Non-Permanent Mesh for Non-Midline Abdominal Wall Defects
Adam Levy, MD, Jarrod T. Bogue, MD, David M. Otterburn, MD, Thomas A. Imahiyerobo, MD, Christine H. Rohde, MD.
New York-Presbyterian Hospital, New York, NY, USA.
BACKGROUND: Despite the robust literature on midline ventral hernia repair, there is a paucity of literature addressing non-midline abdominal wall defects. These atypical defects are seen following en bloc resection of abdominal wall tumors or organ transplantation and pose a significant reconstructive challenge in a highly morbid population. Established repair methods(e.g. components separation) are often impossible with defects transecting rectus abdominis muscles, large eccentric fascial defects and multiplanar incisions that limit reconstructive options. We reviewed our experience in reconstructing complex, non-midline abdominal wall defects using biologic and resorbable mesh.
METHODS: A retrospective review between 2012-2018 identified 21 patients(22 cases) requiring non-midline abdominal wall reconstruction(AWR). All cases were performed at a single university hospital and included patients with transverse, flank, subcostal, "H", "T" or Chevron pattern incisions or patients with oncologic abdominal wall resection. Methods of repair included mobilization of available myocutaneous or fascial flaps with primary fascial closure when possible, followed by placement of bridging biologic and/or onlay mesh reinforcement. Patients were followed up to 49 months.
RESULTS: Twenty-one patients(22 cases; 43% male, 57% female; mean age 50.1 yo, range 27-70; mean BMI 26.6 kg/m2, range 17-39) underwent non-midline AWR. Nine(43%) patients were smokers and 13(62%) were on immunosuppressive medication following transplant. Mean defect size was 379 cm2(range 60-1000). Indications included non-midline hernia(11, 52%), open abdomen(3, 14%), infected mesh(3, 14%), and abdominal wall tumor resection(7, 33%). Defect locations were subcostal(9, 43%), lateral(6, 28%), inferior/pubic(3, 14%), flank(3,14%), or multiple defects(12,57%). Repair required bridging with biologic mesh (Surgimend, 6; Xenmatrix, 6) in 10(48%), underlay(4,19%), overlay(8, 38%), or combination(8, 38%). Primary fascial closure was achieved in 11(52%) cases. Two patients had hernia recurrence, both were asymptomatic and appreciably smaller than the initial defect. Other complications included superficial wound infections treated with oral antibiotics(3) and mesh exposure(2). No patient developed seroma or had open wounds at the study conclusion. Six patients were deceased at time of chart review.
CONCLUSIONS: We find that in this highly complex and morbid population , primary fascial closure is often not possible through standard techniques, and bridging mesh can be utilized with satisfactory results. Despite excellent short-term outcomes, long-term durability of repair is unknown. Patients should be counseled that normal restoration of abdominal wall dynamic is unlikely. Potential avoidance of unfavorable incisions and minimization of initial hernia defects may be possible with earlier plastic surgery involvement during index operations or subsequent attempts at repair by the general surgeon.
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