The use of component separation during abdominal wall reconstruction in contaminated fields: A case-control analysis

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Highlights

  • ā€¢

    This is a propensity score matching study finding similar results in AWR with and without component separation.

  • ā€¢

    The data shows similar wound complications, hernia recurrences, and mesh infections in both groups.

  • ā€¢

    This suggests that the use of component separation techniques in contaminated wounds is safe and effective in hernia repair.

Abstract

Background

Component separation technique (CST) allows fascial medialization during abdominal wall reconstruction (AWR). Wound contamination increases the incidence of wound complications, which multiplies the incidence of repair failure. The aim of this study was to compare the impact of CST on AWR outcomes in contaminated fields in comparison to those operations without CST.

Methods

A prospective, single institution hernia database was queried for patients undergoing AWR with CST and contamination. A case control cohort was identified using propensity score matching.

Results

There were 286 CSTs performed in contaminated cases. After propensity score matching, 61 CSTs were compared to 61 No-CSTs. These groups were matched by defect area (CST:287.1ā€ÆĀ±ā€Æ150.4 vs No-CST:277.6ā€ÆĀ±ā€Æ218.4ā€Æcm2, pā€Æ=ā€Æ0.156), BMI (32.0ā€ÆĀ±ā€Æ7.0 vs 32.2ā€ÆĀ±ā€Æ6.0ā€Ækg/m2, pā€Æ=ā€Æ0.767), diabetes (26.2% vs 32.8%, pā€Æ=ā€Æ0.427), and panniculectomy (52.5% vs 36.1%, pā€Æ=ā€Æ0.068). Groups had similar rates of wound complications (42.6% vs 40.7%, pā€Æ=ā€Æ0.829) and recurrence (4.9% vs 13.1%, pā€Æ=ā€Æ0.114).

Conclusions

The use of CST in the face of contamination is not associated with an increase in wound complications, mesh complications, or recurrence.

Introduction

Ventral hernia repair (VHR) remains one of the most common surgeries in the United States with over 350,000 cases performed yearly.1 Achievement of fascial re-approximation, mesh reinforcement, reduced incidence of wound complications, and the avoidance of bridging meshes have all been demonstrated to reduce recurrence rates.2, 3, 4, 5, 6, 7, 8, 9 When the fascial defect is large and there is loss of domain, component separation techniques (CST) may be required to allow for medialization of the linea alba and approximation of the fascia in the midline. The term CST was coined by Ramirez etĀ al., in 1990 when they described the release of the external oblique (EOR) combined with posterior rectus sheath release.10 However, the use of fascial division to allow for ā€œtension reliefā€ to assist in repair of ventral hernias was described by Young in the early 1960s.11 Perhaps the greatest challenge of these operations, especially EOR with large skin flap dissection, is the increased risk of wound complications.12 Given this and the musculo-fascial division required as part of CST, the performance of CST versus a bridging technique might be questioned. In a recent meta-analysis, Holihan etĀ al. examined CST versus a bridging mesh repair and demonstrated that CST was associated with a decrease in recurrence rate.7 In a more recent study examining 775 CSTs, our group demonstrated similar findings.13

Surgical wound class defined by the level of contamination has been well delineated by the Center for Disease Control (CDC). The CDC Wound Class from 1 to 4 correlates directly with an increasing risk of surgical site occurrences (SSO), especially infection, in VHR,14 and often results in an alteration in the controversial and much debated mesh selection for these cases.15, 16, 17, 18, 19, 20 Wound complications in abdominal wall reconstruction (AWR) increase hernia recurrence by 3ā€“5 times compared to those operations without these complications.13,21,22 Thus, the combination of CST used in a contaminated field could potentially pose a marked increased risk of wound complications, which may offset the benefits attributable to CST. The purpose of this study was to be one of the first to examine the outcomes of CST AWR in the setting of CDC class 2, 3, and 4 wounds as compared to similar cases that did not involve CST.

Section snippets

Study population

All CST were performed at the Carolinas Medical Center in Charlotte, North Carolina. The majority of patients were referred from other centers, frequently with recurrent hernias and most had co-morbidities. All open AWR utilizing CST were examined, including incisional, ventral, and flank hernias. A propensity match was performed for case control.

Study design

After Institutional Review Board approval, an institutional, prospectively-maintained, hernia-specific database was queried for all CST between 2006

Results

There were 286 CSTs performed in contaminated cases. After applying exclusion criteria, there were 186 CSTs analyzed for matching with 63 No-CST cases. After propensity score matching, there were 61 cases with CST matched to 61 cases without CST for comparison.

A subset analysis was performed initially to compare the anterior CST and the posterior CST that were included after matching. Twenty patients received anterior CST and 41 received posterior techniques. These two groups differed in terms

Discussion

This study examined patients undergoing open ventral hernia repair in a contaminated setting and compared outcomes based on performance of CST. This allowed for applicable comparisons in AWR in the setting of CDC class 2, 3, and 4 wounds. The two groups identified have similar pre-operative characteristics with few exceptions, which were limited to COPD and the mean number of previous VHRs. The CST and No-CST groups had very similar hernias, including an equal number of patients in the various

Conclusions

The use of CST in the face of contamination is not associated with an increase in wound complications, mesh infection, or recurrence. These results demonstrate that the use of CST in contaminated fields during preperitoneal open ventral hernia repair is safe and effective.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

Drs. Maloney, Oma, Schlosser, and Sing have nothing to disclose. Ms. Prasad has nothing to disclose. Dr. Kercher is on the speakersā€™ bureau at Bard, Ethicon, and W.L. Gore.

Dr. Colavita is on the speakersā€™ bureau at Allergan.

Dr. Augenstein is on the speakersā€™ bureau at Allergan, Intuitive, Acelity, and W.L. Gore.

Dr. Heniford is on the speakersā€™ bureau at Allergen and W.L. Gore and has received grants from Allergen and W.L. Gore.

References (38)

  • A. Jack et al.

    Abdominal incision

    Lancet

    (1989)
  • J.H. Booth et al.

    Primary fascial closure with mesh reinforcement is superior to bridged mesh repair for abdominal wall reconstruction

    JĀ Am Coll Surg

    (2013)
  • J.W. Burger et al.

    Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia

    Ann Surg

    (2004)
  • W.S. Cobb et al.

    Infection risk of open placement of intraperitoneal composite mesh

    Am Surg

    (2009)
  • D. Den Hartog et al.

    Isokinetic strength of the trunk Xexor muscles after surgical repair for incisional hernia

    Hernia

    (2010)
  • J.L. Holihan et al.

    Component separation vs. Bridged repair for large ventral hernias: a multi-institutional risk-adjusted comparison, systematic review, and meta-analysis

    Surg Infect (Larchmt).

    (2016)
  • R.W. Luijendijk et al.

    AĀ comparison of suture repair with mesh repair for incisional hernia

    NĀ Engl J Med

    (2000)
  • K. Suwa et al.

    Primary fascial closure with laparoscopic ventral hernia repair: systematic review

    Dan Med J

    (2016)
  • O.M. Ramirez et al.

    ā€œComponents separationā€ method for closure of abdominal-wall defects: an anatomic and clinical study

    Plast Reconstr Surg

    (1990)
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