Long-Term Outcomes of Complex Abdominal Herniorraphy: Experience with 106 Cases

INTRODUCTION:  Reconstruction of large abdominal wall defects is a challenging problem.  Ventral incisional hernias can occur in up to 11% of initial laparotomies.  Even more problematic is that the recurrence rates increase after each successive herniorraphy, with rates up to 54% to 67%.  Our study investigated peri-operative factors to determine which variables were associated with poor outcomes.

METHODS:  Data were collected on all patients who underwent ventral abdominal wall repair by three senior-level surgeons at our institution over an eight-year time period.  In all cases, placement of either a synthetic or a biologic mesh was used to provide additional reinforcement of the repair.  Multivariate analysis was performed to identify factors contributing to post-operative complications and hernia recurrences. 

RESULTS:  106 patients were included with 42 men (39.6%) and 64 women (60.4%).  The average age was 57 years (range 19-87 years).  Sixty-seven patients developed a post-operative complication (63%).  Skin necrosis was the most common complication (n=21, 19.8%).  Other complications included seroma (n=19, 17.9%), cellulitis (n=19, 17.9%), abscess (n=14 13.2%), pulmonary embolus/DVT (n=3, 2.8%), small bowel obstruction (n=2, 1.9%), and fistula (n=8, 7.5%).  Factors that significantly contributed to post-operative complications (p<0.05) included:  obesity, diabetes, hypertension, fistula at the time of the operation, a history of more than 2 prior hernia repairs, a history of more than 3 prior abdominal operations, hospital stay greater than 14 days, defect size > 300 square cm, and the use of human-derived mesh allograft.  Factors that significantly increased the likelihood of a hernia recurrence (p<0.05) included:  a history of more than 2 prior hernia repairs, the use of human-derived allograft, using an overlay-only mesh placement, and the presence of a post-operative complication, particularly infection.   Hernia recurrences were significantly reduced (p<0.05) by using a “sandwich” repair with both a mesh overlay and underlay, and by using component separation.

CONCLUSIONS:  A history of multiple abdominal operations is a major predictor of complications and recurrences, and these patients should be appropriately counseled.  The surgeon should always strive for a primary tension-free repair.  If needed, component separation should be used to achieve this goal, which minimizes the likelihood of hernia recurrences.  Mesh reinforcement used concomitantly in a “sandwich” repair with component separation leads to reduced recurrence rates and may provide the optimal repair.