A 5-Year Clinical Experience With Single-Staged Repairs of Infected and Contaminated Abdominal Wall Defects Utilizing Biologic Mesh

From the Case Comprehensive Hernia Center, University Hospitals Case Medical Center, Cleveland, OH.
Annals of surgery (Impact Factor: 7.19). 02/2013; 257(6). DOI: 10.1097/SLA.0b013e3182849871
Source: PubMed

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. CONCLUSION:: 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.

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    ABSTRACT: Background Ventral hernia repair (VHR), an increasingly common procedure, may have a larger impact on healthcare costs than is currently appreciated. Readmissions have the potential to further increase these costs and negatively impact patient outcomes. New national registry data allows for an in-depth look at the predictors and rates of readmission after VHR. Methods The American College of Surgeon’s National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for all patients who underwent only an incisional or ventral hernia repair in 2011. Patients who had any concomitant procedure were excluded from the study. Using readmission as the dependent variable, a multivariate logistic regression model was created to identify independent predictors of readmission. Results Ventral hernia repair had a 4.9% thirty-day readmission rate in 2011. Deep/incisional (12.6%) and superficial site infections (10.5%) were the most common wound complications seen in readmitted patients (both p<0.001), while sepsis/septic shock (10.14%, p<0.001) was the most common systemic complication. Higher-class body mass index is not associated with readmission (p=0.320). Smoking and chronic obstructive pulmonary disease function as predictors of readmission independently from their association with complications (OR 1.3, 95% CI 1.1-1.6; OR 1.6, 95% CI 1.1-2.3, respectively). Operative factors such as the use of mesh (OR 1.3, 95% CI 0.995-1.7) or laparoscopy (OR 1.2, 95% CI 0.96-1.6) do not increase likelihood of readmission. Conclusions There is room for improvement in VHR readmission rates. Though complications are the main driver of readmission, surgeons must be aware of the comorbidities that independently increase odds of readmission even when a complication does not occur.
    Surgery 01/2013; 155(4). DOI:10.1016/j.surg.2013.12.021 · 3.11 Impact Factor
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    Annals of surgery 04/2013; 257(6). DOI:10.1097/SLA.0b013e3182942797 · 7.19 Impact Factor
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    ABSTRACT: Background. Components separation has been proposed as a means to close large ventral hernia without undue tension. We report a modification on open components separation that allows for the incorporation of onlaid noncrosslinked porcine acellular dermal matrix (Strattice, LifeCell Corp, Branchburg, NJ) as a load-sharing structure. Methods. This was a retrospective case series including all cases using Strattice from July 2008 through December 2009. Data evaluated included patient demographics, comorbidities associated with risk of recurrence, hernia grade, and postoperative complications. The primary outcomes were hernia recurrence and surgical site occurrences. Results. There were 58 patients; 60.8% presented with a recurrent incisional hernia. Average length of follow-up was 384 days. There were 4 hernia recurrences (7.9%). Complications included surgical site infection (20.7%), seroma (15.5%), and hematoma (5%) requiring intervention. Four deaths occurred in the series due to causes unrelated to the hernia repair, only 1 within 30 days of operation. Conclusions. This series demonstrates that components separation reinforced with noncrosslinked porcine acellular dermal matrix onlay is an efficacious, single-stage repair with a low rate of recurrence and surgical site occurrences.
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