral hernia repair. METHODS PubMed, Embase, Cochrane Library, and Clinical Trials.gov databases were searched for studies comparing biological meshes with biological or synthetic meshes for ventral hernia repair. The outcomes were hernia recurrence rate, surgical site infection, and seroma. We performed a two-step network meta-analysis to investigate the outcomes of several biological meshes: non-cross-linked human acellular dermal matrix (NCHADM), non-cross-linked porcine ADM (NCPADM), non-cross-linked bovine ADM (NCBADM), cross-linked porcine ADM (CPADM), and porcine small intestinal submucosa (PSIS). RESULTS From 6304 publications, 23 studies involving 2603 patients were finally included. We found no differences between meshes in recurrence at 1-year follow-up and in surgical site infection rate. NCBADM was associated with the lowest recurrence rate and the lowest surgical site infection rate. NCHADM implantation was associated with the lowest rate of seroma. PSIS was associated with a higher risk of seroma than NCHADM (pooled risk ratio 3.89, 95% confidence interval 1.13-13.39) and NCPADM (RR 3.42, 95% CI 1.29-9.06). CONCLUSIONS Our network meta-analysis found no differences in recurrence rate or surgical site infection among different biological meshes. The incidence of postoperative seroma was higher with PSIS than with acellular dermal matrices. We observed large heterogeneity in the studies of ventral hernia repair using biological meshes, and, therefore, well-designed randomized clinical trials are needed.
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Affiliation(s)
- H Zhou
- The Third Clinical Medical School of Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Y Shen
- Department of Hernia and Abdominal Wall Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Z Zhang
- The Third Clinical Medical School of Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - X Liu
- Department of Hernia and Abdominal Wall Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - J Zhang
- Department of General Surgery, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China.
| | - J Chen
- Department of Hernia and Abdominal Wall Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China.
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23
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Layer T, Benammi S, Dubuisson V, Manfredelli S, Passot G, Charleux-Muller D, Renard Y, Ortega-Deballon P, Romain B. Incisional hernia repair with a slowly absorbable P4HB mesh: what happens after the mesh disappears? A retrospective longitudinal clinical study. Hernia 2022; 27:387-394. [PMID: 35536373 DOI: 10.1007/s10029-022-02616-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 04/09/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE To analyze the incisional hernia recurrence rate at a long-term follow-up using a biosynthetic long-term absorbable mesh in patients with a higher risk of surgical infection in a contaminated surgical field. METHODS This was a retrospective multicentric study. All patients undergoing incisional hernia repair between 2016 and 2018 at 6 participating university centers were included. Patients were classified according to the Ventral Hernia Working Group (VHWG). All consecutive patients who underwent abdominal wall repair using biosynthetic long-term absorbable mesh (Phasix®) in contaminated fields (grade 3 and 4 of the VHWG classification) were included. Patients were followed-up until September 2021. Preoperative, operative, and postoperative data were collected. All patients' surgical site infections (SSIs) and surgical site occurrences (SSOs) were recorded. The primary outcome of interest was the clinical incisional hernia recurrence rate. RESULTS One hundred and eight patients were included: 77 with VHWG grade 3 (71.3%) and 31 with VHWG grade 4 (28.7%). Median time follow-up was 41 months [24; 63]. Twenty-four patients had clinical recurrence during the follow-up (22.2%). The SSI and SSO rates were 24.1% and 36.1%, respectively. On multivariate analysis, risk factors for incisional hernia recurrence were previous recurrence, mesh location, and postoperative enterocutaneous fistula. CONCLUSIONS At the 3 year follow-up, the recurrence rate with a biosynthetic absorbable mesh (Phasix®) for incisional hernia repair in high-risk patients (VHWG grade 3 and 4) seemed to be suitable (22.2%). Most complications occurred in the first year, and SSI and SSO rates were low despite high-risk VHWG grading.
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Affiliation(s)
- T Layer
- Department of General and Digestive Surgery, Hautepierre Hospital, Strasbourg University Hospital, 2 avenue Molière, 67200, Strasbourg, France
| | - S Benammi
- Department of General and Digestive Surgery, Hautepierre Hospital, Strasbourg University Hospital, 2 avenue Molière, 67200, Strasbourg, France
| | - V Dubuisson
- Department of Vascular and General Surgery, Bordeaux University Hospital, Place Amélie Raba Léon, 33076, Bordeaux, France
| | - S Manfredelli
- Department of General and Digestive Surgery, Hautepierre Hospital, Strasbourg University Hospital, 2 avenue Molière, 67200, Strasbourg, France.,Department of Digestive and Oncologic Surgery, Liver Transplantation Unit, University Hospital of Besançon, Besançon, France
| | - G Passot
- Department of General, Digestive and Endocrine Surgery, Hospital Lyon Sud, Hospices Civils de Lyon, 165, Chemin du grand Revoyet, Pierre Bénite, 69495, Lyon, France.,EMR 3738, University Hospital, Claude Bernard Lyon 1, Lyon, France
| | - D Charleux-Muller
- Department of General and Digestive Surgery, Hautepierre Hospital, Strasbourg University Hospital, 2 avenue Molière, 67200, Strasbourg, France
| | - Y Renard
- Department of General and Digestive Surgery, Robert Debre University Hospital, University of Reims Champagne Ardenne, Reims, France
| | - P Ortega-Deballon
- Department of General and Digestive Surgery, University Hospital of Dijon, Dijon, France
| | - B Romain
- Department of General and Digestive Surgery, Hautepierre Hospital, Strasbourg University Hospital, 2 avenue Molière, 67200, Strasbourg, France. .,Streinth Lab (Stress Response and Innovative Therapies), Strasbourg University, Inserm UMR_S 1113 IRFAC (Interface Recherche Fondamental et Appliquée à la Cancérologie), 67200, Strasbourg, France.
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24
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Comparative Effectiveness Analysis of Resorbable Synthetic Onlay and Biologic Intraperitoneal Mesh for Abdominal Wall Reconstruction: A 2-Year Match-Paired Analysis. Plast Reconstr Surg 2022; 149:1204-1213. [PMID: 35311754 DOI: 10.1097/prs.0000000000009021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Abdominal wall reconstruction persists as a challenging surgical issue with a multitude of management strategies available. The aim of this study was to examine the efficacy of resorbable synthetic mesh onlay plane against biologic mesh in the intraperitoneal plane. METHODS A single-center, two-surgeon, 5-year retrospective review (2014 to 2019) was performed examining subjects who underwent abdominal wall reconstruction in the onlay plane with resorbable synthetic mesh or in the intraperitoneal plane with biologic mesh. A matched paired analysis was conducted. Data examining demographic characteristics, intraoperative variables, postoperative outcomes, and costs were analyzed. RESULTS Eighty-eight subjects (44 per group) were identified (median follow-up, 24.5 months). The mean age was 57.7 years, with a mean body mass index of 30.4 kg/m2. The average defect size was 292 ± 237 cm2, with most wounds being clean-contaminated (48.9 percent) and 55 percent having failed prior repair. Resorbable synthetic mesh onlay subjects were significantly less likely (4.5 percent) to experience recurrence compared to biologic intraperitoneal mesh subjects (22.7 percent; p < 0.026). In addition, mesh onlay suffered fewer postoperative surgical-site occurrences (18.2 percent versus 40.9 percent; p < 0.019) and required fewer procedural interventions (11.4 percent versus 36.4 percent; p < 0.011), and was also associated with significantly lower total costs ($16,658 ± $14,930) compared to biologic intraperitoneal mesh ($27,645 ± $16,864; p < 0.001). CONCLUSIONS Abdominal wall reconstruction remains an evolving field, with various techniques available for treatment. When faced with hernia repair, resorbable synthetic mesh in the onlay plane may be preferable to biologic mesh placed in the intraperitoneal plane because of lower long-term recurrence rates, surgical-site complications, and costs. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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25
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Timmer AS, Claessen JJM, Brouwer de Koning IM, Haenen SM, Belt EJT, Bastiaansen AJNM, Verdaasdonk EGG, Wolffenbuttel CP, Schreurs WH, Draaisma WA, Boermeester MA. Clinical outcomes of open abdominal wall reconstruction with the use of a polypropylene reinforced tissue matrix: a multicenter retrospective study. Hernia 2022; 26:1241-1250. [PMID: 35441284 PMCID: PMC9525385 DOI: 10.1007/s10029-022-02604-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/14/2022] [Indexed: 02/06/2023]
Abstract
Objective To assess mesh behaviour and clinical outcomes of open complex abdominal wall reconstruction (CAWR) with the use of a polypropylene reinforced tissue matrix. Methods A multicenter retrospective study of adult patients who underwent open CAWR with the use of a permanent polypropylene reinforced tissue matrix (OviTex®) between June 2019 and January 2021. Results Fifty-five consecutive patients from four hospitals in the Netherlands were analysed; 46 patients with a ventral hernia and 9 patients with an open abdomen. Most patients with a ventral hernia had one or more complicating comorbidities (91.3%) and one or more complicating hernia characteristics (95.7%). Most procedures were performed in a (clean) contaminated surgical field (69.6% CDC 2–4; 41.3% CDC 3–4). All nine patients with an open abdomen underwent semi-emergent surgery. Twelve out of 46 patients with a ventral hernia (26.1%) and 4 of 9 patients with an open abdomen (44.4%) developed a postoperative surgical site infection that made direct contact with the mesh as confirmed on computed tomography (CT), suspicious of mesh infection. No patient needed mesh explantation for persistent infection of the mesh. During a median follow-up of 13 months, 4 of 46 ventral hernia patients (8.7%) developed a CT confirmed hernia recurrence. Conclusion Polypropylene reinforced tissue matrix can withstand infectious complications and provides acceptable mid-term recurrence rates in this retrospective study on open complex abdominal wall reconstructions. Longer follow-up data from prospective studies are required to determine further risk of hernia recurrence. Supplementary Information The online version contains supplementary material available at 10.1007/s10029-022-02604-y.
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Affiliation(s)
- Allard S Timmer
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam Infection and Immunity, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, 1100 DD, Amsterdam, The Netherlands
| | - Jeroen J M Claessen
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam Infection and Immunity, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, 1100 DD, Amsterdam, The Netherlands
| | | | - Suzanne M Haenen
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam Infection and Immunity, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, 1100 DD, Amsterdam, The Netherlands
| | - Eric J T Belt
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | | | | | | | | | - Werner A Draaisma
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam Infection and Immunity, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, 1100 DD, Amsterdam, The Netherlands.
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26
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Rosen MJ, Krpata DM, Petro CC, Carbonell A, Warren J, Poulose BK, Costanzo A, Tu C, Blatnik J, Prabhu AS. Biologic vs Synthetic Mesh for Single-stage Repair of Contaminated Ventral Hernias: A Randomized Clinical Trial. JAMA Surg 2022; 157:293-301. [PMID: 35044431 PMCID: PMC8771431 DOI: 10.1001/jamasurg.2021.6902] [Citation(s) in RCA: 74] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
IMPORTANCE Biologic mesh is widely used for reinforcing contaminated ventral hernia repairs; however, it is expensive and has been associated with high rates of long-term hernia recurrence. Synthetic mesh is a lower-cost alternative but its efficacy has not been rigorously studied in individuals with contaminated hernias. OBJECTIVE To determine whether synthetic mesh results in superior reduction in risk of hernia recurrence compared with biologic mesh during the single-stage repair of clean-contaminated and contaminated ventral hernias. DESIGN, SETTING, AND PARTICIPANTS This multicenter, single-blinded randomized clinical trial was conducted from December 2012 to April 2019 with a follow-up duration of 2 years. The trial was completed at 5 academic medical centers in the US with specialized units for abdominal wall reconstruction. A total of 253 adult patients with clean-contaminated or contaminated ventral hernias were enrolled in this trial. Follow-up was completed in April 2021. INTERVENTIONS Retromuscular synthetic or biologic mesh at the time of fascial closure. MAIN OUTCOMES AND MEASURES The primary outcome was the superiority of synthetic mesh vs biologic mesh at reducing risk of hernia recurrence at 2 years based on intent-to-treat analysis. Secondary outcomes included mesh safety, defined as the rate of surgical site occurrence requiring a procedural intervention, and 30-day hospital direct costs and prosthetic costs. RESULTS A total of 253 patients (median [IQR] age, 64 [55-70] years; 117 [46%] male) were randomized (126 to synthetic mesh and 127 to biologic mesh) and the follow-up rate was 92% at 2 years. Compared with biologic mesh, synthetic mesh significantly reduced the risk of hernia recurrence (hazard ratio, 0.31; 95% CI, 0.23-0.42; P < .001). The overall intent-to-treat hernia recurrence risk at 2 years was 13% (33 of 253 patients). Recurrence risk with biologic mesh was 20.5% (26 of 127 patients) and with synthetic mesh was 5.6% (7 of 126 patients), with an absolute risk reduction of 14.9% with the use of synthetic mesh (95% CI, -23.8% to -6.1%; P = .001). There was no significant difference in overall 2-year risk of surgical site occurrence requiring a procedural intervention between the groups (odds ratio, 1.22; 95% CI, 0.60-2.44; P = .58). Median (IQR) 30-day hospital direct costs were significantly greater in the biologic group vs the synthetic group ($44 936 [$35 877-$52 656] vs $17 289 [$14 643-$22 901], respectively; P < .001). There was also a significant difference in the price of the prosthetic device between the 2 groups (median [IQR] cost biologic, $21 539 [$20 285-$23 332] vs synthetic, $105 [$105-$118]; P < .001). CONCLUSIONS AND RELEVANCE Synthetic mesh demonstrated superior 2-year hernia recurrence risk compared with biologic mesh in patients undergoing single-stage repair of contaminated ventral hernias, and both meshes demonstrated similar safety profiles. The price of biologic mesh was over 200 times that of synthetic mesh for these outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02451176.
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Affiliation(s)
- Michael J. Rosen
- Department of Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - David M. Krpata
- Department of Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Clayton C. Petro
- Department of Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Alfredo Carbonell
- Department of Surgery, Prisma Health Upstate, Greenville, South Carolina
| | - Jeremy Warren
- Department of Surgery, Prisma Health Upstate, Greenville, South Carolina
| | - Benjamin K. Poulose
- Department of Surgery, Center for Abdominal Core Health, The Ohio State University Wexner Medical Center, Columbus
| | - Adele Costanzo
- Department of Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Chao Tu
- Department of Statistics, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jeffrey Blatnik
- Department of Surgery, Washington University in St Louis, St Louis, Missouri
| | - Ajita S. Prabhu
- Department of Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, Ohio
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27
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Goldblatt MI. Complex hernia repair in contaminated fields: Are we done using biologics for single-stage repairs? Surgery 2022; 172:476. [DOI: 10.1016/j.surg.2022.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 03/09/2022] [Indexed: 10/18/2022]
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28
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Lima DL, Estrada A, Pereira X, Alcabes A, Sreeramoju P, Malcher F. VERSATILITY OF POLY-4-HYDROXYBUTYRATE (PHASIX™) MESH IN ABDOMINAL WALL SURGERY. ARQUIVOS DE GASTROENTEROLOGIA 2022; 59:226-230. [PMID: 35830033 DOI: 10.1590/s0004-2803.202202000-41] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/03/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Poly-4-hydroxybutyrate (P4HB) is a naturally occurring polymer derived from transgenic E. coli bacteria with the longest degradation rate when compared to other available products. This polymer has been manufactured as a biosynthetic mesh to be used as reinforcement when repairing a variety of abdominal wall defects. OBJECTIVE We aim to describe our center initial experience with this mesh and discuss the possible indications that may benefit from the use of P4HB mesh. METHODS This is a descriptive retrospective study of patients who underwent abdominal wall repair with a P4HB mesh from October 2018 to December 2020 in a single, large volume, academic center. RESULTS A total of 51 patients (mean age 54.4 years, range 12-89) underwent abdominal wall reconstruction with a P4HB mesh between October 2018 and December 2020. The mean BMI was 30.5 (range 17.2-50.6). Twenty-three (45%) patients had a prior hernia repair at the site. We grouped patients into six different indications for the use of P4HB mesh in our cohort: clean-contaminated, contaminated or infected field (57%), patient refusal for permanent meshes (14%), those with high risk for post-operative infection (12%), visceral protection of second mesh (10%), recurrence with related chronic pain from mesh (6%), and children (2%). Median follow-up was 105 days (range 8-648). Two patients had hernia recurrence (4%) and 8 (16%) patients developed seroma. CONCLUSION P4HB mesh is a safe and a viable alternative for complex hernias and high-risk patients with a low complication rate in the short-term.
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Affiliation(s)
- Diego L Lima
- Department of Surgery, Montefiore Medical Center, The Bronx , New York, United States
| | - Arturo Estrada
- Department of Surgery, Montefiore Medical Center, The Bronx , New York, United States
| | - Xavier Pereira
- Department of Surgery, Montefiore Medical Center, The Bronx , New York, United States
| | - Analena Alcabes
- Department of Surgery, Montefiore Medical Center, The Bronx , New York, United States
| | - Prashanth Sreeramoju
- Department of Surgery, Montefiore Medical Center, The Bronx , New York, United States
| | - Flavio Malcher
- Division of General Surgery, NYU Langone Health, New York, United States
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29
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Jeong E, Jang H, Jo Y, Park Y, Lee N, Kim J. Traumatic abdominal wall hernia with hemoperitoneum caused by blunt injury: laparoscopic exploration with mini-laparotomy repair. A case report. JOURNAL OF TRAUMA AND INJURY 2022. [DOI: 10.20408/jti.2021.0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Traumatic abdominal wall hernia is a very rare clinical entity. Herein, we report the case of a patient who was transferred from a local clinic to the emergency department because of left lower abdominal pain. Initially, an intra-abdominal hematoma was observed on computed tomography and no extravasation was noted. Conservative treatment was initiated, and the patient’s symptoms were slightly relieved. However, though abdominal pain was relieved during the hospital stay, bowel herniation was suspected in the left periumbilical area. Follow-up computed tomography showed traumatic abdominal wall hernia with hemoperitoneum in the abdomen. We performed a laparoscopic exploration of the injury site and hernia lesion. The anterior abdominal wall hernia was successfully closed.
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30
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Huang W, Lu H, Zhang YX, Song Y. Anterolateral thigh flaps in closing large abdominal wall defect after the resection of mucinous adenocarcinoma: a case report. BMC Surg 2022; 22:100. [PMID: 35303836 PMCID: PMC8932151 DOI: 10.1186/s12893-022-01550-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 03/07/2022] [Indexed: 02/08/2023] Open
Abstract
Background It is a big challenge to repair a large abdominal wall defect after tumor resection, and en bloc resection with vascularized tissue reconstruction might be an alternative to achieve an improved survival for abdominal wall tumors. Case presentation A 45-year-old woman presented with a 1-year history of persistent abdominal pain of the right lower quadrant and a mass with dermal ulceration. An enhanced computed tomography scan and biopsy of the mass were performed to achieve the definite diagnosis of abdominal mucinous adenocarcinoma. After four courses of “FOLFOX” chemotherapy, the tumor grew to 6 × 5 cm during preoperative examination. Thereafter, we removed the tumor and involved tissues and organs and repaired the sizeable abdominal wall defect used by biological meshes and vascularized anterolateral thigh flaps. The patient suffered green drainage of 450 ml in the abdominal cavity and intestinal anastomotic fistula, for which she readmitted and recovered afterward. Conclusions Biological mesh combined with vascularized anterolateral thigh flaps could effectively repair the large abdominal wall defect and restore the biological function of the abdominal wall.
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Affiliation(s)
- Weijia Huang
- Department of Day Surgery Center, West China Hospital, Sichuan University, No. 37 Guoxue Alley, 610041, Chengdu, China.,Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, China.,West China School of Medicine/West China Hospital, Sichuan University, Chengdu, China
| | - Hanpeng Lu
- Department of Day Surgery Center, West China Hospital, Sichuan University, No. 37 Guoxue Alley, 610041, Chengdu, China.,West China School of Medicine/West China Hospital, Sichuan University, Chengdu, China
| | - Yu-Xiao Zhang
- Department of Day Surgery Center, West China Hospital, Sichuan University, No. 37 Guoxue Alley, 610041, Chengdu, China.,West China School of Medicine/West China Hospital, Sichuan University, Chengdu, China
| | - Yinghan Song
- Department of Day Surgery Center, West China Hospital, Sichuan University, No. 37 Guoxue Alley, 610041, Chengdu, China.
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Building a Center for Abdominal Core Health: The Importance of a Holistic Multidisciplinary Approach. J Gastrointest Surg 2022; 26:693-701. [PMID: 35013880 DOI: 10.1007/s11605-021-05241-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 12/31/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND This article seeks to be a collection of evidence and experience-based information for health care providers around the country and world looking to build or improve an abdominal core health center. Abdominal core health has proven to be a chronic condition despite advancements in surgical technique, technology, and equipment. The need for a holistic approach has been discussed and thought to be necessary to improve the care of this complex patient population. METHODS Literature relevant to the key aspects of building an abdominal core health center was thoroughly reviewed by multiple members of our abdominal core health center. This information was combined with our authors' experiences to gather relevant information for those looking to build or improve a holistic abdominal core health center. RESULTS An abundance of publications have been combined with multiple members of our abdominal core health centers members experience's culminating in a wide breadth of information relevant to those looking to build or improve a holistic abdominal core health center. CONCLUSIONS Evidence- and experience-based information has been collected to assist those looking to build or grow an abdominal core health center.
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Single-stage abdominal wall reconstruction in contaminated and dirty wounds is safe: a single center experience. Surg Endosc 2022; 36:5766-5771. [DOI: 10.1007/s00464-022-09058-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 01/17/2022] [Indexed: 10/19/2022]
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Synthetic Mesh in Contaminated Abdominal Wall Surgery: Friend or Foe? A Literature Review. J Gastrointest Surg 2022; 26:235-244. [PMID: 34590215 DOI: 10.1007/s11605-021-05155-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 09/17/2021] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The use of synthetic mesh in contaminated fields is controversial. In the last decade, published data have grown in this matter suggesting favorable outcomes. However, multiple variables and scenarios that influence the results still make difficult to obtain convincing recommendations. METHODS We performed a review of relevant available data in English regarding the use of synthetic meshes in contaminated abdominal wall surgery using the Medline database. Articles including patients undergoing ventral hernia in contaminated fields were included for analysis. RESULTS Most studies support the use of synthetic meshes for ventral hernia repair in contaminated fields, as they have shown lower recurrence rate and similar wound morbidity. Although no mesh seems ideal in this setting, most surgeons advocate for the use of reduced-in-weight polypropylene mesh. Sublay location of the prosthesis associated with complete fascial closure appears to offer better results in these patients. In addition, current evidence suggests that the use of prophylactic synthetic mesh when performing a stoma or for stoma reversal incisional hernias might be beneficial. CONCLUSION A better understanding of surgical site occurrences and its prevention, as well as the introduction of new reduced-in-weight meshes have allowed using synthetic meshes in a contaminated field. Although the use of mesh has indeed shown promising results in these patients, the surgical team should still balance pros and cons at the time of placing synthetics in contaminated fields.
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Head WT, Thomas CS, Eriksson E. Botox, Abdominal Wall Transection, and Body Positioning: A Case of Complex Abdominal Wall Reconstruction With Seat Belt Syndrome. Cureus 2021; 13:e19043. [PMID: 34853758 PMCID: PMC8608678 DOI: 10.7759/cureus.19043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2021] [Indexed: 11/22/2022] Open
Abstract
Seat belt syndrome (SBS) represents all injury profiles associated with seat belt injuries and motor vehicle crashes (MVCs). Seat belt syndrome classically presents with a superficial seat belt sign that may signify deeper intra-abdominal and/or spinal involvement. The amount of force transmitted from the restraint to the passenger ultimately dictates the amount and severity of the injury. We present a unique case of a 59-year-old female involved in a motor vehicle crash with multiple traumatic injuries, including seat belt syndrome, abdominal wall transection, and bowel injuries. She later had reconstruction of her traumatic abdominal wall hernias (TAWHs). Three unique approaches were used in the management of her traumatic abdominal wall hernias: (1) preoperative Botulinum toxin (Botox) injections, (2) operative use of biologic and bioabsorbable meshes in contaminated fields, and (3) postoperative physical therapy and body positioning. The patient did not experience any recurrence of these hernias after her abdominal wall reconstruction and remains alive at the time this case was written. The diagnostic criteria and surgical management of traumatic abdominal wall hernias have yet to be established, and the case presented here provides approaches that should serve as future areas for study.
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Affiliation(s)
- William T Head
- Department of Surgery, The Medical University of South Carolina, Charleston, USA
| | - Christopher S Thomas
- Department of Surgery, The Medical University of South Carolina, Charleston, USA
| | - Evert Eriksson
- Department of Surgery, The Medical University of South Carolina, Charleston, USA
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75 Years of Excellence: The Story of Reconstructive Surgery. Plast Reconstr Surg 2021; 148:1423-1428. [PMID: 34847136 DOI: 10.1097/prs.0000000000008529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Podolsky D, Ghanem OM, Tunder K, Iqbal E, Novitsky YW. Current practices in complex abdominal wall reconstruction in the Americas: need for national guidelines? Surg Endosc 2021; 36:4834-4838. [PMID: 34786641 DOI: 10.1007/s00464-021-08831-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 10/19/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Component separation (CS) procedures have become an important part of surgeons' armamentarium. However, the exact criteria for training, procedure/mesh choice, as well as patient selection for CS remains undefined. Herein we aimed to identify trends in CS utilization between various cohorts of practicing surgeons. STUDY DESIGN Members of the Americas Hernia Society were queried using an online survey. Responders were stratified according to their experience, practice profile (private vs academic, general vs hernia surgery), and volume (low (< 10/year) vs high) of CS procedures. We used Chi-squared tests to evaluate significant associations between surgeon characteristics and outcomes. RESULTS 275 responses with overwhelming male preponderance (88%) were collected. The two most common self-identifiers were "general" (66%) and "hernia" (28%) surgeon. PCS was the most commonly (67%) used type of CS; endoscopic ACS was least common (3%). Low-volume surgeons were more likely to utilize the ACS (p < 0.05). Only 7% of respondents learned PCS during their residency, as compared to 36% that use ACS. 65% felt 0-10 cases was sufficient to become proficient in their preferred technique. 10 cm-wide defect was the most common indication for CS; 23% used it for 5-8 cm defects. Self-identified "hernia" and high-volume surgeons were more likely to use synthetic mesh in the setting of previous wound infections and/or contaminated field (p < 0.05). More general/low-volume surgeons use biologic mesh. Contraindications to elective CS varied widely in the cohort, and 9.5% would repair poorly optimized patients electively. Severe morbid obesity was the most feared comorbidity to preclude CS. CONCLUSION The use of CS varies widely between surgeons. In this cohort, we discovered that PCS was the most commonly used technique, especially by hernia/high-volume surgeons. There are differences in mesh utilization between high-volume and low-volume surgeons, specifically in contaminated fields. Despite its prevalence, CS training, indications/contraindications, and patient selection must be better defined.
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Affiliation(s)
- Dina Podolsky
- Department of Surgery, Columbia University Medical Center, 177 Fort Washington, 6th floor, South Knuckle, New York, NY, 10032, USA.
| | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Kelly Tunder
- Department of Surgery, Columbia University Medical Center, 177 Fort Washington, 6th floor, South Knuckle, New York, NY, 10032, USA
| | - Emaad Iqbal
- Department of Surgery, Columbia University Medical Center, 177 Fort Washington, 6th floor, South Knuckle, New York, NY, 10032, USA
| | - Yuri W Novitsky
- Department of Surgery, Columbia University Medical Center, 177 Fort Washington, 6th floor, South Knuckle, New York, NY, 10032, USA
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Lightfoot RW, Thrash C, Thompson S, Richmond BK. A Comparison of Component Separation With Porcine Acellular Dermal Reinforcement to Bovine Acellular Dermal Matrix in the Repair of Significant Midline Ventral Hernia Defects. Am Surg 2021:31348211050844. [PMID: 34772290 DOI: 10.1177/00031348211050844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The optimal material for reinforcement of complex abdominal ventral hernia repair (VHR) remains controversial. Biologic prostheses such as porcine and bovine acellular dermal matrix (PADM/BADM) have shown favorable results, but few head-to-head comparisons between the two types exist. We sought to provide such a comparison. METHODS We performed a retrospective cohort study comparing 40 consecutive patients who underwent open component separation (CS/VHR) with PADM reinforcement to 39 consecutive patients who underwent open CS/VHR with BADM reinforcement at our institution. Patient characteristics, outcomes, complications, reoperations, and hernia recurrences were obtained by chart review. Fisher's exact and t-test analyses compared patient characteristics and outcomes between the 2 cohorts. Statistical significance was set as P < .05. RESULTS Patient groups did not differ significantly in race (P=.36), age (P=.8), BMI (P=.34), sex (P=.09), steroid usage (p-1.00), COPD (P=.43), number of previous abdominal operations (P=.66), and duration of follow-up (P=.65). There were significantly more smokers in the PADM group (37.5% vs 12.8%, P=.01). Mean defect size was significantly greater in the PADM group (372.5 cm2 vs 292. cm2 in the BADM group, P=.001) as was the number of Ventral Hernia Working Group (VHWG) grade III/IV hernias (65.0% vs 38.4%, P=.02). Recurrence rates were lower in the BADM group, (12.5% vs 5.1%, P=.26), as was recurrence or complications requiring reoperation (17.5% vs 5.1%, P=.15). Postoperative wound events were also significantly lower in the BADM group (30.0% vs 2.6%, P=.001). CONCLUSIONS In our series, CS/BADM was associated with significantly fewer wound complications. Recurrences and complications requiring reoperation were also fewer, which trended toward but did not reach statistical significance, presumably due to the small sample size. These findings indicating superiority of BADM over PADM are potentially confounded by the higher percentage of smokers, the larger mean defect size, and the higher number of VHWG III/IV patients in the PADM group. Further prospective study of these findings is warranted.
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Affiliation(s)
- Robert W Lightfoot
- Department of Surgery, 20205Charleston Area Medical Center, Charleston, WV, USA
| | - Caleb Thrash
- Department of Surgery, 20205Charleston Area Medical Center, Charleston, WV, USA
| | - Stephanie Thompson
- Charleston Area Medical Center - Health Education and Research Institute, 20205Charleston Area Medical Center, Charleston, WV, USA
| | - Bryan K Richmond
- Department of Surgery, 37297West Virginia University/Charleston Division and the CAMC Institute for Academic Medicine, Charleston, WV, USA
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Heise D, Schram C, Eickhoff R, Bednarsch J, Helmedag M, Schmitz SM, Kroh A, Klink CD, Neumann UP, Lambertz A. Incisional hernia repair by synthetic mesh prosthesis in patients with inflammatory bowel disease: a comparative analysis. BMC Surg 2021; 21:353. [PMID: 34579686 PMCID: PMC8474889 DOI: 10.1186/s12893-021-01350-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 09/21/2021] [Indexed: 02/06/2023] Open
Abstract
Background Patients with inflammatory bowel disease (IBD) have a high-life time risk undergoing abdominal surgery and are prone to develop incisional hernias (IH) in the postoperative course. Therefore, we investigated the role of IBD as perioperative risk factor in open ventral hernia repair (OVHR) as well as the impact of IBD on hernia recurrence during postoperative follow-up. Methods The postoperative course of 223 patients (Non-IBD (n = 199) and IBD (n = 34)) who underwent OVHR were compared by means of extensive group comparisons and binary logistic regressions. Hernia recurrence was investigated in the IBD group according to the Kaplan–Meier method and risk factors for recurrence determined by Cox regressions. Results General complications (≥ Clavien-Dindo I) occurred in 30.9% (72/233) and major complications (≥ Clavien-Dindo IIIb) in 7.7% (18/233) of the overall cohort with IBD being the single independent risk-factor for major complications (OR = 4.2, p = 0.007). Further, IBD patients displayed a recurrence rate of 26.5% (9/34) after a median follow-up of 36 months. Multivariable analysis revealed higher rates of recurrence in patients with ulcerative colitis (UC, 8/15, HR = 11.7) compared to patients with Crohn’s disease (CD, 1/19, HR = 1.0, p = 0.021). Conclusion IBD is a significant risk factor for major postoperative morbidity after OVHR. In addition, individuals with IBD show high rates of hernia recurrence over time with UC patients being more prone to recurrence than patients with CD.
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Affiliation(s)
- Daniel Heise
- Department of General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Charles Schram
- Department of General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Roman Eickhoff
- Department of General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Jan Bednarsch
- Department of General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Marius Helmedag
- Department of General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Sophia M Schmitz
- Department of General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Andreas Kroh
- Department of General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Christian Daniel Klink
- Department of General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Ulf Peter Neumann
- Department of General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Andreas Lambertz
- Department of General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
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Ghimire N, Silva DJ, Bavikatte A, Olugbemi M, Mishra A, Smith SA. Bowel obstruction secondary to gallstone ileus within an inguinoscrotal hernia: a rare diagnosis in an elderly patient. BJR Case Rep 2021; 7:20200207. [PMID: 35047199 PMCID: PMC8749400 DOI: 10.1259/bjrcr.20200207] [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: 12/03/2020] [Revised: 02/02/2021] [Accepted: 02/24/2021] [Indexed: 11/05/2022] Open
Abstract
Gallstone ileus and obstructed inguinal hernias are respectively, rare and common causes of small bowel obstruction. There are no published cases of these pathologies occurring simultaneously. Here, we describe a unique case of an elderly male patient presenting with a small bowel obstruction caused by these combined pathologies. Following an acute presentation with obstructive symptoms, a CT scan demonstrated small bowel obstruction due to a large gallstone lodged in the neck of an inguinoscrotal hernia with associated pneumobilia. The case may have been managed conservatively if it was not for the presence of the gallstone. Previous imaging had incidentally demonstrated gallstones in the gallbladder and a large uncomplicated right inguinoscrotal hernia. It is presumed that a cholecystoduodenal fistula formed and a gallstone then migrated downstream to lodge within the neck of the inguinoscrotal hernia. This case underscores the concept that even in the presence of an “obvious” cause of small bowel obstruction, such as an irreducible, large inguinoscrotal hernia, we must always maintain a healthy clinical skepticism and an open mind to other unexpected aetiologies, which may account for the clinical presentation that might impact subsequent management.
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Aldohayan A, Alamri H, Aljunidel R, Alotaibi A, Alosaimi M, Alburakan A, Bamehriz F. Laparoscopic Ventral Hernia Repair with Poly-4-Hydroxybutyrate Absorbable Barrier Composite Mesh. JSLS 2021; 25:JSLS.2020.00105. [PMID: 33879989 PMCID: PMC8035817 DOI: 10.4293/jsls.2020.00105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Repair of ventral and incisional hernias (VIHR) is a common procedure, newly introduced resorbable mesh biomaterials provide an attractive option to reduce the use of permanent synthetic mesh in hernia surgery and reduce its complications. However, data on the use of slowly resorbable mesh materials remains scarce, this study aims to evaluate the use of poly-4-hydroxybutyrate/absorbable barrier composite mesh (P4HB/ABCM) in laparoscopic repair of VIHR. Methods This is a retrospective study of a sequential cohort of patients undergoing laparoscopic VIHR utilizing a P4HB/ABCM mesh. Perioperative characteristics and clinical outcomes were collected. Results In total, 26 patients including 10 females and 7 males underwent laparoscopic VIHR using P4HB/ABCM. All surgeries were performed in a single institution by the same surgeon. The average patient age was 52.6, and the mean BMI was 35.5. All patients had a clean wound classification. The average defect size was 136.4 cm2. All patients were seen in clinic with a median follow-up of 28 months. We observed 4 wound seromas, and no wound infections or recurrences during the follow-up period. Conclusion Results of laparoscopic VIHR with P4HB/ABCM are favorable and encourages further studies on the role of absorbable biosynthetic mesh materials in hernia surgery.
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Affiliation(s)
- Abdullah Aldohayan
- Department of Surgery, College of Medicine, King Saud University, P.O. Box 7805, Riyadh 11472, Kingdom of Saudi Arabia
| | - Hussam Alamri
- Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Rana Aljunidel
- Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdullah Alotaibi
- Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Majed Alosaimi
- Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ahmed Alburakan
- Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Fahad Bamehriz
- Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Xu X, Zhan M, Li X, Chen T, Yang L. In vivo Analysis of the Resistance of the Meshes to Escherichia coli Infection. Front Surg 2021; 8:644227. [PMID: 34250004 PMCID: PMC8264128 DOI: 10.3389/fsurg.2021.644227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 05/26/2021] [Indexed: 01/17/2023] Open
Abstract
Background: The mesh infection is mostly related to the gram-negative bacteria, such as Escherichia coli (E. coli) for emergency surgery of incarcerated hernia. However, few study investigated the effects of E. coli concentration, mesh materials and antibiotic prophylaxis on mesh infection after hernioplasty. The aim of this study was to evaluate the bacterial resistance to E. coli for three different materials of mesh, and to measure the minimum E. coli concentration for mesh infection with and without antibiotic prophylaxis in a rat model. Methods: Three types of mesh (polytetrafluoroethylene, polypropylene, and biologic meshes) were used in the repair of an acute ventral hernia rat model in the setting of different concentrations of E. coli loads and antibiotics. At the 8th day after surgery, mesh samples were sent for microbiologic and histologic analyses. Results: The positive rates of bacterial culture increased with E. coli concentration. The biologic mesh showed better bacterial resistance compared to polytetrafluoroethylene mesh and polypropylene mesh when the concentration of E. coli ranges from 106 CFU/ml to 108 CFU/ml (P = 0.002 and P = 0.029, respectively). Prophylactical ceftriaxone treatment could not decrease the colonization rate of E. coli at 106 CFU/ml or 108 CFU/ml in each group (P > 0.05). The scores of neovascularization in polypropylene mesh and biologic mesh were similar, which was higher than that of polytetrafluoroethylene mesh (P < 0.05). Compared with other meshes, biologic mesh showed better tolerance to 106 CFU/ml E. coli with respect to inflammation, depth of inflammation, neovascularization, cellular repopulation and foreign body giant cells. Conclusion: The biologic mesh had better E. coli resistance compared to polytetrafluoroethylene mesh and polypropylene mesh when the E. coli concentration is higher than 106 CFU/ml in rats. Antibiotic prophylaxis was useful when the contamination was not particularly severe.
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Affiliation(s)
- Xinsen Xu
- Department of Biliary-Pancreatic Surgery, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ming Zhan
- Department of Biliary-Pancreatic Surgery, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xinxing Li
- Department of General Surgery, Changzheng Hospital, The Second Military Medical University, Shanghai, China
| | - Tao Chen
- Department of Biliary-Pancreatic Surgery, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Linhua Yang
- Department of Biliary-Pancreatic Surgery, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
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Charleux-Muller D, Romain B, Boisson C, Velten M, Brigand C, Lejeune C. Cost-effectiveness analysis of resorbable biosynthetic mesh in contaminated ventral hernia repair. J Visc Surg 2021; 159:279-285. [PMID: 34116953 DOI: 10.1016/j.jviscsurg.2021.06.001] [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] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of this study was to compare, in terms of cost and serious complications, the use of biosynthetic resorbable parietal mesh with biologic mesh in patients undergoing contaminated ventral hernia repair (modified Ventral Hernia Working Group grade 3). Poly-4-hydroxy-butyrate (P4HB) biosynthetic mesh has rarely been the subject of comparative studies in the context of contamination. Data are required to confirm the effects of a transition from biological mesh to biosynthetic resorbable mesh. PATIENTS AND METHODS A cost-effectiveness analysis was conducted. It was based on a decision analysis model built with clinical and economic data issued from a before-after study that included 94 patients hospitalized for ventral hernia repair at the University Hospital of Strasbourg (France) from June 2011 to February 2018. The effectiveness endpoint was the number of patients presenting with a serious specific complication or a general complication at 6 months. Data for surgical hospitalization stays, home hospitalizations and ambulatory care costs were included. RESULTS We found fewer serious complications with biosynthetic mesh: 21% versus 33% with biologic mesh. A cost savings of US $5146 was determined. Deterministic sensitivity analyses and a probabilistic analysis confirmed our findings and the robustness of the model. CONCLUSION P4HB biosynthetic resorbable mesh appeared to be the most effective and the least costly option. Additional data will be needed to confirm the superiority of biosynthetic mesh in terms of the recurrence risk reduction over a longer period.
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Affiliation(s)
- D Charleux-Muller
- Department of Digestive Surgery, University Hospital of Strasbourg, 1 avenue Molière, 67200 Strasbourg, France.
| | - B Romain
- Department of Digestive Surgery, University Hospital of Strasbourg, 1 avenue Molière, 67200 Strasbourg, France
| | - C Boisson
- Clinical Epidemiology Unit, Clinical Investigation Center, INSERM, CIC1432, Dijon University Hospital
| | - M Velten
- Department of Public Health, INSERM, UMR-S1113, University Hospital of Strasbourg, 1 place de l'hôpital, 67100 Strasbourg, France
| | - C Brigand
- Department of Digestive Surgery, University Hospital of Strasbourg, 1 avenue Molière, 67200 Strasbourg, France
| | - C Lejeune
- Clinical Epidemiology Unit, Clinical Investigation Center, INSERM, CIC1432, Dijon University Hospital; INSERM, LNC UMR1231, University Bourgogne Franche-Comté, Dijon, France
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Outcomes of mid-term and long-term degradable biosynthetic meshes in single-stage open complex abdominal wall reconstruction. Hernia 2021; 25:1647-1657. [PMID: 34097187 PMCID: PMC8182350 DOI: 10.1007/s10029-021-02415-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 04/12/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess clinical outcomes in patients that underwent open single-stage complex abdominal wall reconstruction (CAWR) with biosynthetic mesh. METHODS Retrospective observational study of two prospectively registered series of consecutive patients undergoing CAWR with either long-term degradable (LTD) Phasix™ or mid-term degradable (MTD) BIO-A® biosynthetic mesh in a single institution between June 2016 and December 2019. RESULTS From 169 patients with CAWR, 70 consecutive patients were identified who underwent CAWR with either LTD or MTD biosynthetic mesh. More than 85% of patients had an incisional hernia that could be classified as moderately complex to major complex due to a previous wound infection (67%), one or more complicating comorbidities (87.1%), one or more complicating hernia characteristics (75.7%) or contaminated or dirty defects (37.1%). Concomitant component separation was performed in 43 of 70 patients (61.4%). Overall surgical site infection (SSI) rate in these CAWR patients was 45.7%. Seventeen of 70 patients (24.3%) had computed tomography (CT) - and culture-confirmed SSI in direct contact of mesh, suspicious of mesh infection. Mesh removal for persistent local infection occurred in 10% (7 of 70) after a median of 229 days since surgery. Salvage rate of mesh after direct contact with infection was 58.8%. All removed meshes were in the LTD group. Seven patients (10%) had a recurrence; four patients in the LTD group (10%) had a recurrence at a median follow-up of 35 months and three patients in the MTD group (10%) at a median follow-up of 11 months. Three of the seven recurrences occurred in patients with SSI in persistent and direct contact with mesh. CONCLUSIONS Comorbid patients undergoing open complex abdominal wall reconstruction are at high risk of postoperative wound complications regardless of which type of biosynthetic mesh is used. When in persistent and direct contact with infection, long-term biodegradable biosynthetic meshes may need to be removed, whereas mid-term biodegradable biosynthetic meshes can be salvaged.
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Ayuso SA, Elhage SA, Aladegbami BG, Kao AM, Kercher KW, Colavita PD, Augenstein VA, Heniford BT. Delayed primary closure (DPC) of the skin and subcutaneous tissues following complex, contaminated abdominal wall reconstruction (AWR): a propensity-matched study. Surg Endosc 2021; 36:2169-2177. [PMID: 34018046 DOI: 10.1007/s00464-021-08485-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/28/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Wound complications following abdominal wall reconstruction (AWR) in a contaminated setting are common and significantly increase the risk of hernia recurrence. The purpose of this study was to examine the effect of short-term negative pressure wound therapy (NPWT) followed by operative delayed primary closure (DPC) of the skin and subcutaneous tissue after AWR in a contaminated setting. METHODS A prospective institutional hernia database was queried for patients who underwent NPWT-assisted DPC after contaminated AWR between 2008 and 2020. Primary outcomes included wound complication rate and reopening of the incision. A non-DPC group was created using propensity-matching. Standard descriptive statistics were used, and a univariate analysis was performed between the DPC and non-DPC groups. RESULTS In total, 110 patients underwent DPC following AWR. The hernias were on average large (188 ± 133.6 cm2), often recurrent (81.5%), and 60.5% required a components separation. All patients had CDC Class 3 (14.5%) or 4 (85.5%) wounds and biologic mesh placed. Using CeDAR, the wound complication rate was estimated to be 66.3%. Postoperatively, 26.4% patients developed a wound complication, but only 5.5% patients required reopening of the wound. The rate of recurrence was 5.5% with mean follow-up of 22.6 ± 27.1 months. After propensity-matching, there were 73 patients each in the DPC and non-DPC groups. DPC patients had fewer overall wound complications (23.0% vs 43.9%, p = 0.02). While 4.1% of the DPC group required reopening of the incision, 20.5% of patients in the non-DPC required reopening of the incision (p = 0.005) with an average time to healing of 150 days. Hernia recurrence remained low overall (2.7% vs 5.4%, p = 0.17). CONCLUSIONS DPC can be performed with a high rate of success in complex, contaminated AWR patients by reducing the rate of wound complications and avoiding prolonged healing times. In patients undergoing AWR in a contaminated setting, a NPWT-assisted DPC should be considered.
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Affiliation(s)
- Sullivan A Ayuso
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Sharbel A Elhage
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Bola G Aladegbami
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Angela M Kao
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Kent W Kercher
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Paul D Colavita
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Vedra A Augenstein
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - B Todd Heniford
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA.
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McGuirk M, Kajmolli A, Gachabayov M, Smiley A, Samson D, Latifi R. Independent Predictors for Surgical Site Infections in Patients Undergoing Complex Abdominal Wall Reconstruction. Surg Technol Int 2021; 38:179-185. [PMID: 33823057 DOI: 10.52198/21.sti.38.hr1431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Complex abdominal wall reconstruction (CAWR) in patients with large abdominal defects have become a common procedure. The aim of this study was to identify independent predictors of surgical site infections (SSI) in patients undergoing CAWR. MATERIALS AND METHODS This was an ambidirectional cohort study of 240 patients who underwent CAWR with biologic mesh between 2012 and 2020 at an academic tertiary/quaternary care center. Prior superficial SSI, deep SSI, organ space infections, enterocutaneous fistulae, and combined abdominal infections were defined as prior abdominal infections. Univariable and multivariable logistic regression models were performed to determine independent risk factors for SSI. RESULTS There were a total of 39 wound infections, with an infection rate of 16.3%. Forty percent of patients who underwent CAWR in this study had a history of prior abdominal infections. In the multivariable regression models not weighted for length of stay (LOS), prior abdominal infection (odds ratio [OR]: 2.49, p=0.013) and higher body mass index (BMI) (OR: 1.05, p=0.023) were independent predictors of SSI. In the multivariable regression model weighted for LOS, prior abdominal infection (OR: 2.2, p=0.034), higher BMI (OR: 1.05, p=0.024), and LOS (OR: 1.04, p=0.043) were independent predictors of SSI. CONCLUSION The history of prior abdominal infections, higher BMI, and increased LOS are important independent predictor of SSI following CAWR.
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Affiliation(s)
- Matthew McGuirk
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Agon Kajmolli
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Mahir Gachabayov
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Abbas Smiley
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - David Samson
- Department of Surgery Clinical Research Unit, Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Rifat Latifi
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
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The effect of negative pressure wound therapy on surgical site occurrences in closed incision abdominal wall reconstructions: a retrospective single surgeon and institution study. Hernia 2021; 25:1549-1555. [PMID: 34009506 DOI: 10.1007/s10029-021-02427-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/06/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The use of closed incision negative pressure wound therapy (ciNPWT) in abdominal wall reconstruction is heavily debated. The current literature shows mixed results for its efficacy in preventing surgical site occurrences (SSOs), and many of the studies are limited by small sample size or a lack of generalizability. We sought to assess whether the use of prophylactic ciNPWT has an effect on reducing the rate of SSOs. METHODS Following institutional review board approval, a retrospective analysis of a prospectively collected abdominal wall reconstruction database of a single surgeon at a single institution was completed. Two hundred and seventy patients were reviewed. Univariate and multivariate logistic regressions were performed to assess the effect of each variable on the rate of SSOs. RESULTS Two hundred and fifty-eight patients (95.56%) met inclusion criteria. One hundred and fifty-nine (61.63%) of these patients received ciNPWT. The median duration of ciNPWT was 6 days. Multivariate logistic regression analysis showed no significant difference in the prevalence of SSOs between groups (OR = 0.843, 95% CI [0.445-1.594], p = 0.598). It did, however, show a significant decrease in the rates of seroma (7.07% vs. 0.63%, p = 0.004). Moreover, skin resection was associated with a decreased rate of SSO (OR = 0.295, 95% CI [0.096-0.911], p = 0.034). CONCLUSIONS ciNPWT was not associated with a decrease in SSOs following abdominal wall reconstruction but did show a statistically significant decrease in postoperative seromas. Future, large prospective analyses may help further discover the utility of ciNPWT in reducing SSOs.
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San Miguel-Méndez C, López-Monclús J, Munoz-Rodriguez J, de Lersundi ÁRV, Artes-Caselles M, Blázquez Hernando LA, García-Hernandez JP, Minaya-Bravo AM, Garcia-Urena MÁ. Stepwise transversus abdominis muscle release for the treatment of complex bilateral subcostal incisional hernias. Surgery 2021; 170:1112-1119. [PMID: 34020792 DOI: 10.1016/j.surg.2021.04.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/14/2021] [Accepted: 04/08/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND Management of subcostal incisional hernias is particularly complicated due to their proximity to the costochondral limits in addition to the lack of aponeurosis on the lateral side of the abdomen. We present our results of posterior component separation through the same previous incision as a safe and reproducible technique for these complex cases. METHODS We presented a multicenter and prospective cohort of patients diagnosed with bilateral subcostal incisional hernias on either clinical examination or imaging based on computed tomography from 2014 to 2020. The aim of this investigation was to assess the outcomes of abdominal wall reconstruction for subcostal incisional hernias through a new approach. The outcomes reported were short- and long-term complications, including recurrence, pain, and bulging. Quality of life was assessed with the European Registry for Abdominal Wall Hernias Quality of Life score. RESULTS A total of 46 patients were identified. All patients underwent posterior component separation. Surgical site occurrences occurred in 10 patients (22%), with only 7 patients (15%) requiring procedural intervention. During a mean follow-up of 18 months (range, 6-62 months), 1 (2%) case of clinical recurrence was registered. Also, there were 8 (17%) patients with asymptomatic but visible bulging. The European Registry for Abdominal Wall Hernias Quality of Life score showed a statistically significant decrease in the 3 domains (pain, restriction, and cosmetic) of the postoperative scores compared with the preoperative score. CONCLUSION Posterior component separation technique for the repair of subcostal incisional hernias through the same incision is a safe procedure that avoids injury to the linea alba. It is associated with acceptable morbidity, low recurrence rate, and improvement in patients' reported outcomes.
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Affiliation(s)
- Carlos San Miguel-Méndez
- General and Digestive Surgery Department, Hospital Universitario del Henares, Francisco de Vitoria University, Madrid, Spain
| | - Javier López-Monclús
- General and Digestive Surgery Department, Hospital Universitario Puerta de Hierro, Autónoma University of Madrid, Spain.
| | - Joaquín Munoz-Rodriguez
- General and Digestive Surgery Department, Hospital Universitario Puerta de Hierro, Autónoma University of Madrid, Spain
| | - Álvaro Robin Valle de Lersundi
- General and Digestive Surgery Department, Hospital Universitario del Henares, Francisco de Vitoria University, Madrid, Spain
| | - Mariano Artes-Caselles
- General and Digestive Surgery Department, Hospital Universitario Puerta de Hierro, Autónoma University of Madrid, Spain
| | - Luis Alberto Blázquez Hernando
- General and Digestive Surgery Department, Hospital Universitario Ramón y Cajal, Alcalá de Henares University Madrid, Spain
| | | | - Ana María Minaya-Bravo
- General and Digestive Surgery Department, Hospital Universitario del Henares, Francisco de Vitoria University, Madrid, Spain
| | - Miguel Ángel Garcia-Urena
- General and Digestive Surgery Department, Hospital Universitario del Henares, Francisco de Vitoria University, Madrid, Spain
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A Herniorrhaphy Lamination Technique for the Reconstruction of Midline Abdominal Wall Defects. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3558. [PMID: 33912375 PMCID: PMC8078233 DOI: 10.1097/gox.0000000000003558] [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: 12/17/2020] [Accepted: 03/02/2021] [Indexed: 12/04/2022]
Abstract
The primary goal of abdominal wall reconstruction is to prevent hernia recurrence through robust and durable repair. Synthetic mesh utilization can provide sound strength but is susceptible to extrusion, infection, and intestinal fistulization. The use of autologous fasciae latae to reinforce the primary fascial reapproximation has mostly been abandoned, presumably because synthetic patches are readily available. There is a specific demand for a sustainable, less-invasive, and ready-to-use repair method without mesh. The authors devised a herniorrhaphy lamination technique using local musculofascial flaps inspired by composite laminates. In this procedure, the primary fascial reapproximation is reinforced with 3 additional laminated musculofascial layers: (1) turnover hinge flaps of the anterior sheath of the rectus abdominis, (2) bilateral rectus abdominis, and (3) advancement flaps of newly generated edges of the fascia of the rectus sheath. Our technique’s stability is essentially due to the mechanical superiority of the centralized pipe-like structure of musculofascia. Between February 2009 and November 2019, we used the lamination technique to repair midline incisional hernias in 10 patients. The operative procedure was successful in all patients, and there has been no evidence of recurrence. The follow-up period ranged from 12 to 69 months, with a mean follow-up of 35 months. The herniorrhaphy lamination technique to reinforce the primary repair can help prevent hernia recurrence. Although our technique is suitable for a small-sized defect, it is less invasive, and can be readily applied. Because it does not include any mesh, it is suitable for the contaminated abdominal wall reconstruction.
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Parker SG, Mallett S, Quinn L, Wood CPJ, Boulton RW, Jamshaid S, Erotocritou M, Gowda S, Collier W, Plumb AAO, Windsor ACJ, Archer L, Halligan S. Identifying predictors of ventral hernia recurrence: systematic review and meta-analysis. BJS Open 2021; 5:6220253. [PMID: 33839749 PMCID: PMC8038271 DOI: 10.1093/bjsopen/zraa071] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/08/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Ventra hernias are increasing in prevalence and many recur despite attempted repair. To date, much of the literature is underpowered and divergent. As a result there is limited high quality evidence to inform surgeons succinctly which perioperative variables influence postoperative recurrence. This systematic review aimed to identify predictors of ventral hernia recurrence. METHODS PubMed was searched for studies reporting prognostic data of ventral hernia recurrence between 1 January 1995 and 1 January 2018. Extracted data described hernia type (primary/incisional), definitions of recurrence, methods used to detect recurrence, duration of follow-up, and co-morbidity. Data were extracted for all potential predictors, estimates and thresholds described. Random-effects meta-analysis was used. Bias was assessed with a modified PROBAST (Prediction model Risk Of Bias ASsessment Tool). RESULTS Screening of 18 214 abstracts yielded 274 individual studies for inclusion. Hernia recurrence was defined in 66 studies (24.1 per cent), using 41 different unstandardized definitions. Three patient variables (female sex, age 65 years or less, and BMI greater than 25, 30, 35 or 40 kg/m2), five patient co-morbidities (smoking, diabetes, chronic obstructive pulmonary disease, ASA grade III-IV, steroid use), two hernia-related variables (incisional/primary, recurrent/primary), six intraoperative variables (biological mesh, bridged repair, open versus laparoscopic surgery, suture versus mesh repair, onlay/retrorectus, intraperitoneal/retrorectus), and six postoperative variables (any complication, surgical-site occurrence, wound infection, seroma, haematoma, wound dehiscence) were identified as significant prognostic factors for hernia recurrence. CONCLUSION This study summarized the current evidence base for predicting ventral hernia recurrence. Results should inform best practice and future research.
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Affiliation(s)
- S G Parker
- Abdominal Wall Unit, Department of Surgery, University College Hospital, London, UK
| | - S Mallett
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - L Quinn
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,University College London Medical School, London, UK
| | - C P J Wood
- Abdominal Wall Unit, Department of Surgery, University College Hospital, London, UK
| | - R W Boulton
- Abdominal Wall Unit, Department of Surgery, University College Hospital, London, UK
| | - S Jamshaid
- Abdominal Wall Unit, Department of Surgery, University College Hospital, London, UK
| | - M Erotocritou
- Abdominal Wall Unit, Department of Surgery, University College Hospital, London, UK
| | - S Gowda
- Abdominal Wall Unit, Department of Surgery, University College Hospital, London, UK
| | - W Collier
- Abdominal Wall Unit, Department of Surgery, University College Hospital, London, UK
| | - A A O Plumb
- Centre of Medical Imaging, University College Hospital, London, UK
| | - A C J Windsor
- Abdominal Wall Unit, Department of Surgery, University College Hospital, London, UK
| | - L Archer
- Centre for Prognosis Research, School of Primary, Community and Social Care, Keele University, Keele, UK
| | - S Halligan
- Centre of Medical Imaging, University College Hospital, London, UK
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50
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Christopher AN, Patel V, Othman S, Jia H, Mellia JA, Broach RB, Fischer JP. Onlay Poly-4-Hydroxybutyrate (P4HB) Mesh for Complex Hernia: Early Clinical and Patient Reported Outcomes. J Surg Res 2021; 264:199-207. [PMID: 33838404 DOI: 10.1016/j.jss.2021.02.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 02/01/2021] [Accepted: 02/27/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND While mesh re-enforcement and advanced surgical techniques are cornerstones of complex ventral hernia repair (CVHR), the risk of complications and recurrence is common. We aim to evaluate the efficacy, safety, and patient reported outcomes (PROs) of patients undergoing CVHR with onlay Poly-4-hydroxybutyrate (P4HB). METHODS Adult (>18 y old) patients undergoing VHR with P4HB (Phasix) in the onlay plane by a single surgeon from 01/2015 to 05/2020 were reviewed. VHR was considered complex if patients had significant co-morbidities, large abdominal wall defects, a history of extensive abdominal surgery, and/or concurrent intra-abdominal pathology. A composite of postoperative outcomes including surgical site occurrences (SSO), surgical site infection (SSI), and surgical site occurrences requiring procedural intervention (SSOpi), as well as PROs as defined by the Abdominal Hernia-Q (AHQ), were analyzed. RESULTS A total of 51 patients were included with average age and body mass index of 56.4 and 29.9 kg/m2. Median follow up was 20 mo with a hernia recurrence rate of 5.9% (n = 3). 21 patients had an SSO (41.2%), 8 had an SSI (15.7%), and 6 had an SSOpi (11.8%). There was an association with Ventral Hernia Working Group ≥ 2 and development of SSO. There was a significant improvement in overall PROs (P < 0.0001) with no difference in those patients with and without complications (P > 0.05). CONCLUSION For hernia patients with large defects and complex intra-abdominal pathology, a safe and effective repair is difficult. The use of onlay P4HB was associated with acceptable postoperative outcomes and recurrence rate.
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Affiliation(s)
- Adrienne N Christopher
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA; Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Viren Patel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sammy Othman
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Hanna Jia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Joseph A Mellia
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA.
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