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35 Enterotomy During Hernia Repair: Prevention and Management
Fig. 35.2 Incidence of
enterotomy or bowel resection
(EBR) by the type o f hernia
repair. Reprinted from Gray
SH, Vick CC, Graham LA
et al. (2008) Risk of
Complications From
Enterotomy or Unplanned
Bowel Resection During
Elective Hernia Repair. Arch
Surg 143(6):582–586
373
[ 11 ]. Eighty-one percent of surgeons responding
to the survey who were not performing laparoscopic ventral hernia repair did not anticipate
performing this procedure in the future. The second most common reason that the surgeons did
not anticipate performing this procedure in the
future was the perceived risk of enterotomy during laparoscopic ventral hernia repair.
Nevertheless, the reported incidence of enterotomy in laparoscopic ventral hernia repair has
been comparable to open ventral hernia repair in
independent, prospective, longitudinal noncomparative studies. In a series of 850 consecutive
patients undergoing laparoscopic ventral hernia
repair repairs , Heniford et al. reported 10 (1.2%)
enterotomies [ 12 ]. This is comparable to the rate
of 1.4% reported by Sharma et al. in 2346 patients
over a 17-year period [ 13 ]. However, in a meta-
analysis of randomized, controlled trials of laparoscopic versus open ventral hernia repair, Awaiz
et al. revealed a statistically signifi cant increase
in “bowel complications” in the laparoscopic
group [ 14 ]. However, enterotomies, serosal tears,
and postoperative small bowel obstruction were
pooled and reported as “bowel complications,”
confounding the actual incidence of enterotomy.
One of the most devastating situations after
laparoscopic ventral hernia repair is an unrecognized enterotomy or one that occurs in a delayed
fashion . It should be noted that this is not exclusive to laparoscopic ventral hernia repair. The
mortality rate for an unrecognized enterotomy
after laparoscopic ventral hernia repair approaches
8% [ 15 ]. An enterotomy most frequently happens
during adhesiolysis, although a trocar or access
injuries can occur, especially in the re-operative
abdomen. The trocar placement strategy is critical in the re-operative abdomen to avoid bowel
injury. An ideal location for the initial trocar is in
an abdominal quadrant remote from previous surgery. An open (Hasson) or closed (Veress) technique is appropriate and the method for placement
should be based on the surgeon’s experience. If
the optical trocar without Veress insuffl ation is
chosen, the access point should be right off the
costal margin at the mid-clavicular or anterior
axillary lines, away from previous scars/operations. The overwhelming majority of iatrogenic
enterotomies occur in the small intestine. An unrec-
374
Table 35.1 Adhesion characteristics defined by tenacity, surface area, and ratio of adhesiolysis time to mesh
surface area
Adhesion characteristics Score
No adhesion 0
Filmy adhesions: viscera/omentum not attached to mesh, disrupted manually 1
Dense adhesion: viscera/omentum attached to mesh requiring blunt dissection
to separate viscera/omentum from mesh
Dense adhesion: viscera/omentum attached to mesh requiring sharp dissection
to separate viscera/omentum from mesh
Dense adhesion: viscera/omentum entwined to mesh requiring sharp dissection
to separate mesh from abdominal wall, leaving mesh attached to viscera/
omentum
Adhesion surface
Intraperitoneal mesh Adhesion tenacity
DualMesh ( n = 14)
Composix ( n = 17)
Absorbable-barrier-coated mesh ( n = 18)
Uncoated macroporous mesh ( n = 12)
Biologic mesh ( n = 8)
Reprinted from
to intraperitoneal mesh and adhesiolysis-related complications during laparoscopic re-exploration after prior ventral
hernia repair. Surg Endosc 24(12):3002–7
Jenkins ED , Yom V , Melman L et al. (2010) Prospective evaluation of adhesion characteristics
2.4 ± 0.6 5.9 ± 1.8 0.14 ± 0.1
3.5 ± 0.6 8.6 ± 1.1 0.36 ± 0.1
3.2 ± 0.5 6.9 ± 2.0 0.21 ± 0.1
3.5 ± 0.9 8.4 ± 1.1 0.38 ± 0.4
2.9 ± 0.4 6.6 ± 1.8 0.33 ± 0.1
area (0–10)
2
3
4
Adhesiolysis time per mesh
surface area (min/cm 2 )
B.D. Matthews
ognized enterotomy can occur due to the inherent
diffi culty with examining the intestine laparoscopically if it has moved out of the fi eld of vision.
As such, vigilance is paramount. Inspection of the
bowel is recommended after initial trocar entry,
during adhesiolysis and at the conclusion of adhesiolysis or the end of the procedure. A delayed
enterotomy may be the result of a partial thickness injury at the time of laparoscopic adhesiolysis or the consequences of a thermal injury to the
intestine. Electrosurgery or ultrasonic coagulation
should be employed judiciously for adhesiolysis
and minimized or avoided when the intestine is in
close proximity. Maneuvers to enable adhesiolysis and minimize the risk of enterotomy are
described in the Guidelines for Laparoscopic
Ventral Hernia Repair from the Society of
American Gastrointestinal and Endoscopic
Surgeons [ 16 ]. These maneuvers, many funda-
mental to laparoscopic surgery, include traction/
counter-traction technique , use of an angled or
fl exible laparoscope, alternating the laparoscope
among the various ports, improved exposure utilizing outside pressure on the abdominal wall for
“inline” dissection, meticulous sharp dissection
under direct vision, limited use of an energy
source, particularly near the hollow viscera, repositioning/adding ports to maintain appropriate
ergonomic position and access to the operative
fi eld, use of instruments with appropriate length
(as longer instruments are occasionally required
to maintain the fulcrum near the middle of the
instrument shaft), avoiding too much torque on
access ports during critical aspects of the adhesiolysis, keeping a clear camera image, maintaining a conscious vigilance for the mucosa of the
gastrointestinal tract (as an enterotomy may only
be visible for a fl eeting moment), and mandatory
fi nal inspection of the bowel to identify
enterotomies.
Management of Enterotomies
There is a general debate about the most appropriate management strategy for an enterotomy during laparoscopic and open ventral hernia repair.
This highlights the paucity of evidence-based
data to support a preferred approach. In a survey
of practicing general surgeons, Adler et al. asked
“if you encounter an enterotomy, how would you
proceed?” [
11 ]. Only 3% of respondents would
35 Enterotomy During Hernia Repair: Prevention and Management
375
place mesh regardless of the amount of spillage
from the gastrointestinal tract while 41% would
place mesh only if “minimal” spillage occurred.
The majority, 56% of respondents, would not
place mesh. If the respondents were to delay the
ventral hernia repair, the mean time from the
enterotomy would be 4 weeks (range, 3 days–6
months). Regardless of the treatment strategy, the
patient should be knowledgeable preoperatively,
as part of the informed consent process, of the
procedural options and basic decision algorithm
for management of an enterotomy. Typically, the
hernia sac has not been violated during laparoscopic adhesiolysis; therefore options exist for
staging the ventral hernia repair in 3 months or
beyond to avoid a ventral hernia repair in a clean/
contaminated or contaminatied fi eld. This is the
most conservative approach and preferable if the
enterotomy can be repaired without conversion to
open. Nonetheless, this is considered Level 4 evidence (expert committee opinions, or clinical
experience of respected authorities, or both) in
published guidelines for the management of
bowel injury during laparoscopic ventral incisional hernia repair. In the Guidelines for
Laparoscopic Treatment of Ventral and Incisional
Abdominal Wall Hernias , the International
Endohernia Society gives Grade C (low-quality
evidence) recommendations for enterotomy management [ 17 ]. The recommendations from the
International Endohernia Society include:
1. Conversion to laparotomy is advisable if the
surgeon is not profi cient with laparoscopic
bowel repair techniques.
2. A primary open repair is advisable in the presence of gross spillage. An open prosthetic
repair may be undertaken if conditions remain
sterile.
3. A small laparotomy away from the hernia
defect may be used to repair a bowel injury
and may be followed by continuation of laparoscopic ventral hernia repair.
4. If a bowel injury is repaired laparoscopically,
laparoscopic ventral hernia repair may be performed after an observation period of 3–7
days on intravenous antibiotic therapy if no
evidence of infection is observed.
5. A laparoscopic ventral hernia repair may be
performed in the event of a bowel injury
repaired immediately with minimal spillage,
but this option requires experience with laparoscopic repair of bowel injury.
A staged repair during the index hospitaliza-
tion with a period of observation (3–7 days) on
broad spectrum intravenous antibiotics, and return
to the operating room for a laparoscopic ventral
hernia repair has been described as a successful
approach [ 18 ]. The unpredictability of infection-
related complications after the 7-day period presents additional risk versus a 3 month or greater
interval. Recent published data would support a
more conservative management algorithm. In 33
patients who had an inadvertent enterotomy during laparoscopic ventral hernia repair, Sharma
et al. reported 6-month follow-up in 31 patients
[ 13 , 19 ]. The additional 2 patients died postopera-
tive due to sepsis and multisystem organ failure
for a mortality rate of 6% in this cohort. The overall complication rate was 49%. The most common
complications were wound infection (27%), ileus
(24%), hernia recurrence (24%), mesh infection
(18%), unplanned readmission (18%), and fi stula
formation (6%). Additional surgical procedures
were required in 55% of these patients within 6
months of the index procedure. As expected, outcomes were worse in patients who had an enterotomy recognized postoperatively.
In the event the enterotomy occurs during an
open ventral hernia repair or conversion to
open is required to repair the intestinal injury
or perform a bowel resection and the hernia sac
is violated, several options exist for management of the ventral hernia. If possible, primary
repair is a simple option, although the majority
of patients will develop a recurrent ventral hernia. More commonly, surgeons are repairing
the hernia using a biologic (allograft or xenograft) or absorbable synthetic mesh [ 20 ].
Depending on the complexity of the hernia and
the degree of contamination, a retrorectus
(Rives-Stoppa) repair, transversus abdominis
release (TAR), anterior component release or
external oblique aponeurosis release, may be
required for re-approximation of the linea alba.
376
B.D. Matthews
Outcomes studies describing single-stage
repairs utilizing biologics or absorbable synthetic mesh for clean- contaminated, contaminated and infected wounds are limited. The
RICH (Repair of Infected and Contaminated
Hernias) trial is the only long-term multicentered, prospective trial to evaluate biologic
mesh in CDC Class II–IV wounds [ 21 ]. This
prospective trial reported a 66% surgical site
occurrence rate and 37% hernia recurrence rate
(intention-to-treat) after 2 years follow-up in
patients who underwent ventral hernia repair
with a non-crosslinked porcine dermis. The
recurrence rate in “bridged” ventral hernia
repairs was 45%. In addition, location of mesh
placement appeared to infl uence recurrence
rates with a higher rate of recurrence when the
biologic mesh was placed intraperitoneal compared to the retrorectus position. In a similar
multicentered prospective, longitudinal clinical
trial, an absorbable synthetic mesh was evaluated in single-staged ventral hernia repair in
Class II–III wounds [ 22 ]. The primary endpoint
in the COBRA (Complex Open Bioabsorbable
Reconstruction of the Abdominal Wall) trial
was ventral hernia recurrence. Based on
Kaplan-Meier analysis, the overall hernia
recurrence rate was 17% at 24 months, almost
20% less than in the RICH trial. Similar to the
RICH trial, hernias repaired with intraperitoneal mesh in the COBRA trial had a higher
recurrence rate (3.41-fold increase). Although
the RICH and COBRA trials describe ventral
hernia repair in clean-contaminated and contaminated wounds, the clinical scenario is different from an unanticipated enterotomy during
elective ventral hernia repair in a patient with
an initial clean wound. Extrapolating data from
these trials to an enterotomy during elective
ventral hernia repair may not be representative
of actual clinical outcomes.
There is an increasing amount of experience
with synthetic mesh in clean-contaminated and
contaminated wounds. Specifi cally, clinical studies evaluating large pore, reduced weight synthetic mesh in clean-contaminated and
contaminated ventral hernia repairs have been
published. Carbonell et al. reported primary out-
comes of SSI, surgical site occurrence, need for
mesh removal, and hernia recurrence in 100
patients with Class II–III wounds undergoing
ventral hernia repair with retrorectus mesh placement [ 23 ]. The overall incidence of surgical site
occurrence was 31%, higher in the contaminated
then clean-contaminated cases. The 30-day SSI
rate was 14%. The recurrence rate was 7% (intention-to-treat) at mean follow-up of 10.8 ± 9.9
months (range 1–63 months). Mesh removal was
required in 4 patients, all due to unrelated explorations for anastomotic leaks. The impetus for
permanent synthetic mesh is to reduce the recurrence rate witnessed for biologic and absorbable
synthetic mesh and reduce the cost primarily
associated with biologic meshes. Carbonell et al.
calculated that the overall cost for the 100 pieces
of 30 × 30 cm large pore, reduced weight synthetic mesh (15 cents/cm 2 ) to repair the ventral
hernias was equivalent to the cost of one single
piece or biologic mesh ($10,000). Despite the signifi cant potential for reduction in healthcare
expenditures with the use of synthetic mesh in
these patients, it is off-label to use synthetic mesh
in clean-contaminated, contaminated, or infected
wounds. In addition, extrapolating data from this
clinical trial to an enterotomy during elective ventral hernia repair in initially clean wounds may
not be representative of actual clinical outcomes.
Conclusions
An inadvertent enterotomy during a laparoscopic
or open ventral hernia repair is unavoidable. An
enterotomy is associated with an increased risk
of wound infections, mesh infections, enterocutaneous fi stulas, and hernia recurrences. Multiple
options exist for management of the ventral hernia when an enterotomy occurs; however, the
management of the enterotomy takes priority.
A postoperatively recognized enterotomy increases
the mortality rate after ventral hernia repair so
attentiveness is paramount throughout the entire
procedure. Although certain risk factors associated with an increased risk of enterotomy during
ventral hernia repair, such as previous surgical
history, previous ventral hernia repair with mesh
35 Enterotomy During Hernia Repair: Prevention and Management
377
and in situ intraperitoneal mesh, are identifi able
preoperatively, all patients should be advised of
the risk of enterotomy and instructed of the basic
decision algorithm for management of an enterotomy during the informed consent process.
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Abdominal Wall Surgery
in the Setting
of an Enterocutaneous Fistula:
Combined Versus Staged
Defi nitive Repair
Michael G. Sarr
Enterocutaneous fi stulas are usually the consequence of an intra-abdominal operation gone bad
and, as such, are all-too-often accompanied by an
incisional hernia, further complica ting an already
unpleasant situation for both the patient and surgeon. Both parties (patient and surgeon) want the
fi stula and the hernia fi xed as soon as possible,
raising the questions of “How soon can it be
done?” and “Please, can we fi x both at the same
time?” However, it is important to remember that
the basic principles of the management of enterocutaneous fi stulae, as well as the basic principles
of repair of incisional hernias, must be followed
and each considered individually. Level 1 evidence for the latter topic is absent, as is Level 2
evidence, and much of the discussion on this
topic is fi lled with bravado, opinion, and lack of
appropriate follow-up [
thing can be done (simultaneous repair of both
fi stula and hernia) does not mean it should be
done. Failed hernia repairs in this setting will
have major consequences. This chapter will
address briefl y the preoperative considerations of
preparing for the repair of the fi stula and then
will address whether a simultaneous or staged
DEFINITIVE repair is prudent.
M. G. Sarr , M.D. (*)
James C. Masson Professor of Surgery, Department
of Surgery, Subspecialty General Surgery , Mayo
Clinic , 200 1st St SW , Rochester , MN 55902 , USA
sarr.michael@mayo.edu
e-mail:
1 ]. Just because some-
36
Preoperative Considerations in the Patient with an Enterocutaneous Fistula
Most often, an enterocutaneous or colocutaneous
fi stula occurs from a complication of an intraperitoneal procedure (enteric or colonic anastomosis
or unappreciated enterotomy) and is complicated
initially by some element of abdominal wall sepsis
that disrupts the fascial closure leading to the hernia. Thus, the clinical situation is often complicated by sepsis, nutritional challenges, and
abdominal wall infection, colonization, and/or an
open wound such as an enteroatmospheric fi stula,
each of which will challenge the option of any
defi nitive repair of the hernia.
The Basics First
Initially, the focus must be directed at the fi stula
from the aspect of a GI surgeon, and not from that
of a “herniologist.” One of the best overall discussions of the evaluation and approach to the management of enterocutaneous fi stulas was by
Visschers and colleagues [ 2 ] who proposed the
SOWATS approach : S-sepsis; O-optimization of
nutrition; W-wound care; A-anatomy; T-timing of
operation; and S-surgical strategy. This approach
should be utilized during the three phases of the
clinical course of an enterocutaneous fi stula: development, the early phase, and the late phase [ 3 , 4 ].
Y.W. Novitsky (ed.), Hernia Surgery, DOI 10.1007/978-3-319-27470-6_36
379© Springer International Publishing Switzerland 2016
380
M.G. Sarr
Development : If the fi stula occurs early postop-
eratively, immediate reoperation in the fi rst week to
10 days (before the hernia forms) should be considered, provided there was not an extensive adhesiolysis , because if there was an extensive
adhesiolysis, then after the second or third postoperative day, the bowel will be agglutinated. Most
fi stulas, however, become evident later, and reoperation is not necessarily a consideration.
Early phase : This phase requires the focus to
be directed on control of sepsis, nutritional resuscitation, and control of the fi stula; reoperation
during this phase is contraindicated.
Late phase : Here the focus should be on the
planning for operative repair after adequate maturation and resolution of the acute infl ammatory
phase, maximizing nutritional resuscitation, and
defi nition of all the relevant anatomy.
The GI surgical approach should involve the
following points during the early phase (Table
36.1 ). Read all prior operative notes; you will
want no surprises in the operating room. Exclude
any areas of sepsis; persistent undrained collections can prevent fi stula closure and nutritional
Table 36.1 Surgical principles of evaluation and repair
of an enterocutaneous fi stula
Early phase
Read and understand all operative notes
Exclude undrained sepsis
Maximize nutrition
Feed the gut whenever possible; re-feed
pancreatobiliary secretions distal to the fi stula
Multidisciplinary approach (in addition to surgeon)
• Nutritionist/dietician
• Psychiatrist—situational depression helped by
antidepressant(s)?
• Physical therapist—reverse deconditioned state
• Family support
• Social worker
Bag/control the fi stula—consult a trained
enterostomal therapist if any diffi culty
Late phase
Image all the pertinent gut
Defi ne the anatomy—no surprises in the OR!
Allow acute/subacute infl ammation to resolve; do
not be bullied into operating too soon
Plan the operation; recruit the potential help of a
reconstructive plastic surgeon
resuscitation. Maximize nutrition possibly by
feeding (or re-feeding enteric content) distal to
the fi stula; enteric feeding is more effective than
parenteral feeding and maintains the health,
integrity, and function of the distal gut. Involve a
multidisciplinary team, including a nutritionist
(dietitian or physician), physical therapist, psychologist if necessary (patients are often situationally depressed), family/social supports, and,
very importantly, an enterostomal therapist if you
are having any diffi culty bagging the fi stula [ 1 ].
For the patient, there is nothing worse than an
uncontrolled fi stula. And, fi nally, remember TPN
can be cycled and given via a backpack to allow
increased patient mobility.
The GI approach to the late phase requires
experience and a resolute surgeon. Everyone will
be pressuring you to operate—the patient, the family, and all the other physicians who are not surgeons [ 4 ]! Your goal is to allow the acute/subacute
infl ammation to subside. Most fi stulas require 3
months to mature, some 6 months, and some
maybe even 12 months. A good barometer of resolution of the infl ammation is the ability to “pinch”
a skin graft if present or the redness of the primary
incision. Remember, many fi stulas occur/reoccur
from too early a reoperation. Other considerations
involve the nutritional state of the patient, as shown
by Visschers et al. [ 2 ]. Optimal outcomes , occur
when the patient’s serum albumin is ≥3.0 g/
dL. Operative planning requires imaging of all
parts of the involved gut, especially excluding any
distal obstruction. Likewise, the goals of a successful fi stula repair are careful technique, full
mobilization, and coverage of the repair with
autogenous tissue; the latter may require assistance of a reconstructive plastic surgeon.
Should You Fix the Hernia Concurrently?
Your operative plan should be FIRST to fi x the
fi stula—that is the patient’s primary concern!
The fi stula takes precedence, while the repair of
the hernia should be a somewhat distant second
precedence. The decision to repair the abdominal
wall hernia should not be infl uenced by emotion,
36 Abdominal Wall Surgery in the Setting of an Enterocutaneous Fistula: Combined…
381
but rather by good, sound, surgical judgment
based on several considerations: patient factors/
nutritional state, local conditions/tissues/risk of
infection, confi dence in your repair of the fi stula,
size of the defect/need for tissue advancement
(components separation), and, in this author’s
opinion, whether the patient is a hernia-former
which goes hand-in-hand with the latter consideration of the need for tissue advancement,
because use of a permanent, alloplastic prosthesis
classically is contraindicated (although see
below—“Use of Permanent Prosthetic Material”).
D e fi nitive Herniorrhaphy at Time
of Fistula Repair
Obviously, the worries of any operation involving
takedown of an enterocutaneous fi stula are anastomotic leak and surgical site infection, both of
which jeopardize markedly any abdominal wall
hernia repair. Takedown of a traumatic enterocutaneous fi stula in an otherwise healthy, non-malnourished, non-obese, 22-year-old male is
completely different from an enterocutaneous fi stula in an obese, elderly patient in whom the fi stula
developed secondary to an unrecognized enterotomy that occurred during an extensive adhesiolysis while attempting to repair an abdominal wall
hernia or in a patient who is immunosuppressed
either from chronic disease/malnutrition, malignancy, or because of a prior organ transplantation.
The spectrum of clinical presentation of enterocutaneous fi stulas complicated by concomitant
abdominal wall hernias is very broad.
Who are the best candidates for a defi nitive
repair concurrently (Table 36.2 ) Note: Just
because a defi nitive repair can be done does not
mean it should be done. This decision requires
non-emotional, good, mature surgical judgment.
In addition, there are some senior surgeons who
feel that many (perhaps most) abdominal wall
hernias complicating an enterocutaneous fi stula
should not undergo any complicated defi nitive
repair other than a simple autogenous fascia
reapproximation. Ideal patients are those lacking
any of the underlying risk factors for incisional
hernia—obesity, malnutrition, prior incisional
Table 36.2 Who can be considered for simultaneous
repair of the abdominal wall hernia?
Small defect allowing primary fascial reapproximation
None of the following underlying risk factors for
incisional hernia
• Marked obesity
• Large open wound
• Malnutrition
• Immunosuppressed patient
• Concomitant infected mesh
• Prior incisional hernia
• Smoking
Larger defect able to be repaired by components
separation in the ideal patient
• The patient who is not a hernia-former
• Has no malnutrition
• Has good local tissues
a
Taken at a calculated risk, because wound infection will
probably lead to fascial breakdown, hernia formation, and
a very diffi cult subsequent hernia to repair
a
hernia (i.e., a hernia-former), or signs of local
abdominal wall infection, cellulitis, or a large
surface area of open wound (that contains bacterial colonization). Small defects able to be closed
with a primary, autogenous tissue repair are dealt
with quite easily by simple reapproximation of
the fascia and, should a wound infection occur
and develop into another hernia, no loss of
abdominal wall tissue has occurred; equally
important, a later defi nitive repair has not been
jeopardized by lateral dissection. In contrast,
when the defect is large, unable to be reapproximated by primary repair, and will require
some form of tissue transfer/myocutaneous
advancement (components separation) to obtain
midline myofascial approximation, very serious
pause should be taken. A wound infection would
lead to a subsequent hernia that will be very diffi cult to repair. Two large series [ 5 , 6 ] of com-
bined takedown of fi stulas and components
separation techniques describe what in this
author’s opinion are unsatisfactory outcomes
with rates of recurrent hernias of 21% and 32%,
respectively, and recurrent fi stulas of 26% and
20%. Thus, only the low-risk, ideal patients
should be considered for takedown of an enterocutaneous fi stula with simultaneous abdominal
382
M.G. Sarr
wall reconstruction. In this author’s opinion, consideration of defi nitive repair by a so-called
“tension- free” components separation in a herniaformer should be reconsidered; remember, this
repair is an autogenous tissue repair, and the
“tension-free” situation is only when the patient
is anesthetized and paralyzed–not when the
patient coughs, sits up, or strains to have a bowel
movement. Use of permanent prosthetic material
to reinforce the repair is classically contraindicated (see below, “Use of Permanent Prosthetic
Material”). The recurrence rate will be very high,
and should a surgical site infection occur, the
resultant hernia will be extremely diffi cult to
repair, because your best option in this high-risk
group of patients has already been used—and
you have burned your bridges. This group of
patients gets one good chance at defi nitive hernia
repair (abdominal wall reconstruction), and a
staged repair seems most prudent.
Who should not have a defi nitive repair?
(Table 36.3 ) By “defi nitive” repair, I mean either
a permanent, prosthetic-based incisional herniorraphy or a true abdominal wall reconstruction
requiring myofascial advancement/transfer.
Inappropriate candidates include the markedly
obese, malnourished, or immunosuppressed
patients, those with dirty or open wounds, the
chronically ill or markedly deconditioned, those
with infected/colonized mesh from a prior
abdominal wall herniorraphy, or those with a history of a prior incisional hernia (the “herniaformer”). It should go without saying that a
defi nitive repair should not be entertained seriously in someone still smoking and especially
any form of tissue transfer !
Table 36.3 Who should not have a simultaneous
DEFINITIVE hernia repair ?
Dirty wound (subjective observation)
Large open area
Poor nutrition
Large defect “able to be closed” by components
separation in patients with risk factors
• Obesity
• Prior incisional hernia (hernia-formers)
• Concomitant mesh infection?
How to Deal with the Hernia Defect
After takedown of the enterocutaneous fi stula,
every attempt should be used to provide two
important principles: (1) autogenous, vascularized tissue coverage of all anastomoses, and (2)
abdominal wall stability, even if only temporary
(several weeks to several months). Ideally, primary fascial closure is best and will provide
abdominal wall stability; although recurrence of
the hernia may be quite high and should be
expected in the high-risk patient (hernia-former,
malnourished, immunosuppressed, etc.), you
provide autogenous coverage and at least temporary abdominal wall stability.
The larger defects unable to be reapproximated present major challenges that are more diffi cult. Again, autogenous coverage of the
anastomoses is paramount. Input and options
from a reconstructive plastic surgeon can really
help [ 7 ]. Techniques include omental coverage,
mesenteric or serosal coverage from adjacent
bowl, or use of the hernia “sac.” On rare occasions, a vascularized tissue transfer from the
thigh (rectus femoris or gracilis grafts) or back
(latissimus dorsi grafts) can provide vascularized
tissue cover, but these types of “fl aps” do not provide abdominal wall stability and cannot reach
the areas of the abdominal wall cranial to the
umbilicus.
Some form of abdominal wall stability is
usually necessary to prevent evisceration. In the
very unusual patient with a frozen abdomen in
whom you can repair the fi stula and provide
viable, vascularized coverage of exposed bowel
but cannot provide coverage of adhesed bowel
not at risk for evisceration, no attempt at spanning the hernia defect may actually be the best
choice. The open wound can then be managed
with a wound vac (not directly on bowel, however) or simple dressings with the future aim of
placing a skin graft and delaying the hernia
repair to the future under ideal conditions
(closed epithelialized wound, full nutritional
resuscitation, and a planned elective abdominal
wall reconstruction) [ 8 ].
Unfortunately, the more common situation is
the patient in whom a more extensive adhesiolysis for fi stula repair results in mobile bowel that
36 Abdominal Wall Surgery in the Setting of an Enterocutaneous Fistula: Combined…
383
demands provision of some form of abdominal
wall stability. In this situation, the possible solutions involve performing a components separation (in the appropriate patient) with a primary
autogenous fascial closure, possibly reinforced
with a bioprosthesis or synthetic absorbable
prosthesis placed as either a sublay or an onlay
[ 5 , 6 ]. The concept of performing a components
separation, knowing that fascial re- approximation
will not be possible but planning on spanning the
fascial defect with a bioprosthesis, is not a good
option in my opinion, because the likelihood of
such bioprosthesis providing a defi nitive repair
is highly unlikely [ 9 , 10 ]. Similarly, spanning
such a defect with a permanent prosthesis in this
type of “contaminated” wound would not be
considered standard of care, and also result in
violating spaces that may preclude the use of a
technique that would be best for a future abdominal
wall reconstruction.
In most patients, a better solution would be to
accept the idea of not being able to provide a
defi nitive repair of the hernia, plan for a staged
repair, and to span (patch) the hernia defect with
either a bioprosthesis or a synthetic absorbable
prosthesis [ 1 , 3 ]. Although adding a components
separation would decrease the size of the hernia
defect, it will essentially prevent the ability to use
this technique of abdominal wall reconstruction
to perform a much better, defi nitive repair in the
future under elective conditions. Therefore, the
goal should be to fi x the primary indication for
operation and the major complaints of the
patient—i.e., THE FISTULA—and to address
the secondary concern—i.e., THE HERNIA—at
a later date under elective, non-bacterially contaminated conditions in a stable, nutritionally
optimized patient.
Choice of “temporary,” absorbable prostheses
vary considerably with their characteristics [ 3 ].
These bioprostheses are usually constructed from
proprietary processes that remove most cells and
immunologic epitopes that could cause a true
immune response when implanted in humans.
The tissues from which these bioprostheses are
commonly derived include human cadaveric or
porcine dermis, porcine intestinal submucosa, or
bovine pericardium. Most of the bioprostheses
are designed biochemically to encourage vascular ingrowth and deposition of native host connective tissue. While proprietary claims allege
the reproduction of a “functional neo-abdominal
wall,” the extent to which this really happens is
questionable. These bioprostheses, however, do
provide stable, albeit temporary, abdominal wall
support (coverage of the intra-abdominal viscera)
for 6–12 months before being broken down by
host tissues or “stretching.” This time frame
allows healing of the fi stula, closure of any skin
wounds, nutritional repletion, and reversal of
physical deconditioning.
Another option involves the absorbable synthetic prostheses, which also provide temporary
abdominal wall stability, but generally for a shorter
duration than the bioprostheses. The polyglactin
meshes are initially permeable (they are meshed)
and allow drainage of peritoneal fl uid/transudate
for the fi rst 4–7 days, which may be an advantage
in selected patients; the bioprostheses are generally considered watertight. The disadvantage of
these prostheses is that they are degraded more
rapidly and become less stable as an abdominal
wall support after 6–8 weeks; thus, these more
rapidly absorbed prostheses are used in selected
patients who may not need a prolonged abdominal
wall support. When these more rapidly absorbable
prosthetics are used, the eventual goal is often to
skin graft the subsequent wound in 1–2 months.
This concept of split- thickness skin grafting [ 8 ]
should be evaluated carefully, because although
the skin graft will “cover” the wound, the skin
graft will also stop further medial wound contracture and will usually delay eventual abdominal
wall reconstruction for about 6 months. This
6-month time interval allows the skin graft to
mature such that safe excision of the graft is possible (i.e., when the skin graft is “pinchable”
meaning that the infl ammatory vascularization
response has largely abated).
Several newer synthetic, absorbable prostheses have been developed to last longer and for up
to 6–18 months. Again, the manufacturing details
of how they are constructed are proprietary, but
these prostheses do have their place in selected
patients, although long-term clinical experience
is still lacking.