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Components Separation for Abdominal Wall Reconstruction: The Pitt Experience, A Review of 605 Cases.
Sanjay Naran, MD, Sameer Shakir, BS, Patrick Emelife, BS, Meghan Quigley, MD, James Russavage, DMD, MD, Ernest Manders, MD, J Peter Rubin, MD, Carolyn De La Cruz, MD, Michael Gimbel, MD, Vu Nguyen, MD.
University of Pittsburgh, Pittsburgh, PA, USA.
Components separation of the abdominal musculature is a mainstay for closing complicated midline and para-median abdominal wall defects. We set out to critically analyze our institutional experience with this operative technique, and in doing so identify prognosticators that affect long-term clinical outcomes.
We retrospectively reviewed all patients who underwent components separation between 2000-2010. Over 40 data points were collected for each patient and examined as to whether they affected long-term clinical outcomes. Demographics including BMI, co-morbidities, and operative details were collected. We documented major and minor complications including hernia recurrence, heamatoma, seroma, ischemia, infection, superficial wound breakdown, and DVT/PE.
Our cohort consists of 605 patients, 51.1% of which were female, with a mean age of 53.6±13.45 years, BMI of 32.7±7.8 kg/m2, and defect size of 202.9±228.7 cm2. The average defect width was 12±2 cm. 85% had a prior abdominal surgery, and 31.7% had a prior mesh placement. 79.1% underwent a concurrent procedure at the time of component separation, 17.7% of which involved bowel enterotomies. 2.6% required prosthetics for closure. Mean post-operative stay was 7.2±6.0 days, and average follow-up was 2.5±2.4 years. The recurrence rate was 20.0%. Post-operative complications included infection (13.3%), seroma (6.4%), superficial wound breakdown (5.5%), heamatoma (3.8%), ischemia (3.0%), , and DVT/PE (3.0%). The presence of a respiratory co-morbidity (p=0.001) was associated with an increased risk of recurrence (OR=2.49). The prior use of a prosthetic (p=0.001, OR=2.01), and the use of a prosthetic at the time of separation (p=0.048, OR=1.73), were also significant predictors of recurrence. The occurrence of any post-operative complication (p<0.001) significantly increased the likelihood of eventual recurrence. We found no association between recurrence and BMI. Subgroup analysis identified additional risk factors related to specific post-operative complications.
This study provides a comprehensive review of the largest series utilizing components separation to date. We identify various risk factors that are statistically significant in their association with particular complications. Patients with respiratory co-morbidities, prior use of a prosthetic, and use of a prosthetic at the time of separation, are significantly more likely to have a recurrence; however, in our cohort the components separation technique remains a reliable method of abdominal wall reconstruction even in the setting of co-morbidities thought to be associated with recurrence.
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