Sunday, October 10, 2004

Repair of Complex Recurrent Abdominal Wall Hernias in Obese Patients Utilizing Autologous Dermal Grafts

Thomas D. Samson, MD, Edward W. Buchel, MD, Patrick B. Garvey, MD, and Kristen A Kalkbrenner, PA.

Purpose: Closure of complex recurrent abdominal wall hernias in obese patients is a very challenging problem for surgeons. Patients usually present having had at least one attempted repair with prosthetic mesh. Hernia recurrence complicated by a wound infection or enterocutaneous fistula, further limits the reconstructive options. We present a novel approach to closing these defects utilizing autologous dermis as an adjunct to tissue reconstruction.

Methods/Materials: We retrospectively reviewed the charts of all patients who underwent repair of complex abdominal hernias complicated by infection or enterocutaneous fistula. At surgery, all prosthetic mesh was removed, enterocutaneous fistulas were resected and bowel continuity was re-established. Patients underwent abdominal wall reconstruction as well as pannus resection. The resected pannus was deepithelialized and de-fatted, creating autologous dermal sheet grafts. These dermal grafts were then used to reinforce or bridge the fascial approximation at the midline and any other fascial weak points. Drains were placed and antibiotics continued for a minimum of 2 weeks. Routine postoperative follow-up recorded hernia recurrence, resolution of enterocutaneous fistula, wound separation, wound debreidments and seroma formations.

Experience: Ten obese patients, six women and four men with an average age of 58.4 years and an average BMI of 33.9 kg/m2, had repair of complex abdominal wall hernias over the last two years. Abdominal wall reconstruction was accomplished utilizing the separation of components technique (9) and rectus turnover flap (1). All patients had autologous dermal graft reinforcement along the fascial defect. Mean follow up was 11.8 months.

Summary: In these 10 patients a total of 23 previously attempted abdominal wall repairs had been performed with a range of 1-6 per patient. At the time of our repair, all of the patients had abdominal wound infections. Seven patients had infected mesh, five had enterocutaneous fistulas, and two had draining abscesses to the abdominal wall. To date, all of the patients have complete resolution of their abdominal wound hernias with no sign of recurrence. All enterocutaneous fistulas and draining abscesses resolved with surgery. Four patients had partial wound separation. Debreidment was performed and the wound was allowed to close by secondary intention. Abscess formation requiring percutaneous drainage occurred in two patients. Seroma formation was seen in one patient. No long term wound infections were seen.

Conclusion: Fascial reconstruction of recurrent abdominal wall defects is the mainstay of treatment for these complex hernias. Typically a components separation technique is employed. The use of autologous dermis for fascial reinforcement of the reconstructed abdominal wall is an effective alternative to prosthetic mesh or Alloderm ( LifeCell, Branchburg, NJ). Defects complicated by infection or fistula effectively rule out the use of prosthetic mesh. Alloderm has been used as an adjunct in these situations, however, it imposes a significant financial burden on the patient. In the obese patient, panniculectomy provides both a source of autologous dermis and decreases the subcutaneous dead space created by the component separation technique. This leads to a decrease in postoperative seroma formation, wound infection and the consequent hernia recurrence. Within 5 days postoperatively, the dermis has taken as a graft and effectively resists infection while reinforcing the underlying repair in a permanent fashion. The ability to utilize autologous dermis allows reinforcement of the fascial repair even in the face of bacterial contamination.