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Complex Ventral Hernia Reconstruction: Long-Term Results After Component Separation and Porcine Biologic Graft
Purpose: Complex ventral hernias represent unique challenges in reconstructive surgery. The abdominal wall serves as both a structural entity as well as a dynamic, functional one; both elements are important to consider in its reconstruction. Biologic implants have provided surgeons with reconstructive alternatives to successfully manage complex ventral hernias when risk of wound complications associated with synthetic mesh is excessive. This study reviews and evaluates our results using an acellular porcine dermal implant (Permacol Biologic Implant™) to restore both the structure and function of the abdominal wall.
Methods: This study is a retrospective review of forty-five consecutive patients who underwent abdominal wall reconstruction by a single surgeon between 9/2006 and 2/2011 using Permacol™. Preoperative (age, BMI, and comorbidities), perioperative (hernia size, wound classification, type/location of mesh, components separation, quilting sutures, number/duration of drains) and postoperative variables (length of follow-up, complications including recurrence, enterocutaneous fistulae, and seroma) were examined.
Results: Forty-five patients underwent abdominal wall reconstruction using Permacol™. Mean age and BMI were 55.2 years and 32.4, respectively. Mean defect size was 202 cm2, measured via preoperative CT scan. Most (89%) had overlay mesh placement with 80% undergoing component separation. Twelve (27%) patients developed seromas, five required reoperation. Four of twenty-nine who had quilting sutures developed seromas (14%) compared with eight seromas (50%) out of sixteen non-quilted
patients (p < 0.05). Mean mesh size was 489 cm2. With an average follow-up of 18.0 months (range 0-53), there were two recurrences (4.4%).
Conclusion: The combination of component separation technique with onlay of crosslinked acellular porcine dermis has provided stable abdominal wall reconstruction in our series. We report a lower recurrence rate than typically reported. Placement of quilting sutures significantly decreased seroma formation. We primarily employed an overlay technique, allowing reloading of the external oblique by sewing to its cut edges. We hypothesize that this maneuver, in concert with re-medialization of the rectus muscles, allows for a physiologic reconstruction of the abdominal wall.