Porcine dermal collagen (Permacol) for abdominal wall reconstruction

OBJECTIVE: A review of Eisenhower Army Medical Center's experience using Permacol (Tissue Science Laboratories, Covington, Georgia) for the repair of abdominal wall defects. METHODS: Retrospective review of medical records of patients undergoing abdominal wall reconstruction with Permacol. RESULTS: From July 30, 2003 to February 12, 2005, 9 patients underwent repair of complicated fascial defects with Permacol. Indications for surgery included reoperative incisional hernia repair after removal of a infected mesh (3 patients), reconstruction of a fascial defect after resection of an abdominal wall tumor (2 patients), incisional hernia repair in a patient with a previous abdominal wall infection after a primary incisional hernia repair (1 patient), incisional hernia repair in a patient with an ostomy and an open midline wound (1 patient), emergent repair of incisional hernia with strangulated bowel and multiple intra-abdominal abscesses (1 patient), and excision of infected mesh and drainage of intra-abdominal abscess with synchronous repair of the abdominal wall defect (1 patient). At a median follow-up of 18.2 months, 1 recurrent hernia existed after intentional removal of the Permacol. This patient developed an abdominal wall abscess 7 months after hernia repair secondary to erosion from a suture. Overall, 1 patient developed exposure of the Permacol after a skin dehiscence. The wound was treated with local wound care, and the Permacol was salvaged. Despite the presence of contamination (wound classification II, III, or IV) in 5 of 9 patients (56%), no infectious complications occurred. CONCLUSION: Complex reconstruction of the abdominal wall can be associated with a high complication rate. Placement of a permanent prosthetic mesh in a contaminated field is associated with a high rate of wound infections and subsequent mesh removal. Permacol becomes incorporated by tissue ingrowth and neovascularization. Permacol is a safe and acceptable alternative to prosthetic mesh in the repair of complicated abdominal wall defects.     

Closure of abdominal wounds with polydioxanone. A prospective study

Polydioxanone, an absorbable synthetic monofilament suture, was used to close abdominal wounds in 200 consecutive operative procedures. All patients were followed up for one year. Despite a high incidence of risk factors for impaired wound healing, the incidence of dehiscence and evisceration was zero; incisional hernia occurred in 2.9% of vertical midline wounds and in 3.6% of transverse incisions. This new suture material is safe and effective for closure of abdominal wounds.     

Meta-analysis of techniques for closure of midline abdominal incisions

BACKGROUND: Various randomized studies have evaluated techniques of abdominal fascia closure but controversy remains, leaving surgeons uncertain about the optimal method of preventing incisional hernia. METHOD: Medline and Embase databases were searched. All trials with a follow-up of at least 1 year that randomized patients with midline laparotomies to closure of the fascia by different suture techniques and/or suture materials were subjected to meta-analysis. Primary outcome was incisional hernia; secondary outcomes were wound dehiscence, wound infection, wound pain and suture sinus formation. RESULTS: Fifteen studies were identified with a total of 6566 patients. Closure by continuous rapidly absorbable suture was followed by significantly more incisional hernias than closure by continuous slowly absorbable suture (P < 0.009) or non-absorbable suture (P = 0.001). No difference in incisional hernia incidence was found between slowly absorbable and non-absorbable sutures (P = 0.75), but more wound pain (P < 0.005) and more suture sinuses (P = 0.02) occurred after the use of non-absorbable suture. Similar outcomes were observed with continuous and interrupted sutures, but continuous sutures took less time to insert. CONCLUSION: To reduce the incidence of incisional hernia without increasing wound pain or suture sinus frequency, slowly absorbable continuous sutures appear to be the optimal method of fascial closure.     

Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia

OBJECTIVE: The objective of this study was to determine the best treatment of incisional hernia, taking into account recurrence, complications, discomfort, cosmetic result, and patient satisfaction. BACKGROUND: Long-term results of incisional hernia repair are lacking. Retrospective studies and the midterm results of this study indicate that mesh repair is superior to suture repair. However, many surgeons are still performing suture repair. METHODS: Between 1992 and 1998, a multicenter trial was performed, in which 181 eligible patients with a primary or first-time recurrent midline incisional hernia were randomly assigned to suture or mesh repair. In 2003, follow-up was updated. RESULTS: Median follow-up was 75 months for suture repair and 81 months for mesh repair patients. The 10-year cumulative rate of recurrence was 63% for suture repair and 32% for mesh repair (P < 0.001). Abdominal aneurysm (P = 0.01) and wound infection (P = 0.02) were identified as independent risk factors for recurrence. In patients with small incisional hernias, the recurrence rates were 67% after suture repair and 17% after mesh repair (P = 0.003). One hundred twenty-six patients completed long-term follow-up (median follow-up 98 months). In the mesh repair group, 17% suffered a complication, compared with 8% in the suture repair group (P = 0.17). Abdominal pain was more frequent in suture repair patients (P = 0.01), but there was no difference in scar pain, cosmetic result, and patient satisfaction. CONCLUSIONS: Mesh repair results in a lower recurrence rate and less abdominal pain and does not result in more complications than suture repair. Suture repair of incisional hernia should be abandoned.     

Closure of burst abdomen after major gastrointestinal operations--comparison of different surgical techniques and later development of incisional hernia.

OBJECTIVE: To find out the incidence of incisional hernia in patients who had resuture of a burst abdomen and to compare different methods of wound closure and the development of incisional hernia. DESIGN: Retrospective study. SETTING: University hospital, Norway. SUBJECTS: 78 adults patients who had their burst abdomens resutured between January 1986 and December 1995. INTERVENTIONS: Five different methods were used to close the burst abdomen: interrupted or continuous sutures with or without retention sutures, or retention sutures alone. MAIN OUTCOME MEASURE: Incisional hernia after at least one year follow-up. RESULTS: Postoperative mortality was 14% (11/78), and 53 patients were followed up for at least a year. Incisional hernias developed in 43% (23/53) of the patients. When interrupted sutures were used (with or without retention sutures) 34% (13/38) of patients developed incisional hernias compared with 6/10 when the wound was closed with a continuous suture. Retention sutures did not reduce the incidence of incisional hernia. CONCLUSIONS: Incisional hernia is a common complication after resuture of a burst abdomen. We found no significant differences in the incidence of incisional hernias when continuous and interrupted techniques were compared. Retention sutures do not reduce the incidence of incisional hernias. There is still a need for refinements of the technique of closure of a burst abdomen.     

Wound dehiscence: outcome comparison for sutured and mesh reconstructed patients

Purpose

Treatment guidelines for abdominal wound dehiscence (WD) are lacking. The primary aim of the study was to compare suture to mesh repair in WD patients concerning incisional hernia incidence. Secondary aims were to compare recurrent WD, morbidity, mortality and long-term abdominal wall complaints.

Methods

A retrospective chart review of 46 consecutive patients operated for WD between January 2010 and August 2012 was conducted. Physical examination and a questionnaire enquiry were performed in January 2013.

Results

Six patients were treated by vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) before definitive closure. Three patients died early resulting in 23 patients closed by suture and 20 by mesh repair. Five sutured, but no mesh repair patients had recurrent WD (p = 0.051) with a mortality of 60 %. Finally, 18 sutured and 21 mesh repair patients were eligible for follow-up. The incidence of incisional hernia was higher for the sutured patients (53 vs. 5 %, p = 0.002), while mesh repair patients had a higher short-term morbidity rate (76 vs. 28 %, p = 0.004). Abdominal wall complaints were rare in both groups.

Conclusions

Suture of WD was afflicted with a high incidence of recurrent WD and incisional hernia formation. Mesh repair overcomes these problems at the cost of more wound complications. VAWCM seems to be an alternative for treating contaminated patients until definitive closure is possible. Long-term abdominal wall complaints are uncommon after WD treatment.     

Incisional Hernia in Recipients of Adult to Adult Living Donor Liver Transplantation

Background

After receiving a living donor liver transplant (LDLT), an incisional hernia is a potentially serious complication that can affect the patient’s quality of life. In the present study we evaluated surgical hernia repair after LDLT.

Materials and methods

Medical records of patients who underwent surgery to repair an incisional hernia after LDLT in Turgut Ozal Medical Center between October 2006 and January 2010 were evaluated in this retrospective study. A reverse-T incision was made for liver transplantation. The hernias were repaired with onlay polypropylene mesh. Age, gender, post-transplant relaparatomy, the type, the result of surgery for the incisional hernia, and risk factors for developing incisional hernia were evaluated.

Results

An incisional hernia developed in 44 of 173 (25.4 %) patients after LDLT. Incisional hernia repair was performed in 14 of 173 patients (8.1 %) who underwent LDLT from October 2006 to January 2010. Relaparatomy was associated with incisional hernia (p = 0.0002). The mean age at the time of the incisional hernia repair was 51 years, and 79 % of the patients were men. The median follow-up period was 19.2 (13–36) months after the hernia repair. Three patients with intestinal incarceration underwent emergency surgery to repair the hernia. Partial small bowel resection was required in one patient. Postoperative complications included seroma formation in one patient and wound infection in another. There was no recurrence of hernia during the follow-up period.

Conclusions

The incidence of incisional hernia after LDLT was 25.4 % in this study. Relaparatomy increases the probability of developing incisional hernia in recipients of LDLT. According to the results of the study, repair of an incisional hernia with onlay mesh is a suitable option.     

The search for an ideal method of abdominal fascial closure: a meta-analysis

BACKGROUND AND OBJECTIVE: The ideal suture for abdominal fascial closure has yet to be determined. Surgical practice continues to rely largely on tradition rather than high-quality level I evidence. The authors conducted a systematic review and meta-analysis of randomized controlled trials to determine which suture material and technique reduces the odds of incisional hernia. METHODS: MEDLINE and Cochrane Library databases were searched for articles in English published from 1966 to 1998 using the keywords "suture", "abdomen/surgery", and "randomized controlled trials". Randomized controlled trials, trials of adult patients, and trials with a Jadad Quality Score of more than 3, comparing suture materials, technique, or both, were included. Two independent reviewers critically appraised study quality and extracted data. The reviewers were masked to the study site, authors, journal, and date to minimize bias. The primary outcome was postoperative incisional hernia. Secondary outcomes included wound dehiscence, infection, wound pain, and suture sinus formation. RESULTS: The occurrence of incisional hernia was significantly lower when nonabsorbable sutures were used. Suture technique favored nonabsorbable continuous closure. Suture sinuses and wound pain were significantly lower when absorbable sutures were used. There were no differences in the incidence of wound dehiscence or wound infection with respect to suture material or method of closure. Subgroup analyses of individual sutures showed no significant difference in incisional hernia rates between polydioxanone and polypropylene. Polyglactin showed an increased wound failure rate. CONCLUSIONS: Abdominal fascial closure with a continuous nonabsorbable suture had a significantly lower rate of incisional hernia. The ideal suture is nonabsorbable, and the ideal technique is continuous.     

Incisional hernias in midline incisions: An eight-year follow up

Summary The aim of this study was to report the incidence of incisional hernias following midline laparotomy incisions after 12 months and after 8 years. 374 patients who underwent midline laparotomy between August 1989 and December 1990 were included. The wounds were closed with a continuous suture and the technique was monitored by the suture length to wound length ratio. The incidence of incisional hernia, defined as a palpable defect in the fascia or a protrusion beyond this level, was monitored at 12 months and after 8 years. Early wound dehiscence occurred in 3 patients (1%) and wound infection in 32 (9%). At the 12-month examination 58 (20%) incisional hernias were detected in 292 patients. After 8 years 142 patients were examined and 5 (3%) hernias were found. All hernias that caused inconvenience or required surgical repair were detected at 12 months follow-up. Most hernias appearing later have probably been overlooked at the first examination.     

疝补片在剖宫产术后腹壁切口子宫内膜异位症术中的应用

目的探讨疝补片在剖宫产术后腹壁切口子宫内膜异位症治疗中的应用。方法回顾性分析2008年1月至2012年10月,山西医科大学第二医院收治的22例应用疝补片的腹壁切口子宫内膜异位症患者的治疗效果,并观察术后并发症及复发情况。结果本组所有患者手术顺利,手术时间30～60min,术中出血少,术后均恢复良好,术后手术切口无红肿,切口均甲级愈合。平均住院时间（6．2±1．6）d。术后随访3年,均无病灶复发、感染及切口疝发生。结论病灶较大的腹壁切口子宫内膜异位症应做到根治性切除;病灶切除后,可应用疝补片彻底修复较大的腹壁缺损,防止术后切口疝的复发。     

Addition of Rectus Sheath Relaxation Incisions to Emergency Midline Laparotomy for Peritonitis to prevent Fascial Dehiscence

The incidence of fascial dehiscence and incisional hernia after two methods for abdominal wound closure (rectus sheath relaxation incisions and conventional mass closure) was studied in a randomized prospective clinical trial in a consecutive series of 100 patients undergoing midline laparotomy for peritonitis. The two groups were well matched for etiologies of peritonitis, the surgical procedures performed, and the presence of known risk factors for fascial dehiscence. Fifty patients each were randomized either to the conventional continuous mass closure procedure or the rectus sheath relaxation incision technique (designed to increase wound elasticity and decrease tension in the suture line) using identical polypropylene sutures. The incidence of postoperative complications such as duration of ileus, chest infection, and wound infection were not statistically different between the two groups. The intensity of postoperative pain in the rectus sheath relaxation incision group was significantly less. The incidence of wound hematoma was significantly increased in the rectus sheath relaxation incision group. The incidences of fascial dehiscence (16% vs,28%; p < 0.05) and incisional hernia (18% vs, 30%; p < 0.05) were significantly lower after rectus sheath relaxation incisions compared to conventional mass closure. Closure of the midline laparotomy wound in cases of peritonitis using the rectus sheath relaxation technique is safe and less painful, provides increased wound elasticity and decreased tension on the suture line, and significantly decreases the incidence of wound dehiscence.     

腹壁切口疝补片修补术后复发的再手术治疗

目的总结腹壁切口疝补片修补术后复发再次手术治疗的经验。方法回顾性分析我院2007年1月至2010年12月期间收治的16例腹壁切口疝补片修补术后复发再次手术患者的资料。结果所有患者均再次采用补片进行修补,其中13例除去旧补片置入新补片修补,2例新补片与原补片重叠并扩大范围修补,1例在原补片上直接重叠新补片修补。术后所有患者切口均Ⅰ期愈合,3例发生补片上方积液,经穿刺加压后治愈。术后住院时间7～16 d,平均9 d。术后引流管拔除时间2～7 d,平均4 d。所有患者均获随访,随访时间5～36个月,平均20个月,1例有轻微腹壁异物感,无修补区慢性疼痛,无疝复发。结论补片修补术后复发性切口疝再次手术时需综合考虑复发疝的位置以及既往选用的补片类型和修补方法,再次手术需选用合适的补片及修补方法方可取得满意效果。     

Late results of mesh wound closure after elective open aortic aneurysm repair.

INTRODUCTION: Incisional hernia is a common late complication after abdominal aortic aneurysm (AAA) repair. We examined the outcome after prophylactic placement of a pre-peritoneal polypropylene mesh during abdominal closure in consecutive patients having elective AAA repair. REPORT: At least 30 months after surgery, 28 patients underwent clinical and ultrasound examination of their surgical wound for incisional hernias. Only one patient had a hernia in the original surgical scar. No patients had late mesh-related wound problems. DISCUSSION: Pre-peritoneal polypropylene mesh placement is a simple, safe and effective method to decrease the incidence of incisional hernia after AAA repair.     

Controlled clinical trial of three suture materials for abdominal wall closure after bowl operations

One hundred sixty-one consecutive patients who underwent bowel procedures were randomly assigned a nonabsorbable multifilament suture material, a nonabsorbable monofilament suture material or a long-term absorbable suture material for abdominal closure. All patients had midline incisions; closure was by an interrupted single layer technique. Patients were evaluated 1 month, 6 months and 1 year after operation. No statistically significant difference was seen in the incidence of wound infection in these groups. By 1 year, six patients had incisional hernias, none in the long-term absorbable suture group. The absence of suture sinus formation and the failure to demonstrate an increased incidence of wound dehiscence or incisional hernia imply that long-term absorbable suture material may be the most appropriate choice after bowel operations.     

Use of synthetic absorbable sutures for abdominal and chest wound closure. Experience with 650 consecutive cases.

The advent of synthetic collagen suture (polyglycolic acid and polyglacin 910) has provided a new dimension in surgical suturing. However, surgeons in general have not yet taken full advantage of the potential that this new material offers. Associated evisceration and wound dehiscence rates as well as the incidence rate of wound infection were assessed since these represent standards by which the suture material can be evaluated. In an entire series of 650 cases, there has been one case of wound dehiscence with evisceration. The incidence of infection has been less than 1%, which is comparable to previous experience with interrupted, nonabsorbable sutures. The time required for closure using the new material has been approximately one third of that associated with the use of conventional interrupted closure sutures. This implies a substantial cost reduction for the patient. As a result of this experience, the synthetic absorbable sutures seem to represent the material of choice for routine abdominal or chest wound closure.     

Intraperitoneal Mesh Implantation for Fascial Dehiscence and Open Abdomen

Background

Postoperative fascial dehiscence and open abdomen are severe postoperative complications and are associated with surgical site infections, fistula, and hernia formation at long-term follow-up. This study was designed to investigate whether intraperitoneal implantation of a composite prosthetic mesh is feasible and safe.

Methods

A total of 114 patients with postoperative fascial dehiscence and open abdomen who had undergone surgery between 2001 and 2009 were analyzed retrospectively. Contaminated (wound class 3) or dirty wounds (wound class 4) were present in all patients. A polypropylene-based composite mesh was implanted intraperitoneally in 51 patients, and in 63 patients the abdominal wall was closed without mesh implantation. The primary endpoint was incidence of incisional hernia, and the incidence of enterocutaneous fistula was a secondary endpoint.

Results

The incidence of enterocutaneous fistulas after wound closure post-fascial dehiscence (13% vs. 6% without and with mesh, respectively) or post-open abdomen (22% vs. 28% without and with mesh, respectively) was not significantly different. The incidence of incisional hernia was significantly lower with mesh implantation compared with no-mesh implantation in both contaminated (4% vs. 28%; p?=?0.025) and dirty abdominal cavities (5% vs. 34%; p?=?0.01).

Conclusions

Intra-abdominal contamination is not a contraindication for intra-abdominal mesh implantation. The incidence of enterocutaneous fistula is not elevated despite the presence of contamination. The rate of incisional hernias is significantly reduced after intraperitoneal mesh implantation for postoperative fascial dehiscence or open abdomen.     

肌后筋膜前补片植入手术治疗腹壁切口疝28例临床分析

目的：探讨应用肌后筋膜前补片植入手术（retromuscular prefascial,Sublay）修补法对腹壁切口疝的治疗。方法：2002年1月-2009年7月应用聚丙烯补片修补切口疝28例,其中男10例,女18例,年龄47～78岁,平均年龄65.2岁。疝环直径3～28cm,平均15.5cm。均采用肌后筋膜前补片植入手术修补法。结果：全部患者顺利完成手术,无严重并发症,手术时间75～140min,平均100min,术后住院时间9～21d,平均12.8d,随访3～60个月,平均35个月,无肠梗阻,无复发。结论：应用聚丙烯补片肌后筋膜前补片植入手术修补法修补切口疝是一种安全、有效的方法。     

Wound closure with Dexon (polyglycolic acid) mass suture.

A series of 814 consectuvie laparotomy incisions at three hospitals were closed with No 2 Dexon (polyglycolic acid) sutures using the 'near and far' technique. The incidence of wound dehiscence was 0.5%, of sinus formation 1%, and of incisional hernia 2.2% at 6 months and 6% at 3 years.     

Incidence of incisional hernia after dehiscence of the abdominal wound

The records of 103 patients whose abdominal wounds burst were studied in an attempt to assess the subsequent incidence of incisional hernia. Sufficient information about seventy patients was obtained. Forty-nine patients (47.6 per cent) had a hernia whereas twenty-one patients (20.4 per cent) definitely did not have a hernia. The incidence of hernia was associated with the age of the patient, the site of the wound, the day of resuture, an original diagnosis of malignancy, and the postoperative blood urea level but not with the technic employed in the resuture nor with infection.It is suggested that a blood-stained serous discharge and the “dip sign” should enable an early diagnosis of dehiscence to be made before the small bowel appears in the wound; after diagnosis, the wound should either be explored electively or the skin sutures left for at least three weeks until the skin heals.     

Multilayer reconstruction of abdominal wall defects with acellular dermal allograft (AlloDerm) and component separation

Multiple techniques have been employed for the repair of abdominal incisional hernias with varying rates of success. Primary fascial apposition and prosthetic implantation have been associated with high rates of secondary recurrence, infection, and other complications, often due to insufficient alleviation of tension and implant intolerance. This study evaluates the repair of incisional and recurrent abdominal hernias with multilayered acellular dermal allograft (AlloDerm; LifeCell Corporation, Branchburg, NJ) and musculofascial separation. Patients with incisional or recurrent abdominal hernias were treated between January 2003 and March 2004. The surgical technique involved musculofascial release of the external oblique, followed by a double-layer implantation of dermal allograft. The primary allograft layer was placed as an "underlay" interposition, sutured under moderate tension beneath the fascial edges of the defect. When minimal tension remained, the native fascial margins of the defect were directly repaired. A second allograft layer was then placed and sutured to the superficial aspect of the ventral fascia to complete the repair. Data were reviewed retrospectively. Sixteen patients were treated. There were 10 males and 6 females, mean age 56 years (range 44--72 years). Fifteen patients (94%) had previous hernia repair procedures, and 6 patients (38%) had undergone 2 or more previous procedures. Nine patients (56%) were treated with hernia site infections or prosthetic exposure. Mean follow-up is 16 months (range 9 to 23 months). There were 2 seromas (13%). One patient (6%) developed a wound dehiscence with allograft exposure that healed by secondary intention. There were no recurrences. By minimizing tension and providing a durable biocompatible matrix for support, component separation with bilaminar acellular dermal allograft should be considered for the repair of complex and recurrent ventral hernias.