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Rifat Lati
Editor
Surgery of Complex
Abdominal Wall Defects
Practical Approaches
Second Edition
123
Surgery of Complex Abdominal Wall Defects
Rifat Latifi
Editor
Surgery of Complex
Abdominal Wall Defects
Practical Approaches
Second Edition
Editor
Rifat Latifi
Department of Surgery
Westchester Medical Center
and New York Medical College
Valhalla, NY, USA
ISBN 978-3-319-55867-7 ISBN 978-3-319-55868-4 (eBook)
DOI 10.1007/978-3-319-55868-4
Library of Congress Control Number: 2017938303
© Springer International Publishing AG 2013, 2017
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction
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Foreword to the First Edition
A surgeon can do more for the community by operating on hernia cases and seeing that his recurrence
rate is low than he can by operating on cases of malignant disease.
Sir Cecil Wakeley, president of the Royal College of Surgeons, 1949–1954.
Oh, if only it were that simple! Certainly, Sir Wakeley was referring to inguinal and perhaps
umbilical hernias in this well-known quotation from the middle of the last century. I wonder if
at the time he could have imagined the true complexity of the problem: our limited understanding of the dynamic physiology of abdominal wall tension and the need for more refined surgical techniques to manage abdominal wall defects. Perhaps most shocking of all to Sir Wakeley
might have been the ability for patients to withstand and survive catastrophic illness resulting
in complex abdominal wall defects. Even as recently as 25 years ago, it was hard to believe that
a patient who had lost integrity of the abdominal wall as a result of injury, abdominal sepsis,
or gastrointestinal failure could even survive, let alone return to functional status. However,
with the evolution of resuscitation, operation, and surgical critical care for patients with devastating abdominal injury and illness, a high survival rate is now a reality. With this, our ability
to manage the attendant complications, including complex abdominal wall defects with and
without intestinal fistula, has improved dramatically. This has happened because the clinical
circumstances have demanded it, and our zeal to improve care is no less ardent than that of Sir
Wakeley over a half century ago. The editor, Dr. Rifat Latifi, and contributors to this work have
produced what I believe is the quintessential and seminal resource on this vexing and challenging topic. Surgery of Complex Abdominal Wall Defects is the first textbook of its kind to provide a comprehensive review of modern management of abdominal wall problems. It eloquently
reviews the anatomy and physiology of the abdominal wall and the pathophysiology of abdominal wall defects. It provides a valuable history of abdominal wall repair and then systematically provides the latest approach to operative repair, including preoperative preparation, acute
management of the open abdomen, the approach to the hostile abdomen in the intermediate
term, critical strategies in long-term reconstruction, and the full spectrum of special circumstances that arise along the way. Nowhere will you find a more comprehensive and practical
guide for the management of these patients. If nothing else, this text provides the fundamental
context in which these problems will be discussed and in which future advances are made.
I commend the authors on this accomplishment, and I encourage the readers to pay close
attention to the content. Herein lies the state-of-the-art surgical management for patients with
complex abdominal wall defects. Sir Wakeley would be proud to know how far the art and
science of the approach to these patients have come.
Michael F. Rotondo
University of Rochester Medical Center
Rochester, NY, USA
v
Foreword to the Second Edition
The world of herniology has changed dramatically in the last two decades and even markedly
in the last several years. These advances have changed the way we think about and approach
the repair of an abdominal wall hernia, especially incisional hernias after a laparotomy.
This book edited by Dr. Latifi, now in its second edition, offers a comprehensive approach
to many of the typical and atypical patients that we all see as general and plastic surgeons who
repair abdominal wall hernias. The book is complete for the practicing surgeon and concentrates on abdominal wall and incisional hernias both in the postoperative setting and after
trauma, the latter being especially relevant with the recent concept of damage control and the
subsequent need for management of the open abdomen. While this second edition is in some
respects similar to the first edition (3 of the 27 chapters are reproductions of the last edition), I
want to emphasize that there are 11 new chapters dealing with other topics not addressed in the
last edition, an indication of how the field has changed over these few intervening years; the
remainder of the chapters have been markedly updated to reflect the current state of the art. I
should like to remind the readers that the first edition had over 17,000 downloads in the first
18 months post-publication—truly an indication of its worth and relevance to the practicing
surgeon. The new chapters include chapters on very relevant topics to most general surgeons,
such as the timing of takedown of an enterocutaneous fistula and when and how to repair the
concurrent abdominal wall hernia, how to deal with infected mesh, and which approach is best
for the patient with a flank hernia of traumatic origin or after a prior flank incision. In addition,
I would like to stress the importance of three new chapters, which deal with the management
of abdominal wall hernias in the transplant patient, the potential for use of tissue engineering
in the future, and, what I consider to be one of if not the most common associated risk factor,
the obese patient indicative of the epidemic of obesity in our country and worldwide and management of post-bariatric abdominal wall hernias.
For the reconstructive plastic surgeon, the role of tissue transfer and insightful tissue management has become of prime importance in the large and complicated abdominal wall hernia.
New consideration of the importance of the perforator vessels in the abdominal wall has taken
on more of a focus, as we realize why the older component separation techniques involving the
development of skin/subcutaneous flaps were associated with such a high incidence of wound
complications approaching 40%. The use of the newer, perforator-sparing techniques has
markedly lessened the incidence of wound complications. The recognition of the importance
of a close interaction between the general surgeon and the reconstructive plastic surgeon has
been a major advance in the repair of complicated abdominal wall hernias by more than just
placement of a prosthetic mesh with the introduction of a true abdominal wall reconstruction.
While we all read and talk about gene therapy, oncologic tour de forces involve pancreatectomy, esophagectomy, etc.; nevertheless, we as general surgeons and as reconstructive plastic
surgeons see inguinal and abdominal wall hernias much more commonly; they are a staple in
our practice, and many, if not most, of these hernias are complicated by other very relevant
comorbidities, but require repair, in order to restore the functionality and patient mobility.
vii
viii
This comprehensive book will be pertinent for almost all abdominal wall hernias encountered
in your practice, whether the hernias are large or small. Enjoy this state-of-the-art book.
Michael G. Sarr
Mayo Clinic
Rochester, MN, USA
Foreword to the Second Edition
Preface
Complex abdominal wall defects have become the new surgical disease; thus, the number of complex abdominal wall reconstructions has increased dramatically. As a considerable number of
surgical patients who have sustained major abdominal trauma or catastrophic emergency surgery
are treated with the open abdomen technique, the questions of how, when, and with what tools to
perform these reconstructions have become serious considerations in the surgical practice.
Most surgeons use native abdominal wall during surgical procedures whenever possible.
Evidence suggests, however, that synthetic or biologic mesh needs to be added to large ventral
hernia repairs and in particularly complex defects. One particular group of patients that exemplify the word “complex” are those with contaminated wounds, such as enterocutaneous fistulas (ECFs), enteroatmospheric fistulas (EAFs), and/or stoma(s), where synthetic mesh is to be
avoided, if at all possible. Most recently, biologic mesh has become the standard in high-risk
patients with contaminated and dirty-infected wounds. However, while biologic mesh is currently the most common tissue engineered in this field of surgery in North America, Level I
evidence is needed on its indication for use and long-term outcomes. Various techniques for
reconstructing the abdominal wall have been described; however, the long-term outcomes for
most of these studies are rarely reported.
Complex abdominal wall hernias and complex abdominal wall defects, including stomas or
the complications associated with any of the above, are common and challenging for surgeons.
The lack of high-quality evidence leaves surgeons without clear guidance regarding the selection of technique or material to be used when treating these serious problems.
The first edition of Surgery of Complex Abdominal Wall Defects, written to provide this
guidance, was received very well by readers across the world; thus, the decision was made to
proceed with the publication of the second edition. As with the first edition, the second edition
of this book will cover the surgical anatomy of the abdominal wall; the pathology of abdominal wall defects, such as hernias and enterocutaneous or enteroatmospheric fistulas; and indications for surgical techniques used to reconstruct the abdominal wall from the practical
standpoint. In addition, through a number of illustrations, the placement of mesh in the abdominal wall reconstruction and manipulation of patient’s tissue including lateral component
release techniques and other tissue transfer techniques are described in detail. The text also
covers reconstruction of complex contaminated abdominal wall defects in patients with complex enteric fistulas, stomas, defects created after the excision of previously placed infected
prosthetic mesh, and defects associated with acute tissue loss after severe trauma or necrosis
of abdominal wall such as necrotizing soft tissue infections. Complex abdominal wall defects
in the pediatric population and long-term outcomes and durability of these repairs are also
addressed. The second edition of Surgery of Complex Abdominal Wall Defects is written by
experts in their respective areas from around the world and has been updated thoroughly with
new chapters and new approaches. Just like the first edition, my hope is that it will continue to
serve as a guide for current practicing surgeons, including general, trauma, acute care, plastic,
and reconstructive surgeons.
Valhalla, NY, USA Rifat Latifi
ix
Prologue
When I conceived the idea to put together this book, I was fully cognizant of the huge task
ahead of me. This was true for the first edition, and it is true now for the second edition. One
would think that the second edition is easier. No it is not. It is just as difficult as the first edition.
In fact, one may argue that the second edition is more difficult. The readers expect more; you
yourself expect more. Nonetheless, the biggest motive to have this book was and continues to
be that this book will help us as surgeons take better care of our patients. So, finalizing this
book has been a great, albeit difficult, journey. Many times during this process, I have asked
myself these questions: Why another edition of book? Will this one make a significant contribution, perhaps more than the first one? Will it change patient care for the better? Do practicing
surgeons need this book to take care of patients with complex surgical problems or will this
book help surgical teachers educate students and residents of surgery? The answers to each of
these questions became clearer as I made progress. There was a great need for such a book, and
a second edition became the next goal, although there are a number of books on the subject
already written by some authorities in the field.
And now, seeing it complete, I do think it will add to our knowledge and improve our practice. I hope that you, the reader, will find a positive answer to these questions as well.
Here are the main reasons that drove me to produce this book that you now hold in your
hands. On the first edition, I had eight reasons why this book is in your hand. This time, I have
described nine reasons. There are nine steps in abdominal wall reconstruction in patients with
complex defects, so nine reasons become logical.
Reason 1: Surgeons’ Need
Admittedly, a number of well-written textbooks focus on hernias, a number of great surgical
textbooks touch on abdominal wall reconstruction, and a number of books deal with surgical
complications. However, in all my years of taking care of seriously ill patients with complex
abdominal wall defects (with or without associated fistulas, stomas, and loss of abdominal wall
domain), I have not been able to find a real reference textbook that reflects the latest advances
in biologic and synthetic meshes, especially when we deal with open abdomen and abdominal
wall reconstruction. In my surgical practice—initially in Richmond, Virginia; then at the
University of Arizona and in Doha, Qatar; and now at the Westchester Health Network in
New York—I have continued to care for this group of patients, due to in large part my interest
in re-operative surgery and complex surgical procedures. I have longed for such a book to keep
on my desk and refer to daily, something written by actual practicing surgeons for actual practicing surgeons.
I hope that my collaborators and I have now filled this gap. This was my main motive for
taking on this project. As an editor of this book, I have read every word in this book and have
carefully looked over every illustration and every figure. Every line represents a patient or a
group of patients, offering practical evidence of bona fide surgical opinions and treatments.
Real-world know-how is the power of this book, helping us to truly help patients with complex
abdominal wall defects, patients who often see us as their last chance.
xi
xii
Reason 2: Patients’ Need
Recently a patient who had a complex abdominal defect with continuous low-output fistula
and multiple comorbidities, told me that his 7-year-old daughter never saw him “normal” until
we reconstructed his abdominal wall.
Another recent patient of mine with truly complex abdominal wall defect, managed by open
abdomen, ileostomy, and on TPN for surgical diversion induced short gut syndrome, as we were
getting ready to go to the operating room, surprised me when she pulled out a copy of the first
edition and asked me to sign it. All I wrote was “Good luck” and signed. No pressure, right! She
showed me a handwritten note “I need my abdomen to look like this” pointing out a figure of the
patient with a large defect and ileostomy that underwent reconstruction now with normal abdominal wall.
Patients with complex abdominal wall defects are not eligible for same-day surgery; they
are not among those who can undergo an operation in the morning and then go home in the
afternoon—not at all. In fact, far from it. Such patients will be in the hospital for a long time
postoperatively; most of them have already been with us for a long time, having survived a
number of previous operations. Most of them have battled, for months or even years, the consequences of major trauma or the abdominal catastrophes, cancer, or necrotizing infections
that left them without an abdominal wall (a part of the anatomy that we all take for granted
until we lose it).
This monstrous defect, or set of defects, results in a foul-smelling odor most of the time; it
severely limits the patients’ ability to work, to exercise, to have a sex life, and even to be in
public. So, the need to know how to take care of these patients is enormous; as we continue to
make progress in medicine and surgery, this need will be even bigger.
Prologue
Reason 3: Need to Share Knowledge and the Existing Expertise
There is no better way to share the expertise that one has than written word. For this I asked
some of the best practicing surgeons in the world who deal almost daily with this problem to
help me put this book together. The topic is not a simple one, just as it is not a simple endeavor
to take care of patients with complex abdominal wall defects. I asked the contributors to say
something new, something that they think will help other practicing surgeons care for their
patients. We are not dealing with small umbilical hernias, but rather giant abdominal defects
that are often associated with fistulas, stomas, obesity, and the lack of an abdominal wall.
These defects pose enormous problems for patients and surgeons alike. Specific medical and
physiologic expertise, complicated surgical interventions, and a well-coordinated team
approach are required. In each of our chapters, we share what we have learned, with an emphasis on current principles and practices and an eye toward new strategies.
Reason 4: Increased Frequency of Abdominal Wall Defects
Currently, complex abdominal wall defects are more common than in the past: a larger number
of patients are surviving serious injuries and intra-abdominal catastrophes, thus living longer
with significant comorbidities. As surgeons, we have made significant progress—in terms of
technology, knowledge, and skills—in caring for patients with open abdomens. Often, the end
result is a patient who has survived an initial insult and now has an open abdomen, with a
temporary cover, that requires delayed reconstruction of an abdominal wall defect, a giant
ventral hernia, or, in the worst-case scenario, a frozen abdomen with enteric fistulas. Preventing
or managing complications is of utmost importance.