Monday, November 23, 2009

Abdominal Wall Reconstruction – an Article Review

Updated 3/2017--  all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Last year I wrote a post on abdominal wall reconstruction.   Repairing acquired abdominal wall defects can be challenging.  This article from the November issue of the Archives of Surgery Journal looks at using the “components separation” procedure to repair the defects.
The article authors begin by point out the lack of consensus on the best method of abdominal wall closure.
For primary repair, recurrence rates range from 24% to 54%, with seemingly high recurrence rates after mesh (24%) and suture (43%) repairs.  Although mesh repairs have led to improved recurrence rates overall, synthetic mesh repair is associated with various morbidities. 
They correctly point out the one of the main problems with comparing outcomes in abdominal wall reconstruction is the “lack of a common starting point for patients.”
In other words, midline hernias can be of various sizes, and patients differ in age, weight, tissue quality, wounds, and the need for concurrent bowel surgery.
The “components separation” procedure uses the patients tissues.  It relies on bilateral release of the external oblique muscle and fascia, thereby allowing medial movement of the rectus muscles toward the midline to achieve an innervated midline closure.
The study is a retrospective medical record review of all patients (200, 115 men and 85 women) who underwent the components separation technique for midline abdominal wall defects by a single surgeon (G.A.D.) at Northwestern Memorial Hospital, Chicago, Illinois, between August 2, 1996, and July 2, 2007.
Anyone who sees these issues might find this article of interest.  The “components separation” procedure is not a cure-all. 
For the abdominal wall, despite the lateral releases, the midline repair fails after primary closure of the hernia in 22.5% of cases, independent of whether the repair is performed in a contaminated field.

I would commend the surgeon (G.A.D.) for analyzing his technique over time to see what works and what doesn’t.
Heavyweight polypropylene mesh was used in the early years of the study but was abandoned due to the stiff feel of the prosthetic material rather than to a specific postoperative finding…..
In 2004, consecutive patients had their midline repair augmented with cadaveric dermis with the idea that even if the dermis was not long-lasting, its presence could shield and protect the repair in the early stages of healing. In fact, just the opposite was found: the hernia recurrence rate with a cadaveric dermis underlay was even higher than that for primary closure. …..
Continued dissatisfaction with hernia recurrences after components separation, seen with primary repair and cadaveric dermis, led to the subsequent use of soft midweight polypropylene mesh for augmentation of the strength of the midline closure. At mean follow-up of 13.8 months, no patient who has undergone a components separation procedure using intra-abdominal soft polypropylene mesh in this series has required a revision. ……

Related post

Abdominal Wall Reconstruction:  Lessons Learned From 200 "Components Separation" Procedures;  Arch Surg. 2009;144(11):1047-1055; Jason H. Ko, MD; Edward C. Wang, PhD; David M. Salvay, MS; Benjamin C. Paul, BA; Gregory A. Dumanian, MD


StorytellERdoc said...

I like your website. Where else can you find a pic of a felon beside "Shirley's Arbor Window" LOL

Started my new site and it seems to be going well. Writing more about human emotions than medicine...

I will be following.

gillies said...

Sometimes newer is not always better. The same group published an interesting finding in the September 2009 PRS (124(3) pp 836-837)

Costly acellular cadaveric dermis produces inferior results to traditional prolene and marlex mesh. Another example of the need for evidence-based recommendations on many of the surgical and medical procedures that are assumed to be optimal.