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Evolution of Ventral Hernia Repair with Component Separation - Development of a Unified Algorithm With Improved Outcomes
Peter F. Koltz, MD, Jordan D. Frey, BS, Derek E. Bell, MD, John A. Girotto, MD, Jose G. Christiano-Neto, MD, Howard N. Langstein, MD.
University of Rochester Medical Center, Rochester, NY, USA.
Purpose:Ventral hernia repair (VHR) continues to evolve and now frequently includes some form of component separation (CS), yet there is little consensus regarding technique. Debate remains regarding the utility of reinforcing the repair and mesh location, biologic or synthetic mesh, and optimal management of overlying soft tissue. To determine the optimal technique for VHR, we evaluated our outcomes before and after we refined and simplified our algorithm for VHR with CS, a strategy that emphasizes careful patient selection and a stepwise approach to abdominal reconstruction.
Methods:One hundred five (105) consecutive patients undergoing VHR and bilateral CS as part of comprehensive abdominal wall reconstruction over a 9 year period were examined. Patients were divided into two groups - those operated on after August 2009 (Group 1) at which point our simplified and consistent algorithm was adopted, and before (Group 2) with no formal approach to repair. Our algorithm includes careful patient selection, bilateral CS preserving perforators only when large (>2mm), attempted closure of the posterior fascia, reinforcing mesh placed in the retrorectus space (synthetic if clean case, bioprosthetic [porcine acellular dermal matrix - pADM] if contaminated, dirty, or high risk) or intraperitoneal (IPOM) when not possible, closure of linea alba when feasible, aggressive drainage with quilting of soft tissues, and vertical panniculectomy(VP) of excess central tissue. Comprehensive pre-, intra-, and post-operative variables were analyzed. Primary outcomes included wound infection, dehiscence, and hernia recurrence. Chi-square and student’s t-tests were utilized with p-values less than 0.05 deemed significant.
Results:Seventy-eight (74.3%) patients underwent repair utilizing our algorithm for treatment (Group 1) while 27 (25.7%) underwent repair prior to utilization of this algorithm (Group 2). The average age of patients in Group 1 and Group 2 are 56.55 and 55.59 years (p=0.7453), respectively. The average defect size in Group 1 is 235.71 cm2 while the average size in Group 2 is 207.07 cm2 (p=0.5626). Hernia recurrence in Group 1 was 2.6% while that in Group 2 was 29.6% (p<0.001). Of those experiencing hernia recurrence, one and three patients (p<0.001) underwent surgical intervention in Group 1 and Group 2, respectively. The incidence of wound infection in Group 1 was 10.3% while that in Group 2 was 33.3% (p<0.001). The rate of wound dehiscence in Group 1 was 17.9% versus 25.9% in Group 2 (p<0.001). 97.4% in Group 1 and 92.6% in Group 2 achieved primary midline closure of the abdominal fascial defect (p<0.001). Of all CS repairs within the past 4 years at our institution, 54.7% utilized pADM. Of all non-bridged VHR/CS repairs within the past 2 years at our institution, 47% utilized retrorectus mesh placement, the remainder utilizing IPOM .
Conclusion:Simplifying and unifying our algorithm for VHR with CS has yielded improved results. Our algorithm highlights the importance of careful patient selection, routine use of component separation to allow complete restoration of the linea alba, retro-rectus placement of synthetic or biologic mesh based on infectious risk, and proper soft tissue management. Recurrence and wound healing complications utilizing this approach are favorable compared with published outcomes.
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