Plastic Surgery Research Council

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Absorbable Onlay Mesh in Complex Abdominal Wall Reconstruction
Adam S. Levy, MD1, Jaime L. Bernstein, BS2, Kerry A. Morrison, MD2, Alfons Pomp, MD2, Christine H. Rohde, MD3, David M. Otterburn, MD2, Jason A. Spector, MD2.
1New York-Presbyterian Hospital - Cornell/Columbia, New York, NY, USA, 2New York-Presbyterian Hospital - Weill Cornell Medicine, New York, NY, USA, 3New York-Presbyterian Hospital - Columbia, New York, NY, USA.

Purpose: Complex abdominal wall reconstruction (CAWR) for ventral hernia repair addresses a challenging and morbid patient population. Patients often have multiple prior attempts at hernia repair as well as contaminated or infected wounds. There remains significant disagreement in the surgical community regarding optimal choice of mesh and location of mesh placement, although underlay and permanent mesh has generally been preferred. Beginning several years ago with the arrival of Poly-4-hydroxybutyrate (P4HB) in mesh form, this material has become our preferred mesh used in CAWR. This biosynthetic, degradable polymer retains strength for at least 6 months, the time required for wound healing to reach maximal post injury strength. Because it degrades thereafter, complications associated with permanent synthetic materials are avoided. Further, because it becomes rapidly infiltrated with host tissue, it is relatively resistant to infection and is non-seromagenic. Given these appealing characteristics, we have used this mesh in the onlay position, making the placement of the mesh much more efficient. We reviewed our experience using P4HB mesh in CAWR as an onlay in the setting of bilateral component separation.
Methods: All patients (n=101) undergoing CAWR between June 2014 and March 2017 at two major university hospitals were followed prospectively. In all cases, surgical repair involved bilateral components separation with elevation of the external oblique 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 38 months.
Results: 101 patients (106 cases; 50 male, 51 female; mean age 59 years, range 22-84) underwent CAWR. Mean BMI was 29 (range 16-48). 56(55%) patients underwent prior repair with an average of 3.5 prior abdominal operations (range 0-12, median 3). 67(66%) patients had at least 2 major medical comorbidities and 77(76%) patients were ASA 3 or greater. 16(15%) were contaminated or infected prior to repair. Average follow up was 15.6 months (range 1-38). 9(8%) patients developed a recurrence at an average of 10.1 months (range 2-18), all of which were appreciably smaller than the original defect. Of the 9 recurrences, 5 were located superiorly and 2 inferiorly to prior mesh placement, 1 in a prior stoma site and 1 in the epigastric midline. 5(5%) patients developed infections treated with antibiotics alone and 6(6%) developed seromas requiring aspiration in the office. Mesh exposure occurred in 8(8%) patients and was treated with local wound care alone in 5 cases. Three patients required operative debridement and re-closure of chronic non-healing wounds; two were found to have retained packing material.
Conclusions: These data demonstrate an effective, reproducible technique across 2 institutions using a biosynthetic onlay mesh for CAWR with very low rates of hernia recurrence, seroma and other common complications. Notably, no patient developed mesh infection or required mesh excision, even when used in a contaminated surgical field. Although longer follow up is needed, we believe P4HB mesh used as an onlay is a viable option for complex abdominal wall reconstruction. 


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