Preservation of Deep Epigastric Perforators during Anterior Component Separation Technique Results in Equivalent Wound Complications Compared with Transversus Abdominis Release

Abstract

BACKGROUND: In complex abdominal wall reconstruction, the use of CST increases fascial medialization and facilitates fascial closure; however, ACST has been associated with a high rate of wound complications.1 The purpose of this study was to compare wound complications and perioperative outcomes between a perforator sparing (PS)-ACST and (TAR). METHODS: From a prospective, tertiary hernia center database, patients who underwent open abdominal wall reconstruction with PS-ACST or TAR from 2016 to 2020 were identified. Patients undergoing concurrent panniculectomy were excluded. Outcomes included wound complications, need for reintervention, length of stay, and 30-day readmission. The Carolinas Equation for Determining Associated Risks application was used to predict wound complication rates. A univariate analysis was performed between the PS-ACST and TAR groups. Standard statistical methods and logistic regression were performed. RESULTS: A total of 92 patients met criteria; 37 had PS-ACST and 55 had TAR performed. The PS-ACST and TAR groups were similar in terms of BMI (29.8 ± 8.9 versus 31.3 ± 6.3 kg/m2, P = 0.23) and diabetes (16.2% versus 25.5%, P = 0.32), but the PS-ACST group a greater history of smoking (51.4% versus 14.5%, P < 0.01). Both groups had five comorbidities on average (P = 1.00). Most hernias were recurrent (59.5% versus 61.8%, P = 0.83). CDC wound classes were equivalent. The Carolinas Equation for Determining Associated Risks predicted wound complication rates were: PS-ACS-56.9% (range: 14.2–92.9%) and TAR-39.7 % (range: 7.3–92.2%). Preoperative botulinum toxin A was performed in 43.8% versus 19.1% of cases (P = 0.06). The PS-ACST group had a larger hernia defect size (374.9 ± 156.4 versus 223.7±119.7 cm2, P < 0.01) and increased intraoperative time (242.1 ± 63.8 versus 209.5 ± 71.0 min, P < 0.01). Despite the larger defect size, the mesh size was comparable (1096.0 ± 535.6 versus 944.4 ± 391.5, P = 0.71). Biologic mesh was more frequently utilized in PS-ACS patients (51.4% versus 27.3%, P = 0.03). All PS-ACST patients had a bilateral CST compared with 72.7% who received a TAR (P < 0.01). The fascial defect was fully closed in all but two cases (94.6% versus 100.0%, P = 0.16). Placement of an incisional vacuum-assisted closure device occurred more frequently in the PS-ACST group (32.4% versus 14.5%, P < 0.01). The overall wound complication rate was not significantly different (16.2% versus 20.0%, P = 0.79), neither was superficial dehiscence (5.7% versus 5.7%, P = 1.00), deep wound infection (5.7% versus 9.5%, P = 0.70), or seroma requiring reintervention (5.4% versus 5.5%, P = 0.99). There were no patients in the PS-ACST who required return to the operating room for wound-related issues (0.0% versus 9.6%, P = 0.08), and requirement for a percutaneous drain was uncommon (2.9% versus 7.7%, P = 0.64). Length of stay was one and a half days longer for PS-ACST patients (8.9 ± 5.4 versus 7.3 ± 4.0 days, P = 0.04), but 30-day readmissions were no different (5.4% versus 10.9%, P = 0.47). Using logistic regression, none of the factors that were significantly different in the univariate analysis correlated with wound complications (P > 0.05). CONCLUSIONS: PS-ACST, despite being used for larger defects, had equivalent rates of wound complications and need for reintervention compared with patients undergoing TAR. REFERENCE: 1. Maloney SR, Schlosser KA, Prasad T, et al. Twelve years of component separation technique in abdominal wall reconstruction. Surgery (United States). 2019;166:435–444. doi:10.1016/j.surg.2019.05.043