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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1498_Библиотеки_им_академика_М_И_Перельмана.pdf
292
M.M. Ott and J.J. Diaz Jr.
This technique, described by Fabian et al., involves achieving visceral
coverage with STSG or skin only closure and returning at a later date to
fi x the abdominal wall defect [ 36 ] . Ideally, the abdominal wall
reconstruction is not performed until 3–12 months after the original
operation to allow for the development of a “neo-peritoneum” and a
softening of intra-abdominal adhesions.
Treatment Options: Abdominal Wall Reconstruction
Abdominal wall reconstruction in the patient with a complex
abdominal wall requires signi fi cant preoperative planning (Fig. 24.7 ). As
discussed previously, optimizing nutritional status, smoking cessation,
adequate blood glucose control, and pulmonary and cardiac clearance
are essential prior to undergoing this complex operation. Patients need to
be counseled that they may require time in the intensive care unit, may
require mechanical ventilation postoperatively, and are at signi fi cant risk
for perioperative complications [ 37, 38 ] .
An important step to remember prior to attempting abdominal wall
reconstruction is reducing the bio-burden in the operative fi eld. If fi stula
or ostomy output is poorly controlled, or there is a chronically infected
wound or mesh, a staged procedure may be preferable, or the procedure
Fig. 24.6. Planned ventral hernia.
293
24. What Is a Complex Abdominal Wall?
should be delayed. The Ventral Hernia Working Group has helped
develop a hernia grading system that can assist the surgeon in evaluating
a patient’s risk for complications [ 39 ] .
(a) Grade 1 = low risk. These patients are at low risk for complications,
having had no history of wound infection and an uncomplicated
past medical history. By de fi nition, almost none of the patients
with a complex abdominal wall fall under this category.
(b) Grade 2 = comorbid. Includes patients who smoke; are obese,
diabetic, immunosuppressed, and malnourished; and have
COPD or other factors associated with poor wound healing.
(c) Grade 3 = potentially contaminated. Includes patients who have
had a previous wound infection, have a stoma or fi stula present,
or have violation of the GI tract during their procedure.
(d) Grade 4 = infected. These patients have had gross contamination
and/or active infection.
Although, this grading system still requires validation, it provides a
resource for surgeons to assist their clinical decision making and counsel
their patients.
The primary goal in reconstructing the complex abdominal wall is
reapproximating the midline to the greatest extent possible. This
should be accomplished using component separation when appropriate
Fig. 24.7 Abdominal wall reconstruction.
294
M.M. Ott and J.J. Diaz Jr.
[ 33, 39– 41 ] . Our group favors component separation with the use of a
biologic mesh underlay or onlay to maximize support. The reasoning
behind the choice of a biologic mesh is that the majority of these patients
will have multiple risk factors for recurrence and/or surgical site infection.
Technical details of component separation and other techniques for repair
of the complex abdominal wall are discussed elsewhere in this book.
Conclusion
The complex abdominal wall provides a unique challenge for a
surgeon. Understanding the etiology of this clinical entity, meticulous
perioperative planning, management of patient risk factors, and a
systematic approach to the management of these patients will lead the
best outcomes.
References
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conference of experts on intra-abdominal hypertension and abdominal compartment
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are treatments improving? Surgery. 2006;140:570–6.
23. Ramsay PT, Mejia VA. Management of enteroatmospheric fi stulae in the open
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25. Wind J, van Koperen PJ, Slors JF, Bemelman WA. Single-stage closure of
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using the components separation technique. Am J Surg. 2009;197:24–9.
26. Diaz Jr JJ, Conquest AM, Ferzoco SJ, et al. Multi-institutional experience using human
acellular dermal matrix for ventral hernia repair in a compromised surgical fi eld. Arch
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27. Finan KR, Vick CC, Kiefe CI, Neumayer L, Hawn MT. Predictors of wound infection
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28. Dunne JR, Malone DL, Tracy JK, Napolitano LM. Abdominal wall hernias: risk
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29. van Boele HP, Wind J, Dijkgraaf MG, Busch OR, Carel GJ. Temporary closure of the
open abdomen: a systematic review on delayed primary fascial closure in patients with
an open abdomen. World J Surg. 2009;33:199–207.
30. Ghazi B, Deigni O, Yezhelyev M, Losken A. Current options in the management of
complex abdominal wall defects. Ann Plast Surg. 2011;66(5):488–92.
31. Miller PR, Meredith JW, Johnson JC, Chang MC. Prospective evaluation of vacuum-
assisted fascial closure after open abdomen: planned ventral hernia rate is substantially
reduced. Ann Surg. 2004;239:608–14.
32. Miller RS, Morris Jr JA, Diaz Jr JJ, Herring MB, May AK. Complications after 344
damage-control open celiotomies. J Trauma. 2005;59:1365–71.
33. Ko JH, Wang EC, Salvay DM, Paul BC, Dumanian GA. Abdominal wall reconstruction:
lessons learned from 200 “components separation” procedures. Arch Surg.
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34. Candage R, Jones K, Luchette FA, Sinacore JM, Vandevender D, Reed RL. Use of
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35. Howdieshell TR, Proctor CD, Sternberg E, Cue JI, Mondy JS, Hawkins ML. Temporary
abdominal closure followed by de fi nitive abdominal wall reconstruction of the open
abdomen. Am J Surg. 2004;188:301–6.
36. Fabian TC, Croce MA, Pritchard FE, et al. Planned ventral hernia. Staged management
for acute abdominal wall defects. Ann Surg. 1994;219:643–50.
37. DiCocco JM, Magnotti LJ, Emmett KP, et al. Long-term follow-up of abdominal wall
reconstruction after planned ventral hernia: a 15-year experience. J Am Coll Surg.
2010;210:686–8.
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reconstruction following open abdomen. J Trauma. 2011;70:285–91.
39. Breuing K, Butler CE, Ferzoco S, et al. Incisional ventral hernias: review of the
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40. de Vries Reilingh TS, van Goor H, Charbon JA, et al. Repair of giant midline abdominal
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Part VI
Techniques for Ventral and Incisional
Hernia Repair
299
B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair,
DOI 10.1007/978-1-4614-4824-2_25,
© Springer Science+Business Media New York 2013
25. Synthetic Prosthetic Choices in
Ventral Hernia Repair
Sheila A. Grant
Background on Hernia Mesh for Ventral Repair
Ventral hernia repair is a common procedure with over 250,000
repairs each year in the United States [ 1 ] . Most ventral hernias are
repaired using tension-free type of repair, but prior to 1970, tension
(primary suture) repair was common. Due to the high tension and stress
placed on either side of the defect, this tension-type repair led to many
complications, such as pain, discomfort, and recurrence [ 2– 8 ] . To reduce
complications, a mesh that could bridge the defect and/or reinforce the
abdominal wall was introduced that led to a tension-free type of repair.
In 1959, Usher and colleagues are credited with the fi rst modern tension-
free repair when they utilized a synthetic polymeric material, a
polypropylene mono fi lament mesh known then as Marlex. However, this
need for reinforcement materials was noted as far back as the 1900s.
Much earlier, mesh material designs were investigated such as silver
mesh (1900 and 1940s), tantalum (1948), and stainless steel (1950s) [ 8 ] .
The problems stemming from these metallic meshes were disintegration
of the metal, metallic fatigue, and fracture, and thus, metallic meshes
were discontinued.
The utilization of mesh to bridge the hernia defect led to the reduction
of recurrences and alleviated some complications. Many studies have
been performed detailing the ability of hernia mesh to reduce compli-
cations and recurrences [ 9– 13 ] . For example, in a study from the
Netherlands, hernia recurrence with a sutured tissue repair resulted in a
63% recurrence rate, as opposed to a 32% recurrence rate using a
prosthetic [ 13 ] . Unfortunately, even with a mesh scaffold, the recurrence
rates are still very high with the standard ventral hernia repair. For
example, Luijendijk et al. performed a prospective clinical study that
300
S.A. Grant
demonstrated an approximate 25% recurrence rate of ventral hernias
repaired with synthetic mesh within 3 years [ 14 ] . Another study showed
reoperation rates of 12.3% at 5 years and 23% at 13 years when using
hernia mesh for ventral repair [ 15 ] .
Many of the complications that result when synthetic mesh is used
are potentially due to the body’s foreign body response. Initially, an
aggressive foreign body response was touted as necessary since it
resulted in scar plate formation that, for all intents and purposes,
reinforced the abdominal wall. However, it has since been discovered
that this response may also lead to mesh degradation and other
complications. Numerous studies have shown shrinkage, contraction,
and distortion of the hernia mesh that have led to pain and recurrence
[ 16– 20 ] . The use of mesh in ventral hernia repair also presented such
complications as visceral adhesions, erosion into the bowel, extrusion of
the repair materials, and infection [ 1 ] . Figure 25.1 displays an explanted
hernia mesh. Scar tissue, contraction, and distortion of the mesh are
apparent, which may be due to excess foreign body response, mismatch
of material-tissue properties, and/or non-inertness of the mesh (oxidation,
hydrolysis, etc.), which all could be enhanced by particular patient
demographics [ 16, 17 ] .
Fig. 25.1. Explanted polypropylene mesh.
301
25. Synthetic Prosthetic Choices in Ventral Hernia Repair
Surgeons are faced with controversies and a general lack of consensus
on what type of repair should be reinforced, what type of mesh material
to use (synthetic vs. biologic), and what type of technique to use for
repair. To improve the outcome of ventral hernia repair, Breuing and
colleagues [ 1 ] developed an algorithm, which provided fl owcharts for
treatment considerations for incisional ventral hernia repair. Their
algorithm took into account the surgical technique (laparascopic vs.
open), the size of the defect (less than or greater than 2 cm), and patient
assessment for risk of surgical-site occurrence or hernia recurrence.
Their group, the Ventral Hernia Working Group, was established to
evaluate new technologies and techniques in ventral hernia repair. While
the group did mention mesh materials in a broad sense, detailed
algorithms are also needed for choosing the “best” hernia mesh for the
patient.
Today’s mesh can be broadly classi fi ed as synthetic, biologic, or
resorbable. This chapter will not address the biologic hernia mesh but
will investigate the state of the current permanent synthetic and resorbable
synthetic mesh.
Current Mesh Materials
An ideal mesh for laparoscopic ventral hernia repair would elicit the
correct physiological response such as no adhesion formation on the
visceral side, no infection, no allergic or hypersensitivity reaction, limited
foreign body reaction, and adequate biocompatibility to recapitulate
tissue. But the mesh material would ideally also possess certain engineering
properties such as strength, ease of handling, proper mechanical strains
(similar to the abdominal wall), be sterilizable, be inert to body and tissue
fl uids, and be capable to be fabricated in different forms (knits,
mono fi laments, etc.). Unfortunately, there will never be an ideal mesh
because of the complex and variable interactions between the various
types of mesh and the complex characteristics and responses presented by
different groups of patients. However, using the principles of complexity
science, it should be possible over time to make better and better mesh
decisions for various techniques and patient groups (clusters).
The three main types of hernia mesh materials are polypropy-
lene, polyethylene terephthalate, and expanded polytetra fl uoroethylene
(ePTFE). Polypropylene is a semicrystalline material with hydrophobic
tendency. Typically polypropylene fi bers are extruded and then are
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S.A. Grant
woven or knitted into particular mono fi lament or multi fi lament designs.
These designs dictate the overall mechanical strength and strain of the
mesh. Initially, most polypropylene hernia mesh utilized a small,
dense pore design. These “heavyweight mesh” had small pores and a
surface area greater than 90 g/m
2
area of material, which resulted in an
intense foreign body response. The resulting rigid scar plate formed due
to granuloma bridging between the small pores. Numerous clinical
problems such as mesh extrusion and bowel fi stulas, which have
occurred with heavyweight polypropylene, have been well documented
in literature [ 21 ] .
To reduce the foreign body response and granuloma bridging [ 22 ] ,
mid- and lightweight polypropylene mesh with larger pores (>1 mm),
and smaller fi laments were designed that still could withstand the intra-
abdominal pressures but also would have less material per square meter.
While clinical evidence has demonstrated that the ef fi cacy of most
lightweight meshes are an improvement over the heavyweight mesh in
some patient groups and clinical uses, granulomas and scar tissue
formation may still occur [ 23 ] . Additionally, lighter weight mesh with
larger, open pore design may suffer from premature failure due to mesh
displacement or rupture [ 24 ] .
Polyethylene terephthalate, commonly known as PET or polyester, is
another popular hernia mesh. Like polypropylene, PET can also be
extruded into synthetic fi bers wherein it can be woven into a variety of
mesh designs; PET is also less hydrophobic than polypropylene. Clinical
evidence has also shown a considerable in fl ammatory reaction with gross
tissue ingrowth into the macroporous interstices of the mesh, causing
variable degrees of scar formation. To mitigate some of the in fl ammatory
response and ingrowth potential when placed in contact with the viscera,
coated PET mesh became available (Table 25.1 ).
Polytetra fl uoroethylene (PTFE) is a fl uorocarbon-based polymer and
is a commonly utilized mesh material. Unlike polypropylene and PET,
PTFE is extremely hydrophobic and one of the most chemically inert
polymers. Also utilized as a hernia mesh material is ePTFE, which is
produced by stretching a sheet of PTFE, creating micropores.
Unfortunately, clinical data has shown that the microporous structure
results in poor integration and scar tissue formation, resulting in mesh
contraction and shrinkage [ 25 ] . To allow better tissue integration, PTFE
mesh is available in an open macroporous, mono fi lament design (In fi nit
®
by W.L. Gore and Associates). Another macroporous PTFE mesh is