Improved Outcomes in the Management of High-Risk Incisional Hernias Utilizing Biological Mesh and Soft-Tissue Reconstruction: A Single Center Experience
Corresponding Author
J. R. A. Skipworth
- [email protected]
- +44-786-649-8366
Department of Surgery and Interventional Science, University College London, Medical School Building, 74 Huntley Street, WC1E 6AU London, UK
Royal Free and University College London Hospital Complex Hernia Unit, Royal Free Hospital and University College London Hospital NHS Trusts, London, UK
Tel.: +44-786-649-8366, [email protected]Search for more papers by this authorS. Vyas
Royal Free and University College London Hospital Complex Hernia Unit, Royal Free Hospital and University College London Hospital NHS Trusts, London, UK
Search for more papers by this authorL. Uppal
Royal Free and University College London Hospital Complex Hernia Unit, Royal Free Hospital and University College London Hospital NHS Trusts, London, UK
Search for more papers by this authorD. Floyd
Royal Free and University College London Hospital Complex Hernia Unit, Royal Free Hospital and University College London Hospital NHS Trusts, London, UK
Search for more papers by this authorA. Shankar
Royal Free and University College London Hospital Complex Hernia Unit, Royal Free Hospital and University College London Hospital NHS Trusts, London, UK
Search for more papers by this authorCorresponding Author
J. R. A. Skipworth
- [email protected]
- +44-786-649-8366
Department of Surgery and Interventional Science, University College London, Medical School Building, 74 Huntley Street, WC1E 6AU London, UK
Royal Free and University College London Hospital Complex Hernia Unit, Royal Free Hospital and University College London Hospital NHS Trusts, London, UK
Tel.: +44-786-649-8366, [email protected]Search for more papers by this authorS. Vyas
Royal Free and University College London Hospital Complex Hernia Unit, Royal Free Hospital and University College London Hospital NHS Trusts, London, UK
Search for more papers by this authorL. Uppal
Royal Free and University College London Hospital Complex Hernia Unit, Royal Free Hospital and University College London Hospital NHS Trusts, London, UK
Search for more papers by this authorD. Floyd
Royal Free and University College London Hospital Complex Hernia Unit, Royal Free Hospital and University College London Hospital NHS Trusts, London, UK
Search for more papers by this authorA. Shankar
Royal Free and University College London Hospital Complex Hernia Unit, Royal Free Hospital and University College London Hospital NHS Trusts, London, UK
Search for more papers by this authorAbstract
Introduction
Repair of incisional hernias is complex in the setting of previous/current infection, loss of domain and bowel involvement, and is often on the background of significant co-morbidities. Reported repair techniques are associated with significant morbidity and led our unit to develop a novel technique for complex incisional hernia repair.
Methods
A retrospective case notes review of all high-risk (Ventral Hernia Working Group grade 2–4) incisional hernia repairs was undertaken. Standardized repair involved resection of attenuated soft tissue and hernia sac (bioburden reduction), component separation (where necessary), intra-peritoneal Strattice™ biological mesh insertion, midline fascial closure, and soft-tissue reconstruction, performed in combination with a plastic surgeon as a single-stage procedure.
Results
A total of 58 patients underwent hernia repair between February 2009 and September 2012 (median age 59 years; 59 % female). Eleven patients (19 %) were grade 4, 19 (33 %) were grade 3, and 28 (48 %) were grade 2. Nineteen (33 %) were recurrent hernias, and midline fascial closure was achieved in 52 (90 %). Early complications included 15 (26 %) surgical-site occurrences, three (5 %) respiratory complications, two (3 %) cardiac complications, and two (3 %) urinary tract infections. Follow-up has revealed three (5 %) asymptomatic hernia recurrences and no patients requiring mesh explantation.
Conclusions
This technique was associated with a low risk of surgical site occurrences and hernia recurrence, with no requirements for mesh explantation. Repair of such complex incisional hernias remains challenging, and further randomized controlled trials are required to elucidate the optimal method of closure and mesh type.
References
- 1AmbrosianiN, HarbJ, GavelliA et al. Failure of the treatment of eventrations and hernias with the PTFE plate (111 cases). Ann Chir (1994) 48: 917–9207733591
- 2HenifordBT, ParkA, RamshawBJ et al. Laparoscopic ventral and incisional hernia repair in 407 patients. J Am Coll Surg (2000) 190: 645–6501087299810.1016/S1072-7515(00)00280-5
- 3HenifordBT, ParkA, RamshawBJ et al. Laparoscopic repair of ventral hernias: nine years’ experience with 850 consecutive hernias. Ann Surg (2003) 238: 391–399discussion 399–400
- 4HelgstrandF, RosenbergJ, KehletH et al. Nationwide analysis of prolonged hospital stay and readmission after elective ventral hernia repair. Dan Med Bull (2011) 58: A432221975153
- 5MavrosMN, AthanasiouS, AlexiouVG et al. Risk factors for mesh-related infections after hernia repair surgery: a meta-analysis of cohort studies. World J Surg (2011) 35: 2389–23982191313610.1007/s00268-011-1266-5
- 6SatterwhiteTS, MiriS, ChungC et al. Outcomes of complex abdominal herniorrhaphy: experience with 106 cases. Ann Plast Surg (2012) 68: 382–3882242148410.1097/SAP.0b013e31823b68b1
- 7HuschittN, FellerM, LotspeichE et al. Open intraperitoneal hernia repair for treatment of abdominal wall defects-early results by placement of a polypropylene-ePTFE-mesh. Zentralbl Chir (2006) 131: 57–611648521210.1055/s-2006-921411
- 8DurAH, den HartogD, TuinebreijerWE et al. Low recurrence rate of a two-layered closure repair for primary and recurrent midline incisional hernia without mesh. Hernia (2009) 13: 421–4261929619610.1007/s10029-009-0487-0
- 9HalmJA, WallLL, SteyerbergEW et al. Intraperitoneal polypropylene mesh hernia repair complicates subsequent abdominal surgery. World J Surg (2007) 31: 423–429discussion 430
- 10IqbalCW, PhamTH, JosephA et al. Long-term outcome of 254 complex incisional hernia repairs using the modified Rives–Stoppa technique. World J Surg (2007) 31: 2398–24041795270110.1007/s00268-007-9260-7
- 11OhanaG, BramnikZ, MillerA et al. Treatment of large incisional abdominal wall hernias, using a modified preperitoneal prosthetic mesh repair. Hernia (2006) 10: 232–2351645307310.1007/s10029-006-0070-x
- 12RohrichRJ, LoweJB, HackneyFL et al. An algorithm for abdominal wall reconstruction. Plast Reconstr Surg (2000) 105: 202–2161062699310.1097/00006534-200001000-00036
- 13SlaterNJ, van der KolkM, HendriksT et al. Biologic grafts for ventral hernia repair: a systematic review. Am J Surg (2013) 205: 220–2302320098810.1016/j.amjsurg.2012.05.028
- 14ChoiJJ, PalaniappaNC, DallasKB et al. Use of mesh during ventral hernia repair in clean-contaminated and contaminated cases: outcomes of 33,832 cases. Ann Surg (2012) 255: 176–1802167756110.1097/SLA.0b013e31822518e6
- 15BerryMF, PaisleyS, LowDW et al. Repair of large complex recurrent incisional hernias with retromuscular mesh and panniculectomy. Am J Surg (2007) 194: 199–2041761880410.1016/j.amjsurg.2006.10.031
- 16DocimoL, ManziF, SparavignaL et al. Dynamic suture less repair of incisional hernia. Acta Biomed (2003) 74(Suppl 2): 38–4015055032
- 17GeislerDJ, ReillyJC, VaughanSG et al. Safety and outcome of use of nonabsorbable mesh for repair of fascial defects in the presence of open bowel. Dis Colon Rectum (2003) 46: 1118–11231290791010.1007/s10350-004-7290-x
- 18IannittiDA, HopeWW, NortonHJ et al. Technique and outcomes of abdominal incisional hernia repair using a synthetic composite mesh: a report of 455 cases. J Am Coll Surg (2008) 206: 83–881815557210.1016/j.jamcollsurg.2007.07.030
- 19JezupovsA, MihelsonsM The analysis of infection after polypropylene mesh repair of abdominal wall hernia. World J Surg (2006) 30: 2270–2278
- 20KimH, BruenK, VargoD Acellular dermal matrix in the management of high-risk abdominal wall defects. Am J Surg (2006) 192: 705–7091716107910.1016/j.amjsurg.2006.09.003
- 21HawnMT, GraySH, SnyderCW et al. Predictors of mesh explantation after incisional hernia repair. Am J Surg (2011) 202: 28–332174151710.1016/j.amjsurg.2010.10.011
- 22de Vries ReilinghTS, van GoorH, CharbonJA et al. Repair of giant midline abdominal wall hernias: “components separation technique” versus prosthetic repair: interim analysis of a randomized controlled trial. World J Surg (2007) 31: 756–7631737266910.1007/s00268-006-0502-x
- 23BreuingK, ButlerCE, FerzocoS et al. Incisional ventral hernias: review of the literature and recommendations regarding the grading and technique of repair. Surgery (2010) 148: 544–5582030445210.1016/j.surg.2010.01.008
- 24HellerL, McNicholsCH, RamirezOM Component separations. Semin Plast Surg (2012) 26: 25–282337245510.1055/s-0032-1302462
- 25MuysomsFE, MiserezM, BerrevoetF et al. Classification of primary and incisional abdominal wall hernias. Hernia (2009) 13: 407–4141949592010.1007/s10029-009-0518-x
- 26DindoD, DemartinesN, ClavienPA Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg (2004) 240: 205–2131527354210.1097/01.sla.0000133083.54934.ae
- 27ConnorJ, McQuillanD, SandorM et al. Retention of structural and biochemical integrity in a biological mesh supports tissue remodeling in a primate abdominal wall model. Regen Med (2009) 4: 185–1951931763910.2217/17460751.4.2.185
- 28BurnsNK, JaffariMV, RiosCN et al. Non-cross-linked porcine acellular dermal matrices for abdominal wall reconstruction. Plast Reconstr Surg (2010) 125: 167–1761991085510.1097/PRS.0b013e3181c2a6ed
- 29XuH, WanH, SandorM et al. Host response to human acellular dermal matrix transplantation in a primate model of abdominal wall repair. Tissue Eng Part A (2008) 14: 2009–20191859333910.1089/ten.tea.2007.0316
- 30OrensteinS, QiaoY, KaurM et al. In vitro activation of human peripheral blood mononuclear cells induced by human biologic meshes. J Surg Res (2010) 158: 10–141985326010.1016/j.jss.2009.05.033
- 31OrensteinSB, QiaoY, KaurM et al. Human monocyte activation by biologic and biodegradable meshes in vitro. Surg Endosc (2010) 24: 805–8111969708610.1007/s00464-009-0664-3
- 32HarthKC, BroomeAM, JacobsMR et al. Bacterial clearance of biologic grafts used in hernia repair: an experimental study. Surg Endosc (2011) 25: 2224–22292129854210.1007/s00464-010-1534-8
- 33ButlerCE, BurnsNK, CampbellKT et al. Comparison of cross-linked and non-cross-linked porcine acellular dermal matrices for ventral hernia repair. J Am Coll Surg (2010) 211: 368–3762080019410.1016/j.jamcollsurg.2010.04.024
- 34CampbellKT, BurnsNK, RiosCN et al. Human versus non-cross-linked porcine acellular dermal matrix used for ventral hernia repair: comparison of in vivo fibrovascular remodeling and mechanical repair strength. Plast Reconstr Surg (2011) 127: 2321–23322161746610.1097/PRS.0b013e318213a053
- 35ItaniKM, RosenM, VargoD et al. Prospective study of single-stage repair of contaminated hernias using a biologic porcine tissue matrix: the RICH Study. Surgery (2012) 152: 498–5052276326210.1016/j.surg.2012.04.008
- 36RosenMJ, DenotoG, ItaniKM et al. Evaluation of surgical outcomes of retro-rectus versus intraperitoneal reinforcement with bio-prosthetic mesh in the repair of contaminated ventral hernias. Hernia (2013) 17(1): 31–352241544010.1007/s10029-012-0909-2
- 37PatelKM, NahabedianMY, GattiM et al. Indications and outcomes following complex abdominal reconstruction with component separation combined with porcine acellular dermal matrix reinforcement. Ann Plast Surg (2012) 69(4): 394–3982215688710.1097/SAP.0b013e31822f997b
- 38ButlerCE, CampbellKT Minimally invasive component separation with inlay bioprosthetic mesh (MICSIB) for complex abdominal wall reconstruction. Plast Reconstr Surg (2011) 128: 698–7092157237810.1097/PRS.0b013e318221dcce
- 39KissaneNA, ItaniKM A decade of ventral incisional hernia repairs with biologic acellular dermal matrix: what have we learned?. Plast Reconstr Surg (2012) 130(5 Suppl 2): 194S–202S2309697110.1097/PRS.0b013e318265a5ec
- 40Malik A, Macdonald AD, de Beaux AC et al (2013) The peritoneal flap hernioplasty for repair of large ventral and incisional hernias. Hernia (in press)
- 41MathesSJ, SteinwaldPM, FosterRD et al. Complex abdominal wall reconstruction: a comparison of flap and mesh closure. Ann Surg (2000) 232: 586–5961099865710.1097/00000658-200010000-00014
- 42KantersAE, KrpataDM, BlatnikJA et al. Modified hernia grading scale to stratify surgical site occurrence after open ventral hernia repairs. J Am Coll Surg (2012) 215: 787–7932299932810.1016/j.jamcollsurg.2012.08.012
- 43BellowsCF, WheatleyBM, MorozK et al. The effect of bacterial infection on the biomechanical properties of biological mesh in a rat model. PLoS One (2011) 6: e212282169817910.1371/journal.pone.0021228
- 44BellowsCF, WheatleyB, MorozK et al. Histologic and biomechanical evaluation of biologic meshes following colonization with Pseudomonas aeruginosa. J Surg Res (2012) 175: e35–e422226158710.1016/j.jss.2011.10.044
- 45RosenMJ, ReynoldsHL, ChampagneB et al. A novel approach for the simultaneous repair of large midline incisional and parastomal hernias with biological mesh and retrorectus reconstruction. Am J Surg (2010) 199: 416–420
- 46CicilioniOJr, AraujoG, MimbsN et al. Initial experience with the use of porcine acellular dermal matrix (Strattice) for abdominal wall reinforcement after transverse rectus abdominis myocutaneous flap breast reconstruction. Ann Plast Surg (2012) 68: 265–2702186292010.1097/SAP.0b013e31822af89d
