Open preperitoneal retrofascial mesh repair for multiply recurrent ventral incisional hernias.

BACKGROUND: Because herniorrhaphy failure and complication rates appear proportional to the number of previous repairs, multiply recurrent hernias (MRH) represent a formidable challenge. We sought to determine the safety and efficacy of open preperitoneal retrofascial mesh repair of MRH. STUDY DESIGN: We conducted a retrospective review of consecutive patients undergoing an open preperitoneal retrofascial mesh repair of multiply (two or more) recurrent hernias at a tertiary care referral center. RESULTS: From January 2001 to May 2005, 128 patients underwent surgical repair of an MRH; 32 of these underwent an open preperitoneal repair. The average body mass index was 39.1 +/- 8.4 kg/m2 (range 28.9 to 61.0 kg/m2). All patients had significant comorbidities; 18.8% were smokers. The number of previous herniorrhaphies was 3.6 (range 2 to 24). Polypropylene mesh was used in all patients, including lightweight polypropylene in 10 (31.2%) patients. The average mesh size was 937 +/- 531 cm2 (range 225 to 1,800 cm2). There were no major intraoperative complications. Wound infection occurred in 4 patients (12.5%, all smokers), requiring partial mesh excision in 1 patient. Univariate analysis revealed smoking as the only predictor of wound or mesh-related morbidity (p = 0.0004). At a mean followup of 28.1 months (range 8 to 60 months), there has been 1 recurrence (3.1%) in the patient requiring partial mesh removal. CONCLUSIONS: Open preperitoneal retrofascial mesh repair resulted in an effective herniorrhaphy with low perioperative morbidity in patients with MRH. Smoking cessation appears to be important in minimizing infectious complications. Given the technical challenge, surgical care of patients with MRH may be best provided in referral centers with interest and expertise in complex hernia repairs.

Multidisciplinary approach to abdominal wall reconstruction after decompressive laparotomy for abdominal compartment syndrome.

INTRODUCTION: Decompressive laparotomy for abdominal compartment syndrome has been shown to reduce mortality in critically ill patients, but little is known about the outcome of abdominal wall reconstruction. This study investigates the role of plastic surgeons in the management and reconstruction of these abdominal wall defects. METHODS: We performed a retrospective review of 82 consecutive critically ill patients who underwent decompressive laparotomy for abdominal compartment syndrome, at a university level 1 trauma center, from April 2000 to May 2004. Patients reconstructed by trauma surgeons alone (n = 15) were compared with patients reconstructed jointly with plastic surgeons (n = 12), using Student t test and chi analysis. RESULTS: Eighty-two patients underwent decompressive laparotomy for abdominal compartment syndrome, yielding 50 survivors (61%). Of the 27 patients who underwent abdominal wall reconstruction, 6 had early primary fascial repair, and 21 had staged reconstruction with primary fascial closure (n = 4), components separation alone (n = 3), components separation with mesh (n = 10), or permanent mesh only (n = 4). Compared with patients whose reconstruction was performed by trauma surgeons, patients who underwent a combined approach with plastic surgeons were older (50.5 versus 31.7 years, P < 0.05), had more comorbidities (P < 0.001), were less likely to have a traumatic etiology (P < 0.001), had a longer delay to reconstruction (407 versus 119 days, P < 0.05), and were more likely to undergo components separation (P < 0.05). Mean follow-up of 11.5 months revealed 2 recurrent hernias in the combined reconstruction group, both of which were successfully repaired. CONCLUSIONS: A multidisciplinary approach is essential to the successful management of abdominal wall defects after decompressive laparotomy for abdominal compartment syndrome. Although carefully selected patients can undergo early primary fascial repair, most of reconstructed patients had staged closure of the abdominal wall via components separation, with a low rate of recurrent hernia. High-risk patients with large defects and comorbidities appear to benefit from the involvement of a plastic surgeon.

Assessment of adhesion formation to intra-abdominal polypropylene mesh and polytetrafluoroethylene mesh.

BACKGROUND: The development of intra-abdominal adhesions, bowel obstruction, and enterocutaneous fistulas are potentially severe complications related to the intraperitoneal placement of prosthetic biomaterials. The purpose of this study was to determine the natural history of adhesion formation to polypropylene mesh and two types of polytetrafluoroethylene (ePTFE) mesh when placed intraperitoneally in a rabbit model that simulates laparoscopic ventral hernia repair. MATERIALS AND METHODS: Thirty New Zealand white rabbits were used for this study. A 10-cm midline incision was performed for intra-abdominal access and a 2 cm x 2 cm piece of mesh (n = 60) was sewn to an intact peritoneum on each side of the midline. Two types of ePTFE mesh (Dual Mesh and modified Dual Mesh, W.L. Gore & Assoc., Flagstaff, AZ) and polypropylene mesh were compared. The rate of adhesion formation was evaluated by direct visualization using microlaparoscopy (2-mm endoscope/trocar) at 7 days, 3 weeks, 9 weeks, and 16 weeks after mesh implantation. Adhesions to the prosthetic mesh were scored for extent (%) using the Modified Diamond Scale (0 = 0%, 1 50%). At necropsy the mesh was excised en bloc with the anterior abdominal wall for histological evaluation of mesothelial layer growth. RESULTS: The mean adhesion score for the polypropylene mesh was significantly greater (P < 0.05) than Dual Mesh at 9 weeks and 16 weeks and modified Dual Mesh at 7 days, 9 weeks, and 16 weeks. Fifty-five percent (n = 11) of the polypropylene mesh had adhesions to small intestine or omentum at necropsy compared to 30% (n = 6) of the Dual Mesh and 20% (n = 4) of the modified Dual Mesh. There was a significantly greater percentage (P < 0.003) of ePTFE mesh mesothelialized at explant (modified Dual Mesh 44.2%; Dual Mesh 55.8%) compared to the polypropylene mesh (12.9%). CONCLUSIONS: Serial microlaparoscopic evaluation of intraperitoneally implanted polypropylene mesh and ePTFE mesh in a rabbit model revealed a progression of adhesions to polypropylene mesh over a 16 week period. The pore size of mesh is critical in the development and maintenance of abdominal adhesions and tissue ingrowth. The macroporous polypropylene mesh promoted adhesion formation, while the microporous nature of the visceral side of the ePTFE served as a barrier to adhesions.

Comparison of adhesion formation to intra-abdominal mesh after laparoscopic adhesiolysis in the New Zealand White rabbit.

The purpose of this study was to investigate the effects of early adhesiolysis on long-term adhesion formation after the intraperitoneal implantation of polypropylene (PP) mesh and expanded polytetrafluoroethylene (ePTFE) mesh in a rabbit model. Through a small midline laparotomy a 2 x 2-cm piece of mesh (n = 80) was sewn to an intact peritoneum on each side of a midline incision in 40 New Zealand White rabbits. Two types of ePTFE mesh [Dual Mesh (Dual) and modified Dual Mesh (C-Type), W.L. Gore and Associates, Flagstaff, AZ] and PP mesh (Marlex, C.R. Bard, Murray Hill, NJ) were compared. In 10 rabbits (n = 20) a laparoscopic adhesiolysis (LapA) was performed at one week. Mesh adhesions were scored using a modified Diamond scale (0, 0%; 1, 1-25%; 2, 26-50%; and 3, > 50%) at 1, 3, 9, and 16 weeks by serial microlaparoscopic (2 mm) examinations. After recording the final adhesion score at 16 weeks the prosthetic biomaterials were excised en bloc with the anterior abdominal wall for histologic evaluation of mesothelial layer growth (%) on the visceral surface of the mesh. Statistical differences (P value < 0.05) were measured by chi-square and Wilcoxon signed rank tests. There were no statistical differences in mean adhesion scores at adhesiolysis at 7 days. The mean adhesion scores in the groups undergoing laparoscopic adhesiolysis was statistically less (P < 0.05) for PP and both ePTFE meshes at 3-, 9-, and 16-week intervals compared with those not undergoing adhesiolysis. The percentage of mesothelialization on the visceral surface of the mesh was not statistically different between the adhesiolysis and control groups for any of the prosthetic biomaterials. Laparoscopic adhesiolysis at one week minimizes subsequent adhesion formation to PP and ePTFE mesh over a 4-month follow-up. Adhesion formation within the first 7 days after mesh implantation appears to determine the long-term adhesion score. Eliminating adhesions to mesh by mechanical or other means during this critical time may control adhesions to the mesh and subsequent mesh-related complications.

Comparison of thermal spread after ureteral ligation with the Laparo-Sonic ultrasonic shears and the Ligasure system.

BACKGROUND AND PURPOSE: The extent of lateral spread of tissue injury is important in the success of a primary anastomosis. We compared the injury produced by the Laparo-sonic Coagulation Shears and the Ligasure system. MATERIALS AND METHODS: Ureters were harvested from domestic farm pigs and ligated with the Laparo-sonic (N = 13) or Ligasure (N = 9) system. The tissues were then fixed, stained, and examined by two pathologists without knowledge of the type of treatment. RESULTS: The mean length of thermal damage from the Ligasure was 2.11 mm (range 1.0-4.0 mm) whereas it was 1.92 (range 0.5-4.25 mm) from the Laparo-sonic system. The difference is not statistically significant. CONCLUSION: Debridement of as much as 5 mm of each cut end produced by the Laparo-sonic or Ligasure system may be beneficial in reducing stricture and leak.

The economic benefit of practice guidelines for stress ulcer prophylaxis.

The development of practice guidelines is an effective way to provide consistent and cost-effective patient care. Despite much progress in developing practice guidelines for various other clinical problems data documenting the efficacy of these guidelines are lacking. The purpose of this study was to compare usage patterns and cost effectiveness of a stress ulcer prophylaxis guideline in a trauma intensive care unit. The trauma intensive care unit team was observed for a 50-day period. Immediately after this period a stress ulcer prophylaxis guideline was implemented, and the team was again observed for a 50-day period. All information was recorded prospectively. The trauma intensive care unit team was blind to the existence of the study. The days of appropriate use of prophylaxis (ulcer prophylaxis prescribed per the practice guidelines) and inappropriate use (use other than per the practice guidelines) in each study phase and the resulting costs were calculated as the primary measurement of outcome. Forty-six patients were studied. The use of practice guidelines in the period after the guideline was implemented of the study reduced overall stress ulcer prophylaxis by 17 per cent (P = 0.04). The appropriate prophylaxis was not significantly different when comparing the two periods of study; however, inappropriate use of prophylaxis (and associated charges) was statistically significantly less frequent after implementation of the practice guidelines. No patients developed clinically important gastrointestinal bleeding. The estimated annual savings of $102,895 in patient charges and $11,333 in actual drug costs in our trauma intensive care unit were due to the implementation of stress ulcer prophylaxis guidelines. We conclude that use of practice guidelines can significantly reduce patient charges without compromising patient care.