Repair Of Massive Ventral Hernias Research Articles

Massive Ventral Hernia Repair: A Novel Technique with an Innovative Device

Massive Ventral Hernia Repair: A Novel Technique with an Innovative Device

Defining surgical outcomes and quality of life in massive ventral hernia repair: an international multicenter prospective study

BackgroundOur goal was to set criteria for massive ventral hernia and to compare surgical outcomes and quality of life after ventral hernia repair (VHR). MethodsThe International Hernia Mesh Registry was queried for patients undergoing VHR from 2007 to 2013. Defect was categorized as massive if the width or length was greater than 15 cm or area greater than 150 cm2. Massive VHR was compared to regular VHR. ResultsA total of 878 patients underwent VHR: 436 open, 442 laparoscopic with 13 deaths (1.5%) and 45 hernia recurrences (5.1%). Of those, 158 patients (18%) met criteria for massive VHR. Massive VHR patients had longer length of stay (LOS) and operative time and more hematomas, wound infections, wound complications, and pneumonias (P < .05). On multivariate analysis, LOS was longer, and early postoperative pain and activity limitation were greater in massive VHRs (P < .01). Massive VHR in the laparoscopic approach resulted in greater long-term mesh sensation (P < .01). ConclusionsVHR in massive hernias have increased rates of complications and longer LOS.

Repair of massive ventral hernias with "quilted" mesh.

Prosthetic reinforcement is a critical component of hernia repair. For massive defects, mesh overlap is often limited by the dimensions of commercially available implants. In scenarios where larger mesh prosthetics are required for adequate reinforcement, it may be necessary to join several pieces of mesh together using non-absorbable suture. Here, we report our outcomes for abdominal wall reconstructions in which "quilted" mesh was utilized for fascial reinforcement. Patients undergoing open incisional hernia repair utilizing posterior component separation and transversus abdominis muscle release, with use of quilted synthetic mesh placed in the retromuscular position, were reviewed. Main outcome measures included patient, hernia, and operative characteristics and post-operative outcomes, including surgical site occurrence (SSO), surgical site infection (SSI), and recurrence. Thirty-two patients (mean age 55.7 ± 9.3, BMI 38.3 ± 5.8 kg/m(2)) underwent open ventral hernia repair with "quilted" mesh placed in the retromuscular position. The mean defect area was 760.1 ± 311.0 cm(2) with a mean width of 24.7 ± 6.4 cm. Quilted meshes consisted of two-piece (69 %), three-piece (19 %) and four-piece (12 %) configurations. Wound morbidity consisted of eight (25 %) SSOs, including four (13 %) SSIs, all of which resolved without mesh excision. With mean follow-up of 9.0 ± 13.6 months, there were two (6.3 %) lateral recurrences, both unassociated with mesh-to-mesh suture line failure. Massive ventral hernias that require giant mesh prosthetics, currently not commercially available, may be successfully repaired using multiple mesh pieces sewn together in a quilt-like fashion. Such retromuscular repairs are durable, without added morbidity due to the mesh-to-mesh suture line. However, additional operative time is required for quilting the mesh together, prompting strong calls for manufacturing of larger mesh prosthetics.

Panniculectomy: an alternative approach to the revision of a difficult stoma

We describe a modified abdominoplasty technique as an alternative approach to the revision of a difficult stoma. A patient with a retracted colostomy secondary to change in abdominal wall contour following significant weight loss was treated with this technique. The patient had previous colostomy revision with marlex mesh insertion for combined parastomal and massive ventral hernia repair. A preoperatively marked crescent shaped left upper quadrant segment of skin and subcutaneous fat was excised and the defect was approximated in multiple layers. This shifted the stoma opening cephalad and eliminated the cutaneous crease that originally made it difficult to obtain a proper stoma seal. At one year follow up the patient was extremely satisfied with the results and was able to properly pouch the stoma. Modified abdominoplasty can be used as an alternative, low morbid approach in dealing with selected patients with difficult stoma problems.

Prospective Measurements of Intra-Abdominal Volume and Pulmonary Function After Repair of Massive Ventral Hernias With the Components Separation Technique

To assess the effect of components separation on abdominal volume and pulmonary function after repair of hernias with loss of domain. Immediate postoperative abdominal compartment syndrome is a feared complication after hernia repair in patients with a "loss of abdominal domain." Replacement of the viscera within an unyielding stiff abdominal wall may compromise the perfusion of the intestines, elevate the diaphragm, and interfere with ventilation. The components separation technique, used to repair these massive hernias, employs bilateral relaxing incisions in the external oblique muscle and fascia to approximate the rectus abdominis muscles in the midline. Nineteen consecutive patients with large ventral hernias were enrolled. Intra-abdominal volumes were prospectively measured before and after hernia repair, using computer analysis of abdominal CT scans. Pulmonary function tests were similarly obtained before and after surgery. Statistical analysis was performed using paired student's t test. This study was registered at clinicaltrials.gov (ID# NCT00894582). Nine women and 10 men ages 24 to 76 with an average BMI of 30 kg/m had an average hernia size of 915 mL. Intra-abdominal volume increased significantly after separation of parts hernia repair from an average of 7640 to 8166 mL (P=0.01). Diaphragm height did not change significantly (37.1 cm to 37.5 cm, P=0.42). Intraoperative peak airway pressures remained within normal limits for all patients. Pulmonary function testing revealed no significant differences before and after surgery. The components separation repair technique acts to restore lost abdominal domain by increasing its volume, and can be performed on patients with large ventral hernias with acceptable outcomes and without measurable changes in pulmonary function.

Repair of Massive Ventral Hernias with the Separation of Parts Technique: Reversal of the ‘Lost Domain’

Massive ventral hernia repairs are sometimes complicated by the "loss of domain". The separation of parts hernia repair reverses the loss of domain by increasing intra-abdominal volume, but not by elevating the hemidiaphragms into the thoracic cavity. Hernia repair in patients with a "loss of abdominal domain" is thought to be associated with postoperative pulmonary difficulties. A retrospective chart review was performed on 102 patients treated by a single surgeon. The 10 patients with matching preoperative and postoperative abdominal CT scans were computer-analyzed for intra-abdominal volume changes and diaphragm height measurements. Postoperative pulmonary complications in these 102 patients were recorded. Intra-abdominal volume increased after separation of parts hernia repair from 8600 +/- 2800 mL to 9700 +/- 2700 mL (P = 0.01). Diaphragm height did not statistically change. Two of the 102 patients had prolonged intubations, and seven other patients were ventilated briefly. The separation of parts technique is able to close large ventral hernias without a high incidence of pulmonary complications as a result of its ability to expand the abdominal domain without a change in diaphragmatic height.

Recurrent Abdominal Laxity Following Interpositional Human Acellular Dermal Matrix

Repair of large complex abdominal hernias with significant loss of domain requires component separation in combination with either a synthetic or biologic interpositional material. We previously described an algorithm for complex abdominal hernia repair, which incorporates Alloderm as an interpositional material and selective use of prolene mesh as an overlay. We now report recurrent laxity in a series of patients who were repaired with interpositional Alloderm alone without prolene mesh overlay. We reviewed all patients who underwent repair of massive ventral hernias and identified 7 patients who presented with abdominal wall laxity following component separation with interpositional Alloderm alone. All patients developed laxity within 12 months and required a secondary procedure. At the time of re-exploration, severe attenuation in the Alloderm was noted. The segment was excised, the edges closed primarily, and prolene mesh was placed as an onlay. Although Alloderm has been reported to be an effective biologic material for abdominal hernia reconstruction, we have noted significant laxity requiring secondary intervention.

Pregnancy as a Tissue Expander in the Repair of a Massive Ventral Hernia

The use of tissue expanders has been described in numerous applications, including the closure of massive abdominal wall defects. The advantages of tissue expansion include providing adequate soft tissue for stable coverage of prosthetic material. In a subfascial plane, expanders can also expand muscle and fascia to allow total autologous repair of massive ventral hernias. These techniques for abdominal wall reconstruction are well established to cover viscera, to repair hernias, and to restore acceptable contour. The authors present the novel case of a woman with unstable skin graft coverage of a massive ventral hernia whose pregnancy was used as a surrogate intra-abdominal tissue expander to facilitate abdominal wall reconstruction.

Simple technique for laparoscopic paracolostomy hernia repair.

The aim of this study was to describe a simple, minimally invasive, and effective technique for repair of paracolostomy hernia. Mesh is fastened laparoscopically over the colostomy and hernial defect with wide overlap, without dissecting out the sac or repairing the defect, while ensuring enough room for the colon to prevent obstruction at the level of the mesh. The technique has been used successfully in four patients, with follow-up of 2 to 12 months. Operating time and length of stay were short, and there was no recurrence or prolapse of the colostomy. This seems to be an effective, simple, and minimally invasive technique for repairing a difficult problem. Although the number of cases is small and the follow-up has been short, the technique mimics that used in massive ventral hernia repair with good results.

Silon sheeting in the staged repair of massive ventral hernias in children : S. H. Ein, J. C. Fallis and J. S. Simpson. Canadian J. of Surg. 13:127–134 (April), 1970

Silon sheeting in the staged repair of massive ventral hernias in children : S. H. Ein, J. C. Fallis and J. S. Simpson. Canadian J. of Surg. 13:127–134 (April), 1970