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Posterior component separation and transversus abdominis muscle release for complex incisional hernia repair in patients with a history of an open abdomen.
Journal of Trauma and Acute Care Surgery 2015 Februrary
BACKGROUND: The best reconstructive approach for large fascial defects precipitated from a previous open abdomen has not been elucidated to date. We use a posterior component separation with transversus abdominis muscle release (TAR) in this scenario.
METHODS: Patients with a history of an open abdomen who ultimately underwent complex hernia repair with TAR from 2010 to 2013 at Case Medical Center were identified in our prospective database and analyzed.
RESULTS: Of 34 patients (mean [SD] age, 54 [11.3] years; mean [SD] body mass index, 32.5 [7.2]) with a history of an open abdomen, the fascia was closed primarily in 11 and skin alone closed primarily in 4 patients after a mean (SD) of 5.9 (6.7) days. Those unable to achieve primary closure either received a skin graft (n = 16) or healed by secondary intention (n = 3). Patients presented to our institution a mean (SD) of 25.1 (26.5) months after their initial operation, eight having already undergone at least one hernia repair, including four anterior component separations. Operations consisted of 21 (61.8%) contaminated cases, including 7 enterocutaneous fistula takedowns, 2 stoma revisions, 2 stoma reversals, and 3 excisions of infected mesh. Wound morbidity consisted of 12 (35%) surgical site occurrences: 1 wound dehiscence, 2 hematomas, 1 seroma, 8 surgical site infections (23.5%; 3 superficial, 3 deep, and 2 organ space), and no enterocutaneous fistulas or chronic mesh infections. One reoperation was necessary for debridement of a hematoma and deep surgical site infection. With a mean follow-up of 18 months (range, 3-42 months), two (5.9%) new parastomal hernias and three (8.8%) midline recurrences have been documented.
CONCLUSION: To our knowledge, this is the first report describing the use of TAR in patients with a history of an open abdomen for definitive abdominal wall reconstruction. We have demonstrated that this approach is associated with low significant perioperative morbidity and recurrence.
LEVEL OF EVIDENCE: Therapeutic study, level V.
METHODS: Patients with a history of an open abdomen who ultimately underwent complex hernia repair with TAR from 2010 to 2013 at Case Medical Center were identified in our prospective database and analyzed.
RESULTS: Of 34 patients (mean [SD] age, 54 [11.3] years; mean [SD] body mass index, 32.5 [7.2]) with a history of an open abdomen, the fascia was closed primarily in 11 and skin alone closed primarily in 4 patients after a mean (SD) of 5.9 (6.7) days. Those unable to achieve primary closure either received a skin graft (n = 16) or healed by secondary intention (n = 3). Patients presented to our institution a mean (SD) of 25.1 (26.5) months after their initial operation, eight having already undergone at least one hernia repair, including four anterior component separations. Operations consisted of 21 (61.8%) contaminated cases, including 7 enterocutaneous fistula takedowns, 2 stoma revisions, 2 stoma reversals, and 3 excisions of infected mesh. Wound morbidity consisted of 12 (35%) surgical site occurrences: 1 wound dehiscence, 2 hematomas, 1 seroma, 8 surgical site infections (23.5%; 3 superficial, 3 deep, and 2 organ space), and no enterocutaneous fistulas or chronic mesh infections. One reoperation was necessary for debridement of a hematoma and deep surgical site infection. With a mean follow-up of 18 months (range, 3-42 months), two (5.9%) new parastomal hernias and three (8.8%) midline recurrences have been documented.
CONCLUSION: To our knowledge, this is the first report describing the use of TAR in patients with a history of an open abdomen for definitive abdominal wall reconstruction. We have demonstrated that this approach is associated with low significant perioperative morbidity and recurrence.
LEVEL OF EVIDENCE: Therapeutic study, level V.
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