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Table 2
Published series on open and laparoscopic repair of subxiphoid hernias
Number
Author/Year Technique of Repair
Cohen & Starling,
Davidson & Bailey,
Bouillot et al,
32
1985 Polypropylene onlay 14 4–36 NR NR 0 0
33
1987 Open primary repair 8 22 NR NR NR 0
34
1997 Retromuscular repair with
of Patients
23 1–5 y NR NR NR 0
polypropylene mesh
35
Muscarella et al,
Landau et al,
Mackey et al,
2000 Laparoscopic 1 6 NR NR NR 0
36
2001 Laparoscopic 10 — 55 — 30 10
28
2005 Open and laparoscopic primary
45 48 NR NR NR 36
and mesh repair
Eisenberg et al,
Carbonell et al,
37
2008 Laparoscopic 4 NR 122 6.5 50% NR
38
2011 Open double-mesh technique 35 4–80 NR NR 20 0
Mean
Follow-Up
(mo)
Operating
Room Time
(min)
Length of
Hospital
Stay (d)
Complication
Rate (%)
Recurrence
Rate (%)
Abbreviation: NR, not recorded.
Data from Refs.
28,32–38
Atypical Hernias
1157
Table 3
Published series on open and laparoscopic repair of flank hernias
Number
Author/Year Technique of Repair
Shekarriz et al,
Petersen et al,
Zieren et al,
Edwards et al,
Fei & Li,
39
2001 Laparoscopic 3 12 138 2 0 0
40
2002 Open retromuscular 4 33 208 15 0 0
41
2007 Open retromuscular and onlay 15 60 101 NR NR 13
42
2009 Laparoscopic 27 3.6 144 3.1 3.7 0
43
2010 Open retromuscular 23 24.5 NR NR 13 13
of Patients
Open extended retromuscular 18 26.2 NR NR 27.8 0
Veyrie et al,
Phillips et al,
44
2012 Open retromuscular 61 47 136 7 18 4.9
45
2012 Open retromuscular 16 16.8 178 6.3 19 0
Mean
Follow-Up
(mo)
Operating
Room Time
(min)
Length of
Hospital
Stay (d)
Complication
Rate (%)
1158
Hope & Hooks III
Recurrence
Rate (%)
Abbreviation: NR, not recorded.
Data from Refs.
39–45
Atypical Hernias
and colleagues28evaluated a few patients undergoing primary repair (14), laparoscopic repair with mesh (10), and open repair with mesh (21), with recurrence rates
of 43%, 30%, and 33%, respectively. These investigators also reported that previous
sternal wound infection was a risk factor for recurrent hernias after repair, with 6 of 16
patients with recurrences also having a previous sternal wound infection.
28
Data related to incidence and ou tcomes of flank hernias, resulting mostly from
traumatic injuries and incisions, are also a mixture of open and l aparoscopic cases.
Although not true hernias, there are data related to the incidence of flank bulging
after retroperitoneal incisi ons and possible mechanism of this occu rrence. Chatterjee and colleagues
tomy an d reported 49% of patients complaining of flank bulging. Gardner and
colleagues
30
29
evaluated 70 patients undergoing flank incisions for nephrec-
performed an analysis of flank bulge using neurophysiologic testing,
cadaver dissection, and clinical data on 63 patients. T hese investigators reported
an 11% incidence of flank bulge and showed that this phenomenon is related to
intercostal nerve injury with subsequent paralysis of the abdominal wall musculature. Da ta from series (>1 patient) on open and laparoscopic repair of fl ank hernias
are shown in Table 3. In general, these series rep ort on standard techniques of the
open an d laparoscopic repair of the flank hernia, adhering to the principles of wide
overlap of mesh with appropriate fixation. However, because o f patient factors,
slight differences in techniques, and use of mesh, there is some variability in the
outcomes.
A few other published reports on the topic of atypical hernia repair deserve mention,
although they do not fit specifically into 1 category of hernia repair. Ferrari and
colleagues
31
reported on a series of 39 patients undergoing laparoscopic repair of
suprapubic (18), subxiphoid (15), and lateral hernias (6). These investigators showed
acceptable outcomes, with a 3% conversion rate, 18% complication rate, mean
hospital stay of 5.1 days, and at a mean follow-up of 38 months, a 7.7% recurrence
rate. There are also 2 reports on the use of bone anchor fixation for atypical hernias.
Carbonell and colleagues
19
reported on 10 patients undergoing open retromuscular
repair of lumbar hernias with the use of bone anchors for fixation. These investigators
reported excellent outcomes, with a mean hospital length of stay of 5.2 days, no postoperative complications, and at a mean follow-up of 40 months, no recurrences.
and colleagues
20
evaluated bone anchor fixation in laparoscopic repairs in 30 patients,
19
Yee
with 17 suprapubic, and 13 lateral. These investigators reported an average length of
hospital stay of 5.2 days, 23.3% complication rate, 3.3% mortality, and a 6.7% recurrence rate at a mean follow-up of 13.2 months.
1159
SUMMARY
Atypical hernias or hernias located at the abdominal borders can be challenging to
repair. Thorough knowledge of anatomy, appropriate preoperative planning, and reliance on the principles of hernia repair, including wide mesh overlap and fixation,
ensure successful outcomes. Many options for repair, including technique and
mesh choice, are available for the surgeon. The hernia surgeon should be well versed
in the open and laparoscopic approaches and apply them based on the individual clinical presentation. Long-term outcomes related to suprapubic, subxiphoid, and lateral
hernia repairs are limited; however, open and laparoscopic repairs using wide mesh
overlap and adequate fixation have acceptable outcomes and recurrence rates.
Future research will likely focus on comparative studies based on patient factors,
techniques, mesh, and cost to help surgeons choose the appropriate repairs for individual patients.
1160
Hope & Hooks III
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quent incisional hernia. Surgeon 2003;1:17–22.
18. Frantzides CT, Welle SN. Cardiac tamponade as a life-threatening complication in
hernia repair. Surgery 2012;152:133–5.
19. Carbonell AM, Kercher KW, Sigmon L, et al. A novel technique of lumbar hernia
repair using bone anchor fixation. Hernia 2005;9:22–5.
20. Yee JA, Harold KL, Cobb WS, et al. Bone anchor mesh fixation for complex lapa-
roscopic ventral hernia repair. Surg Innov 2008;15:292–6.
21. Carbonell AM, Kercher KW, Matthews BD, et al. The laparoscopic repair of supra-
pubic ventral hernias. Surg Endosc 2005;19:174–7.
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22. Palanivelu C, Rangarajan M, Parthasarathi R, et al. Laparoscopic repair of supra-
pubic incisional hernias: suturing and intraperitoneal composite mesh onlay. A
retrospective study. Hernia 2008;12:251–6.
23. Varnell B, Bachman S, Quick J, et al. Morbidity associated with laparoscopic
repair of suprapubic hernias. Am J Surg 2008;196:983–7 [discussion: 87–8].
24. Sharma A, Dey A, Khullar R, et al. Laparoscopic repair of suprapubic hernias:
transabdominal par tial extraperitoneal (TAPE) technique. Surg Endosc 2011;25:
2147–52.
25. Jenkins ED, Yom VH, Melman L, et al. Clinical predictors of operative complexity
in laparoscopic ventral hernia repair: a prospective study. Surg Endosc 2010;24:
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26. Kim HS, Kim KB, Hwang HY, et al. Subxiphoid incisional hernia development after
coronary artery bypass grafting. Korean J Thorac Cardiovasc Surg 2012;45:
161–5.
27. Barner HB. A technical modification of median sternotomy to eliminate subxi-
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sternotomy. J Am Coll Surg 2005;201:71–6.
29. Chatterjee S, Nam R, Fleshner N, et al. Permanent flank bulge is a consequence
of flank incision for radical nephrectomy in one half of patients. Urol Oncol 2004;
22:36–9.
30. Gardner GP, Josephs LG, Rosca M, et al. The retroperitoneal incision. An evalu-
ation of postoperative flank ’bulge’. Arch Surg 1994;129:753–6.
31. Ferrari GC, Miranda A, Sansonna F, et al. Laparoscopic repair of incisional her-
nias located on the abdominal borders: a retrospective critical review. Surg Laparosc Endosc Percutan Tech 2009;19:348–52.
32. Cohen MJ, Starling JR. Repair of subxiphoid incisional hernias with Marlex mesh
after median sternotomy. Arch Surg 1985;120:1270–1.
33. Davidson BR, Bailey JS. Repair of incisional hernia after median sternotomy.
Thorax 1987;42:549–50.
34. Bouillot J, Badawy A, Alexandre J. Incisional abdominal hernia after median ster-
notomy. Repair with the use of Dacron mesh. Hernia 1997;1:129–30.
35. Muscarella P, Needleman B, Goldstein A, et al. Laparoscopic repair of a subxi-
phoid incisional hernia following median sternotomy. Surg Rounds 2000;23:
605–11.
36. Landau O, Raziel A, Matz A, et al. Laparoscopic repair of poststernotomy subxi-
phoid epigastric hernia. Surg Endosc 2001;15:1313–4.
37. Eisenberg D, Popescu WM, Duffy AJ, et al. Laparoscopic treatment of subxiphoid
incisional hernias in cardiac transplant patients. JSLS 2008;12:262–6.
38. Carbonell Tatay F, Garcia Pastor P, Bueno Lledo J, et al. Subxiphoid incisional
hernia treatment: a technique using a double mesh adjusted to the defect. Cir
Esp 2011;89:370–8.
39. Shekarriz B, Graziottin TM, Gholami S, et al. Transperitoneal preperitoneal lapa-
roscopic lumbar incisional herniorrhaphy. J Urol 2001;166:1267–9.
40. Petersen S, Schuster F, Steinbach F, et al. Sublay prosthetic repair for incisional
hernia of the flank. J Urol 2002;168:2461–3.
41. Zieren J, Menenakos C, Taymoorian K, et al. Flank hernia and bulging after open
nephrectomy: mesh repair by flank or median approach? Report of a novel technique. Int Urol Nephrol 2007;39:989–93.
42. Edwards C, Geiger T, Bartow K, et al. Laparoscopic transperitoneal repair of flank
hernias: a retrospective review of 27 patients. Surg Endosc 2009;23:2692–6.
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43. Fei Y, Li L. Comparison of two repairing procedures for abdominal wall recon-
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Zhi 2010;24:1506–9 [in Chinese].
44. Veyrie N, Poghosyan T, Corigliano N, et al. Lateral incisional hernia repair by the
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Takedown of Enterocutaneous
Fistula and Complex Abdominal
Wall Reconstruction
Dominic Alexander James Slade, MB ChB, FRCS,
Gordon Lawrence Carlson,
KEYWORDS
Intestinal failureOpen abdomenSepsisStomaSeparation of components
KEY POINTS
Reconstruction of the gastrointestinal tract and an associated abdominal wall defect is not
an operation to be undertaken on an occasional basis.
Patients with enterocutaneous fistulas have complex physical and psychological health
problems, which need to be fully addressed preoperatively by a multidisciplinary team.
Definitive reconstructive surgery should never be undertaken until the patient’s condition
has been optimized, with particular regard paid to eradicating sepsis and restoration of
nutritional status.
Preoperative assessment of the gastrointestinal tract and abdominal wall should be
undertaken, to enable a detailed plan to be devised for reconstruction of both.
Definitive reconstructive surgery may require several, staged procedures.
Large complex abdominal wall defects continue to present exceptionally challenging
problems and may be best addressed by plastic surgical reconstruction and staged
reconstruction of the gastrointestinal tract.
Newer approaches, including biologic implants, may offer alternatives for reconstruction
of large contaminated abdominal wall defects in patients with enterocutaneous fistulas
but have not yet been adequately evaluated.
BSc, MD, FRCS
*
INTRODUCTION
Reconstruction of a large contaminated abdominal wall defect represents a significant
challenge, even for the experienced surgeon. Perhaps the most extreme example of
the difficulties and complexities associated with these procedures is that of the large
abdominal wall defect associated with an enterocutaneous fistula. The surgical
Department of Surgery, National Intestinal Failure Centre, Salford Royal NHS Foundation Trust,
Eccles Old Road, Salford, Manchester M6 8HD, UK
* Corresponding author.
E-mail address: gordon.carlson@srft.nhs.uk
Surg Clin N Am 93 (2013) 1163–1183
http://dx.doi.org/10.1016/j.suc.2013.06.006 surgical.theclinics.com
0039-6109/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved.
1164
Slade & Carlson
management of a complex abdominal wall defect in the setting of enterocutaneous
fistulation involves a series of important issues, including the following:
Management of abdominal sepsis
Optimization of nutritional status, to facilitate definitive reconstructive surgery
and postoperative healing
Detailed assessment of intestinal anatomy
Control of underlying medical disease (especially inflammatory bowel disease)
Preservation of intestinal length and avoidance of short bowel syndrome after
reconstructive surgery
Creation of (often multiple) bowel anastomoses or stomas
Absence of abdominal musculature and skin cover as a result of fistula-related
wound infection and necrosis
Significant contamination of the operative field with enteric organisms and their
associated biofilm
Loss of abdominal domain and the potential for abdominal hypertension after
abdominal wall reconstruction
Inability to use many prosthetic materials because of the degree of contamina-
tion, and unproven efficacy of those materials that are available
Psychological support, especially for patients with enteroatmospheric fistulation
and prolonged hospitalization
Surgery to take down enterocutaneous fistulas and reconstruct sizable complex
abdominal wall defects is technically challenging and relatively high risk, even in
expert hands. Attention to detail is vital if acceptable results are to be obtained, and
the complex, multifaceted nature of the care lends itself to a multidisciplinary team
approach. Awareness of these issues in the United Kingdom has led to the establishment of nationally designated acute intestinal failure units, offering specialized treatment of patients with enterocutaneous fistulas.
ACUTE INTESTINAL FAILURE AND ENTEROCUTANEOUS FISTULATION
Many patients with enterocutaneous fistulas have intestinal failure, a condition characterized by dependence on the parenteral provision of fluids/electrolytes or nutrition for
the maintenance of health (Table 1).
Acute intestinal failure, which is reversible, is distinguished from chronic intestinal
failure (short bowel syndrome), which is not.
1
2
Acute intestinal failure is usually further
subclassified into type 1 (which is self-limiting, usually within 14 days) and type 2 intestinal failure, which is also capable of resolution, but over a longer time course.
Most patients with type 1 intestinal failure have simple ileus or postoperative intestinal
obstruction, whereas intestinal failure occurring in patients with enterocutaneous fistulas is usually type 2 intestinal failure, requiring many months of treatment and,
frequently, major reconstructive surgery before nutritional autonomy is restored.
Management of patients with type 2 intestinal failure is best undertaken by dedicated
teams of health professionals, comprising surgeons, physicians, nurses, enterostomal
therapists, dieticians, pharmacists, clinical biochemists, and psychologists.
CAUSE AND CLASSIFICATION
2,3
An intestinal fistula is an abnormal communication between the intestinal tract and
another epithelialized surface, usually the skin. Intestinal fistulas can be internal,
communicating with other loops of bowel or another hollow viscus (eg, bladder or vagina) or external, communicating with the skin (enterocutaneous). When fistulation
1
Takedown of Enterocutaneous Fistula
Table 1
Classification of intestinal failure
Classification Clinical Behavior and Therapy Cause
Type 1 Self-limiting
Duration <14 d
TPN
Type 2 Medium-term
Duration 14 d–6 mo
Likely to require surgery
TPN/fistuloclysis
Type 3 Long-term TPN
Usually permanent
May require intestinal
lengthening/transplantation
Abbreviation: TPN, total parenteral nutrition.
From Lal S, Teubner A, Shaffer JL. Review article: intestinal failure. Aliment Pharmacol Ther
2006;24(1):19–31; with permission.
Usually postoperative (eg, ileus, small
bowel obstruction)
Intestinal fistula, high-output stoma
Postoperative septic and metabolic
complications
Short bowel syndrome after multiple
resections or severe intrinsic disease
occurs in an open abdomen, leaving open loops of bowel exposed within the wound,
the fistula is said to be enteroatmospheric (Fig. 1). Simple fistulas open directly onto
the skin surface, whereas complex fistulas involve abscess cavities or another viscus.
Enterocutaneous fistulas are often classified according to the daily volume of intestinal effluent. High-output intestinal fistulas produce greater than 500 mL of fluid per
day, and treatment usually requires parenteral nutrition.
Intestinal fistulation may result from intrinsic disease of the gastrointestinal tract or
as a consequence of complications of abdominal surgery (Table 2).
4
Any operation in which dissection of the small intestine occurs may result in postoperative intestinal fistulation. More than three-quarters of enterocutaneous fistulas
develop as a consequence of surgery, usually because of breakdown of an intestinal
anastomosis or an enteric injury.
4
Up to half of postoperative small bowel fistulas
occur after surgery in which no resection or anastomosis has been performed. Division
of abdominal adhesions, resulting in unplanned enterotomy and postoperative enteric
leakage, either as result of unrecognized small bowel injury, or from an enterotomy
repair, account for many of these cases. Avoiding accidental bowel injury is therefore
crucially important when undertaking reconstructive surgery (see later discussion).
1165
Fig. 1. Obliterated peritoneal cavity in severe abdominal sepsis associated with fistulation in
the open abdomen.
1166
Slade & Carlson
Table 2
Cause of small bowel fistula
No Intrinsic Small Bowel Disease
>75%
Enterotomy/resection
Adhesiolysis
Injury to small bowel exposed in open abdomen
Data from Berry SM, Fischer JE. Classification and pathophysiology of enterocutaneous fistulas.
Surg Clin North Am 1996;76(5):1009–18.
Intrinsic Small Bowel Disease
<25%
Crohn’s disease
Diverticulosis
Carcinoma
Lymphoma
Radiation enteritis
Appendicitis
Vasculitis/ischemia
Trauma
Pancreatitis
Tuberculosis
Enteroatmospheric fistulation almost always results from management of the open
abdomen. Although open abdominal management as part of damage control laparotomy for trauma and severe abdominal sepsis has been reported to be beneficial,
5–7
allowing improved sepsis control, facilitating inspection of the abdominal contents,
and avoiding abdominal hypertension, a potentially disastrous consequence of open
abdominal management is the danger of injury to the exposed viscera. The open
abdomen seems to be an inherently fistulogenic environment,
8
especially in the setting
of abdominal sepsis. Although negative pressure wound therapy (NPWT) seems to be
safe when used for short-term wound care after damage control laparotomy, with fistulation reported in 5% or less of patients,
more common when NPWT is used for the management of abdominal sepsis,
with an incidence varying between 10% and 21%. Fistulation in the open abdomen
is particularly difficult to manage and significantly increases mortality.
6,9–13
fistulation seems to be considerably
14
14–17
PREOPERATIVE MANAGEMENT
Reconstructive surgery for a patient with an enterocutaneous fistula should not be undertaken until the patient’s condition is optimized. This optimization requires a detailed
appraisal of the patient’s fitness for surgery, eradication of sepsis, correction of nutritional depletion, and assessment of local, abdominal conditions that are likely to
determine the timing of, and techniques used for, reconstructive surgery. It is helpful
to deal with issues that limit the patient’s suitability for surgery in order of their importance with regard to threat to life. These management principles may be usefully summarized with the acronym SNAP:
Sepsis: elimination of sepsis and provision of skin care
Nutrition: appropriate, effective, and uncomplicated nutritional support
Anatomy: definition of the anatomy of fistulas, proximal and distal gastrointestinal
tract, and the abdominal wall
Procedure: planning and undertaking the surgical procedure to take down the
fistula and close the associated abdominal wall defect (where appropriate)
DIAGNOSIS AND MANAGEMENT OF ABDOMINAL SEPSIS
Sepsis remains as important a negative prognostic factor in patients with intestinal
18
fistulas
as it was when described in 1978.19Inadequately treated abdominal sepsis