Simplifying Technique While Improving Surgical Outcomes in Complex Abdominal Wall Reconstruction
Adam Levy, MD1, Jaime Bernstein, BA1, Kerry A. Morrison, BA1, Michael D. Lieberman, MD1, Alfons Pomp, MD1, Christine Rohde, MD2, David M. Otterburn, MD1, Jason A. Spector, MD1.
1New York-Presbyterian Hospital - Weill Cornell, New York, NY, USA, 2New York-Presbyterian Hospital - Columbia, New York, NY, USA.
Background: Complex abdominal wall reconstruction (CAWR) for ventral hernia repair addresses a challenging and morbid patient population. Patients often have multiple prior attempts at hernia repair as well as contaminated or infected wounds. To date, no ideal mesh material for CAWR has been described. Poly-4-hydroxybutyrate (P4HB, Phasix®) is a biosynthetic, degradable polymer mesh that retains strength for at least 6 months, the minimal time required for wound healing to reach maximal post repair strength. Because it degrades thereafter, complications associated with permanent synthetic materials are largely avoided. Further, although there is controversy regarding the optimal location to place mesh, there is no doubt that underlay and interposition techniques are more technically challenging and time consuming than onlay. We reviewed our experience using P4HB mesh in CAWR when used as an onlay in the setting of bilateral component separation.
Methods: All patients (n=99) undergoing CAWR between June 2014 and December 2016 at two major university hospitals were followed prospectively for post-operative outcomes. In all cases, surgical repair involved bilateral components separation with elevation of the external oblique musculoaponeurotic complex laterally to the origin of its segmental vascular supply, followed by primary fascial repair at the midline and P4HB mesh onlay secured to the released lateral edges of the external oblique fascia. Patients were followed up to 30 months post-operatively.
Results: 99 patients (48 male, 51 female; mean age 59 years, range 22-84) underwent CAWR. Mean BMI was 29.1 (range 15-48) and 42 (42%) patients were obese (BMI ≥30 kg/m2). Fifty four (54%) patients underwent prior attempted repair with an average of 3.5 ± 2.2 (median 3) prior abdominal operations (range 0-12). Most (91%) had major medical comorbidities and 70 (74%) patients were ASA 3 or greater. 16 cases (16%) were contaminated or infected prior to repair. Follow up ranged up to 30 months (Mean 8.5 ± 6.39). Seven (7%) patients developed a bulge/recurrence at an average of 10.7 ± 4.6 months (range 4-18), all of which were appreciably smaller than the original defect. Eight (8%) patients developed infections treated with antibiotics alone and 6 (6%) developed seromas requiring aspiration. Mesh exposure following skin breakdown occurred in 8 (8%) patients and was treated with local wound care alone in 6 cases. Two patients required operative debridement and re-closure of chronic non-healing wounds; both were found to have retained packing material.
Conclusions: These data demonstrate an effective, reproducible technique across 2 institutions using a novel biosynthetic onlay mesh for CAWR with very low rates of hernia recurrence, seroma and other common complications in a morbid patient population. Notably, no patient developed mesh infection or required total mesh explantation, even when used in a contaminated surgical field. Although longer follow up is needed, we believe using P4HB as an onlay reinforcing mesh is a promising and relatively straightforward approach for soft tissue reinforcement during complex abdominal wall reconstruction.
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