Tissue Expander‐Assisted Ventral Hernia Repair for the Skin‐Grafted Damage Control Abdomen

Abstract

In the article under discussion, Carr presents a series of three patients with late reconstruction of skin grafted large ventral hernias [1]. What makes his article exceptional is that he has used tissue expansion before reconstructing the hernias. Tissue expansion is more a tradition of pediatric plastic surgeons and is rarely used in the treatment of abdominal wall defects. In his work, tissue expansion was used in patients with enterostomies that were not published before. He did not encounter any infectious complications in his patients which is significant. Nevertheless, the number of patients is so small that it is not possible to draw very strong conclusions regarding this treatment method. The report can be judged more or less as an extended case study. Moreover, there are a few remarks that I would like to make. In the introduction the author claims that after damagecontrol surgery many patients are now surviving with skingraft-on-bowel ventral hernias. In the past this has been the case, but the number of skin grafted open abdomen patients has become strongly reduced lately. This is so because of the use of negative pressure devices with mesh-mediated traction in the initial phase of open abdomen treatment. With such techniques it is now rare for an open abdomen patient to end up having a skin grafted hernia [2]. Carr also states that: ‘‘operative steps do not include any mention of what to do in the patient who does not have sufficient skin to close the wound after the skin graft is removed.’’ This might be true according to the references used in this article, but for a reconstructive surgeon a large full-thickness abdominal wall defect is a straightforward indication for a flap reconstruction [3]. For fascial closure, Carr has used component separation and acellular dermal matrix (ADM) mesh with the bridging method. According to current experience, a bridged ADM is only a temporary solution for hernia repair. A bulking or recurrent hernia is to be expected in long run [4]. In this series one patient already had a recurrent hernia, and two were good at one year of follow-up and it is to be seen if this might show up after the follow-up period for these two patients. Late correction of a ventral hernia after skin expansion is not a piece of cake. The defect should be closed with a material more durable than ADM in the secondary phase. The risk of a wound complication is evident because the expanded thin skin has to be released in order to replace the ADM with a new mesh. For these reasons my choice would be a flap reconstruction is this kind of case. With a thigh flap one can get a living fascia to replace the missing fascia and skin. Under a flap one can use a mesh for temporary closure to make sure that the hernia will not recur. Tissue expansion is principally an easy operation. Creating a pocket for an expander is not difficult. Nevertheless, tissue expansion is combined with a lot of problems that are faced by surgeons who use it a lot. Placing the expanders, choosing the form and size, and determining filling intervals and the amount of filling, etc. require a lot of experience to be done safely and effectively. There are well known complications with expanders like infection, extrusion, and rupture of the implant, for which the surgeon has to be prepared. In one case reported by Carr, one of the expanders ruptured and was not replaced by another. Because of this, the author could not remove the skin graft completely, leading to an expected wound necrosis and secondary healing. Looking back, he should have completed the expansion as planned by replacing the ruptured implant with another. Carr states that ‘‘what is unique about the experience described in this article is that the tissue expanders were H. Kuokkanen (&) Tampere University Hospital, Tampere, Finland e-mail: hannu.kuokkanen@pshp.fi