Single-Staged Repairs of Contaminated Abdominal Wall Defects
Single-Staged Repairs of Contaminated Abdominal Wall Defects
Objective: Our objective was to evaluate the safety and durability of biologic mesh for single-staged reconstruction of contaminated fields.
Introduction: The presence of contamination during ventral hernia repair (VHR) poses a significant challenge. Some advocate for a multistaged reconstructive approach with delayed definitive repair, whereas others perform definitive repair at the initial operation.
Methods: Patients undergoing single-staged VHR in a contaminated field with biologic mesh over a 5-year period were retrospectively reviewed from a prospectively maintained database. Outcome measures included wound complication and hernia recurrence.
Results: A total of 128 patients (76 F, 52 M) were identified, with a mean age of 58.2 years, mean American Society of Anesthesiologist (ASA) score 3.1, and mean body mass index (BMI) 34.1 ± 9.7 kg/m. Comorbidities included COPD (n = 29), diabetes (n = 65), smoking (n = 29), and immunosuppression (n = 8). Mean hernia defect size was 431 cm (range 40–2450 cm). Reasons for contamination included the presence of infected mesh (n = 45), stoma (n = 24), concomitant gastrointestinal (GI) surgery (n = 17), enterocutaneous fistula (n = 25), open nonhealing wound(s) (n = 6), enterotomy/colotomy (n = 5), and chronic draining sinus (n = 6). Postoperative wound complications were identified in 61 (47.7%) patients. Predictors of wound complications included ASA score, diabetes, smoking, number of previous abdominal surgeries or hernia repairs, hernia defect size, and operative time. With a mean follow-up time of 21.7 months, hernia recurrence was identified in 40 (31.3%) patients. The majority of recurrent hernias were asymptomatic and 7 patients underwent repair.
Conclusions: Despite the high rate of wound morbidity associated with single-staged reconstruction of contaminated fields, it can safely be performed with biologic mesh reinforcement. Although biologic mesh in these situations is safe, the long-term durability seems to be less favorable.
The presence of contamination during ventral hernia repair (VHR) poses a significant challenge for hernia surgeons. Various degrees of contamination, ranging from inadvertent enterotomies to overwhelming mesh infection, influence the surgical decision -making process during abdominal wall reconstruction. It is well established that synthetic mesh utilization during repair of clean ventral hernias has led to a 50% reduction in hernia recurrence. Mesh selection in the presence of contamination is highly controversial, but an important question to address given the impact of mesh on repair durability.
The challenge of managing contaminated ventral hernias is that synthetic mesh materials are perceived as contraindicated. As a result, some advocate for a multistaged reconstructive approach with delayed definitive repair. This method requires an initial operation to remove and clear the infectious source. Patients then return for definitive repair of their hernia 6–12 months later. This prolonged convalescence and the complexity of the large abdominal wall defect created has prompted surgeons to investigate options for a single-staged approach to repairing contaminated abdominal wall hernias. The development of biologic grafts has been instrumental in providing the potential for a single-staged approach. These grafts reportedly promote cellular infiltration, neovascularization, and potentially regenerate into native tissue that might provide significant advantages over synthetic materials in the setting of contamination. With the introduction of these materials into the surgical armamentarium, several small series with relatively short-term follow-up have suggested these materials are safe to use. However, the ultimate measure of success of these materials is to provide a durable single-staged repair with a low hernia recurrence rate and avoid long-term infectious complications for these patients. The aim of this study was to provide the first long-term data evaluating the durability of biologic grafts when utilized during the single-staged repair of contaminated and infected abdominal wall hernia repairs.
Abstract and Introduction
Abstract
Objective: Our objective was to evaluate the safety and durability of biologic mesh for single-staged reconstruction of contaminated fields.
Introduction: The presence of contamination during ventral hernia repair (VHR) poses a significant challenge. Some advocate for a multistaged reconstructive approach with delayed definitive repair, whereas others perform definitive repair at the initial operation.
Methods: Patients undergoing single-staged VHR in a contaminated field with biologic mesh over a 5-year period were retrospectively reviewed from a prospectively maintained database. Outcome measures included wound complication and hernia recurrence.
Results: A total of 128 patients (76 F, 52 M) were identified, with a mean age of 58.2 years, mean American Society of Anesthesiologist (ASA) score 3.1, and mean body mass index (BMI) 34.1 ± 9.7 kg/m. Comorbidities included COPD (n = 29), diabetes (n = 65), smoking (n = 29), and immunosuppression (n = 8). Mean hernia defect size was 431 cm (range 40–2450 cm). Reasons for contamination included the presence of infected mesh (n = 45), stoma (n = 24), concomitant gastrointestinal (GI) surgery (n = 17), enterocutaneous fistula (n = 25), open nonhealing wound(s) (n = 6), enterotomy/colotomy (n = 5), and chronic draining sinus (n = 6). Postoperative wound complications were identified in 61 (47.7%) patients. Predictors of wound complications included ASA score, diabetes, smoking, number of previous abdominal surgeries or hernia repairs, hernia defect size, and operative time. With a mean follow-up time of 21.7 months, hernia recurrence was identified in 40 (31.3%) patients. The majority of recurrent hernias were asymptomatic and 7 patients underwent repair.
Conclusions: Despite the high rate of wound morbidity associated with single-staged reconstruction of contaminated fields, it can safely be performed with biologic mesh reinforcement. Although biologic mesh in these situations is safe, the long-term durability seems to be less favorable.
Introduction
The presence of contamination during ventral hernia repair (VHR) poses a significant challenge for hernia surgeons. Various degrees of contamination, ranging from inadvertent enterotomies to overwhelming mesh infection, influence the surgical decision -making process during abdominal wall reconstruction. It is well established that synthetic mesh utilization during repair of clean ventral hernias has led to a 50% reduction in hernia recurrence. Mesh selection in the presence of contamination is highly controversial, but an important question to address given the impact of mesh on repair durability.
The challenge of managing contaminated ventral hernias is that synthetic mesh materials are perceived as contraindicated. As a result, some advocate for a multistaged reconstructive approach with delayed definitive repair. This method requires an initial operation to remove and clear the infectious source. Patients then return for definitive repair of their hernia 6–12 months later. This prolonged convalescence and the complexity of the large abdominal wall defect created has prompted surgeons to investigate options for a single-staged approach to repairing contaminated abdominal wall hernias. The development of biologic grafts has been instrumental in providing the potential for a single-staged approach. These grafts reportedly promote cellular infiltration, neovascularization, and potentially regenerate into native tissue that might provide significant advantages over synthetic materials in the setting of contamination. With the introduction of these materials into the surgical armamentarium, several small series with relatively short-term follow-up have suggested these materials are safe to use. However, the ultimate measure of success of these materials is to provide a durable single-staged repair with a low hernia recurrence rate and avoid long-term infectious complications for these patients. The aim of this study was to provide the first long-term data evaluating the durability of biologic grafts when utilized during the single-staged repair of contaminated and infected abdominal wall hernia repairs.
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