Designing a ventral hernia staging system.

INTRODUCTION: The absence of a standardized classification scheme for ventral hernias hinders comparisons within the literature, indirectly delaying meaningful discussions regarding technique. We aimed to generate a comprehensive staging system that stratifies patients by risk of developing wound morbidity and hernia recurrence. METHODS: Our prospective database of all ventral hernia repairs (2006-2013) was reviewed with no exclusion based on technique or prosthetic. The presence of patient comorbidities, contamination and hernia dimensions-width/location on computed topography-was evaluated to identify variables most closely associated with surgical site occurrence (SSO) and recurrence. Predicted odds ratios and relative hazards, for SSO and recurrence, respectively, were used to partition patients into stages corresponding with increasing levels of risk. RESULTS: Hernia width (OR 2.24, HR 1.73) and the presence of contamination (OR 1.81, HR 2.04) were most significantly associated with increased risk of SSO and recurrence, while hernia location and the presence of comorbidities were not. Stage I hernias are <10 cm/clean and associated with low SSO and recurrence risk. Stage II hernias are 10-20 cm/clean or <10 cm contaminated and carry an intermediate risk of SSO and recurrence. Stage III hernias are either ≥10/contaminated or any hernia ≥20 cm, and these are associated with high SSO and recurrence risk. Stages I-III carry a concordance index of 0.67 for SSO and 0.61 for recurrence. CONCLUSION: Hernia width and wound class can be used to stratify patients into stages (I-III) with increasing risk of wound morbidity and recurrence. This can be the foundation for future inclusion and exclusion criteria.

Repair of massive ventral hernias with "quilted" mesh.

INTRODUCTION: Prosthetic reinforcement is a critical component of hernia repair. For massive defects, mesh overlap is often limited by the dimensions of commercially available implants. In scenarios where larger mesh prosthetics are required for adequate reinforcement, it may be necessary to join several pieces of mesh together using non-absorbable suture. Here, we report our outcomes for abdominal wall reconstructions in which "quilted" mesh was utilized for fascial reinforcement. METHODS: Patients undergoing open incisional hernia repair utilizing posterior component separation and transversus abdominis muscle release, with use of quilted synthetic mesh placed in the retromuscular position, were reviewed. Main outcome measures included patient, hernia, and operative characteristics and post-operative outcomes, including surgical site occurrence (SSO), surgical site infection (SSI), and recurrence. RESULTS: Thirty-two patients (mean age 55.7 ± 9.3, BMI 38.3 ± 5.8 kg/m(2)) underwent open ventral hernia repair with "quilted" mesh placed in the retromuscular position. The mean defect area was 760.1 ± 311.0 cm(2) with a mean width of 24.7 ± 6.4 cm. Quilted meshes consisted of two-piece (69 %), three-piece (19 %) and four-piece (12 %) configurations. Wound morbidity consisted of eight (25 %) SSOs, including four (13 %) SSIs, all of which resolved without mesh excision. With mean follow-up of 9.0 ± 13.6 months, there were two (6.3 %) lateral recurrences, both unassociated with mesh-to-mesh suture line failure. CONCLUSIONS: Massive ventral hernias that require giant mesh prosthetics, currently not commercially available, may be successfully repaired using multiple mesh pieces sewn together in a quilt-like fashion. Such retromuscular repairs are durable, without added morbidity due to the mesh-to-mesh suture line. However, additional operative time is required for quilting the mesh together, prompting strong calls for manufacturing of larger mesh prosthetics.