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Complex Abdominal Wall Reconstruction Made "Simple": Long-term Outcomes Using Component Separation With P4hb Onlay Technique
Adam S. Levy, MD1, Jaime L. Bernstein, MD1, Kerry A. Morrison, MD2, Ishani D. Premaratne, BS3, Michael Lieberman, MD3, Alfons Pomp, MD3, Christine H. Rohde, MD4, David M. Otterburn, MD3, Jason A. Spector, MD3.
1NY Presbyterian Hospital - Cornell/Columbia, New York, NY, USA, 2NYU Langone Medical Center, New York, NY, USA, 3NY Presbyterian Hospital - Weill Cornell Medicine, New York, NY, USA, 4Columbia University Medical Center, New York, NY, USA.

Purpose: Complex abdominal wall reconstruction (CAWR) for ventral hernia repair addresses a challenging and morbid patient population. Increasingly, patients have multiple prior attempts at hernia repair leaving them without a rectus and/or posterior sheath available to perform a retrorectus repair, as well as contaminated or infected wounds, both of which obviate use of permanent plastic mesh. We have previously shown our onlay mesh technique utilizing biosynthetic mesh (Poly-4-hydroxybutyrate; P4HB) yields excellent results in the short and medium term (5% recurrence at 7mo; 8% at 16mo). Herein we review the long term results from our first three years using a P4HB onlay after performing component separation (CS).
Methods: All patients (n=105) undergoing CAWR between June 2014 and May 2017 at two major university hospitals were followed prospectively for post-operative outcomes. In this particular cohort, surgical repair involved bilateral components separation with elevation of the external oblique musculoaponeurotic complex laterally to the origin of its segmental vascular supply, followed by primary fascial repair at the midline and P4HB mesh onlay secured to the released lateral edges of the external oblique fascia. Patients were followed up to 63 months to track outcomes, including wound complications, hernia recurrence, and incidence of reoperation.
Results: 105 patients (110 cases; 52 male, 53 female; mean 59 years, range 22-84) underwent CAWR. Mean BMI was 29 (range 16-48). Fifty-seven (54%) patients had failed at least one prior attempted repair with >3.5 prior abdominal operations on average (range 0-12). 69 (66%) patients had at least 2 major medical comorbidities and 79 (72%) patients were ASA 3 or greater. In thirty-three (30%) cases the field was contaminated (either infected and/or bowel lumen exposed) at time of repair. Median follow up was 35 months (range 9-63). There were 19 (17%) recurrences at an average of 17.6 months (range 2-36), all of which were appreciably smaller than the original defect. Five (4.5%) patients developed infections treated with antibiotics alone and 6 (5.5%) developed seromas requiring aspiration in the office. Mesh exposure occurred in 8 (7.6%) patients and was treated with local wound care alone in 6 cases. Two patients required operative debridement with removal of the involved portion of mesh and re-closure of chronic non-healing wounds; both were found to have retained packing material and both went on to heal fully.
Conclusions: CS with P4HB onlay is a simple and effective technique for CAWR in a morbid cohort of patients with long-term durability. These data suggest that P4HB may be used in patients with active infection or contamination, unlike synthetic meshes. Placing the mesh in the subcutaneous onlay position is a simpler and faster technique that does not require the significant dissection associated with a retrorectus approach, and allows mesh reinforcement without intraperitoneal placement in patients with an extensively scarred or missing rectus/posterior sheath. Further, when the mesh becomes exposed, it will usually granulate well and heal. The technique described herein should be considered for the appropriately chosen patient requiring CAWR.


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