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Purpose – Contaminated abdominal hernias carry high morbidity in the morbidly obese. The use of synthetic mesh in contaminated fields has re-emerged as an option, although wound infection, mesh explantation and hernia recurrence are unacceptably high. The separation of abdominal components is commonly the last resort in the repair algorithm due to its higher morbidity. We studied the population of a bariatric center of excellence to evaluate the outcomes of component separation with bio-absorbable mesh reinforcement.
Methods – Retrospective study of morbidly obese patients with contaminated ventral hernias undergoing repair with bio-absorbable mesh. Complications analyzed were superficial surgical site infection (SSSI), deep surgical site infection needing mesh explantation (DSSI), hernia recurrence and non-wound related complications such as pneumonia, ventilator dependence, sepsis and shock. Patients undergoing abdominal component separation with bio-absorbable mesh reinforcement were compared with those repaired using other techniques. Statistical analysis was performed with SAS® software. A p value of less than 0.05 was considered significant.
Results – 50 males and 23 females with a mean BMI of 41.99 kg/m² (35-66 kg/m²) and age of 53.6 years were included. Indications for hernia repair included incarcerated hernia with or without bowel obstruction, necrotic bowel, intra-abdominal abscess, and those with a chronic draining sinus, enterocutaneous fistula, or infected mesh from previous repair. Abdominal component separation with mesh reinforcement (Group 1) was performed in 28.7% of the patients and 71.3% of patient underwent repair with other techniques (Group 2). These included mesh underlay (45.2%), overlay (9.8%), and Rives-Stoppa repair (8.2%). Patients in Group 1 had a history of previous hernia repair in 95%
of the cases compared to 75% in Group 2. The meshes used were Strattice®, Gore Bio-A®, Ultrapro®, and Alloderm®. Complication rates in Group 1 were: 14.2% of SSSI (p>0.05), 4.7% of DSSI needing mesh explantation (p>0.05), 9.52% recurrence (p>0.05) and 14% of non wound related complications (p>0.05). Group 2 had slightly higher complication rates with 15.6% of SSSI (p>0.05), 5.7% of DSSI needing mesh explantation (p>0.05), 13.46% recurrence (p>0.05) and 13.5% of non-wound related complications (p>0.05). Patient’s demographics, comorbidities, repair indications, additional procedures performed during the repair, had no impact on the development of SSSI, DSSI or recurrence. Hernia size and quantity were not documented in the medical records; we suspect selection bias for patients with more complex defects to Group 1. Fisher’s Exact Test showed no difference complications between the two groups. Patients with higher BMI had a trend to higher rates of SSSI (p<0.1). Average follow up was 8.9 months (2-29 months).
Conclusions – Abdominal component separation with bio-absorbable mesh reinforcement is comparable to other techniques with similar rates of SSSI, mesh explantation and hernia recurrences, in the morbidly obese population with a contaminated ventral hernia. Because is more challenging, component separation is commonly left as the last resort to repair complex recurrent defects. We show that its morbidity is comparable to other techniques in the contaminated setting when reinforced with a bio-absorbable mesh, despite these patients having a more deteriorated abdominal wall.