Outcomes of Synthetic Mesh in Contaminated Ventral Hernia Repairs
TL;DR: Although perhaps not yet considered standard of care in the United States, this work has demonstrated favorable infection, recurrence, and mesh removal rates associated with the use of synthetic mesh in contaminated VHR.
Abstract: Background Given the questionable long-term durability of biologic meshes, additional prosthetic options for ventral hernia repairs (VHR) in contaminated fields are necessary. Recent evidence suggests improved bacterial resistance of reduced-weight, large-pore synthetics, giving a potential mesh alternative for repair of contaminated hernias. We aimed to evaluate the clinical outcomes of 2 institutions' experience implanting lightweight polypropylene synthetic mesh in clean-contaminated and contaminated fields. Study Design Open VHRs performed with polypropylene mesh in the retro-rectus position in clean-contaminated and contaminated fields were evaluated. Primary outcomes parameters included surgical site infection, surgical site occurrence, mesh removal, and hernia recurrence. Results One hundred patients (50 male, 50 female) with a mean age of 60 ± 13 years and a mean body mass index (calculated as kg/m 2 ) of 32 ± 9.3 met inclusion criteria. There were 42 clean-contaminated and 58 contaminated cases. The incidence of surgical site occurrence was 26.2% in clean-contaminated cases and 34% in contaminated cases. The 30-day surgical site infection rate was 7.1% for clean-contaminated cases and 19.0% for contaminated cases. There were a total of 7 recurrences with a mean follow-up of 10.8 ± 9.9 months (range 1 to 63 months). Mesh removal was required in 4 patients: 2 due to early anastomotic leaks, 1 due to stomal disruption and retraction in a morbidly obese patient, and 1 from a long-term enterocutaneous fistula. Conclusions Although perhaps not yet considered standard of care in the United States, we have demonstrated favorable infection, recurrence, and mesh removal rates associated with the use of synthetic mesh in contaminated VHR.
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TL;DR: In this paper, the authors evaluated biosynthetic absorbable mesh in single-staged contaminated (Centers for Disease Control class II and III) ventral hernia (CVH) repair over 24 months.
Abstract: Objective:The aim of the study was to evaluate biosynthetic absorbable mesh in single-staged contaminated (Centers for Disease Control class II and III) ventral hernia (CVH) repair over 24 months.Background:CVH has an increased risk of postoperative infection. CVH repair with synthetic or biologic m
200 citations
TL;DR: In this large series of complex AWR patients, it is demonstrated that posterior component separation via TAR with wide synthetic mesh sublay provides a very durable repair with low morbidity, even in comorbid patients with large defects.
Abstract: Objective:To evaluate the safety and efficacy of transversus abdominis muscle release (TAR) with retrorectus synthetic mesh reinforcement in a large series of complex hernia patients.Background:Posterior component separation via TAR during abdominal wall reconstruction (AWR) continues to gain popula
160 citations
Cites background from "Outcomes of Synthetic Mesh in Conta..."
...We have utilized synthetic mesh in clean-contaminated and contaminated instances, with minimal gross spillage, and have previously reported acceptable outcomes.(42) We attribute these favorable prosthetic choices coupled with bilaminar fascial coverage in our ability to overcome wound morbidity....
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TL;DR: Using synthetic sublay mesh resulted in a significantly lower wound morbidity and more durable outcomes versus a similar cohort of biologic repairs, likely secondary to improved bacterial clearance and faster integration of macroporous synthetics.
119 citations
Cites background from "Outcomes of Synthetic Mesh in Conta..."
...Moreover, there is mounting evidence that certain synthetic meshes may not only serve as a viable option in contaminated repairs, but may actually be better able to overcome infective complications.(7,9) Although the pendulum appears to be swinging away from biologics, there remains widespread hesitancy to deploy synthetic implants in contaminated operative fields where the risk of mesh infective complications may outweigh their potential benefit in terms of lower recurrence rates....
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01 Jan 2017
TL;DR: In this prospective longitudinal study, biosynthetic absorbable mesh showed efficacy in terms of long-term recurrence and quality of life for CVH repair patients and offers an alternative to biologic and permanent synthetic meshes in these complex situations.
Abstract: Objective:The aim of the study was to evaluate biosynthetic absorbable mesh in single-staged contaminated (Centers for Disease Control class II and III) ventral hernia (CVH) repair over 24 months.Background:CVH has an increased risk of postoperative infection. CVH repair with synthetic or biologic m
110 citations
TL;DR: Wound events are common after open mesh repairs of complex incisional hernias and previous mesh infections and recurrent repairs increase the likelihood of an SSI, which significantly increases the risk of recurrence.
Abstract: Background Mesh repair of incisional hernias has been consistently shown to diminish recurrence rates after repair, with an increased risk of infectious complications. We present a consecutive series of elective, retrorectus mesh repairs of the abdominal wall and attempt to determine predictors of wound events and recurrence. Study Design A retrospective review was performed to include elective, retromuscular mesh repairs of complex incisional hernias from August 2006 to August 2013. Demographics, operative details, and postoperative events including wound events, surgical site infections (SSI), and recurrences were recorded. Results Over the 7-year period, 255 retromuscular mesh repairs of midline incisional defects were performed. Median age of the patients was 58 years, with an average BMI of 32.2 kg/m 2 . Average size of the fascial defect was 181.4 cm 2 , with recurrent defects making up 48% of repairs. Wound events occurred in 37.7% of cases; SSIs occurred in 19.6% of cases. Recurrence rate was 16.9%, with mean time to recurrence of 19.2 months. With respect to mesh type, recurrences were 16.2% with synthetic, 17.1% for bioabsorbable, and 25% for biologic mesh. When evaluating polypropylene meshes, recurrence was more likely with lightweight mesh (22.9%) vs midweight mesh (10.6%) (p = 0.045). Predictors of SSI included history of mesh infection (odds ratio [OR] 4.8, 95% CI 1.9 to 12.1; p Conclusions Wound events are common after open mesh repairs of complex incisional hernias. Previous mesh infections and recurrent repairs increase the likelihood of an SSI, which significantly increases the risk of recurrence. Recurrences after retrorectus mesh repairs are significantly higher with lightweight compared with mid-weight meshes.
109 citations
References
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TL;DR: Among patients with midline abdominal incisional hernias, mesh repair is superior to suture repair with regard to the recurrence of hernia, regardless of the size of the hernia.
Abstract: Background Incisional hernia is an important complication of abdominal surgery. Procedures for the repair of these hernias with sutures and with mesh have been reported, but there is no consensus about which type of procedure is best. Methods Between March 1992 and February 1998, we performed a multicenter trial in which we randomly assigned to suture repair or mesh repair 200 patients who were scheduled to undergo repair of a primary hernia or a first recurrence of hernia at the site of a vertical midline incision of the abdomen of less than 6 cm in length or width. The patients were followed up by physical examination at 1, 6, 12, 18, 24, and 36 months. Recurrence rates and potential risk factors for recurrent incisional hernia were analyzed with the use of life-table methods. Results Among the 154 patients with primary hernias and the 27 patients with first-time recurrent hernias who were eligible for the study, 56 had recurrences during the follow-up period. The three-year cumulative rates of recurren...
1,722 citations
TL;DR: It is suggested that large abdominal- wall defects can be reconstructed with functional transfer of abdominal-wall components without the need for resorting to distant transposition of free-muscle flaps.
Abstract: Closure of large abdominal-wall defects usually requires the transposition of remote myocutaneous flaps or free-tissue transfers. The purpose of this study was to determine if separation of the muscle components of the abdominal wall would allow mobilization of each unit over a greater distance than possible by mobilization of the entire abdominal wall as a block. The abdominal walls of 10 fresh cadavers were dissected. This demonstrated that the external oblique muscle can be separated from the internal oblique in a relatively avascular plane. The rectus muscle with its overlying rectus fascia can be elevated from the posterior rectus sheath. The compound flap of the rectus muscle, with its attached internal oblique-transversus abdominis muscle, can be advanced 10 cm around the waistline. The external oblique has limited advancement. These findings were utilized clinically in the reconstruction of abdominal-wall defects in 11 patients, ranging in size from 4 x 4 to 18 x 35 cm. This study suggests that large abdominal-wall defects can be reconstructed with functional transfer of abdominal-wall components without the need for resorting to distant transposition of free-muscle flaps.
1,185 citations
TL;DR: A novel hernia grading system based on risk factor characteristics of the patient and the wound is proposed so that surgeons may better assess each patient's risk for surgical-site occurrences and thereby select the appropriate surgical technique, repair material, and overall clinical approach for the patient.
873 citations
TL;DR: VHRs continue to rise in incidence and cost and a cost saving of US $32 million dollars for each 1% reduction in operations would result, which is critical to cost effective healthcare.
Abstract: Purpose
Ventral hernia repair (VHR) lacks standardization of care and exhibits variation in delivery. Complications of VHR, notably recurrence and infection, increase costs. Efforts at obtaining federal funding for VHR research are frequently unsuccessful, in part due to misperceptions that VHR is not a clinical challenge and has minimal impact on healthcare resources. We analyzed national trends for VHR performance and associated costs to demonstrate potential savings resulting from an improvement in outcomes.
719 citations