Long-Term Outcomes (>36 Months) for Complex Abdominal Wall Reconstruction with Acellular Dermal Matrix

Background: Abdominal wall reconstructions (AWR) employing acellular dermal matrix (ADM) appear to experience low rates of wound infections and similar hernia recurrence rates compared to synthetic mesh, particularly in more complicated patients. However, the long term durability of AWRs with ADM is unclear, as studies with sufficient long-term follow-up are lacking.  We hypothesized that AWRs using ADM experience durable long-term outcomes with respect to hernia recurrence rates.

Methods: We retrospectively reviewed prospectively collected data from consecutive patients who underwent AWR with ADM for repair of complex hernia and/or oncologic resection over a 10-year period at a single institution.  We only included patients with a minimum of 36 months of postoperative follow-up and excluded any patients with less than 36 months follow-up.  Univariate and multivariate logistic regression and Cox proportional hazard regression analyses identified potential associations and predictive/protective factors for hernia recurrence.

Results: We included 191 consecutive patients with a mean follow-up of 55.6 months (range 36-104 months).  Approximately 80% of patients underwent AWR with component separation and 8% had a bridged fascia repair. The most frequently used bioprosthetic was porcine ADM (56.5%), followed by bovine ADM (31.1%) and human cadaveric ADM (10.9%). The surgical site occurrence rate was 25.1%. The overall hernia recurrence rate was 16.2%, with a hernia recurrence rate of 13.0% at 3 years postoperative and 16.7% at 5 years postoperative. Logistic regression analysis showed the strongest predictors of hernia recurrence to be bridged fascia repair (HR=10.1, p<0.001), body mass index >30 kg/m²(HR=1.9, p=0.089), and use of human cadaveric ADM (HR=2.52, p=0.044). Subset analysis was performed of only those reconstructions that employed neither bridged fascia repair nor human cadaveric ADM.  This subset of optimally performed AWRs revealed a hernia recurrence rate of only 8.2% within 3 years and 10.7% at 5 years follow-up.

Conclusions: Contrary to the conventional opinion that the use of ADM rather than synthetic mesh in complex AWR leads to compromised durability of the repair, we found that complex AWRs using ADM demonstrated low and acceptable rates of hernia recurrence with long-term follow-up, particularly when optimal practices were employed such as avoiding the creation of a bridged fascial defect or the use of human cadaveric ADM.