Improving Outcomes in Complex Abdominal Wall Reconstruction: Primary Fascial Closure with Bioprosthetic Mesh Reinforcement is Superior to Bridged Repair

INTRODUCTION: Many believe primary fascial closure with mesh reinforcement should be the goal of abdominal wall reconstruction (AWR),¹ yet others have reported acceptable outcomes using mesh to bridge the fascial edges.²  The true impact of complete fascial closure on AWR outcomes is currently unknown; however, subset analysis in a recent publication found bridged repairs to be associated with an increased risk of hernia recurrence.³ We hypothesized that bridged repairs result in higher hernia recurrence rates than tension-sharing, mesh-reinforced fascial repairs that achieve full fascial coaptation.

METHODS: We retrospectively reviewed prospectively-collected data from consecutive patients with >1 year of follow-up who underwent AWR between 2/2000 and 10/2011 at a single center.  We compared surgical outcomes between patients with bridged and mesh-reinforced fascial repairs.  Univariate and multivariate logistic regression analysis identified potential associations.

RESULTS: A total of 222 patients were included (mesh-reinforced N=195).  Patient characteristics, mean follow-up (31.1 ± 14.2 months), and use of component separation were similar between groups.  Mean defect width was greater in the bridged group (15.9cm vs. 13.8cm; p=0.023).  The bridged repairs experienced a markedly higher risk of hernia recurrence (56% vs. 8%; HR=9.5; p<0.001) as well as a higher overall complication rate (74% vs. 32%; OR=3.9; p<0.001).  Among patients who developed hernia recurrence, the interval to recurrence was over 9 times shorter in the bridged group (HR=9.5; p<0.001).  No bridged repairs were recurrence-free at 4 years post-AWR.  Multivariate regression analysis found bridged repair and defect width >15 cm to be independent predictors of hernia recurrence (HR=7.3; p<0.001 and HR=2.5; p=0.03, respectively) while bridged repair and BMI >30 kg/m²were predictive of overall complications (OR=6.0; p<0.001 and OR=3.1; p<0.001, respectively).

CONCLUSION: Mesh-reinforced abdominal wall reconstructions that achieved primary fascial coaptation experienced fewer hernia recurrences and overall complications than bridged repairs.  Surgeons should employ all means necessary, including component separation, to achieve primary fascial coaptation in abdominal wall reconstruction.