Outcomes of the fascial component separation technique with synthetic mesh reinforcement for repair of complex ventral incisional hernias in the morbidly obese

doi:10.1016/j.amjsurg.2008.01.010

The American Journal of Surgery

Volume 195, Issue 5, May 2008, Pages 575-579

https://doi.org/10.1016/j.amjsurg.2008.01.010 Get rights and content

Abstract

Introduction

Complex ventral incisional hernias (VIH) in the morbidly obese remain a difficult management problem for the general surgeon. Multiple methods of repair with variable rates of success are described. The outcomes and techniques of a fascial component separation technique with synthetic mesh reinforcement in the morbidly obese are described.

Methods

Records of patients undergoing VIH repair between June 1996 and May 2007 who had a body mass index (BMI) greater than 30 kg/m² were reviewed from a prospectively maintained database. Patient demographics, BMI, hernia characteristics, perioperative and long-term complications, and long-term hernia recurrence rate were documented.

Results

A total of 90 patients (22 men and 68 women) meeting study criteria were identified. The mean age was 55 years (range 30–82 years). Mean BMI was 39.9 (range 30–68). Recurrent hernias were present in 43 patients (48%) Mean number of recurrences was 1.5 (range 1–5). A total of 42 patients (47%) had multiple fascial defects. Major perioperative morbidity was 8% and perioperative mortality was 1.1%. Postoperative wound infections occurred in 9 patients (10%). Hernia recurrence was observed in 5 patients (5.5%) with a mean follow-up of 50 months (range 1–132).

Conclusions

Fascial component separation can be performed with acceptable perioperative morbidity and mortality. Rates of wound sepsis, mesh infection, mesh explantation and gastrointestinal mesh erosion are low. Operative time, hospital length of stay, and long-term VIH recurrence are also acceptably low. Fascial component separation is a viable technique for repair of complex VIH in the morbidly obese population.

Section snippets

Methods

A prospectively maintained database of all patients undergoing ventral incisional hernia (VIH) repair from June 1996 to May 2007 was reviewed after Institutional Review Board approval. Patients undergoing fascial component separation with prosthetic mesh reinforcement and a body mass index (BMI) greater than 30 mg/m² were included in the current study. The data were obtained from a single community surgical practice. Patient demographics and hernia characteristics are listed in Table 1.

All

Results

The 90 patients included in the study have been followed for a mean of 50 months (range 1–132). Mean operative time was 92 minutes (range 41–255) with a mean blood loss of 60 mL. There were no intraoperative complications and no patients required blood transfusion. Five patients had combined intra-abdominal procedures. Mean length of stay was 3.4 days (range 0–38).

The most prevalent complications were wound-related. Superficial skin closure issues affected 8 (9%) patients and deep infections

Comments

Repair of incisional hernias is a common procedure confronting the practicing general surgeon. Etiologic factors are multiple but are substantially influenced by preoperative comorbidities, BMI, perioperative infection, and hernia size.¹³ Obesity is a major contributing factor in the initial development of a hernia and a major predictor for the likelihood of recurrence after an operative repair.14, 15 The widespread application of mesh based repairs has dramatically reduced recurrence rates

References (20)

A. Espinosa-de-los-Monteros et al.
Reconstruction of the abdominal wall for incisional hernia repair
Am J Surg
(2006)
D. McLanahan et al.
Retrorectus prosthetic mesh repair of midline abdominal hernia
Am J Surg
(1997)
M.J. Rosen et al.
Laparoscopic versus open-component separation: a comparative analysis in a porcine model
Am J Surg
(2007)
D. Vargo
Component separation in the management of the difficult abdominal wall
Am J Surg
(2004)
Y.W. Novitsky et al.
Open preperitoneal retrofascial mesh repair for multiply recurrent ventral incisional hernias
J Am Coll Surg
(2006)
Z.T. Awad et al.
Mechanisms of ventral hernia recurrence after mesh repair and a new proposed classification
J Am Coll Surg
(2005)
K.R. Finan et al.
Predictors of wound infection in ventral hernia repair
Am J Surg
(2005)
R.W. Luijendijk et al.
A comparison of suture repair with mesh repair for incisional hernia
N Engl J Med
(2000)
R.E. Stoppa
The treatment of complicated groin and incisional hernias
World J Surg
(1989)
A.M. Duce et al.
The Rives operation for the repair of incisional hernias
Hernia
(1997)

There are more references available in the full text version of this article.

Cited by (60)

Repair of lumbar incisional hernia using polypropylene mesh strip sutures – A case report
2021, International Journal of Surgery Case Reports
Lumbar hernias are considered rare and they constitute less than 1.5% of all abdominal wall hernias.
Here we present a case of a 72-year-old female with a left flank swelling since 2-years diagnosed as a lumbar incisional hernia. This lumbar incisional hernia¹ was repaired successfully using polypropylene mesh strip sutures.²
Many surgical techniques have been described for repair of LIH. Suture repair, mesh repair and myofascial flaps have been described for lumbar hernias. Repairing a lumbar hernia can be surgically challenging because of its proximity to bony structures, which can limit proper dissection and mesh overlap. We performed defect closure with PMSS. Patient has no recurrence after 2 years of follow up.
In our case of left lumbar incisional hernia, defect closure with PMSS was an effective operation. This technique may also be effective in potentially contaminated settings due to reduced implant load. Further studies are required to understand its biomechanics and long-term outcomes.
American Society for Metabolic and Bariatric Surgery and American Hernia Society consensus guideline on bariatric surgery and hernia surgery
2018, Surgery for Obesity and Related Diseases
The American Society for Metabolic and Bariatric Surgery issues the following guidelines for the purpose of enhancing quality of care in hernia treatment through metabolic and bariatric surgery. In this statement, suggestions for management are presented that are derived from available knowledge, peer-reviewed scientific literature, and expert opinion. This was accomplished by performing a review of currently available literature regarding obesity, obesity treatments, and hernia surgery. The intent of issuing such a guideline is to provide objective information regarding the impact of obesity treatment on effective and durable hernia repair. The guideline may be revised in the future should additional evidence become available.
Component separation technique for giant incisional hernia: A systematic review
2018, American Journal of Surgery
Citation Excerpt :
It is easy to see how some of these factors might be of influence on reported outcomes. Several of the included studies showed patient age,21,40 contaminated wound status40 and hernia width to be possible predictors of a Surgical Site Infection40 and obesity22,29,32,35 or previous incisional hernia repair3 as factors influencing recurrences. All these patient-related variables should be taken into account for absolute statistical validity, a rather impossible task taken into account the excessive heterogeneity in reporting between studies.
The component separation technique (CST) has gained popularity among general surgeons in the management of giant abdominal hernia.
A systematic review of the MedLine and EMBASE databases was performed. 36 observational cohort studies were included for data-analysis and divided in 4 main groups: Open Anterior Approach (OAA), Transversus Abdominis Release (TAR), Laparoscopic Anterior Approach (LAA) and Perforator Preserving Approach (PPA). Surgical Site Occurrences (SSO) occurred in 21.4%, 23.7%, 20.3% and 16.0% respectively. Incidence of recurrence was 11.9% (OAA), 5.25% (TAR), 7.02% (LAA) and 6.47% (PPA) with a significant difference in the advantage of TAR over OAA (p < 0.001).
Limitations in this systematic review were a lack of randomized trials, a heterogenous population and non-standardized methods for measuring outcomes, all making it difficult to postulate conclusions about CST and its modifications. Based on pooled results of 36 studies, the prevalence of SSO is comparable between the techniques with an average of one in five and the prevalence of recurrences is highest when using the Open Anterior Approach at 11.9%.
Complex hernias with loss of domain in morbidly obese patients: role of laparoscopic sleeve gastrectomy in a multi-step approach
2017, Surgery for Obesity and Related Diseases
Citation Excerpt :
Definitive hernia repair was achieved with fascial closure and intraperitoneal mesh augmentation. This approach carries a minimal morbidity compared with other techniques such as component separation, which might be difficult to perform in devascularized tissue, even more in the context of morbid obesity [11]. Fascial closure could be achieved without problems after preparatory LSG.
Morbid obesity and its associated co-morbidities are risk factors for the development of abdominal hernias, add complexity to their repair, and increase perioperative risk. Repair of hernias with loss of domain (LoD) is further complicated by risk of abdominal compartment syndrome. A staged concept with an initial weight loss procedure might enable a reposition of the herniated viscera, improve co-morbidities for, and prohibit abdominal compartment syndrome in the subsequent repair.
To evaluate a multistep treatment strategy that entails initial laparoscopic sleeve gastrectomy (LSG) followed by open repair in the treatment of complex hernias with LoD in morbidly obese patients
University hospital
Retrospective analysis of all patients (n = 15) with morbid obesity and hernias with LoD treated in a staged concept between April 2010 and December 2015
Median initial body mass index was 45 kg/m². All hernias were recurrent incisional hernias with≥2 failed repairs. No major complications occurred during or after LSG. After a median of 185 days, the second stage at a median body mass index of 33.6 kg/m² was performed. No bowel resections were needed. The only major perioperative complication was pneumonia in 2 patients (13%). Within 24 months (6–68) after the second step, there were 3 reoperations (small recurrence [7%], infected seroma [7%], and infected mesh [7%]). One patient (7%) was lost to follow-up after 2 years.
A 2-step approach to treat massive hernias with LoD in morbidly obese patients is safe and effective. LSG as initial weight loss procedure addresses LoD successfully without a need for further preoperative measures to condition for hernia repair.
A randomized controlled experimental study comparing chitosan coated polypropylene mesh and Proceed™ mesh for abdominal wall defect closure
2015, Annals of Medicine and Surgery
Citation Excerpt :
Incisional hernias can occur after abdominal surgery and can cause serious complications. The use of prosthetic mesh in incisional hernia repair is the accepted current practice [1–3]. The meshes are placed either extraperitoneally or intraperitoneally.
Abdominal wall defects and hernias are commonly repaired with synthetic or biological materials. Adhesions and recurrences are a common problem. A study was conducted to compare Chitosan coated polypropylene mesh and a polypropylene–polydioxanone composite with oxidized cellulose coating mesh (Proceed™) in repair of abdominal wall defect in a Rabbit hernia model.
A randomized controlled experimental study was done on twelve New Zealand white rabbits. A ventral abdominal defect was created in each of the rabbits. The rabbits were divided into two groups. In one group the defect was repaired with Chitosan coated polypropylene mesh and Proceed mesh™ in the other. The rabbits were operated in two phases. They were followed up at four weeks and twelve weeks respectively after which the rabbits were sacrificed. They were evaluated by open exploration and histopathological examination. Their efficacy in reducing adhesion and ability of remodeling and tissue integration were studied.
There was no statistical significance in the area of adhesion, the force required to remove the adhesions, tissue integration and remodeling between Chitosan and Proceed™ group. Histological analysis revealed that the inflammatory response, fibrosis, material degradation and remodeling were similar in both the groups. There were no hernias, wound infection or dehiscence in any of the studied animals.
Chitosan coated polypropylene mesh was found to have similar efficacy to Proceed™ mesh. Chitosan coated polypropylene mesh, can act as an anti adhesive barrier when used in the repair of incisional hernias and abdominal wall defects.
The partial underlay preperitoneal with panniculectomy repair for incisional abdominal hernia in the morbidly obese
2014, Surgery for Obesity and Related Diseases
Because of high frequency, high morbidity, and difficulty of repair, incisional hernias in obese patients represent a particularly vexing and common problem for surgeons. The objective of this study was to describe a highly selective technique for incisional hernia repair with panniculectomy in the morbidly obese. We also describe perioperative characteristics and preliminary outcomes for a limited series of patients who underwent this procedure.
We performed a preperitoneal partial mesh underlay with a panniculectomy (PUPP) on 10 patients with incisional hernias and a body mass index (BMI)>40 kg/m². The hernia repair was performed by a general surgery team, and the panniculectomy was performed by a plastic surgery team. We retrospectively analyzed perioperative variables for each patient. Phone interviews were conducted to obtain follow-up.
Mean patient age was 53 years (range 32–75 yr) with mean BMI of 46 kg/m² (range 41–60 kg/m²). Patients had a history of 3.4 average prior abdominal operations, and a median of 3 prior hernia repairs. The average operative time was 371 minutes with a mean estimated blood loss of 162 ccs. Three patients experienced a minor wound complication. There were no major wound complications, and the 30-day mortality rate was zero. At a median and average follow-up time of 805 and 345 days, respectively, one patient developed a hernia recurrence. Patients were satisfied with their appearance and the hernia repair, with mean satisfaction scores of 4.3 and 4.9 out of 5 (very satisfied), respectively.
The PUPP hernia repair is a viable option for incisional herniorrhaphy and concurrent panniculectomy in the morbidly obese.

View all citing articles on Scopus

View full text

North Pacific Surgical AssociationOutcomes of the fascial component separation technique with synthetic mesh reinforcement for repair of complex ventral incisional hernias in the morbidly obese

Abstract

Introduction

Methods

Results

Conclusions

Section snippets

Methods

Results

Comments

Am J Surg

Am J Surg

Am J Surg

Am J Surg

J Am Coll Surg

J Am Coll Surg

Am J Surg

A comparison of suture repair with mesh repair for incisional hernia

N Engl J Med

The treatment of complicated groin and incisional hernias

World J Surg

The Rives operation for the repair of incisional hernias

Hernia

North Pacific Surgical Association
Outcomes of the fascial component separation technique with synthetic mesh reinforcement for repair of complex ventral incisional hernias in the morbidly obese