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: 8.33).
02/2013; 257(6). DOI: 10.1097/SLA.0b013e3182849871
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.
Available from: Eddy C Hsueh
- "Biologic tissue matrices are commonly used in contaminated or infected surgical fields for one-stage repair with little to no subsequent graft removal, but hernia recurrence over a 5-year period may be greater than 50% . Therefore, the durability of biologic grafts for single-stage repair in contaminated settings needs further evaluation . Further prospective, randomized trials need to be conducted before practice guidelines are established. "
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Biologic grafts have been shown to support tissue regeneration in various animal models. Very few reports in the literature exist to show tissue remodeling in patients after placement of a biologic graft.
We report the case of a 69-year-old Caucasian man with a history of small bowel carcinoid resection and concurrent recurrent ventral hernia repair with component separation and underlay biologic graft placement who underwent re-operation for metastatic carcinoid tumor to his liver. Complete incorporation of the biologic graft was observed. Tissue analysis of the incised midline fascia revealed tissue remodeling at the site of the previous abdominal wall defect.
Placement of a biologic graft in ventral hernia repair supports tissue regeneration similar to that previously reported in animal models.
Available from: Ian R Daniels
- "Numerous other single-institution series have followed the RICH study, most notably that of Rosen et al, who published their 5-year experience of abdominal wall reconstruction with biologic mesh.33 Of the 128 patients in their series, 102 were repaired with Strattice. "
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ABSTRACT: Soft-tissue reconstruction for a variety of surgical conditions, such as abdominal wall hernia or pelvic organ prolapse, remains a challenge. There are numerous meshes available that may be simply categorized as either synthetic or biologic. Within biologic meshes, porcine dermal meshes have come to dominate the market. This review examines the current evidence for their use and the limitations of knowledge. Although there is increasing evidence to support their safety, long-term follow-up studies that support their efficacy are lacking. Numerous clinical trials that remain ongoing may help elucidate their precise role in soft-tissue reconstruction.
Available from: Boris Yoffe
- "On the other hand, recent in vitro and in vivo study , comparing three collagen bioprostheses (Collamend, Surgisis, and Permacol) to a control polytetrafluoroethylene mesh in a contaminated field, reported that the collagen bioprostheses failed to show any bacterial adhesion or bacterial clearance benefits. In addition, Rosen et al.  reported five years of experience with the repair of infected and contaminated abdominal wall defects utilizing biologic mesh. No long-term infectious complications related to the biologic mesh were reported. "
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ABSTRACT: The presence of a contaminated surgical field in abdominal wall defects caused by trauma presents a challenge for surgeons. Both primary suture and synthetic meshes are strongly discouraged as surgical treatments in such cases. We describe the use of a porcine dermal collagen (Permacol) implant in an eight-year-old patient with multiple injuries. Three months after discharge, the child remains well with good cosmetic results. He is free of pain and has returned to full activity levels with complete wound closure and without any evidence of residual hernia. In conclusion, our experience indicates that the use of Permacol can be considered an efficient technique for reconstructing an infected abdominal wall defect of a pediatric multitrauma patient.
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