BACKGROUND:
Midline ventral hernias remain a significant problem following abdominal surgery. Ramirez et. al described a component separation technique which mobilized myofascial flaps. The advent of mesh has helped to lower recurrence rates, restore abdominal domain and prevent evisceration in complex ventral hernia surgery. This retrospective review analyzes synthetic and biologic mesh implantation using component separation and hernia recurrence rates.
METHODS:
A ten year retrospective review was performed from January 1996 through December 2006 of ventral hernia repairs at a Thomas Jefferson University Hospital (TJUH). During this time period, 1743 ventral hernia repairs were performed on 1722 patients. A total nine types of mesh were implanted, defined as biologic (human and porcine) or synthetic (nonabsorbable and absorbable). A synthetic or biologic mesh was implanted in 858 of these cases. The database was analyzed using the SAS program by SAS Institute Inc. Chi-square analysis was used to determine the risk factors of statistical significance (p<.05) for hernia recurrence.
RESULTS:
The modified myofascial flap technique was utilized on 545 patients and 100 recurrences were observed. The myofascial flap recurrence rate was 18.3% versus 38.0% for all other ventral hernia repair techniques. This reduction in recurrence was statistically significant (chi-square 72.78, df=1, p<.001). Age >65 years (65% of patients, p=0.0075), BMI>30 kg/m² (62%, p=.001), previous infection (6%, p=.0034) and postoperative seroma (4%, p=.0002) were significant risk factors for recurrence. Non-significant risk factors were smoking, COPD, hernia size or mesh. The mesh were placed as underlay, interposition and/or onlay buttresses. No statistically significant reduction in hernia recurrence was observed in respect to the type of mesh utilized or location. Goretex mesh had a significantly higher number of complications (24.5%), defined as enterocutaneous fistula (p<.0001), incarceration (p=.003) and strangulation rate (p=.0096).
CONCLUSIONS:
Our institutional review determined the component separation technique reduced the ventral hernia recurrence rate significantly from 38% to 18.3% ( p<.001). It also demonstrated that the material (synthetic or biologic) implanted to buttress the repair was not a statistically significant factor to reduce the hernia recurrence rate. However, the overall complication rates (enterocutaneous fistula, incarceration and strangulation) were increased with the synthetic nonabsorbale goretex mesh. The algorithm used for complex hernias (i.e. radiation, seroma, infection, loss of domain, gastrointestinal contamination, number of previous surgeries) was to first attempt primary closure. Depending on the complexity of the hernia, comordities and/or previous repairs synthetic meshes were implanted in sterile fields and biologics were placed in contaminated fields. Buttressing the component separation technique is a safe adjuvant therapy for ventral hernia repair but direct comparison of mesh material did not determine a superior synthetic or biologic mesh.