Abstract: Posterior Sheath Repair in Abdominal Wall Reconstruction: Achieving Retromuscular Mesh Placement

Abstract

INTRODUCTION: Ventral hernia repair (VHR) remains a difficult surgical problem to manage. Retromuscular sublay mesh placement in VHR consistently provides favorable outcomes regardless of mesh type utilized, presumably highlighting the importance of the posterior rectus sheath. We hypothesized that posterior sheath repair to achieve retromuscular closure demonstrates improved outcomes compared to intraperitoneal repair as well as comparable recurrence and complication profiles to retromuscular sublay repair. METHODS: We performed a single-institution retrospective review over three-years of consecutive hernia repairs for two surgeons. Included patients were grouped according to repair-type: A) sublay placement with reconstructed posterior sheath, B) retromuscular repair with unaltered posterior sheath, and C) intraperitoneal or underlay repair. Primary outcome measures included hernia recurrence and surgical site occurrence (SSO). Analysis included multivariate logistic regression and descriptive statistics. RESULTS: One-hundred seventy-nine patients met inclusion criteria. There were 25 (14.0%) in Group-A, 89 (48.7%) in Group-B, and 65 (36.3%) in Group-C. Groups did not differ in average age 56.5 (p<0.298), BMI 32.4 (p<0.774), incidence of diabetes, hypertension, hyperlipidemia, COPD, tobacco use, OR time, or ostomy reversal. The majority of cases consisted of ASA class 3 (54.2%), Ventral Hernia Working Group (VHWG) class 2 (47.5%), and clean wound classification (63.7%). Prior hernia repairs were performed in 102 (57%) patients. Biologic mesh was used in 56 (31.3%) patients, synthetic in 103 (57.5%), and biosynthetic in 20 (11.2%). Patient post-operative follow-up averaged 15.5 months. Analysis of 11 recurrences yielded significant differences between Groups-B and C (p<0.009), a trend towards significance between Groups-A and C (p<0.058), and no difference between Groups-A and B (p<0.608). Retromuscular mesh placement and anterior components separation demonstrated protective effects on recurrence (OR: 0.148, p<0.081 and OR: 0.259, p<0.067). Postoperative mesh infection (OR: 72.03, p<0.012) and seroma (OR: 8.992, p<0.036) were significant predictors of hernia recurrence. BMI (OR: 1.052, p<0.015), VHWG (OR: 1.617, p<0.036), and hyperlipidemia (OR: 2.157, p<0.049) were significant predictors of SSO on multivariate regression. The posterior sheath was reconstructed primarily using absorbable suture for small defects, or biologic mesh for larger defects. CONCLUSION: Initial analysis of posterior sheath repair to allow for retromuscular VHR suggests noninferiority, when compared to traditional sublay reconstruction. We present the first known description of discrete posterior sheath reconstruction to aid in retromuscular closure of complex ventral hernia.